Combination therapy with interleukin-2 and alpha-interferon for the treatment of patients with advanced cancer

Biologic therapy of melanoma with cytokines and lymphocytes

Melanoma has a somewhat unpredictable behavior, and spontaneous regressions do occasionally occur. Many have surmised that these are the result of immunologic attack by the host. Immunologic treatment has been more successful for melanoma than for most other neoplasms, even with relatively crude therapies, such as bacterial products. With the availability of recombinant cytokines, immunotherapy for melanoma has entered a new era. Interleukin-2 (IL-2), which acts entirely through immunologic mechanisms, has been tested extensively, either alone, in combination with other cytokines, or with adoptive cellular therapy. Alone, it has only modest antitumor activity, even at high doses. Its utility may be greater when combined with immunocompetent cells, especially tumor-sensitized T lymphocytes, in adoptive immunotherapy. On the other hand, nonspecific lymphokine-activated killer (LAK) cells do not appear to add significantly to the efficacy of IL-2 alone. Interferon-alpha (IFN-alpha) [corrected] also has had fairly limited activity in the advanced disease setting, but, on the basis of a recently completed randomized trial, has arguably become the "standard of care" in the adjuvant setting for patients with high-risk melanoma, particularly node-positive patients. A number of regimens combining IL-2, IFN-alpha, and chemotherapeutic agents have yielded striking response rates in small trials and await confirmation in larger studies. With better delineation of the host immune response and definition of relevant tumor antigens, we can look forward to exciting results with combinations of vaccines, cytokines, and adoptive cellular approaches, particularly in patients with micrometastatic disease.

Renal cell carcinoma metastatic to the lung: potential benefit in the combination of biological therapy and surgery

PURPOSE

We evaluated outcomes in cases of renal cell carcinoma metastatic to the lung treated with surgery or biological therapy followed by surgery.

MATERIALS AND METHODS

We retrospectively evaluated 22 patients treated with surgical resection and 29 treated with biological therapy followed by surgery.

RESULTS

At the time of this study 31 patients (61%) were alive, including 15 with no residual disease and 16 with disease. Of the 22 patients treated with surgery without initial biological therapy 12 (55%) were alive at a median followup of 57 months (range 17 to 148) and 19 of the 29 (66%) treated with combination therapy were alive at a median followup of 48 months (range 19 to 78). A total of 19 patients (37%) died of progressive disease.

CONCLUSIONS

Our results suggest a role for an aggressive surgical approach in select patients with metastatic renal cell carcinoma, and demonstrate that patients who do not achieve a complete response to biological therapy may benefit from surgical resection of residual disease.

Treatment of metastatic melanoma with combined chemotherapy containing cisplatin, vinblastine and dacarbazine (CVD) and biotherapy using interleukin-2 and interferon-alpha

BACKGROUND

Metastatic melanoma is commonly treated with chemotherapy and/or biological agents used separately. In this study we have investigated the efficacy of combined chemotherapy using cisplatin, vinblastine, DTIC (CVD) and biological therapy using interleukin-2 (IL-2) and interferon-alpha (IFN-alpha) in patients with metastatic melanoma.

PATIENTS AND METHODS

All patients had advanced, inoperable melanoma without prior treatment with chemotherapy or biotherapy, a performance status of ECOG 0-2 and no evidence of symptomatic brain metastases. The CVD regimen consisted of cisplatin 20 mg/m2/d x 4, vinblastine 1.6 mg/m2/d x 5 and DTIC 800 mg/m2 x 1, repeated at 21-day intervals. The biotherapy regimen included IL-2, 9 x 10(6) IU/ m2/d x 4 days and IFN-alpha 5 x 10(6) U/m2/d SC x 5 days. The CVD and biotherapy regimens were integrated initially, in an alternating manner at 6-week intervals and subsequently, in a sequential fashion where patients were randomized to receive either CVD immediately followed by biotherapy (CVD/Bio) or the reverse sequence (Bio/CVD). Patients were admitted to the hospital for IL-2 administration and for monitoring and treatment of IL-2 induced side effects. The phase II results of the integrated therapy (biochemotherapy) studies were retrospectively compared to our previously reported results with the CVD regimen used alone.

RESULTS

The alternating biochemotherapy program was used in 40 patients and the sequential biochemotherapy was used in 62 patients. The alternating regimen produced 2 CRs and 11 PRs for an overall response rate of 33% among 39 evaluable patients. The sequential biochemotherapy produced 14 CRs and 23 PRs for an overall response rate of 60% (95% CI, 47% to 72%). The sequence of CVD/Bio resulted in a higher response rate (11 CRs + 11 PRs (69%)) compared to the Bio/CVD sequence (3 CRs + 12 PRs (50%)). Although the duration of PRs was short (median, 8 months), the median duration of CRs was 3+years and 10 of 16 CRs are currently disease free for periods of 3+ to 6+ years. The median survival of patients receiving sequential biochemotherapy was 13 months compared to 9 months for the CVD treated group (P = 0.04). Treatment with biochemotherapy was associated with severe toxicity including intense myelosuppression, infections, IL-2 induced constitutional toxicity and hypotension. However, the IL-2 induced toxicities were generally manageable on a regular ward, except for 15% of the patients who required transfer to an intensive care unit for treatment of complications associated with the treatment.

CONCLUSIONS

The sequential combination of CVD with IL-2 + IFN-alpha appears to have produced an increase in the number of durable responses in patients with metastatic melanoma. The toxicity of this program, although severe, was manageable. The biochemotherapy regimen produced an apparent increase in the median survival compared to that observed with the CVD regimen. However, a prospective comparison of these two regimens will be required to confirm these observations.

Dose efficacy study of two schedules of high-dose bolus administration of interleukin 2 and interferon alpha in metastatic melanoma

Forty-three patients with metastatic melanoma were treated with a 5 day (18 patients) and a 3 day (25 patients) schedule of high-dose IL-2 11.7 MIU m2 and IFN-alpha 3 MIU m2 i.v. by bolus administration every 8 h, repeated every 21 days for a total of three courses. The 5 day schedule resulted in a high response rate of 41% (CI 18-67%), but was accompanied by severe cardiotoxicity (41%) and central nervous system toxicity (28%). The 3 day schedule was associated with manageable toxicity, but yielded a moderate response rate of 20% (CI 7-43%).

Fluoxiuridine (FUDR) chronoinfusion and Interferon for treatment of metastatic renal carcinoma

Fluoxiuridine (FUDR) chronoinfusion through a subcutaneous pump seems to give a 24% objective response rate with mild side effects. From April 1992 to December 1993 we included 18 patients with metastatic renal cell cancer and good performance status (ECOG 0-2) in a phase II study. In our experience we observed a 16% objective response rate without any major side effect. Based on these results we suggest a phase III prospective randomized study.

A phase II study of dacarbazine, cisplatin, interferon-alpha and high-dose interleukin-2 in 'poor-risk' metastatic melanoma

Melanoma patients with very advanced disease have usually not been included in chemo-immunotherapy trials. We report on 22 melanoma patients, including 5 with reduced performance status (Karnofsky PS < 70), 8 with metastatic ocular melanoma, 6 with brain metastases, and 4 who had pretreatment with interleukin-2. These were treated with a combination regimen of dacarbazine (250 mg/m2, days 1-3), cisplatin (30 mg/m2, days 1-3), interferon-alpha 2a (IFN-alpha, 10 Mio IU/m2 s.c., days 1-5) and IL-2 (i.v., 18 Mio IU/m2 for 6, 12, 24 h, followed by 13.5 Mio IU/m2 in 72 h). In the case of brain metastases radiotherapy was added. No grade IV toxicity occurred and no dose reductions were necessary. 21 patients were evaluable for response. 6 (29%) had disease progression, 5 (24%) had partial response and 10 (48%), had stable disease. Sites of response included skin, lymph nodes, muscle, lung, pleura, liver, pancreas, adrenal gland and brain. The described treatment schedule is safe and active even in patients with metastatic melanoma and poor prognosis.

Consolidation biochemotherapy for patients with advanced nonsmall cell lung carcinoma responding to induction PVM (cisplatin, vinblastine, mitomycin-C) regimen. A phase II study

BACKGROUND

The authors investigated a consolidation biochemotherapy program with subcutaneous recombinant interleukin-2 (rIL-2) and recombinant interferon-alpha (rIFN alpha) biologic response modifiers (BRM) in patients with advanced nonsmall cell lung carcinoma (NSCLC) with responsive or stable disease to induction chemotherapy.

METHODS

Patients with proven, advanced, previously untreated NSCLC were entered into the study. Induction chemotherapy consisted of cisplatin, 120 mg/m2 intravenously (i.v.), on Day 1; vinblastine, 6 mg/m2 i.v., on Day 1; and mitomycin-C, 6 mg/m2 i.v., on Day 1 (PVM), every 3 weeks. Subsequently, patients with complete response (CR), partial response (PR), and stable disease (SD) received consolidation biochemotherapy with subcutaneous rIL-2, 3 MU/m2 twice/day, and rIFN alpha, 3 MU once/day, 5 days a week, starting 2 weeks after the second PVM course. After 3 and 6 weeks of BRM treatment, patients had a 14-day rest period to intercalate consolidating PVM courses.

RESULTS

Seventy-seven patients were enrolled in the trial. After 2 PVM induction courses, 16 patients progressed and went off the study, whereas 61 patients were eligible for consolidation biochemotherapy. Among the 61 patients, 9 were not treated with BRM for several reasons, whereas 52 patients began biochemotherapy and were evaluable for toxicity. Furthermore, a few days after starting BRM, 9 patients discontinued therapy due to side effects; the remaining 43 patients received adequate treatment and were fully evaluable. In the 52 evaluable patients, the following BRM related toxicities were observed: World Health Organization (WHO) grade 2-3 fever in 85% of patients, asthenia in 71%, anorexia in 63%, and flu-like syndrome in 18.5%. PVM-related vomiting was present in 19% of patients. WHO Grade 3-4 myelosuppression, from both BRM and PVM (overlapping toxicity), was anemia in 16% of patients, leukopenia in 12%, and thrombocytopenia in 19%. There were three toxic deaths: two due to BRM-induced hypotension and one from pneumonia. In the 43 fully evaluable patients (23 PR and 20 SD after induction chemotherapy), after a median of 6 weeks of biochemotherapy (range, 3-16 weeks), we observed 5 of 20 patients achieving PR from SD, and 6 of 23 with confirmed PR. In these 11 patients, the median duration of response was 21 weeks (range, 7-80 weeks). Overall response improvement was 11.6% in the 43 patients and 6.4% in the 77 total enrolled patients. Median survival was 41 weeks (range, 15-173 weeks) in the 43 patients and 38 weeks (range, 1.4-173 weeks) in the 77 patients.

CONCLUSIONS

In this study, biochemotherapy, when administered by this dose and schedule, did not offer substantial benefit although it caused significant toxicity.

Enhancement in vivo of the antiinflammatory and antitumor activities of type I interferon by association with the synthetic immunomodulator murabutide

The therapeutic efficacy of type I interferon (IFN) has been reported to vary considerably in different indications. The use of the cytokine as adjuvant therapy has been suggested to enhance its efficacy and reduce the toxicity frequently associated with long-term and high-dose administration. In this study, we have assessed the activity of type I IFN in the protection against and treatment of acute hepatitis induced in mice by the administration of concanavalin-A (ConA). At the same time, we have evaluated the efficacy of the synthetic immunomodulator murabutide when administered alone or in combination with type I IFN to protect against ConA hepatitis and in the treatment of tumors in MethA sarcoma-bearing mice. Our results demonstrate a prophylactic effect as well therapeutic effects of type I IFN and of murabutide in the inflammation-mediated model of liver damage. The use of combination therapy presented enhanced efficacy in inhibiting the ConA-induced elevation of plasma transaminases. Both compounds were found to suppress IFN-gamma mRNA accumulation in the livers of ConA treated mice. This activity is discussed with respect to the mechanism of action of the two immunomodulators. In addition, the combination of murabutide with type I IFN exhibited synergistic antitumor activity that was clearly seen in the significant regression of MethA tumors and resulted in almost 50 percent tumor-free mice. The potential clinical application of combination therapies using a cytokine and a safe immunomodulator is analyzed in terms of enhancing the cytokine efficacy and extending its use to new indications.

Direct gene transfer of a plasmid carrying the herpes simplex virus-thymidine kinase gene (HSV-TK) in transplanted murine melanoma: in vivo study

The aim of the study was to use a virus-free system to transfer the Herpes Simplex Virus-thymidine kinase (HSV-TK) gene in mice bearing melanoma tumours. B16 F1 murine melanoma cells were injected subcutaneously. On days 11 and 14, an intratumoral injection of either naked plasmid containing the HSV-TK gene (pAG0) or pAG0-lipofectamine complexes was given. Ganciclovir (120 mg/kg/day) was given for 5 days starting on day 14. Tumour weight reduction (40-50%) was observed in treated animals versus different control groups. Moreover, histopathological analysis on tumours showed large areas of cavitary necrosis (85%) in treated groups compared to controls (10%). Using a simple and safe method, the results presented here demonstrated that virus-free mediated delivery of the HSV-TK gene is efficient in vivo in murine malignant melanoma.

Natural killer cells and cancer

BACKGROUND

Natural cytotoxicity, mediated by natural killer (NK) cells and cell with lymphokine-activated killer (LAK) activity, is believed to play an important role in host anti-cancer mechanisms.

METHODS

The authors critically review recent publications on the role of natural cytotoxicity in patients with cancer.

RESULTS

In patients with cancer, several studies have noted variations in the numbers and activity of NK and cells with LAK activity in different body compartments. NK cell activity in the peripheral blood lymphocytes (PBLs) is higher than that found in lymph nodes and within tumors, and this appears to be due to the presence of suppressor factors. The natural cytotoxicity of PBLs in patients with different types of cancers varies. However, there appears to be a trend for natural cytotoxicity to be reduced in certain cancer patients, possibly related to tumor volume or dissemination. Anti-cancer treatments (e.g., surgery, hormonal modulation, radiotherapy and chemotherapy) can also result in suppression of natural cytotoxicity, although the long-term effect on response to treatment and development of metastases is at present unknown.

CONCLUSIONS

NK and LAK cells, through the use of immune biologic modifiers, have been demonstrated to have a therapeutic role in the treatment of human cancers. Further studies are required to determine the optimal dosages and combinations of chemotherapeutic agents, the timing of surgery, and the adjuvant use of immune biologic response modifiers. An increasing awareness and understanding of this field, may allow for the future development of anti-cancer therapies.

Medical treatment of advanced renal cell carcinoma: present options and future directions

The treatment of patients with metastatic renal cell carcinoma (MRCC) continues to be disappointing. A large number of hormones, chemotherapeutic agents and combinations have been tested with poor and non-reproducible results. Among the immunological treatments investigated in MRCC, the best results have been claimed with interferons (IFNs) and interleukin-2 (IL-2) and, although no randomized studies have shown higher activity than cytotoxic drugs, hormones or even no treatment, many oncologists feel it justified to consider these biologic agents the treatment of choice for this disease. Of patients treated with alpha-IFN, 15-20% achieve an objective remission and 3-5% achieve a long-lasting complete response. No substantial increase of the therapeutic activity of alpha-IFN was produced by combination with chemotherapeutic agents and gamma-IFN or tumour necrosis factor. High doses of IL-2 with or without lymphokine-activated killer cells led to successful results in about 20-30% of patients with 5-10% complete responses. More recently, less toxic regimens with lower doses of IL-2 alone or combined with alpha-IFN produce similar response rates. Many studies have clarified the importance of prognostic factors in patient selection for response and survival during treatments with IFNs and IL-2. Good performance status, a long interval from diagnosis to treatment, and only one site of disease seem to be the most important predictors for survival. Both IFNs and IL-2 appear to possess encouraging antitumour activity in patients with favourable prognostic factors, but further studies are needed to identify the treatment of choice, the optimal dose regimen and route of administration in this subgroup of patients. Patients with poor prognosis should be encouraged to enter controlled studies aimed to evaluate investigational drugs and new therapeutic methods.

Immunomodulation following chemotherapy

In the last decade, immunomodulation has emerged as a mode of therapy capable of mediating the regression of cancer in some patients. This article reviews our experience with immunomodulation following transplant and non-transplant chemotherapy. We used interferon and cyclosporine A following conventional chemotherapy in a non-transplant setting for a B16 melanoma in a murine model. This combination generated cells with MHC-unrestricted cytotoxicity. We have also used immunotherapy in the transplant setting with IL-2 activated PBSC in patients with breast cancer. Of the 28 patients treated, 20 developed GVHD and the average time to reconstitution was 12 days (comparable to a control group). This article also raises the possibility of extending immunomodulation to breast cancer patients in the nontransplant setting to induce an antitumor immune response following cytoreductive chemotherapy.

Modulation of immune parameters in patients with metastatic renal-cell cancer receiving combination immunotherapy (IL-2, IFN alpha and autologous IL-2-activated lymphocytes)

We treated 72 patients with metastatic renal-cell cancer according to 2 protocols consisting of two 5-week induction cycles of continuous i.v. high-dose interleukin-2 (IL-2), i.m. interferon-alpha (IFN alpha) and ex vivo IL-2-activated lymphocytes, followed for patients with stable disease (SD), partial response (PR) or complete response (CR) by four 4-week maintenance cycles of IL-2 and IFN alpha. Protocol 2 (55 patients) differed from protocol 1 (17 patients) in (i) the addition of IFN alpha to the first IL-2 infusions in both induction cycles; (ii) the use of Teceleukin IL-2, reconstituted with carrier protein, instead of Proleukin IL-2 without carrier protein. We classified 23 patients with CR and PR as responders (4 in protocol 1 and 19 in protocol 2) and 45 patients with SD and progressive disease as non-responders. Prior to immunotherapy, patients entered into protocol 2 already had higher IFN gamma serum concentrations, higher peripheral blood CD56-,3+ and CD8-,4+ lymphocyte numbers and lower NKK562 activity than those entered into protocol 1. These differences persisted during and after immunotherapy. In line with these observations, ex vivo IL-2-activated lymphocytes had larger proportions of CD56-,3+ and CD8-,4+ lymphocytes and lower NKK562 activity in protocol 2 than in protocol 1. Higher IL-2 serum concentrations were reached during the IL-2 infusion in protocol 2 than in protocol 1. In addition, the immunomodulation in protocol 2 was stronger than in protocol 1 as indicated by higher TNF alpha serum concentrations and a more pronounced eosinophilia. Differences between responders and non-responders treated according to the 2 protocols were not significant, except for the total number of lymphocytes obtained by apheresis, which was higher in responders than in non-responders.

Evaluation of interleukin-2 administered by continuous infusion in patients with metastatic melanoma

BACKGROUND

Interleukin-2 (IL-2) has been used widely in the treatment of advanced melanoma, most often using a high dose bolus schedule of administration. We have evaluated the antitumor activity and toxicity of IL-2 when administered by a continuous infusion schedule in patients with metastatic melanoma.

METHODS

Thirty-three patients with metastatic melanoma were treated with IL-2 using the maximum tolerated dose level of 12 x 10(6) IU/m2 as a continuous infusion over 24 hours x 4d/week for 4 weeks every 6 weeks. All patients but one had previously received and failed chemotherapy and had evidence of progressive disease. They were required to have normal organ functions and a performance status of 0 to 1.

RESULTS

We observed 1 complete response and 6 partial responses among 31 evaluable patients for a response rate of 22% (95%, confidence interval; 10% to 41%). The median response duration was 6 months, with a range of 4 to 18 months. The toxicity of IL-2 was severe but manageable on the general inpatient ward. One patient died of hepatic necrosis that was probably related to IL-2. Five patients required dose reduction of IL-2 due to toxicity in the form of hepatic or renal insufficiency, which was rapidly reversible.

CONCLUSIONS

IL-2, used as a continuous infusion at a dose level of 12 x 10(6) IU/m2/day, 4 times every week for 4 weeks, has activity against metastatic melanoma similar to that reported with high dose IL-2 given in a bolus schedule.

Cytokines and bone marrow transplantation

This article summarizes the various current uses of cytokines, and bone marrow and peripheral blood stem cell transplantation for cancer treatment. Interferons, interleukin-2 and hematopoietic growth factors are extensively used for the treatment of hematopoietic as well as nonhematopoietic malignancies, either as the main therapeutic agents or as an adjuvant. Research on gene therapy using cytokines is in progress. Stem cell transplantation is also discussed in the context of gene therapy of cancer. Gene therapy is expected to become a future modality in cancer treatment.

Subcutaneous administration of interleukin 2 and interferon-alpha-2b in advanced renal cell carcinoma: a confirmatory study

Recent clinical studies have suggested that the combination of subcutaneous recombinant human interleukin 2 (rIL-2) and interferon alpha (rIFN-alpha) is especially promising in advanced renal cell carcinoma. We assessed the safety, activity and toxicity of home therapy with these two agents in 50 patients. Each treatment cycle consisted of a 2 day pulse phase, with 9 x 10(6) IU m-2 of rIL-2 being given subcutaneously every 12 h, followed by a 6 week maintenance phase during which rIL-2 1.8 x 10(6) IU m-2 was administered subcutaneously every 12 h on days 1-5 and rIFN-alpha 2b 5 x 10(6) IU m-2 once a day on days 1, 3 and 5. Objective responses (CR+PR) occurred in 9/50 (18%) patients, six of whom (12%) achieved a complete response. Disease stabilisation was observed in 17 cases (34%) and 18 patients progressed during therapy. In the other six cases, treatment was interrupted early for toxicity or patient refusal. One patient died of myocardial infarction during the second cycle. The overall median survival was 12 months. Home therapy with subcutaneous rIL-2 + rIFN-alpha 2b proved to be active, feasible and moderately toxic, but serious adverse events can sometimes occur.

Adjuvant radiation or systemic therapy for renal cell carcinoma: A brief review

Several clinical trials have been performed in which radiation therapy or systemic therapy have been given to patients in an attempt to reduce relapse following nephrectomy for renal cell carcinoma. Since only randomized trials can give valid information about the value of adjuvant therapy as compared with surgery alone, this short review evaluates critically the randomized trials that have been performed. Four randomized trials of radiation therapy given pre- or postoperatively suggest an overall detrimental effect on survival because of toxicity. Randomized trials of medroxyprogesterone acetate and of interferon-α have shown no benefit. There is current interest in the potential benefit of adjuvant treatment with other biological modifiers such as interleukin-2, but adjuvant therapy of any type should only be given in the context of a well-designed, randomized clinical trial.

Interleukin-2-induced renal dysfunction in cancer patients is reversed by low-dose dopamine infusion

Recombinant interleukin-2 (rIL-2) is widely used in patients with advanced cancer to enhance killer cell functions. However, the main drawback of rIL-2 therapy is the frequent development of oliguric acute renal failure (ARF), presumably due to a vascular leak syndrome. The aim of this study was to evaluate the effect of low-dose dopamine infusion on this form of ARF. Nine patients with metastatic renal cancer and previous unilateral nephrectomy were treated with a continuous intravenous infusion of rIL-2 (3 x 10(6) Cetus units/m2/d) for 5 days (study A). After 1 week, all the patients repeated the same cycle, but with the addition of a continuous intravenous infusion of dopamine (2 micrograms/min/kg body weight) that was started at the third day of treatment (study B). During study A, all patients showed a progressive (up to 34%) decrease of creatinine clearance. After rIL-2 withdrawal, these alterations persisted and were associated with a reduction in urinary output, sodium urinary excretion, and plasma protein. In study B, dopamine administration after renal function impairment (delta glomerular filtration rate = -44%) led to a prompt improvement of creatinine clearance. Creatinine clearance showed a further significant enhancement after the withdrawal of both drugs, reaching a value within the baseline range on the third day of follow-up. Similarly, the decline in urinary output and sodium excretion during rIL-2 was promptly counteracted by dopamine; in addition, after withdrawal of rIL-2 and dopamine, plasma protein levels were normalized. In conclusion, our data suggest that rIL-2-induced ARF in cancer patients is due to renal hypoperfusion mainly caused by a reduction in oncotic pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Lipoprotein(a) concentration in patients with chronic active hepatitis C before and after interferon treatment

Patients with chronic active hepatitis C show low lipoprotein(a) (Lp[a]) values. We studied the changes in Lp(a) levels caused by treatment with interferon in 24 patients (9 men and 15 women; mean age, 56.8 +/- 7.3 years) affected by chronic active hepatitis C. Fifteen healthy subjects (6 men and 9 women; mean age, 57.4 +/- 10.3 years) were used as controls. All of the patients with chronic hepatitis C were treated with intramuscular interferon, 3 million units 3 times per week for 6 months. These patients had lower baseline serum Lp(a) concentrations than the controls (4.8 +/- 3.8 mg/dL vs 13.4 +/- 10.3 mg/dL, respectively; P = 0.0007). A significant increase in Lp(a) levels (6.6 +/- 7.2 mg/dL; P = 0.05) occurred after 6 months of treatment in patients with chronic active hepatitis C. Only complete responders presented a significant increase in Lp(a) values (P = 0.01). We believe that increased Lp(a) levels represent an expression of improved liver functions.

Final report of a phase II study of interleukin 2 and interferon alpha in patients with metastatic melanoma

Fifty-seven patients with metastatic melanoma were treated with interleukin 2 (IL-2) 7.8 MIU m-2 day-1 as a continuous infusion for 4 days combined with interferon alpha (IFN-alpha) 6 MIU m-2 day-1 subcutaneously on days 1 and 4. The cycle was repeated every 2 weeks for a maximum number of 13 cycles. Of the 51 evaluable patients, one (2%) achieved a complete and seven (14%) a partial response (total response rate 16%; CI 7-29%). Median time to progression and median survival were 2.5 and 11.3 months respectively. This regimen of IL-2 and IFN-alpha appeared to be only moderately active.

Lack of efficacy of low-dose subcutaneous recombinant interleukin-2 and interferon-alpha in the treatment of metastatic renal cell carcinoma

OBJECTIVE

To evaluate the efficacy and toxicity of subcutaneous immunotherapy using a combination of recombinant interleukin-2 (r-IL2) and interferon-alpha (IFN-alpha) for the treatment of patients with metastatic renal cell carcinoma (RCC).

PATIENTS AND METHODS

Initially a maximum of 45 patients with advanced RCC were to be included in the study, according to a Fleming three-stage procedure. To be included patients had to have measurable metastasis. Of a potential 45 patients with advanced RCC, 15 patients were included in the study (10 men and five women, mean age 51 years, range 25-69). From the first week of treatment r-IL2 was given subcutaneously on day 1 to 5, at 18 x 10(6) units once a day and then 9 x 10(6) units once a day for the following 5 weeks. IFN-alpha was given three times a week for the last 5 weeks. Minimum follow-up was 6 months.

RESULTS

All patients initially underwent radical nephrectomy. Seven patients were found to have metastases at the time of diagnosis. All patients received ambulatory therapy, except for the first 5 days of treatment. Overall, 80% of the patients received more than 75% of the complete dose of r-IL2. One patient suffered toxicity greater than the World Health Organization (WHO) grade 2 (neutropenia). No patient had a complete or partial response, two patients had a minor response, two patients had stable disease and 11 patients had disease progression.

CONCLUSIONS

Subcutaneous r-IL2 and IFN-alpha had no beneficial effect on the first 15 patients and the study was discontinued, in accordance with the Fleming rules. The dose, administration and combination of r-IL2 and IFN-alpha may explain the lack of efficacy. Other studies have shown that low doses of r-IL2 are not effective and the superiority of the combination of r-IL2 and IFN-alpha has not been proven. Therefore, a high dose of r-IL2, in association with other cytokines, chemotherapy and adoptive immunotherapy, may be the only way to improve the response rate of metastatic RCC.

Leukocyte Interleukin, Inj. (LI) augmentation of natural killer cells and cytolytic T-lymphocytes

A serum free lymphokine preparation derived from human buffy-coat mononuclear cells [buffy coat interleukins (BC-IL)], also named Leukocyte Interleukin, Inj. (LI), trade name Multikine, containing glycosylated interleukin-2 (IL-2) among other interleukins, was tested in three head and neck cancer patients. They responded with tumor regressions associated with increased tumor infiltration of lymphocytes and tumor cell lysis indicating an LI Interleukin-2 induced tumor-specific immune response. To determine whether these responses elicited by LI were IL-2 driven, augmentation of natural killer cells (NKC) and cytolytic T cells (CTL), was tested both in vitro and in vivo. A single intraperitoneal (i.p.) injection of LI in adult BALB/c mice at doses of 3, 10, 30 and 100 of IL-2 equivalence International Units per mouse, led to significant (p < 0.01) augmentation of NKC cytotoxicity to YAC tumor cells. NKC cytotoxicity remained elevated for 7 days, peaking at 5 days post-treatment. Multiple treatments with LI did not increase NKC cytotoxicity above single injection, nor did it lead to NKC hyporesponsiveness. The most effective treatment routes leading to heightened NKC cytotoxicity were: intravenous(i.v.) > intraperitoneal (i.p.) > intramuscular (i.m.) > subcutaneous (sc). Significant (p < 0.05 to < 0.01) NKC cytotoxicity was achieved by all four routes. In vitro incubation of murine splenocytes with 30 and 100 International Units/ml (IU/ml) of IL-2 equivalent elevated NKC cytotoxicity significantly (p < 0.01) at all effector to target cell ratios tested and exceeded the response achieved with rhIFN gamma. NKC cytotoxicity of human peripheral blood lymphocytes (HPBL) against the K562 human tumor cell was also significantly elevated (p < 0.01) at the 30 and 100 IU/ml doses and (p < 0.05) at 3 and 10 IU/ml doses. Of particular interest was the significant increase of CTL response in HPBL generated by LI. Significant activity (p < 0.01) was achieved with levels of 10, 30 and 100 IU/ml at effector to target cell ratios as low as 6 to 1. These results indicate that the LI containing IL-2 led to the significant increase in NKC and CTL cytolytic activities. Relatively lower doses of LI were needed to attain equivalent cytolytic activities as achieved with rhIL-2 or rhIFN gamma.

[Immunotherapy of malignant melanoma. New prospects]

Malignant melanoma is an immunogenic tumor which can induce host humoral and cellular responses, and is a good model for development of anti-cancer immunotherapy. During the last decade systemically-administrated interferon and interleukin-2 have been used. Advances in immunology and molecular biology could allow a more specific and active immunotherapy. Perspectives include chemo-immunotherapy, monoclonal antibodies alone or in combination with cytotoxic agents, adoptive immunotherapy with tumor-infiltrating lymphocytes (TIL), gene therapy designed to increase tumor immunogenicity, and active immunotherapy with vaccines.

Mechanisms of interleukin-2-induced depression of hepatic cytochrome P-450 in mice

Interleukin-2 (15 micrograms/mouse, i.p. twice daily for 4 days and once on the 5th day) significantly lowered cytochrome P-450 and heme content and increased heme oxygenase mRNA accumulation; the activities of 7-ethoxycoumarin O-deethylase, ethoxy- and pentoxyphenoxazone O-dealkylases were decreased. The activity of the type O form of hepatic xanthine oxidase increased, but there was no increase in lipid peroxide, expressed in terms of microsomal malondialdehyde. In vivo inactivation of xanthine oxidase activity by feeding mice with tungstate did not substantially change the degree of interleukin-2-induced cytochrome P-450 depression, suggesting that the two processes are not causally linked. Induction of tolerance to endotoxin by a 4-day pretreatment with lipopolysaccharide resulted in 50% protection against this depression despite inhibition of the interleukin-2 induced formation of tumor necrosis factor. This suggests that the release of tumor necrosis factor per se does not fully account for the depression of cytochrome P-450. Dexamethasone, already used in patients to reduce the toxicity of interleukin-2 therapy, provided full protection against the cytochrome P-450 depression.

Super-sensitive epithelial cell line and colorimetric assay to replace the conventional K562 target and chromium release assay for assessment of non-MHC-restricted cytotoxicity

Using colorimetric MTT assay the susceptibility of a newly established bladder epithelial cell line, Fen cells was compared with conventional target cells, i.e., K562 and Daudi and other epithelial lines for investigation of non-specific killing activity (NK/LAK) of effector cells previously activated with interleukin-2 (IL-2). The results showed that Fen cell line was more sensitive than K562 and Daudi targets and this was seen whether the effector cells were IL-2-activated or not. The percent killing of effector cells from nine normal donors against Fen, K562 and Daudi targets at effector/target (E/T) ratio of 10/1 after IL-2 activation were 63.4 +/- 7.3, 42.6 +/- 4.3 (p = 0.0001) and 38.6 +/- 5.1 (p = 0.0001) respectively. The corresponding values for inactivated effector cells at 50/1, E/T ratio were 44.8 +/- 9.0, 25.1 +/- 8.3 (p = 0.0001) and 24.4 +/- 9.4 (p = 0.0001) indicating exquisite sensitivity of Fen cells to NK/LAK killing. The susceptibility of Fen cells was found to increase by pre-treatment of target cells with interferons (IFN). Thus the percent killing of untreated, IFN-alpha (1000 U/ml), beta (2000 U/ml) and gamma (100 U/ml) treated cells were 52%, 64% (p = 0.005), 70% (p = 0.001) and 67% (p = 0.001) respectively. These results indicated that Fen cells were more susceptible to NK/LAK killing than the conventional K562 and Daudi target cells. These results and the epithelial origin of Fen cells indicate that this cell line might prove to be a more realistic system to replace the conventional approach for assessment of NK/LAK activity in patients with cancer of epithelial origin.

Immunotherapy in liver tumors: III. A new experimental model of metastatic liver tumors from colorectal carcinoma for cytokine therapy

A new model of metastatic liver tumors in Wistar/Furth rats is introduced. A colorectal adenocarcinoma cell line (LDLX40) induced by 1,2-dimethylhydrazine was injected through one of the branches of the ileal mesenteric vein to develop metastatic liver tumors in rats. On day 30 after the inoculation of tumor cells, micrometastases were detected under microscopy in all animals that received tumor inoculation. Macrometastases in 87.7% of animals were found by either the tumor staining test or ultrasonography. No extrahepatic tumor developed in this tumor model. To observe the effects of different treatment strategies on metastatic liver tumors, 35 animals were randomly divided into four groups. Group I served as control. Group II underwent hepatic artery ligation (HAL). Group III received intraportal administration of recombinant interleukin-2 (rIL-2) and interferon-alpha (IFN-alpha). Group IV had intraportal medication of rIL-2 and IFN-alpha + HAL (the IIH protocol). Results indicated that rapid tumor growth was seen in the control tumors. HAL produced little response to metastatic liver tumors as compared to the control group (P > 0.05). The combined application of rIL-2 and IFN-alpha showed an improved result, with 22% of tumor growth inhibition or regression (P < 0.05 compared to the control group). Twenty-eight percent of tumor growth restraint or regression was found in the group treated with the IIH protocol (P < 0.05 compared to the control group). We conclude that this new experimental model of metastatic liver tumors is reproducible, and that the IIH protocol is effective in the treatment of metastatic liver tumors in rats. These beneficial effects from the IIH protocol may be introduced into patients with metastatic liver tumors.

Diabetes mellitus in cancer patients treated with combination interleukin 2 and alpha-interferon

Diabetes mellitus is thought to be an autoimmune disease caused by destruction of beta cells in pancreatic islets. Insulin resistance in the peripheral tissues may also play a role. Both interleukin 2 (IL-2) and alpha interferon can enhance immune function by stimulating formation of cytolytic T cells and/or antigen expression on both normal and tumor cells. This report describes three patients with advanced malignancy who were treated with combination IL-2 and alpha interferon who had the onset or worsening of diabetes mellitus. One patient died as a result. There is evidence that interferon can increase insulin resistance and it is likely that both agents can initiate or enhance an ongoing autoimmune process. Physicians using this combination of drugs should be aware of this potential serious toxicity.

Interleukin 2-induced increase of vascular permeability without decrease of the intravascular albumin pool

Interleukin 2 (IL-2) exhibits anti-tumour activity. High-dose IL-2 regimens are limited by side-effects such as pulmonary oedema and a systemic vascular leak. The mechanisms by which IL-2 mediates transvascular fluid and protein losses in humans are largely unknown. We have, therefore, measured the transcapillary escape rate (TER) of albumin as a reflection of the vascular permeability by injecting [125I]albumin (5 microCi i.v.). In ten melanoma patients pretreated with interferon alpha (IFN-alpha) TER of albumin was measured before and after IL-2 injections (1.5 x 10(6) Cetus-U. s.c. daily for 4 days). The TER of albumin increased from 9.4 +/- 2.7% h-1 before to 14.9 +/- 3.3% h-1 (P < 0.001) after IL-2 injections and the absolute outflux of albumin (Jalb) from 159 +/- 28 mg kg-1 h-1 to 261 +/- 44 mg kg-1 h-1 (P < 0.001), whereas the intravascular albumin pool remained stable (136 +/- 19 g vs 136 +/- 18 g). IL-2 and IL-6 were not detectable in the plasma prior to IL-2 injections and increased to 549 +/- 315 U ml-1 (P < 0.001) and 7 +/- 6 pg ml-1 (P < 0.01), respectively, after IL-2 administration. In conclusion, IL-2 increases the vascular permeability in humans, without affecting the intravascular albumin pool. This suggests that mechanisms such as the lymphatic return can compensate for the severe transendothelial fluid/albumin losses.

Interleukin-2-based immunotherapy and chemoimmunotherapy in metastatic melanoma

This report summarizes our experience in the treatment of advanced melanoma with immunotherapy and chemoimmunotherapy. A total of 45 patients initially received immunotherapy with interferon-alpha (IFN alpha) and a decrescendo regimen of high-dose interleukin-2 (IL-2). The objective response rate is 31% with an additional 36% of mixed response (MR) and stable disease (SD). A total of 18 patients failing immunotherapy with IFN-alpha/IL-2 received subsequent chemotherapy with dacarbacine (DTIC), followed by IFN-alpha. The response rate for this second-line regimen is 22%. A further 11 patients failing IFN-alpha/IL-2 received a single dose of DTIC or cisplatinum (CDDP) on day 1, followed by IFN-alpha/IL-2 according to the same protocol as previously, without chemotherapy. The addition of DTIC or CDDP was fairly well tolerated. Induction of secondary mediators was not inhibited, suggesting that the immunologic effects mediated by IL-2 are not impaired. A randomized clinical trial is now being performed to compare combined chemoimmunotherapy with immunotherapy alone.

Perspectives of cytokine treatment in malignant skin tumors

Cytokines have been tested in the treatment of different skin cancers during the last decade, and treatment schedules have been established or proposed for several malignant skin tumors. Preferentially, the interferons and interleukin-2 were found to be effective in treating skin cancers. Interferons alpha and beta have been approved for the treatment of human immunodeficiency virus (HIV)-associated Kaposi's sarcoma, cutaneous T cell lymphoma, and malignant melanoma in several countries. Interferon alpha was found to be most effective in cutaneous T cell lymphoma with 40%-60% overall responses. When combining interferon alpha with psoralens and ultraviolet A (PUVA) or with retinoids, even higher response rates up to 60%-90% were reported, and long-term remissions have been described. A considerable activity of interferon alpha was found in HIV-associated Kaposi's sarcoma with response rates of 30%-50%. The effectiveness of Kaposi's sarcoma's treatment was further improved by combining interferon alpha and zidovudine. Responses to interferon alpha in metastatic malignant melanoma are rather seldom (10%-15%), but a stabilization of the disease with prolonged survival was reported after interferon alpha treatment. Additionally, interleukin-2 was found to be active in metastatic melanoma, with overall response rates of about 20%, and both biological agents were found to have an additive efficacy in combination. Several combined regimens of interferon alpha, interleukin-2, and polychemotherapy have been described in metastatic melanoma, and overall response rates higher than 50% were found with these combined treatment modalities. Interferon alpha and beta were also intralesionally injected into basal cell carcinomas and other epithelial skin cancers, and complete responses were found in more than 80% of tumors treated. Local applications of interferons and interleukin-2 were likewise found to be effective in the treatment of cutaneous melanoma metastases and cutaneous manifestations of Kaposi's sarcoma. Cytokines and their combination with other treatment modalities has greatly enriched the treatment facilities in malignant skin tumors during recent years, and additional new cytokines will be introduced in skin cancer treatment in near future.

Serum levels of cytokines and soluble cytokine receptors in patients with metastatic renal cell carcinoma or malignant melanoma receiving IL-2/interferon-alpha combination therapy

Elevated serum levels of soluble tumour necrosis factor receptor (sTNFR-55) and (at a lesser degree) of sTNFR-75 were found in most of the patients with metastatic renal cell carcinoma (RCC) or malignant melanoma (MM) before immunotherapy and with further increase during treatment (intravenous infusions of interleukin-2 [IL-2] and subcutaneous interferon-alpha [IFN-alpha]). In the majority of the patients with MM the pretreatment serum levels of IL-2 and soluble IL-2 receptor (sIL-2R) were increased, whereas fewer patients with RCC presented with increased serum levels of IL-2 and sIL-2R. Twelve days' treatment with IL-2/IFN-alpha, with a rest on days 6 and 7, resulted in a consistent further increase in the serum levels of sIL-2R and sTNFRs. In most patients the increase of sIL-2R and sTNFRs lasted for at least 3 weeks after treatment discontinuation. The clinical significance of the increase remains unknown.

Cardiopulmonary toxicity of treatment with high dose interleukin-2 in 199 consecutive patients with metastatic melanoma or renal cell carcinoma

BACKGROUND

Administration of recombinant interleukin-2 (rIL-2) can mediate tumor regression in patients with metastatic melanoma and renal cell carcinoma. In response to recent FDA approval of high dose rIL-2 for use in renal cell carcinoma, the authors recent experience with the cardiopulmonary toxicity associated with high dose IL-2 therapy is reviewed.

METHODS

The treatment courses of all patients receiving high dose intravenous bolus rIL-2 from January, 1988, until December, 1992, were evaluated for cardiopulmonary toxicity.

RESULTS

One hundred ninety-nine patients received 310 courses of treatment. There were no treatment-related deaths. Respiratory distress occurred in 3.2% of the courses, requiring intubation in one patient. Three obtunded patients were endotracheally intubated for airway control. Arrhythmias occurred in 6% of the courses (18 patients) with hypotension developing in two of the 199 patients as a result. Eleven of these patients were retreated and recurrent atrial fibrillation developed in two. One episode of significant ventricular tachycardia was noted. Hypotension occurred in 53% of courses; no patients developed hypotension unresponsive to vasopressors. There were no myocardial infarctions; however, 2.5% of patients experienced elevated creatine phosphokinase levels associated with elevated MB isoenzymes attributed to cardiac toxicity. Only one of these patients developed symptoms. Response rates of 19.6% and 15.7% were noted in patients with renal cell carcinoma and melanoma, respectively. Hypotension requiring vasopressors was associated with a significantly improved rate of response in patients with melanoma compared with patients not requiring vasopressors (23.2% vs. 6.5%, P2 = 0.037).

CONCLUSIONS

Although high dose intravenous rIL-2 therapy can be associated with cardiopulmonary toxicity, toxic side effects generally are not severe and are rapidly reversible.