Radioimmunotherapy of lymphoma: a UC Davis experience

Current results and future applications of radioimmunotherapy management of non-Hodgkin's lymphoma

Monoclonal antibodies labeled with radionuclides have become an important therapeutic tool in the treatment of patients with non-Hodgkin's lymphomas (NHL). At the present time, their use in the US is approved for patients with rituximab-resistant, low-grade, follicular or transformed NHL. Encouraging responses seen in the relapsed and refractory patients have prompted their evaluation in earlier disease or in other histologic sub-types either alone or in combination with conventional chemotherapy. Additionally, they have been included as preparative regimens for stem cell transplant protocols within the context of clinical trials. This review discusses the latest clinical trials and future directions of radioimmunoconjugates in the treatment of NHL, with emphasis on US Food and Drug Administration (FDA) approved radioimmunoconjugates, namely 131I-tositumomab and 90Y-ibritumomab tiuxetan.

Drug targeting systems for cancer chemotherapy

Tumour specific drug targeting has been a very actively investigated area for over 2 decades. Various approaches have involved the use of drug delivery systems that can localise the anticancer agent at the tumour site without damaging the normal cells. For this purpose, various delivery systems that have been utilised are liposomes, microspheres and recently, nanoparticles. Two liposome formulations containing anticancer drugs for example, adriamycin and daunomycin are already on the market in the USA and Europe. Microspheres are also being investigated for delivering various anticancer drugs and protein/peptides for anticancer treatment, and several formulations are in Phase I/II clinical trials. Antitumour drugs have also been linked to tumour specific monoclonal antibodies via various chemical linkages. Doxorubicin was linked to a chimeric monoclonal antibody that was targeted to the Lewis Y antigen. Though this conjugate initially showed potential, it was recently dropped from Phase II clinical trials. Another approach with monoclonal antibodies has been the use of immunotoxins. Immunotoxins initially showed promise as potential anticancer agents at picomolar concentrations but several clinical and preclinical studies have not shown much promise in this regard. Drug containing liposomes and microspheres have been further linked to tumour specific monoclonal antibodies to enhance their tumour specificity. Most of the studies with immunoliposomes or targeted microspheres have not gone beyond the preclinical studies. New therapeutic approaches are presently emerging based on natural products like cytokines, peptide growth factor antagonists, antisense oligonucleotides and specific genes. These approaches need the help of delivery systems to deliver these complex molecules to tumour cells. One of the current pursued approaches is the use of cationic liposomes. Several clinical studies are undergoing with various cationic liposomes and the next few years will demonstrate the usefulness of this approach. In recent years, the problems in cancer treatment have been complicated with the emergence of resistance strains leading to resistant and cross-resistant tumour cells. Several agents have been used to overcome or reverse drug-resistance in solid tumours and it remains a highly pursued area in cancer treatment.

Advancing role of radiolabeled antibodies in the therapy of cancer

This review focuses on the use of radiolabeled antibodies in the therapy of cancer, termed radioimmunotherapy (RAIT). Basic problems concerned with the choice of antibody, radionuclide, and physiology of the tumor and host are discussed, followed by a review of the pertinent clinical publications of various radioantibody constructs in the treatment of hematopoietic and solid tumors of diverse histopathology, grade, and stage, and in different clinical settings. Factors such as dose rate delivered, tumor size, and radiosensitivity play a major role in determining therapeutic response, while target-to-nontarget ratios and, particularly, circulating radioactivity to the bone marrow determine the principal dose-limiting toxicities. RAIT appears to be gaining a place in the therapy of hematopoietic neoplasms, such as non-Hodgkin's lymphoma: several agents are advancing in clinical trials toward registration, and one has recently been approved by the FDA. Although RAIT of solid tumors has shown less progress, use of pretargeting strategies, such as an affinity-enhancement system consisting of bispecific antibodies separating targeting from delivery of the radiotherapeutic, appears to enhance tumor-to-nontumor ratios, and may increase radiation doses to tumors more selectively than directly labeled antibodies.

Therapeutic cancer targeting peptides

Antitumor monoclonal antibodies have shown clinical promise as cancer cell surface targeting agents. More tumor targeting antibodies are likely to be approved by the FDA in the next few years. However, there are two major limitations in antibody-targeted therapy: large size and nonspecific uptake of the antibody molecules by the liver and the reticuloendothelial system. These result in poor tumor penetration of antibody pharmaceuticals and dose-limiting toxicity to the liver and bone marrow. Peptides are excellent alternative targeting agents for human cancers, and they may alleviate some of the problems with antibody targeting. In the last decade, several investigators have successfully used combinatorial library methods to discover cell surface binding peptides that may be useful for cancer targeting. The phage-display library technique and the "one-bead one-compound" combinatorial library method are the two approaches that have been used. Cancer cell surface receptors or endothelial cell surface receptors of the neovasculature are the two popular therapeutic targets for cancer. Results from preclinical studies with some peptides are encouraging in their targeting potential.

The role of radiolabeled antibodies in the treatment of non-Hodgkin's lymphoma: the coming of age of radioimmunotherapy

This review summarizes the current clinical status of radioimmunotherapy (RAIT) in the treatment of patients with non-Hodgkin's lymphoma (NHL), as a prototype of the advances of RAIT in the management of cancer. Four radiolabeled antibody products are progressing towards commercialization for the RAIT of NHL: 131I-tositumomab (Bexxar), 90Y-ibritumomab tiuxetan, 90Y-epratuzumab (hLL2), and 131I-Lym-1. All except epratuzumab are murine monoclonal antibodies (Mabs) labeled with an isotope, except that ibritumomab (Zevalin) adds chimeric rituximab to the product, whereas epratuzumab is solely a humanized Mab. Bexxar and Zevalin target CD20, epratuzumab binds to CD22, and Lym-1 reacts with HLA-DR. Clinical studies have shown that all four antibody products can be safe and efficacious. Bexxar has been shown to induce responses that are relatively better than the prior chemotherapy, and has also been shown to be effective in combination with chemotherapy as a frontline therapy of low-grade and transformed NHL. However, since it is a fully murine Mab, it did show a approximately 60% HAMA rate in untreated patients. Zevalin has been found to be more effective than rituximab, its naked chimeric Mab counterpart, as well as in chemotherapy-relapsed low-grade NHL patients. Both radiolabeled epratuzumab and Lym-1 have shown efficacy in patients who have failed chemotherapy, either with low-grade or aggressive forms of NHL. It appears that Bexxar and Zevalin will be the first two radiolabeled antibodies that may be available for widespread use in the U.S., and will mark the final introduction of RAIT as an approved cancer treatment modality. Future studies will help define the role of these RAIT products in the management of NHL, especially as part of a multimodal therapy of this disease.

Immunotherapy of Non-Hodgkin's lymphomas

Recent years have witnessed the development of a variety of promising immunotherapies for treating patients with non-Hodgkin's lymphomas. Foremost among these advances is the exciting success of monoclonal antibodies directed against lymphocyte surface antigens. Rituximab is a chimeric (human-mouse) anti-CD20 antibody that induces responses in approximately half of the patients with relapsed indolent lymphomas and a third of patients with relapsed aggressive lymphomas when used as a single agent. Response rates appear even higher (up to 70%) for newly diagnosed patients treated with Rituximab monotherapy. Other promising antibodies for treatment of B cell malignancies include epratuzumab (anti-CD22), CAMPATH-1H (anti-CD52w), and Hu1D10 (anti-class II HLA). Even more exciting than antibody monotherapy is the prospect of combination antibody therapy (e.g. rituximab + epratuzumab) or combination chemotherapy and antibody therapy. In this regard, a recent phase III randomized trial from the GELA group in France demonstrated statistically significantly superior complete and overall response rates and superior event-free and overall survivals for elderly patients with newly diagnosed diffuse aggressive B cell lymphomas treated with CHOP + rituximab compared with CHOP alone. Confirmatory cooperative group trials combining chemotherapy with antibody therapies are currently underway. Another approach to augment the efficacy of antibodies is to deploy them in radiolabeled form. Iodine-131, Yttrium-90, and Copper-67 labeled monoclonal antibodies targeting CD-20, CD-22, HLA class II, and other cell surface antigens have been tested and demonstrate higher overall response rates (50-80%) and complete response rates (20-40%) than unlabeled antibodies. Pilot studies combining radiolabeled antibodies with either standard dose chemotherapy or myeloablative chemoradiotherapy with stem cell transplantation also appear very promising. Lymphoma vaccines have also produced very encouraging results in single institution studies at Stanford and the National Cancer Institute, with responding patients demonstrating superior event-free and overall survival than historical controls. Phase III randomized trials of idiotype vaccines are currently underway and novel new vaccine approaches are also being tested.

Clinical radioimmunotherapy

Radioimmunotherapy (RIT) is a promising new therapy for the treatment of a variety of malignancies. General principles of RIT are discussed, including important considerations in the selection of monoclonal antibodies (MAb) and radionuclides for RIT. Results of clinical trials using RIT for the treatment of lymphoma, leukemia, and solid tumors are summarized. The results from many of these trials are promising, especially for the treatment of lymphohematopoietic malignancies, in which a variety of MAb, radionuclides, and study designs have resulted in high response rates with a number of durable responses. Encouraging results have also been obtained using RIT to treat some solid tumors, primarily in patients with relatively low tumor burdens. RIT is generally well tolerated, with the primary toxicity being transient reversible myelosuppression in most nonmyeloablative studies. Nonhematologic toxicity, especially at nonmyeloablative doses, has been minimal in most studies. Approaches for increasing the therapeutic index of RIT are reviewed, which may further potentiate the efficacy and decrease the toxicity of RIT.

Monoclonal antibodies in the treatment of human B-cell malignancies

Monoclonal antibody technology emerged in the 1970's and was greeted by a wave of optimism. Many believed this new form of therapy would be effective in the treatment of human cancers. Early clinical trials in B-cell lymphomas demonstrated both the potential and limitations of unlabeled murine monoclonal antibody therapy, and taught us valuable lessons regarding the importance of the antibody structure, and nature of the targeted antigen. Since that time modifications in antibody structure and careful selection of target antigen have improved the clinical efficacy of these agents. Clinical trials using humanized antibodies have demonstrated that human/mouse chimeric antibodies and humanized antibodies have enhanced anti-tumor activity, decreased immunogenicity, and a very favorable toxicity profile. Radiolabeled monoclonal antibodies can induce durable remissions in lymphoma with toxicity limited largely to bone marrow suppression. Clinical trials with immunotoxins have demonstrated anti-tumor activity but also have been associated with significant toxicity. Standard treatment options for B-cell lymphoma will soon include antibody-based therapies. Further basic and clinical research is needed so we can understand more thoroughly the mechanisms responsible for the observed anti-tumor effects, and explore more extensively the best approach to their clinical use.

Combined modality radioimmunotherapy with Taxol and 90Y-Lym-1 for Raji lymphoma xenografts

Despite effective therapies for non-Hodgkin's lymphoma (NHL), the majority of patients are not cured. Radioimmunotherapy (RIT) has shown good results in preclinical and clinical trials even in patients that are non-responsive to standard chemotherapy. To make RIT more effective, agents such as paclitaxel (Taxol), that can enhance radiation effects, are being tested. Nude mice bearing human Burkitt's lymphoma (Raji) xenografts were treated with: 1) 150 or 200 microCi (5.5 or 7.3 MBq) of 90Y-2IT-BAD-Lym-1 alone, 2) 600 micrograms of Taxol alone, 3) 150 or 200 microCi of 90Y-2IT-BAD-Lym-1 plus 600 micrograms of Taxol given 24 hours after RIT, or 4) no treatment. Tumor size, survival, mouse weight and blood counts were monitored to assess efficacy and toxicity. Survival for mice treated in this 84 day trial was: 71% for 90Y-2IT-BAD-Lym-1 (200 microCi) plus Taxol, 29% for Taxol alone, 6% for 90Y-2IT-BAD-Lym-1 (200 microCi) alone and 14% in the untreated group. Average tumor volume in the 90Y-2IT-BAD-Lym-1 (200 microCi) plus Taxol group was reduced by 89 and 99% compared to the RIT alone and Taxol alone groups, respectively. Mice treated with 150 microCi had less toxicity than those treated with 200 microCi of 90Y-2IT-BAD-Lym-1, however, the higher radiation dose, and Taxol, were required for improved survival. Mouse weights and myelotoxicity in the combined modality (RIT plus Taxol) groups were similar to those receiving the same dose of RIT alone. In the Raji tumored nude mouse model, addition of Taxol to 90Y-2IT-BAD-Lym-1, in doses clinically achievable in humans, provided therapeutic synergy without increased or excessive toxicity.

Targeted therapy for lymphoma with peptides

Using the newly developed combinatorial peptide library methods, D-amino acid containing peptides that are specific against pan-B cell markers such as CD19, CD20, and CD22 can potentially be identified. These peptides can then be used as targeting agents for human lymphoma.

The potential for immunoconjugates in lymphoma therapy

Contemporary combination chemotherapy offers curative treatment for 30% to 50% of patients with advanced-stage, aggressive non-Hodgkin's lymphomas (NHL). However, conventional therapies cure few patients with indolent lymphomas or relapsed lymphomas of any histology. Myeloablative chemoradiotherapy with bone marrow or stem cell transplantation can provide pro-longed disease-free survival for a minority (20% to 50%) of patients with relapsed NHL, but new treatment approaches are clearly needed. In recent years, several groups of investigators have provided preliminary evidence suggesting that monoclonal antibodies (mAbs), in unmodified form or conjugated to toxins, drugs, or radioisotopes, may offer another effective therapeutic modality for patients with relapsed lymphomas. This article reviews current immunotherapy of NHL using antibody immunoconjugates.

Decreased C-MYC and BCL2 expression correlates with methylprednisolone-mediated inhibition of Raji lymphoma growth

Methylprednisolone (MP) and related corticosteroids are a fundamental part of regimens used to treat lymphoma and leukemia. In many of these malignancies, oncogenic activation of C-MYC and BCL2 is seen. Abnormalities of the tumor suppressor p53, which exerts growth-suppressing and apoptosis-enhancing functions through the transcriptional regulation of downstream genes including CDKN1, GADD45, and BCL2, are also often found. The goal was to determine the modulation of expression of the oncogenes (C-MYC and BCL2), the p53 pathway described above, and the apoptosis marker TGF-beta 1 in the human Raji lymphoma following MP treatment. Raji xenografts were grown in nude mice and growth curves characterized by sequential measurement. Mice were treated daily for 8 days with MP. Tumors were harvested untreated, or at 1 or 8 days after cessation of MP treatment, and the RNA was extracted. RT-PCR was used to determine the level of mRNA expression of the genes. Tumor growth was greatly reduced in the MP-treated mice. Gene expression levels for C-MYC and BCL2 were reduced at 1 day following MP and approached control levels 8 days after MP treatment. Expression levels of p53, CDKN1, and GADD45 were moderately and coordinately decreased at 1 day after cessation of MP treatment and remained repressed a week later. TGF-beta 1 exhibited no change in expression levels. These results suggest that decreased expression of C-MYC and BCL2 may play a role in the molecular events that initiate and are responsible for the growth inhibition of Raji lymphoma xenografts by MP.