Carcinoma of the lung: immunotherapy with intradermal BCG and allogeneic tumor cells

Generation and characterization of non-small-cell lung cancer cell lines and clones for use in the study of immunotherapy

The in vitro study of cancer has been made easier by the use of stable tumor cell (TC) lines derived from patients to study antigen expression, immunogenicity, and response to both experimental and conventional therapeutic agents. However, the routine generation of these cell lines in some tumor histologies such as non-small-cell lung cancer (NSCLC) is difficult. In many cases, colonies of TCs do not survive, most likely due to a lack of critical growth factors in cell culture medium. Other times, TC colonies are overgrown by fibroblasts, which appear to have less stringent growth requirements. In some cases, cultures are overgrown by bacteria or mold contained in the biopsy arriving from the surgical or pathology suite. This study presents the characteristics of three new NSCLC cell lines and associated autologous clones generated from both adenocarcinoma and squamous cell carcinoma tissue. Different culture media and variable techniques were used to generate these stable TC lines. Limiting dilution analysis resulted in numerous clones, some of which displayed heterogeneity in terms of growth, antigen expression, and the ability to release cytokines. The successes and failures associated with generating TC lines are discussed in this article. Both parental cultures and related clones serve as critical reagents for the continued study of the cellular immune response to NSCLC.

Granulocyte-macrophage colony-stimulating factor gene-modified autologous tumor vaccines in non-small-cell lung cancer

To evaluate the feasibility, safety, and efficacy of vaccination with autologous tumor cells genetically modified with an adenoviral vector (Ad-GM) to secrete human granulocyte-macrophage colony-stimulating factor (GM-CSF), we conducted a phase I/II multicenter trial in patients with early and advanced stage non-small-cell lung cancer (NSCLC). Vaccines were generated from autologous tumor harvests. Intradermal injections were given every 2 weeks for a total of three to six vaccinations. Tumors were harvested from 83 patients, 20 with early-stage NSCLC and 63 with advanced- stage NSCLC; vaccines were successfully manufactured for 67 patients, and 43 patients were vaccinated. The most common toxicity was a local injection-site reaction (93%). Three of 33 advanced-stage patients, two with bronchioloalveolar carcinoma, had durable complete tumor responses (lasting 6, 18, and >or=22 months). Longer survival was observed in patients receiving vaccines secreting GM-CSF at more than 40 ng/24 h per 10(6) cells (median survival = 17 months, 95% confidence interval [CI] = 6 to 23 months) than in patients receiving vaccines secreting less GM-CSF (median survival = 7 months, 95% CI = 4 to 10 months) (P =.028), suggesting a vaccine dose-related survival advantage.

Granulocyte-macrophage colony-stimulating factor gene-transfected autologous tumor cell vaccine: focus[correction to fcous] on non-small-cell lung cancer

Traditionally, non-small-cell lung cancer (NSCLC) is not thought of as an immunosensitive malignancy. However, recent clinical results with GVAX, a granulocyte-macrophage colony-stimulating factor (GM-CSF) gene-transduced autologous tumor vaccine, may suggest otherwise. This review summarizes immune-induced activity caused by GM-CSF protein and GM-CSF gene-transfected vaccines. Initial indication of use for GM-CSF protein (sargramostim) was to improve neutrophil recovery following cytotoxic chemotherapy. However, several trials involving patients with hematologic malignancy demonstrated improvement in survival related to delayed disease progression in patients receiving sargramostim in combination with chemotherapy. Subsequently, others explored potential antitumor activity with sargramostim in a variety of trials. Results did not consistently demonstrate sufficient antitumor activity to justify routine use of sargramostim as an anticancer agent. Preclinical work with GM-CSF gene-transfected vaccines, however, did demonstrate significant activity, thereby justifying clinical investigation. Patients with metastatic NSCLC who had previously failed chemotherapy demonstrated response to GVAX (3 of 33 complete responses) and dose-related improvement in survival (471 days vs. 174 days).

Vaccination with irradiated autologous tumor cells engineered to secrete granulocyte-macrophage colony-stimulating factor augments antitumor immunity in some patients with metastatic non-small-cell lung carcinoma

PURPOSE

We demonstrated that vaccination with irradiated tumor cells engineered to secrete granulocyte-macrophage colony-stimulating factor (GM-CSF) stimulates potent, specific, and long-lasting antitumor immunity in multiple murine models and patients with metastatic melanoma. To test whether this vaccination strategy enhances antitumor immunity in patients with metastatic non-small-cell lung cancer (NSCLC), we conducted a phase I clinical trial.

PATIENTS AND METHODS

Resected metastases were processed to single-cell suspension, infected with a replication-defective adenoviral vector encoding GM-CSF, irradiated, and cryopreserved. Individual vaccines consisted of 1 x 10(6), 4 x 10(6), or 1 x 10(7) cells, depending on overall yield, and were administered intradermally and subcutaneously at weekly and biweekly intervals.

RESULTS

Vaccines were successfully manufactured for 34 (97%) of 35 patients. The average GM-CSF secretion was 513 ng/10(6) cells/24 h. Toxicities were restricted to grade 1 to 2 local skin reactions. Nine patients were withdrawn early because of rapid disease progression. Vaccination elicited dendritic cell, macrophage, granulocyte, and lymphocyte infiltrates in 18 of 25 assessable patients. Immunization stimulated the development of delayed-type hypersensitivity reactions to irradiated, dissociated, autologous, nontransfected tumor cells in 18 of 22 patients. Metastatic lesions resected after vaccination showed T lymphocyte and plasma cell infiltrates with tumor necrosis in three of six patients. Two patients surgically rendered as having no evidence of disease at enrollment remain free of disease at 43 and 42 months. Five patients showed stable disease durations of 33, 19, 12, 10, and 3 months. One mixed response was observed.

CONCLUSION

Vaccination with irradiated autologous NSCLC cells engineered to secrete GM-CSF enhances antitumor immunity in some patients with metastatic NSCLC.

Cancer Vaccines for the Treatment and Prevention of Non–Small-Cell Lung Cancer

Cancer vaccines targeting non small-cell lung cancer (NSCLC) have been studied for decades; clinical trials, for the most part, have focused on the use of autologous and allogeneic whole-tumor cell vaccines. Recent advances in molecular biology and immunology, however, have allowed the identification of many tumor antigens involved in the generation of immunity to NSCLC. Although small-cell lung cancer (SCLC) is commonly thought of as an immunogenic tumor, it is now clear that NSCLC is also capable of eliciting an endogenous immune response in patients with the disease and, in fact, has a natural history that may make NSCLC more amenable to vaccine therapy as an adjuvant treatment strategy. This review will high-light the major components of the immune system that may potentially interact with tumor-associated proteins as well as outline the immunologic similarities and differences between SCLC and NSCLC. Tumor antigens that elicit immune responses in patients with NSCLC will be discussed. Finally, clinical trials of whole-tumor cell vaccines, both autologous and allogeneic, and tumor antigen-specific vaccines will also be discussed.

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.

Perioperative therapy for locoregional nonsmall-cell lung cancer

Surgical therapy remains the treatment of choice for resectable nonsmall-cell lung cancer (NSCLC). However, the 5-year survival results of surgical therapy is 40-70%, which is far from acceptable. In this report, past results of perioperative therapies were reviewed to identify the future direction of effort in improving the therapy of NSCLC. Two perioperative modes of treatment that may possibly improve postsurgical survival were identified, i.e., neoadjuvant chemotherapy for resectable NSCLC and postoperative specific active immunotherapy.

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.

Cultured cell lines from human breast cancer biopsies and xenografts

Eighty-five breast cancer specimens were processed as part of a program in tumor acquisition, propagation, and preservation for biotherapy. Nine long-term culture cell lines were developed. Four cell lines were from solid tumor metastases, two lines were from pleural fluid specimens, and three were from xenograft tumors grown in nude mice. Two of the xenograft-derived cell lines were from biopsies which produced tumor cell lines as well. Success in establishing cultures did not correlate with the viability of the biopsy received. Poor tumor cell attachment to culture plastic was the most common problem. For certain specimens, attachment and growth were enhanced on collagen and extracellular matrix substrates. Collagen was beneficial in the development of one cell line. The cell lines were characterized and each of the lines contained more nuclear DNA than found in normal cells. Four of five lines tested were tumorigenic in nude mice. Five of nine were clonogenic in soft agar. Each of the cell lines tested reacted with at least two anti-tumor monoclonal antibodies. Xenograft and biopsy-derived cell lines from the same tumor were similar in their characteristics. While breast cancers are indeed difficult to establish and propagate in culture, the use of xenografts and special substrates appears to be beneficial in the development of cell lines from some tumors.

Tumor acquisition, propagation, and preservation. The culture of human colorectal cancer

Fourteen new colorectal cancer cell lines were developed as part of a tumor acquisition, propagation, and preservation program for biotherapy. Fifty-six specimens were received. Nine cell lines were generated from biopsies; seven of these cell lines were from metastatic lesions. Five additional cell lines were developed from xenografts grown in nude mice. Biopsies that produced three of these xenografts gave rise to parallel culture cell lines. Biopsy-derived and xenograft-derived cell lines from the same tumor behaved similarly in culture and exhibited similar markers when assessed immunohistochemically. Collagen substrate was beneficial in the primary culture of 50% of the specimens tested. Collagen was required for the successful propagation of two cell lines.

Adjuvant specific immunotherapy of resectable squamous cell lung carcinoma. Analysis at the eighth year

From June 1976 to June 1981, 86 patients with resectable (Stage I and II) squamous cell lung carcinoma were entered into a randomized controlled study with three arms: Control Group - no treatment postoperatively. Specific Immunotherapy Group - three monthly doses of 500 micrograms of tumor associated antigen (TAA) emulsified with complete Freund's adjuvant (CFA). Nonspecific Immunotherapy Group - three monthly doses of CFA emulsified in saline. All the patients in the study received skin tests with PPD (5TU) and 100 micrograms of the same TAA used for the immunotherapy at 1, 4, 6, 9, and 12 months postoperatively. Patients in both immunotherapy groups showed a tendency for a better disease-free interval and overall survival compared to those of the control, but these interval and beneficial therapeutic effects were statistically significant only in the Group III patients who had no hilar lymph node metastasis (T1N0 and T2N0). Although Group III was originally designated as a nonspecific immunotherapy group, retrospectively, it should be called a lowdose specific immunotherapy group because these patients actually received a total of 500 micrograms of TAA (as skin tests) and three doses of CFA at separate sites.

Autologous x-irradiated tumour cells and percutaneous BCG in operable lung cancer

To determine the value of specific immunotherapy with adjuvant BCG in operable lung cancer, the immunological and clinical results of serial postoperative injections of autologous irradiated tumour cells and BCG were compared with those of a single preoperative injection of BCG in two randomly selected groups of patients undergoing resection of their tumours. There was a significant rise in tuberculin skin reactivity from seven weeks to 11 months after operation in the treated group. Actuarial curves for survival and freedom from tumour recurrence and median survival times showed an advantage for the treated patients who had stage I tumours, but these differences were significant only at the levels p = 0.07 - 0.09. Survival and duration of freedom from tumour recurrence was greater in autograft-treated patients whose skin responded to a weak test dose of dinitrochlorobenzene (DNCB) after sensitisation with 2% DNCB than in control DNCB-positive patients (p = 0.02). There were no significant differences in the actual proportion of patients from each group surviving at two years. The results show that this form of specific immunotherapy with adjuvant may have a beneficial effect in patients with stage I tumours and those who become sensitised to 2% DNCB after the first exposure.