Phase I trial of intravenous infusion of ex-vivo-activated autologous blood-derived macrophages in patients with non-small-cell lung cancer: toxicity and immunomodulatory effects

Potential applications of macrophages in cancer immunotherapy

Immunotherapy has improved cancer treatment based on investigations of tumor immune escape. Manipulation of the immune system stimulates antitumor immune responses and blocks tumor immune escape routes. Genetically adoptive cell therapy, such as T cells, has yielded promising results for hematologic malignancies, but their application to solid tumors has been challenging. Macrophages have a wide broad of capabilities in regulating immune responses, homeostasis, and tissue development, as well as the ability to phagocyte, present antigens, and infiltrate the tumor microenvironment (TME). Given the importance of macrophages in cancer development, they could serve as novel tool for tumor treatment. Therefore, macrophages are used in different formats for direct and indirect targeting of tumor cells. This review summarized the available data on the various applications of macrophages in cancer immunotherapy.

Intratumoral adoptive transfer of inflammatory macrophages engineered by co-activating TLR and STING signaling pathways exhibits robust antitumor activity

Despite the success of chimeric antigen receptor (CAR) T cells in hematologic malignancies, adoptive cell therapy (ACT) has not been effective in treating solid tumors. Here, we developed an inflammatory macrophage-based ACT to effectively treat solid tumors. We engineered inflammatory macrophages to enhance their antitumor activities, including proinflammatory cytokine secretion and co-stimulatory molecule expression by co-activating toll-like receptor and stimulator of interferon genes signaling pathways. Engineered macrophages maintain an inflammatory phenotype after their adoptive transfer into the anti-inflammatory tumor microenvironment (TME), whereas conventional inflammatory macrophages prepared using interferon-γ treatment are repolarized to an anti-inflammatory phenotype. In a mouse melanoma model, intratumoral adoptive transfer of engineered macrophages showed robust tumor growth inhibition by increasing CD8+ T cells in the TME and tumor antigen-specific CD8+ T cells in the blood. This study demonstrated that engineered inflammatory macrophages have potential as an effective ACT for treating solid tumors.

Ex Vivo Generation of CAR Macrophages from Hematopoietic Stem and Progenitor Cells for Use in Cancer Therapy

Chimeric antigen receptor (CAR) T-cell therapies have shown impressive results in patients with hematological malignancies; however, little success has been achieved in the treatment of solid tumors. Recently, macrophages (MΦs) were identified as an additional candidate for the CAR approach, and initial proof of concept studies using peripheral blood-derived monocytes showed antigen-redirected activation of CAR MΦs. However, some patients may not be suitable for monocyte-apheresis, and prior cancer treatment regimens may negatively affect immune cell number and functionality. To address this problem, we here introduce primary human hematopoietic stem and progenitor cells (HSPCs) as a cell source to generate functional CAR MΦs ex vivo. Our data showed successful CAR expression in cord blood (CB)-derived HSPCs, with considerable cell expansion during differentiation to CAR MΦs. HSPC-derived MΦs showed typical MΦ morphology, phenotype, and basic anti-bacterial functionality. CAR MΦs targeting the carcinoembryonic antigen (CEA) and containing either a DAP12- or a CD3ζ-derived signaling domain showed antigen redirected activation as they secreted pro-inflammatory cytokines specifically upon contact with CEA⁺ target cells. In addition, CD3ζ-expressing CAR MΦs exhibited significantly enhanced phagocytosis of CEA⁺ HT1080 cells. Our data establish human HSPCs as a suitable cell source to generate functional CAR MΦs and further support the use of CAR MΦs in the context of solid tumor therapy.

Engineered CAR-Macrophages as Adoptive Immunotherapies for Solid Tumors

Cellular immunotherapies represent a promising approach for the treatment of cancer. Engineered adoptive cell therapies redirect and augment a leukocyte’s inherent ability to mount an immune response by introducing novel anti-tumor capabilities and targeting moieties. A prominent example of this approach is the use of T cells engineered to express chimeric antigen receptors (CARs), which have demonstrated significant efficacy against some hematologic malignancies. Despite increasingly sophisticated strategies to harness immune cell function, efficacy against solid tumors has remained elusive for adoptive cell therapies. Amongst cell types used in immunotherapies, however, macrophages have recently emerged as prominent candidates for the treatment of solid tumors. In this review, we discuss the use of monocytes and macrophages as adoptive cell therapies. Macrophages are innate immune cells that are intrinsically equipped with broad therapeutic effector functions, including active trafficking to tumor sites, direct tumor phagocytosis, activation of the tumor microenvironment and professional antigen presentation. We focus on engineering strategies for manipulating macrophages, with a specific focus on CAR macrophages (CAR-M). We highlight CAR design for macrophages, the production of CAR-M for adoptive cell transfer, and clinical considerations for their use in treating solid malignancies. We then outline recent progress and results in applying CAR-M as immunotherapies. The recent development of engineered macrophage-based therapies holds promise as a key weapon in the immune cell therapy armamentarium.

CARs and beyond: tailoring macrophage-based cell therapeutics to combat solid malignancies

Recent understanding of the role and contribution of immune cells in disease onset and progression has pioneered the field of immunotherapies. Use of genetic engineering to deliver, correct or enhance immune cells has been clinically successful, especially in the field of cancer immunotherapy. Indeed, one of the most attractive approaches is the introduction of chimeric antigen receptors (CARs) to immune cells, such as T cells. Recent studies revealed that adapting this platform for use in macrophages may widen the spectrum of CAR applications for better control of solid tumors and, thus, extend this treatment strategy to more patients with cancer. Given the novel insights into tumor-associated macrophages and new targeting strategies to boost anticancer therapy, this review aims to provide an overview of the current status of the role of macrophages in cancer therapy. The various genetic engineering approaches that can be used to optimize macrophages for use in oncology are discussed, with special attention dedicated to the implication of the CAR platform on macrophages for anticancer therapy. The current clinical status, challenges and future perspective of macrophage-based drugs are highlighted.

Macrophages as a Double-Edged Weapon: The Use of Macrophages in Cancer Immunotherapy and Understanding the Cross-Talk Between Macrophages and Cancer

Macrophages (Mϕs) play an essential role in maintaining body homeostasis. They perform dual functions produced by different subtypes. Mϕs not only fight against pathogens and foreign bodies such as bacteria or cancer cells but also participate in healing and repairing damaged tissue since they maintain both proinflammatory and anti-inflammatory effects sequentially. Tumors possess the ability to polarize Mϕs from proinflammatory M1 subtype to anti-inflammatory M2-like Mϕs called tumor-associated macrophages, which, in turn, help the tumors to acquire cancer hallmarks. Consequently, this polarization allows tumors to grow and spread. In this light, Mϕs have been a subject of intense study, and researchers have developed protocols to derive different Mϕs subtypes either as a new state-of-the-art therapeutic approach or to understand the cross-talk between cancer and Mϕs. In this review, we present the use of primary Mϕs in adoptive immunotherapy for cancer, illustrate the reciprocating interplay between cancer and Mϕs, and the resulting structural and functional change on both cell types. Furthermore, we summarize the recent cutting-edge approaches of using Mϕs in cancer immunotherapy.

Therapeutic potential of regulatory macrophages generated from peritoneal dialysate in adriamycin nephropathy

Cell therapy using macrophages requires large amounts of cells, which are difficult to collect from patients. Patients undergoing peritoneal dialysis (PD) discard huge numbers of peritoneal macrophages in dialysate daily. Macrophages can be modulated to become regulatory macrophages, which have shown great promise as a therapeutic strategy in experimental kidney disease and human kidney transplantation. This study aimed to examine the potential of using peritoneal macrophages (PMs) from peritoneal dialysate to treat kidney disease. Monocytes/macrophages accounted for >40% of total peritoneal leukocytes in both patients and mice undergoing PD. PMs from patients and mice undergoing PD were more mature than peripheral monocytes/macrophages, as shown by low expression of C-C motif chemokine receptor 2 (CCR2) and morphological changes during in vitro culture. PMs from patients and mice undergoing PD displayed normal macrophage function and could be modulated into a regulatory (M2) phenotype. In vivo, adoptive transfer of peritoneal M2 macrophages derived from PD mice effectively protected against kidney injury in mice with adriamycin nephropathy (AN). Importantly, the transfused peritoneal M2 macrophages maintained their M2 phenotype in kidney of AN mice. In conclusion, PMs derived from patients and mice undergoing PD exhibited conventional macrophage features. Peritoneal M2 macrophages derived from PD mice are able to reduce kidney injury in AN, suggesting that peritoneal macrophages from patients undergoing PD may have the potential for clinical therapeutic application.

Function of miR-146a-5p in Tumor Cells As a Regulatory Switch between Cell Death and Angiogenesis: Macrophage Therapy Revisited

Tumors survive and progress by evading killing mechanisms of the immune system, and by generating a tumor microenvironment (TME) that reprograms macrophages in situ to produce factors that support tumor growth, angiogenesis, and metastasis. We have previously shown that by blocking the translation of the enzyme inducible nitric oxide synthase (iNOS), miR-146a-5p inhibits nitric oxide (NO) production in a mouse renal carcinoma cell line (RENCA), thereby endowing RENCA cells with resistance to macrophage-induced cell death. Here, we expand these findings to the mouse colon carcinoma CT26 cell line and demonstrate that neutralizing miR-146a-5p's activity by transfecting both RENCA and CT26 cells with its antagomir restored iNOS expression and NO production and enhanced susceptibility to macrophage-induced cell death (by 48 and 25%, respectively, p < 0.001). Moreover, miR-146a-5p suppression simultaneously inhibited the expression of the pro-angiogenic protein EMMPRIN (threefolds, p < 0.001), leading to reduced MMP-9 and vascular endothelial growth factor secretion (twofolds and threefolds, respectively, p < 0.05), and reduced angiogenesis, as estimated by in vitro tube formation and scratch assays. When we injected tumors with pro-inflammatory-stimulated RAW 264.7 macrophages together with i.v. injection of the miR-146a-5p antagomir, we found inhibited tumor growth (sixfolds, p < 0.001) and angiogenesis (twofolds, p < 0.01), and increased apoptosis (twofolds, p < 0.01). This combination therapy increased nitrites and reduced TGFβ concentrations in tumor lysates, alleviated immune suppression, and allowed enhanced infiltration of cytotoxic CD8⁺ T cells. Thus, miR-146a-5p functions as a control switch between angiogenesis and cell death, and its neutralization can manipulate the crosstalk between tumor cells and macrophages and profoundly change the TME. This strategy can be therapeutically utilized in combination with the macrophage therapy approach to induce the immune system to successfully attack the tumor, and should be further explored as a new therapy for the treatment of cancer.

Macrophage-based cell therapies: The long and winding road

In the quest for better medicines, attention is increasingly turning to cell-based therapies. The rationale is that infused cells can provide a targeted therapy to precisely correct a complex disease phenotype. Between 1987 and 2010, autologous macrophages (MΦs) were used in clinical trials to treat a variety of human tumors; this approach provided a modest therapeutic benefit in some patients but no lasting remissions. These trials were initiated prior to an understanding of: the complexity of MΦ phenotypes, their ability to alter their phenotype in response to various cytokines and/or the environment, and the extent of survival of the re-infused MΦs. It is now known that while inflammatory MΦs can kill tumor cells, the tumor environment is able to reprogram MΦs into a tumorigenic phenotype; inducing blood vessel formation and contributing to a cancer cell growth-promoting milieu. We review how new information enables the development of large numbers of ex vivo generated MΦs, and how conditioning and gene engineering strategies are used to restrict the MΦ to an appropriate phenotype or to enable production of therapeutic proteins. We survey applications in which the MΦ is loaded with nanomedicines, such as liposomes ex vivo, so when the drug-loaded MΦs are infused into an animal, the drug is released at the disease site. Finally, we also review the current status of MΦ biodistribution and survival after transplantation into an animal. The combination of these recent advances opens the way for improved MΦ cell therapies.

Therapy of peritoneally disseminated colon cancer by TAP-deficient embryonic stem cell-derived macrophages in allogeneic recipients

We established a method to generate a large quantity of myeloid lineage cells from mouse embryonic stem (ES) cells, termed ES cell-derived proliferating myeloid cell lines (ES-ML). ES-ML continuously proliferated in the presence of M-CSF and GM-CSF. ES-ML genetically modified to express an anti-HER2 (neu) mAb single-chain V region fragment reduced the number of cocultured mouse Colon-26 cancer cells expressing HER2. Stimulation of ES-ML with IFN-γ plus LPS or TNF resulted in almost complete killing of the Colon-26 cells by the ES-ML, and the cytotoxicity was mediated, in part, by NO produced by ES-ML. When ES-ML were injected into mice with i.p. established Colon-26 tumors, they efficiently infiltrated the tumor tissues. Injection of ES-ML with rIFN-γ and LPS inhibited cancer progression in the mouse peritoneal cavity. Coinjection of TNF-transfected or untransfected ES-ML with rIFN-γ inhibited cancer growth and resulted in prolonged survival of the treated mice. In this experiment, transporter associated with Ag processing (TAP)1-deficient ES-ML exhibited therapeutic activity in MHC-mismatched allogeneic recipient mice. Despite the proliferative capacity of ES-ML, malignancy never developed from the transferred ES-ML in the recipient mice. In summary, TAP-deficient ES-ML with anticancer properties exhibited a therapeutic effect in allogeneic recipients, suggesting the possible use of TAP-deficient human-induced pluripotent stem cell-derived proliferating myeloid cell lines in cancer therapy.

Immunomodulatory effects of interferons in malignancies

Investigation of the antitumor and immunomodulatory activities of interferon (IFN) began shortly after the cytokine was discovered in 1957. Early work showed a direct correlation between administration of IFN and inhibition of symptoms associated with virally induced leukemia in mice as well as an increase in their survival time. Subsequent studies with purified IFNs confirmed the direct and indirect stimulation of immune cells, resulting in antitumor activities of IFN. Clinically, IFN-alphas (αs) have been shown to have activity against a variety of tumors. Initially, the U.S. Food and Drug Administration licensed 2 recombinant IFN-αs for the treatment of hairy-cell leukemia and then later for several other cancers. The success rate seen with IFNs and certain tumors has been varied. Unfortunately, some neoplasms show no response to IFN. Monocytes/macrophages play an important role in cancer progression. Monocytes in combination with IFN may be an important therapy for several cancers. This article focuses on the role of IFN and monocytes alone or in combination in affecting malignancies.

Imaging of cellular therapies

Cellular therapy promises to revolutionize medicine, by restoring tissue and organ function, and combating key disorders including cancer. As with all major developments, new tools must be introduced to allow optimization. For cell therapy, the key tool is in vivo imaging for real time assessment of parameters such as cell localization, numbers and viability. Such data is critical to modulate and tailor the therapy for each patient. In this review, we discuss recent work in the field of imaging cell therapies in the clinic, including preclinical work where clinical examples are not yet available. Clinical trials in which transferred cells were imaged using magnetic resonance imaging (MRI), nuclear scintigraphy, single photon emission computed tomography (SPECT), and positron emission tomography (PET) are evaluated from an imaging perspective. Preclinical cell tracking studies that focus on fluorescence and bioluminescence imaging are excluded, as these modalities are generally not applicable to clinical cell tracking. In this review, we assess the advantages and drawbacks of the various imaging techniques available, focusing on immune cells, particularly dendritic cells. Both strategies of prelabeling cells before transplant and the use of an injectable label to target cells in situ are covered. Finally, we discuss future developments, including the emergence of multimodal imaging technology for cell tracking from the preclinical to the clinical realm.

Quantitative magnetic resonance and SPECT imaging for macrophage tissue migration and nanoformulated drug delivery

We posit that the same mononuclear phagocytes (MP) [bone marrow (BM) and blood monocytes, tissue macrophages, microglia, and dendritic cells] which serve as targets, reservoirs, and vehicles for HIV dissemination, can be used as vehicles for antiretroviral therapy (ART). Toward this end, BM macrophages (BMM) were used as carriers for nanoparticle-formulated indinavir (NP-IDV), and the cell distribution was monitored by single photon emission computed tomography (SPECT), transverse relation time (T2)* weighted magnetic resonance imaging (MRI), histology, and gamma-scintillation spectrometry. BMM labeled with super paramagnetic iron oxide and/or 111indium oxine were infused i.v. into naïve mice. During the first 7 h, greater than 86% of cell label was recorded within the lungs. On Days 1, 3, 5, and 7, less than 10% of BMM were in lungs, and 74-81% and 13-18% were in liver and spleen, respectively. On a tissue volume basis, as determined by SPECT and MRI, BMM densities in spleen and liver were significantly greater than other tissues. Migration into the lymph nodes on Days 1 and 7 accounted for 1.5-2% of the total BMM. Adoptive transfer of BMM loaded with NP-IDV produced drug levels in lymphoid and nonlymphoid tissues that exceeded reported therapeutic concentrations by 200- to 350-fold on Day 1 and remained in excess of 100- to 300-fold on Day 14. These data show real-time kinetics and destinations of macrophage trafficking and demonstrate the feasibility of monitoring macrophage-based, nanoformulated ART.

Immunotherapy of lung cancer: an update

In Germany lung cancer is the leading cause of cancer-associated death in men. Surgery, chemotherapy and radiation may enhance survival of patients suffering from lung cancer but the enhancement is typically transient and mostly absent with advanced disease; eventually more than 90% of lung cancer patients will die of disease. New approaches to the treatment of lung cancer are urgently needed. Immunotherapy may represent one new approach with low toxicity and high specificity but implementation has been a challenge because of the poor antigenic characterization of these tumors and their ability to escape immune responses. Several different immunotherapeutic treatment strategies have been developed. This review examines the current state of development and recent advances with respect to non-specific immune stimulation, cellular immunotherapy (specific and non-specific), therapeutic cancer vaccines and gene therapy for lung cancer. The focus is primarily placed on immunotherapeutic cancer treatments that are already in clinical trial or well progressed in preclinical studies. Although there seems to be a promising future for immunotherapy in lung cancer, presently there is not standard immunotherapy available for clinical routine.

Anti-tumor properties of human-activated macrophages produced in large scale for clinical application

When properly activated, macrophages can be tumoricidal. To harness the therapeutic potential of these cells, we have developed a process for ex vivo production of large numbers of IFN-gamma-activated monocyte-derived macrophages. These monocyte-derived activated killer (MAK) cells have been safely administered to cancer patients with minimal residual disease in phase I/II clinical studies. To evaluate efficacy of treatment with MAK cells, phase III clinical studies are necessary. The process of MAK cell production has been further optimized and qualified for use in large cohorts of patients. In this study, we characterized MAK cells produced in large scale by studying their phenotype and functions. MAK cells were shown to exert anti-tumor activity by killing tumor cells and inhibiting their proliferation. These activities were enhanced by activation with IFN-gamma and addition of anti-tumor antibodies. Tumor necrosis factor-alpha (TNF-alpha) was one of the mediators used by MAK cells to inhibit tumor proliferation. To facilitate logistics of clinical trials, a process for MAK cell cryopreservation has been developed. We verified in vitro that cryopreserved cells retained the activity of fresh cells and were stable during storage. The safety and efficacy of cryopreserved MAK cells (Bexidem) are currently being assessed on superficial bladder cancer patients in a phase II/III clinical trial.

Mechanisms regulating the recruitment of macrophages into hypoxic areas of tumors and other ischemic tissues

The mechanisms responsible for recruiting monocytes from the bloodstream into solid tumors are now well characterized. However, recent evidence has shown that these cells then differentiate into macrophages and accumulate in large numbers in avascular and necrotic areas where they are exposed to hypoxia. This parallels their tendency to congregate in ischemic areas of other diseased tissues such as atherosclerotic plaques and arthritic joints. In tumors, macrophages appear to undergo marked phenotypic changes when exposed to hypoxia and to switch on their expression of a number of mitogenic and proangiogenic cytokines and enzymes. This then promotes tumor growth, angiogenesis, and metastasis. Here, we compare the various mechanisms responsible for monocyte recruitment into tumors with those regulating the accumulation of macrophages in hypoxic/necrotic areas. Because the latter are best characterized in human tumors, we focus mainly on these but also discuss their relevance to macrophage migration in ischemic areas of other diseased tissues. Finally, we discuss the relevance of these mechanisms to the development of novel cancer therapies, both in providing targets to reduce the proangiogenic contribution made by hypoxic macrophages in tumors and in developing the use of macrophages to deliver therapeutic gene constructs to hypoxic areas of diseased tissues.

Potent stimuli combined with lipopolysaccaride and IFNgamma may improve immunotherapy against HCC by increasing the maturation and subsequent immune response of the dendritic cells

Dendritic cells (DCs)-based immunotherapy is a new strategy for cancer treatment and has been used in some clinical trials against cancer, including melanoma, and has shown promising results. However, the conventional protocol of DC immunotherapy may not be effective for hepatocellular carcinoma (HCC) because of impaired DC maturation in HCC patients. In order to induce sufficient maturation on HCC derived DCs, we tested various stimuli such as tumor necrosis factor (TNF) alpha, lipopolysaccharide (LPS), interferon (IFN)gamma and CD40-ligand. In stimulating with LPS + IFNgamma, DCs of HCC patients expressed significantly high levels of CD86 (p < 0.05) and produced high levels of IL-12 as compared to DCs stimulated with TNFalpha alone. Moreover, it showed better ability to stimulate allogeneic mixed lymphocyte reaction. It concluded that LPS and IFNgamma was the best combination of stimuli for induction of sufficient maturation on DCs derived from HCC.

Local immunostimulation induced by intravesical administration of autologous interferon-gamma-activated macrophages in patients with superficial bladder cancer

We conducted a phase I/II clinical trial of the safety and efficacy of intravesical administration of autologous IFN-gamma-activated macrophages (MAK) in patients with superficial bladder cancer. Monocyte-derived MAK cells were prepared in vitro and patients received six instillations of 1.4 x 10(8) to 2.5 x 10(8) cells, once a week, for five consecutive weeks. Treatment was well tolerated, with seven grade 1 and five Grade 2 protocol-related adverse effects. Nine out of 17 included patients had no recurrences during the year following the first instillation of MAK. The aim of the present study was to search for immune parameters related to local immunostimulation induced by MAK. Monitoring of the patients showed that urinary IL-8, GM-CSF and, to a lesser extent, IL-18 were increased following MAK instillations, with inter-individual differences. The urinary IL-8 level was about 10-fold higher than that observed for other cytokines, and its biological activity was reflected by a concomitant increase of urinary elastase, indicating neutrophil activation and degranulation. We also showed that nine out of 12 patients investigated presented an increase of urinary neopterin, a marker of IFN-gamma-activated macrophages, 7 days after MAK instillation, while serum neopterin levels were almost stable. These results are in line with persistence of activated macrophages in the bladder wall after infusions. Moreover, there was evidence of macrophages in urine smears 2 months after the sixth MAK instillation, and the score of macrophages correlated with the quantity of neutrophils in the urine. Overall, this study provides evidence of a local immunostimulation induced by this novel and safe immunotherapeutic approach of MAK instillations in patients with superficial bladder cancer.

Treatment of metastatic renal cell carcinoma with activated autologous macrophages and granulocyte--macrophage colony-stimulating factor

Fifteen patients with progressive metastatic renal cell carcinoma were treated with granulocyte-macrophage colony-stimulating factor and intravenous infusions of activated autologous macrophages (AAMs). The latter were prepared from leukapheresis-separated mononuclear cells cultured in the presence of granulocyte-macrophage colony-stimulating factor, exposed to gamma interferon, and submitted to elutriation to separate AAMs. Three intravenous injections of AAMs were performed within a 2-week interval. This treatment cycle was repeated once or twice, in cases of tumor response or stabilization. Ninety-seven preparations containing a mean 3 x 10(9) AAMs were administered and usually well tolerated. One partial response, eight stabilizations and six progressions were observed. The median time to progression and median overall survival time after inclusion were 7 and 9 months, respectively. The cells injected did not accumulate substantially in tumor lesions, as shown by scintigraphic imaging of indium-111-labeled AAMs. Thus, combined granulocyte-macrophage colony-stimulating factor and AAM treatment was well tolerated and resulted in transitory stabilization (n = 8) or partial regression (n = 1) in 9 of 15 patients.

[Adoptive immunotherapy: evaluation and perspectives in the treatment of certain cancers]

INTRODUCTION

Adoptive immunotherapy was first introduced in the 1980s. This new anticancer therapeutic approach has already demonstrated promising results in both animal models and humans affected by various tumors.

CURRENT KNOWLEDGE AND KEY POINTS

This review summarizes the requirements of such therapies involving either activated lymphocytes, tumor-infiltrating lymphocytes or activated macrophages. It focuses more particularly on the promising approaches that represent antigen presenting cells such as macrophages and antigen-loaded dendritic cells in the development of safe and effective cancer vaccines.

FUTURE PROSPECTS AND PROJECTS

Standardized procedures for macrophages and dendritic cell generation, as well as preliminary results of clinical applications in patients with either prostate cancer or melanoma, are also discussed.

In vitro generation of dendritic cells from human blood monocytes in experimental conditions compatible for in vivo cell therapy

DC are professional APC that are promising adjuvants for clinical immunotherapy. Methods to generate in vitro large numbers of functional human DC using either peripheral blood monocytes or CD34+ pluripotent HPC have been developed recently. However, the various steps of their in vitro production for further clinical use need to fit good manufacturing practice (GMP) conditions. Our study focused on setting up such a full procedure, including collection of mononuclear cells (MNC) by apheresis, separation of monocytes by elutriation, and culture of monocytes with GM-CSF + IL-13 + autologous serum (SAuto) in sterile Teflon bags. The procedure was first developed with apheresis products from 7 healthy donors. Its clinical feasibility was then tested on 7 patients with breast cancer. The characteristics of monocyte-derived DC grown with SAuto (or in some instances with a pooled AB serum) were compared with those obtained in the presence of FBS by evaluation of their phenotype, their morphology in confocal microscopy, and their capacity to phagocytize latex particles and to stimulate allogeneic (MLR) or autologous lymphocytes (antigen-presentation tests). The results obtained demonstrate that the experimental conditions we set up are easily applicable in clinical trials and lead to large numbers of well-defined SAuto-derived DC as efficient as those derived with FBS.

Immunoregulating properties of peptides related to tumor rejection antigens: effect on human monocytes and natural killer cells

The authors analyzed the effect of several 15-amino acid peptides with sequences related to tumor-rejection antigens, tyrosinase, and the MAGE family on peripheral blood mononuclear cells from healthy donors cultured for periods of 1 to 7 days. Some of these peptides promoted stimulation of monocytes, manifested by phenotypic changes, release of interleukin (IL)-1a, IL-6, and tumor necrosis factor-alpha, and induction of nitric oxide synthase on differentiated CD14++/+ CD16+ DR++ monocytes. An increase in the percentage of cytotoxic monocytes (CD14+/- CD16+) containing granule-associated DNase activity was also observed. Active peptides induced the release of IL-2 and interferon-gamma. Nonspecific natural killer and lymphokine-activated killer cell-mediated cytotoxicity was also observed against classical target cell lines (K-562 and Daudi) and allogenic melanoma cell lines AC and BB, together with an increase in granule-associated DNase in the natural killer cell-enriched population. Monocytes were needed to enhance this innate response, because peptides failed to induce the release of IL-2 on monocyte-depleted peripheral blood mononuclear cells. Data show an enhancement of the rapid innate immune response by peptides related to tumor rejection antigens and suggest that they could also determine the nature of a slow and more definitive specific immune response against tumor cells.

Coexpression of tissue factor and tissue factor pathway inhibitor by human monocytes purified by leukapheresis and elutriation. Response of nonadherent cells to lipopolysaccharide

BACKGROUND

Counterflow centrifugal elutriation is the method of choice for obtaining a large quantity of highly purified monocytes. In spite of the fact that this technique has been used for many years to isolate monocytes for cellular immunotherapy, it is not known whether the process of elutriation can stimulate tissue factor (TF) expression and therefore trigger coagulation in patients receiving these cell preparations. The aim of the present study is thus to identify TF and TF pathway inhibitor (TFPI) in elutriated monocytes and to evaluate their ability to trigger thrombin generation.

STUDY DESIGN AND METHODS

Human monocytes are separated by leukapheresis and elutriation in sterile, endotoxin-free conditions. TF and TFPI mRNA is detected by reverse transcription-polymerase chain reaction. TF and TFPI are measured by enzyme-linked immunosorbent assay in cell lysates. TF antigen expression on cell surface is evidenced by direct-flow cytometry. Two functional tests (a chronometric test and an amidolytic assay) assess the capacity of monocytes to trigger thrombin generation. The response to lipopolysaccharide (LPS) is evaluated with each technique. Monocytic cell line THP-1 is used as a positive control.

RESULTS

Elutriated monocytes coexpress TF mRNA and TFPI mRNA. The expression of TF mRNA is dramatically increased by LPS activation. This is correlated with a 100-fold increase in the amount of TF antigen in monocyte lysates. Flow immunocytometry confirms the expression of TF antigen on cell membrane in response to LPS stimulation, whereas TFPI mRNA is slightly increased after LPS stimulation. The amount of TFPI antigen in cell lysates is small when compared to that in plasma. Elutriated monocytes have a strong potential to trigger thrombin generation in response to LPS.

CONCLUSION

In spite of the coexpression of TF mRNA and TFPI mRNA, elutriated monocytes are capable of supporting prothrombinase activity. This should be taken into account in the evaluation of the safety of adoptive cellular immunotherapy.

Autologous human macrophages and anti-tumour cell therapy

Most technical problems concerning the production of human macrophages have been resolved by cultures in hydrophobic plastic, gas-permeable bags. This process enables collection of non-adherent macrophages and is well adapted to the safety requirements of cell therapy. Under optimized culture conditions, about one billion macrophages are currently obtained from a single leukapheresis product. In most clinical trials, macrophages have been activated by interferon-gamma (IFNgamma). The injections have little or no toxic effect. The anti-tumour activity of the intravenous (i.v.) administrations is more pronounced in certain protocols than in others. The mechanism remains poorly understood. In vitro, the cytolytic effect of macrophages requires cell-to-cell contact but macrophages injected i.v. show no particular tropism for tumour tissue. This could result from modifications in adhesion molecules occurring during monocyte-macrophage differentiation which might modify recruitment in inflammatory foci. Macrophages can, however, infiltrate tumour cell clusters, which could explain their improved efficacy when injected intratumorally (i.t.). Moreover, several arguments would favour the use of macrophages as human tumour antigen-presenting cells (APCs). In vitro, macrophages are as efficient as monocyte-derived dendritic cells (MDDCs) in stimulating cytotoxic T lymphocyte (CTL) clones or circulating CTL precursors.

Immunotherapy in lung cancer

More research and new treatment options are needed in all stages of lung cancer. To this end immunotherapy needs a revival in view of recent improved technologies and greater understanding of the underlying biology. In this review we discuss mechanisms of tumour immunotherapy, non-specific, specific and adoptive, with particular reference to a direct therapeutic action on all subtypes of lung cancer.

Use of cellular and cytokine adjuvants in the immunotherapy of cancer

Cellular and cytokine adjuvants, often immune effector cells and soluble factors, respectively, are supplemental and/or follow-up treatments of human origin for cancer patients who have unsatisfactory clinical responses to conventional chemotherapy, radiotherapy, and surgery. Since many human studies with these reagents are in their infancy, extensive data collection is only now being performed to determine which strategy provides the greatest therapeutic benefit. Research published in the literature since the genesis of this approach to cancer treatment is summarized in this report. Methodologies attempting to generate anticancer responses by provoking or enhancing the patient's own immune system are new compared with the other standard types of cancer treatment. Although a few encouraging human studies can be discussed, many of the most promising techniques are only now being transferred from the laboratory to the clinic. The administration of immune effector cells in combination with immunomodulators, such as interferons or interleukins, often enhances clinical outcome. The literature cited in this report indicate that immune-cell- and cytokine-based therapies hold promise in our attempts to improve the quality and duration of life in those with cancer. With each report reaching the literature, more effective clinical trials are being designed and implemented.

Monocyte/macrophages as effector cells in cancer immunotherapy

Among the different strategies which have been developed for immunotherapy of cancer, adoptive immunotherapy uses leucocytes activated in vitro and reinfused into the patients. Five leucocytes subsets can be employed for this immunotherapy with activated autologous cells. Blood monocytes can be isolated in high purity and large numbers and under special culture conditions differentiated into macrophages for adoptive transfer. Once activated ex vivo, these cells display very high antibody dependent and independent specific cytotoxicity for tumour cells, are capable of phagocytosis of cancer cells and, as antigen presenting, cells are able to involve CTL in the anticancer response. As the understanding of this activation to cytotoxicity is only recent, the present paper first provides a literature review of the main points in the field. Our own results are then discussed in relation to the development of a clinical protocol for adoptive transfer of MAK (macrophage activated killer) cells, a therapeutic strategy having a pivotal role in the immunosurveillance of cancer.

Mistletoe lectins I, II and III induce the production of cytokines by cultured human monocytes

The three mistletoe (Viscum album L.) lectins. ML I, ML II and ML III, were tested on their ability to enhance the secretion of the cytokines tumor necrosis factor (TNF)alpha, interleukin (IL)-1 alpha, IL-1 beta and IL-6 by human monocytes obtained from healthy donors. At lectin concentrations from 0.02 to 20/pg ml (100-10,000-fold lower than those showing toxic effects), stimulations of cytokine production several-fold over control values were observed. The immunoactivating concentrations by the three lectins were found different for each donor. At toxic concentrations, the amounts of IL-1 alpha, IL-1 beta and to a less extent of TNF alpha in monocytes supernatants were particularly high. The data are discussed in relationship with the cytotoxic and immunoactivating effects of mistletoe lectins and their interest in cancer treatment.

Phase I/II trial of autologous activated macrophages in advanced colorectal cancer

Autologous activated macrophage (AAM) therapy is an adoptive cellular therapy based on ex vivo differentiation and activation of autologous peripheral blood monocytes. This study was undertaken to evaluate the tolerance, efficiency and biological effects of AAMs in chemoresistant progressive colorectal cancers. From January 1993 to May 1995, 15 patients were treated. Mononuclear cells were collected six times by weekly apheresis, cultured for 7 days, and activated with interferon-gamma. AAMs were then separated by elutriation and re-infused intravenously, with a mean total of 7.95 x 10(9) macrophages per patient. Clinical tolerance was good: toxicity consisted only of a World Health Organisation grade 2 fever after 28% of the infusions. Responses were not seen in the 14 evaluable patients, as expected with very bulky tumours: in 11, the tumours continued to progress, but disease was stabilised in 3 patients who experienced progression-free survival for 14, 12 and 12 weeks, respectively.

Immune therapy with macrophages: present status and critical requirements for implementation

Adoptive transfer of activated macrophages has been validated in animal experimental tumor models; clinical trials are ongoing (70 patients up to now). The mechanisms involved are reviewed as well as improved and standardized procedures for macrophage differentiation and activation. New developments including specific Ag presentation and gene therapy are discussed.

Biological treatment of NSCLC. The need for conclusive studies

Despite extensive investigation, biological treatments for non-small cell lung cancer (NSCLC) remain largely undeveloped. The lack of satisfactory models has frequently led to inadequate phase II studies and to small and inconclusive phase III trials. Nonuniformity of trials has prevented clearer conclusions from being reached by meta-analysis. In general, immunotherapy has failed to fulfill expectations for clinical usefulness. The benefit with this approach, if any, seems to be marginal, but it is not clear whether this is a result of lack of activity or faulty clinical testing. The future of biological agents in cancer treatment lies in ongoing advances in molecular biology, for example in making tumors more immunogenic. Another avenue of further clinical research includes novel forms of therapy with monoclonal antibodies. Adequate models for testing and appropriate clinical trial settings could clarify the role of biological agents in NSCLC.

Fate of mouse macrophages radiolabelled with PKH-95 and injected intravenously

Mouse macrophages purified by elutriation from thioglycollate-induced peritoneal exudate cells were labelled with indium-111-oxine and injected intravenously into mice. A substantial amount of unbound radioactivity remained in the circulation, suggesting that the radionuclide was not stably bound to the cells. Culture experiments with radiolabelled cells showed that indium-111 was released in the medium. Another cell marker, PKH-95, an iodine-125-labelled aliphatic compound insertable into the cell membrane, bound more stably than indium-111. Five minutes after injection of 125I-PKH-95-labelled macrophages, about 98% of the cells were in a non-circulating pool. It was checked that PKH-95 labelling did not compromise the viability and functions of the macrophages and that autologous erythrocytes and blood mononuclear cells labelled with PKH-95 remained in the circulation after i.v. injection. One hour after injection, 125I-PKH-95-labelled macrophages were distributed mainly in lung (36%), liver (19%) and spleen (5%). Subsequently, radioactivity decreased in the lung while increasing in liver, spleen and in an artificially induced footpad inflammation. The radioactivity accumulation in the inflammation persisted at least for 7 days. It represented a small proportion of radioactivity injected (0.2%) but was trapped very specifically in the inflammation. This raised the hypothesis that macrophages of the non-circulating pool could be released in the circulation and recruited into the inflammation with slow kinetics.

Eicosanoids and the immunology of cancer

Studies in both cancer patients and in animal tumor models have shown that immune defenses can mediate destruction of tumor, but these defenses are often functioning at a suppressed or suboptimal level. Frequently, prostaglandins, mainly PGE2, have been implicated in this tumor-associated subversion of immune function, with immune reactivities to tumor typically being enhanced by prostaglandin synthesis inhibitor. Both the tumor and tumor-induced host immune suppressive macrophages have the capacity to suppress immune functions through their production of PGE2. Although the inhibitory functions have been more widely studied, recent evaluations of the effects of PGE2 have led to the surprising realization that not all of the PGE2's effects are inhibitory to immune function. Summarized below are some of the well characterized inhibitory effects of PGE2, as well as the lesser studied stimulatory effects of PGE2 toward the effector cells that are considered to be important in the immune defense against cancer.

Interactions between human macrophages and tumor cells in three-dimensional cultures

Human blood mononuclear cells were cultured for 7 days in hydrophobic plastic bags. Macrophages differentiated from monocytes and purified by elutriation were then cocultured with round-shaped aggregates of epithelial cells (spheroids). Spheroids prepared from the SK-MES-1 carcinoma cell line were cultured individually, under constant stirring, in multiwell plates coated with agarose. Macrophage/spheroid interactions were investigated under various experimental conditions. Macrophages activated with interferon gamma aggregated to each other and to spheroids, in contrast to control unactivated macrophages. Histological examination, after staining with a macrophage-specific monoclonal antibody, showed that both control and interferon-gamma-activated macrophages migrated between epithelial tumor cells and infiltrated the spheroids. The addition of anti-ICAM-1 monoclonal antibody inhibited macrophage homotypic aggregation as well as aggregation to and penetration into spheroids. The macrophages did not exert cytolytic effects, as judged by a chromium-51 release assay, but provoked a diminution of tritiated thymidine incorporation by tumor cells. Cytostatic activity was observed with effector: target ratios as low as 1:16, and was maximal (99% at a 1:1 E:T ratio) with macrophages differentiated in the presence of granulocyte/macrophage-colony-stimulating factor. The cytostatic effect was not related to tumor necrosis factor alpha secretion.

Large scale isolation of human blood monocytes by continuous flow centrifugation leukapheresis and counterflow centrifugation elutriation for adoptive cellular immunotherapy in cancer patients

The increasing interest in mononuclear phagocytes for adoptive cellular immunotherapy (ACI) trials in cancer patients led us to define a procedural approach to harvest reproducibly highly purified single-cell suspensions of large numbers of functional human circulating blood monocytes (Mo). A semiclosed counterflow centrifugal elutriation (CCE) system has been developed, using a new large capacity Beckman JE 5.0 rotor with one interchangeable 40 ml or 5 ml separation chamber, to purify Mo from mononuclear cell (MNC) concentrates of healthy donors and cancer patients obtained by continuous flow centrifugation leukapheresis (CFCL). This method does not require a Ficoll density gradient centrifugation step. A total of 115 leukapheresis procedures were carried out in 35 patients and in 30 healthy donors by either Cobe 2997 or Cobe Spectra, with a similar efficiency in MNC apheresis. The average yield per leukapheresis procedure was 5.6 x 10(9) MNC of purity 90-100% (25-45% Mo, 40-65% lymphocytes). The average yields per elutriation procedure (R/O fraction) were 1.1 x 10(9) cells (purity 93% Mo) using the 5 ml separation chamber, and 1.5 x 10(9) cells (purity 91%) using the 40 ml separation chamber, with a respective recovery of 82 +/- 7% and 78 +/- 8% Mo. In vitro analysis of the viability and function of the purified Mo shows that neither morphological integrity nor physiological activity was compromised by this two-step isolation procedure, which additionally provides highly purified human Mo suspensions, in a quantity suitable for ACl of cancer patients.

In vitro purging of clonogenic leukaemic cells from human bone marrow by interferon-gamma-activated monocytes

With a view to the immunologically mediated purging of autologous bone marrow transplants in acute myeloid leukaemia, the efficacy of cytotoxic monocytes to eradicate leukaemic cells has been studied using clonogenic assays. U937 cells were found to be sensitive to highly purified and interferon-gamma-activated human monocytes whereas HL60 cells were rather resistant as measured in an MTT-based cytotoxicity assay under liquid conditions. A spectrophotometric clonogenic assay measured almost complete inhibition of clonogenic activity for U937 cells at low effector-to-target cell (E/T) ratios of at least 0.1. Limiting dilution analysis detected a 2-3 log10 unit reduction in clonogenic activity. In an experimental mixture of U937 cells with a 20-fold excess of normal bone marrow nuclear cells a maximum 2-log10-unit killing could be measured at E/T = 10. Only at high E/T ratios could a reduction in granulocyte/macrophage-colony-forming units (cfu) be observed with only marginal effects on erythroid cfu and erythroid burst-forming. In conclusion, cytotoxic monocytes are highly potent anti-leukaemic effector cells, as measured in clonogenic assays, that do not compromise normal human progenitors.

Identification and activation of tumor-reactive cells for adoptive immunotherapy

The use of adoptive immunotherapy to treat cancer has several potential advantages. Although extensive evaluation has been undertaken, issues regarding the source of cells and methods of ex vivo activation continue to be controversial. A number of potential effector cells, including natural killer cells, monocytes/macrophages, cytolytic T cells and helper T cells, are exploitable and are the focus of clinical trials. A number of methods of activating these cells, including the use of recombinant cytokines, tumor cells, monoclonal antibodies, and gene insertion, have been developed. Varying specificities, trafficking and lytic potentials have been observed. In addition, the logistics of activating and expanding the various effectors ex vivo vary considerably. Although the optimal methods of identifying and activating cells have not been established, adoptive therapy with immunologically active cells can effect clinically significant responses in selected patients. Efforts to build upon the initial preclinical and clinical observations are in progress.

Autologous lymphocytes prevent the death of monocytes in culture and promote, as do GM-CSF, IL-3 and M-CSF, their differentiation into macrophages

Blood monocytes collected by apheresis from healthy donors were differentiated in vitro to macrophages which were subsequently activated with recombinant human interferon-gamma. 7 day cultures were established by seeding Ficoll-separated mononuclear cells or elutriation-purified monocytes under different culture conditions. The best macrophage yields required the seeding of mononuclear cells (instead of purified monocytes) in teflon bags with a high air-liquid surface interface. The effects of GM-CSF, IL-3 and M-CSF on the macrophage yield were then evaluated. GM-CSF increased the average yield by 3.6- and 2.3-fold when purified monocytes or total mononuclear cells were seeded respectively. The corresponding increases with IL-3 were 2.5- and 2.1-fold respectively and with M-CSF 1.2- and 1.4-fold respectively. Macrophages matured under these various conditions displayed similar CD14, CD64, CD71, HLA-DR and Max 1 antigen expression and similar in vitro anti-tumoral activity against U937 cells. Culturing in the presence of cytokines permits the large scale production of activated macrophages for adoptive immunotherapy trials.

The cellular composition in the peritoneal cavity and the cytotoxic function of the peritoneal cells from patients with ovarian cancer; effect of tumor necrosis factor-alpha treatment

In patients with epithelial ovarian cancer (EOC), the cellular composition in the peritoneal cavity and the functional capacities of the peritoneal cells (PC) are unknown. Especially the peritoneal macrophages (m phi) could play an important role in defense against tumor cells. To study the cellular composition in the peritoneal cavity and the functional capacities of PC, these cells were obtained from three patients with EOC. The PC were immunophenotyped and tested functionally in vitro in a cytotoxicity assay. One of the patients was treated intraperitoneally (i.p.) with a single dose of 0.06 mg/m2 tumor necrosis factor-alpha (TNF-alpha). PC were obtained before the treatment, after 24 h and after 1 week. PC from healthy women undergoing laparoscopic sterilization served as controls. It appeared that patients with EOC have a lower percentage of macrophages (m phi) in the peritoneal cavity than healthy persons. These m phi of patients were also less capable of killing U 937 tumor cells as compared to the peritoneal m phi of control persons. However, in the patient treated i.p. with TNF-alpha the cytotoxic capacities of the peritoneal m phi were strongly improved. The percentage cytotoxicity at an effector to target ratio of 10, increased from 17% to 80%. Thus, the peritoneal m phi in this patient were activated in vivo to a tumoricidal state. These findings indicate that PC in patients with EOC differ from controls, but further investigation is necessary to define the contribution of the disease and/or prior chemotherapy to this defect.

Hemostatic changes in human adoptive immunotherapy with activated blood monocytes or derived macrophages

Human blood monocytes (Mo) and monocyte-derived macrophages (M psi) possess cytotoxic effects against tumor cell lines when appropriately stimulated by various biological response modifiers, e.g., gamma interferon (gamma IFN) and muramyltripeptide (MTP). Activated Mo/M psi represent a new tool for the treatment of human malignancies, termed "adoptive cellular immunotherapy". Activated Mo/M psi express tissue factor procoagulant activity (PCA), which is a physiological trigger of blood coagulation. PCA was evaluated in vitro using a modification of the one-stage recalcification clotting time, and hemostatic changes were studied in vivo in cancer patients. Nine patients with peritoneal carcinomatosis were injected intraperitoneally with activated Mo and 11 patients with non-small cell lung carcinomas were infused intravenously with activated M psi. Hemostatic changes were followed using activated partial thromboplastin time (APTT), prothrombin time (PT), thrombin time (TT), fibrinogen level, antithrombin III (ATIII) and protein C (PC) activities. Fibrinolytic activity was estimated by euglobulin lysis time and assays for plasminogen and fibrin/fibrinogen degradation products (FDP). These assays were performed before and after each autologous infusion and on days 2 and 3. Activated Mo and M psi expressed potent PCA (85.5 +/- 7.5 U/ml for MTP activated Mo and 50 +/- 5.3 U/ml for gamma IFN activated M psi suspensions). In both groups of patients, APTT, PT, and TT underwent no significant variations. There was no significant consumption of ATIII or PC, and fibrinolysis was not activated during the study period. In the group injected intraperitoneally with MTP-activated Mo, fibrinogen showed a significant and progressive increase in relation to the development of an inflammatory reaction, reaching a maximum average value of 6.1 g/l at the end of the therapy with a concomitant increase in FDP levels. This increase was not observed after intravenous therapy with gamma IFN-activated M psi. No patient suffered from hemorrhagic or thrombotic events. In our experience, repeated injections of activated Mo or M psi expressing potent tissue factor PCA did not induce significant in vivo activation of the coagulation system in cancer patients.

Tumour-cytolytic human monocyte-derived macrophages: a simple and efficient method for the generation and long-term cultivation as non-adherent cells in a serum-free medium

We report a simple and efficient culture procedure for the generation of tumour-cytolytic human monocyte-derived macrophages (MAC). In this method, normal human peripheral blood mononuclear cells, isolated using a conventional Ficoll-Hypaque density gradient procedure, are cultured as a heterogenous leukocyte population in Teflon or other hydrophobic cultureware, in a commercially available serum-free culture medium (M-SFM) that has been formulated specifically for the cultivation and ex vivo stimulation of human monocytes and MAC, and in the absence of exogenous mitogens, antigens, cytokines or other stimulants. This procedure features a negative-selection technique that takes advantage of the differential survival of blood leukocytes. Using the prescribed in vitro conditions, lymphocytes survived relatively poorly, whereas monocytes differentiated in the absence of exogenous stimulants into mature tumour-cytolytic MAC. The MAC were present as non-adherent, single cells that expressed good viability (greater than 95%) for a prolonged period (greater than 60 days). When compared to conventional procedures for generating MAC, the prescribed technique is thought to offer several important advantages in that it: (a) eliminates the tedious and cumbersome monocyte isolation procedures, thus providing a significant savings not only in time and money but also in eliminating repetitive cell manipulations that have often been associated with damage to monocyte morphology and/or function; (b) reduces the loss of monocyte subsets that are not recovered during specific isolation procedures; (c) facilitates harvesting a single cell, non-adherent suspension of immunocompetent MAC suitable for various examinations including analyses defining MAC morphology, cytochemistry, phenotype and function; and (d) eliminates variability and artifacts associated with different sera that are utilised frequently as medium supplements. The utility of the prescribed method is illustrated by the results of ongoing studies in which scanning electron microscopy and confocal laser scanning microscopy are being used to define MAC function in different immunological reactions, and examples of these observations are presented herein.

Adoptive immunotherapy with bispecific antibodies: targeting through macrophages

We report on two applications of bispecific antibodies to enhance the antitumoral function of human macrophages: (1) use of rhuIFN gamma (recombinant human IFN gamma) encapsulated in human red blood cells coated with anti-Fc gamma RI/anti-RhD+ bispecific antibodies to target and to activate human macrophages; encapsulated rhuIFN gamma was more potent than free IFN gamma in activating mature macrophages in vitro, demonstrating the efficacy of this delivery system to initiate in situ activation of macrophages and also to maintain a high antitumoral efficacy of macrophages with less side effects than after systemic injection of IFN gamma; (2) targeting of activated macrophages to tumours by bispecific antibodies directed against macrophage Fc gamma RI and against human adenocarcinoma antigen; differentiated human macrophages became cytotoxic for human adenocarcinoma in vitro and in vivo (tumours implanted in nude mice) when activated by rhuIFN gamma; this effect was increased in the presence of bispecific antibodies. These two approaches were aimed at increasing the efficacy of cellular immunotherapies using activated macrophages as effector cells (macrophage-activated killer, or MAK), an adoptive therapy which we have developed. Bispecific antibodies could increase specific homing and activation of cytotoxic MAK effectors at tumour sites.