Chemoimmunotherapy of adult acute leukaemia. Prolongation of remission in myeloblastic leukaemia with B.C.G

Spontaneous remission in three cases of AML M5 with NPM1 mutation

Patients with NPM1-mutated AML M5 who develop spontaneous remission (SR) after antibiotic therapy at diagnosis seem to form a favorable prognosis and chemo sensitive subtype. We report three cases of AML M5 patients with the same genotype that experienced transient SR and are now leukemia free after standard treatment.

Immunotherapy of AML

The applications of chemotherapy for the treatment of AML have been unchanged over the past three decades, with only 30% of patients demonstrating disease-free survival (DFS) [118]. Despite achieving CR following induction chemotherapy, the majority of patients relapse and succumb to their disease [6]. In view of the limitations encountered by cytarabine/anthracycline based regimes, attention has shifted to immunotherapy as a means to treat AML and provide significant long-term DFS. This chapter will discuss the role of the immune system and recent advances in immunotherapy for the treatment of AML, focusing on cellular and non-cellular approaches.

Acute myeloid leukaemia

Acute myeloid leukaemia (AML) is a heterogeneous clonal disorder of haemopoietic progenitor cells and the most common malignant myeloid disorder in adults. The median age at presentation for patients with AML is 70 years. In the past few years, research in molecular biology has been instrumental in deciphering the pathogenesis of the disease. Genetic defects are thought to be the most important factors in determining the response to chemotherapy and outcome. Whereas significant progress has been made in the treatment of younger adults, the prospects for elderly patients have remained dismal, with median survival times of only a few months. This difference is related to comorbidities associated with ageing and to disease biology. Current efforts in clinical research focus on the assessment of targeted therapies. Such new approaches will probably lead to an increase in the cure rate.

Treatment of minimal residual disease in myeloid leukemia--the immunotherapeutic options with emphasis on Linomide

It is now known that syngeneic transplantation, T lymphocyte depletion and absence of graft-versus-host disease all increase the risk of relapse following allogeneic transplantation for the myeloid leukemias, both acute and chronic. Leukemia-specific immune responses appear to play a major role in the therapy of the myeloid leukemias. In recent years attempts have been made to better characterize and effectively utilize these antileukemic immune responses, concentrating on clinical states of minimal residual disease. This review will discuss the role of such immunotherapy following autologous bone marrow transplantation for myeloid leukemias, and will focus on recent experience and ongoing clinical trials using the novel immunomodulator Linomide.

Agar capillary clonogenic microassays for cellular immunocytotoxic activities in human leukaemia and lymphoma

Current concepts of immunotherapeutic approaches in leukemias and lymphomas using activated cytotoxic lymphocytes and macrophages are briefly reviewed. Defective cellular immunocytotoxic activities and effects of interleukins and chemotherapeutic drugs thereupon are discussed. In vitro assays to measure lymphokine-activated killer (LAK) and natural killer (NK) cell activities suffer from various problems, depending on the quality of the endpoints. Our clonogenic microassay for LAK cell activity, using agar-containing glass capillaries, avoids some of the potential artifacts and offers several advantages that are discussed. As an example the stimulatory effect of low mafosfamide concentrations on the LAK cell activity versus K562 human myeloid leukemia cells is demonstrated. Thus, our clonogenic LAK microassay provides a valid tool for preclinical screening of immunomodulatory agents.

Therapy of acute myelogenous leukemia

Treatment of acute myelogenous leukemia (AML) is divided into remission induction and post-remission therapy. Remission induction is usually with cytarabine and an anthracycline. Daunorubicin is commonly used but recent data suggest idarubicin or mitoxantrone are equally effective, possibly better. High-dose cytarabine has also been used for remission induction but is not proven superior. Post-remission treatment is typically with two or more courses of drugs similar to those used for remission induction. Other studies use non-cross resistant drugs and/or high-dose cytarabine. Although some data favor use of high-dose cytarabine, no approach is clearly superior. There is considerable controversy whether persons in first remission and with an HLA-identical sibling should receive a bone marrow transplant immediately or after relapse. Although transplant results appear superior, especially in persons less than 20 years of age, the most effective strategy may be reserving transplants for persons failing chemotherapy. This strategy also applies to persons receiving autologous transplants or transplants from alternative donors, like HLA-matched related or unrelated persons.

The treatment of cancer with activated cytotoxic leukocyte subsets

Cancer biotherapy focuses on stimulating natural defense mechanisms designed to control or eradicate cancer. Many distinct cancer biotherapy strategies have been formulated over the past two decades; one of the most promising involves the removal of cytotoxic leukocyte subsets from cancer patients, augmenting the cytotoxic function of these cells ex vivo and re-administering these activated cells with additional function-enhancing biologicals. This approach is termed adoptive cellular immunotherapy and is best represented at present by the activated killer monocyte and the lymphokinc activated killer cell therapies. The activation of cytotoxic monocytes with gamma interferon and the activation of cytotoxic lymphocytes with interleukin-2 are prototypic examples of adoptive immunotherapy research activity which is likely to expand in the near future.

Randomized controlled study of chemoimmunotherapy of acute myelogenous leukemia (AML) in adults with Nocardia rubra cell-wall skeleton and irradiated allogeneic AML cells

The effect of immunotherapy with Nocardia rubra cell-wall skeleton (N-CWS) on remission duration and survival of adults with acute myelogenous leukemia (AML) was studied in a prospective randomized controlled study. After having been induced into complete remission and having been consolidated, 73 patients were randomized either to maintenance chemotherapy or maintenance chemotherapy plus immunotherapy with N-CWS and irradiated allogeneic AML cells. Thirty-four patients in the chemotherapy group and 32 in the chemoimmunotherapy group were evaluable. Six months after the closure of the study, the immunotherapy showed a borderline beneficial effect on remission duration (P = 0.080) and on survival length (P = 0.098). When the data were analyzed at 30 months after the entry, there was a borderline significant difference in remission duration (P = 0.080) between the two groups, prolonging the 50% remission period by 110 days; but no significant difference in survival length (P = 0.314), although the 50% survival was 168 days longer in the chemoimmunotherapy group. However, there were 4 (18.2%) 5-year relapse-free survivors among 22 patients (11 in each group) who had been diagnosed more than 5 years before the time of the present analysis, and all of them belonged to the chemoimmunotherapy group (P = 0.090). Thus, immunotherapy with N-CWS and irradiated allogeneic AML cells seems to be active in the treatment of adult AML when used for maintenance therapy in combination with chemotherapy.

Spontaneous remission in adult acute leukemia

A spontaneous complete remission of 34 months' duration was observed in an adult patient with acute myeloblastic leukemia. The remission occurred after a severe febrile pneumonia, which was treated with leukocyte transfusions. At relapse, chromosomal abnormalities reappeared slowly. Such spontaneous complete remissions, almost always associated with bacterial infections and blood transfusions, are extremely rare, and are usually of short duration. Previous cases are summarized, and the role of etiologic factors, including those related to the leukemic proliferation, are discussed.

Biological response modifiers: preclinical evaluation and clinical activity

Biological response modifiers are agents capable of affecting the host immune response toward tumors and include those biological substances produced by the human mammalian cell genome. Interferons and other lymphokines, tumor antigens, antibodies and agents which can activate or stimulate host immune responses are all included in this general category of agents. With the advent of genetic engineering and with monoclonal antibody technology, highly pure preparations of these biological substances can now be produced for tests of activity in preclinical models and in man. As the initial results accrue with highly purified preparations of interferon and with monoclonal antibodies alone or conjugated to toxic substances, the possibility of tumor specific therapy is becoming a reality. The development of preclinical models to predict for clinical activity remains a most important task to attempt to bring to clinical trials the substances most likely to be efficacious as anticancer agents. Early clinical results indicate that many of these agents can give responses in patients with clinically perceptible disease and Phase II activity studies are just beginning to define the range of clinical activity for a variety of biological response modifying agents. The development of biological response modifiers through preclinical testing and into clinical trials will be discussed in detail.

A randomized trial of chemoimmunotherapy of acute nonlymphocytic leukemia in adults using a protein-bound polysaccharide preparation

The effect of immunotherapy with a protein-bound polysaccharide preparation termed PSK on remission duration and survival of adults with acute nonlymphocytic leukemia (ANLL) was studied in a prospective randomized cooperative trial. After having achieved complete remission and receiving a consolidation therapy, 73 patients were randomized either to maintenance chemotherapy or to maintenance chemotherapy plus immunotherapy with PSK. Ultimately 36 patients in the chemotherapy group and 31 in the chemoimmunotherapy group were evaluable. Six months after the last entry, immunotherapy with PSK showed a borderline beneficial effect on remission duration (P = 0.089) and on duration of survival (P = 0.062). When the data were analyzed 12, 18, and 24 months after the last entry there were no significant differences in duration of remission and survival between the two groups. However, analysis of the data of patients who had maintained complete remission for more than 270 days revealed that immunotherapy had a suggestive beneficial effect (P = 0.105), prolonging the 50% remission period by 418 days (885 vs 467 days). Thus, immunotherapy with PSK seems to be active in the treatment of adult ANLL when used for maintenance therapy in combination with chemotherapy, especially in patients with a good prognosis.

Improved complete remission rates and survival for patients with large cell lymphoma treated with chemoimmunotherapy. A Southwest Oncology Group Study

Between 1974 and 1977, 652 patients with non-Hodgkin's lymphoma without prior chemotherapy were randomized to 1 of 3 combination chemotherapy programs designed to induce complete remission (CR): COP-bleomycin (180 patients), CHOP-bleomycin (232 patients) or CHOP plus immunotherapy with Bacillus Calmette Guerin (BCG) (240 patients). With mature follow-up, the major effect of BCG immunotherapy was observed in patients with large cell lymphomas (diffuse or nodular "histiocytic") and not in other common lymphoma subtypes. CR rate for 65 patients with large cell lymphoma treated with CHOP-BCG was 68% compared to 48% in 61 patients treated with CHOP-bleomycin (P = 0.02) (two-tailed test) or 44% for 45 patients treated with COP-bleomycin (P = 0.02). CR duration for both CHOP-based regimens was similar and superior to that produced by COP-bleomycin (P = 0.03). Survival of patients with large cell lymphoma treated with CHOP-BCG was better than that observed with CHOP-bleomycin (P = 0.02) or COP-Bleomycin (P = 0.002). Although the explanation for the favorable effect of BCG remains unclear, further clinical trials to evaluate the combination of chemotherapy and other "biologic response modifiers" is warranted for patients with lymphoma.

Intermittent combination chemotherapy with or without bacillus Calmette-Guérin for treatment of acute lymphoblastic leukemia of childhood

Seventy-four children ranging in age from 6 months to 17.5 years with acute lymphoblastic leukemia newly diagnosed between 1976 and 1979 were entered on a study incorporating intermittent chemotherapy with or without the addition of bacillus Calmette-Guérin (BCG). The chemotherapy program consisted of induction with vincristine, dexamethasone, and intrathecal methotrexate, intensification with adriamycin and asparaginase, central nervous system treatment with cranial irradiation and intrathecal methotrexate, and continuation treatment with 5-day courses of combination chemotherapy administered every three weeks. The first phase of continuation therapy incorporated vincristine, adriamycin, 6-mercaptopurine, and dexamethasone. In the second phase, oral methotrexate was substituted for the adriamycin in non-T-cell patients; in T-cell patients, cytosine arabinoside or cyclophosphamide and methotrexate in alternating cycles were substituted for the adriamycin and asparaginase was added. Total duration of therapy was approximately 2.5 years. Connaught BCG was administered by Heaf gun on days 8 and 15 of each 3-week cycle for the first 8 months of treatment in approximately one-third of the patients. Actuarial disease-free survival with a median follow-up of 59 months shows no difference in outcome between the BCG and non-BCG poor-risk patients. However, there is an improvement in disease-free survival of BCG-treated good- and average-risk girls (P = 0.04). While patients were actively receiving BCG there was also a trend toward the development of fewer significant infections than when patients were not receiving BCG (P = 0.85). Toxicities from BCG administration included satellite rashes, local tenderness, lymphadenopathy, secondary infection, and residual scars. Overall disease-free survival by actuarial analysis is 60% at 6 years; for patients with unfavorable prognostic features it is 40%. In this trial the addition of BCG prolonged the disease-free survival of girls with good- and average-risk prognostic features and also may have decreased the susceptibility to infection while it was being administered. However, the benefit does not appear sufficient to warrant its routine use, especially in view of the toxicities encountered.

Postoperative adjuvant immunotherapy of gastric cancer with BCG-cell wall skeleton. 3- to 6-year follow up of a randomized clinical trial

The clinical effectiveness of immunotherapy with the cell wall skeleton of Bacillus Calmette-Guérin was assessed in a study involving 140 consecutive patients with gastric cancer, who were gastrectomized at a single institution from January 1976 through December 1978. These patients were randomized by an envelope method after operation and divided into three treatment groups: 'control', 'chemotherapy', and 'chemotherapy plus immunotherapy with BCG-CWS.' Only two patients who died during surgery were excluded, and a survey of survival periods was made on the remaining 138 patients in January 1982. As a result, statistically significant differences in the survival rate curve were observed between the control and chemotherapy plus immunotherapy groups (P less than 0.01), and between the chemotherapy and chemotherapy plus immunotherapy groups (P less than 0.05). These results emphasize effectiveness of BCG-CWS as an adjuvant immunotherapeutic agent in gastrectomized cancer patients.

Immunotherapy maintenance in acute non-lymphocytic leukaemia

Between January 1975 and December 1977, 264 adult patients with acute non-lymphocytic leukaemia entered the Australian National Leukaemia Trial. Of 251 evaluable patients, three induction regimens achieved similar complete response (CR) rates. CROP (cytosine arabinoside, daunorubicin, vincristine, prednisolone) produced CR in 41% of patients, 7 and 3 (cytosine arabinoside, daunorubicin) in 42% and 7 and 3 plus hydroxyurea in 52%. Remission duration and survival were similar when induction regimens were compared. Forty-five patients reaching maintenance therapy were randomised to either chemo-immunotherapy (BCG plus intradermal leukaemic blast cells) or chemotherapy alone. The duration of CR in these two groups was almost identical, though patients receiving chemotherapy alone had prolonged survival (median 161 weeks) when compared to the chemo-immunotherapy group (84 weeks, p = 0 . 07). Institutions with less developed supportive facilities reported lower CR rates (p = 0 . 04). Leucocytosis (greater than 100 X 10(9)/1) and older age (greater than 50 years) were associated with shortened survival. The Trial has failed to show any advantage for this form of immunotherapy.

Small doses of ARA-C in the treatment of acute myeloid leukaemia: differentiation of myeloid leukaemia cells?

Three patients with acute myeloid leukaemia were treated with small doses of ARA-C (10 mg/m2/12 h, subcutaneous injections) and complete remission was obtained. The small doses of ARA-C, the progressive evolution, the absence of aplasia before remission, the simultaneous presence of normal islets of promyelocytes and leukaemic myeloblasts, favour a differentiating role for the drug rather than an antimitotic effect.

Therapeutic effectiveness of neuraminidase-treated allogeneic myeloblasts as immunogen in acute myelocytic leukemia

Our chemoimmunotherapy study shows significantly longer remission and survival in acute myelocytic leukemia (AML) patients who have been immunized with neuraminidase-treated allogeneic myeloblasts as compared to patients who received chemotherapy alone or neuraminidase-treated myeloblasts plus MER. MER impairs the immunotherapeutic effectiveness of neuraminidase-treated allogeneic myeloblasts in AML patients. The in vivo and in vitro immunologic status in each arm of the protocol correlate well with the duration of remission and survival of the patient.

Adjuvant specific immunotherapy in maintenance treatment of adult acute non-lymphocytic leukemia

From 1976 until 1978, 136 adult patients with acute leukemia were treated in four hospitals in Berlin. A complete remission was achieved in 47 patients (35%). Twenty-six patients with non-lymphocytic acute leukemia, who had achieved a complete remission with induction chemotherapy consisting of daunorubicin (45 mg/m2/day, day 1, 2 and 3) and cytosine-arabinoside (100 mg/m2/day, continuous infusion, day 1 to day 7) were entered into a randomized trial. Thirteen patients were treated with an intermittent combination chemotherapy at 4-week intervals; the other group of patients received in addition a specific immunotherapy consisting of neuraminidase-modified allogeneic blast cells. The results revealed that the addition of this kind of immunotherapy did not increase the duration of first remission or survival.

Prolonged remissions in adults with acute leukemia following late intensification chemotherapy and immunotherapy

Sixty-two patients with acute leukemia who remained in continuous complete remission for 8 to 45 months received three courses of intensified therapy with new chemotherapeutic agents, after which they received no further chemotherapy. Immunotherapy with BCG was then administered to 55 of these patients. They have been observed for up to 117 months off all chemotherapy, and 37 patients have relapsed. Thirty-two relapses occurred within 24 months, and 22 occurred within six months after completion of late intensification therapy. Only 1 of 24 patients who remained in unmaintained remission for four years after late intensification therapy has relapsed subsequently. Toxicity from intensification therapy was usually mild, and the most serious side effects were liver function abnormalities. These results suggest that late intensification therapy plus BCG immunotherapy results in prolonged disease-free survival for some patients with acute leukemia.

Chemoimmunotherapy of adult acute leukemia

Sixty-two adult patients with acute myeloid leukemia were treated with a chemotherapy program of Adriamycin, Cytosine Arabinoside (Ara-C), vincristine, and prednisone (Ad-OAP). Immunotherapy with BCG by scarification was administered before and/or during remission induction therapy. Maintenance chemoimmunotherapy consisted of Ara-C, vincristine, prednisone, and BCG. Patients still in remission after 12 months received late intensification chemotherapy for three courses before discontinuing chemotherapy. Forty-four (71%) patients achieved a complete remission (CR). The CR rate for patients less than 50 years of age ws 84% (32/38). Age was strongly predictive for response and survival. An additional 14 patients with acute lymphoid leukemia were treated with the same program; ten patients responded, all have relapsed and died. Nine patients with AML remain alive 4 1/2-6+ years from diagnosis.

Cellular immune modulation after a single high dose of Levamisole in patients with carcinoma

The effect of a single high dose of Levamisole (200 mg/M2) on delayed-type hypersensitivity (DTH) in vivo and on lymphocyte blastogenesis to mitogens and antigens in vitro was studied in 26 patients with carcinoma. Similar studies were conducted in 24 control patients. Levamisole had a moderate but significant enhancing effect on DTH to Dermatophytin detectable no earlier than eight hours and still present at 48 hours after the drug administration. A moderate but significant enhancing effect on lymphocyte blastogenesis to mitogens and antigens was also demonstrated during the same time sequence. Further clinical trials with Levamisole should be conducted with more attention paid to schedule of drug administration.

Active immunotherapy for the treatment of acute myelogenous leukaemia: report of two controlled trials

Over 6 1/2 years, 182 patients with acute myelogenous leukaemia were treated with one of two combinations of chemotherapy containing cytosine arabinoside and an anthracycline (daunorubicin or doxorubicin). Eighty-one patients achieved remission and 79 of them were entered into one of two trials of active immunotherapy. The first trial compared maintenance chemotherapy and i.v. BCG immunotherapy with chemotherapy alone. The results have shown that the group given i.v. BCG survived for a significantly longer time (P = 0.035) than the group treated only with chemotherapy. The i.v. BCG treated group also had a significantly longer survival (P = 0.042) after their first relapse and a higher incidence of subsequent remissions. However, there was no difference in the length of first remissions for the two groups. The second trial compared two different types of active immunotherapy. The results show no significant difference in remission duration or survival after first relapse for 34 patients randomly allocated to treatment with i.v. BCG or irradiated leukaemic blast cells. Sixteen patients relapsed and subsequently 10 patients entered a second remission after reinduction chemotherapy. These patients were distributed evenly between the two immunotherapy groups and this high rate of second remissions is similar to that for the immunotherapy group in the first Cardiff Trial. In the two trials, 21 (62%) of 34 patients receiving immunotherapy entered a second remission after reinduction chemotherapy and six patients achieved third remissions.

Factors related to length of complete remission in adult acute leukemia

Two hundred and two adult patients with acute leukemia were analyzed to determine pretreatment and treatment factors that could predict for duration of bone marrow remission. Several factors had a significant effect on remission duration, including morphologic diagnosis (AML greater than ALL greater than AUL), initial blast cell count, age, serum LDH, fibrinogen level, labeling index, and in vitro agar colony growth. Patients who attained a remission quickly or in whom leukemic cells in blood and bone marrow were rapidly cleared had long remissions. After applying regression model fitting methods, the six major factors, in order of significance, were the initial serum LDH level, pretreatment fibrinogen level, the number of courses of treatment to obtain a remission, morphologic diagnosis, the halving rate of leukemic cells in the blood, and the age of the patient. The model derived from this study was applied to the 202 patients and suggested that patients likely to have short or long bone marrow remission can be identified.

Treatment of acute leukemia in protected environment units

Thirty evaluable patients with acute leukemia (AL), aged 14 to 48-year-old received remission induction chemotherapy on a protected environment-prophylactic antibiotic program. Twenty-seven (90%) of these patients achieved complete remission and 17 remained in complete remission for 1 to 22 months. Although these patients spent 36% of their time with neutrophil counts less than 100/mm3, they spent only 20% of their time with fever. Major infection was present during only 7% of the days when neutrophil count was less than 100/mm3. No patient died of an infectious complication during remission induction therapy.

Remission induction and remission maintenance in adult acute nonlymphocytic leukemia employing a modified cytostatic (COAP) regimen

Thirty adult patients suffering from acute nonlymphocytic leukemia (ANLL) were treated according to a modified COAP regimen. Vincristine, cyclophosphamide, and prednisone were given by push injection, while cytosine arabinoside was infused over periods of 8 h. Nineteen patients (63%) achieved complete remission. Remission maintenance therapy consisted of 6-mercaptopurine daily and methotrexate twice weekly. Later in the study, COAP consolidation and reinduction was added, which improved the median duration of complete remission from 7 to 24 months. Comparison of the results with the literature shows that the modified COAP regimen is one of the most effective treatment schedules for adult ANLL.

Adjuvant immunotherapy of lung cancer with BCG cell wall skeleton (BCG-CWS)

Four hundred fifty-five patients with lung cancer were treated with oil-attached cell-wall skeleton of bacillus Calmette-Guérin (BCG-CWS) as adjuvant immunotherapy following initial conventional therapy. The overall survival period of the patients was prolonged significantly as compared with that of 380 patients in a historical control group receiving initial conventional therapy alone (p less than 0.0001). The prolongation of the survival period of the patients was also statistically significant when classified according to clinical stages and histological cell types. The therapeutic effect was remarkable in patients combined with malignant pleurisy. Intrapleural injection of BCG-CWS resulted in not only prevention of accumulation of pleural effusion and abrogation of tumor cells but also in prolongation of survival period (P = 0.016). No serious side effects due to BCG-CWS were experienced. From the previous experimental studies and clinical experiences with human tumors, it can be concluded that adjuvant immunotherapy with BCG-CWS is a useful therapeutic modality for lung cancer, especially in cases combined with malignant pleurisy.

Impact of specific immunotherapy in acute myelocytic leukemia

Our studies clearly show that significantly longer remission duration was attained in groups of AML patients immunized with neuraminidase treated allogeneic myeloblasts as compared to patients who received chemotherapy alone or neuraminidase treated myeloblasts plus MER. IT is clear that MER, albeit apparently active alone in certain other clinical studies impairs the immunotherapeutic value of neuraminidase treated allogeneic myeloblasts in AML patients. The in vivo and in vitro immunological tests results reflect the host's immunological status in each arm of the protocol and correlate well with the duration of remission achieved with specific vs. combination of specific plus adjuvant immunotherapy.

Improved remission induction rate with D-ZAPO but unimproved remission duration with addition of immunotherapy to chemotherapy in previously untreated children with ANLL

In 163 children with acute nonlymphocytic leukemia (ANLL), a D-ZAPO induction program consisting of daunomycin, 5-azacytidine, cytosine arabinoside, prednisone, and vincristine resulted in a remission rate of 71.8%. Immunologic therapy was employed during maintenance with the aim of prolonging remission and improving survival. The administration of immunotherapy consisting of a mixture of bacillus Calmette-Guérin (BCG) and allogenic acute myelomonocytic leukemic cells injected intradermally on day 14 of each of the first three monthly cycles of 6-thioguanine for ten days, 5-azacytidine and cytosine arabinoside for four days, and vincristine for one day did not improve remission duration or survival compared to that due to chemotherapy alone. Important prognostic factors identified in this study included a remission induction rate significantly better for females than males (P = 0.04), for children between the ages of 5 and 10 years compared to those greater than this age group (P = 0.01), and a prolonged remission duration (P = 0.04), and survival (P less than 0.01) for patients with initial white blood counts of less than 20 x 10(9)/liter.

Clinical trials of immunotherapy: present status

This brief review of the more promising clinical trials suggests that immunotherapy is indeed beneficial for selected cancer patients. Because of its limited potency, it should not be used as primary treatment for malignant disease except as local immunotherapy for certain accessible tumors. It is effective for eradication of primary neoplasms of the skin as well as cutaneous metastases of malignant melanoma and breast carcinoma. The most important role for immunotherapy is in combination with other modalities. It may help control occult micrometastases that cause recurrence and death following surgical procedures or irradiation. Results of adjuvant immunotherapy appear promising for malignant melanoma, for carcinoma of the lung, breast, and colon, and for soft-tissue sarcomas. In combination with chemotherapy, immunotherapy appears to prolong remission and survival in acute myelogenous leukemia and in disseminated tumors of the lung and breast. Clearly, immunotherapy is not a panacea for malignant disease, but it could become an important arm in a multimodality attack on cancer.

Comparison of the effects of single versus multiple agent chemotherapy on lymphocytes assayed by the rosette technique

The percentage of peripheral blood Total T, Active T and B-Rosette Forming Cells (RFC) were determined serially (Day 0, 1, 2, 7, and 21) following administration of single (SAT) versus multiple (MAT) agent chemotherapy. SAT caused essentially a decrease in the percentage of B-RFC. MAT resulted in profound decrease of Active T and B-RFC and to a lesser degree of Total T-RFC percentages with nadirs being reached in 48 hours. The most striking decrease involved the percentage of Active T-RFC which remained 15% below pretreatment level 7th posttreatment day. The posttreatment changes in the absolute numbers of Total T, Active T and B-RFCs following MAT were similar to that noted on the RFC percentage. Effects of the two most commonly used multiple agent treatments (COBAM and DOMF) were comparable. MAT causes a more profound decrease in the percentage of various RFCs than SAT. The differences between the nadirs of various RFC reached Day 1 and 2 with MAT versus SAT are statistically significant (p less than .001). We conclude that the effects of chemotherapy on peripheral RFC may be best evidenced by serial determination of their percentage rather than their absolute numbers. Subpopulation of the T-RFC which has been labeled Active T-RFC appears to be the best indicator of the chemotherapy effects on the lymphocyte population since they demonstrate the most profound and persistent changes.

Immunotherapy with BCG administered by scarification: standardization of reactions and management of side effects

The method of administering BCG by scarification is described in detail. A system of classifying the intensity of local reactions is proposed to standardize administration. The experience of the M.D. Anderson Hospital involving over 2700 patients is reviewed. Administration of BCG by scarification has been accomplished with safety and has been well tolerated and accepted. The most commonly observed side effects are discussed as well as their management.