Phase II trial of high-dose intermittent interleukin-2 in metastatic renal cell carcinoma: a Southwest Oncology Group study

Long-Term Survival in Patients with Metastatic Renal Cell Carcinoma Treated with Continuous Intravenous Infusion of Recombinant Interleukin-2: The Experience of a Single Institution

Aim and background

Metastatic renal cell carcinoma is one of the few tumors for which a clear benefit of immunotherapy has been demonstrated. The aim of this study was to evaluate the long-term survival of patients with metastatic renal cell carcinoma, along with response rate and other prognostic and predictive factors.

Patients and methods

Between July 1989 and May 1995, 56 patients with metastatic renal cell carcinoma were treated in a single institution with high-dose recombinant interleukin-2 in continuous infusion. Survival was measured by the Kaplan and Meier method. Prognostic factors were assessed by univariate and multivariate analyses of survival (Cox proportional hazard ratio model).

Results

Of 56 patients, 15 had objective responses (26.8%), 16 stable disease (28.6%), 18 disease progressions (32.1%), and 7 (12.5%) were not valuable for response. Median overall survival was 20 months, and probability of 2- and 5-year survival was 41% and 21%, respectively. At multivariate analysis, the increased risk of death for: performance status ≥2 vs 0 (HR = 6.20), stable disease (HR = 1.87), disease progression (HR = 10.61) vs partial or complete remission, and for hypotension and oliguria toxicity, G3 + G4 vs G1 + G2 (HR = 2.19).

Conclusions

Our study confirms the activity of IL-2 based immunotherapy in renal cell carcinoma. Moreover, ECOG performance status, clinical response, hypotension and oliguria toxicity resulted as independent survival prognostic factors.

The Role of High Dose Interleukin-2 in the Era of Targeted Therapy

PURPOSE

We assessed survival outcomes following high dose interleukin-2 in a contemporary cohort of patients during the era of targeted agents.

MATERIALS AND METHODS

We retrospectively reviewed the records of patients with metastatic renal cell carcinoma treated with high dose interleukin-2 between July 2007 and September 2014. Clinicopathological data were abstracted and patient response to therapy was based on RECIST (Response Evaluation Criteria In Solid Tumors), version 1.1 criteria. The Kaplan-Meier method was used to estimate progression-free and overall survival in the entire cohort, the response to high dose interleukin-2 in regard to previous targeted agent therapy and the response to the targeted agent in relation to the response to high dose interleukin-2.

RESULTS

We identified 92 patients, of whom 87 had documentation of a response to high dose interleukin-2. Median overall survival was 34.4 months from the initiation of high dose interleukin-2 therapy in the entire cohort. Patients who received targeted therapy before high dose interleukin-2 had overall survival (median 34.4 and 30.0 months, p = 0.88) and progression-free survival (median 1.5 and 1.7 months, p = 0.8) similar to those in patients who received no prior therapy, respectively. Additionally, patients with a complete or partial response to high dose interleukin-2 had similar outcomes for subsequent targeted agents compared to patients whose best response was stable or progressive disease (median overall survival 30.1 vs 25.4 months, p = 0.4).

CONCLUSIONS

Our data demonstrate that patient responses to high dose interleukin-2 and to targeted agents before and after receiving high dose interleukin-2 are independent. As such, carefully selected patients should be offered high dose interleukin-2 for the possibility of a complete and durable response without the fear of limiting the treatment benefit of targeted agents.

Landmarks in the diagnosis and treatment of renal cell carcinoma

The most common renal cancer is renal cell carcinoma (RCC), which arises from the renal parenchyma. The global incidence of RCC has increased over the past two decades by 2% per year. RCC is the most lethal of the common urological cancers: despite diagnostic advances, 20-30% of patients present with metastatic disease. A clearer understanding of the genetic basis of RCC has led to immune-based and targeted treatments for this chemoresistant cancer. Despite promising results in advanced disease, overall response rates and durable complete responses are rare. Surgery remains the main treatment modality, especially for organ-confined disease, with a selective role in advanced and metastatic disease. Smaller tumours are increasingly managed with biopsy, minimally invasive interventions and surveillance. The future promises multimodal, integrated and personalized care, with further understanding of the disease leading to new treatment options.

Activity of outpatient intravenous interleukin-2 and famotidine in metastatic clear cell kidney cancer

Outpatient daily intravenous infusions of interleukin-2 (IL-2) have been developed to maintain anticancer activity and decrease toxicity of this agent against kidney cancer. Lymphokine activated killer cell (LAK) numbers are increased with these IL-2 schedules. Famotidine may enhance the LAK activity by increasing IL-2 internalization by the IL-2 receptor on lymphocytes. Fifteen patients with metastatic clear cell kidney cancer received IL-2 18 million IU/M² intravenously over 15-30 minutes preceded by famotidine 20 mg IV daily for 3 days for 6 consecutive weeks as outpatients. Cycles were repeated every 8 weeks. Patient characteristics were seven males/eight females, median age 59 (range: 28-70), median Eastern Cooperative Oncology Group (ECOG) performance status-1; common metastatic sites were lungs (14), lymph nodes (9), liver (4), bone (4), and pancreas (4). Prior systemic therapies were oral tyrosine kinase inhibitor (8), IL-2 (6), and mTor inhibitor (2). Most common toxicities were rigors, arthralgia/myalgia, nausea/emesis, fever, and hypotension. All episodes of hypotension were reversible with intravenous fluid. No patients required hospitalization due to toxicity. One complete response (7%) and four partial responses (26%) were seen (total response rate=33%; 95% confidence interval: 15%-59%). Responses occurred in the lungs, liver, lymph nodes, and bone. Outpatient intravenous IL-2 with famotidine has activity in metastatic clear cell kidney cancer.

A systematic review of the relation between interleukin-2 schedule and outcome in patients with metastatic renal cell cancer

In Europe, interleukin 2 (IL-2) is one of the two treatment modalities officially approved for patients with metastatic renal cell cancer. Traditionally, IL-2 has been administered by three different routes: intermittent bolus injection (BIV), continuous intravenous infusion (CIV) and subcutaneous injection (SC). There have been few randomized trials designed to compare these routes of administration. This paper describes a systematic review of the literature in which an attempt has been made to determine which schedule of administration is superior. Heterogeneity of the data makes firm conclusions difficult. It appears that the number of complete remissions (CR) is similar between BIV and SC routes and that these are higher than for CIV schedules. The durability of the CRs induced by BIV appeared superior to those induced by SC IL-2 and definitely higher than with CIV protocols. This analysis highlights some of the difficulties of using evidence-based medicine to determine standard of care when the clinical-trial data are heterogeneous. These data emphasize the importance of randomized clinical trials in determining what should be regarded as optimum therapy.

Outpatient experience with moderate dose bolus interleukin-2 in metastatic malignant melanoma and kidney cancer

Twenty patients with either melanoma ( 7) or kidney cancer ( 13) were treated with outpatient bolus interleukin (IL)-2 18-22 MIU/m2 IVPB for 3 consecutive days for 6 consecutive weeks followed by a 2-week rest break (on an 8-week cycle). Patient characteristics included 16 males/4 females, eleven patients had received no prior systemic therapy, median ECOG performance status = 1, and most common disease sites being lung, lymph node, subcutaneous, bone, and liver. Two patients with melanoma (29% response rate) (95% CI: 8-64%) and two with kidney cancer (15%) (95% CI: 3-43%) have achieved partial responses. Two minor responses in kidney cancer were also seen. The most common toxicities were nausea, fatigue, rigors, fever, and myalgias/arthralgias. No cardiac events occurred, and no patients required hospitalization due to toxicity. IL-2 at this outpatient dose and schedule is well tolerated and displays some evidence of activity in melanoma and kidney cancer. Larger patient numbers are required to corroborate these response rates and to determine whether complete responses are possible.

Interleukin-2 Based Therapy for Kidney Cancer

In summary, IL-2 based therapy remains the basis for treatment of metastatic renal cell cancer. Un-answered questions remain in the development of regimens that exceed a mean response rate of 20%. Additionally, there may be differences among the histologic subtypes of renal cell cancer that predispose to response or lack there of to immunotherapy, and this is being further explored. As can be noted from the studies presented in this paper, there are numerous variations on the regimens for IL-2 based therapy. Current recommendations are to use the simplest and most feasible in a given institution. Certainly high dose IL-2 remains the standard regimen to which all others are measured.

Rational approaches to human cancer immunotherapy

Over most of the 20th century, immunotherapy for cancer was based on empiricism. Interesting phenomena were observed in the areas of cancer, infectious diseases, or transplantation. Inferences were made and extrapolated into new approaches for the treatment of cancer. If tumors regressed, the treatment approaches could be refined further. However, until the appropriate tools and reagents were available, investigators were unable to understand the biology underlying these observations. In the early 1990s, the first human tumor T cell antigens were defined and dendritic cells were discovered to play a pivotal role in antigen presentation. The current era of cancer immunotherapy is one of translational research based on known biology and rationally designed interventions and has led to a rapid expansion of the field. The beginning of the 21st century brings the possibility of a new era of effective cancer immunotherapy, combining rational, immunological treatments with conventional therapies to improve the outcome for patients with cancer.

Adjuvant effect of a Flt3 ligand (FL) gene-transduced xenogeneic cell line in a murine colon cancer model

BACKGROUND

Flt3 Ligand (FL) has been shown to elicit antitumor responses induced by tumor antigen stimulation. Allogeneic and xenogeneic cell lines transduced with cytokine genes may be used to augment the antitumor efficacy of tumor antigens.

OBJECTIVES

The objective was to evaluate the augmentation of tumor lysate-induced immunity by a more clinically applicable FL gene-transduced xenogeneic cell line in combination with interleukin-2 (IL-2) in a CC-36 murine colon cancer model.

METHODS

Human 143B osteosarcoma tumor cells were transduced with full-length FL cDNA (143B-FL). Secretion of FL from 143B-FL was analyzed in vivo in normal BALB/c mice transplanted with 143B-FL, and expansion of dendritic cells (DC) was also analyzed in the same mice by flow cytometry. Eight-week-old, male BALB/c mice were used in a prophylactic vaccination protocol utilizing tumor lysate (CLy), 143B-FL, and soluble IL-2. Prophylactic group designations (n = 10/group) were as follows: ten million 143B-FL cells (alone, with tumor lysate, or with tumor lysate and IL-2), IL-2 with tumor lysate, IL-2 alone, or a no treatment control. The tumor lysate (200 microg of protein) and IL-2 (100,000 IU) injections were administered intraperitoneally. Mice were challenged subcutaneously with 10(3) CC-36 tumor cells. Tumor protection and tumor burden (TB), as mean tumor diameter, were determined. Peripheral blood lymphocytes (PBLs) from the 143B-FL + IL-2 + tumor lysate vaccinated group were analyzed for cytolytic activity in 4-h chromium release assays. In addition, plasma cytokine concentrations of interleukin-12 (IL-12) and interferon gamma (IFN-gamma) were assessed by ELISA. Student's t tests were used for all statistical comparisons.

RESULTS

In vivo expression of FL was observed 24 h following the inoculation of 143B-FL, and a four fold increase in DCs was observed in the peripheral blood of these mice. Mice immunized with a combination of 143B-FL, tumor lysate and IL-2 showed statistically significant protection against tumor development (10%) for 100 days after tumor challenge; incidences in other groups ranged from 40 to 100% (P < 0.05). Moreover, this immunization protocol produced the lowest TB at 3- and 6-week time points (0, 1.6 mm) when compared to all other groups (TB between 7.2 and 15.9 mm) (P < 0.05). In addition, PBLs from vaccinated mice showed increased cytolytic activity against CC-36 target cells. This corresponded to increased levels of IL-12 and IFN-g in the plasma of mice following vaccination.

CONCLUSIONS

These data suggest that FL gene-transduced xenogeneic tumor cells may augment the immunity induced by tumor antigens and systemic IL-2 through the activation of dendritic cells and T-cell-mediated mechanisms.

A multi-institutional phase II trial of a novel inpatient schedule of continuous interleukin-2 with interferon alpha-2b in advanced renal cell carcinoma: major durable responses in a less highly selected patient population

BACKGROUND

A prospective multi-institutional phase II trial was undertaken to define the activity and toxicity of a unique decrescendo infusion of interleukin-2 (IL-2) in combination with interferon (IFN) in patients with metastatic renal cell carcinoma. The identical regimen has shown promise in advanced melanoma.

PATIENTS AND METHODS

Between February 1997 and March 1999, 47 patients with metastatic renal cell carcinoma, from five institutions, were treated with outpatient s.c. IFN (10 mU/m2/day) on days 1-5, followed by inpatient IL-2 via continuous i.v. decrescendo infusion [18 million International Units (MIU) (I mg)/m2/6 h, followed by 18 MIU/m2/12 h, then 18 MIU/m2/24 h and 4.5 MIU/m2/24 h for the following 3 days] on days 8-12, in a hospital ward without intensive care unit (ICU)-type monitoring. Treatment was repeated every 4 weeks. In contrast to high dose IL-2 protocols, patient eligibility did not require pulmonary function tests and allowed serum creatinine up to 2 mg/dl.

RESULTS

Among 44 eligible patients, 57% (25) had their primary in place, 57% (25) had bone or visceral involvement, and only 4% (2) had lung as their only site of disease. The overall response rate in 43 response-evaluable patients was 16.3% [95% confidence interval (CI) 5.3 to 27.3], with three complete responses and four partial responses observed. The median survival was 13 months; nine patients remain alive at >23 months. The median duration of response is 36 months (range 11.5 to 48+ months). Toxicity was modest, consisting of typical cytokine-induced systemic symptoms and rare organ dysfunction. Severe grade 4 toxicity occurred in only 13% of the 130 cycles.

CONCLUSIONS

This unique, reasonably well tolerated IL-2/IFN combination induced a modest response rate with a number of durable remissions. While the optimal IL-2-based regimen for the treatment of advanced renal cell carcinoma remains elusive, the present regimen should attract considerable interest. This is based on tumor activity very similar to high dose IL-2 in a patient population not as carefully selected for optimal organ function.

Phase I trial of simultaneously administered GM-CSF and IL-6 in patients with renal-cell carcinoma: clinical and laboratory effects

BACKGROUND

Metastatic renal-cell carcinoma is a neoplasm that is minimally responsive to cytotoxic chemotherapy. Tumor regression following therapy with cytokines such as interferon alpha and or interleukin-2 is seen in selected subsets of patients. Investigations with other immunomodulatory cytokines, such as GM-CSF and IL-6 are therefore of interest.

PATIENTS AND METHODS

A phase I trial of concomitantly administered granulocyte macrophage-colony stimulating factor (3.0 mcg/kg/day s.c. d1-14) and escalating doses of interleukin-6 (1.0, 5.0 or 10.0 microg/kg/day d1-14) was conducted in patients with metastatic renal-cell carcinoma to explore the toxicity of the combination and its hematologic effects.

RESULTS

The most common side effects seen were fever, fatigue and arthralgias. Dose limiting toxicity included thrombocytosis and hyperbilirubinemia in patients receiving 10 microg/kg/day of IL-6. The hematologic effects of IL-6 and GM-CSF included leukocytoses and thrombocytosis, with increases in peripheral blood progenitors (BFU-E, CFU-GM, and CFU-GEMM). Evidence of platelet activation demonstrated by increased platelet expression of CD62 was found. No clinical responses were observed.

CONCLUSIONS

The combination of IL-6 and GM-CSF has pleotropic hematologic effects. Further studies with this combination for the treatment of renal-cell carcinoma are not recommended.

Dendritic cell-based immunotherapy of renal cell carcinoma

Although mostly resistant to cytotoxic therapy, renal cell carcinoma has been a testing ground for immunotherapy. The approval of interleukin-2 for the treatment of renal cell carcinoma was a landmark "proof of principle" which showed that agents working solely via the immune system can cause durable cancer remission. Dendritic cells are central to immune-mediated surveillance and destruction of abnormal cells. They possess all the components required to educate immune effector cells that can then mediate tumor destruction. In vitro strategies to expand and load dendritic cells with antigens have now led to human vaccine trials in renal cell carcinoma and other malignancies.

Interferon gamma-1b compared with placebo in metastatic renal-cell carcinoma. Canadian Urologic Oncology Group

BACKGROUND

Most trials of immunomodulators in metastatic renal-cell carcinoma have been uncontrolled and subject to selection bias. The objective of this blinded, placebo-controlled study was to compare overall response rates, time to disease progression, and survival of patients with metastatic renal-cell carcinoma treated with recombinant human interferon gamma-1b or placebo.

METHODS

Patients with biopsy-proved metastatic renal-cell carcinoma were randomly assigned to receive interferon gamma-1b (60 microg per square meter of body-surface area subcutaneously once weekly) or placebo. The primary tumor had been treated by nephrectomy or angioinfarction at least three weeks previously. Patients were evaluated for radiologic evidence of progression, and all responses were independently reviewed by a committee that was unaware of the treatment.

RESULTS

A total of 197 patients with metastatic renal-cell carcinoma were enrolled at 17 centers in Canada. One hundred eighty-one patients could be evaluated; of these, 91 were assigned to receive interferon gamma-1b and 90 were given placebo. The groups were well balanced in terms of prognostic factors. Two thirds of all patients had Karnofsky scores of 90 or 100, and more than half had two or more metastatic sites. Grade I and II toxicity, mostly chills, fever, asthenia, or headaches, was reported in 91 percent and 61 percent, respectively, of the patients in the interferon group, as compared with 76 percent and 63 percent in the placebo group. Life-threatening drug-related events were rare, occurring in 1 percent of patients in the interferon group. No significant differences between groups were observed in overall response rates, time to disease progression, or survival. The overall response rate was 4.4 percent (3.3 percent complete response and 1.1 percent partial response) in the interferon group and 6.6 percent (3.3 percent complete response and 3.3 percent partial response) in the placebo group (P=0.54), with a rate of durable complete response of 1 percent in both groups. The median time to disease progression was 1.9 months in both groups (P=0.49), and there was no significant difference in median survival (12.2 months with interferon vs. 15.7 months with placebo, P=0.52).

CONCLUSIONS

No difference in outcome was observed in patients with metastatic renal-cell carcinoma who were treated with interferon gamma-1b as compared with placebo. These results emphasize the necessity of testing the efficacy of immunomodulators in randomized studies.

Cytoreductive surgery before high dose interleukin-2 based therapy in patients with metastatic renal cell carcinoma

PURPOSE

We defined the outcome of a strategy using cytoreductive surgery before high dose interleukin-2 (IL-2) therapy in patients with metastatic renal cell carcinoma.

MATERIALS AND METHODS

During an 11-year period, 195 patients underwent cytoreductive surgery as preparation for high dose IL-2 based therapy. The renal primary and locoregional metastatic disease that could be safely resected was removed.

RESULTS

Because of the large size 176 of 195 renal tumors (90%) were resected through transabdominal incision and in 45 patients (23%) a second additional significant procedure was performed. Five cases (2.6%) were unresectable and 2 (1%) perioperative deaths occurred. After surgery 121 of 195 patients (62%) were eligible for treatment with high dose IL-2 based protocols. Overall response rate to IL-2 based protocols was 18%.

CONCLUSIONS

Cytoreductive surgery can be performed safely in patients with metastatic renal cell carcinoma. Although the impact of cytoreductive surgery on response to immunotherapy remains undefined, this combination of primary debulking and systemic IL-2 can result in durable complete tumor regression in some patients with metastatic renal cell carcinoma.

Common cancers--immunotherapy and multidisciplinary therapy: Parts III and IV

The refractoriness of many solid tumors to cytotoxic chemotherapy has led to the exploration of new therapeutic modalities, including immunotherapy. Immunotherapy does not have a direct cytotoxic effect on the cancer cell but is an attempt to promote rejection of the tumor by the host, chiefly through the cellular arm of the immune system. The clinical success with immunotherapy (primarily adoptive immunotherapy) among patients with unresectable malignant melanoma and cancer of the kidney has not been marked by the large numbers of patients responding but by occasional dramatic effectiveness of therapy for these cancers, which usually are refractory to chemotherapy. Long-lasting responses and even complete disappearance of all known metastases are possible for a small percentage of patients with melanoma or renal cell carcinoma who undergo immunotherapy. A reasonable approach for patients with good performance status (no symptoms or ambulatory with symptoms but not bedridden) is entrance to clinical trials, especially trials examining adoptive or active immunotherapy for melanoma or adoptive immunotherapy for renal cancer. The overall treatment of patients with cancer has changed. Primary-care physicians detect almost all cancers. The days when "taking it out" is the best we could offer a patient are over. As we learn more about the use of adjuvant or neoadjuvant chemotherapy and radiation therapy, it is likely one or both of these modalities will be incorporated into the treatment of additional solid tumors previously managed solely with surgical resection. Increasingly, additional therapy is being given for earlier-stage disease as we define how to maximize the potential for cure with minimal toxicity. Many new therapies are on the horizon, including the use of noncytotoxic treatments as an adjunct to a surgical procedure. Such therapies include the use of angiogenesis inhibitors, tumor vaccines, and immunotherapy. Now and in the future, patients will be best served when treated in an environment that can integrate medical, surgical, and radiation oncology actively.

Natural history and therapy of metastatic renal cell carcinoma: the role of interleukin-2

BACKGROUND

Despite significant advances in understanding the biology of renal cell carcinoma (RCC) during the past decade, metastatic disease remains nearly incurable and a major medical challenge. Because RCC is known to be immunogenic, immunotherapeutic agents such as recombinant human interleukin-2 (rIL-2) and interferon-alpha (IFN-alpha) have represented encouraging treatment modalities.

METHODS

A review of the natural history of and therapeutic approaches to RCC was examined. Studies involving rIL-2 alone and in combination with other adjuvant therapies were critically evaluated.

RESULTS

Overall response rates for metastatic RCC patients treated with rIL-2 were similar (i.e., in the range of 15-20%), regardless of whether rIL-2 was administered as monotherapy or in combination with IFN-alpha. Recombinant IL-2 monotherapy response rates were similar to those of IFN-alpha, but with an increased frequency of complete responses and enhanced response duration. Subcutaneous administration generally resulted in lower toxicity than intravenous administration. The roles of chemotherapy or adoptive immunotherapy in combination with rIL-2 and IFN-alpha therapy remain unclear and require further study. The importance of patient performance status as a predictor of response and survival in rIL-2 therapy was demonstrated.

CONCLUSIONS

The use of rIL-2 with or without IFN-alpha may represent the most useful therapeutic approach currently available for patients with good performance status. In patients with borderline performance status or severe comorbid disease, therapeutic approaches depend on patient factors and outcome expectation and may involve cytokine therapy. However, regardless of performance status, palliative measures and/or observation are important choices, because the majority of patients with metastatic RCC are incurable.

High-dose continuous intravenous infusion of interleukin-2 therapy for metastatic renal cell carcinoma: the University of Chicago experience

OBJECTIVES

Treatment of patients with metastatic renal cell carcinoma with high-dose interleukin-2 (IL-2) administered as continuous intravenous (CIV) infusion or as bolus injection results in response rates of 15% to 30%; however, toxicities with these regimens have been severe. A trial in which CIV IL-2 was administered at high doses during days 1 to 5 and at reduced doses during days 10 to 20 reported less toxicity without a decrease in response rates. We treated a series of patients with this regimen and our experience is presented.

METHODS

Seventeen patients with metastatic renal cell carcinoma were treated with IL-2 by CIV at a dose of 18 x 10(6) IU/m2/day for 5 days followed by 4 to 6 days of rest followed by 10 days of CIV IL-2 at a dose of 6 x 10(6) IU/m2/day. Five patients also received CT-1501R, a pentoxifylline derivative.

RESULTS

There was 1 partial responder (PR) and there were no complete responses. The patient with the PR had a 14 x 9 cm(2) renal tumor with metastases to lung, pancreas, and liver. A surgical resection induced a CR, but he relapsed 9 months later. Severe toxicities included hyponatremia (serum sodium of less than 123 mmol/L) (n=3), biopsy-proven cardiomyopathy (n=1), creatinine more than 4.5 mg/dL (n=7), and sudden death (n=1).

CONCLUSIONS

We conclude that high-dose CIV IL-2 therapy of renal cell carcinoma results in severe toxicity and cannot be recommended for general use. Alternatives need to be developed.

Cytokine gene-modified vaccines in the therapy of cancer

Therapeutic strategies based on the insertion of cytokine genes into the genome of tumour cells, followed by vaccination with the resulting genetically modified, cytokine-producing cells, represent a new potential prospect for treatment of cancer patients. In this review, the concept of cytokine gene-modified cancer vaccines is discussed; the discussion is focused on the rationale, characterization, progress in the development, preclinical testing, and first clinical trials. An effort is made to analyse and integrate the results obtained in different experimental model systems in order to determine the needed approaches and directions for further research.

Adjuvant radiation or systemic therapy for renal cell carcinoma: A brief review

Several clinical trials have been performed in which radiation therapy or systemic therapy have been given to patients in an attempt to reduce relapse following nephrectomy for renal cell carcinoma. Since only randomized trials can give valid information about the value of adjuvant therapy as compared with surgery alone, this short review evaluates critically the randomized trials that have been performed. Four randomized trials of radiation therapy given pre- or postoperatively suggest an overall detrimental effect on survival because of toxicity. Randomized trials of medroxyprogesterone acetate and of interferon-α have shown no benefit. There is current interest in the potential benefit of adjuvant treatment with other biological modifiers such as interleukin-2, but adjuvant therapy of any type should only be given in the context of a well-designed, randomized clinical trial.

Selective cytokine gene expression in renal cell carcinoma tumor cells and tumor-infiltrating lymphocytes

The progression of tumors such as renal cell carcinoma (RCC), despite the presence of substantial lymphocytic infiltrates (TIL), suggests that the ability of the local immune response to control tumor growth is impaired. Cytokine gene expression was examined to further investigate the nature of this response. Initial studies were performed with frozen tumors using PCR-assisted mRNA amplification with cytokine-specific primers for interleukin 10 (IL-10), interleukin 2 (IL-2) and interferon-gamma (IFN-gamma). IL-2 mRNA was not detected, despite the presence of T cells as defined by the expression of CD3 gamma mRNA. In contrast, mRNA for IFN-gamma was expressed in 4/9 and for IL-10 in 5/9 tumors. To confirm this, 5 fresh tumor specimens were examined, and PCR demonstrated that IL-10 mRNA was detectable in 4/5 tumors from which RNA was isolated at the time of nephrectomy. In these experiments multiple cycles and dilutions were employed to semi-quantitate the expression of IL-10. To identify potential sources of this cytokine in the tumor bed, IL-10 mRNA expression in freshly isolated lymphocytes and tumor cells, TIL lines, cultured RCC and established RCC lines was examined. Our studies demonstrate that within the tumor TIL may be one source of IL-10. Lymphocyte-enriched populations from 4/5 tumors expressed IL-10 mRNA as did 4/6 freshly isolated tumor cell preparations. IL-10 gene expression was not detected, however, in tumor cells after one passage in vitro in short-term cultured RCC tumor cells (passages 2-5) or in established RCC tumor cell lines. Finally, 4/9 CD4+ and 2/5 CD8+ TIL lines expressed IL-10 mRNA either constitutively or after stimulation with anti-CD3 antibody. This finding was associated with IL-10 production in vitro. Our studies demonstrate that IL-10 mRNA is frequently present in RCC tumors and may originate from the tumor-infiltrating mononuclear cell population.

The impact of adjuvant nephrectomy on multimodality treatment of metastatic renal cell carcinoma

Multimodality treatment of metastatic renal cell carcinoma with biological response modifiers and cytoreductive surgery has produced durable responses. The timing and impact of cytoreductive surgery on the success of immunotherapy require further study. We reviewed the treatment of 62 patients with metastatic renal cell carcinoma and primary tumors in place who qualified for multimodality treatment comprising adjuvant nephrectomy and biological response modifier protocols at our institution between 1987 and 1992. Of the patients 37 were scheduled to undergo initial adjuvant nephrectomy followed by biological response modifier therapy. A total of 25 patients underwent initial biological response modifier therapy with planned delayed adjuvant nephrectomy if a response to treatment was demonstrated. Of the 37 patients undergoing initial adjuvant nephrectomy, 8 (22%) were unable to enter induction of immunotherapy because of perioperative complications (1), medical contraindications (2), tumor progression (4) or death (1). Three patients in the initial adjuvant nephrectomy group (8%) had a partial response and the median survival in this group was 12 months (range 1 to 57). In the initial biological response modifier group 3 patients (12%) with an objective response (2 complete and 1 partial) to biological response modifier therapy underwent nephrectomy. The median survival for the initial biological response modifier group was 14 months (range 1 to 48). These results add to our understanding of the impact of adjuvant nephrectomy on patients with metastatic renal cell carcinoma considered for immunotherapy protocols.

In vitro modulation of the invasive and metastatic potentials of human renal cell carcinoma by interleukin-2 and/or interferon-alpha gene transfer

BACKGROUND

Continuous local delivery of interleukin-2 (IL-2) and interferon-alpha (IFN-alpha) via gene transfer appears to be more effective than systemic therapy in preventing the growth of human renal cell carcinoma (RCC) in vitro and in vivo. To understand further if cytokine-gene transfection of RCC could alter certain cellular properties that are associated with the invasive and metastatic potentials of tumor, the authors characterized six cell lines that produce IL-2 and/or IFN-alpha in their expression of intercellular adhesion molecule-1 (ICAM-1) and CD44; binding affinity to extracellular matrix (ECM) components (fibronectin, laminin, type IV collagen, and vitronectin); and preference in forming homotypic aggregation and mRNA levels of c-myc, epidermal growth factor receptor (EGF-R), tumor transforming growth factor-beta (TGF-beta) and type IV collagenase. These six lines were compared with control vector transfected parental R11 line.

METHODS

The expression of ICAM-1 and CD44 was determined by fluorescence-activated cell sorter (FACS) analysis, the tumor cell binding affinity to ECM components was measured by cell attachment assay, the degree of homotypic aggregation was quantified by cell aggregation assay, and the mRNA levels of c-myc, EGF-R, TGF-beta, and collagenase were analyzed by a quantitative polymerase chain reaction analysis.

RESULTS

Both IL-2-gene- and IFN-alpha-gene-modified R11 exhibited enhanced expression of ICAM-1, suppression of CD44, and decreased binding affinity to ECM components, when compared with the R11-control vector. All cytokine-producing tumor lines showed a decreased preference to form homotypic aggregation. Interferon-alpha gene transfer downregulated c-myc, EGF-R, and type IV collagenase mRNA expression, whereas only the higher producers of IL-2 downregulated TGF-beta mRNA expression. Exogenous IL-2 and/or IFN-alpha treatment of a IFN-alpha-resistant RCC enhanced both HLA class I antigen and ICAM-1 expression and suppressed CD44 expression, but had no effect on tumor growth rate.

CONCLUSIONS

The local production of high concentrations of IL-2 and IFN-a at the tumor site may directly alter tumor properties associated with invasive and metastatic phenotypes of RCC. Interleukin-2 and/or IFN-alpha gene therapy may be an effective strategy for treatment of patients with advanced renal cancer.

Phase II trial of low dose gamma-interferon in metastatic renal cell carcinoma

We conducted a phase II trial to confirm the activity of fixed, low dose gamma-interferon in metastatic renal cell carcinoma. A total of 35 patients with metastatic renal cell carcinoma, who had not received prior immunotherapy and who had a Zubrod performance status of 2 or less, was enrolled in this study. Primary tumors were controlled by nephrectomy or embolization before treatment began. gamma-Interferon was administered weekly as a subcutaneous injection at a fixed dose of 100 micrograms. Toxic effects were limited to low grade fever, chills and myalgias within 24 hours of injection. There were no incidences of grade 3 or 4 toxicity. Responses could be evaluated in 34 patients. There were 1 complete and 4 partial responses, for an objective response rate of 15% (95% confidence interval 5 to 32%). Durations of response to date are 21+, 17+, 13+, 9 and 2 months. We conclude that gamma-interferon is an active agent for metastatic renal cell carcinoma when administered according to this dose and schedule. The response rate compares favorably with those of alpha-interferon and interleukin-2, and toxicity is minimal. gamma-Interferon has excellent potential for use in combination with other biological or chemotherapeutic agents and in the adjuvant setting.

Phase II study of low dose cyclophosphamide and intravenous interleukin-2 in metastatic renal cancer

Thirteen patients with metastatic renal cancer were treated in a phase II trial with interleukin-2, 21.6 million IU/m2 intravenously daily for five days on two consecutive weeks, starting 3 days after the administration of low dose cyclophosphamide 350 mg/m2 intravenously. Treatment cycles were repeated every 21 days. No responses were seen (95% Confidence Interval: 0-22%). The most common toxicities were fever, fatigue, hypotension, nausea/emesis, and myalgia/arthralgia. There were 11 episodes of Grade III toxicity including Grade III hypotension in 7 patients. Because of the significant toxicity and the lack of observed response, the study was discontinued. Cyclophosphamide and interleukin-2 at the dose and schedule used in this study has considerable toxicity and is unlikely to improve on response rates previously seen with other IL-2 based regimens in metastatic renal cancer.

Laboratory correlates of chemoimmunotherapy with low-dose recombinant interleukin-2 and mitomycin C in patients with advanced carcinoma

Based on our clinical findings that the ability of cancer patients to generate lymphokine-activated killer (LAK) cells was remarkably augmented after mitomycin C (MMC) administration, we designed a treatment regimen that consisted of MMC 12 mg/m2, i.v. on day 1 and recombinant interleukin-2 (IL-2) 700 U/m2, i.v. every 12 hr from day 4 through day 8. Of 29 patients with advanced carcinoma treated with this regimen, 10 had a partial response (PR) and 4 had a minor response. The correlation of hematological and immunological changes associated with this treatment with the antitumor response to this therapy was investigated. Pretreatment values of total white blood cell and lymphocyte counts, and the level of increase of eosinophil counts in responder patients who showed a PR, were significantly greater than those in nonresponder patients. However, there was no correlation between clinical response and cytotoxic activities of peripheral blood mononuclear (PBM) cells, including NK and LAK activity, and the ability to generate LAK cells after the treatment. The capacity of adherent cells in PBM to produce IL-1-beta was increased after the treatment in both responders and nonresponders, whereas IL-1-alpha production was not increased. In addition, a significant increase in the ability to produce TNF-alpha was observed only in responders, indicating the correlation of TNF-alpha production with clinical response to this therapy. Since these correlations had been reported in the previous studies using IL-2, the present results suggested that the therapeutic effectiveness of this therapy against advanced carcinoma, is due to IL-2 probably augmented by its combination with MMC. In addition, these parameters might be predictive of therapeutic efficacy of this treatment.

Combination of lymphokine-activated killer cells and interleukin-2 in treating metastatic renal cell carcinoma

OBJECTIVE

To study the properties of lymphokine-activated killer (LAK) cells and the effect of immunotherapy with a combination of autologous LAK cells and interleukin-2 (IL-2) [LAK therapy] in 10 patients with metastatic renal cell carcinoma (RCC).

MATERIALS AND METHODS

The LAK cells were generated from peripheral blood lymphocytes (PBL) by incubation in a serum-free medium (AIM-V) supplemented with IL-2 for 4 days and killer cells were administered intravenously twice a week. The LAK cells showed cytotoxicity against allogenic RCC cell lines and augmented NK and LAK activities. Their phenotypes were CD25+, HLA-DR+, CD3+, and CD16+. Furthermore, LAK cells released IFN-gamma, IL-1 beta, and TNF-alpha. The total number of LAK cells administered ranged from 3.8 x 10(9) to 52.6 x 10(9) cells and the total amount of IL-2 ranged from 150 x 10(5) to 900 x 10(5) U. The effect on pulmonary metastasis in response to LAK therapy was studied.

RESULTS

The outcome was complete response (1), partial response (1), minor response (2), no change (4) and disease progression (2). Toxic effects were transient and no serious side-effects occurred. Evaluation of host immune parameters indicated that a clinical response was expected in patients with increasing proportions of CD16+, CD25+, CD57+, HLA-DR+ and CD3+DR+ cells among PBL and with augmentation of NK and LAK activities. Brain metastases were detected in three patients during or after treatment.

CONCLUSION

LAK therapy appears to be effective in treating some patients with RCC and pulmonary metastasis. The potential for inducing brain metastasis, however, should be taken into account.

The treatment of metastatic renal cell carcinoma by continuous intravenous infusion of recombinant interleukin-2

Between March 1989 and June 1990, 133 patients were treated with interleukin 2 (rIL-2) for metastatic renal cell carcinoma (RCC) in a multicentre open non-randomised study. The results show an objective response rate of 14% (95% confidence interval 8-21) with 4 patients achieving a complete remission. This is in keeping with the data from previous studies using rIL-2 by continuous infusion. It is of interest that 87% of objective responses occurred in hospitals that entered 5 or more patients.

Treatment of metastatic renal cell carcinoma with recombinant interleukin-2 in combination with vinblastine or lymphokine-activated killer cells

Fifty patients with metastatic renal cell carcinoma were treated with recombinant interleukin-2 alone or in combination with the antitumor drug vinblastine or lymphokine-activated killer cells. Of 34 evaluable patients treated with intravenous bolus interleukin-2, 1 (3%) had a partial response. Vinblastine increased myelotoxicity but did not enhance response to interleukin-2 in 15 of these patients. Two partial responses were observed among 15 patients treated with lymphokine-activated killer cells in addition to interleukin-2. In 1 patient biopsy documented complete resolution of hepatic metastases lasting for 1 year was observed. All responders had undergone previous nephrectomy and none had multiple sites of metastatic disease. Toxicity was significant and caused termination of therapy in 40% of the patients. Biological therapy using interleukin-2 can result in prolonged responses in renal cell cancer but future trials should be directed at lessening toxicity.

Short-duration in vitro interleukin-2-activated mononuclear cells for advanced cancer. A Hong Kong biotherapy pilot study trial

BACKGROUND

In vitro studies have demonstrated that a brief exposure of peripherally collected mononuclear cells to high-dose human recombinant interleukin-2(rIL-2) will generate a population of pulsed lymphokine-activated killer (LAK) cells. These cells have similar cytotoxicity against natural killer cells and resistant and sensitive target cells as compared with the standard LAK cells incubated for 3-7 days with rIL-2. Therefore, the authors conducted a pilot study to investigate the activity of pulsed LAK cells in patients with advanced cancer.

METHODS

Nineteen patients were enrolled in a pilot study, and pulsed LAK cell treatment was administered two times per week for 4 weeks, followed by similar cycles if patients remained free of disease progression and unacceptable toxic effects.

RESULTS

Toxic effects consisted mainly of fever, chills, nausea, and dizziness but were self-limiting and mild. Most cycles were administered on an outpatient basis. There were six partial responses (31%), occurring in two of three patients with renal cell carcinoma, two of four with hepatocellular carcinoma, one of seven with non-small cell lung carcinoma, and one of one with ovarian carcinoma. Two minimal responses were seen in one case each of melanoma and carcinoma of colon. Nine other patients had disease stabilization for 16 weeks, and two additional patients had disease progression. Phenotyping of peripheral mononuclear cells showed increases in CD56 and CD25 populations with no in vivo rIL-2 being administered after treatment with pulsed LAK cells.

CONCLUSIONS

The relative ease in generating pulsed LAK cells and the associated mild toxic effects enable prolonged stimulation of the effector cells of the patients against sensitive tumor targets, with a response rate comparable to those of high-dose rIL-2 and LAK cell treatment. Therefore, it may be a theoretically ideal adjuvant for patients with renal cell carcinoma, melanoma, and hepatoma and other applicable patients after bone marrow transplantation. The initial high response rate in patients with late-stage renal cell carcinoma and hepatocellular carcinoma indicates the need for additional confirmation.

Interleukin-2: use in solid tumors

Recombinant interleukin-2 (rIL-2) is a cytokine that has a central immunoregulatory role in controlling T cell function and growth. Clinical trials of rIL-2 regimens in various solid tumors have been initiated, and 337 patients at the Cleveland Clinic Foundation have been treated in a sequence of trials. The studies have involved rIL-2 or polyethylene-glycol conjugated rIL-2 (PEG-IL-2) as single agents, combinations of rIL-2 with recombinant interferon alpha, IL-4, or doxorubicin, and trials of rIL-2 with tumor infiltrating lymphocytes (TILs). These studies are summarized and involve Phase I or Phase II investigations in patients with renal cell carcinoma (191 patients), malignant melanoma (49 patients) or miscellaneous solid tumors (97 patients). Response rates in each category, respectively, were 12%, 20% and 2%. Toxicity varied depending on the regimen and generally reflected the dose and schedule of rIL-2 being employed. This series of clinical studies demonstrates the role of rIL-2 in various malignancies and documents the activity in patients with malignant melanoma and renal cell carcinoma. Additional studies to investigate potential mechanisms of antitumor activity and response determinants are underway.

Clinical applications of interleukin-2

Interleukin-2 (IL-2) is a cytokine with potent immunomodulating properties which has shown considerable antitumour activity in preclinical models. In clinical trials, the effects of IL-2 given by various routes and schedules have been investigated. IL-2 has been administered either as single drug or in combination with other cytokines and immunomodulating agents, chemo therapeutic agents, or reinfusions of ex vivo activated autologous cytotoxic effector cells. The results of published clinical studies with IL-2 based immunotherapy are reviewed in this paper.

Correlation of eosinophilia with clinical response in patients with advanced carcinoma treated with low-dose recombinant interleukin-2 and mitomycin C

On the basis of our clinical findings that the ability of cancer patients to generate lymphokine-activated killer cells became markedly augmented after mitomycin C administration, we designed a treatment regimen comprising mitomycin C 12 mg/m2, i.v. on day 1 and recombinant interleukin-2 700 U/m2 (8000 IU/kg), i.v. every 12 h from day 4 through day 8. The treatment course was repeated at almost 7-day intervals. Altogether 33 patients with advanced carcinoma, including mainly gastrointestinal carcinoma, were treated with this regimen. Of these, 10 had a partial response (PR) and 4 had a minor response (MR). Since eosinophil counts peaked 1 day after either the first or second course of the therapy, the posttreatment values were compared to each pretreatment level, with regard to the clinical antitumor response to this treatment. When patients who showed PR were defined as responders, absolute eosinophil counts and the percentage of eosinophils in responders after both the first and second courses of the therapy were significantly greater than each pretreatment value or the posttreatment level in nonresponders. Further, these findings were almost identical, when both PR and MR were considered to be a true remission and therefore patients who exhibited PR or MR were defined as responders, although the difference between posttreatment levels of eosinophils in responders and nonresponders was not significant at the second course. These results indicate that eosinophilia induced by this treatment correlates with the clinical response to this therapy.

Interleukin-2 therapy for refractory and relapsing lymphomas

Recombinant interleukin-2 (rIL-2) has been reported to be active in metastatic renal cell carcinoma and malignant melanoma. The purpose of this trial was to determine the efficacy and toxicity of rIL-2 administered in continuous infusion in patients with Hodgkin's disease (HD) and non-Hodgkin lymphoma (NHL). 21 patients with HD (4 patients), diffuse large-cell NHL (7) or low-grade NHL (10) in failure or relapse after multiple-conventional treatments were included in this trial. rIL-2 therapy consisted of an induction period of two cycles separated by 3 weeks of rest, and, in the absence of progressive disease or undue toxicity, a maintenance period of 4 monthly cycles. Each induction cycle comprised the continuous infusion of rIL-2: 18 x 10(6) IU/m2 per day on days 1-5 and days 12-16. Each maintenance cycle comprised the continuous infusion of rIL-2: 18 x 10(6) IU/m2 per day on days 1-5. Among the 21 treated patients, 5 (all of those with low-grade NHL) responded to the induction phase (1 complete response, 4 partial responses) and 2 patients had a mixed response. Conversely, no response was observed in patients with HD or large-cell NHL. The median duration of response was 4 months. rIL-2 administered as a continuous infusion was well tolerated and most patients received the full dosage, and management did not require intensive care. During the induction period, 2 patients experienced grade III cardiovascular or renal toxicity. During the maintenance period, rIL-2 had to be interrupted in 1 patient because of a myocardial infarction. This trial confirms the inefficacy of rIL-2 for the treatment of large-cell NHL and HD. Conversely, in low-grade NHL, rIL-2 activity needs to be explored by further studies. rIL-2 may have a place in the early phase of the disease, when the immune system is not compromised, as an adjuvant treatment in residual disease in order to improve the duration of response.