Identifying prognostic biomarkers for palbociclib add-on therapy in fulvestrant-resistant breast cancer using cell-free DNA sequencing

BACKGROUND

The FUTURE trial (UMIN000029294) demonstrated the safety and efficacy of adding palbociclib after fulvestrant resistance in patients with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) advanced and metastatic breast cancer (ABC/MBC). In this planned sub-study, cancer panel sequencing of cell-free DNA (cfDNA) was utilized to explore prognostic and predictive biomarkers for further palbociclib treatment following fulvestrant resistance.

MATERIALS AND METHODS

Herein, 149 cfDNA samples from 65 patients with fulvestrant-resistant disease were analysed at the time of palbociclib addition after fulvestrant resistance (baseline), on day 15 of cycle 1, and at the end of treatment using the assay for identifying diverse mutations in 34 cancer-related genes.

RESULTS

During the course of treatment, mutations in ESR1, PIK3CA, FOXA1, RUNX1, TBX3, and TP53 were the most common genomic alterations observed. Analysis of genomic mutations revealed that before fulvestrant introduction, baseline PIK3CA mutations were marginally lower in metastatic aromatase inhibitor (AI)-treated patients compared to adjuvant AI-treated patients (P = 0.063). Baseline PIK3CA mutations were associated with poorer progression-free survival [hazard ratio: 1.62, P = 0.04]. Comparative analysis between baseline and early-changing gene mutations identified poor prognostic factors including early-changing MAP3K1 mutations (hazard ratio: 4.66, P = 0.04), baseline AR mutations (hazard ratio: 3.53, P = 0.04), and baseline PIK3CA mutations (hazard ratio: 3.41, P = 0.02). Notably, the relationship between ESR1 mutations and mutations in PIK3CA, MAP3K1, and TP53 weakened as treatment progressed. Instead, PIK3CA mutations became correlated with TP53 and FOXA1 mutations.

CONCLUSIONS

Cancer panel testing for cfDNA identified prognostic and predictive biomarkers for palbociclib add-on therapy after acquiring fulvestrant resistance in patients with HR+/HER2- ABC/MBC.

Abstract P4-06-06: Comparison of the immunological and clinical effect of personalized peptide vaccination for patients with breast cancer

Background: Selected therapeutic personalized peptide vaccines (PPV) were effective for boosting anticancer immune response that was associated with the clinical outcome as a prognostic factor for metastatic recurrent breast cancer (mrBC) 1-2. In this study, we investigated the immunological and clinical effect of PPV as the prophylactic cancer vaccine for non-recurrent but high-risk BC (nrhrBC) patients (pts), and we compared it's features to those of the mrBC pts who had active cancers or became resistant to the standard therapies(TR-mrBC). Methods: Material and Patient eligibility criteria: The peptides were selected from the 31 PPVs according to the results of HLA typing and peptide-specific IgG titers. Pts with a histological diagnosis of BC and their HLA-A molecules should be each of -A2, A3, A11, A24, A26, A31 or A33. The clinical protocols were approved by the institutional review board. (UMIN000003081and 00000184400000). Treatment schedule: A maximum of 4 peptides was administrated as weekly for initial four vaccinations and as biweekly for further inoculations. The concomitant standard endocrine therapy and the chemo-endocrine therapy were available for nrhrBC pts after finishing the standard adjuvant chemotherapy, and for mrBC pts concurrently. Immune and clinical response assessment: Specific T-cell responses, IgG titers and cytokines were evaluated using by interferon (IFN)-γ ELISPOT, Luminex assay and ELISA system in every 6-8 vaccinations. Toxicity, clinical response and correlation with the immune responses were investigated. Results: 16 pts with nrhrBC, 41 pts with mrBC and 79 pts with TR-mrBC received median 18, 16 and 14 vaccines, respectively. After PPV therapies, peptide-specific IgG and CTLs increased significantly in a total of 47 (77%) and 37(60%) in nrhrBC pts, 102 (63%) and 98 (61%) in mrBC pts, and 150(53%) and 100 (42%) in TR-mrBC pts. Pts experienced Grade 1-3 skin reaction at injection site, no other grade 3 or 4 SAEs were associated with PPV but with the disease progression or combination therapy. The median time to progression (TTP) and overall survival (OS) were not reached in nrhrBC pts, 7.8 and 29 months in mrBC pts, and were 7.5 and 15.9 months in TR-mrBC pts, respectively. The peptide specific CTL response was correlated significantly with OS in nrhrBC pts and the IgG levels were associated with the better OS in either non TR-mrBC pts or TR-mrBC pts. High levels of IL-6, GM-CSF, IFN-g, IL-2 receptor, BAFF were associated with worse prognosis for pts with TR-mrBC. And high levels of GM-CSF and BAFF were associated with worse prognosis for pts with nrhrBC and mrBC, respectively. In contrast, High levels of IL-2 were associated with the better prognosis for pts with mrBC. Conclusion: This study indicated that immunological features of these three groups were different from each other with most potent PPV-induced immune boosting for nrhrBC pts. Pts with mrBC who had lower immune-suppressive cytokine levels had the better prognosis. These results suggested the PPV therapy could be effective for postoperative prophylactic vaccination in patients with nrhrBC. References: 1. Takahashi R, Toh U, et al. Breast Cancer Res. 2014; 2. Toh U, Okabe M, et al. THE BREAST 2015.

Citation Format: Toh U, Okabe M, Takao Y, Tanaka Y, Shigaki T, Takenaka M, Iwakuma N, Sudo T, Yamada A, Shichijo S, Itoh K, Akagi Y. Comparison of the immunological and clinical effect of personalized peptide vaccination for patients with breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-06-06.

Abstract OT2-01-01: Observational study of axilla treatment for breast cancer patients with 1 to 3 positive micrometastases or macrometastases in sentinel lymph nodes

[Background] Axilla surgery in node-positive breast cancer is dramatically changing from axillary lymph node dissection (ALND) to sentinel node biopsy (SNB). From the results of ACOSOG Z0011, IBCSG23-01 and AMAROS trials, adjuvant therapy and regional node irradiation could reduce regional lymph node recurrence for sentinel node-positive breast cancer patients. However, optimal indication of SNB alone remains uncertain. Trial design: To evaluate the outcome of sentinel node-positive breast cancer patients, the Japanese Society for Sentinel Node Navigation Surgery (SNNS) conducted a prospective cohort study in 2013 (UMIN000011782, Jpn J Clin Oncol, p.876-9, 2014). [Eligibility criteria] For eligible patients, SNB was performed or scheduled after 1 January 2012. Then 1 to 3 positive micrometastases or macrometastases in sentinel lymph nodes are confirmed by histological or molecular diagnosis. Primary chemotherapy before or after SNB is also acceptable for registration. [Specific aims] The primary endpoint is the 5-year recurrence rate of regional lymph node in patients treated with SNB alone. The secondary endpoint is the 5-year overall survival rate of this cohort. Patients treated with SNB followed by ALND are also registered simultaneously to compare the prognosis. The propensity score matching (PSM) is used to make the distributions of baseline risk factors comparable. [Statistical method] Based on an estimated recurrence rate of 5% at 5 years among patients treated with SNB alone, 240 patients are needed to give a 80% power to reject the null hypothesis that the recurrence rate is 10% with a one-sided type I error rate of 2.5%. If we consider that some patients will be lost to follow-up or become ineligible, a total of 250 patients will be needed to comprise the sample. [Present accrual] Eight hundred and eighty patients who underwent SNB alone or SNB followed by ALND were registered from 27 participating institutes between 2013 and 2016. Data cleaning is being performed. Patient's background and PSM will be reported.

Citation Format: Imoto S, Saito Oba M, Masuda N, Nagashima T, Wada N, Takashima T, Kitada M, Kawada M, Hayashida T, Taguchi T, Aihara T, Miura D, Toh U, Yoshida M, Sugae S, Yoneyama K, Matsumoto H, Jinno H, Sakamoto J. Observational study of axilla treatment for breast cancer patients with 1 to 3 positive micrometastases or macrometastases in sentinel lymph nodes [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-01-01.

Abstract P3-05-09: Prognostic factors for therapeutic personalized peptide vaccines in patients with metastatic recurrent breast cancer

Background: We have previously reported the prognostic role of humoral antigen spreading response against prostate-related antigen (PRA) for metastatic recurrent breast cancer (mrBC) patients who received personalized peptide vaccine (PPV) therapy (Toh U, SABCS 2015). The prognostic effect was additionally evaluated by the clinical relevant factors including intrinsic subtype, the regimens of combined chemo-hormonal therapies in present study.

Methods:We analyzed serum IgG responses to all of the peptide candidates included PRAs (PSA, PAP and PMSA) after PPV therapy by the Luminex systemusing peripheral blood samples from 77 vaccinated mrBC patients. The clinical factors and relevant events were statistically evaluated.

Results: After 6 and 12cycles of PPV therapy, the serum IgG of anti-PSA, anti-PAP, and/or anti-PMSA increased significantly in 31 patients (PRA response group), and the median progression free survival (PFS) and median overall survival (OS) were 8.1 and 14.3 months, but were 5.1 and 10.8 months, respectively, in the remaining 46 patients with no anti-PRA IgG response (PRA non-response Group). The anti-PRA IgG level was marginally correlated withPFS (p=0.059) and OS (p=0.082) between these two groups, which was a significant prognostic factor for PFS (Log-rank: 0.009) in estrogen-positive cancer patients (ER+). The statistical analyses showed that the clinical outcome was in favor of > 60 year-old patients, those with longer PPV therapies (>3 months), and those who received combined standard hormonal therapies or bisphosphonate/anti-RANKL therapy.

Conclusions: This study indicated a clinical significance between the pre-and post- PPV therapy measurement of serum anti-PRA IgG in patients with mrBC, which may be a useful prognostic marker for monitoring peptide vaccine treatment outcomes, particularly for patients > 60 years with ER+ breast cancer. These results also suggest that the immunotherapeutic peptide vaccine could be efficiently combined with hormonal therapy, anti-HER2 therapy, and bisphosphonate/anti-RANKL therapy in mrBC patients.

Citation Format: Toh U, Saku S, Iwakuma N, Takao Y, Okabe M, Akashi M, Yamada A, Shichijo S, Itoh K, Akagi Y. Prognostic factors for therapeutic personalized peptide vaccines in patients with metastatic recurrent breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-05-09.

Abstract P4-21-25: The importance of hormone receptor status on biomarker expression and the efficacy of lapatinib plus capecitabine therapy after progression on trastuzumab in HER2 positive recurrent and advanced breast cancer

Background: Anti-HER2 treatment using trastuzumab (Tmab) has contributed to improving the clinical outcome of HER2-positive breast cancerpatients. However, some patients do not respond to Tmab therapy and the combination of Lapatinib and capecitabine (LC) is an effective treatment option after progression on Tmab. Hormone receptor status is also an important factor for deciding if the patient should be treated with endocrine therapy as well. The aim of this study was to investigate the clinical significance of hormone receptor status in biomarker expression and to evaluate the efficacy of lapatinib therapy.

Materials and Methods: Eighty patients with HER2 positive breast cancer refractory to Tmab were enrolled in this prospective trial (KBC-SG 1107) between December 2011 and March 2014. The following treatment began after enrollment; lapatinib 1250-mg tablets were administered orally once daily and capecitabine (2000 mg/m2 per day) on days 1 to 14 every 21 days until disease progression or until severe adverse events. Total HER2 (H2T), p95HER2 (p95), and total HER3 (H3T) expression levels were quantified in formalin-fixed paraffin embedded samples using VeraTag assays. ER and progesterone receptor (PgR), PTEN and p95 expressions were evaluated using immunohistochemistry (IHC) and PIK3CA mutation using direct sequencing. Statistical analyses were performed using SPSS (ver. 21). A two-sided P<0.05 was considered a statistically significant difference.

Results: The ER- and PgR-positive rates were 55.0% and 33.8%, respectively. The response rate to LC was 30% (CR: 1 case; PR: 23 cases), the clinical benefit rate was 51.3% and the median progression-free survival (PFS) was 174.5 days. Both ER and PgR negativity significantly correlated with higher H2T (cutoff: 13.8), p95HER2 (cutoff: 2.8) and PTEN expression levels (cutoff: H score of 100). Lower H2T expression levels and PIK3CA mutation rates were often observed in the non-responders (both: p=0.087). The ER and PgR status did not correlate with response. A high p95 and PTEN expression significantly correlated with longer PFS in ER and/or PgR positive cases (p=0.02 and 0.03), respectively. The overall survival (OS) after LC significantly correlated with the number of recurrence organs (p=0.0002) but not with the p95 and PTEN expression levels.

Conclusion: LC therapy was effective in Tmab-refractory HER2 positive breast cancer. Moreover, the biomarker expression differed depending on the ER/PgR status and a high p95 and PTEN expression correlated with longer PFS in ER and/or PgR positive cases. Further study is necessary to validate these findings.

Citation Format: Arima N, Nishimura R, Toh U, Tanaka M, Saimura M, Okumura Y, Saito T, Tanaka T, Teraoka M, Shimada K, Koga T, Kurashita K, Todoroki H, Ueo H, Ohi Y, Toyoshima S, Mitsuyama S, Tamura K. The importance of hormone receptor status on biomarker expression and the efficacy of lapatinib plus capecitabine therapy after progression on trastuzumab in HER2 positive recurrent and advanced breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-21-25.

Abstract P5-08-16: Local immunologic environment related with tumor infiltrating lymphocytes (TIL) and PD-1/PD-L1 expression in early stage breast cancer

Purpose:

Recent studies have shown that local immune environment revealed with programmed death 1(PD-1)/programmed death ligand 1(PD-L1) and tumor infiltrating lymphocytes(TIL) affects the tumor-growth and prognosis. In this study, we evaluated the tumor local immune environments using immunohistological staining for analysis of PD-1/PD-L1 expression and TIL of tumor local in operable early-stage breast cancer.

Method:

A total of 100 surgical specimens of stageI-III invasive breast carcinoma paraffinembedded between 1995 and 2005 were analyzed. Immunohistological staining for PD-1, PD-L1, PTEN, CD3, CD8, and CD163 were performed by the conventional PAP method. In addition, intratumoral and intrastromal TILs and macrophages were simultaneously stained by anti-CD3, CD8, CD163 antibodies and measured by 'Win ROOF' computer software (version 5.7, Mitani Corporation, Japan).

Results:

Intratumoral PD-1 expressed significantly higher in triple negative breast cancer (TNBC) compared to other subtype BC (p=0.0094), intratumoral and intrastromal CD3+ lymphocytes and CD163+ macrophages were also significantly higher in TNBC, respectively (CD3: p=0.0002; 0.0139 and CD163: p=0.0043; 0.0270). PTEN loss was also more frequently observed in TNBC (p=0.0475). In addition, after a median 5-year follow-up, patients of luminal A subtype with lower PD-L1 and PTEN expression showed better disease free survival (DFS) with a significant difference (p=0.0148, p=0.0475).

Conclusion:

Local expression of PD-1/PD-L1 antigens on tumor cells, CD3+ lymphocytes, CD163+ macrophages infiltration singnificantly increased in early-stage TNBC. PTEN expression on tumor local might be associated with DFS in patients with early-stage BC.

Citation Format: Okabe M, Toh U, Iwakuma N, Mishima M, Kawahara A, Kage M, Itoh K, Akagi Y. Local immunologic environment related with tumor infiltrating lymphocytes (TIL) and PD-1/PD-L1 expression in early stage breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-16.

Abstract P2-11-04: Serum IgG response against prostate-related antigen revealed by personalized peptide vaccination in patients with metastatic recurrent breast cancer

Purpose: We have indicated that IgG and CTL boosting response could be a potential prognostic factor for overall survival (OS) and progression free survival (PFS) in metastatic recurrent breast cancer (mrBC) patients, who had received personalized selected peptide vaccine (PPV) therapy in our previously reported clinical phase II study. The aim of this study is to identify the prognostic role of serum value of IgG antibody against prostate related-antigen (PRA), including prostate-specific antigen (PSA), prostate specific membrane antigen (PSMA) and prostate acid phosphatase (PAP) in mrBC patients

Methods: Peripheral blood samples of 77 patients with mrBC were analyzed for serum anti-PRA IgG levels before and after 6th and 12th PPV therapy prospectively. Most of the peptides using for PPV are derived from cancer associated antigens expressing in various types of advanced cancers, but the peptides derived from PRAs were not used in this study.

Results: After PPV therapy, total serum levels of anti-PRA IgG were significantly increased in 31 mrBC patients (Group 1) whereas in remaining 46 rmBC patients (Group 2). Either serum anti-PSA, anti-PAP and/or anti-PMSA IgGs showed a significant increase in patients of Group 1 after 6th (p=0.045) and 12th PPV treatment (p < 0.001), irrespective of their intrinsic subtypes. The median PFS and median OS of Group 1 patients were 8.1 and 14.3 months, while those of Group 2 patients were 5.1 and 10.8 months, respectively. Anti-PRA IgG levels were significantly associated with PFS (p=0.0073; HR: 0.37) and OS (p=0.025; HR: 0.43) between these two groups, whereas no significant relation was found with age, clinical response rate and recurrent metastatic status.

Conclusions: The Group 1 patients with elevated anti-PRA IgG may have better prognosis compared to Group 2 patients who showed no IgG elevation after PPV treatment for rmBC. These results indicated a clinical significance between pre-and post- treatment measurement of serum anti-PRA IgGs in mrBC patients receiving PPV therapy, and may be a useful prognostic marker for monitoring the outcome to PPV treatment of breast cancer.

Citation Format: Toh U, Okabe M, Iwakuma N, Mishima M, Shichijo S, Yamada A, Noguchi M, Itoh K, Akagi Y. Serum IgG response against prostate-related antigen revealed by personalized peptide vaccination in patients with metastatic recurrent breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-11-04.

Abstract P5-01-05: Personalized peptide vaccines in combination with conventional chemo- or endocrine therapy for metastatic breast cancer: A single-arm phase II study

Background: Immunotherapy using multiple personalized peptide vaccines (PPV) has been reported to be effective for boosting anticancer immunity in patients (pts) with advanced prostate cancer and glioblastoma. The PPVs binding HLA-A2, A24, A3 family and A26 molecules were selected from 31 candidate peptides derived from various tumor associated antigens. Currently, we performed a phase II trial to evaluate the benefit of the PPVs in combination with conventional chemo-or endocrine therapy for pretreated metastatic breast cancer (MBC). Methods: Seventy-one pretreated pts had histologically confirmed measurable MBC and their HLA A molecules matched each of HLA-A2, A24, A26 and A3 family. Pre-vaccination plasma was measured for their IgG levels reactive to each of 31 peptides followed by administration subcutaneously of the four peptides at maximum showing higher levels of IgG in order with schedule of every 1-2 week. The concurrent conventional chemotherapy or endocrine therapy was available for the combination of PPVs. The primary endpoint was anti-tumor immunologic effect and safety, and the secondary endpoints were clinical responses and survival. Levels of IgG reactive to each of the 31 peptides in the pre- and post-treatment plasma at every 6 times of vaccination were measured using LUMNEX system. The CTL responses were simultaneously evaluated using ELISPOT method. Clinical response was evaluated by RECIST criteria. Results: Between May 2009 and December 2012, a total of 71 pts (Luminal-Her2- cases: 39; Her2+cases: 18; Triple negative(TN) cases:14) were enrolled in this study. The median duration of follow-up was 20.7 months. Concurrent chemotherapies (capecitabine, gemcitabine, eribulin, vinorelbine etc.) and endocrine therapies (aromatase inhibitor, toremifen or fulvestrant) were administered to 36 and 24 pts, respectively. Trastuzumab, Laptinib or Bevacizumab was simultaneously used for 13 pts. After 6th vaccination, the IgG reaction and CTL response were identified in 53 of 71 (74.6%) pts and 33 of 63 (52.3%) pts. There were no significant differences between TN cases and the other cases of MBC with regard to immunological humoral and/or cellular responses. No vaccine-related severe adverse events were observed. Clinical response rate of assessable 61 pts was 14.8% (CR 3, PR 6, SD 24, PD 28). The median PFS and OS were 7.6 m and 20.7 m, respectively. In contrast, the PFS and OS of luminal type, Her2 type or TN type were 12, 4.6 or 8.3 m and 24, 15 or 12 m. Conclusions: The phase II PPVs study for MBC demonstrated the promising response and safety, and further studies are essential to identify the clinical benefits of this novel therapy. Clinical trial information: UMIN000001482.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-01-05.

Phase II study of S-1 in combination with paclitaxel as a first-line treatment for patients with advanced/recurrent gastric cancer

e15615

Background: Taxanes and S-1 have been shown to be effective in patients with advanced gastric cancer and they have a considerable single-agent activity, respectively. We evaluated the combination of paclitaxel and S-1 as first-line chemotherapy for advanced or recurrent gastric cancer (AGC). Methods: All patients with histologically confirmed AGC with unresectable or metastatic diseases, measurable lesions, PS 0–2, age between 18 and 75, and no contraindication to chemotherapy were eligible in this study. Prior adjuvant chemotherapy finished at least 6 months before enrollment was allowed. Treatment included S-1 80 mg/m2 p.o. twice daily on days 1–14 and paclitaxel 60 mg/m2 i.v. on day 1, 8, 15 with a 2-week interval until disease progression or unacceptable toxicities. Results: Between MAY 2004 and Match 2008, total 20 pts were enrolled in this study. The median age was 56.5 years (range, 38–73). Nine pts had recurrent disease after previous curative gastrectomy and 8 had previous adjuvant chemotherapy. After a median 4 (range, 1–9) cycles of chemotherapy, 12 pts were evaluable for toxicity and 20 pts for response. In intention-to-treat analysis, the overall response rate was 62.9% (95% C.I., 36.2–69.6%), including 0 CR, 6 PRs, 8 SDs, and 6 PDs. After a median follow-up of 8.6 months (range, 0.9–17.9), median time to progression was 6.3 months (95% C.I., 3.6–6.9) and median overall survival was 11.6 months (95% C.I., 8.5–20.7). Commonly observed grade 3/4 adverse events were neutropenia (40% of patients), anemia (10%). There was no neutropenic fever or treatment-related death. Conclusions: The combination of paclitaxel and S-1 appear to have well efficacy, manageable toxicity and is well tolerated in patients with AGC. Further studies of this combination should be considered.

No significant financial relationships to disclose.

Combination of gemcitabine and adoptive cell therapy of autologous anti-tumor CTL induces clinical activities in patients with refractory lung cancer

3053

Background: Cytotoxic T cells selectively kill autologous tumor cells is powerful for adoptive cell therapy of cancer. Gemcitabine (GEM) is able to induce molecular changes in cancer cells that make them to induce an antigen specific CTL response. This study was to evaluate the anti-tumor and the immunological activity using the CTL in combination with GEM. Methods: The 50Gy irradiated autologous tumor cells were cocultured with PBMCs and CTLs was developed with RPMI 1640 and rIL-2 (50 u/ml) for 7–14 days. Nine pts with non small cell lung cancer failed their prior chemotherapy were enrolled this pilot study. GEM regimen [intravenous (iv.) GEM (1000mg/m2) - day 1, 8 and 15 ] was started without CTL administration for 1st cycle. GEM was administered at least 2 cycles with a 1-week interval and combined with iv. CTL therapy (0.9 x 108 - 4.6 x 108 cells/injection + IL-2 0.4 MIU; biweekly for 6 to 12 injections) from 2nd cycle. The mean total administered T cells were reached to 3.9 x 109 - 5.6 x 109. PBMCs were analyzed their surface markers by Flow Cytometry and the cytokine productions of IFN-γ etc. in the serum were measured by ELISA before and after 1st cycle of GEM administration and 3rd cycles of CTL injection. Results: After finishing 2 cycles of GEM and 3 injections of CTL, the ratio of CD4/CD8 in PBMCs increased in 7/9 pts. In contrast, CD3/CD19 decreased in 6/9 pts. The cytokine production of IFN-γ in the serum revealed an increase after treatment, the levels of TGF-β were decreased simultaneously. There was no remarkable change in the levels of NKG2D in the PBMCs and MIG, IP10 in the serum. The clinical response showed PR/SD/PD was 2/5/2. The tumor marker proteins (CEA) were also decreased significantly in 4 of 9 pts. The adverse effects were tolerable with grade <2 fever, nausea and fatigue and no bone marrow suppression was observed. Conclusions: These results suggested the synergistic enhancement of antitumor effect might be induced between CTLs and anti-cancer agent GEM. Marked clinical responses were observed in two pts after the treatment. Thus this chemo-immunotherapy will be applicable for the patients with refractory lung cancer.

No significant financial relationships to disclose.

Intrapericardial cellular immunotherapy for malignant pericardial effusion using autologous IL-2-activated TILs

2555

Background: Pericardial effusion (PE) and cardiac tamponade caused by malignant pericarditis are critical conditions in cancer patients, which still lack a recommended protocol for their long-term management. The aims of this study were to investigate the presence of cytotoxic T lymphocytes (CTLs) in malignant PE and to determine the clinical response to administering autologous tumor-infiltrating lymphocytes (TILs) into the pericardial cavity. Methods: Initially, we identified human lymphocyte antigen class-I-restricted and tumor-specific CTLs within the interleukin-2 (IL-2)-activated TILs in PEs from four patients, on the basis of interferon-g production and lactate dehydrogenase-release assays. Clinically we observed favorable responses to the pericardial transfer of IL-2-activated autologous TILs in four patients: one male with advanced esophageal cancer, one female with recurrent lung cancer and two female with recurrent breast cancer, respectively. Autologous TILs from PEs were expanded in vitro with IL-2, characterized for CD3, CD4 and CD8 markers, checked for contamination and then infused into the patient’s pericardial space through a catheter. This was repeated biweekly. Results: After treatment, there were no signs of recurrence of PE in either case, as determined by radiography, echocardiography and computed tomography. The only adverse effects seen were grade 1 fevers. Conclusions: These results suggested that intrapericardial cellular immunotherapy with autologous TILs could be a safe and effective treatment for controlling malignant pericarditis with associated cardiac tamponade, and that tumor-specific CTLs present in malignant PE might be important for tumor rejection.

No significant financial relationships to disclose.

[Cellular immunotherapy for local recurrence of rectal cancer after surgery by activated lymphocyte administration--a case report]

Intrapelvic recurrence of the rectal cancer after surgery is a challenging status. We report here a case of intrapelvic tumor due to the recurrence of rectal cancer postoperatively treated by adoptive cellular immunotherapy.

CASE REPORT

A 57-year-old Japanese man with an intrapelvic tumor showing bone destruction due to the recurrence of rectal cancer after abdomino-peritoneal resection was diagnosed by CT scan. He consented to simultaneous adaptive cellular immunotherapy for local recurrent lesions by administration of the activated lymphocytes. The tumor sample used for the activation of PBMC was obtained by operation. Tumor cells were prepared by mincing and enzymatic digestion of the tumor sample, and they were irradiated with a dosage of 50 Gy. Peripheral blood samples were collected from the same patient. PBMC for about 2 weeks to prepare cells for treatment were obtained from the blood sample. One million PBMC were incubated in 2 ml of the culture medium containing 10(5) irradiated autologous tumor cells and 100 IU/ml recombinant IL-2. The activated PBMCs, as autologous cancer specific killer T cells, were administered by direct regional injection (from 2 million to 8 x 10(7) cells). These injections were given repeatedly about once a week at 2-week intervals for three months. The surface phenotypes of activated PBMC or PBMC were tested by two color immunostaining technique with anti-CD3, -CD4, -CD8 and also anti-CD16, -CD25 or -CD56. Natural killer cell activity was also investigated. The clinical outcome was evaluated by CT scan and serum CEA levels. In the cultured activated PBMCs, NK cell activity was 40%, both CD3 and CD4 positive cells was 30%, and both CD3 and CD8 positive cells was 48%. There were far more CD8 cells than CD4 cells. In the PBMC, NK cell activity had increased, both CD3 and CD4 positive cells had decreased and both CD3 and CD8 positive cells had increased. There were then predominantly more CD8 cells than CD4 cells by repeated administration of the cultured activated PBMCs. The only adverse effect was grade 2 fever. Serum CEA levels fell from 293.7 ng/ml to 160 ng/ml, but the tumor size on the CT scan was slightly increased except for the directly administered region. We have been observing him as an outpatient.

Optimum treatment strategy for superficial esophageal cancer: endoscopic mucosal resection versus radical esophagectomy

This study was designed to determine the optimum treatment for a superficial esophageal cancer involving the mucosal or submucosal layer of the esophagus. The subjects were 150 patients with a superficial esophageal cancer who underwent endoscopic mucosal resection (EMR) or esophagectomy in Kurume University Hospital from 1981 to 1997. The mortality and morbidity rates, survival rate, and recurrence rate were retrospectively compared for (1) 35 patients who underwent EMR and 37 patients who underwent esophagectomy for a mucosal esophageal cancer and (2) 45 patients who underwent extended radical esophagectomy and 33 patients who underwent less radical esophagectomy for a submucosal esophageal cancer. Among the 72 patients with a mucosal cancer, lymph node metastasis/recurrence was observed in only one (1%); whereas of 78 patients with a submucosal cancer it was observed in 30 (38%). Among patients with a mucosal cancer the mortality and morbidity rates after EMR were lower than for those after esophagectomy. The survival rate after EMR was the same as that after esophagectomy. No recurrence was observed after either treatment modality. Among the patients with a submucosal cancer, the survival rate was higher and the recurrence rate lower after extended radical esophagectomy; than after less radical esophagectomy; the mortality and morbidity rates after extended radical esophagectomy were the same as those after less radical esophagectomy. Multivariate analysis demonstrated that the treatment modality (EMR versus esophagectomy) did not influence the survival of patients with a mucosal esophageal cancer, whereas it strongly influenced the survival of patients with a submucosal esophageal cancer. We concluded that EMR was the mainstay of treatment for a mucosal esophageal cancer, and extended radical esophagectomy was the mainstay of treatment for a submucosal esophageal cancer.

Locoregional cellular immunotherapy for patients with advanced esophageal cancer

The objectives of the present study were to determine the safety of locoregional administration of autologous lymphocytes stimulated with autologous tumor cells and interleukin (IL) 2 in vitro and to find laboratory markers to predict either clinical toxicity or clinical response. Eleven patients with advanced (n = 4) or recurrent (n = 7) esophageal cancers received the locoregional administration of these activated lymphocytes every 2 weeks for two to nine times (mean, 5.6 times), and mean numbers of the administered cells were 0.8 x 10(9) cells per treatment. The activated lymphocytes that were pretested for their surface markers and CTL activity were endoscopically injected into primary tumor sites (n = 4) or directly injected into metastatic lymph nodes (n = 2), pleural (n = 4) or ascitic (n = 1) regions. Grade 3 hypotension, grade 2 diarrhea, and grade 1 fever were observed in 1, 1, and 6 patients, respectively, and there was no adverse effect in the remaining three patients. The clinical outcome was as follows: one, complete response (CR); three, partial response (PR); two, stable response (SR); and five, progressive disease (PD). CTL activity in the administered cells was observed in 5 of the 11 patients (1 CR, 3 PR, and 1 PD) and was not observed in the remaining 6 patients (2 SR and 4 PD). Percentages of CD16+ cells in the peripheral blood of the responder group (CR+PR) significantly increased when compared with those before treatment or with those of the nonresponder group before as well as after treatment. Because the clinical toxicity was moderate and tolerable, this new method of locoregional immunotherapy will be applicable for use in treatment of patients with advanced and recurrent esophageal cancers. Both CTL activity in the administered cells and the percentages of CD16+ cells in the peripheral blood may be useful laboratory markers for predicting of clinical response.

[New trends in neoadjuvant chemoradiotherapy for locally-advanced esophageal cancer: esophagectomy--is it necessary?]

In responders to neoadjuvant chemoradiotherapy for locally-advanced esophageal cancer, there was no significant difference in the long-term outcome between patients who underwent esophagectomy and those who did not. Esophagectomy might be unnecessary for patients who achieve a complete response with chemoradiotherapy for an esophageal cancer, in cases when salvage surgery is considered in order to treat any future recurrence.

Radical esophagectomy and secondary anastomosis for high-risk patients with intrathoracic esophageal carcinoma

OBJECTIVE

We have often conducted esophageal reconstruction via a thoracic subcutaneous route in high-risk patients to avoid major complications following anastomotic leakage. This type of reconstruction is nonphysiological, however, and presents a poor cosmetic appearance. In better risk patients, therefore, we usually conduct gastric-tube replacement via a posterior mediastinal route. We have recently begun gastric-tube replacement via the posterior mediastinal route with secondary anastomosis for high-risk patients to avoid anastomotic leakage.

RESULTS

From 1996 to 1999, secondary anastomosis was conducted in 25 patients with different degrees of risk--10 with diabetes mellitus, 7 with liver dysfunction, 3 with simultaneous laryngeal and/or pharyngeal cancer, 2 each with induction chemoradiotherapy, cardiac failure, renal dysfunction, respiratory failure, and cardiorespiratory dysfunction, and 1 with cerebral infarction. 6 patients had with multiple combined diseases. Secondary anastomosis was conducted 3-12 weeks (mean: 5.5 weeks) after esophagectomy. Stomach-tube necrosis was not seen in any of the 25 patients undergoing this 2-step procedure. Anastomosis leakage was seen in 5 of the 25 patients (20%), but was slight, in all but 1.

CONCLUSION

Our 2-step procedure has the following advantages: low risk of anastomotic leakage, radical surgery for esophageal cancer, the potential for early adjuvant therapy after esophagectomy, easy and early training in swallowing, and no cosmetic problem. Its disadvantages are prolonged hospitalization, multiple surgery, and esophageal stoma formation. Secondary anastomosis thus appears helpful in treating high-risk patients with advanced esophageal cancer.

Histopathological analysis of non-malignant and malignant epithelium in achalasia of the esophagus

We studied the premalignant nature of achalasia using anti-Ki-67 and anti-p53 monoclonal antibodies immunohistochemically. In this study, four patients with esophageal carcinoma and achalasia were investigated. Three tumors were pT4 (UICC pTNM) and one tumor was pT1. The majority of non-malignant esophageal epithelium showed esophagitis and/or dysplasia histologically. Esophageal epithelial cells in the lesions of esophagitis and/or dysplasia had a higher number of Ki-67-positive cells than normal epithelial cells. p53 protein was expressed in two tumors and it was not expressed in non-malignant epithelium. From these results, we found that esophageal epithelium in achalasia lesions is changed to varying degrees of esophagitis and/or dysplasia by stagnation of intake foods, and these abnormal epithelial cells showed a high proliferative state compared with the normal cells without the p53 gene mutation. We suggest that the distinct proliferative status is a cause of carcinogenesis.

Continuous intra-arterial 5-FU chemotherapy in a patient with a repeated recurrence of rectal cancer: report of a case

PURPOSE

We report a patient with a recurrent pelvic tumor after abdominoperineal resection of a rectal carcinoma who was treated sufficiently by repeated intra-arterial infusions of 5-fluorouracil.

METHODS

A continuous, 24-hour 5-fluorouracil administration was made through the bilateral internal iliac artery at a dosage of 250 mg/m2/day by the subcutaneous reservoir located at both upper legs using a Baxter infusor.

RESULTS

In this patient pain in the hip and pelvis was relieved. A complete regression in the infused field of pelvic tumor was observed not only with computed tomography and magnetic resonance imaging but also confirmed by operative findings at the seventh month after the intra-arterial infusion. The abnormal serum level of carcinoembryonic antigen and carbohydrate antigen 19-9 was decreased to within the normal range at the 19th and 3rd week respectively. When the repeated recurrence was suspected in follow-up, normalization of the re-elevated carcinoembryonic antigen and carbohydrate antigen 19-9 levels was also obtained by repeating the same treatment. The side effects and complications were tolerable, consisting of local skin erosion on the hips and lower extremity neuropathy caused by the 5-fluorouracil.

CONCLUSIONS

Clinical local regression of a pelvic recurrence was observed in a patient with rectal recurrent tumor who received continuous intra-arterial chemotherapy. Local recurrence of rectal cancer may be controlled effectively and safely by repeating long-term, continuous, intra-arterial 5-fluorouracil infusion.

Induction of human leukocyte antigen-A26-restricted and tumor-specific cytotoxic T lymphocytes by a single peptide of the SART1 antigen in patients with cancer with different A26 subtypes

Peptide antigens available for use in specific immunotherapy of patients with cancer have not been fully determined. Although the authors have reported the SART1 gene encoding epitopes recognized by HLA-A2601-restricted and tumor-specific cytotoxic T lymphocytes (CTLs), the HLA-A26 allele is mainly subdivided into A2601, A2602, and A2603 subtypes. In this study, the authors attempted to determine whether the SART1-derived peptide at position 736-744 (KGSGKMKTE) is suitable to induce HLA-A26-restricted and tumor-specific CTLs in patients with cancer who have these subtypes. This peptide induced the HLA-A26 subtype-restricted and tumor-specific CTLs in HLA-A2601+ or HLA-A2603+ peripheral blood mononuclear cells, respectively. It also induced the HLA-A26-restricted CTL activity in HLA-A2602+ peripheral blood mononuclear cells. Therefore, this peptide could be useful for specific immunotherapy of patients with cancer who have any of the three HLA-A26 subtypes.

Functional outcome of double-stapled and transanal ileal pouch-anal anastomosis after proctocolectomy

Improvement of functional outcome after proctocolectomy for ulcerative colitis and familial adenomatous polyposis was compared between transanal ileal pouch-anal anastomosis (T-IAA group, n = 29) and double-stapled ileal pouch-anal anastomosis (DS-IAA group, n = 8). Clinical functions were evaluated using a functional scoring system, and physiologic functions by anorectal manometry after one year postoperatively. Although in the T-IAA group 4 of the 29 patients (13.8%) displayed partial incontinence (< 9 points), all of 8 patients in the DS-IAA group showed good results referring to continence (> 10 points). The maximum resting pressure was 44.3 +/- 5.2 cmH2O in the T-IAA group vs. 56.6 +/- 5.8 cmH2O in the DS-IAA group, and postoperatively the maximum squeezing pressure was 96.8 +/- 9.2 cmH2O in the T-IAA group vs. 106.3 +/- 8.1 cmH2O in the DS-IAA group. There was a significant difference of maximum resting pressure and no significant difference of maximum squeezing pressure between the two groups. The length of the high pressure zone in the anal canal was significantly shorter in patients of the T-IAA group (2.1 +/- 0.8 cm) than in those of the DS-IAA group (3.5 +/- 1.1 cm) (p < 0.05). The DS-IAA is associated with excellent objective physiologic and subjective functional results. This reflects the sacrifice of the internal anal sphincter 1.5 cm cephalad necessary to effect this anastomosis at a mean of 1.4 cm from the dentate line.

Clinical aspects of total colectomy--laparoscopic versus open technique for familial adenomatous polyposis and ulcerative colitis

Clinical aspects of laparoscopy combined total colectomy (LTC) (n = 10) and open total colectomy (OTC) (n = 29) with ileorectal anastomosis for familial adenomatous polyposis and ulcerative colitis are compared in a retrospective study. The mean operative time was 282 (range, 169 to 420) minutes in the LTC group and 274 (range, 139 to 570) minutes in the OTC group. The mean volume of operative blood loss was 321 (range, 52 to 728) ml and 471 (range, 48 to 1040) ml for the LTC and OTC groups, respectively. Nasogastoric tube could be removed after POD 1.2 vs. 5.8 (p < 0.05), the mean time to passage of stool was 1.9 (range, 1 to 3) vs. 5.2 (range, 3 to 7) days (p < 0.01), and in the LTC group watery stool was soon made solidification after POD 23.4 vs. 84.1 (p < 0.01). Laparoscopy combined total colectomy may prove to have one-stage restorative total colectomy without a temporary ileostomy due to early solidification of watery stool and more benefits than conventional open surgery.

Effect of combination therapy with a methionine-mitomycin C conjugate and a methionine-deficient diet on tumor growth

BACKGROUND

We investigated effects of a combination therapy of a methionine-mitomycin C conjugate (M-M conj) and methionine-free nutrition both in vitro and in vivo, compared to mitomycin C (MMC) administration alone.

MATERIALS AND METHODS

The human esophageal cancer cell line, KE-3, incubated in either standard or methionine-free media, was treated with phosphate buffered saline (PBS), M-M conj in PBS, or MMC in PBS. The rate of cell survival was determined. The tumor bearing mice were maintained on either a standard or methionine-free diet (MFD) and treated with PBS, MMC, or M-M conj.

RESULTS

The lowest tumor cell survival rate was found with the M-M conj plus methionine-free media at every dose tested (p < 0.05). Tumor weight was significantly lower with the M-M conj plus MFD than in any other group (p < 0.003).

CONCLUSION

Methionine targets MMC to tumor during administration of MFD.

The effect of radioimmunotherapy using murine monoclonal antibody KIS1 on esophageal squamous cell carcinoma-bearing nude mice

The monoclonal antibody (MoAb) KIS1 has been shown to react specifically with an antigen of human squamous cell carcinoma (SCC); however, a major problem in its clinical application is that the intact murine antibody induces a human anti-mouse antibody (HAMA). To overcome this problem, we produced the KIS1 F(ab')2 fragment, then radioiodinated the intact KIS1 antibody and its F(ab')2 fragment. Nude mice bearing human esophageal SCC implants were injected with 100 microCi of 131I-intact KIS1 or 131I-KIS1 F(ab')2, and images were obtained using a gamma camera. Radioimmunotherapy (RIT) was performed by injecting the tumor-bearing nude mice with 131I-intact KIS1 or 131I-KIS1 F(ab')2 at a dosage of 300 microCi, following which 7 or 3 days were required to produce high quality tumor images by scintigraphy. The tumor-bearing mice treated with 131I-KIS1 F(ab')2 showed significant tumor growth inhibition, about 5.4 times greater than that of the control group and 1.8 times greater than that of the 131I-intact KIS1 group 21 days after the injection. These results indicate that the KIS1 F(ab')2 fragment is superior to intact KIS1, and that it may be clinically useful for radioimmunodetection followed by tumor targeting therapy for patients with SCC of the esophagus.

HLA class I-restricted and tumor-specific cytotoxic T lymphocytes from metastatic lymph nodes of esophageal cancers

This paper investigates the presence of HLA class I-restricted and tumor-specific cytotoxic T lymphocytes (CTL) in tumor sites of esophageal cancers. Five CTL lines were established from the metastatic lymph nodes or pleural effusion by incubation with interleukin-2 of tumor-infiltrating lymphocytes: cases 1 and 5, HLA-A26- and HLA-A33-restricted and squamous cell carcinoma (SCC)-specific CTL; case 2, HLA-Cw0102-restricted and esophageal SCC-specific CTL; case 3, HLA-A24- and HLA-A26-restricted CTL recognizing histologically different tumor cells; and case 4, HLA-A26-restricted and esophageal SCC-specific CTL. These results suggest the existence of HLA class I-restricted and tumor-specific CTL in metastatic esophageal SCC.

A monoclonal antibody KIS-1 recognizing a new membrane antigen on human squamous-cell carcinoma

A KIS-1 monoclonal antibody (MAb) (IgG1, kappa) recognizing a membrane antigen on human squamous-cell carcinomas (SCC) was developed to understand their antigenicity using an esophageal SCC as an immunogen. The KIS-1 MAb recognized a membrane antigen on a majority of esophageal, lung, and oral- cavity SCC by immunofluorescent and by immunohistochemical analyses. In contrast, it showed little reactivity to adenocarcinomas from different organs, and none to keratinocyte cell lines. This MAb showed reactivity to the cells in the basal layer of normal esophageal epithelium adjacent to the esophageal SCC, but none of the other normal tissues, including esophageal epithelium far from the SCC and that from patients with non-malignant disease. The KIS-1 MAb immunoprecipitated a 46-kDa membrane protein of the esophageal SCC in non-reducing and in reducing conditions. It recognized the 46- and the 40-kDa proteins of the esophageal SCC by immunoblot analysis. These results suggest that the KIS-1 MAb recognizes a new membrane antigen preferentially expressed on SCC, and that this antigenicity is shared only by the cells in the basal layer of the esophageal epithelium adjacent to SCC. The KIS-1 MAb may be a new tool for understanding the antigenicity of SCC.

HLA A2601-restricted CTLs recognize a peptide antigen expressed on squamous cell carcinoma

The CD4-CD8+ CTL (KE-4 CTL) cell line against autologous tumor cells was established in a patient with esophageal cancer. This KE-4 CTL recognized a peptide antigen on esophageal and lung squamous cell carcinomas in an HLA A2601-restricted manner, as evaluated by cytotoxicity against a panel of tumor cells, transfection experiments with HLA A2601 cDNA, and reconstitution with eluted peptides. None of the normal cells tested was lysed by this CTL. These results suggest the existence of HLA A2601-restricted CTL precursors recognizing a peptide antigen on SCC in a patient with esophageal cancer.

Cervico-thoraco-abdominal (3-field) lymph node dissection for carcinoma in the thoracic esophagus

The efficacy of an extended radical lymph node dissection for carcinoma in the thoracic esophagus is controversial. Results of a multivariate analysis using clinical data from 127 cases collected from 1982 to 1988 are reported. Twenty-seven of these patients underwent an extended radical (cervico-thoraco-abdominal: 3 fields) lymph node dissection which was recently developed in Japan, while others underwent a standard (thoraco-abdominal: 2 fields) lymph node dissection. They all had a locally-curative resection of the tumor through a right thoracotomy. In this study, 13 factors commonly affecting prognosis were examined: sex, age, cancer location, tumor length, radiographic type, depth of invasion, lymph node metastasis, tumor differentiation, postoperative radiotherapy, chemotherapy, operative risk, postoperative complications, and 3-field or 2-field dissection. Based on the survival-rate curves using Kaplan-Meier's statistics, the 3-field dissection was superior to the 2-field dissection. Moreover, when other prognostic factors were adjusted using Cox's proportional hazards general linear model, the same result was obtained from survival-rate curves. From this analysis, it can be concluded that a 3-field dissection is a better approach for management of carcinoma in the thoracic esophagus.