Evaluation of Toxic Effects following Administration of Monoclonal Antibody MBr1 in Patients with Breast Cancer

Twelve patients with disseminated breast cancer were injected with monoclonal antibody MBr1 at the National Cancer Institute of Milan, Italy, from January 1983 to March 1985. The first seven patients had advanced disease and the remaining five operable breast cancer. In the first seven patients the initial dosage of MBr1 was 0.5 mg and was doubled in the next patient up to 16 mg. The last five women received 10 mg of MBr1. No general side effects such as broncospasm, hypotension, immediate or delayed allergic reactions were observed. Four patients who were injected with 10 mg or more experienced fever, shudder and vague abdominal and articular pain. The following tests were monitored: R.B.C., W.B.C., percentage of lymphocytes, blood glucose, urenitrogen and creatinine, serum levels of Na+, K+, Cl–, total proteins levels, albumins and globulins, bilirubin, GOT, GPT, alkaline phosphatase, LDH, amylase, γGT and CPK. No major modifications were observed: a limited increase of the transaminases, LDH and γGT was evident at the last check. An early temporary alteration of CPK was observed in the four patients who had symptoms. Serum levels of MBr1 are detectable immediately after injection starting from 4 mg, and all sera were negative 48 hours later. It is concluded that the scanty toxicity allows to continue clinical investigations to verify the linkage between MBr1 and Ca-MBr1 « in vivo » after a single injection of no more than 16 mg of the MoAb. The increase of this dosage as well as multiple injections do not seem safe at present.

A Phase II Study of the Administration of Recombinant Interleukin 2 (rIL-2) Plus Lymphokine Activated Killer (LAK) Cells in Stage IV Melanoma Patients

From January 1987 to February 1988, 15 stage IV melanoma patients were treated with two courses of bolus injection of rIL-2 plus LAK cell infusions at the National Cancer Institute of Milan. The original treatment regimen included a first course of rIL-2 administration (400 μg/m5 bolus injection 3 times a day [TID] for 4 days) and a second course of rIL-2 administration (800 μg/m2 bolus injection TID for 7 days) separated by 4 consecutive daily leukaphereses. Autologous lymphokine activated killer (LAK) cells were reinfused into each patient on three occasions during the second period of rIL-2 administration. Due to the appearance of grade III–IV neurological, hepatic and cardiopulmonary toxicity, 7 patients discontinued dosing before the end of treatment, one patient desired to be withdrawn and one patient died from rapidly progressive disease, although complications of rIL-2 administration may have contributed to her death. Only 6 patients completed the schedule without evidence of major intolerance, even though the planned dose during the second course of rIL-2 was reduced to 400 μg/m2. The complete duration of treatment ranged from 11 to 19 days. The total dose of rIL-2 injected ranged from 12.6 to 30.4 mg. The number of infused LAK cells ranged from 15.5x109 to 60x109/patient. Two of the 14 evaluable patients showed a minor anti-tumor response. In 5 patients new metastases in other sites were documented from 2 to 5 months after completion of dosing. No apparent association was found between progression of the disease (or the appearance of new metastases) and the total dose of rIL-2 injected, the number of LAK cells administered or the number of days of treatment. By December 1988, all patients had died of their disease in a period ranging from 3 to 14 months from the last injection of rIL-2. The lack of significant clinical responses in this study and the high toxicity of this treatment lead us to conclude that at least as far as melanoma patients are concerned, adoptive immunotherapy with rIL-2 plus LAK cells (as described here) is not a justifiable treatment option unless new evidence presents itself.

Surgical Treatment of Recurrences following Sphincter-Saving Procedures for Cancer of the Rectum

Of 77 patients treated by sphincter-saving procedures (anterior or pull-through resection) for cancer of the rectum, 17 (22 %) developed a local recurrence; 10 of them were submitted to abdominoperineal resection. The « rescue » operation was technically difficult, and major problems, including large blood loss and uretheral complications, were often encountered. At operation the recurrent malignancy was more extended than preoperative diagnosis suggested, and reoperation was not macroscopically radical in one case. All patients but one died for the disease after a mean period of 19.8 months. Causes of local failure are analyzed to interpret the rationale of surgical approach related to the poor results observed; intensive follow-up programs are also discussed. It is concluded that surgical treatment of local recurrence after sphincter-saving procedures must be reserved only to selected patients, with limited malignancy, and adjuvant radiochemotherapy should also be employed.

Hyperthermic Antiblastic Perfusion in the Treatment of Cancer of the Extremities

From February 1982 to December 1983, 42 patients affected by neoplasms of the limbs were treated at the Istituto Nazionale Tumori of Milan by hyperthermic antiblastic perfusion in extracorporeal circulation at the temperature of 40-41 °C for 1 h. Thirty-two were affected by melanoma, 4 by osteogenic sarcoma, 2 by squamous-cell carcinoma, 1 by liposarcoma, 1 by hemangiopericytoma, 1 by clear-cell sarcoma and 1 by Kaposis's sarcoma. As regards the immediate response, a complete plus partial remission rate of 88 % without any major complication was obtained. The follow-up period is too short for any considerations about overall survival. However, because of these good clinical results we consider this method able to locally control the evolution of neoplasms of the extremities, allowing in many cases a limb salvage.

Limb-Salvage Procedure in Two Patients with Spindle Cell Carcinoma of the Lower Extremities using Isolation Perfusion

Two patients with extensive squamous cell carcinoma of the lower extremities, candidate for demolitive surgery, were treated by hyperthermic antiblastic perfusion in extracorporeal circulation. The temperature reached was 41 degrees C and the drug used was methotrexate at the dosage of 500 mg. Radical excision of the ulcer was possible in the 2 patients. Both tumors underwent extensive necrosis, and histology done 1 month after perfusion on surgical specimens showed limited areas of residual malignancy. These 2 patients suggest that hyperthermic antiblastic perfusion may be a limb salvage procedure in the multimodal management of extended squamous cell carcinoma of the extremities.

A Phase I Study of Recombinant Interleukin 2 in Melanoma Patients. Toxicity and Clinical Effects

Toxicity and clinical effects of a new brand of recombinant interleukin 2 (rIL2, Bioleukin™, Biogen, Geneva) were evaluated by a phase I study in 12 patients with stage III melanoma. Escalating doses from 100 μg/m2 to 800 μg/m2 were administered thrice a day with bolus injections given via a peripheral venous catheter for up to a maximum of 7 days. All patients showed malaise, fever and chills and mild gastrointestinal side effects. A modest electrolyte imbalance (hypocalcemia and hypokalemia) was detected in all 12 patients. Renal toxicity as judged by serum creatinine was not observed, and hepatic toxicity was moderate with the possible exception of one patient who had an unclear previous history of liver dysfunction. Mild, transient leukopenia was found in several patients, whereas thrombocytopenia developed in 4 patients; no anemia was observed. Cutaneous rash was seen in half of the patients treated. Fluid retention was minimal, with a weight gain associated to treatment that never exceeded 10% of pretreatment body weight. Electrocardiographic alterations developed in 2 patients in the form of ventricular and supraventricular extrasystoles. In 2 patients given the highest dose of rIL2, a significant reduction in transfer lung factor for carbon monoxide was seen, indicating alterations in pulmonary functions. Other dose-related toxicities were thrombocytopenia and malaise. All side effects disappeared 2-3 days after the end of rIL2 administration. No major responses were seen in association with the 4-8 days of treatment given in this study.

Breast Cancer: Primary Tumor Characteristics Related to Lymph Node Involvement

From November 1st 1977 to August 31st 1978, 842 consecutive patients with operable breast cancer were observed at the National Cancer Institute of Milan. Characteristics of the primary tumor and the status of regional lymph nodes were evaluated at clinical and postsurgical examination: it was found that qualitative characteristics of the primary were properly defined by clinicians, who usually overestimated maximum diameter of the primary. The status of regional lymph nodes is not reliable at clinical examination: 34.5 % of clinically uninvolved nodes were found to contain metastatic growth at histologic examination. Age of patients, maximum diameter of the primary, histologic type and quadrant of origin of the primary tumor were significantly related to the frequency of regional node metastases. Multifactorial analysis showed that the last three factors were independent variables, while age, which is significant by itself, loses importance when adjusted by at least one of the other three factors. Frequency of extension of node metastases beyond the lymph node capsule was found to be related to the number of involved nodes: maximum diameter, histologic type and site of origin are significantly related to the frequency of extracapsular invasion. This study confirms that the evaluation of the status of regional lymph nodes is not reliable at clinical examination and indicates that characteristics of the primary may be useful in predicting regional lymph node involvement. The direct correlation between the number of involved nodes and the frequency of infiltration beyond the capsule suggests that prognosis of patients with positive nodes depends more on this factor than on the number of involved nodes.

Substance P activates ADAM9 mRNA expression and induces α-secretase-mediated amyloid precursor protein cleavage

Altered levels of Substance P (SP), a neuropeptide endowed with neuroprotective and anti-apoptotic properties, were found in brain areas and spinal fluid of Alzheimer's disease (AD) patients. One of the hallmarks of AD is the abnormal extracellular deposition of neurotoxic beta amyloid (Aβ) peptides, derived from the proteolytic processing of amyloid precursor protein (APP). In the present study, we confirmed, the neurotrophic action of SP in cultured rat cerebellar granule cells (CGCs) and investigated its effects on APP metabolism. Incubation with low (5 mM) potassium induced apoptotic cell death of CGCs and amyloidogenic processing of APP, whereas treatment with SP (200 nM) reverted these effects via NK1 receptors. The non-amyloidogenic effect of SP consisted of reduction of Aβ(1-42), increase of sAPPα and enhanced α-secretase activity, without a significant change in steady-state levels of cellular APP. The intracellular mechanisms whereby SP alters APP metabolism were further investigated by measuring mRNA and/or steady-state protein levels of key enzymes involved with α-, β- and γ-secretase activity. Among them, Adam9, both at the mRNA and protein level, was the only enzyme to be significantly down-regulated following the induction of apoptosis (K5) and up-regulated after SP treatment. In addition to its neuroprotective properties, this study shows that SP is able to stimulate non-amyloidogenic APP processing, thereby reducing the possibility of generation of toxic Aβ peptides in brain.

Neuroscience and oncology. A unified view

Evidence has been produced that the neoplastic event is the result of a multistep multifactorial process involving virtually every functional system within the organism. Traditional concepts such as cellular autonomy, uncontrolled growth and monoclonality of cancer are revised in the light of current data. Microenvironmental stimuli appear to affect relevant cancer cell functions, including locomotion, differentiation and gene expression. The complex interconnection between biological functions and messages, relevant among which are nervous inputs, requires the identification of new physiological models if the neoplastic process is to be understood.

In vivo activation of lymphocytes in melanoma patients receiving escalating doses of recombinant interleukin 2

A phase-I study of the recombinant, non-mutagenized interleukin 2 (rIL2, BioleukinTM) was performed in 12 melanoma patients (Pts). From 100 to 800 micrograms/m2 of rIL2 were administered by i.v. bolus injection, TID for 4-8 days. Side-effects included fever, malaise, low serum K+ and Ca++ values, electrocardiographic abnormalities, leukopenia and thrombocytopenia. No major organ toxicity and no significant fluid retention were observed at the administered doses. Treatment induced a rapid depletion of peripheral blood lymphocytes (PBL) with a rebound (2-6 times the pre-treatment values), 24-48 hr after rIL2 discontinuation. PBL obtained between the 5th treatment day and the 2nd post-treatment day showed: (a) enhanced proliferation (II/12 Pts) with stimulation indexes of 6-52; (b) increased cytotoxicity against autologous tumor cells (2/2 Pts), allogeneic melanomas (5/7 Pts), the Daudi (5/6 Pts) and K562 cell lines (7/12 Pts); and (c) increased expression of IL2 receptors (8/12 Pts) and of DR antigens (6/12 Pts). Lymphocytes collected 1-2 days after treatment and activated in vitro with rIL2 showed a more rapid development of tumor cytotoxicity, with an earlier loss of activity. Spontaneous proliferation, autologous or allogeneic tumor cytotoxicity and expression of IL2 receptors obtained after in vivo treatment with rIL2 were significantly weaker than those induced during in vitro stimulation. No major objective responses were detected in these patients.

Hyperthermic antiblastic perfusion with DTIC in stage IIIA-IIIAB melanoma of the extremities

The aim of this paper is to evaluate the effectiveness of DTIC when employed at a local level in hyperthermic antiblastic perfusion (HAP) for stage IIIA-IIIAB melanoma patients. Twenty-seven consecutive patients have been treated at the National Cancer Institute of Milan from October 1983 to June 1985. All the patients were submitted to HAP at 40 degrees for 60' with DTIC at the dosage of 2.5 g/m2 [corrected] for lower extremities and 1.5 g/m2 [corrected] for upper extremities. We observed a complete local response in three patients and a partial local response 50% in seven patients, 10 patients has a response less than 50% and 4 patients did not show any response. After surgical removal of the residual tumor when possible, 14 patients are alive without detectable disease while 11 are alive with disease and two dead for progression. No serious complications were observed. These data indicate that DTIC seems able to obtain in HAP, results superimposable to L-PAM without any significant toxicity.

Infusion of Autologous Alloactivated Lymphocytes in Melanoma Patients: Toxicity and Immunologic Monitoring

Previous work has shown that infusion of autologous helper-enriched, alloactivated lymphocytes in melanoma patients may induce, in addition to other mild signs of toxicity, a transient but sharp elevation of blood pressure. To avoid such a disturbing symptom, the in vitro protocol of peripheral blood lymphocyte activation has been modified. In the present study we show that such a modification has led to a lower toxicity of autologous lymphocyte infusion in 4 melanoma patients; in particular, hypertension was no longer observed. In addition, an immunologic monitoring was carried out in these patients. In 1 of 4 patients the treatment enhanced the in vitro cytotoxic activity of peripheral blood lymphocytes against autologous tumor cells. Other parameters such as NK activity and T4/T8 ratio did not show significant trends. The possible implications of these findings for clinical trials of adoptive immunotherapy with lymphocytes are discussed.

Regional non-nodal metastases of cutaneous melanoma

The authors studied the prognosis of patients with so called local recurrences, satellites and in-transit metastases from cutaneous melanoma on the basis of 291 patients. These are the 19.3% of the 1503 patients with stage I and II melanoma originally submitted to surgical treatment at the National Cancer Institute of Milano (Italy). The majority of patients were males (M/F = 0.7): 102 had local recurrence, 99 in-transit metastases, 24 satellites and 66 both local and in-transit metastases. Regional non-nodal metastases were not related with the site of origin, and inadequate treatment of primary. These metastases were more frequently observed in patients who were submitted to regional node dissection no matter whether in discontinuity or in continuity with primary tumor. The frequency of regional non-nodal metastases was found to increase with increasing thickness of primary melanoma or, in stage II patients, with the number of involved nodes. Local and in-transit metastases were related with prognostic criteria in the same way. The overall survival was very close between in-transit and local metastases. Similar survival rates were observed comparing regional non-nodes and disseminated cutaneous and subcutaneous metastases. The authors conclude that the distinction between local recurrences, satellites and in-transit metastases is artificial and that these metastatic events are not prognostically dissimilar from metastases in distant skin areas.

Systemic administration of autologous, alloactivated helper-enriched lymphocytes to patients with metastatic melanoma of the lung. A phase I study

A phase I study was carried out to test the feasibility and toxicity of infusing large numbers of autologous, alloactivated helper lymphocytes into patients with metastatic melanoma. Patient peripheral blood lymphocytes (Pt-PBL) obtained by lymphopheresis and expressing the helper phenotype BT5/9 were separated and stimulated for 48 or 72 h with a pool of PBL from four to six healthy donors. Patients were then infused with such activated lymphocytes over a 2-3 h period. A total of 4 phereses and infusions (2/week for 2 weeks) were carried out for each cycle in each patient. Of the five patients treated, two received a second round of infusions. Infusion of autologous PBL stimulated in vitro for 48 h caused chills, fever, headache, and increased blood pressure. All symptoms disappeared in 2-3 h and were easily controlled by appropriate therapy. When lymphocytes were given after 72 h of allostimulation, no or very mild toxicity was observed. Serum chemistry, coagulation, autoimmunity, and urine analysis showed no gross abnormalities during therapy or follow-up of the patients. Immunological parameters (OKT4/OKT8 ratio, NK activity and cytotoxic T cell activity to autologous melanoma) were evaluated before starting the therapy, during its course and during the 3 to 6 months follow-up. The OKT4/OKT8 ratio increased significantly but transiently soon after the first course of infusions in one of the two patients tested. NK activity increased after 75-100 days in the three patients tested and in one of them it was high even after 180 days. No correlation between NK activity and prognosis was apparent. Cytotoxicity to autologous tumor was assessed in two patients, only of one of whom exhibited an increased activity from 75 to 180 days, which was associated with a prognosis better than that of the negative patient. Five patients were treated: two had progressive disease, two had stable disease for 5 and 6 months, respectively. In the first of these patients, a new cycle of lymphocyte infusions was carried out which caused a measurable reduction of lung tumor nodules whose growth, however, resumed 4 months later. This patient died 14 months after the onset of therapy. The fifth patient had a partial regression of pulmonary and intracranial metastases after therapy, but eventually died 3 months later. These results indicate that infusion of a high numbers of autologous, allostimulated helper PBL is a feasible and safe procedure, which could therefore be used in future studies of adoptive immunotherapy of cancer.

The inhibition of lymphocyte stimulation by autologous human metastatic melanoma cells correlates with the expression of HLA-DR antigens on the tumor cells

Previous studies indicated that peripheral blood lymphocytes from patients (Pt-PBL) with lymph node metastatic melanomas proliferated in vitro and developed into tumor-restricted cytotoxic lymphocytes in response to alloantigens or interleukin 2 (IL-2). However, Pt-PBL were not stimulated by irradiated autologous metastatic melanoma (Auto-Me) cells. In the present study we report that the lack of stimulatory activity of Auto-Me cells may be due to a suppressive effect exerted by Auto-Me cells on the responder lymphocytes. In fact, we found that in 62% of cases examined, the addition of 5-10% Auto-Me cells to Pt-PBL cultures strongly inhibited both proliferation and the generation of tumor cytotoxic lymphocytes induced by alloantigens or IL-2. The inhibition was dose-dependent and tumor-restricted, and was not due either to toxicity, medium depletion or IL-2 absorption by Auto-Me cells. Normal fibroblasts, K562 cells and autologous E-lymphocytes were not suppressive. Auto-Me cells were able to inhibit Pt-PBL responses only when added during the first 24 h of culture and not later. Phenotypic analysis of Auto-Me cells using monoclonal antibodies directed against HLA-A,B,C, HLA-DR and melanoma-associated antigens revealed that the expression of high levels of DR antigens on Auto-Me cells was associated with an elevated suppressive activity. Conversely, Auto-Me cells with low or undetectable levels of DR antigens were not inhibitory. Furthermore, the increased expression of DR antigens on Auto-Me cells obtained by in vitro treatment with human interferon gamma (IFN-gamma) also resulted in an increased suppressive activity. We conclude that HLA-DR+ metastatic melanoma cells can interfere with the generation of an anti-tumor immune response, thus potentially favoring the escape of the tumor from the host's control mechanism.

Characterization of a subset of human natural killer cells that express OKM1 but lack HNK-1 (Leu-7) antigens

The HNK-1(Leu-7) monoclonal antibody selectively identifies a population of human granular lymphocytes with natural killer (NK) cell activity. We previously reported that the HNK-1+ cell fraction purified from blood mononuclear cells accounted for virtually all NK activity in six individuals. In this study we analysed additional normal individuals and found that in eight out of 14 donors HNK-1+ cells, purified with a fluorescence-activated cell sorter (FACS), exhibited greatly enriched NK cell activity, whereas HNK-1- cells did not have significant activity. In four donors the HNK-1+ cells were enriched in NK activity compared with HNK-1- cells; however, the HNK-1- cells also had moderate levels of activity. In the two remaining donors, NK activity was not enriched in the HNK-1+ fraction in comparison with the HNK-1- fraction. To determine the cell type responsible for NK activity in the HNK-1- subset, these cells were further sorted with the FACS onto OKM1+ and OMK1- fractions and analysed for morphology and function. HNK-1- OKM1- cells were found to be small- to medium-sized lymphocytes devoid of NK activity in all donors tested, whereas most HNK-1- OKM1+ cells were granular lymphocytes and in some donors demonstrated NK function at a level comparable to HNK-1+ cells. Thus some individuals have an important subset of granular lymphocytes with NK-cell activity and the HNK-1- OKM1+ phenotype. It is important to account for these cells in studies involving granular lymphocytes and NK cell function.

Prognosis of skin melanoma with regional node metastases (stage II)

566 stage-II melanoma patients treated at the National Cancer Institute of Milan, Italy, were analyzed to evaluate the prognosis. Among the criteria considered, four were significantly associated with survival when considered as single factors: growth pattern, levels of invasion, the number of involved lymph nodes, and the extent of metastatic growth. As regards growth pattern, the observed 5-year survival rates were 41.9% for superficial spreading melanoma and 20.5% for nodular melanoma (P = 10(-3)). As regards levels, the 5-year survival rates were as follows: level II, 20.9%; level III, 33.1%; level IV, 43.2%; level V, 10.2% (P = 10(-3)). Patients with a partial node metastasis had 64.5% 10-year survival, while those with extension beyond the capsule had 32.6% 10-year survival (P = 10(-9). Patients with one metastatic node had 43.4% 10-year survival, and patients with three or more positive nodes had 26.0% 10-year survival (P = 10(-9)). Multifactorial analysis shows that growth pattern and extent of node metastases significantly affect survival (P = 10(-2) and P = 10(-4), respectively) while the number of involved nodes turns to borderline P-value (0.051) and the levels are no longer significant (P = 0.4).

Early local complications following colostomy closure in cancer patients

Early surgical complications following colostomy closure in 65 cancer patients operated on at the Istituto Nazionale Tumori of Milan were evaluated retrospectively. The overall complication rate was 24.6 per cent, including infections (13.8 per cent), fistulas (6.1 per cent), wound dehiscence (3.0 per cent), and distal stenosis (1.5 per cent). Type and rate of complications were analyzed to find a correlation with type, site, and location of colostomy, technique of closure, presence or absence of drains, or time interval between construction and closure of colostomy. No statistically significant association between the aforementioned factors and occurrence and rate of complications was found. The authors think, therefore, that surgical attention, including meticulous manipulation of the stoma, avoidance of contamination of the wound, tension of sutures, dead spaces, and collection of blood in the wound, and use of antibiotics and antiseptics are the most important principles to minimize postoperative complications.

Results of extended surgery for cancer of the rectum and sigmoid

The clinical records of 61 patients who underwent extended surgery, including resection of parietes or other viscera, from 1965 to 1977 for cancer of the rectum and sigmoid were reviewed. Abdominoperineal resection was performed in 41 patients, anterior resection in 18 and Hartmann's resection in 2. The postoperative mortality rate was 8.2 per cent, the non-lethal morbidity rate 30.3 per cent, but 4 patients presented multiple complications. The 5-year survival rate was evaluated separately for patients with and without microscopic evidence of neoplastic involvement of the simultaneously excised structures; in the first group it was 32 per cent, in the second 75 per cent. Local or distant recurrence occurred in 66 per cent of patients with microscopic infiltration and in 24 per cent of patients without microscopic infiltration. These results compare favourably with those reported after ordinary resections of Dukes' C cancers of the rectum and sigmoid, and seem to justify the use of extended surgery when cancer of the rectum and sigmoid has invaded contiguous structures.

Microsphere angiography in hepatic artery infusion for cancer

99mTc-human albumin microspheres were injected at a slow rate into the hepatic arteries of 24 patients before starting intraarterial chemotherapy for liver cancer. The distribution patterns of radiolabeled microspheres were significantly different from those obtained in contrast angiography in 13 of 22 patients. Liver uptake of slowly injected microspheres was greater than 75% in 16 of 24 patients and less than 25% in 4 of 24 patients. A significantly increased arterial blood supply to intrahepatic neoplastic regions was demonstrated in 12 of 20 patients. Microsphere examination allowed an easy evaluation of the relative perfusion of the liver and of the intrahepatic distribution of arterial blood flow in all patients.