Pilot trial of infusional 5-fluorouracil, interleukin-2, and subcutaneous interferon-alpha for advanced renal cell carcinoma

Immunomodulation in a Treatment Program Including Pre- and Post-Operative Interleukin-2 and Chemotherapy for Childhood Osteosarcoma

Aims and Background

The treatment applied in our Institution to children with localized osteosarcoma between 1991 and 1999 consisted of four interleukin 2 (IL-2) courses (9 x 106 IU/mL/daily x 4), alternated with pre- and post-operative polichemotherapy. The aims of the present study were to quantify the modifications of some immunological parameters induced by IL-2 and to verify whether polychemotherapy could reduce them. An additional aim was to assess whether any correlation between the immune modifications and the clinical outcome could be found.

Patients and Methods

We evaluated in 18 consecutive patients the following changes, induced in blood by each IL-2 course: number of lymphocyte subpopulations and natural killer (NK) cells, lymphokine activated killer (LAK) and NK activities.

Results

Chemotherapy did not influence the modifications of the number of NK and CD4+ cells and of the LAK and NK activities, induced by each of the four courses of IL-2. The magnitudo of the NK activity and the peak of the NK absolute counts significantly correlated with the clinical outcome.

Conclusions

The results show that the use of IL-2 permitted a repeated immune activation despite the intensive chemotherapy. Furthermore, although the limited number of cases precludes any definitive conclusion, the results suggest a possible role of the NK cells in the control of osteosarcoma.

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

Aims and background

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

Patients and methods

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

Results

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

Conclusions

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

Phase II studies of antiangiogenic four drug regimens for the treatment of advanced renal cell carcinoma: FUNIL-retinoid and the FUNIL-thalidomide protocols

BACKGROUND AND PURPOSE

The objective of these studies was to determine the activity of two alternative 4- drug combinations using cis-retinoic acid or thalidomide administered with a previously developed combination of 5 fluorouracil, interferon-alpha, and interleukin 2 (FUNIL), for patients with metastatic renal cell carcinoma (RRC).

METHODS

Patients enrolled in these studies had progressive measurable metastatic renal cell cancer and signed an informed consent. Treatments included continuous infusions of 5-fluorouracil, interferon-alpha, 6 MIU/m2 given subcutaneous on days 1, 3, and 5 every week, interleukin-2 6 MIU/m2/day given by continuous infusion days 2 to 5 every week, and either cis-retinoic acid at a dose of 1 mg/kg/day orally in two divided doses or thalidomide given at an initial dose of 200 mg per day. Each cycle consisted of 6 or 4 weeks of the combinations, respectively, followed by a 2-week rest. Patients were evaluated for response prior to each successive cycle. A 2-step mini-max statistical design was used.

RESULTS

In the cis-retinoid study, 20 patients were enrolled. One patient was ineligible. There were 1 complete and 2 partial responses (one confirmed and one unconfirmed) (15.8%), 1 stable disease, and 15 disease progression. In the thalidomide combination study, 20 patients were enrolled, but only 19 are assessable. One patient progressed early and was never treated. There were 2 partial responses (10.5%), 4 stable disease, and 13 progressive disease.

CONCLUSION

Neither the FUNIL-cis-retinoid nor the FUNIL-thalidomide regimens met their primary objective first step endpoint of 3 confirmed responses. Both regimens had significant adverse effects and neither is considered promising for further study.

Chemo-immunotherapy of colorectal carcinoma: preclinical rationale and clinical experience

Advanced colorectal cancer is a common disease with an high mortality rate. For four decades, pharmacological treatment of the advanced disease was based on the use of 5-fluorouracil alone or in combination with biomodulators such as folinic acid and intereferon alpha. In the last 5 years, response to therapy has been considerably ameliorated thanks to the discovery of new drugs such as oxaliplatin and CPT-11. These agents, in combination with 5-fluorouracil, according to various schedules of treatment, have reached a significant improvement of palliation, response rate and survival. Immunotherapy is an uprising modality of treatment for human cancer including colorectal carcinoma. Its rationale is based on the knowledge that tumour cells are genetically unstable and produce molecular structures which allow their recognition and destruction by the immune-surveillance system. Therefore, humoral as well as cellular compartments of the immune system can be utilized according to a "passive" strategy (e.g. monoclonal antibody administration and adoptive immunotherapy) or an "active" approach, by using different modalities of vaccine therapy. In this context, monoclonal antibodies (mAbs) and cancer vaccines are being tested for the treatment of advanced colorectal cancer. Due to their genetic instability and extraordinary adaptative potential, tumour cells may acquire resistance to the immune effectors and mAbs exactly as they do for cytotoxic drugs. To improve the results of both immunological and chemical modality of cancer treatment, an increasing number of authors is starting to combine chemo and immunotherapy in the attempt to circumvent the limitations of both strategies. This report tries to review the possible rationale of the chemo-immunotherapy combination, illustrating preliminary results of preclinical and clinical studies.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Age does not impair the efficacy of immunochemotherapy in patients with metastatic renal carcinoma

PURPOSE

Based on the increasing proportion of elderly cancer patients, we compared the efficacy of subcutaneous cytokine based home therapy in older (age > or = 60 years) and younger (age < 60 years) patients with metastatic renal cell carcinoma.

PATIENTS AND METHODS

As a rule, patients at an age of 60 years or older received a 20% dose reduction of s.c. IL-2. Treatment consisted of (A) s.c. interferon-alpha2a (s.c. INF-alpha2a), s.c. interleukin-2 (s.c. IL-2), (B) s.c. IFN-alpha2a, s.c. IL-2 and i.v. 5-fluorouracil (5-FU) or (C) s.c. IFN-alpha2a, s.c. IL-2 and i.v. 5-FU combined with p.o. 13-cis-retinoic acid (p.o. 13cRA).

RESULTS

Patient age groups > or = 60 years (n=174) and < 60 years (n=251) showed no significant difference in objective response (27% versus 31%), in median overall survival (22 months versus 19 months), and in progression-free survival (6 months versus 5 months). Within the elderly patients group, median overall survival was 20 months (pts. 60-64 years) versus 23 months (pts. > or = 65 years) and median progression-free survival was 4 months (pts. 60-64 years) versus 8 months (pts. > or = 65 years).

CONCLUSION

Our results demonstrated that patient age and related IL-2 dose reduction do not impair the efficacy of s.c.-IL-2 plus s.c.-INF-2a based outpatient immunochemotherapy in metastatic renal carcinoma.

Dendritic cell-mediated cross-presentation of antigens derived from colon carcinoma cells exposed to a highly cytotoxic multidrug regimen with gemcitabine, oxaliplatin, 5-fluorouracil, and leucovorin, elicits a powerful human antigen-specific CTL response with antitumor activity in vitro

Gemcitabine, oxaliplatin, leucovorin, and 5-fluorouracil (GOLF) is a novel multidrug regimen inducing high levels of necrosis and apoptosis in colon carcinoma cells. This regimen is also able to promote a process of Ag remodeling including up-regulation of immunotherapy targets like carcinoembryonic Ag (CEA), thymidylate synthase (TS). We have conducted a preclinical study aimed to investigate whether these drug-induced modifications would also enhance colon cancer cell immunogenicity. Several CTL lines were thus generated by in vitro stimulating human HLA-A(*)02.01(+) PBMCs, from normal donors and colon cancer patients, with autologous dendritic cells cross-primed with cell lysates of colon cancer cells untreated, irradiated, or previously exposed to different drug treatments including the GOLF regimen. Class I HLA-restricted cytolytic activity of these CTL lines was tested against colon cancer cells and CEA and TS gene transfected target cells. These experiments revealed that CTLs sensitized with GOLF-treated cancer cells were much more effective than those sensitized with the untreated colon carcinoma cells or those exposed to the other treatments. CTL lines sensitized against the GOLF-treated colon cancer cells, also expressed a greater percentage of T-lymphocyte precursors able to recognize TS- and CEA-derived peptides. These results suggest that GOLF regimen is a powerful antitumor and immunomodulating regimen that can make the tumor cells a suitable means to induce an Ag-specific CTL response. These results suggest that a rationale combination of GOLF chemotherapy with cytokine-based immunotherapy could generate a chemotherapy-modulated Ag-specific T-lymphocyte response in cancer patients able to destroy the residual disease survived to the cytotoxic drugs.

Chemo-immunotherapy of metastatic colorectal carcinoma with gemcitabine plus FOLFOX 4 followed by subcutaneous granulocyte macrophage colony-stimulating factor and interleukin-2 induces strong immunologic and antitumor activity in metastatic colon cancer patients

PURPOSE

Tumor cell killing by anticancer drugs may be supported by their immuno- and pharmacologic effects. Chemotherapy is in fact able to (A) upregulate tumor-associated antigen expression, including carcinoembryonic antigen (CEA) or other target molecules such as thymidylate synthase (TS); and (B) downregulate tumor cell resistance to the death signals induced by tumor antigen-specific cytotoxic T lymphocytes. This provides the rationale for combining chemo- and immunotherapy.

MATERIALS AND METHODS

We describe the results of a translational phase II trial designed to evaluate the toxicity, antitumor activity and immunologic effects of gemcitabine + FOLFOX-4 (oxaliplatin, fluorouracil, and folinic acid) polychemotherapy followed by the subcutaneous administration of granulocyte macrophage colony-stimulating factor and low-dose interleukin-2 in colorectal carcinoma patients. The study involved 29 patients (16 males and 13 females with a mean age of 69 years), 21 of whom had received a previous line of treatment, and 19 had liver involvement.

RESULTS

The treatment was well tolerated and induced very high objective response (68.9%) and disease control rates (96.5%), with an average time to progression of 12.5 months. An immunologic study of peripheral blood mononuclear cells (PBMCs) taken from 20 patients showed an enhanced proliferative response to colon carcinoma antigen and a significant reduction in suppressive regulatory T lymphocytes (CD4+CD25T-reg+). A cytofluorimetric study of the PBMCs of five HLA-A(*)02.01+ patients who achieved an objective response showed an increased frequency of cytolytic T lymphocyte precursors specific for known CEA- and TS-derived epitopes.

CONCLUSION

The results show that our regimen has strong immunologic and antitumor activity in colorectal cancer patients and deserves to be investigated in phase III trials.

Adjuvant treatment with interleukin-2- and interferon-alpha2a-based chemoimmunotherapy in renal cell carcinoma post tumour nephrectomy: results of a prospectively randomised trial of the German Cooperative Renal Carcinoma Chemoimmunotherapy Group (DGCIN)

We conducted a prospectively randomised clinical trial to investigate the role of adjuvant outpatient immunochemotherapy administered postoperatively in high-risk patients with renal cell carcinoma. In total, 203 renal carcinoma patients' status post radical tumour nephrectomy were stratified into three risk groups: patients with tumour extending into renal vein/vena cava or invading beyond Gerota's fascia (pT3b/c pN0 or pT4pN0), patients with locoregional lymph node infiltration (pN+), and patients after complete resection of tumour relapse or solitary metastasis (R0). Patients were randomised to undergo either (A) 8 weeks of outpatient subcutaneous interleukin-2 (sc-rIL-2), subcutaneous interferon-alpha2a (sc-rIFN-α2a), and intravenous 5-fluorouracil (iv-5-FU) according to the standard Atzpodien regimen (Atzpodien et al, 2004) or (B) observation. Two-, 5-, and 8-year survival rates were 81, 58, and 58% in the treatment arm, and 91, 76, and 66% in the observation arm (log rank P=0.0278), with a median follow-up of 4.3 years. Two, 5-, and 8-year relapse-free survival rates were calculated at 54, 42, and 39% in the treatment arm, and at 62, 49, and 49% in the observation arm (log rank P=0.2398). Stage-adapted subanalyses revealed no survival advantages of treatment over observation, as well. Our results established that there was no relapse-free survival benefit and the overall survival was inferior with an adjuvant 8-week-outpatient sc-rIL-2/sc-rIFN-α2a/iv-5-FU-based immunochemotherapy compared to observation in high-risk renal cell carcinoma patients following radical tumour nephrectomy.

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.

Treatment of colon and breast carcinoma cells with 5-fluorouracil enhances expression of carcinoembryonic antigen and susceptibility to HLA-A(*)02.01 restricted, CEA-peptide-specific cytotoxic T cells in vitro

Cancer vaccines directed against tumor associate antigen (TAA) have produced encouraging results in preclinical models but not in cancer patients. A major limitation of this strategy is the relative degree of tolerance to these antigens and the low and heterogeneous tumor cell expression of TAA and major histocompatibility complex (MHC). Previous studies have shown that 5-fluorouracil (5-FU) can upregulate the expression of membrane-associated carcino-embryonic antigen (CEA), and MHC molecules in colon and breast carcinoma cell lines. We have investigated whether this drug can also enhance their sensitivity to the lytic effects of CEA-peptide specific Cytotoxic T cell lymphocytes (CTL). The CEA peptide-specific CTLs generated in our laboratory from normal HLA-A(*)02.01(+) donor PBMCs, were able to kill HLA-A(*)02.01(+)/CEA(+) breast (MCF-7-T103) and colon (HLA-A(*)02.01 gene-transfected HT-29 and C22.20) carcinoma cells in HLA-A(*)02.01 restricted manner. The treatment of target cells with 5-FU, enhanced their CEA expression and susceptibility to CTL-mediated lysis. Cold competition assays confirmed these results, thus supporting the hypothesis that immune target cell lysis and 5-FU mediated enhancement were dependent on CEA peptide presentation by cancer cells. 5-FU treatment of functionally "mature" CTL after in vitro expansion, did not reduce their cytolytic activity against MT-2 target cells but, when the anti-metabolite was added during the immune-sensitization phase, CTL generation was significantly inhibited. These results provide a rationale for investigating a possible new role of 5-FU as an immuno targeting amplifier agent in breast and colorectal cancer patients immunized with CEA-directed cancer vaccines.

Effects of 13-cis-retinoic acid on chemoimmunotherapy of metastatic renal cell carcinoma--results of a retrospective analysis

Chemoimmunotherapy (CIT) with interleukin-2, interferon-alpha2a, and 5-fluorouracil is an accepted treatment option of metastatic renal cell carcinoma (mRCC). Because of the enhancement of the antiproliferative effects of interferon-alpha2a, 13-cis-retinoic acid (13-CRA) might be of potential usefulness for immunotherapy. We have investigated the effect of 13-CRA in patients treated with chemoimmunotherapy. Seventy-two patients with mRCC and a Karnofsky performance index > or = 80% were retrospectively analyzed. Thirty-six patients received chemoimmunotherapy and 36 other patients were treated similarly but with addition of daily 60 mg 13-CRA. Response was assessed according to the UICC criteria. Survival was calculated by Kaplan Meier estimation and compared with the log-rank test. In the CIT group objective remissions occurred in 34.3% (95% CI 19.1-52.2) and stabilizations in 42.9% (median follow-up 16 months). In the CIT plus 13-CRA group, objective remissions were seen in 26.4% (95% CI 12.9-44.4) and stabilizations in 50% (median follow-up 17 months). One- and three-year survival rates were 76% and 32% in the CIT group and 82% and 37% in the CIT plus 13-CRA group. The combination of CIT and 13-CRA did not significantly differ in objective remissions and estimated survival compared with CIT. Our retrospective data suggest that 13-CRA does not enhance the therapeutic efficacy of CIT in mRCC patients with a good performance status.

Potential of interferon-alpha in solid tumours: part 1

Interferon-alpha (IFNalpha) is a pleiotropic cytokine with direct and indirect antitumour effects. These include prolongation of the cell cycle time of malignant cells, inhibition of biosynthetic enzymes and apoptosis, interaction with other cytokines, and immunomodulatory and antiangiogenic effects. The first clinical trials in solid tumours used crude preparations of natural IFNalpha and demonstrated that tumour regressions in solid tumours and haematological malignancies were possible. Since the advent of genetic engineering technology, recombinant (r) IFNalpha has been widely evaluated in solid tumours. This review discusses the use and potential of rIFNalpha in solid tumours; the first part focuses on malignant melanoma and metastatic renal cell carcinoma (RCC). In the adjuvant treatment of malignant melanoma, rIFNalpha has been tested in randomised trials in more than 6000 patients. High-dosage IFNalpha (> or =10MU) prolongs disease-free survival (DFS) but not overall survival (OS). Low-dosage IFNalpha (< or =3MU) has not been shown to prolong DFS or OS, and current data do not support its use outside clinical trials. The latest United Kingdom Co-ordinating Committee on Cancer Research meta-analysis of ten randomised trials that used adjuvant rIFNalpha has shown that there is a benefit in DFS but not OS. No conclusions can be reached for intermediate-dosage IFNalpha (5 to 10MU) until the mature results of the European Organization for Research and Treatment of Cancer (EORTC) study 18952 are available. In RCC, current evidence does not support the use of adjuvant IFNalpha. In metastatic malignant melanoma and RCC, reported response rates to rIFNalpha are approximately 15%. In a minority of responding patients, however, these responses can be long-standing. In metastatic malignant melanoma, IFNalpha combined with other cytotoxic agents with or without interleukin-2 has achieved high response rates but has not improved survival. In metastatic RCC, intermediate dosages of rIFNalpha should be used and therapy should probably be prolonged (>12 months); response depends on prognostic factors such as good performance status, whereas survival is affected by factors such as low tumour burden. Nephrectomy should therefore be considered in patients with good performance status prior to IFNalpha immunotherapy in advanced RCC, even in patients with metastatic disease. The toxicity of high-dosage IFNalpha and the lack of definite benefit on OS with high- or low-dosage IFNalpha do not support its use outside clinical trials. Data from the ongoing US Intergroup studies, the ongoing EORTC 18991 study (long-term therapy with pegylated IFNalpha) and mature data from EORTC 18952 (intermediate-dosage IFNalpha) will help establish the role of IFNalpha as adjuvant therapy in malignant melanoma.

A literature analysis of prognostic factors for response and quality of response of patients with renal cell carcinoma to interleukin-2-based therapy

OBJECTIVE

To characterize prognostic factors for response of advanced renal cell carcinoma to interleukin-2-based regimens.

PATIENTS AND METHODS

Data compiled from 80 published series were examined for associations between patient characteristics and outcomes.

RESULTS

Response rates were highest in trials utilizing interleukin-2 combinations. Longer median survivals were associated with high percentages of patients with nephrectomy, good performance status, with publication year, response rates, and inversely with median ages. Associations of performance status and prior nephrectomy with response rates were detected in trials with individual patient details. The response rate was higher for patients older than the median age of patients entering each trial, and also higher for males. Among responders, attainment of complete response was associated with fewer sites of involvement. Pooled response duration of patients reported to have complete responses exhibited durability, but no correlation with prognostic factors. Selection factors may have influenced apparent differences between types of regimens. We confirm the potential for durable remissions from interleukin-2-based regimens.

Renal cell carcinoma

The overall incidence of renal cell carcinoma is rising, for reasons not fully explained by increased abdominal imaging. Risk factors associated with renal cell carcinoma include hypertension, smoking, increased body mass index, and diet. There is an inverse association of renal cell carcinoma risk with consumption of a variety of carotenes. In addition, increased red meat intake has been associated with increased risk. Partial nephrectomy may be as effective as radical nephrectomy as treatment for localized disease, and radiosurgery may be as effective as surgical resection in the management of brain metastases. Immunotherapy remains the mainstay for systemic treatment, with response rates between 5% and 20%. Survival in renal cell carcinoma is related to pathologic stage, nuclear grade, microscopic vascular invasion, DNA content, nuclear morphometry, and histologic pattern. In addition, patients with deletion (8p)/-8, +12, and +20 appear to have a worse prognosis.