BCG and cancer (first of two parts)

The past, present, and future of immunotherapy for colorectal cancer

Colorectal cancer is prevalent worldwide, with various factors influencing the survival rate of late-stage metastatic cases. Current standard treatments include surgical removal, adjuvant chemotherapy, and neoadjuvant chemotherapy. Novel immunotherapy research shows promising results for various cancer types, including colorectal cancer. Current immunotherapy options are limited to specific molecular subtypes of colorectal cancer, while the remaining are limited to standard protocol. This review article summarizes approved, developing, and potential sources for novel colorectal cancer immunotherapy treatment through active-specific, checkpoint inhibitor, cytokine, cytotoxic, and adoptive T-cell immunotherapy. Such a study would be beneficial to patients with colorectal cancer.

A BCG success story: From prevention of tuberculosis to optimal bladder cancer treatment

BCG remains the most important vaccine for tuberculosis 100 years after its first use, and over the past 4 decades it has become the most widely accepted, effective drug used in the treatment of aggressive localized bladder cancer. This review chronicles the narrow path that led to approval and world-wide acceptance of BCG immunotherapy for bladder cancer while immunotherapy trials in other malignancies were abandoned. Six intravesical instillations of 5x10^8 CFU of BCG weekly after bladder tumor resection, first reported in 1976, is superior to resection alone and resection plus intravesical chemotherapy. Maintenance of effective immune stimulation is surprisingly difficult, but 3 weekly treatments 3, 6, and 12, 18, 24, 30 and 36 months after induction produces further significant reduction in tumor recurrence. This 3 week BCG maintenance schedule alone has reduced disease progression and mortality in multicenter randomized clinical trials. In the new age of immuno-oncology patients with many types of cancer now benefit from immunotherapy, but currently these modern agents are prohibitively expensive for most of the world. In contrast, the low cost and therefore low profitability of BCG has resulted in recurrent shortages that threaten both bladder cancer patients and children at risk for tuberculosis and other serious infections. Humanity has greatly benefited from early 20th century science that developed BCG and the benevolence of doctors Calmette and Guerin who put people over profit and widely shared cultures of the vaccine. The 21st century is bringing new immunotherapies and greatly expanding the types of malignancies that can be treated. Recombinant technology is expected to improve both the efficacy and production of BCG, hopefully expanding the availability of BCG and relieving the recurring supply shortage for both vaccination and cancer therapy.

BCG: a vaccine with multiple faces

BCG has been recommended because of its efficacy against disseminated and meningeal tuberculosis. The BCG vaccine has other mechanisms of action besides tuberculosis protection, with immunomodulatory properties that are now being discovered. Reports have shown a significant protective effect against leprosy. Randomized controlled trials suggest that BCG vaccine has beneficial heterologous (nonspecific) effects on mortality in some developing countries. BCG immunotherapy is considered the gold standard adjuvant treatment for non-muscle-invasive bladder cancer. BCG vaccine has also been tested as treatment for diabetes and multiple sclerosis. Erythema of the BCG site is recognized as a clinical clue in Kawasaki disease. BCG administration in the immunodeficient patient is associated with local BCG disease (BCGitis) or disseminated BCG disease (BCGosis) with fatal consequences. BCG administration has been associated with the development of autoimmunity. We present a brief review of the diverse facets of the vaccine, with the discovery of its new modes of action providing new perspectives on this old, multifaceted and controversial vaccine.

Modulation of the tumor microenvironment by intratumoral administration of IMO-2125, a novel TLR9 agonist, for cancer immunotherapy

The objective of cancer immunotherapy is to prime the host's immune system to recognize and attack malignant tumor cells. IMO‑2125, a Toll‑like receptor 9 (TLR9) agonist, exhibited potent antitumor effects in the murine syngeneic A20 lymphoma and the CT26 colon carcinoma models. IMO‑2125 exhibited superior A20 antitumor activity when injected intratumorally (i.t.) compared with equivalent subcutaneous doses. In mice bearing dual CT26 grafts, the i.t. injection of right flank tumors elicited infiltration of cluster of differentiation (CD)3+ T lymphocytes into tumors, resulting in the regression of injected and uninjected left flank tumors. Depletion of CD8+, but not CD4+, T‑cells abrogated the IMO‑2125‑mediated antitumor response, suggesting that CD8+ lymphocytes are required for the antitumor activity. In mice harboring right flank CT26 and left flank β‑galactosidase (β‑gal)‑expressing CT26.CL25 grafts, the i.t. administration of IMO‑2125 to the CT26 graft resulted in potent and dose‑dependent antitumor activity against the two grafts. Splenic T‑cells isolated from these mice responded to AH1 antigen (present in the two tumors) and β‑gal antigen (present only in CT26.CL25) in an interferon γ enzyme‑linked immunospot assay, suggesting the clonal expansion of T‑cells directed against antigens from the two tumors. Mice with ablated CT26 tumors by previous IMO‑2125 treatment rejected re‑implanted CT26 tumor cells, but not A20 tumor cells, demonstrating that the initial IMO‑2125 treatment created a long‑lived tumor‑specific immune memory of CT26 antigens. A quantitative increase in CD3+ T lymphocytes in injected A20 tumors and an upregulation of selected checkpoint genes, including indoleamine 2,3‑dioxygenase (IDO)‑1, IDO‑2, programmed cell death protein-1 (PD-1); programmed cell death protein ligand 1 (PD-L1), carcinoembryonic antigen‑related cell adhesion molecule 1, tumor necrosis factor receptor superfamily member 4 (OX40), OX40 ligand, T‑cell immunoglobulin and mucin‑domain‑containing 3 protein, lymphocyte‑activation gene 3, cytotoxic T‑lymphocyte‑associated protein 4, were observed following IMO‑2125 treatment. IMO‑2125 also increased immune checkpoint gene expression in injected and uninjected contralateral CT26 tumors, suggesting that the co‑administration of anti‑CTLA‑4, anti‑PD‑1 or anti‑PD‑L1 therapies with IMO‑2125 may provide additional therapeutic efficacy.

Cancer immunotherapy: Breakthrough or "deja vu, all over again"?

From the application of Coley's toxin in the early 1900s to the present clinical trials using immune checkpoint regulatory inhibitors, the history of cancer immunotherapy has consisted of extremely high levels of enthusiasm after anecdotal case reports of enormous success, followed by decreasing levels of enthusiasm as the results of controlled clinical trials are available. In this review, this pattern will be documented for the various immunotherapeutic approaches over the years. The sole exception being vaccination against cancer causing viruses, which have already prevented thousands of cancers. We can only hope that the present high level of enthusiasm for the use of immune stimulation by removal of blocks to cancer immunity will be more productive than the incremental improvements using previous immunotherapies.

Role of the systemic immune system in brain metastasis

Metastatic disease in the central nervous system (CNS) is a cause of increasing mortality amongst cancer patients. As with other types of cancer, cells of the systemic immune system play a range of important roles in the development of metastatic lesions in the CNS, both repressing and promoting tumour growth. Recent advances in immunotherapy have changed the emphasis in cancer treatment away from conventional chemotherapy and radiotherapy for certain tumour types. Despite this, our understanding of systemic immune system involvement in CNS metastases remains poor. The blood-brain barrier prevents the majority of diagnostic and therapeutic agents from crossing into the brain parenchyma until the late stages of metastatic disease. Thus, the development of immunotherapy for CNS pathologies is particularly desirable. This review draws together our current understanding in the relationships between CNS metastases and circulating systemic immune cells. We discuss the roles that circulating systemic immune cells may play in the homing of metastatic cells to the perivascular space, and the pro-metastatic and antagonistic roles that infiltrating systemic immune cells may play at sites of metastasis. This article is part of a Special Issue entitled 'Neuroinflammation in neurodegeneration and neurodysfunction'.

Role of endogenous biological response modifiers in pathogenesis of infectious diseases

Biologic response modifiers (BRMs) interact with the host immune system and modify the immune response. BRMs can be therapeutically used to restore, augment, or dampen the host immune response. Although they have been used for decades, their clinical applications have been expanded in the past decade for diagnosis and treatment of many diseases including cancers, immunologic disorders, and infections. This article discusses endogenous biological response modifiers (ie, naturally occurring immunomodulators as a part of the host immune system), which play vital roles as regulators of both innate and adaptive immune responses.

Calpain-mediated processing of p53-associated parkin-like cytoplasmic protein (PARC) affects chemosensitivity of human ovarian cancer cells by promoting p53 subcellular trafficking

Resistance to cisplatin (CDDP)-based therapy is a major hurdle to the successful treatment of human ovarian cancer (OVCA), and the chemoresistant phenotype in OVCA cells is associated with Akt-attenuated p53-mediated apoptosis. Pro-apoptotic functions of p53 involve both transcription-dependent and -independent signaling pathways, and dysfunctional localization and/or inactivation of p53 contribute to the development of chemoresistance. PARC is a cytoplasmic protein regulating p53 subcellular localization and subsequent function. Little is known about the molecular mechanisms regulating PARC. Although PARC contains putative caspase-3 cleavage sites, and CDDP is known to induce the activation of caspases and calpains and induce proteasomal degradation of anti-apoptotic proteins, if and how PARC is regulated by CDDP in OVCA are unknown. Here, we present evidence that CDDP promotes calpain-mediated PARC down-regulation, mitochondrial and nuclear p53 accumulation, and apoptosis in chemosensitive but not resistant OVCA cells. Inhibition of Akt is required to sensitize chemoresistant cells to CDDP in a p53-dependent manner, an effect enhanced by PARC down-regulation. CDDP-induced PARC down-regulation is reversible by inhibition of calpain but not of caspases or the 26 S proteasome. Furthermore, in vitro experiments confirm the ability of calpain in mediating Ca(2+)-dependent PARC down-regulation. The role of Ca(2+) in PARC down-regulation was further confirmed as ionomycin-induced PARC down-regulation in both chemosensitive and chemoresistant ovarian cancer cells. The data presented here implicate the regulation of p53 subcellular localization and apoptosis by PARC as a contributing factor in CDDP resistance in OVCA cells and Ca(2+)/calpain in PARC post-translational processing and chemosensitivity.

Cancer immunotherapy

Cancer immunotherapy consists of approaches that modify the host immune system, and/or the utilization of components of the immune system, as cancer treatment. During the past 25 years, 17 immunologic products have received regulatory approval based on anticancer activity as single agents and/or in combination with chemotherapy. These include the nonspecific immune stimulants BCG and levamisole; the cytokines interferon-α and interleukin-2; the monoclonal antibodies rituximab, ofatumumab, alemtuzumab, trastuzumab, bevacizumab, cetuximab, and panitumumab; the radiolabeled antibodies Y-90 ibritumomab tiuxetan and I-131 tositumomab; the immunotoxins denileukin diftitox and gemtuzumab ozogamicin; nonmyeloablative allogeneic transplants with donor lymphocyte infusions; and the anti-prostate cancer cell-based therapy sipuleucel-T. All but two of these products are still regularly used to treat various B- and T-cell malignancies, and numerous solid tumors, including breast, lung, colorectal, prostate, melanoma, kidney, glioblastoma, bladder, and head and neck. Positive randomized trials have recently been reported for idiotype vaccines in lymphoma and a peptide vaccine in melanoma. The anti-CTLA-4 monoclonal antibody ipilumumab, which blocks regulatory T-cells, is expected to receive regulatory approval in the near future, based on a randomized trial in melanoma. As the fourth modality of cancer treatment, biotherapy/immunotherapy is an increasingly important component of the anticancer armamentarium.

Preparation and characterization of agonistic monoclonal antibodies against Toll-like receptor 4-MD-2 complex

Ligands for toll-like receptors (TLR) are known to induce a variety of immune responses. Selective induction of desirable responses would be important for the treatment of individual diseases with various pathogenesis. For this purpose, we established six MAbs against the TLR4/MD-2 complex (UT MAbs) from TLR4(-/-) mice or MD-2(-/-) mice. Three MAbs (UT12, 18, and 22) induced NF-kappaB activation and production of pro-inflammatory cytokines, but the other three (UT15, 41, and 49) did not induce such cell responses. Unlike lipopolysaccharide (LPS), agonistic UT MAbs did not require serum components for the functions. UT41 and UT49 recognized TLR4 in the absence of MD-2. On the other hand, the other four MAbs reacted to the TLR4/MD-2 complex, but not to solo TLR4. Agonistic UT MAbs shared the epitopes, but non-agonistic UT15 reacted to distinct epitope on the complex. UT MAbs appear to be useful analyzing the molecular mechanism of TLR signaling and will contribute to the development of novel immunotherapies.

Henoch-Schönlein purpura after intravesical administration of bacillus Calmette-Guérin

The administration of intravesical bacille Calmette-Guérin (BCG) in early stages of bladder cancer is usually a safe therapy. Side-effects of BCG immunotherapy can be of both local and systemic nature. We report the first case of Henoch-Schönlein purpura following intravesical administration of BCG.

Structural-functional relationship of pathogen-associated molecular patterns: lessons from BCG cell wall skeleton and mycoplasma lipoprotein M161Ag

The innate immune system senses microbial components by signaling receptors and induces phagocytosis by uptake receptors. The Toll-like receptor represents the signaling receptors that cause maturation of dendritic cells, while phagocytosis is supported by other receptor families. We identify the structural signatures of microbial components recognized by these receptors to establish the two-receptor hypothesis in innate immunity.

BCG vaccination to prevent implantation of endometriosis: an experimental study in rats

To investigate whether BCG vaccination can prevent endometrial implantation in a rat model. Forty sexually mature virgin Wistar-Albino rats weighing 185-215g were randomly assigned (double-blind) to two groups. The first group (n=20) were injected with BCG 3 weeks before endometrial implantation to the eye. The second group (n=20) with BCG not injected before endometrial implantation was the control. Photobiomicroscopy observation was done weekly and 6 weeks post endometrial implantation all eyes were investigated histologically.Five implants grew in the anterior surface of the iris of the first (vaccinated) group and 17 in the second (control) group. The difference was statistically significant. Systemic prophylaxis with BCG can exert an inhibitory effect on endometrial transplantation.

Development of immunoadjuvants for immunotherapy of cancer

Previously, we have reported that cell-wall skeleton (CWS) fraction was the major adjuvant-active principle of mycobacterial cells which were used in Freund's complete adjuvant (FCA). We have described the biochemical and immunological properties of CWS of mycobacteria and related bacteria, especially the CWS of Mycobacterium bovis BCG strain (BCG-CWS) in detail. The effectiveness of BCG-CWS for the cancer immunotherapy in patients was shown in several clinical trials. On the action mechanism of BCG-CWS on host immune cells, we have suggested that dendritic cells and macrophages express two sorts of receptors, Toll-like receptors, TLR-2 and TLR-4, and a putative binding receptor for BCG-CWS, whose signaling pathways lead to a sufficient antigen-presenting state in the activation of the innate immune system. We have also reported the usefulness of synthetic immunoadjuvants such as muramyldipeptide (MDP) derivatives, trehalose-dimycolates (TDM) and DNA fraction for the application for the cancer and infectious diseases in experimental systems and cancer patients.

Mechanisms of action of intravesical bacille Calmette-Guérin: local immune mechanisms

The local immune response to mycobacteria is complex, but mycobacterial antigen presentation by phagocytes to T helper cells is the pivotal interaction. Bacille Calmette-Guérin (BCG) vaccination is associated with the development of antituberculosis immunity but not necessarily with antitumor immunity. Animal studies have shown that an intact host immune system is required for the antitumor activity of BCG. Immunosuppressed and, particularly, T cell-depleted individuals fail to respond to BCG immunotherapy. Clinical and laboratory evidence suggest that the antitumor activity is concentrated at the site of BCG administration, which reinforces the view that local immune mechanisms are responsible for this phenomenon.

Equine sarcoids

Sarcoids, the most common tumor of the horse, are fibroblastic, wart-like skin lesions that show variable manifestations. They are often invasive and recurrent, although they do not fulfill all criteria of malignancy. Due to their anatomic location, these tumors can sometimes cause loss of use of the horse. There is very strong evidence that sarcoids are caused by viruses closely related or identical to bovine papilloma viruses, and genetic studies have shown associations between genes in or near the equine major histocompatibility complex (MHC) and susceptibility to sarcoid. Several types of treatments have been successful in treating sarcoids, although the response to therapy is not consistent. Current treatment of sarcoids primarily involves antitumor therapy, but the development of preventative measures in the future may be directed against the causative papilloma virus. Sarcoid continues to be an important clinical entity for the equine practitioner.

Dermatologic tumors (excluding sarcoids)

Cutaneous neoplasia represents a clinical problem with which veterinarians are commonly challenged. This article addresses equine cutaneous squamous cell carcinoma, squamous cell papilloma, melanoma, mastocytosis, and lymphosarcoma. Current concepts regarding the origin, pathogenesis, diagnosis and treatment of each neoplasm is emphasized.

Immunotherapy of bladder cancer

Intravesical therapy has been used in the management of superficial transitional cell carcinoma (TCC) of the urinary bladder (i.e., Ta, Tl, and carcinoma in situ) with specific objectives which include treating existing/residual tumor, preventing recurrence of tumor, preventing disease progression, and prolonging survival. The initial clinical stage and grade remain the main determinant factors in survival irrespective of the treatment. Presently, bacillus Calmette-Guerin (BCG) immunotherapy remains the most effective treatment and prophylaxis for TCC (Ta, Tl, CIS) and has positive outcomes on tumor recurrence rate, disease progression, and prolongation of survival. Prostatic urethral mucosal involvement with bladder cancer can be effectively treated with BCG intravesical immunotherapy-it has demonstrated a reduction in tumor recurrence rates, but has had no positive impact on disease progression or prolongation of survival. Interferons, keyhole-limpet hemocyanin (KLH), bropirimine, and PHOTOFRIN-photodynamic therapy (PDT) are under investigation in the management of TCC and early results are encouraging. This comprehensive review highlights recent developments in intravesical therapy of bladder cancer and summarizes the mechanisms of action of BCG, and the important role of intravesical BCG immunotherapy and other immunotherapeutic agents in the therapy and prophylaxis of superficial TCC of the urinary bladder.

Infection of a ruptured aortic aneurysm and an aortic graft with bacille Calmette-Guérin after intravesical administration for bladder cancer

A case of aortic graft infection with bacille Calmette-Guérin (BCG) is described. The graft was placed during urgent repair of a ruptured abdominal aortic aneurysm 2 years after intravesical administration of BCG for grade II transitional cell carcinoma of the bladder with associated carcinoma in situ. At the time of operation, no gross evidence of infection was found and pathologic examination of the aortic wall was unremarkable. Aortic graft infection with BCG was diagnosed 1 year after placement of the graft. Retrospective examination of formalin-fixed, paraffin-embedded aortic wall and thrombus removed at the time of graft placement by the polymerase chain reaction technique demonstrated the presence of mycobacterial DNA. The patient's condition improved with medical therapy during an observation period of 18 months with near total resolution on computed tomography scanning. Ultimately (20 months later), an aortoenteric fistula developed that required graft removal and axillobifemoral bypass.

Efficacy of tumor cell vaccine after incorporating monophosphoryl lipid A (MPL) in tumor cell membranes containing tumor-associated ganglioside

Murine B16 melanoma expresses the ganglioside GM3. GM3 shed from tumor cells is immunosuppressive and promotes tumor growth. Reduction or elimination of the shed GM3 could be therapeutic, and the anti-GM3 antibodies may reduce and clear the shed ganglioside. To test this hypothesis, mice were challenged with tumor cells, with or without inducing anti-GM3 antibody response. Since gangliosides are poor immunogens and T-cell independent antigens, an adjuvant (monophosphoryl lipid A (MPL), a non-toxic lipid A of Salmonella), directed against B-cells, was employed. MPL was incorporated onto liposomes and into the surface membrane of B16 mouse melanoma cells; both are rich in GM3. C57BL/6J mice immunized with MPL-liposomes or MPL-B16 cells responded with elevated levels of anti-GM3 IgM. Non-immunized mice or mice immunized with B16 cells alone or ganglioside GM3 alone (without MPL) elicited poor anti-GM3 IgM response, confirming the GM3's immunologic crypticity and MPL's immunopotentiating effect. MPL's immunopotentiating effect was improved by coupling it to melanoma cell membranes. C57BL/6J mice were immunized with irradiated B16 alone or MPL alone or MPL-conjugated irradiated B16. After three weekly immunizations, each mouse received a challenge dose of viable syngeneic B16. Neither MPL alone nor B16 alone had a significant effect on tumor growth or host survival; however, administration of MPL-conjugated B16 cells significantly prevented tumor growth and prolonged survival. Our results indicate that MPL-incorporated B16 cells augment the anti-GM3 IgM response, which may reverse GM3-induced immunosuppression by eliminating tumor-derived GM3, and restore immunocompetence.

Intravesical Evans bacille Calmette-Guérin for carcinoma in situ of the urinary bladder. Scottish Urological Oncology Group

OBJECTIVE

To study the long-term results of a single 8 week course of intravesical Evans bacillus Calmette-Guérin (BCG) on carcinoma in situ (CIS) of the urinary bladder.

PATIENTS AND METHODS

This study reports on 43 patients who each received a single 8 week course of intravesical BCG.

RESULTS

In spite of the good initial complete response rate of 70%, the long-term follow-up was disappointing with half the patients either having recurrence or progression of their disease by 2 years. The patients had a close follow-up protocol with early radical treatment when disease progressed. The cause specific survival at 5 years was 70%.

CONCLUSION

We feel that similar future treatment protocols without maintenance treatment are not justified.

Psoas abscess following intravesical bacillus Calmette-Guerin for bladder cancer: a case report

An 87-year-old man with an abdominal aortic aneurysm received intravesical bacillus Calmette-Guerin therapy for transitional cell carcinoma of the bladder. He presented 9 months later with a psoas abscess that mimicked a contained retroperitoneal abdominal aortic aneurysm rupture. The abscess cultures yielded Mycobacterium bovis. Recent transurethral resection and high voiding pressures after instillations of bacillus Calmette-Guerin may have led to distant dissemination of the drug.

BCG in the treatment of superficial cancer of the bladder: a review

Superficial Bladder Cancer can be treated in several ways. During the last decades, intravesical instillation of Bacillus Calmette Guerin (BCG) has emerged as an effective therapy. The history of how BCG became an antitumoral treatment is long and intriguing, and the theoretical background is fragile. In numerous studies, involving over 3,000 patients, intravesical instillation of BCG has been shown to be an effective treatment for superficial cancer of the urinary bladder in humans. Temporarily, BCG can eradicate residual disease after surgery, it can prevent local recurrence, and it can halt deterioration of malignancy in recurrences. However, its effect on survival is uncertain. For patients, treatment with BCG is prolonged, expensive, associated with side-effects, and may even be harmful. The mode of action is obscure. The theoretical framework on which this therapy is based is purely speculative, if existing at all. Although BCG has been classified as a biological response modifier, and the treatment is termed immunotherapy, proof is still lacking that the mechanism is immunological.

Intravesical Evans strain BCG therapy: quantitative immunohistochemical analysis of the immune response within the bladder wall

Previous studies have demonstrated that is is the local immune response which is of importance for the anti-tumour activity of BCG therapy. We have investigated this by quantitative immunohistochemical analysis of serial bladder mucosal biopsies taken before, during and after an eight week course of intravesical Evans strain BCG therapy and three monthly thereafter in 16 patients (15 extensive CIS and one extensive G2pTa papillary tumour). This particular group of patients had a 67% complete response rate at six months post-treatment. The main findings on immunohistochemical analysis were the universal induction of MHC Class II antigens by urothelial cells which was statistically significant up to 6 months after completion of therapy, coupled with a T cell dominated cystitis. Increases in CD3+ T cell infiltration of the lamina propria and that of the CD4+ "Helper" subset which predominated were significant up to 3 months post-therapy and these cells showed evidence of increased immunological activation as shown by increased interleukin-2 receptor and MHC Class II antigen expression. There were also significant increases in CD68+ macrophage and the incidence of CD22+ B cell aggregates but CD57+ NK cells were sparse both before and after therapy. The degree of mononuclear cell infiltration for all markers examined (except CD57) was significantly greater in those biopsies in which the urothelial cells expressed MHC Class II antigens than in those that did not. Also the degree of T cell infiltration (CD3, CD4 and CD8) was significantly greater in the eight patients deemed to have had a complete response compared to those seven with a partial response or treatment failure. These results are discussed in terms of possible mechanisms of action for BCG therapy and in particular the role of enhanced antigen presentation by tumour cells.

Incidence and treatment of complications of bacillus Calmette-Guerin intravesical therapy in superficial bladder cancer

Intravesical therapy with bacillus Calmette-Guerin (BCG) has proved to be more effective in the prophylaxis and treatment of superficial bladder tumors and carcinoma in situ than most chemotherapeutic agents. Compared to intravesical chemotherapy, instillations with BCG provoke more local and systemic reactions. In addition to the commonly induced granulomatous inflammatory changes in the bladder, which produce irritative symptoms, this therapy may cause systemic side effects varying from mild malaise and fever to, in rare instances, life-threatening or fatal sepsis. We report the incidence and varieties of toxicities in 2,602 patients treated with intravesical BCG. Side effects are classified according to local and systemic toxicity. Treatment options vary according to the severity of toxicity from delaying or withholding instillations to treatment with antituberculous drugs for up to 6 months. In general, 95% of the patients have no serious side effects. Recognition of risk factors, particularly traumatic catheterization or concurrent cystitis, that result in systemic BCG absorption, as well as the prompt and appropriate treatment of early side effects should significantly decrease the incidence of severe toxicity.

Experimental trials of immunotherapy for malignant melanoma

Conventional treatment for metastatic melanoma consists of surgical resection, chemotherapy, and radiation therapy. New approaches toward treatment of this disease include the development of passive and active immunotherapeutic regimens. Malignant melanoma is particularly amendable to immunotherapy since the tumor is relatively immunogenic, expressing unique cell surface protein and lipid antigens. Clinical trials investigating the benefit of active specific immunotherapy documented increased survival of invasive Stage 1 and metastatic Stage 2 melanoma patients following immunization with tumor cell vaccines and BCG. Additional trials showed that the development of specific antibodies after immunization of Stage 2 patients with a viral oncolysate was correlated with an increased survival compared to matched controls given only BCG. Passive immunotherapy approaches using either lymphokine-activated killer (LAK) cells or tumor-infiltrating lymphocytes (TIL) administered with interleukin 2 have also resulted in regression of disease with complete or partial remissions occurring in 25% of the patients. Additional studies have focused on the generation of specific cytotoxic T lymphocytes by stimulation with autologous tumor in vivo. Future trials will evaluate the therapeutic efficacy of these specific cytologic T lymphocytes relative to LAK and TIL.

Effects of recombinant human interferon alpha on aryl hydrocarbon hydroxylase activity in cultured human peripheral lymphocytes

Interferon and its inducers are known to depress drug biotransformation in vivo by decreasing the levels of cytochrome P-450 (P450) monooxygenase system in the liver. However, very little is known about the effects of interferon on P450 in extrahepatic tissues. In this study we investigated the effects of a recombinant human interferon-alpha (rhIFN-alpha) on aryl hydrocarbon hydroxylase (P450IAI) in cultured human peripheral lymphocytes (HPL). Non-induced and induced (3-methylcholanthrene) mitogen activated lymphocytes were used throughout the study. rhIFN-alpha maximally depressed AHH activity to approximately 58% of control after 24 hrs of incubation in both non-induced and induced lymphocytes. However, after 48 hrs of incubation with rhIFN-alpha, AHH activity had recovered to 86% of control in induced cells and 61% in non-induced cells. rhIFN-alpha had no significant effect on either NADH cytochrome c reductase activity or on viable lymphocyte cell count. This is the first demonstration that rhIFN-alpha can have a direct depressive effect on a P450 dependent monooxygenase system in HPL.

Acute and subacute toxicity of chemotactic conjugates between monoclonal antibody and fMet-Leu-Phe in humans: a phase I clinical trial

Conjugates of the chemotactic peptide fMet-Leu-Phe (fMLP) to IgG retain chemotactic and antigen recognition function in vitro and enhance intra-tumour macrophage numbers in a guinea pig model. We report a study approved by the ethics committee on the acute toxicity of fMLP conjugates in ten consenting cancer patients with metastasizing melanoma and colon cancer. They were given increasing single doses (1-2500 micrograms) IgG-fMLP made with the anti-melanoma monoclonal antibody (mAb) 9.2.27. Clinical examinations and blood cell counts, urinalysis, electrolytes, and liver and kidney function tests before and after the infusion and weekly thereafter revealed no relevant toxicities. One patient had a herpes zooster exacerbation on day 1, which was judged to be coincidental. Peak post-infusion conjugate serum concentrations fell to unmeasurable levels within a few days. In no case was a human humoral anti-(mouse Ig) immune response detected.

Characterization of cellular infiltrates in the rat urinary bladder following BCG and thiotepa intravesical therapy

We examined rat urinary bladders following intravesical administration of BCG and thiotepa. BCG administration resulted in a relatively greater increase in the mucosal infiltration of mononuclear cells relative to polymorphonuclear cells (P less than 0.01) compared to the thiotepa treated bladders. This finding suggests that the mode of action of the therapeutic effects of these agents may be different. These results may also suggest that the mechanism of action of BCG might be immunologic in nature.

Fatal sepsis following intravesical bacillus Calmette-Guerin administration for bladder cancer

Intravesical administration of bacillus Calmette-Guerin has been shown to be highly effective treatment of superficial bladder cancer. Complications from bacillus Calmette-Guerin therapy are usually minor but serious and even fatal reactions can occur. Five recent cases illustrate the gravity of bacillus Calmette-Guerin sepsis. One man with severe debility and the organic brain syndrome died acutely with a fever of 40 C. Two men had frank sepsis that progressed to multiorgan failure and death. Sepsis progressed despite the use of isoniazid, rifampin and streptomycin. Two men who had equally progressive sepsis with intravesical bacillus Calmette-Guerin survived with the use of cycloserine for the first 72 hours of treatment. Triple antituberculous antibiotics, including cycloserine, may be lifesaving. Sepsis resulted from intravenous absorption through inflamed or disrupted urothelium. Bacillus Calmette-Guerin treatment should not be administered in the presence of severe cystitis or after grossly traumatic catheterization.

Fatal disseminated mycobacterial infection following intravesical bacillus Calmette-Guerin

We describe a fatal case of disseminated mycobacteriosis after intravesical bacillus Calmette-Guerin immunotherapy. We summarize the prior safety record of this therapeutic modality, discuss local and systemic pathophysiological mechanisms by which dissemination might have occurred, and review the reported clinical experience with antituberculous chemotherapy for significant bacillus Calmette-Guerin infection. Finally, we offer suggestions for prophylaxis of certain patients with a history of exposure to intravesical bacillus Calmette-Guerin.

Therapy for cutaneous melanoma: an update

This article reviews the current therapy for cutaneous melanoma. Diagnosis, staging, and prognostic evaluation, which are crucial to proper management, are discussed. Surgical excision is the treatment of choice for primary melanoma. The resection margins should be tailored to tumor thickness. Guidelines for surgery are presented. The controversy about elective regional lymph node dissections is discussed. Limb perfusion, chemotherapy, immunotherapy, radiotherapy, and hormonal therapy as adjuvant treatments of primary melanomas as well as the treatment of disseminated melanomas are reviewed and new developments are highlighted. Guidelines for the management of metastatic melanoma at various sites are given. Special issues such as "pregnancy/estrogen and melanoma" and "borderline melanoma" are discussed and approaches to these problems are suggested. Recommendations are given for the follow-up and counseling of patients with melanoma.

Disseminated granulomatous disease (BCGosis) following chemoimmunotherapy for ovarian carcinoma

The use of BCG (bacille Calmette Guérin) in conjunction with cytotoxic chemotherapeutic agents has been advocated in patients with ovarian carcinoma. We describe a patient with stage III, grade I, endometrioid carcinoma of the ovary treated with cisplatin, doxorubicin, cyclophosphamide, and BCG. Following one course of therapy she presented with an elevated temperature, purpuric skin rash, abnormal liver function tests and hematological indices, and multiple organ failure resulting in sepsis and death. At autopsy, disseminated noncaseating granulomas were found in the lungs, hilar lymph nodes, liver, and spleen. Metastatic carcinoma was not present in these organs. This report describes the rapid onset of a disseminated BCG infection (BCGosis) in a patient with ovarian carcinoma receiving chemoimmunotherapy. Clinical recognition of BCGosis in immunocompromised patients is difficult but should be considered in the differential diagnosis of patients presenting with unexplained febrile illness, functional abnormalities in multiple organ systems, and a history of immunotherapy with BCG. Appropriate specimen collection is emphasized.

Adjuvant treatment of malignant melanoma with DTIC + estracyt or BCG

Eighty-two patients with invasive malignant melanoma and no distant metastases were prospectively randomized following their surgical treatment to 1) observation; 2) chemotherapy with Dacarbazine (DTIC) 200 mg/M2 I.V. daily X 5 every 4 weeks and Estracyt 15 mg/kg orally daily for 1 year; and 3) immunotherapy with TICE BCG 1 ml to an area of scarification near the primary site, every 4 weeks for 1 year. At a median follow-up of 73.4 months 31 patients (38%) have relapsed. There was no significant difference in survival according to the treatment, but a weak effect on the course of the disease by either of the treatment protocols cannot be ruled out due to the small sample of patients. Survival and disease-free interval varied significantly according to the histologic status of the regional nodes. The estimated 5-year disease-free rate of patients with negative nodes was 85% and for those with positive nodes it was 35% (P less than 0.0001).

Biologic response modifiers in genitourinary neoplasia

With the exception of testis cancer, the variety of genitourinary cancers have not been found to be consistently responsive to chemotherapeutic agents or regimens for other than anecdotal short duration. This has generated keen interest in the possibility that biologic response modifiers might either directly or through manipulation of immune response mechanisms successfully prevent tumor progression in these systems. In recent years, those substances that have attracted the greatest attention have included interferon (and, more recently, recombinant gamma interferon), bacillus Calmette-Guerin (BCG), tumor necrosis factor, prostaglandin synthetase inhibitors, and interleukin-2. Results with each of these agents in the variety of genitourinary cancers have been both promising and disappointing. A number of mechanisms have been suggested to underlie the actions of each of these substances, and the successful or unsuccessful recruitment of these mechanisms, in the context of the particular intrinsic behavior of the cancers being treated, have been suggested as reasons for the treatment results that have been seen. Therapeutic efficacy has been described in the treatment of renal cell cancer by both systemic interferon and interleukin-2. Successful treatments have been reported in approximately 20% of patients treated with each substance, but generally, these results have been of short duration. Topical BCG has been used with great success to treat superficial transitional cell bladder cancer. In these instances, the generation of tumor necrosis factor has been suggested as possibly accounting for the 70% success rate both in therapy and prophylaxis that has been seen. Leukocyte-derived interferon and, more recently, recombinant gamma interferon, were found in initial trials to generate a 20% response rate in renal cell carcinoma patients. Enthusiasm for these agents, however, has been tempered more recently both by a failure to reproduce these results with any substantial duration as well as by the significant side effects that have been seen. Clearly, these agents continue to be intriguing both because of their intellectual appeal through the mechanisms by which they may be effective, as well as by the absence of any definitive therapy for the cancers they are being used to treat. An understanding of the complex host/tumor cell interaction that may ultimately determine therapeutic efficacy for each of these agents is undoubtedly critical if the role of these substances in the treatment of genitourinary cancer is to be successfully implemented, either alone or in combination with other treatment modalities.