Interleukin-2, Interferon-α and 5-Fluorouracil Immunotherapy for Metastatic Renal Cell Carcinoma: The All Ireland Experience

Characteristics of Metastasis as a Prognostic Factor for Immunotherapy in Metastatic Renal Cell Carcinoma

Aims and background

This study aimed to evaluate the significance of characteristics of metastasis as prognostic factors in metastatic renal cell carcinoma (RCC).

Patients and methods

A total of 148 patients who had received immunotherapy were included in the study. Patients were categorized in various ways according to the characteristics of metastasis, including a synchronous metastasis group (n = 77) vs a metachronous metastasis group (n = 71), and a solitary metastasis group (n = 93) vs a multiple metastases group (n = 55).

Results

In the synchronous and metachronous metastasis groups, median progression-free survival was 4.3 months (95% confidence interval [CI] 2.9-5.7) and 11.1 months (95% CI 6.7-15.5), respectively (P = 0.004). Median overall survival was 17.1 months (95% CI 9.5-24.7) and 54.8 months (95% CI 38.3-71.3) in the two groups (P = 0.019). In the solitary and multiple metastasis groups, median progression-free survival was 11.0 months (95% CI 6.6-15.5) and 3.9 months (95% CI 2.6-5.2), respectively (P <0.001). Median overall survival was 55.2 months (95% CI 50.7-59.7) and 15.6 months (95% CI 10.9-20.3) in the two groups (P <0.001). Multivariate Cox proportional hazards model analysis using the clinical variables showed that T stage (P = 0.026), number of metastatic sites (P = 0.009) and time to metastasis (P = 0.019) were independent predictors of progression-free survival. Using the same variables, only the number of metastatic sites was an independent prognostic predictor of overall survival (P = 0.014).

Conclusions

Our findings suggest that the time to metastasis and the number of metastases are important prognostic factors in metastatic RCC.

Interleukin-22 suppresses the growth of A498 renal cell carcinoma cells via regulation of STAT1 pathway

BACKGROUND

Renal cell carcinoma (RCC) is one of the most common kidney cancers and is highly resistant to chemotherapy. Accumulating evidence suggests that interleukin-22 (IL-22) may mediate host defense against varietal pathogens as a proinflammatory and anti-inflammatory cytokine. The purpose of this study is to assess the inhibitory effects of IL-22 on human RCC cell line A498 and to investigate the possible mechanisms underlying the anti-tumor effects of this cytokine.

METHODOLOGY

A498 cells, a RCC cell line, were used to assess the inhibitory growth effects of IL-22 using the MTT assay and flow cytometric analysis in vitro. BALB/C nude mice bearing A498 cell xenografts were used to examine the antitumor efficacy of IL-22 in vivo. Western blotting assay was performed to detect the regulation of the intracellular signaling pathway of IL-22.

PRINCIPAL FINDINGS

We found that IL-22 suppressed the growth of A498 cells in a dose-dependent manner and inhibited the growth of A498 xenografts. We also observed that IL-22 produced a dose-dependent inhibitory effect on A498 cells that involved the induction of G2/M cell cycle arrest without cell apoptosis. Moreover, we showed that the phosphorylation of STAT1 was increased and the phosphorylation of ERK1/2 was attenuated in A498 cells exposed to IL-22. The growth inhibition of A498 cells was partially revised after IL-22 treatment as the expression of STAT1 was knocked down. And inflammatory cytokines, interferon-α and tumor necrosis factor-α (TNF-α) were barely involved in the suppression of A498 cell xenografts treated with IL-22.

CONCLUSIONS

IL-22 dose-dependently suppresses RCC cell line A498 cells in vitro and induces growth inhibition of A498 cell-bearing mouse xenografts. These results suggest that the anti-RCC effects of IL-22 are at least partially mediated through regulation of STAT1 signaling pathways and G2/M cell cycle arrest, rather than by inducing apoptosis and inflammatory cytokines.

Pretreatment with interferon-alpha2a modulates perioperative immunodysfunction in patients with renal cell carcinoma

INTRODUCTION

Complex perioperative immunodysfunction occurs in patients with renal cell carcinoma undergoing surgery. Here, we report on the effect of preoperative treatment with interferon-alpha2a (IFN-alpha2a).

MATERIALS AND METHODS

30 patients with a renal tumour received preoperative IFN-alpha2a for 6 days beginning 1 week before nephrectomy, 30 did not. Parameters of cellular and humoral immunity were measured in venous blood at various intervals using flow cytometry and ELISA. Endpoints included effects on immune parameters, toxicity, and survival.

RESULTS

Toxicity was grade 1 in 52%, 2 in 30%, and 3 in 4%. During IFN-alpha2a administration, leukocytes, monocytes, granulocytes, B-cell marker CD19, activation markers, CD4+CD25+ regulatory T-cells, and vascular endothelial growth factor (VEGF) dropped significantly, but no difference was observed in T-cell and natural killer (NK)-cell markers, and IL-10. Postoperatively, T-cell and activation markers decreased in both groups, but CD4, CD28, IL-6, IL-10, and HLA-DR alterations were significantly less accentuated in patients who had been treated with IFN-alpha2a. After a median follow-up of 23 months, survival did not differ between the groups (p = 0.54).

CONCLUSIONS

Perioperative immunodysfunction can be modulated by preoperative administration of IFN- alpha2a. IFN-alpha2a decreased the level of VEGF and CD4+CD25+ regulatory T-cells implicating a potential combination with tyrosine kinase inhibitors and vaccines.

No role of adjuvant systemic therapy after complete metastasectomy in metastatic renal cell carcinoma?

OBJECTIVE

To compare the effects of metastasectomy combined with immunotherapy and metastasectomy alone in the treatment of patients with metastatic renal cell carcinoma.

MATERIALS AND METHODS

A total of 93 patients who had undergone metastasectomy were included in the study. Patients were categorized according to immunotherapy status, including the immunotherapy group (n = 70) and the no immunotherapy group (n = 23).

RESULTS

In the immunotherapy group, median overall survival was 56.1 months (95% confidence interval [CI] 34.1-78.2), whereas the no immunotherapy group reached a median overall survival of 21.3 months (95% CI 3.4-39.2), respectively. The 1, 3, and 5-year overall survival rates were calculated at 67.1% and 56.5%, 30.0% and 34.8%, and 7.1% and 19.0%, for the immunotherapy group and the no immunotherapy group, respectively (P = 1.000). When patients were stratified according to the time of metastasis, overall survival was not significantly different among the groups in patients with synchronous metastasis or in those with metachronous metastasis. Multivariate Cox proportional hazards model analysis showed that multiplicity of metastasis (odds ratio 3.68; 95% CI 1.85-7.34; P < 0.001) and metastatic sites (odds ratio 2.12; 95% CI 1.15-3.90; P = 0.016) were independent predictors of overall survival.

CONCLUSIONS

Metastasectomy combined with adjuvant immunotherapy did not result in a significantly higher overall survival rate as compared with metastasectomy alone. Our findings raise the question of "Is there a role of adjuvant immunotherapy after complete metastasectomy in patients with metastatic renal cell carcinoma?"

A phase II study of a 5T4 oncofoetal antigen tumour-targeted superantigen (ABR-214936) therapy in patients with advanced renal cell carcinoma

In a phase II study, 43 renal cell carcinoma patients were treated with individualised doses of ABR-214936; a fusion of a Fab recognising the antigen 5T4, and Staphylococcal enterotoxin A. Drug was given intravenously on 4 consecutive days, treatment was repeated 1 month later. Treatment was associated with moderate fever and nausea, but well tolerated. Of 40 evaluable patients, 28 had disease control at 2 months, and at 4 months, one patient showed partial response (PR) and 16 patients stable disease. Median survival, with minimum follow-up of 26 months was 19.7 months with 13 patients alive to date. Stratification by the Motzer's prognostic criteria highlights prolonged survival compared to published expectation. Patients receiving higher drug exposure had greater disease control and lived almost twice as long as expected, whereas the low-exposure patients survived as expected. Sustained interleukin-2 (IL-2) production after a repeated injection appears to be a biomarker for clinical effect, as the induced-IL-2 level on the day 2 of treatment correlated with survival. The high degree of disease control and the prolonged survival suggest that this treatment can be effective. These findings will be used in the trial design for the next generation of drug, with reduced antigenicity and toxicity.

Autologous renal cell cancer vaccines using heat shock protein-peptide complexes

Investigations into the role of heat shock proteins (HSPs) in immune response have progressed well into a third decade, and indications of their use for the treatment of renal cell carcinoma (RCC) in the adjuvant setting will be revealed in the near future when a randomized phase III clinical trial is completed. Additional ongoing and planned randomized clinical trials will test the efficacy of HSP-based vaccines in more advanced stages of RCC. This review describes the compelling scientific rationale behind testing HSPs in RCC against the backdrop of other immunotherapeutic approaches in this indication.

Metastatectomy prior to Immunochemotherapy for Metastatic Renal Cell Carcinoma

INTRODUCTION

We reviewed our experiences in performing cytoreductive metastatectomy before initiating systemic immunochemotherapy and tried to investigate potential prognostic factors for such an approach.

PATIENTS AND METHODS

A retrospective analysis of 57 patients who received interleukin-2, interferon-alpha, and 5-fluorouracil immunochemotherapy for metastatic renal cell carcinoma was conducted. Before undergoing immunochemotherapy, 20 of the 57 patients had received metastatectomy along with nephrectomy (metastatectomy group) and the other 37 nephrectomy alone (non-metastatectomy group).

RESULTS

The metastatectomy group demonstrated median disease-specific and progression-free survival of 23 and 13 months, respectively. The patients in the metastatectomy group were identified as having a better performance status and primarily demonstrating pulmonary metastasis compared with those in the non-metastatectomy group. As assessed in the metastatectomy group, factors such as the number of metastatic lesions, completeness of metastatectomy, and location of metastatic lesions (lung only vs. others) were observed to be significantly associated with overall survivals on univariate analysis.

CONCLUSIONS

Metastatectomy may still play a significant therapeutic role for metastatic renal cell carcinoma even in the era of immunochemotherapy as part of a multidisciplinary treatment approach in a selected group of patients in adequate general condition who have pulmonary-limited metastasis that can be completely resected.

Adjuvant interleukin-2, interferon-alpha, and 5-fluorouracil immunochemotherapy after radical nephrectomy for locally advanced renal cell carcinoma

OBJECTIVES

To investigate the efficacy of interleukin-2 (IL-2), interferon-alpha, and 5-fluorouracil combination immunochemotherapy as adjuvant therapy after radical nephrectomy for nonmetastatic pathologic Stage T3 renal cell carcinoma.

METHODS

Thirty patients who underwent radical nephrectomy for pT3N0M0 renal cell carcinoma at our department from June 1999 to December 2003 were studied retrospectively. Of the 30 patients, 9 (adjuvant group) also received adjuvant interleukin-2, interferon-alpha, and 5-fluorouracil immunochemotherapy after surgery; the other 21 (nonadjuvant group) did not. A comparative analysis of the two groups was performed with respect to disease-free and overall survival. Side effects from immunochemotherapy were also assessed.

RESULTS

The adjuvant therapy and nonadjuvant therapy groups were not significantly different with respect to age, sex, Eastern Cooperative Oncology Group performance status, pathologic subtype, pathologic stage, tumor size, and Fuhrman's grade. The two groups demonstrated a significant difference in the time to progression (log-rank test, P = 0.011). Although 3 patients had died at a mean follow-up of 23.8 months (range 7.5 to 35) in the nonadjuvant group, apparent differences between the two groups in overall survival were not statistically significant (log-rank test, P = 0.2487). Combination immunochemotherapy was mostly well tolerated, and all side effects were limited to World Health Organization grades 1 and 2.

CONCLUSIONS

Despite the ongoing controversy surrounding its effectiveness in the treatment of metastatic renal cell carcinoma, the results of our preliminary study suggest that interleukin-2, interferon-alpha, 5-fluorouracil combination immunochemotherapy may be effective as adjuvant therapy after complete resection of pT3N0M0 renal cell carcinoma.