Intravenous administration of recombinant human macrophage colony-stimulating factor to patients with metastatic cancer: a phase I study

PURPOSE

Recombinant human macrophage colony-stimulating factor (M-CSF) has been shown to stimulate specifically macrophage lineage differentiation in vitro and to induce cells capable of antitumor activity alone or in combination with an antibody. The administration of M-CSF to mice has demonstrated antitumor therapeutic effects in vivo. Therefore, a phase I trial of M-CSF administration to patients with metastatic cancer was undertaken.

PATIENTS AND METHODS

M-CSF was given by intermittent intravenous bolus infusion every 8 hours for 7 days; the treatment cycle was repeated once after a week of rest. Cohorts of three patients underwent dose escalation from 10 to 100,000 micrograms/m2/d; 23 patients received 27 courses of M-CSF administration. All patients had metastatic solid tumors refractory to conventional therapy, including renal cell carcinoma (RCC) (nine), melanoma (seven), and colorectal carcinoma (seven).

RESULTS

Treatment-related toxicity was minimal; five patients developed transient signs of ocular or periorbital inflammation, with iridocyclitis as the most severe manifestation. At the highest doses, platelet counts decreased with therapy (but remained > 100,000/mm3) and the absolute monocyte count increased during the course of therapy. Only at 30,000 and 100,000 micrograms/m2/d was treatment limited because of toxicity (iritis and malaise). Pharmacokinetic studies demonstrated up to a 1,000-fold increase in circulating serum M-CSF after bolus infusion; half-life varied from 1 to 6 hours. Complete regression of mediastinal adenopathy and multiple pulmonary metastases were observed in one patient with RCC.

CONCLUSION

Recombinant M-CSF can be administered safely to patients with metastatic cancer at doses that demonstrate biologic activity.

Combined use of cyclosporine and ketoconazole in the treatment of endogenous uveitis

Ten patients with endogenous uveitis were in clinical remission attributable to treatment with cyclosporine and prednisone. After the cyclosporine dose was reduced by two thirds, these patients were randomly assigned to treatment with or without ketoconazole, a potent inhibitor of cytochrome P-450, in a double-masked placebo-controlled study. The dose was reduced over three days. During a three-month follow-up, no patients treated with ketoconazole had a relapse of uveitis, while four of six (66%) control subjects had a flare-up. Toxicity in the ketoconazole-treated group was limited to a transient decrease in glomerular filtration rate (20% from baseline) at one month in two of six (33%) patients. Renal function was stabilized by further reduction of the cyclosporine dose.

Differential diagnosis of retinitis and choroiditis in patients with acquired immunodeficiency syndrome

Patients with acquired immunodeficiency syndrome (AIDS) are at high risk for developing retinitis. The most common forms of retinitis in such patients are those caused by cytomegalovirus (CMV) and Toxoplasma; however, retinitis or choroiditis can also be caused by other viral, protozoal, bacterial, and fungal agents. Differential diagnosis of these infections is based on a number of factors, including ophthalmoscopic appearance, underlying disease, clinical history, and severity of underlying immunosuppression. Rapid and accurate diagnosis is essential in preserving functional vision, as some forms of retinitis are rapidly progressive and since appropriate treatment varies by diagnosis.

Retinal toxicity in human immunodeficiency virus-infected children treated with 2',3'-dideoxyinosine

To assess the safety and antiretroviral activity of 2',3'-dideoxyinosine, we enrolled 43 children with symptomatic (Centers for Disease Control class P-2) human immunodeficiency virus infection in a Phase I-II study and monitored them prospectively for the development of ocular complications secondary to HIV infection or drug toxicity. Follow-up ranged from 12 to 103 weeks with a median follow-up of 71 weeks. Three of 43 children (7.0%) developed peripheral atrophy of the retinal pigment epithelium during treatment with 2',3'-dideoxyinosine. The two children with the most severe retinal atrophy were enrolled in the study at the highest dosage studied (540 mg/m2/day). In contrast to findings in children, no retinal atrophy in HIV-infected adults treated with 2',3'-dideoxyinosine has been evident to date.

Treatment of corneal allograft rejection with the cytotoxin IL-2-PE40

IL-2-PE40 is a recombinant chimeric protein composed of IL-2, fused to a modified pseudomonas exotoxin. This molecule is extremely toxic to activated T cells expressing high-affinity IL-2R. We used this new molecule for selective immunosuppression to treat corneal allograft rejection in the rat, using Fisher and Lewis rats, a strain combination differing only in medial and minor histocompatibility antigens. The effect of IL-2-PE40 on the immunologic response was studied using both a heterotopic corneal graft model and orthotopic grafts. At the dose of 0.31 micrograms/g given intraperitoneally every 12 hr, IL-2-PE40 produced a significant reduction of both total lymph node cells and cytotoxic-T-cell (CTL) activity in draining lymph nodes (DLN) of heterotopically grafted animals. IL-2-PE40 treatment also significantly reduced the clinical rejection score and cumulative rejection rate (CRR) in orthotopic grafts and appears to be a very effective immunosuppressive agent.

Role of chorioretinal biopsy in inflammatory eye disease

Two patients who had similar clinical presentations of bilateral multiple chorioretinal lesions and needed a correct diagnosis underwent chorioretinal biopsy. The biopsy from one patient demonstrated mainly a B cell infiltrate in choroidal and subretinal nodules, while the biopsy from the second patient showed mainly macrophages in the retina. These findings directed the therapeutic approach taken in each patient. Although chorioretinal biopsy is an invasive procedure with the potential for serious complications, the resultant finding may aid in the diagnosis and guide the subsequent management of certain patients presenting with serious ocular findings of undefined etiology.

Immunohistochemistry of the inflammatory response in Propionibacterium acnes endophthalmitis

Specimens were obtained from two patients with culture-proven Propionibacterium acnes endophthalmitis who had undergone vitrectomy. Wright's and Giemsa stains were performed using cytospin preparations of the dilute vitreous and revealed a predominance of polymorphonuclear leukocytes (80% to 90%). The remaining inflammatory cells in the vitreous were mostly macrophages (10% to 15%); very few lymphocytes were present (less than 5%). Immunohistochemical studies using monoclonal antibodies confirmed the paucity of lymphocytes. Most lymphocytes were CD4+ helper/inducer T cells. Almost no CD8+ suppressor/cytotoxic T lymphocytes or B lymphocytes were found. The inflammatory response in these two patients is most characteristic of acute inflammation and consistent with an underlying bacterial infection, despite a clinical picture of persistent, low-grade inflammation. Infection with P acnes has been shown to inhibit CD8+ T cells and may play a role in the persistent inflammation in cases of P acnes endophthalmitis.

Analysis of the pivotal residues of the immunodominant and highly uveitogenic determinant of interphotoreceptor retinoid-binding protein

Interphotoreceptor retinoid-binding protein (IRBP), a retinal-specific Ag, induces experimental autoimmune uveitis in a variety of animals. We have previously shown that sequence 1169-1191 of bovine IRBP is the immunodominant epitope of this protein in Lewis rats and is highly immunogenic and uveitogenic in these rats. The active site of peptide 1169-1191 was determined by testing its truncated forms. The shortest peptide to be immunologically active was found to be 1182-1190 (WEGVGVVPD). To determine the role of individual residues of this sequence, we have tested the immunologic activities of nine analogs of peptide 1181-1191, in which each of residues 1182-1190 was substituted with alanine (A). The tested activities included the capacity to induce experimental autoimmune uveitis and cellular responses in immunized rats, as well as the capability to stimulate lymphocytes sensitized against IRBP or the parent peptide 1181-1191. Analogs that did not stimulate these lymphocytes were also tested for their capacity to competitively inhibit the proliferative response to 1181-1191. Analogs A(1184), A(1186), and A(1187) resembled 1181-1191 in their activities, whereas the other analogs exhibited remarkably reduced activities, with several patterns being noticed. Analog A(1182) was inactive in all tests. Analog A(1190) was very weakly uveitogenic and non-immunogenic, but it stimulated lymphocytes sensitized against IRBP or 1181-1191 when added at exceedingly high concentrations. Analogs A(1183) and A(1185) resembled A(1190) in being weakly uveitogenic and A(1185) was also found to be poorly immunogenic. In addition, relatively high concentrations of A(1183) and A(1185) were needed to stimulate lymphocytes sensitized against IRBP or 1181-1191. However, a different pattern of activities was exhibited by analogs A(1188) and A(1189). These peptides were uveitogenic and immunogenic, but failed to stimulate lymphocytes sensitized to IRBP or 1181-1191. Furthermore, A(1188) and A(1189), but not A(1182), also inhibited the response to 1181-1191 of a cell line specific toward this parent peptide. The data are interpreted to show that residues 1188 and 1189 are involved in the interaction of the peptide with the TCR, whereas residues 1182 and 1190 and, perhaps, 1183 and 1185, are pivotal for the binding of peptide 1181-1190 to the MHC molecules on APC.

Analysis of the pivotal residues of the immunodominant and highly uveitogenic determinant of interphotoreceptor retinoid-binding protein

Interphotoreceptor retinoid-binding protein (IRBP), a retinal-specific Ag, induces experimental autoimmune uveitis in a variety of animals. We have previously shown that sequence 1169-1191 of bovine IRBP is the immunodominant epitope of this protein in Lewis rats and is highly immunogenic and uveitogenic in these rats. The active site of peptide 1169-1191 was determined by testing its truncated forms. The shortest peptide to be immunologically active was found to be 1182-1190 (WEGVGVVPD). To determine the role of individual residues of this sequence, we have tested the immunologic activities of nine analogs of peptide 1181-1191, in which each of residues 1182-1190 was substituted with alanine (A). The tested activities included the capacity to induce experimental autoimmune uveitis and cellular responses in immunized rats, as well as the capability to stimulate lymphocytes sensitized against IRBP or the parent peptide 1181-1191. Analogs that did not stimulate these lymphocytes were also tested for their capacity to competitively inhibit the proliferative response to 1181-1191. Analogs A(1184), A(1186), and A(1187) resembled 1181-1191 in their activities, whereas the other analogs exhibited remarkably reduced activities, with several patterns being noticed. Analog A(1182) was inactive in all tests. Analog A(1190) was very weakly uveitogenic and non-immunogenic, but it stimulated lymphocytes sensitized against IRBP or 1181-1191 when added at exceedingly high concentrations. Analogs A(1183) and A(1185) resembled A(1190) in being weakly uveitogenic and A(1185) was also found to be poorly immunogenic. In addition, relatively high concentrations of A(1183) and A(1185) were needed to stimulate lymphocytes sensitized against IRBP or 1181-1191. However, a different pattern of activities was exhibited by analogs A(1188) and A(1189). These peptides were uveitogenic and immunogenic, but failed to stimulate lymphocytes sensitized to IRBP or 1181-1191. Furthermore, A(1188) and A(1189), but not A(1182), also inhibited the response to 1181-1191 of a cell line specific toward this parent peptide. The data are interpreted to show that residues 1188 and 1189 are involved in the interaction of the peptide with the TCR, whereas residues 1182 and 1190 and, perhaps, 1183 and 1185, are pivotal for the binding of peptide 1181-1190 to the MHC molecules on APC.

Large cell lymphoma masquerading as a viral retinitis

A 37 year old woman presented with a bilateral vitritis. 4 months previously, she had developed in her left eye a necrotizing retinitis compatible with acute retinal necrosis (ARN). A trial of Acyclovir was unsuccessful as were systemic steroids. Over the following 2 months the vitritis worsened. The patient underwent a diagnostic vitrectomy revealing the presence of a large B-cell lymphoma with a predominance of lambda light chains.

Cellular immune responses of patients with uveitis to retinal antigens and their fragments

Of two patient populations totaling 82 patients, one in the United States and the other in Japan, we studied the cellular immune responses against S-antigen and interphotoreceptor retinoid binding protein as well as to fragments of each antigen. Behçet's disease, birdshot retinochoroidopathy, pars planitis, ocular sarcoid, sympathetic ophthalmia, and the Vogt-Koyanagi-Harada syndrome were diagnosed in these patients. The response profile of both antigens paralleled each other. This profile was more commonly seen in patients suffering from diseases affecting the retina. Responders reacting to both antigens or to several fragments of an antigen were present. This pattern of response was seen in 26 of the patients tested. Patients with uveitis appeared able to recognize several autoantigens. This might be a consequence of the breakdown of the blood-retinal barrier and may help perpetuate the inflammatory process. Several patients were capable of responding to more than one epitope of the same antigen, which indicates that there are major differences between the experimental model and human autoimmune diseases in the response to autoantigens. Both of these findings may to help develop new immunotherapeutic strategies in the treatment of uveitis.

Prevention of radiation-induced stenosis of the nasolacrimal duct

Epiphora is a recognized complication of radiotherapy of medial canthal tumours. We reviewed the records of 36 patients who underwent prophylactic nasolacrimal duct intubation with silicone tubing before superficial x-ray beam therapy and 42 patients who did not undergo intubation before radiotherapy. The mean length of follow-up was 3.4 years in the intubated group and 7.2 years in the nonintubated group. A total of 31% of the patients in the nonintubated group reported chronic epiphora during the follow-up period, compared with 6% in the intubated group (p less than 0.003).

Immunological features of synthetic peptides derived from the retinal protein IRBP: differences between immunodominant and non-dominant peptides

Interphotoreceptor retinoid-binding protein (IRBP) is a glycoprotein of 1264 residues (bovine) which localizes specifically in the retina and pineal gland and induces inflammatory changes in these organs (EAU and EAP, respectively) in immunized animals. We report here on differences between the immunological activities in Lewis rats of four IRBP-derived synthetic peptides. Only one of these peptides, designated R14 (residues: 1169-1191) is immunodominant, i.e., it has the capacity to stimulate lymphocytes sensitized against whole IRBP. The remaining peptides, R4 (1158-1180), R8 (1197-1209), and R12 (248-266), are non-dominant and are not recognized by IRBP-sensitized lymphocytes. R14 differed profoundly from the other peptides in its immunogenicity, inducing cellular immunity at the low dose of 0.1 nmol/rat, whereas the non-dominant peptides initiated immune responses at doses approximately 100 times higher. R14 was also superior to the non-dominant peptides in its antigenicity, as determined by the lowest concentration required to induce sensitized lymphocytes to proliferate. Responses were stimulated by R14 at a concentration of 10(-6) microM, while the three non-dominant peptides were stimulatory at the much higher concentration of 10(-1) microM. These data support the concept that immunodominance is linked to a high binding affinity of the peptide determinant to the major histocompatibility complex antigens on antigen-presenting cells.

Anterior segment ischemia treated with hyperbaric oxygen

Anterior segment ischemia developed in a 62-year-old dysthyroid patient after two-muscle adjustable suture repair of vertical strabismus. Because of a quiescent pulmonary tuberculous focus he was not treated with systemic steroid therapy but rather with hyperbaric oxygen in the controlled environment of our hospital hyperbaric chamber. He tolerated this treatment well, and his acute symptoms almost completely resolved in 3 days. We believe this to be the first reported case of the use of hyperbaric oxygen in the management of anterior segment ischemia. We also believe it is the first reported case of anterior segment ischemia following surgery to two opposing, not contiguous, rectus muscles in dysthyroid ophthalmopathy.

Orbital manifestations of plasmacytic lymphoproliferations

Orbital involvement by plasmacytic lymphoproliferative disorders is rare. Presented are four cases, with different clinical onsets and courses, demonstrating the diversity of expression of lymphoproliferative plasma cell lesions of the orbit. The first patient presented with a slowly developing palpable mass in the upper and anterior orbit. This localized lesion proved to be a reactive plasma cell proliferation. The second case had a 3-month history of proptosis, diplopia, and droopy eyelid and a pulsatile temporal mass with bone destruction. Results of biopsy and systemic investigations showed a solitary plasmacytoma of bone. In the third case, a patient with a known multiple myeloma for 2 years presented with a progressive osteolytic mass which proved on biopsy to be a plasmacytoma. At the time, she also had other active bone lesions. The fourth case presented as a possible orbital cellulitis in a man with known multiple myeloma for 2 years. He proved to have disseminated myeloma, the orbital infiltrate being secondary to sinus involvement. The differential diagnosis for each case can be quite involved. Each case required a biopsy for an accurate diagnosis in addition to a complete clinical, radiographic, and laboratory workup. The pathologic features of each tumor can be misleading. These will be discussed as well as the use of ancillary diagnostic methods such as electron microscopy and immunohistochemistry to further characterize each lesion. The clinical course and treatment modalities will be discussed.