Prolonged survival of patients receiving active immunotherapy with Canvaxin therapeutic polyvalent vaccine after complete resection of melanoma metastatic to regional lymph nodes

Role of radiation therapy in cutaneous melanoma

Cutaneous melanoma is a disease that often has an aggressive and unpredictable course. It was historically thought to be a radioresistant neoplasm; however, substantial radiobiologic and clinical evidence has emerged to refute this notion. Improved local control has been demonstrated with the use of adjuvant radiation therapy delivered to the primary site or regional lymphatics in patients with high-risk clinical or pathologic features. Despite improved local control, high-risk cutaneous melanoma often spreads systemically, leading to poor survival. In the setting of systemic progression, radiation therapy can frequently palliate symptomatic sites of metastatic disease.

Randomized clinical trials in melanoma

The incidence of melanoma is increasing and it is estimated that, in the United States, the lifetime risk of developing melanoma is 1 in 55. There have been many randomized trials that have refined the treatment and minimized the morbidity of the intervention of this prevalent disease. From 1975 to 2000, there were 154 prospective randomized trials on the treatment of local, regional, and metastatic melanoma. Between 2001 and the end of 2008, there were 52 randomized controlled trials relating to the treatment of patients with malignant melanoma. This article reviews the results of the major studies included in the prior article, and provides a detailed description of selected randomized controlled trials performed from 2001 to 2008.

Multidisciplinary treatment of primary melanoma

This article covers the multidisciplinary treatment of primary melanoma. Excision margins and the need for sentinel lymphadenectomy are mainly dictated by the Breslow thickness although exceptions to this dictum do exist. Interferon is the only FDA approved adjuvant therapy for high risk melanoma although its overall survival benefit is minimal. Trials examining different doses or duration of interferon therapy have not demonstrated any promising survival data so far. There have been several randomized vaccine trials for melanoma but none have shown an overall survival benefit. Research into T-cell regulation continues and will hopefully bring promise for the future of melanoma treatment.

Delivery strategies of melanoma vaccines: an overview

For many years, various cancer vaccines have been widely evaluated, however clinical responses remain rare. In this review, we attempt to address the question of which delivery strategies and platforms are feasible to produce clinical response and define the characteristics of the strategy that will induce long-lasting antitumor response. We limit our analysis and discussion to microparticles/nanoparticles, liposomes, heat-shock proteins, viral vectors and different types of adjuvants. This review aims to provide an overview of the specific characteristics, strengths and limitations of these delivery systems, focusing on their impacts on the development of melanoma vaccine. To date, only adoptive T-cell transfer has shown promising clinical outcomes compared to other treatments.

Translational research in melanoma

Current treatment of malignant melanoma exemplifies not only the need for translational research but also many of the challenges of moving from bench to bedside. Melanoma remains unique among solid tumors in that its treatment primarily is surgical. Radiation is of limited benefit, and chemotherapy has been disappointing in both the adjuvant and metastatic settings. This leaves clinicians with few options for reducing the chance of recurrence after surgery and for treating unresectable disease. With this in mind, there has been a fervent attempt to identify novel approaches to melanoma therapy and translate them into clinical use.

The role of vaccine therapy in the treatment of melanoma

BACKGROUND

Melanoma is a tumour that is usually resistant to systemic therapy. Since it has been considered to be a highly immunogenic tumour, it has become an excellent target for the active specific immunotherapy. Vaccine therapy represents a novel approach to the treatment of melanoma.

OBJECTIVE

To evaluate different vaccines tested in stage III and/or IV melanoma patients.

METHODS

Systematic review of the published evidence on vaccine therapy in melanoma.

RESULTS

Melanoma vaccines can be classified into six groups: whole-cell vaccines, dendritic cell vaccines, peptide vaccines, ganglioside vaccines, DNA vaccines and viral vectors. The main characteristics of these vaccines including their advantages and disadvantages and the results from conducted trials are presented. Clinical responses to melanoma vaccines are still poor and currently there is no melanoma vaccine with a proven efficacy.

CONCLUSION

Vaccine therapy still remains an experimental therapy in patients with metastatic melanoma. Further research is required although a future therapy for advanced melanoma is probably a multimodal approach including vaccines, adjuvants and negative co-stimulatory blockade.

Therapeutic cancer vaccines

Therapeutic cancer vaccines target the cellular arm of the immune system to initiate a cytotoxic T-lymphocyte response against tumor-associated antigens. Immunotherapy offers one of the few therapeutic options that reproducibly leads to a subset of patients with long-term remissions (seemingly cures) of widely metastatic disease. Therapeutic cancer vaccines tested in clinical trials have included inactivated tumor cells administered in immunological adjuvants or after genetic modification to increase their immunogenicity. Other forms are heat shock protein vaccines and anti-ganglioside antibodies. Tumor-associated antigenic peptides have been fully characterized for some cancers. Finally, strategies to directly expand antitumor T lymphocytes and adoptively transfer them to patients with cancer have been developed and shown to induce objective tumor regressions.

Lessons from randomized phase III studies with active cancer immunotherapies--outcomes from the 2006 meeting of the Cancer Vaccine Consortium (CVC)

After years of effort to develop active cancer immunotherapies, seven candidate products achieved promising results in phase I/II studies that triggered phase III randomized studies. One candidate to date has received an approvable letter from the United States Food and Drug Administration (FDA), defining a clear path to licensure for sipuleucel-T (Provenge, Dendreon) within the next couple of years. The other phase III studies failed to achieve statistical criteria for some or all of the critical endpoints. Yet, there is widespread recognition that using a patient's own immune system to target and destroy cancer cells may offer an effective biological therapy with less toxicity than presently available anti-cancer therapies, and several candidates are still being evaluated in clinical studies. This review summarizes the lessons learned from these case studies, evaluates scientific, study design, and business factors that can affect study outcomes, identifies common challenges faced by sponsors developing these innovative therapies, and provides considerations for future study designs that may increase the likelihood of success.

Cell based cancer vaccines: regulatory and commercial development

There is both clinical and regulatory drive to expedite development of safe, efficacious cancer therapies. Stimulation of the patients immune system through vaccination with tumour cells has long been at the vanguard of cancer therapeutic vaccines, and several have been demonstrated to be safe and to have efficacy in early clinical trials for a range of cancers including melanoma, renal cell carcinoma, prostate and colorectal cancers. A number of development-stage vaccines and strategies are currently being tested, utilising either autologous or allogeneic tumour cells, which may also have been ex vivo manipulated (e.g. cytokine transfected cells). It seems likely that clinical trial success, and hence patient benefit, could be improved through better patient identification, possibly by the discovery and use of novel immune response biomarkers. In this review, we aim to summarise the state of tumour cell vaccines in commercial development and to explore not only the difficulties of determining efficacy, but also the production challenges faced when developing a vaccine from proof of principle to pivotal phase III trials.

Immune cell recruitment and cell-based system for cancer therapy

Immune cells, such as cytotoxic T lymphocytes, natural killer cells, B cells, and dendritic cells, have a central role in cancer immunotherapy. Conventional studies of cancer immunotherapy have focused mainly on the search for an efficient means to prime/activate tumor-associated antigen-specific immunity. A systematic understanding of the molecular basis of the trafficking and biodistribution of immune cells, however, is important for the development of more efficacious cancer immunotherapies. It is well established that the basis and premise of immunotherapy is the accumulation of effective immune cells in tumor tissues. Therefore, it is crucial to control the distribution of immune cells to optimize cancer immunotherapy. Recent characterization of various chemokines and chemokine receptors in the immune system has increased our knowledge of the regulatory mechanisms of the immune response and tolerance based on immune cell localization. Here, we review the immune cell recruitment and cell-based systems that can potentially control the systemic pharmacokinetics of immune cells and, in particular, focus on cell migrating molecules, i.e., chemokines, and their receptors, and their use in cancer immunotherapy.

Vaccine therapy for melanoma: current status and future directions

A vaccine is typically defined as any preparation used as a preventive inoculation to confer immunity against a specific disease. Vaccines for infectious diseases are highly effective, acting by inducing antigen-specific immunity that prevents subsequent infection. Unfortunately, the success of vaccines in infectious diseases has not been mirrored in oncology. This failure is the result of several challenges facing cancer vaccines, including the conceptual shift from disease prevention to disease treatment, tumor-induced immunosuppression and other mechanisms of immune escape, the similarity between tumor antigens and self antigens to which the patient is tolerant, unfavorable effector-to-target ratios in patients with established tumors, and financial and regulatory issues. Despite this, cancer remains a promising target for vaccine therapy. Melanoma in particular is known for its inherent immunogenicity on the basis of many anecdotal reports of spontaneous immune-based tumor regression, and thus has been the focus of immunotherapeutic approaches. Rare but significant vaccine-induced clinical regression of melanoma has spurred intensive investigations to augment vaccine efficacy. This review explores the many vaccine strategies that have been clinically tested for the treatment of melanoma and considers future approaches of cancer immunotherapy.

Tumor antigens as surrogate markers and targets for therapy and vaccines

There are a large number of tumor antigens, which may either be specific to the tumor or inappropriately expressed or processed (tumor-associated antigen, TAA). Over the last few years, hundreds of new TAAs have been identified. Some of these represent good targets for both passive (antibody based) and active (vaccine based) therapies. Antibody treatments targeted on tumor-specific antigens, such as Herceptin and Cetuximab, have been effective in clinical trials and are now licensed. In addition, TAAs act as good surrogate markers for use in both the diagnosis and assessment of treatment in cancer patients.

Tumor Cell Vaccines

This chapter reviews the history of tumor cell vaccines, both autologous and allogeneic, as well as adjuvants used with tumor cell vaccines. The chapter discusses various tumor cell modifications that have been tested over the years. The immune response to tumor vaccines is briefly described, as are some methods of immune monitoring after vaccine therapy. Finally, there is a description of various tumor cell-based vaccines that have been tested in clinical trials.

Survival after surgical resection of isolated pulmonary metastases from malignant melanoma

BACKGROUND

The overall prognosis for patients with metastatic malignant melanoma remains poor. However, careful staging and identification of patients with limited metastatic disease offers the opportunity for surgical salvage and improved survival for selected patients.

METHODS

We reviewed the experience over the last 17 years at our institute with isolated pulmonary metastasectomy in 86 patients with advanced malignant melanoma.

RESULTS

Our data demonstrate an overall median time to relapse of approximately 8.4 months and a median survival of 35 months. The 5-year survival rate is estimated at 33%, and 16% remain continuously free of disease after a median follow-up of 35 months. Resection of properly staged and evaluated patients with limited pulmonary metastases appears to convey a significant survival benefit. Patients with a single metastasis fare best.

CONCLUSIONS

These encouraging results offer a rationale for the careful follow-up of resected patients. One third of all relapses will be limited and additional surgery contributes to their overall survival.

Can surgical therapy alone achieve long-term cure of melanoma metastatic to regional nodes?

BACKGROUND

Anecdotal reports of melanoma recurrence 15 years after complete lymphadenectomy have led to claims that the onset of nodal metastasis invariably signals systemic metastases and a terminal diagnosis. Few series in the literature are able to refute this assertion. We therefore examined rates of long-term (> 15-25 years) survival for patients with regional (nodal) melanoma.

PATIENTS AND METHODS

We performed an analysis of patients with American Joint Committee on Cancer stage III melanoma entered into a prospective database for the last 30 years. All patients were seen at the treating institution within 4 months of their diagnosis and monitored thereafter. All patients underwent complete lymphadenectomy. Patients receiving melanoma vaccines were excluded. Statistical comparisons used Chi-square analysis and the log-rank test.

RESULTS

At a maximum follow up of 386 months (32 years) for the population of 1422 patients, rates of 15-, 20-, and 25-year melanoma-specific survival were 36% +/- 1%, 35% +/- 1%, and 35% +/- 1%, respectively. When patients were stratified by clinical status of regional lymph nodes, survival rates were significantly lower (P = 0.001) if nodes were palpable. The number of tumor-positive nodes (P < 0.0001), the pathological primary tumor stage (P = 0.005), age (P = 0.0001), and gender (P = 0.002) also were significantly related to long-term survival.

DISCUSSION

Long-term survivors of melanoma metastatic to regional lymph nodes are not uncommon, and the extremely low rate of recurrence beyond 15 years suggests that this disease-free interval is usually synonymous with cure. Although some risk factors decrease the likelihood of long-term survival, the high overall rates of extended survival in all risk groups clearly support surgical management as the primary treatment for regional metastatic melanoma.

Clinical results of vaccine therapy for cancer: learning from history for improving the future

Active, specific immunotherapy for cancer holds the potential of providing an approach for treating cancers, which have not been controlled by conventional therapy, with very little or no associated toxicity. Despite advances in the understanding of the immunological basis of cancer vaccine therapy as well as technological progress, clinical effectiveness of this therapy has often been frustratingly unpredictable. Hundreds of preclinical and clinical studies have been performed addressing issues related to the generation of a therapeutic immune response against tumors and exploring a diverse array of antigens, immunological adjuvants, and delivery systems for vaccinating patients against cancer. In this chapter, we have summarized a number of clinical trials performed in various cancers with focus on the clinical outcome of vaccination therapy. We have also attempted to draw objective inferences from the published data that may influence the clinical effectiveness of vaccination approaches against cancer. Collectively the data indicate that vaccine therapy is safe, and no significant autoimmune reactions are observed even on long term follow-up. The design of clinical trials have not yet been optimized, but meaningful clinical effects have been seen in B-cell malignancies, lung, prostate, colorectal cancer, and melanoma. It is also obvious that patients with limited disease or in the adjuvant settings have benefited most from this targeted therapy approach. It is imperative that future studies focus on exploring the relationship between immune and clinical responses to establish whether immune monitoring could be a reliable surrogate marker for evaluating the clinical efficacy of cancer vaccines.

Manufacturing and Quality Control of Cell-based Tumor Vaccines: A Scientific and a Regulatory Perspective

Tumor vaccines play an increasingly important role in the therapy of various malignant diseases. The efficacy of these new products is currently being explored in many clinical trials all over the world. Cell-based tumor vaccines can be classified as somatic cell therapy, or, depending on whether genetic modifications have been applied, as gene-transfer medicinal products. Few specific guidance documents are available to standardize the development and production of cell-based tumor vaccines. Here, we review the different types of cell-based cancer vaccines that are currently being used in clinical trials. Furthermore, we discuss regulatory guidance documents available in the European Union and describe methods that have been applied so far to ensure that the cell-based vaccines meet acceptable standards, including potency assays.

Cancer vaccines as a therapeutic modality: The long trek

The development of cancer vaccines has been one of the several false dawns in which initial promising Phase I and Phase II clinical data have not been followed up with conclusive Phase III trials. In this review, we describe some of the successes and failures, and review the most likely reasons for Phase III failure, such as protocol changes, which are common between Phase II and III, and poorly defined patient groups. Nevertheless, significant survival results have been reported with autologous vaccines for colorectal, renal and, more recently, prostate cancer. In addition, it is becoming evident that immunotherapy is potentially synergistic with other treatment modalities, such as chemotherapy, which can reduce T-regulatory activity that inhibits the immune response to cancer vaccines. This potential for synergy should allow cancer vaccines to become part of the standard treatment regimen for many common tumours.

Allogeneic and autologous melanoma vaccines: where have we been and where are we going?

The past three decades have seen substantial research on vaccines for the treatment of metastatic melanoma and the prevention of recurrence following resection. Despite their enormous promise, the actual results have been disappointing, with several high-profile vaccine clinical trials failing to show a benefit. Nonetheless, enthusiasm for melanoma vaccines remains and has increased with our expanding understanding of the immune response to tumor. Cellular vaccines can be divided into autologous, derived from the patient's own tumor and allogeneic vaccines. Autologous vaccines have the advantage of containing all potentially relevant tumor-associated antigens for that particular patient. However, autologous vaccines are difficult to obtain from most patients with advanced disease and impossible to obtain from patients who present after resection of all clinically evident disease. No consensus exists for how tumors should be processed, preserved, modified, and delivered to serve as an effective vaccine. The amount of autologous tumor available is rarely enough to produce more than two or three vaccination doses, and the time between initial tumor harvest and ultimate availability of the vaccine may result in interval tumor progression that diminishes the likelihood of vaccine efficacy. All these drawbacks of autologous tumor vaccination limit its applicability and also limit the ability to test autologous vaccines in prospective trials. Allogeneic vaccines avoid many of these problems, but may not contain all of the tumor-associated antigens present on the patient's own tumor. In particular, neoantigens created by mutations in the patient's tumor would be unlikely to be represented in an allogeneic vaccine. Although allogeneic vaccines can be manufactured in sufficient quantities to allow large-scale trials, there remain significant limiting issues in the manufacture and standardization of the vaccine product.

Survival and prognostic variables of cutaneous melanoma observed between 1995 and 2000 at Istituto Dermopatico Dell'Immacolata (IDI-IRCCS), Rome, Italy

INTRODUCTION

Melanoma is an increasingly common malignancy of melanocytes, with incidence rates steadily rising over the past several decades. The objective of this study was to evaluate 5-year survival and to investigate the association between melanoma mortality and clinical and histological features.

METHODS

We conducted a 5-year cohort study among 1020 patients from the same geographic area (Rome) with a single primary cutaneous melanoma diagnosed between January 1995 and December 2000. Survival probability was determined by Kaplan-Meier estimates, and prognostic factors were evaluated by multivariate analysis (Cox proportional hazards model).

RESULTS

Survival decreased with increasing age (P for trend <0.049) and Breslow thickness (P for trend <0.0001). In the multivariate Cox model, Breslow thickness was the only independent prognostic factor for mortality in primary melanoma patients. The risk of death among patients with melanoma increased with increasing tumour thickness 0.76-1.49 mm (relative risk (RR) 2.67, 95% confidence interval (95% CI) 0.63-11.4); 1.50-4.0 mm (RR 6.38, 95% CI 1.75-23.2), >4.0 mm (RR 34.6, 95% CI 8.23-145.7) (P for trend <0.0001). The Years of Life Lost (YLLs) for the Breslow categories < or =0.75 mm, 0.76-1.49 mm, 1.50-4.0 mm and >4.0 mm were 65.4, 153.6, 274.3 and 317.6 years, respectively.

CONCLUSION

This study shows the great importance of secondary melanoma prevention and illustrates how many years of life could be saved by early diagnosis.

Therapeutic vaccines for melanoma: current status

Considerable clinical research is focused on improving systemic treatments for melanoma. Unfortunately, the disease is generally resistant to standard chemotherapy, and surgical excision remains the best treatment option whenever possible. However, complete spontaneous regression of melanoma has been observed in some patients, a phenomenon thought to be mediated by the immune system. This has stimulated attempts to manipulate the immune system for therapeutic purposes. Vaccination is a form of active specific immunotherapy, such that the response against the tumor is actively generated by the patient's immune system, and is directed against a particular cellular target or specific membrane antigen. Numerous approaches to vaccination for melanoma have been investigated, and have become more complex as our understanding of anti-tumor immunity has increased. Vaccines have been shown to induce measurable immunologic responses that may be correlated with improved clinical outcomes in patients with melanoma. Large phase III clinical trials using peptide, ganglioside, and whole-cell tumor antigens are ongoing. Although anti-tumor vaccination has shown promising results in patients with melanoma, to date no vaccine has been approved for routine therapy of melanoma. Recently, a phase III trial evaluating the Canvaxin whole-cell vaccine in stage IV melanoma was halted because of a low likelihood of significant benefit. However, a larger phase III trial for patients with stage III disease was continued and results are awaited with interest.

American Joint Committee on Cancer Clinical Stage as a Selection Criterion for Sentinel Lymph Node Biopsy in Thin Melanoma

BACKGROUND

A significant proportion of newly diagnosed melanomas are thin lesions (< or = 1.00 mm). Because tumor thickness correlates with the risk for nodal metastases, sentinel lymph node (SLN) biopsy in this subset is controversial. Incorporating other prognostic factors (Clark level and ulceration), we evaluated the 6th edition American Joint Committee on Cancer (AJCC) clinical stage as a simple and widely applicable guideline for offering SLN biopsy for thin melanoma.

METHODS

This study was a review of a prospective melanoma SLN database from 1993 to 2003 with emphasis on SLN positivity rates based on the 6th edition AJCC primary tumor thickness intervals and clinical stage.

RESULTS

Three hundred five patients underwent SLN biopsy, with an overall positivity rate of 17.7%. By the 6th edition AJCC, lesions < or = 1.00 mm had an SLN positivity rate of 6.6%. By 6th edition clinical stage, SLN positivity rates were 4.9% for stage IA and 10.4% for stage IB. By using stage IA as the criterion for not offering SLN biopsy, this procedure would have been avoided in 46% (39 of 85) of < or = 1.00-mm melanoma patients with a negative SLN.

CONCLUSIONS

Sixth edition AJCC clinical stage IB as a selection criterion for performing SLN biopsy in thin melanoma identifies most patients with a positive SLN while also avoiding a negative SLN biopsy in many patients. Until additional widely accepted and validated selection criteria are available, SLN biopsy for clinical stage IB, but not stage IA, thin melanomas is a reasonable approach.

Survivin expression by metastatic melanoma predicts poor disease outcome in patients receiving adjuvant polyvalent vaccine

Survivin and livin are members of the inhibitor of apoptosis protein (IAP) family. We hypothesized that elevated expression levels of these 2 IAP genes in resected advanced-stage metastatic melanoma lesions would be associated with poor disease outcome in patients receiving a polyvalent therapeutic cancer vaccine (Canvaxintrade mark). A quantitative real-time RT-PCR (qRT) assay for survivin and livin genes was used to assess mRNA expression in 63 metastatic melanomas obtained during cytoreductive surgery of American Joint Committee on Cancer (AJCC) stage IV melanoma. Nineteen of 63 metastatic melanoma patients received Canvaxin pre- and postoperatively, and 37 patients received only postoperative Canvaxin. Expression of survivin and livin protein was assessed by immunohistochemistry (IHC) and then correlated with mRNA. Survivin mRNA was detected in 62 of 63 (98%) melanoma specimens ranging from 0-5.96 x 10(4) mRNA copies of total RNA. Lower mRNA copy levels of survivin significantly correlated with improved overall survival among the 37 patients who received Canvaxin postoperatively but not preoperatively (log-rank test, p = 0.023). Among patients with low survivin mRNA copies, those who received postoperative Canvaxin did significantly better than patients who received pre- and postoperative Canvaxin (p = 0.003). Livin mRNA was detectable in 60 of 63 (95%) metastatic melanoma specimens but had no significant prognostic utility. These studies demonstrate that lower levels of survivin in recurrent metastatic melanomas are associated with significantly improved survival in patients receiving postoperative adjuvant immunotherapy. Overall, the study indicates survivin expression in metastatic melanomas can significantly influence disease outcome and patient responses to immunotherapy.

Endogenous immune response to gangliosides in patients with confined prostate cancer

Our study investigated whether endogenous IgM antibodies to gangliosides occur in patients with early stages of prostate cancer (CaP) patients, after defining ganglioside profiles of CaP cell lines. Immune and resorcinol staining detected the presence of gangliosides GM3, GM2, GD3, GD2 and GD1a but not GM1a, GD1b or GT1b in the extracts of normal prostatic epithelial cells (PrEC) and neoplastic androgen-insensitive (PC-3, DU145) and -sensitive (LNCaP-FGC and LNCaP-FGC-10) CaP cells. Using a sensitive ELISA, developed and validated in our laboratory, the titers of IgM against 8 gangliosides from sera of patients with benign prostatic hyperplasia (BPH) (n = 11), organ-confined (T1/T2, n = 36) and unconfined (T3/T4, n = 27) CaP and age-matched healthy men (n = 11) were determined double-blinded. Using ANOVA and Fisher's least significant difference (LSD) methods, the log-titers among different groups were compared. CaP patients differed from healthy and BPH patients in increased titers against GD1a and decreased titers against GD3. Titers of antibodies to other gangliosides exhibited no difference between CaP patients and others. The specific augmentation of anti-GD1a IgM in patients with organ-confined CaP (stage T1/T2) but not in patients with unconfined CaP (stage T3/T4) or BPH or in healthy controls is striking. This finding together with identification of GD1a as a major ganglioside in CaP cell lines and with the accruing studies on the immunosuppressive nature of GD1a indicates that augmentation of anti-GD1a IgM in confined CaP may signify an early endogenous immune response to eliminate a "danger signal" from tumor microenvironment and circulation.

Adjuvant treatment of malignant melanoma: where are we?

To date, no standard adjuvant therapy have increased overall survival in patients with malignant melanoma (MM). The effect of interferon alpha as a single agent or in combination has been widely explored in clinical trials. Critical reading of the major international randomised trials showed that response to interferon (IFN) in terms of improvement of overall survival (OS) may not be strictly correlated with the used dosage and that duration of therapy may impact disease-free survival (DFS) but not OS. Patients' heterogeneity could be an explanation for the discordant data of the international literature. Indeed, majority of these studies started in late 1980s or early 1990s, when accurate staging procedure were not available yet. The adequate surgical treatment should be considered as an independent variable in the analysis of MM adjuvant protocols. Considering the treatment cost, which is the main goal: DFS, OS or quality of life? Answering these questions is difficult, but some considerations must be taken to put order in this field. Putting together data from all different studies, IFN therapy seems to protect MM patients from recurrences during the entire treatment period and a prolonged IFN therapy seems to improve DFS. The only positive result on OS was demonstrated for high-dose IFN (HD-IFN) in a single study (presenting a relatively short follow-up median) and not confirmed in a subsequent study from the same authors. Considering that low-dose interferon (LD-IFN) is tolerated much better than HD-IFN (about 10% versus more than 70% of cases with grade 3-4 toxicity, respectively), a prolonged LD-IFN (more than 2 years) may represent a reasonable opportunity for MM patients, also considering its advantageous cost-effectiveness. Conversely, considering the improvement of OS as the main target of MM adjuvant therapy, the "wait and watch" attitude remains the only approach to be pursued at present. It is a physician's choice.

Melanoma of the head and neck

Staging of cutaneous melanoma has changed in recent years with an increased emphasis upon thickness and ulceration on prognosis of early stage disease. Cutaneous melanoma of the head and neck is treated with complete surgical resection in early stage disease. Resection margins are determined by the size, depth, and presence of satellite lesions. Evaluation for regional and distant metastatic disease is necessary in all cases of advanced stage disease. Sentinel lymph node biopsy and possible parotidectomy and neck dissection should be considered in head and neck cutaneous melanomas greater than 1 mm in thickness or with ulceration. Adjuvant therapy may be indicated in advanced primary, nodal, and metastatic disease. Mucosal melanoma of the head and neck remains a difficult disease to treat, with high locoregional recurrence rates and poor prognosis despite aggressive therapy.

Phase I/II study of immunotherapy with T-cell peptide epitopes in patients with stage IV melanoma

Previous studies in small groups of patients suggested that immunization of melanoma patients with peptide epitopes recognized by T cells could induce regression of melanoma. This approach was tested in 36 patients with stage IV melanoma. The (MHC class I-restricted) peptides were from gp100, MART-1, tyrosinase, and MAGE-3. The gp100 and MART-1 peptides had been modified to increase their immunogenicity. In half the patients (groups 3 and 4) the peptides were given in the adjuvant Montanide-ISA-720, and half the patients in both groups were given GM-CSF s.c. for 4 days following each injection. Treatment was well tolerated except for two severe erythematous responses to Montanide-ISA-720 and marked inflammatory responses at sites of GM-CSF administration in three patients. There were no objective clinical responses but stabilization of disease for periods from 3 to 12 months were seen in seven patients. Five of these were patients given the peptides in Montanide-ISA-720. Delayed-type hypersensitivity (DTH) skin test responses were also seen mainly in the patients given the peptides in Montanide-ISA-720. GM-CSF did not increase DTH responses in patients in the latter group but may have increased DTH responses in those not given peptides in Montanide-ISA-720. Inflammatory responses around s.c. metastases or regional lymph nodes were observed in two patients. These results suggest that the peptides are more effective when given in the adjuvant Montanide-ISA-720. Nevertheless, results from this study, together with those from a number of comparable studies, indicate that peptide vaccines are currently of minimal benefit to patients and support the need for ongoing development of new strategies in treatment of this disease.

Surgical treatment of stage IV melanoma

Surgical therapy plays an important role in the management of selected patients with metastatic melanoma. Patients are frequently symptomatic from metastatic lesions, have few effective therapeutic options, and are faced with dismal outcomes. Surgical resection may provide successful palliation of symptomatic lesions with low morbidity and operative mortality. In carefully selected patients, resections performed with curative intent may result in improved survival if a pattern of disease recurrence suggestive of favorable tumor biology is present, and if complete resection of tumor is achieved. Because the majority of post-surgical metastatic patients eventually relapse and succumb to distant disease, adjuvant immunotherapeutic strategies are currently being evaluated.

Melanoma vaccines

Melanoma vaccines offer new hope to patients with metastatic melanoma, although convincing survival advantages have yet to be reported. This review outlines the progress made in this exciting field of research and looks ahead to the future.

T-cell-based immunotherapy of melanoma: what have we learned and how can we improve?

The lack of effective treatment for advanced stage melanoma by conventional therapies, such as radiation and chemotherapy, has highlighted the need to develop alternative therapeutic strategies. Among them, immunotherapy has attracted much attention because of the potential role played by immunological events in the clinical course of melanoma and the availability of well-characterized melanoma antigens to target melanoma lesions with immunological effector mechanisms. In recent years, T-cell-based immunotherapy has been emphasized, in part because of the disappointing results of the antibody-based trials conducted in the early 1980s, and in part because of the postulated major role played by T-cells in tumor growth control. In this review, the characteristics of antibody and T-cell-defined melanoma antigens will first be described, with emphasis on those used in clinical trials. Following a review of the current immunization and immunomonitoring strategies, the results from the T-cell-based immunotherapy clinical trials conducted to date will be reviewed.

Gangliosides of organ-confined versus metastatic androgen-receptor-negative prostate cancer

Prior development of a unique androgen-receptor (AR)-negative cell line (HH870) from organ-confined (T2b) human prostate cancer (CaP) enabled comparison of the gangliosides associated with normal and neoplastic prostate epithelial cells, organ-confined versus metastatic (DU 145, PC-3), and AR-negative versus AR-positive CaP cell lines. Resorcinol-HCl and specific monoclonal antibodies were used to characterize gangliosides on 2D-chromatograms, and to visualize them on the cell surface with confocal-fluorescence microscopy. AR-negative cells expressed GM1b, GM2, GD2, GD1a, and GM3. GM1a, GD1b, and GT1b were undetectable. GM1b and GD1a were more prominent in AR-negative than in AR-positive cells. PC-3 and HH870 cells were unique in the expression of O-acetylGD2 (O-AcGD2) and two alpha2,3-sialidase-resistant, alkali-susceptible GMR17-reactive gangliosides. Expression of GD1a, GM1b, doublets of GD3, GD2, and O-AcGD2, and the presence of an additional alkali-labile-14.G2a-reactive ganglioside, two alkali-susceptible, and three alkali-resistant GMR17-reactive gangliosides makes HH870 a potential component of a polyvalent-vaccine for active-specific immunotherapy of CaP.

Surgical management of primary anorectal melanoma

BACKGROUND

This aim of this study was to analyse outcome after surgery for primary anorectal melanoma and to determine factors predictive of survival.

METHODS

Records of 40 patients treated between 1977 and 2002 were reviewed.

RESULTS

Twelve men and 28 women of mean age 58.1 (range 37-83) years were included in the analysis. Overall and disease-free survival rates were 17 and 14 per cent at 5 years. Median overall survival was 17 months and disease-free survival was 10 months. The 5-year survival rate was 24 per cent for patients with stage I tumours, and zero for those with stage II or stage III disease. There was no significant difference in overall survival after wide local excision (49 and 16 per cent at 2 and 5 years respectively) and abdominoperineal resection (33 per cent at both time points). In patients with stage I and stage II disease, there was a significant association between poor survival and duration of symptoms (more than 3 months), inguinal lymph node involvement, tumour stage and presence of amelanotic melanoma.

CONCLUSION

Anorectal melanoma is a rare disease with a poor prognosis. Wide local excision is recommended as primary therapy if negative resection margins can be achieved.

Incidence of BRAF oncogene mutation and clinical relevance for primary cutaneous melanomas

PURPOSE

The purpose of the study was to clarify the incidence of B-raf oncogene (BRAF) mutations in primary cutaneous melanomas, their relation to tumor progression, and effect on disease outcome. Somatic mutations of BRAF kinase, a component of the Ras-mitogen-activated protein/extracellular signal-regulated kinase kinase-mitogen-activated protein kinase pathway, are frequently reported (>65%) in nevi and malignant melanomas.

EXPERIMENTAL DESIGN

We assessed BRAF mutation frequency in exons 11 and 15 in primary (n = 59) and metastatic (n = 68) melanomas. Direct sequencing of PCR products was performed on DNA isolated and purified from microdissected tumors.

RESULTS

Eighteen mutations (31%) at exon 15 were detected in primary melanoma with a significantly (P = 0.001) higher frequency in patients < 60 years old. Incidence of BRAF mutation did not correlate with Breslow thickness. Presence of BRAF mutation of primary tumors did not effect overall disease-free survival. BRAF mutation frequency in metastatic lesions was 57% and significantly (P = 0.0024) higher than primary melanomas.

CONCLUSIONS

The study suggests that BRAF mutation may be acquired during development of metastasis but is not a significant factor for primary tumor development and disease outcome.

Peripheral Blood CD4+ T-Cell Response Before Postoperative Active Immunotherapy Correlates with Clinical Outcome in Metastatic Melanoma

BACKGROUND

Canvaxin polyvalent specific active immunotherapeutic (CancerVax Corp., Carlsbad, CA) is a minimally toxic adjuvant after resection of regional metastatic melanoma. Because Canvaxin immunotherapeutic requires induction of an immune response, we hypothesized that survival would be directly correlated with cellular immune responses to Canvaxin cells prior to immunization.

METHODS

We randomly selected 54 patients from a study of Canvaxin therapy after complete resection of American Joint Committee on Cancer (AJCC) stage III melanoma. Peripheral blood lymphocytes (PBLs) collected before immunotherapy were co-cultured with Canvaxin cells; cellular response was determined by flow cytometric measurement of the production of intracellular interleukin 4 (IL4) or interferon gamma (IFNgamma) by CD4(+) T-cells. Results were calculated as percent positive for double staining of CD4(+) plus IL4(+) or CD4(+) plus IFNgamma(+).

RESULTS

The mean (+/- SD) increase in cytokine-producing CD4(+) T-cells after Canvaxin stimulation was 4.8 +/- 2.3% for an IFN response and 5.1 +/- 2.0% for an IL4 response. Both increases were significantly correlated with overall survival by univariate analysis (P = .0471 for IFNgamma and 0.002 for IL4). There was no significant correlation between unstimulated IFNgamma/IL4 responses and overall survival. Multivariate analysis showed that a CD4(+) T-cell IL4 response before Canvaxin therapy was a significant independent prognostic variable.

CONCLUSIONS

In vitro cellular immune response to Canvaxin cells directly correlates with survival after subsequent initiation of immunotherapy for AJCC stage III melanoma. This finding will be evaluated in a multicenter phase III trial of Canvaxin plus bacille Calmette-Guerin (BCG) versus placebo plus BCG after resection of stage III melanoma.

Allogeneic vaccination with a B7.1 HLA-A gene-modified adenocarcinoma cell line in patients with advanced non-small-cell lung cancer

PURPOSE

To determine the safety, immunogenicity, and clinical response to an allogeneic tumor vaccine for non-small-cell lung cancer, we conducted a phase I trial in patients with advanced metastatic disease.

PATIENTS AND METHODS

We treated 19 patients with a vaccine based on an adenocarcinoma line (AD100) transfected with B7.1 (CD80) and HLA A1 or A2. Patients were vaccinated intradermally with 5 x 10(7) cells once every 2 weeks. Three vaccinations represented one course of treatment. If patients had complete response, partial response, or stable disease, they continued with the vaccinations for up to three courses (nine vaccinations). Immune response was assessed by a change between pre-study and postvaccination enzyme-linked immunospot frequency of purified CD8 T-cells secreting interferon-gamma in response to in vitro challenge with AD100.

RESULTS

Four patients experienced serious adverse events that were unrelated to vaccine. Another four patients experienced only minimal skin erythema. All but one patient had a measurable CD8 response after three immunizations. The immune response of six surviving, clinically responding patients shows that CD8 titers continue to be elevated up to 150 weeks, even after cessation of vaccination. Overall, one patient had a partial response, and five had stable disease. Median survival for all patients is 18 months (90% CI, 7 to 23 months), with corresponding estimates of 1-year, 2-year, and 3-year survival of 52%, 30%, and 30%, respectively. HLA matching of vaccine, age, sex, race, and pathology did not bear a significant relation to response.

CONCLUSION

Minimal toxicity and good survival in this small population suggest clinical benefit from vaccination.

Antigen-based immunotherapy of melanoma: Canvaxin therapeutic polyvalent cancer vaccine

As yet there are no FDA-approved cancer vaccines for malignant melanoma, but encouraging response rates and low toxicities reported in phase I/II trials suggest that antigen-based active immunotherapy may complement current treatment modalities. The cumulative data for Canvaxin therapeutic polyvalent cancer vaccine represent the largest phase II clinical trial of any cancer vaccine. Univariate and multivariate analyses of these data have demonstrated the prognostic significance of this allogeneic whole-cell preparation as a postoperative adjuvant treatment for patients with stage III and IV melanoma. The vaccine has also been shown promising results after resection of stage II melanoma and in patients with regional in-transit disease. The consistent correlation between immune and clinical responses to the vaccine suggests that immune parameters may be used to monitor a patient's response to vaccine therapy.

Tumor antigens for cancer immunotherapy: therapeutic potential of xenogeneic DNA vaccines

Preclinical animal studies have convincingly demonstrated that tumor immunity to self antigens can be actively induced and can translate into an effective anti-tumor response. Several of these observations are being tested in clinical trials. Immunization with xenogeneic DNA is an attractive approach to treat cancer since it generates T cell and antibody responses. When working in concert, these mechanisms may improve the efficacy of vaccines. The use of xenogeneic DNA in overcoming immune tolerance has been promising not only in inbred mice with transplanted tumors but also in outbred canines, which present with spontaneous tumors, as in the case of human. Use of this strategy also overcomes limitations seen in other types of cancer vaccines. Immunization against defined tumor antigens using a xenogeneic DNA vaccine is currently being tested in early phase clinical trials for the treatment of melanoma and prostate cancers, with proposed trials for breast cancer and Non-Hodgkin's Lymphoma.

Heated tumour cells of autologous and allogeneic origin elicit anti-tumour immunity

Vaccination with established tumour cell lines may circumvent the problem of obtaining autologous tumour cells from patients, but may also need immunological adjuvants. Up-regulation of heat shock proteins within tumour cell vaccines has resulted in increased immunogenicity in some models, but this has yet to be demonstrated for allogeneic (MHC-disparate) cell vaccines. This was investigated here using a rat model for prostate tumour cell vaccination. Heating of tumour cells (42 degrees C, 1 h) elicited significant increases in HSP70 expression. Vaccination with heated autologous PAIII cells elicited protection against PAIII challenge in 60% of rats >50 days compared to 0% with unheated vaccine and was associated with an increased Th1 (IFNgamma) immune response. Heated allogeneic MLL cells elicited significant protection against PAIII challenge, in contrast to unheated cells. The principle was confirmed in two mouse models, although the allogeneic melanoma vaccine K1735 elicited the best protection when heated and administered mixed with autologous dendritic cells. Thus, while heating of vaccine cells in some models is highly beneficial, and is a means of enhancing immunogenicity without genetic modification or inclusion of potentially toxic adjuvants, additional immune enhancement may be required.

Melanoma

The incidence of malignant melanoma in the UK is still rising despite public health warnings about the risks of excessive sun exposure. This aggressive tumour can metastasize to virtually any organ, even years after resection of the primary lesion and cause a variety of radiological appearances. This review provides examples of both typical and non-specific imaging features of melanoma metastases, as well as examples of primary choroidal melanoma.

Lymphatic mapping and sentinel lymphadenectomy for early-stage melanoma: therapeutic utility and implications of nodal microanatomy and molecular staging for improving the accuracy of detection of nodal micrometastases

OBJECTIVE

Lymphatic mapping and sentinel lymphadenectomy (LM/SL) have been applied to virtually all solid neoplasms since our original description of LM/SL for melanoma. Our objectives were to determine the diagnostic and therapeutic utility of LM/SL, investigate carbon dye for mapping the microanatomy of lymphatic flow within the sentinel node (SN), and determine the prognostic accuracy of molecular assessment of the SN.

METHODS

Since 1985, 1599 patients with AJCC Stage I/II melanoma have been treated by LM/SL at our institution and 4590 have been treated by wide excision (WE) without nodal staging. We examined the incidence of clinical nodal recurrence after WE alone, the incidence of subclinical nodal metastases found by LM/SL, and the incidence of nodal recurrence in basins with histopathology-negative SNs.

RESULTS

In 1514 LM/SL patients with a primary of known Breslow thickness, the incidence of metastasis in nodes claimed to be sentinel was 7.3%, 19.7%, 33.2%, and 39.7% for primary lesions 4.0 mm, respectively. In 3652 WE-only patients, the corresponding rates of nodal recurrence were 12.0%, 32.0%, 34.4%, and 30.1%. Thus, LM/SL detected only 60% of expected nodal metastases from primary melanomas <2.01 mm. Forty of 1599 (3.1%) patients developed recurrence in basins with immunohistochemistry (IH)-negative SNs. To determine whether nonrandom intranodal distribution of tumor cells could explain missed SN metastases, we coinjected carbon particles and blue dye during LM/SL in 166 patients: 25 (16%) patients had nodal metastases, all of which were found only in nodal subsectors containing carbon particles. When paraffin-embedded SNs from a subset of 162 IH-negative patients were re-examined by quantitative multimarker reverse-transcriptase polymerase chain reaction (qRT) assay, 49 (30%) gave positive signals. These patients had a significantly higher risk of disease recurrence and death than did patients whose IH and qRT results were negative (p < 0.0001). Comparison of 287 prognostically matched pairs of patients who underwent immediate (after LM/SL) versus delayed (after observation) dissection of nodal metastases revealed 5-, 10-, and 15-year survival rates of 73%, 69%, and 69% versus 51%, 37%, and 32%, respectively (P < or = 0.001).

CONCLUSIONS

SN assessment based on intranodal compartmentalization of lymphatic flow (carbon dye mapping) should increase the accuracy of IH and, in combination with multimarker qRT assessment, will allow confident identification of most patients for whom surgery alone is curative. Our data suggest a significant therapeutic benefit for immediate dissection based on identification of a tumor-involved SN.

Cancer vaccines: between the idea and the reality

Whether vaccines are designed to prepare the immune system for the encounter with a pathogen or with cancer, certain common challenges need to be faced, such as what antigen and what adjuvant to use, what type of immune response to generate and how to make it long lasting. Cancer, additionally, presents several unique hurdles. Cancer vaccines must overcome immune suppression exerted by the tumour, by previous therapy or by the effects of advanced age of the patient. If used for cancer prevention, vaccines must elicit effective long-term memory without the potential of causing autoimmunity. This article addresses the common and the unique challenges to cancer vaccines and the progress that has been made in meeting them. Considering how refractory cancer has been to standard therapy, efforts to achieve immune control of this disease are well justified.

Molecular tumor markers in the blood: early prediction of disease outcome in melanoma patients treated with a melanoma vaccine

PURPOSE

Patients with American Joint Committee on Cancer (AJCC) stage III melanoma are at high risk of recurrence and death. We hypothesized that a multiple-marker reverse transcriptase polymerase chain reaction (MM-RT-PCR) blood assay could predict, early in the course of therapy, those patients destined to experience treatment failure with a melanoma vaccine (MV) previously shown to improve survival in a phase II clinical trial.

PATIENTS AND METHODS

After complete surgical resection, prospectively collected cryopreserved peripheral-blood lymphocyte specimens (n = 90) from the serial bleeds of 30 patients with AJCC stage III melanoma were studied by MM-RT-PCR, using the markers tyrosinase, melanoma antigen recognized by T cells-1 (MART-1), and universal melanoma antigen gene-A (uMAG-A). All patients were enrolled in a phase II MV trial during the period of blood draws, and were selected for this study in a blinded fashion. Median duration of clinical follow-up was 74 months for the 13 survivors and 11 months for the 17 nonsurvivors.

RESULTS

The presence of at least one melanoma-specific RT-PCR marker was associated with an increased risk of disease recurrence (risk rate, 3.12; P =.02) and decreased risk of survival (relative rate, 2.62; P =.0496) by multivariate analysis.

CONCLUSION

MM-RT-PCR of the blood provided early prediction of subsequent disease recurrence and death in clinically disease-free AJCC stage III melanoma patients enrolled in a MV phase II trial. On the basis of the results of this pilot study, the MM-RT-PCR blood assay should be considered as a clinically important monitoring tool for assessing patient response to adjuvant therapy, and in the surveillance of clinically disease-free patients for the earliest signs of recurrence.

Melacine: an allogeneic melanoma tumor cell lysate vaccine

Cancer vaccines have represented the holy grail of tumor immunology to many. In 2003, there are innumerable approaches to active specific immunotherapy for cancer. The identification of tumor antigens recognized by and able to activate human T-lymphocytes has heightened the enthusiasm for this approach. Melanoma is one of the diseases that has been primarily targeted by vaccine approaches. The identification of peptides and proteins associated with cancer has provided strategies to target specific components of the cancer cell. However, older vaccines utilizing products from whole cells may have a number of advantages. Melacine (Corixa Corp.) is an allogeneic melanoma tumor cell lysate combined with the adjuvant DETOX. Pioneered by Malcolm Mitchell, it has rare but confirmed antitumor activity in metastatic melanoma (5-10%). However, previous analysis of responses in advanced disease and a recent analysis in early-stage adjuvant trials suggest that Melacine may have its greatest benefit in a large subset of melanoma patients who express either the human leukocyte antigen (HLA) class I antigens A2 and/or HLA-C3. This finding must now be confirmed in a large perspective observation-controlled clinical trial to solidify the role of Melacine as an effective cancer vaccine in melanoma.