Immunotherapy in patients with melanoma

Pooled analysis of the efficacy of bacille Calmette-Guerin (BCG) immunotherapy in malignant melanoma

BACKGROUND

The trials of bacille Calmette-Guerin (BCG) as adjuvant therapy in malignant melanoma conducted over the preceding 2 decades have presented conflicting claims of efficacy.

OBJECTIVE

Determination of the role of BCG immunotherapy in malignant melanoma.

METHODS

Critical analysis of randomized clinical trials of stage I and II melanoma and all reported trials of intralesional and oral BCG in stage III melanoma was conducted. A literature search used the Medline data base (1966-1992);bibliographic reviews of relevant texts and pertinent articles.

RESULTS

No significant benefit of BCG as postsurgical adjuvant therapy in stage I malignant melanoma was observed. Although two of seven trials in stage II melanoma demonstrated benefit with the addition of BCG, the trial with the greatest power in this series detected no difference in outcomes. In stage III malignant melanoma, there was no significant benefit with addition of BCG to various chemotherapeutic regimens. Oral BCG monotherapy produced complete responses in 6%, partial responses in 1%, and extended survival in 7% of patients. Objective responses were observed primarily in patients with intracutaneous non-visceral metastases. Pooled analysis of 15 non-controlled trials of intralesional BCG injections revealed complete responses in 19%, partial responses in 26%, and extended survival in 13% of patients with stage III melanoma. Objective responses to intralesional BCG were more likely in patients with solely cutaneous metastases, particularly intradermal lesions.

CONCLUSION

Pooled analysis of non-placebo controlled trials of intralesional BCG for stage III malignant melanoma supports a trend to enhanced survival in patients with cutaneous non-visceral metastases.

The prognostic significance of recall antigen testing in melanoma patients

A quantitative assessment of the long-term prognostic value and clinical usefulness of recall antigen reactions in patients with malignant melanoma is not available. The authors evaluated longitudinal observations of survival made in 846 patients over a 12-year period. Each patient was initially studied with Mantoux-type recall antigen skin tests. The patients were categorized with respect to the following: high (greater than 5 mm) or low (less than or equal to 5 mm) averaged skin test reaction diameters at 48 hr; Clark level; tumor stage (I = localized tumor, II = local extension and/or region lymph node metastasis, III = systemic metastasis); ulceration; site of primary; histologic type; age; and sex. The percentage of high reactors in Stages I, II, and III were 44.3%, 37.4%, and 25%, respectively. Survival was evaluated with the Cox-Mantell hazard function model and the Cox regression model. The significant (chi-squared; probability) risk factors detected were tumor stage (94.58; less than or equal to 0.0001), Clark level (19.37; less than or equal to 0.0001), sex (16.97; less than or equal to 0.0001), and skin test reactivity (7.48; less than or equal to 0.0062). A significant relationship also was detected between skin test reactor status and the tumor stage (p less than or equal to 0.0330). When evaluated within each stage of disease, skin test reactivity predicted survival only in Stage II patients (p less than or equal to 0.0080). Five-year survival estimates among Stage II patients were 58% among high reactors and 38% among low reactors.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of human malignant melanoma antigens by immunofluorescence and autologous postimmune antimelanoma sera

The objectives of this study are to demonstrate the specificity of sera from melanoma patients undergoing autologous immunization and to localize melanoma antigens on a cellular level. Five melanoma patients were immunized with autologous melanoma cells and Bacillus Calmette-Guerin. This immunization program was conducted at Tulane University. Indirect immunofluorescence using both viable and fixed melanoma cells was employed. Four of five postimmune sera were reactive to five of seven melanoma cell lines. Two of the four reactive antisera showed positive binding with two additional melanoma lines obtained from other laboratories. All these sera were negative against seven nonmelanoma lines. Negative controls consisted of sera from 65 nonimmunized melanoma patients and 140 nonmelanoma patients. Membrane immunofluorescence (MIF) demonstrated sequential full MIF, capping, polarization, and extrusion of antigen-antibody complexes on the cell surface. MIF inhibition showed shedding of melanoma antigens in the culture medium. Ethanol, methanol, formalin, trichloroacetic acid, and acetone yielded sharp MIF. Isopentane and isooctane gave bright cytoplasmic fluorescence. In conclusion, this study provides suggestive evidence for the existence of common melanoma antigens as defined by the postimmune antimelanoma sera. These antigens may be localized in the membrane or within the cytoplasm.

An ultrastructural analysis of breast carcinoma presenting as isolated axillary adenopathy

Metastatic adenocarcinoma in the axillary lymph nodes of a female patient often originates from a primary tumor in the ipsilateral breast. Mastectomy may be recommended if adenocarcinoma is found in the axillary nodes even when the primary tumor is not clinically detectable. In these circumstances, the recommendation for mastectomy should be based on the firm histologic diagnosis of adenocarcinoma. In the present report, five female patients are discussed who presented with axillary lymphadenopathy without clinically evident breast masses or mammographic evidence of malignancy. Axillary lymph node biopsies, performed in each patient, were inconclusive after conventional light microscopic examination. Electron microscopy established the diagnosis of adenocarcinoma. These findings were complemented by sex steroid analyses of the tumors where possible. Each patient underwent ipsilateral mastectomy, and in each specimen an occult breast carcinoma was found. The necessity of making a precise tissue diagnosis in all cases of metastatic cancer from an unknown primary is stressed, and special techniques to accomplish this must be considered preoperatively. This is particularly important in the female patient with metastatic breast carcinoma in an isolated axillary lymph node, since ipsilateral mastectomy may be curative.

Primary reconstruction of cheek defect following excision of a large malignant melanoma: Report of a case

A large malignant melanoma of the cheek with metastasis to a submandibular lymph node is described. The tumor was successfully treated by surgical excision and radical neck dissection followed by immunotherapy with intradermal injections of CWS (cell wall skeleton) of noocardia. The cheek and upper lip defects following tumor excision were reconstructed primarily by upward rotation of the cheek and neck skin flap and by lateral advancement of a full-thickness upper lip flap. The oral defect was closed by stretching the distal based mucosal flap from the lower half of the buccal mucosa.

In vivo evaluation of cell mediated immunity against human melanoma

Evaluation of cell mediated immunity against human melanoma target cells was performed in an in vivo model using human tumor xenografts growing in Balb/c athymic mice. Intraperitoneal inoculation of 1 x 10(7) human melanoma cells produced carcinomatosis which lead to death of the animals at 23.8 +/- 2.6 days (N = 12). Peripheral blood lymphocytes (PBL) from normal donors were administered to tumor bearing mice, and survival times of 22.0 +/- 2.3 days were observed (N = 8). Peripheral blood lymphocytes from the four of five normal donors which had been presensitized on monolayers of melanoma tissue culture cells in vitro failed to prolong host survival times. In contrast, PBL obtained from 15 or 20 melanoma patients were found to prolong survival of the tumor bearing nude mice. Of these 15 patients, 8 were undergoing specific active immunotherapy, while 7 had not been sensitized except by the disease process. The ability of PBL obtained from patients to prolong survival of tumor bearing animals did not appear to correlate with either the stage of the disease or the patient's clinical course. The possible mechanisms for the prolonged survival and usefulness of this model are discussed.

Clinical value of immunochemotherapy with OK-432 or PS-K for stomach cancer patients

A prospective clinical trial was undertaken in 121 patients with stomach cancer to compare immunochemotherapy with 5-fluorouracil and FT-207 combined with OK-432 or PS-K, immunostimulators, and plain chemotherapy with 5-fluororacil and FT-207. Of the 121 patients who received immunochemotherapy, 67 patients (group A) had undergone curative removal of the tumor. The other 54 patients had undergone noncurative tumor removal or had recurrence after non-curative tumor removal and they were divided into two groups (groups B and C) on the basis of lymphocyte reactivity induced with PHA. Although group A exhibited a significant increase in PHA-induced lymphocyte transformation and a trifling increase in lymphocyte counts, its survival rate within a 36 month period did not differ from that of the peer controls. Group B, composed of 21 patients showing improvement of PHA-induced lymphocyte transformation, significantly prolonged its survival compared to the peer controls. The survival of group C, composed of 33 patients showing a gradual drop in PHA-induced lymphocyte transformation, was not prolonged compared to the peer control patients; and they showed significant decreases in lymphocyte counts. The overall survival of group B and group C was not superior to that of the 48 peer controls.

Immunobiology of head and neck cancer: basic concepts

Patients with squamous cancer of the head and neck have unique perturbations of the immune system. These patients have marked depression of cellular immunity even in the early stages of disease. The known facts about the immunobiology and the immunodeficiencies that commonly occur are discussed. Also reviewed are the relationships of the immunologic deficits to stage of disease, to prognosis, and to the suspected etiologic factors of smoking, alcoholism, and malnutrition. Highlights are given of current immunotherapeutic trials. To date, most of the successful efforts in both immunologic research and immunotherapy of head and neck cancer have dealt with general, rather than specific, immune reactions. Further development in the area of specific immune responses may permit more meaningful measurements of tumor-specific reactions, thus yielding useful tools for immunodiagnosis as well as providing more effective and precise methods of immunotherapy.

Immunotherapy of guinea pigs with dermal and visceral tumor implants: comparison of living and nonliving BCG

Emulsified cell walls of Mycobacterium bovis (BCG) were immunotherapeutically at least as active as living BCG in prolonging survival of guinea pigs with established dermal tumors and microscopic lymph node and visceral metastases.

Viral infection-homograft interactions in a murine model

The effects on some host defenses of murine cytomegalovirus (MCMV) and(or) EL(4), a mouse ascites homograft, were studied in mice. Assays of cellular and humoral immunity in response to either or both of these perturbations were carried out by quantitation of various immune activities.Limited studies demonstrated no effect of EL(4) inoculation on the host response to MCMV by organ viral titer, duration of viral persistence, or anti MCMV complement-fixing antibody titer. Prior infection with MCMV, however, resulted in greatly reduced numbers of splenocytes, the source in this study of immune effector cells. Residual splenocytes demonstrated less response to both phyto-hemagglutinin and lipopolysaccharide, particularly in the 2-3-wk interval after infection. Similarly, responder cells in mixed lymphocyte cultures were less reactive when derived from infected animals. Lymphocyte-mediated cytolysis of EL(4) was significantly less in mice infected on the day of and 7, 14, and 21 days before the tumor homograft with a return to control levels by 28 days. 90% of the cell-mediated cytolysis could be eliminated by treatment with anti-theta serum. Serum-mediated cytolysis of EL(4) was also reduced in infected animals. No suppressor cells or serum inhibitory factors could be identified in infected animals. Although alternative explanations exist, this study suggests that in infected animals there is a significant reduction in both the number and function of bone marrow-derived and thymus-derived cells directed against the alloantigens in EL(4).

Viral oncolysate in the management of malignant melanoma. II. Clinical studies

Melanoma cell oncolysate, prepared with Newcastle disease virus, was administered as an immunostimulant to 13 patients with metastatic melanoma. The oncolysate was well tolerated. Six treated patients evidenced a decrease in the size of skin nodules or diseased lymph nodes. Visceral lesions were not favorably influenced to any marked degree. One case of fulminating disease showed a change to slow progression and survived a year longer than was otherwise expected. Another patient, whose melanoma could not be controlled by surgery or chemotherapy, has been in complete remission for 2 years. It appears that viral oncolysate might be particularly helpful to patients with early disease.

Disorders of leukocyte chemotaxis

The rapid accumulation of inflammatory cells at sites of microbial invasion or neoplastic transformation is a central event in immunologically-mediated host defense. The availability of methodology to accurately quantify leukocyte migration in vitro has allowed the disclosure of previously unrecognized clinical disorders, namely leukocyte dysmotility syndromes. Although this area of clinical investigation is in its infancy, one can identify several processes associated with abnormal leukocyte accumulation. Abnormalities of immune recognition, chemotactic factor production, cellular motility or inhibitors of chemotaxis have been identified in different human diseases. In the upcoming years, pharmacological intervention directed at correcting specific causes of leukocyte dysmotility may well enhance our ability to treat certain infectious, inflammatory, and neoplastic diseases.

Modifications of macrophage chemotaxis in rats bearing the transplantable tumour reticulosarcoma 'IRE'

Macrophage chemotactic activity was studied as a marker of the anti-inflammatory effect accompanying tumour growth. An inhibiting effect of the tumour on the macrophage mobility was observed by comparing the macrophages collected from normal rats and those from animals bearing the IRE reticulosarcoma. To explain these results, it is postulated that a MIF, or a similar inhibiting factor is released by the tumour. Both the the nature and function of such a factor(s) remain to be clarified.

Quantitative change of serum protein and immunoglobulin in patients with solid cancers

There are many quantitative changes of serum protein and immunoglobulin fractions in patients with cancer of various sites, excluding those with leukemic and lymphoproliferative disorders. The commonest change in serum proteins of patients with neoplastic disease is a reduction in albumin concentration and elevation of alpha globulins, especially alpha-2 fraction. Immunoglobulins (IgG, A,M) are a heterogenous group of proteins contained in the gamma, beta, and alpha-2 electrophoretic fractions of serum proteins. The IgG was found to be significantly increased in patients with cancer of the skin and lung, but decreased in patients with cancer of the prostate and breast. Serum IgM was reported to be elevated in patients with sarcoma, melanoma, brain tumors, but decreased in patients with carcinoma of the ovary. Serum IgA was found to be elevated in patients with cancer of epithelial secretory organs, such as skin, breast, head and neck, lung, gut, prostate, and uterine cervix. Whether these findings reflect specific changes of the humoral arm of tumor-host interaction remains to be investigated.

Abnormal monocyte function in bladder cancer patients

We evaluated 39 patients with various stages of bladder carcinoma to determine alterations in monocyte function. Since the monocyte plays an important role in the effector arm of the immune system defective function may explain the host's inability to destroy neoplastic cells. As a group these 39 patients demonstrated defective monocyte monocyte function. There was no correlation between tumor stage and degree of chemotactic defect. Patients with invasive carcinoma had a significant return of monocyte chemotactic response toward normal postoperatively (p less than 0.005). Monocyte function was improved also in 3 patients who received Bacillus Calmette-Guerin immunotherapy (p less than 0.05).

Monitoring of immunologic status of patients receiving BCG therapy for malignant disease

BCG immunotherapy in a standard regime was administered by scarification to 26 selected patients with controlled malignant disease, 14 with lung cancer and 12 with melanoma. All were followed for 12 months after the first BCG administration or until death. During the first 3 months, when BCG was given weekly, immune reactivity as determined by skin tests and in vitro lymphocyte responses to phytohemagglutinin and recall antigens was enhanced in all patients except those in whom recurrence or extension of malignancy subsequently occurred. Patients who had received prior radiation therapy for lung cancer also did not manifest significant immunoenhancement. During the following 9 months when BCG was administered at increasing intervals, immune responses were maintained except in those patients who experienced recurrence of malignancy, and those who discontinued BCG therapy. The response to PHA was predictive of a favorable clinical course during the following 9 months, and was significantly impaired in advance of the clinical recurrence of malignancy. Tests of cell-mediated immunity, particularly the in vitro response to HA, are valuable in assessing the efficacy of BCG immunotherapy, prognosticating clinical progress, and predicting the recurrence of malignancy.

Cellular immunocompetence in melanoma: effect of extent of disease and immunotherapy

Cell mediated immunocompetence was measured serially in 35 patients with malignant melanoma in order to determine the effect of extent of disease and prognosis as well as the influence of BCG immunotherapy on immune reactivity. Compared with normal adult controls, statistically significant lymphopenia occurred only in patients with widespread disease. Seventeen of 21 patients with negative pre-therapy PPD skin test converted to skin test positivity. PHA blastogenesis was depressed only in patients in the pre-terminal stages of their disease using optimal mitogen concentrations for stimulation. Threshold concentrations of this mitogen more clearly demonstrated a depressed responsiveness which correlated in severity with extent of disease. PPD induced blastogenesis was normal or increased in the majority of patients; however, the degree of stimulation by PPD was less in the BCG induced convertors than in those patients who were skin test positive before BCG treatment. Comparison of the pre- and post BCG assessments reveals no significant differences except in relation to PPD conversion. We conclude that using threshold concentrations of PHA, impaired responses are regularly associated with disease beyond the regional lymph nodes. Routine assessment of lymphocyte function by these parameters did not provide information that was not available from clinical evaluation.

Melanoma of the head and neck

A series of 94 patients with cutaneous malignant melanoma of the head and neck region has been studied. Fifty-three of the patients had regional lymph node dissections performed and the results in 37 performed more than 5 years ago are presented. The policy of elective lymph node dissection for invasive melanoma of the head and neck is strongly endorsed, although not proven by the data presented in this limited series. Whenever possible, a total excisional biopsy should be performed to establish the diagnosis. It is recommended that all melanomas be classified by the method of Clark and Mihm and that the level of invasion also be determined. There is an appreciable error in the clinical evaluation of lymph nodes for metastases. In general, it is suggested that elective regional lymph node dissections be performed for invasive melanoma (levels III, IV and V). The literature pertaining to cutaneous melanoma of the head and neck has been reviewed and surgical and pathological problems peculiar to lesions of this region are emphasized.

Management of recurrent melanoma of the extremity

Two forms of therapy employed for treatment of patients with recurrent melanoma limited to the extremity, and carried out during different intervals of time, are presented. Perfusion of the involved extremity with phenylalanine mustard has resulted in a 5-year survival rate of 28% of 43 patients. A second group of 25 patients has been treated by a four-stage immunotherapy program consisting of sensitization with intradermal BCG, followed in 6 weeks by intra tumor injection of BCG. A third stage involved the activation of the patients's lymphocytes, after removal by a blood cell separator, incubated in vitro with irradiated neuraminidase-treated melanoma cells and reintroduced into the patient either by subcutaneous or intratumor injection. The fourth stage of immunotherapy involves injection of an inoculum of irradiated neuraminidase-treated autochothonous tumor cells plus BCG injected intratumorally or subcutaneously. Sixteen of 24 patients receiving immunotherapy treatment program have experienced arrest of their disease lasting from 5 to 42 months.