Potential of interferon-alpha in solid tumours: part 2

Management of ocular surface squamous neoplasia: Bowman Club Lecture 2021

The gold-standard treatment for ocular surface squamous neoplasia (OSSN) has traditionally been surgical excision with wide margins and a no-touch technique. However, surgery may be associated with several unfavourable sequelae, as well as significant recurrence rates if margins are positive. In recent years, topical chemotherapy with 5-fluorouracil, interferon α-2b and mitomycin C have emerged as valuable agents capable of effectively treating OSSN with varying adverse effects. These medical treatment options usually present additional costs to the patient but can allow patients to avoid surgery with fewer long-term effects. Anterior segment high-resolution optical coherence tomography is an excellent tool for diagnosing and monitoring OSSN and can be a useful aid for both surgical and medical treatments of OSSN.

The current status of immunobased therapies for metastatic renal-cell carcinoma

The management of metastatic renal-cell carcinoma (mRCC) represents an important clinical challenge. Since being approved in the early 1990s, aspecific immunotherapy has been a mainstay of treatment for mRCC and the only therapy that has demonstrated long-term cures for mRCC. However, in recent times there have been landmark advances made in the field of specific immunotherapy for a number of malignancies, including kidney cancer. This review outlines the range of immunobased agents currently available for the treatment of mRCC.

A prosurvival DNA damage-induced cytoplasmic interferon response is mediated by end resection factors and is limited by Trex1

Radiotherapy and chemotherapy are effective treatment methods for many types of cancer, but resistance is common. Recent findings indicate that antiviral type I interferon (IFN) signaling is induced by these treatments. However, the underlying mechanisms still need to be elucidated. Expression of a set of IFN-stimulated genes comprises an IFN-related DNA damage resistance signature (IRDS), which correlates strongly with resistance to radiotherapy and chemotherapy across different tumors. Classically, during viral infection, the presence of foreign DNA in the cytoplasm of host cells can initiate type I IFN signaling. Here, we demonstrate that DNA-damaging modalities used during cancer therapy lead to the release of ssDNA fragments from the cell nucleus into the cytosol, engaging this innate immune response. We found that the factors that control DNA end resection during double-strand break repair, including the Bloom syndrome (BLM) helicase and exonuclease 1 (EXO1), play a major role in generating these DNA fragments and that the cytoplasmic 3'-5' exonuclease Trex1 is required for their degradation. Analysis of mRNA expression profiles in breast tumors demonstrates that those with lower Trex1 and higher BLM and EXO1 expression levels are associated with poor prognosis. Targeting BLM and EXO1 could therefore represent a novel approach for circumventing the IRDS produced in response to cancer therapeutics.

Evaluation of a short-term topical interferon α-2b treatment for histologically proven melanoma and primary acquired melanosis with atypia

OBJECTIVE

To evaluate the efficiency of series of 6-week treatments with brief intervals (6-week = 1 cycle) of topical Interferon α-2b (IFNα-2b) treatment in primary acquired melanosis (PAM) with atypia and melanoma of the conjunctiva.

PATIENTS AND METHODS

Five patients with biopsy-proven PAM with atypia and seven patients with melanoma of the conjunctiva, treated with topical IFNα-2b (1 million units/ml, 5 times daily), were included in the study. All patients had colour photographs and the tumour area was measured manually for each patient before and after treatment.

RESULTS

The median age of 12 patients at initiation of treatment was 61.5 years (range 39-75 years). The mean therapy duration was 2.4 cycles (range 1-6 cycle). Compared to pretreatment lesion dimension, the mean decrease in tumour size were after the first cycle 66% (range 18-98%; p = 0.004; n = 10 patients), after the second cycle 55% (range 10-100%; p = 0.016; n = 7 patients), and after the third cycle 74% (range 23-100%; n = 3 patients). In one patient 6 cycles of topical IFNα-2b were needed. The decrease in size was 22% after the 4(th) cycle, 34% after the 5(th) cycle, and 98% after the 6(th) cycle.

CONCLUSION

Our clinical experience demonstrates promising results of topical IFNα-2b treatment for PAM with atypia and melanoma of the conjunctiva without any local or systemic side effects. However, future multicenter prospective studies are recommended to confirm the efficiency and safety of topical IFNα-2b treatment.

Surgical versus medical treatment of ocular surface squamous neoplasia: a comparison of recurrences and complications

PURPOSE

Treatment for ocular surface squamous neoplasia (OSSN) has historically been surgery, but nonsurgical interventions are increasingly used. Treatment with interferon is efficacious, but evidence is needed regarding recurrence and complication rates in comparison with surgery. The objective of this study is to compare the recurrence and complication rates of surgical treatment and interferon treatment for OSSN.

DESIGN

A matched, case-control study.

PARTICIPANTS

Ninety-eight patients with OSSN, 49 of whom were treated with interferon (IFN) α2b therapy and 49 of whom were treated with surgical intervention.

METHODS

Patients with OSSN were treated with surgery versus IFNα2b therapy, either in topical or injection form. Median follow-up after lesion resolution was 21 months (range, 0-173 months) for the IFNα2b group and 24 months (range, 0.9-108 months) for the surgery group.

MAIN OUTCOME MEASURES

The primary outcome measure for the study was the rate of recurrence of OSSN in each of the treatment groups. Recurrence rates were evaluated using Kaplan-Meier survival analysis.

RESULTS

Mean patient age and sex were similar between the groups. There was a trend toward higher clinical American Joint Committee on Cancer tumor grade in the IFNα2b group. Despite this, the number of recurrences was equal at 3 per group. The 1-year recurrence rate was 5% in the surgery group versus 3% in the IFNα2b group (P = 0.80). There was no statistically significant difference in the recurrence rate between the surgically and medically treated groups. Nonlimbal location was a risk factor for recurrence (hazard ratio, 8.96) in the entire study population. In patients who were treated successfully, the side effects of the 2 treatments were similar, with mild discomfort seen in the majority of patients in both groups. There was no limbal stem cell deficiency, symblepharon, or diplopia noted in either group. Two patients were excluded from the IFNα2b group because of intolerance to the medication.

CONCLUSIONS

No difference in the recurrence rate of OSSN was found between surgical versus IFNα2b therapy.

Ocular surface neoplasias and human immunodeficiency virus infection

PURPOSE OF REVIEW

Ocular surface malignancy is a serious complication in HIV infection, but can often result in successful treatment if diagnosed appropriately. In the literature, most reviews focus on information for the ophthalmic community. Here, we provide a review of the literature with the pertinent information for the nonophthalmologist, as they are the first point of contact for most HIV patients.

RECENT FINDINGS

Ocular surface squamous neoplasia (OSSN) is the most common nonpigmented ocular surface malignancy. It can be treated well with surgery or topical chemotherapy, the newest method of treatment. When presenting in young patients, a high percentage have been found to be HIV positive. Kaposi's sarcoma is an AIDS-defining malignancy and critical to diagnose. It cannot be cured, but treatment is effective for keeping it controlled. Conjunctival lymphoma can be recognized with the salmon patch appearance. External beam radiation, systemic chemotherapy, and intralesional injections are the mainstays of treatment.

SUMMARY

Ocular surface malignancy manifests significantly in the HIV population. OSSN, Kaposi's sarcoma and conjuctival lymphoma all have different clinical presentations. The capacity of the managing physician to recognize these tumours and refer to an ophthalmologist is essential for appropriate treatment.

Intravesical Bacillus Calmette-Guérin versus epirubicin for Ta and T1 bladder cancer

BACKGROUND

Bladder cancer accounts for approximately 4.4% of adult malignancies, and approximately 80% of bladder cancer presents initially as transitional cell carcinoma that is confined to the urothelium (stage Ta) or lamina propria (stage T1). Intravesical administration of Bacillus Calmette-Guérin (BCG) and epirubicin (EPI) has been proven to reduce tumour recurrence and prevent or delay progression to muscle invasion and metastases. However, comparison of the effectiveness and safety of intravesical BCG and EPI in bladder cancer has yet to be explored.

OBJECTIVES

To compare the effectiveness and safety of BCG with EPI in the treatment of Ta and T1 bladder cancer.

SEARCH STRATEGY

A comprehensive search of MEDLINE (1966 to April 2010), EMBASE (1980 to April 2010), Health Services Technology, Administration, and Research (HealthSTAR), the Cochrane Central Register of Controlled Trials (CENTRAL), CancerLit, and Database of Abstracts of Reviews of Effectiveness (DARE), was performed, and handsearching of relevant journals was undertaken.

SELECTION CRITERIA

All randomised or quasi-randomised trials (in which allocation was obtained by alternation - e.g., alternate medical records, date of birth, or other predictable methods) in patients with Ta or T1 bladder cancer that compared intravesical BCG with EPI were included. No language restrictions were applied.

DATA COLLECTION AND ANALYSIS

Trial eligibility, methodological quality and data extraction were assessed independently by two reviewers. We compared dichotomous outcomes (frequency of tumour recurrence, progressive disease by stage, mortality, distant metastases, local and systemic adverse effects, treatment delayed or stopped due to adverse effects) using risk ratios (RR) with 95% confidence intervals (CI).

MAIN RESULTS

Five trials of 1111 participants were included in this review. For BCG, 549 patients were treated, and 562 with EPI. Of the evaluated patients, 35.5% (195/549) in the BCG group and 51.4% (289/562) in the EPI group had tumour recurrence (P < 0.05). For disease progression (BCG, 44/549; EPI, 58/562) and distant metastases (BCG, 23/487; EPI, 31/495), there were no significant differences (P = 0.19 and P = 0.29, respectively). Only two trials, including 769 patients, had sufficient data for us to analyze disease-specific (BCG, 22/383; EPI, 26/386) and overall mortality (BCG, 125/383; EPI, 147/386). Neither comparison was significant (P = 0.93 and P = 0.12, respectively). In four studies reporting toxicity, BCG was associated with significantly more drug-induced cystitis [BCG, 54.1% (232/429); EPI, 31.7% (140/441)] and haematuria [BCG, 30.8% (132/429); EPI, 16.1% (71/440)]. Similarly, in three studies reporting systemic toxicity, BCG had significantly higher toxicity than the EPI (34.8% (134/385) versus 1.3% (5/393), respectively). In a meta-analysis comparing 'treatment delayed or stopped' (BCG, 40/431; EPI, 33/441), there was no significant difference between BCG and EPI treatments (P = 0.82).

AUTHORS' CONCLUSIONS

The data from the present meta-analysis indicate that intravesical BCG treatment is more efficacious than EPI in reducing tumour recurrence for Ta and T1 bladder cancer. However, BCG appears to be associated with a higher incidence of adverse effects, such as drug-induced cystitis, haematuria and systemic toxicity, than EPI. The overall quality of the evidence is rather low. Well-designed, high quality randomised controlled trials with good allocation concealment are required.

Subconjunctival/perilesional recombinant interferon α2b for ocular surface squamous neoplasia: a 10-year review

PURPOSE

To evaluate the biologic effect of subconjunctival recombinant interferon α2b (IFNα2b) for the treatment of ocular surface squamous neoplasia (OSSN).

DESIGN

Retrospective study.

PARTICIPANTS

Patients with primary or recurrent OSSN treated with subconjunctival injections of recombinant IFNα2b were studied retrospectively.

INTERVENTION

Patients were given perilesional subconjunctival injections of 3 million international units in 0.5 ml of IFNα2b (Intron; Schering-Plough, Kenilworth, NJ) until tumor resolution.

MAIN OUTCOME MEASURES

Patients were followed up clinically and photographically for evidence of tumor resolution and were monitored for evidence of tumor recurrence.

RESULTS

The authors present a series of 15 eyes (14 patients) that were treated with perilesional, subconjunctival, recombinant IFNα2b. Clinical resolution of the tumor occurred in 13 of 15 eyes. The median time to resolution was 1.4 months (range, 0.6-5.7). In the time of follow-up after lesion resolution (median, 55 months), only 1 of the 15 eyes in the study exhibited disease recurrence, and this occurred 4 months after clinical resolution.

CONCLUSIONS

Perilesional subconjunctival recombinant IFNα2b may be a viable medical alternative for the treatment of OSSN. Future studies will be needed to evaluate the ideal treatment regimen of IFNα2b.

Angiogenesis meets immunology: Cytokine gene therapy of cancer

Delivery of cytokine genes at the tumor site in pre-clinical models has been shown to recruit host inflammatory cells followed by inhibition of tumor growth. This local effect is often accompanied by systemic protection mediated by the immune system, mainly by CD8(+) T and NK cells. On this basis, cytokine gene-transduced tumor cells have widely been used as vaccines in clinical trials, which have shown good safety profiles and some local responses but substantial lack of systemic efficacy. Are these findings the end of the story? Possibly not, if major improvements will be attained in the coming years. These should be directed at the level of gene selection and delivery, in order to identify the optimal cytokine and achieve efficient and durable cytokine expression, and at the level of improving immune stimulation, i.e. by co-administration of co-stimulatory molecules including B7 and CD40, or boosting the expression of tumor antigens or MHC class I molecules. Interestingly, some of the cytokines which have shown encouraging anti-tumor activity, including IFNs, IL-4, IL-12 and TNF-alpha, are endowed with anti-angiogenic or vasculotoxic effects, which may significantly contribute to local tumor control. Therapeutic exploitation of this property may result in the design of novel approaches which, by maximizing immune-stimulating and anti-angiogenic effects, could possibly lead to starvation of established tumors in patients.

Interferon-alpha prevents apoptosis of endothelial cells after short-term exposure but induces replicative senescence after continuous stimulation

Although the antiangiogenic activity of type I interferons (IFN) is well known, the mechanism by which it occurs is unclear. In the present study, we have investigated effects of short-term and long-term IFN-alpha exposure on different types of endothelial cells (EC). Short-term IFN-alpha treatment resulted in a distinct reduction of apoptosis of serum and growth factor starved HUVEC and HDMEC. This was accompanied by a strong upregulation of the IFN inducible guanylate binding protein-1 (GBP-1) whereas no consistent regulation of several known antiapoptotic proteins was evident. Stable transfection of HUVEC with an expression vector for GBP-1 mimicked the protective effect of IFN-alpha, suggesting that GBP-1 may contribute to the inhibition of apoptosis. When IFN-alpha, together with serum and EC growth factors, was present continuously a decrease of population doublings by more than 40% was observed in both HDMEC and HCAEC. In addition, the cells displayed a senescent phenotype significantly earlier than control cells and showed an increased adherence for monocytes. Our findings suggest that the antiangiogenic effect of IFN-alpha is mediated by inducing EC senescence rather than EC apoptosis. Furthermore IFN-alpha released in chronic inflammatory conditions might contribute via its prosenescent activity to the pathogenesis of atherosclerosis.

Sustained intravesical interferon protein exposure is achieved using an adenoviral-mediated gene delivery system: a study in rats evaluating dosing regimens

OBJECTIVES

To evaluate whether a recombinant replication-deficient adenovirus containing the secreted human interferon alpha-2b gene (rAd-IFN) could improve the tissue and urine levels of IFN protein by transducing the urothelium with the secreted human IFN-alpha gene. We also assessed whether varying the interval between rAd-IFN/Syn3 treatments would improve the duration and levels of gene expression.

METHODS

The rats received intravesical administration of rAd-IFN at varying concentrations in a formulation containing Syn3, an agent identified that facilitates passage of the adenovirus through the protective barrier of the bladder. Urine was collected daily for 7 days, and human IFN was measured in the urine by enzyme-linked immunosorbent assay. For the redosing studies, the animals received a second dose at varying intervals ranging from 1 to 7 days after the first dose or at longer intervals (30, 60, or 90 days).

RESULTS

Rats that received intravesical administration of rAd-IFN in a Syn3 formulation expressed levels of human IFN protein in their urine at peak concentrations of 50,000 to 100,000 pg/mL, but were undetectable by 7 days. Expression was localized to the bladder with only minimal systemic exposure to IFN. Short-term redosing marginally improved the IFN urine concentrations, with maximal levels achieved when a second dose was administered 3 days after a first dose. Although gene expression was attenuated when a second dose was given 5 to 7 days after the first treatment, the levels and duration of IFN expression recovered when the interval was increased to 90 days.

CONCLUSIONS

Intravesical treatment with rAd-IFN facilitates high levels of IFN transgene exposure and may be a new approach to treating superficial bladder cancer.

Preparative and analytical chromatography of pegylated myelopoietin using monolithic media

Monolithic media were compared with Q- and SP-Sepharose high performance chromatography for preparative purification and with Q- and SP-5PW chromatography for analysis of a pegylated form of myelopoietin (MPO), an engineered hematopoietic growth factor. The use of either monolithic or Sepharose based supports for preparative chromatography produced highly purified pegylated MPO with the monolithic media demonstrating peak resolution and repeatability at flow rates of 1 and 5 ml/min resulting in run times as much as five-fold shorter compared to Sepharose separations. The monolithic disks also resulted in 10-fold shorter run times for the analytical chromatography, however, their chromatographic profiles and peak symmetry were not as sharp compared to their Q-5PW and SP-5PW counterparts.

Hypocalcemia and Azotemia Associated with Zoledronic Acid and Interferon Alfa

OBJECTIVE

To describe severe hypocalcemia and acute renal failure associated with zoledronic acid and interferon alfa in a patient with metastatic carcinoid tumors.

CASE SUMMARY

A 39-year-old white man with metastatic carcinoid tumor tolerated treatment with subcutaneous long-acting octreotide monthly and interferon alfa 6 million units 3 times weekly for 6 months. Due to multiple bony metastases, zoledronic acid was prescribed as a monthly 4-mg intravenous infusion over 30 minutes to prevent skeletal-related events. Although the first infusion went well, the patient developed severe hypocalcemia and acute renal failure after the second zoledronic infusion.

DISCUSSION

Bisphosphonates may infrequently cause symptomatic hypocalcemia, especially among patients who have vitamin D deficiency or hypoparathyroidism or receive treatment with an aminoglycoside. Our literature review suggests that zoledronic acid and interferon alfa may exert additive effects on the inhibition of osteoclasts, thus potentially precipitating hypocalcemia. Renal dysfunction may not be a direct consequence of interferon alfa. However, altered mental function due to hypocalcemia may lead to dehydration and further exacerbate renal dysfunction, a known adverse effect of zoledronic acid. Since therapeutic indications of both interferon alfa and zoledronic acid continue to expand, clinicians should be aware of these serious adverse reactions and potential interaction. Supportive treatment with hydration, calcium supplement, and oral calcitriol resulted in resolution of hypocalcemia, but only partial improvement of azotemia.

CONCLUSIONS

In our patient with metastatic carcinoid tumor, treatment with zoledronic acid and interferon alfa was associated with symptomatic hypocalcemia and acute renal failure.