A phase II trial of interferon-alpha and 5-fluorouracil in patients with advanced renal cell carcinoma. A Southwest Oncology Group study

Different responses to two types of 5-fluorouracil prodrugs in combination with interferon-alpha in pulmonary metastases of renal cell carcinoma: a case report

A 66-year-old Japanese man with pulmonary metastases of renal cell carcinoma found 8 months after radical nephrectomy was treated with interferon-alpha and tegafur-uracil. Since it failed to achieve tumor responses resulting in progression, he was given interferon-alpha and capecitabine. After 2 courses of combination therapy with IFN-alpha and capecitabine, significant tumor responses were obtained; two out of four pulmonary metastatic sites disappeared completely, one site showed over 50% decrease in size, and the remaining one site did no change in size. The regimen was well tolerated and toxicity observed was World Health Organization grade 1 anorexia. His disease status was maintained as stable disease by the repeated treatment with interferon-alpha and capecitabine for 17 months after tumor responses were obtained. However, tumor progression was observed thereafter. He is at present under treatment with sorafenib. This is the first case report of metastatic renal cell carcinoma, which showed different responses to two types of 5-fluorouracil prodrugs in combination with interferon-alpha, suggesting the biochemical modulation of capecitabine by interferon-alpha as a possible mechanism underlying the antitumor effect of the combination of interferon-alpha and capecitabine at the clinical setting. Present case also suggests that a combination of tumor-selective capecitabine with interferon-alpha is a potentially useful therapeutic option in metastatic renal cell carcinoma.

Does Radical Nephrectomy with Immunochemotherapy Have Any Superiority over Embolization Alone in Metastatic Renal Cell Carcinoma?

INTRODUCTION

We evaluated the results and effects of radical nephrectomy followed by immunochemotherapy and embolization alone on the survival of patients with metastatic renal cell carcinoma.

PATIENTS AND METHODS

The study included 20 patients with histologically confirmed renal cell carcinoma. Ten patients were in the combined therapy group and the other 10 patients who were unable to undergo nephrectomy because of poor performance status or unresectable tumor were in the embolization group. Radical nephrectomy was performed on patients with good performance status (WHO criteria 0-1). Immunochemotherapy (interferon alpha 2a and 5-fluorouracil) was started within 1 month after surgery. A dose of 9 x 10(6) U/day interferon alpha 2a was subcutaneously administered 3 times a week. A dose of 750 mg/m2 5-fluorouracil was administered intravenously during 4 h in the first 5 days of treatment. 5-Fluorouracil therapy was converted to weekly intervals after the first 12 days. Combined therapy was continued for 3 months. Ethanol was used for transarterial embolization. The main renal arteries and parasitic arteries of the tumor were embolized.

RESULTS

There were no significant differences in age distribution, sex, affected side, tumor size and T stage between the groups. After completion of the combined therapy, 6 patients showed progression at the first control. Only 1 patient (10 %) had stable disease throughout the 10 months after combined therapy. One patient died of myocardial infarction on the 4th day in the embolization group. While progressive disease within the first 3 months was detected in 6 patients, the other 3 patients (30%) had stable disease for 14, 17 and 55 months, respectively. There was no complete response in any group and no patient was alive (died of renal cell carcinoma) at the time of the analysis of the study data. Whereas the median survival time was 11 months (1-80) (mean +/- SE: 22.2 +/- 9.1) in the combined group, this time was a median of 1 month (1-74) (mean +/- SE: 17.5 +/- 8.6) in the embolization group. There was no statistically significant difference in survival time between the groups (p > 0.05).

CONCLUSION

In this preliminary report, the clinical findings in embolization-group patients were definitively worse than the nephrectomy plus immunochemotherapy-group patients. In spite of these differences, combination therapy using radical nephrectomy and immunochemotherapy could not show superiority to embolization alone, especially in terms of survival time.

Role of Cytokine Therapy in 2006 and Beyond for Metastatic Renal Cell Cancer

Metastatic renal cell cancer (mRCC) has a long history as a disease with poor prognosis and limited therapeutic options. Immunotherapy has been the mainstay of treatment since the 1980s, and there have been a number of largely phase II studies examining various schedules of interferon-alpha and interleukin-2 based treatments. With the development of molecular targeted drugs the armentarium against mRCC has significantly expanded and cytokine treatments should be only directed at those most likely to benefit with durable remissions and prolonged survival.

Interferon alpha for the treatment of advanced renal cancer

This paper is an overview on the place of IFN-alpha in metastatic renal cell carcinoma (MRCC). After a presentation of MRCC and the mode of action of IFN-alpha, the results of studies including IFN-alpha alone or in combination with IL-2, chemotherapy and other biological modifiers are presented. Finally, new trends for new drugs, including antiangiogenic therapies, are discussed.

Quantitative analysis of thymidine phosphorylase and dihydropyrimidine dehydrogenase in renal cell carcinoma

OBJECTIVE

The purpose of the present study was to clarify the clinicopathological significance of both thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD) in renal cell carcinoma (RCC) based on a quantitative analysis of RCC patients.

METHODS

Levels of TP and DPD in RCC and/or uninvolved renal tissues from 65 RCC patients were measured by enzyme-linked immunosorbent assay.

RESULTS

The TP level and TP/DPD ratio were significantly higher in RCC than in adjacent uninvolved renal tissues (p < 0.0001). There was no significant difference in DPD levels between RCC and uninvolved renal tissues. The ratio of the highest to the lowest level was 623 in TP level, 28.9 in DPD level, and 985 in TP/DPD ratio. In the univariate analysis, patient's age (p = 0.04), tumor stage (p < 0.0001), tumor size (p = 0.007), TP expression (p = 0.03), and DPD expression (p = 0.04) were significantly associated with increased risk of death. Multivariate analysis showed that patient's age, tumor stage, and TP expression were independent prognostic factors.

CONCLUSIONS

TP and DPD in RCC provide prognostic information although DPD was not an independent prognostic factor. The present finding of a wide range in these enzyme expressions in RCC suggests that a certain subpopulation with a high TP/DPD ratio has potential responsiveness to fluoropyrimidines, especially 5'-deoxy-5-fluorouridine and capecitabine.

Chemotherapeutic strategies for renal cell carcinoma

Metastatic renal cell carcinoma (RCC) is a disease that is highly resistant to systemic chemotherapy. Responses to combination chemotherapy have been reported in patients with collecting duct carcinoma and the sarcomatoid variant of renal cancer. Clinical trials combining chemotherapy with biologic response modifiers have not resulted in significant advances in the treatment of RCC. Patients with advanced local or metastatic RCC should be offered investigational therapeutic options. The identification of novel agents with significantly improved antitumor activity remains a high priority in the treatment of this disease.

Interleukin-2 Based Therapy for Kidney Cancer

In summary, IL-2 based therapy remains the basis for treatment of metastatic renal cell cancer. Un-answered questions remain in the development of regimens that exceed a mean response rate of 20%. Additionally, there may be differences among the histologic subtypes of renal cell cancer that predispose to response or lack there of to immunotherapy, and this is being further explored. As can be noted from the studies presented in this paper, there are numerous variations on the regimens for IL-2 based therapy. Current recommendations are to use the simplest and most feasible in a given institution. Certainly high dose IL-2 remains the standard regimen to which all others are measured.

Phase II trial of subcutaneous interleukin-2, subcutaneous interferon-alpha, 5-fluorouracil and cis-retinoic acid in the treatment of renal cell carcinoma: final results of cancer biotherapy research group 94-10

BACKGROUND

The treatment of metastatic renal cell cancer remains unsatisfactory despite encouraging results with biotherapy. Pilot studies from other investigators have suggested that combining cis-retinoic acid and 5-fluorouracil (5FU) with interleukin-2 (IL-2) and interferon-alpha (IFN) may improve outcomes for such patients.

METHODS

Eligible patients had metastatic renal cell cancer, were in good medical condition, and had not been treated previously with more than two of the study agents. A 56-day treatment cycle consisted of: interferon-alpha 2a 3.0 mu/m2 s.c. Monday, Wednesday, and Friday weeks 1-8, interleukin-2 11 mu/m2 s.c. Tuesday, Thursday and Saturday of weeks 1-4, cis-retinoic acid 1 mg/kg p.o. daily weeks 1-8, and 5-FU 750 mg/m2 i.v. weekly during weeks 5-8. Patients were evaluated for tumor response every 8 weeks, and in the absence of tumor progression, patients could receive treatment for up to one year. Survival was determined from the first date of treatment.

RESULTS

The 58 renal cell carcinoma patients included 41 men and 17 women, with a median age of 57 years with a range of 28-85 who were enrolled between October 1994 and July 1997. Thirty-seven percent were asymptomatic when treatment was initiated. Sites of disease at study entry included 62% lung, 34% bone, 31% lymph node, 22% kidney, 16% liver and 10% adrenal. There were only three patients with significant tumor responses (one complete, two partial) for a response rate of 5% (0-11% 95% CI) based on intent-to-treat analysis, and 6% (0-12%, 95% CI) for the 53 patients who were evaluable for response. The response rate among evaluable nephrectomized patients who had received no prior radiation or systemic treatment was 3/25 (12%). The median failure-free survival was 2.8 months; median overall survival was 10.9 months. The 1-year survival rate was 50% and 2-year survival rate was 33%. The most frequent toxicities were fatigue-81% (26% grade 3 or 4), nausea/vomiting-59%, and leukopenia/neutropenia 57% (16% grade 3 or 4).

CONCLUSION

Despite a disappointing objective response rate, survival in these patients who were treated entirely as outpatients was similar to that seen in our earlier trials of inpatient, intermediate dose continuous infusion IL-2-based therapy.

Enhancement of sensitivity to capecitabine in human renal carcinoma cells transfected with thymidine phosphorylase cDNA

The purpose of the present study was to examine directly the role of thymidine phosphorylase (TP) in the sensitivity of renal cell carcinoma (RCC) to a novel fluoropyrimidine carbamate, capecitabine. TP cDNA-transfected RCC are used in these experiments to provide a basis for improved therapeutic benefit in chemoimmunotherapy. Human RCC line KU2 cells were transfected with pcDNA3.1/zeo(+) with or without human TP cDNA by the lipofectin method. We established a clone transfected with pcDNA3.1/zeo(+)/TP (KU2-TP15) and a clone transfected with pcDNA3.1/zeo(+) as a control (KU2-C1). TP expression levels (mean +/- SD) examined by enzyme-linked immunosorbent assay (ELISA) were 1.3 +/- 0.14 U/mg protein in KU2, 1.6 +/- 0.57 U/mg protein in KU2-C1 and 216 +/- 25.6 U/mg protein in KU2-TP15. Immunohistochemical staining of subcutaneous tumors established in Balb/c nu/nu mice showed that KU2-TP15 was strongly positive for TP expression, whereas KU2 and KU2-C1 were negative. Sensitivities in vitro to 5-fluorouracil (5FU), 5'-deoxy-5-fluorouridine (5'DFUR) and capecitabine in KU2-TP15 were significantly enhanced compared with those in KU2 or KU2-C1. A moderate but statistically significant bystander effect was observed in vitro. KU2-TP15 tumors showed significant increase in the in vivo sensitivities to 5'DFUR and capecitabine as compared with the vehicle alone while KU2-C1 tumors did not. The difference in tumor-free rate in mice bearing KU2-TP15 at 2 months after the cessation of treatment was statistically significant between the capecitabine treatment group and the controls, the 5FU treatment group and the 5'DFUR treatment group. The present study clearly provides direct evidence for the role of TP in mediating the sensitivity of RCC to capecitabine.

Immunotherapy: are we making a difference?

There is a 10-20 year history of immunotherapeutic approaches in metastatic renal cell cancer, which have produced a consistent demonstration of anti-tumour effect in a small percentage of patients. Clarification of dose and schedule of current agents continues to be modified. New technologies for immune system activation are attempting to enhance the response rate and improve outcome. Anti-proliferative effects of immunotherapy produce prolongation of stable disease, and new agents are being developed to enhance this approach.

Pilot trial of infusional 5-fluorouracil, interleukin-2, and subcutaneous interferon-alpha for advanced renal cell carcinoma

The authors developed an outpatient, three-drug combination regimen for advanced renal cell carcinoma. Treatment was administered for 5 days each week for 4 weeks, followed by 2-week rests. Each weekly treatment consisted of 5-fluorouracil 1,750 mg/m2 continuous intravenous infusion for 24 hours followed by interleukin-2 6 mIU/m2 per day continuous intravenous infusion for 4 days, and interferon-alpha2b 6 mU/m2 subcutaneously on days 1, 2, and 5. This trial was undertaken to assess tolerability to this regimen and obtain a preliminary assessment of its effectiveness. Most patients required some dose adjustments (especially of cytokines), treatment interruptions, or both. Toxicities were as would be expected from individual drug profiles with only mild to moderate hematologic toxicities. Among 16 patients with renal cell carcinoma treated, four had major (clinical partial response) responses, one of which was demonstrated to be a pathologic clinical response after surgical resection of a residual mass. Estimated median survival time of all patients was 93 weeks. Response and survival were correlated with known clinical risk factors. Responding patients were noted to be significantly older in age (X = 61.75 years) than nonresponders (X = 48.92 years). There was no correlation between age and other clinical risk factors, treatment tolerance, or survival. The authors conclude that this three-drug regimen is a practical, tolerable, and promising regimen for further study in renal cell carcinoma.

Interferon-alpha and 5-fluorouracil therapy in patients with metastatic renal cell cancer: an open multicenter trial. The Japanese Study Group Against Renal Cancer

OBJECTIVES

Recent clinical trials have implied the cytotoxic and antiproliferative effects of combining 5-fluorouracil and interferon-alpha in the treatment of metastatic renal cell cancer. We therefore conducted an open multicenter trial to test the efficacy of such a combination on this cancer.

METHODS

Human lymphoblastoid interferon (3 MIU per patient) was administered subcutaneously three times weekly for 12 weeks, while 5-fluorouracil was administered (600 mg/m2/day) as a continuous infusion for the first 5 days, followed by an intravenous bolus infusion of 600 mg/m2 once a week from the 3rd week until the 12th week.

RESULTS

Of the 63 patients entered into the trial, 55 were eligible and evaluable for systemic toxicities, and 53 were evaluable for their response. All patients had undergone a prior nephrectomy, and their European Cooperative Oncology Group (ECOG) performance status ranged from 0 to 3 (median 0). Three complete and eight partial responses were induced, with an overall response rate of 20.0%. The median time to progression and the median survival time were 11 and 33 months, respectively. World Health Organization grade 3 toxicities were observed in 8 patients; however, no grade 4 toxicities or toxicity-related deaths were noted.

CONCLUSIONS

Combination therapy of interferon-alpha plus 5-fluorouracil at the above-described dosage and schedule produced no better responses than interferon monotherapies. Prolongation of survival could be attributable to the fair performance status of the patients. This regimen has limited value for the treatment of patients with advanced renal cell cancer.