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IL-12 and IL-10 expression synergize to induce the immune-mediated eradication of established colon and mammary tumors and lung metastasis.

Preclinical studies demonstrated that certain cytokines are potentially useful for the induction of antitumor immune responses. However, their administration in clinical settings was only marginally useful and evoked serious toxicity. In this study, we demonstrate that the combination of autologous inactivated tumor cells expressing IL-12 and IL-10 induced tumor remission in 50-70% of mice harboring large established colon or mammary tumors and spontaneous lung metastases, with the consequent establishment of an antitumor immune memory. Mice treatment with tumor cells expressing IL-12 was only marginally effective, while expression of IL-10 was not effective at all. Administration of the combined immunotherapy stimulated the recruitment of a strong inflammatory infiltrate that correlated with local, increased expression levels of the chemokines MIP-2, MCP-1, IFN-gamma-inducible protein-10, and TCA-3 and the overexpression of IFN-gamma, but not IL-4. The combined immunotherapy was also therapeutically effective on established lung metastases from both colon and mammary tumors. The antitumor effect of the combined immunotherapy was mainly dependent on CD8+ cells although CD4+ T cells also played a role. The production of IFN-gamma and IL-4 by spleen cells and the development of tumor-specific IgG1 and IgG2a Abs indicate that each cytokine stimulated its own Th pathway and that both arms were actively engaged in the antitumor effect. This study provides the first evidence of a synergistic antitumor effect of IL-12 and IL-10 suggesting that a Th1 and a Th2 cytokine can be effectively combined as a novel rational approach for cancer immunotherapy.

Animals↗

Cytokine combinations in immunotherapy for solid tumors: a review.

The use of cytokines alone or in combination with other cytokines or cytotoxic drugs has had a profound effect upon widely metastatic disease in many cases. However, despite the encouraging results in early trials, there is much room for improvement. Few responses to these combinations are complete, and toxicity has in some cases been quite severe. Changes in dose, route, or schedule of administration of the drugs, or the development of cytokine analogs may lead to more efficacious and less toxic regimens. In addition, new cytokines such as interleukin(IL)-7 and IL-12 are currently under investigation for potential use in future immunotherapy trials. These prospects and the use of cytokine combinations are promising advances in the treatment of human cancer.

Animals↗

Combined alpha tumor necrosis factor gene therapy and engineered dendritic cell vaccine in combating well-established tumors.

BACKGROUND: Although current immunotherapeutic strategies including adenovirus (AdV)-mediated gene therapy and dendritic cell (DC) vaccine can all stimulate antitumor cytotoxic T lymphocyte (CLT) responses, their therapeutic efficiency has still been limited to generation of prophylactic antitumor immunity against re-challenge with the parental tumor cells or growth inhibition of small tumors in vivo. However, it is the well-established tumors in animal models that mimic clinical patients with existing tumor burdens. Alpha tumor necrosis factor (TNF-alpha) is a multifunctional and immunoregulatory cytokine that induces antitumor activity and activates immune cells such as DCs and T cells. We hypothesized that a combined immunotherapy including gene therapy and DC vaccine would have some advantages over each modality administered as a monotherapy. METHODS: We investigated the antitumor immunotherapeutic efficiency of gene therapy by intratumoral injection of AdVTNF-alpha and DC vaccine using subcutaneous injection of TNF-alpha-gene-engineered DC(TNF-alpha) cells, and further developed a combined AdV-mediated TNF-alpha-gene therapy and TNF-alpha-gene-engineered DC(TNF-alpha) vaccine in combating well-established MO4 tumors expressing the ovalbumin (OVA) gene in an animal model. RESULTS: Our data show that vaccination of DC(TNF-alpha) cells pulsed with the OVA I peptide can (i) stimulate type 1 immune response with enhanced antitumor CTL activities, (ii) induce protective immunity against challenge of 5 x 10(5) MO4 tumor cells, and (iii) reduce growth of the small (3-4 mm in diameter), but not large, established MO4 tumors (6-8 mm in diameter). Our data also show that AdVTNF-alpha-mediated gene therapy can completely eradicate small tumors in 6 out of 8 (75%) mice due to the extensive tumor necrosis formation, but not the large tumors (0%). Interestingly, a combined AdVTNF-alpha-mediated gene therapy and TNF-alpha-gene-engineered DC(TNF-alpha) vaccine is able to cure 3 out of 8 (38%) mice bearing large MO4 tumors, indicating that the combined immunotherapy strategy is much more efficient in combating well-established tumors than monotherapy of either gene therapy or DC vaccine alone. CONCLUSIONS: This novel combined immunotherapy may become a tool of considerable conceptual interest in the implementation of future clinical objectives.

Animals↗

Antitumor potential of low-dose chemotherapy manifested in combination with immunotherapy of Viva-Natural, a dietary seaweed extract, on Lewis lung carcinoma.

Beneficial antitumor effects of low-dose chemotherapy (Adriamycin, BCNU, cisplatin, 5-fluorouracil, methotrexate, 6-thioguanine or vincristine) combined with an immunotherapy with a partially purified polysaccharide of Viva-Natural, an edible seaweed extract, have been demonstrated against intraperitoneally implanted Lewis lung carcinoma in syngeneic mice. Adriamycin, cisplatin, 5-fluorouracil and vincristine at low doses, that were not effective when given alone, manifested antitumor activity when combined with the polysaccharide fraction of Viva-Natural. Other three drugs (BCNU, methotrexate and 6-thioguanine) at the noneffective low doses exhibited no further antitumor activity when combined with Viva-Natural. Cytotoxic activation of peritoneal macrophages in mice has been induced by single administration of the polysaccharide fraction of Viva-Natural, but the combined regimen of low dose drugs plus viva-Natural was no more effective than Viva-Natural alone. Therefore, the mechanism of action of the beneficial combination is not clear yet.

Animals↗

Combination of immunotherapy with cyclophosphamide/actinomycin D chemotherapy potentiates antileukemic effect and reduces toxicity in a L1210 leukemia model in mice.

The therapeutic effects of the combination of chemotherapy (cyclophosphamide and actinomycin D) and immunotherapy (TNF-alpha and macrophages) were evaluated on L1210 leukemia in mice. When given as single agents, both cyclophosphamide (CY), administered intraperitoneally 2 days after subcutaneous inoculation of leukemic cells, and actinomycin D (Act D), injected intratumorally (i.t.) 4 days following injection of leukemic cells, exerted therapeutic effects and prolonged mice survival. Unexpectedly, combination of CY and Act D did not result in prolongation of mice survival, due mainly to substantial cumulative toxic effects that led to death in several cases. Immunotherapy with TNF-alpha and M phi, injected i.t. on day 4 following inoculation of leukemic cells, did not give significant therapeutic effect, either when used alone or when used in conjunction. However, combination of chemotherapy and immunotherapy, including all four agents, produced a beneficial effect resulting in significant prolongation of the survival of leukemia-bearing mice. This study indicates the potential of appropriate combinations of cytotoxic drugs with immunotherapy against neoplasia.

Animals↗

Augmenting the potency of breast cancer vaccines: combined modality immunotherapy.

Rapid progress in defining the molecular underpinnings of the antitumor immune response has laid the foundation for tumor immunotherapy, leading to multiple early clinical studies testing vaccines for the treatment of breast cancer. Together, these small trials have provided early evidence for the induction of clinically relevant vaccine-induced tumor-specific immunity in some patients. However, they have not convincingly demonstrated a significant impact on disease progression or overall survival in women with advanced breast cancer. These disappointing results are likely due to the negative impact of standard cancer treatments on vaccine-activated antitumor immunity, the limited potency of current tumor vaccine formulations against large burdens of established tumor, and the presence of pre-existing tumor-specific immune tolerance. It is increasingly clear that standard and novel breast cancer treatments can influence the antitumor immune response. Also, signaling pathways that regulate immune responses have emerged as novel targets for immune modulation. The use of preclinical models to elucidate the pharmacodynamic interactions of standard breast cancer treatment modalities and novel, targeted immunotherapeutics with breast cancer vaccines will facilitate the development of combinatorial immunotherapeutic strategies. Combined modality immunotherapies should maximize the potency of the antitumor immune response, thereby improving the outcome of breast cancer therapy.

Breast Neoplasms↗

The treatment of locally advanced pancreatic cancer: a practice guideline.

BACKGROUND: Pancreatic adenocarcinoma is the fourth most common cause of adult cancer death. About 50% of patients present with metastatic disease, 20% with resectable disease and the remaining 30% of patients are diagnosed with incurable, locally advanced unresectable but nonmetastatic pancreatic cancer. OBJECTIVES: To evaluate the current evidence regarding treatment of incurable, locally advanced, unresectable but nonmetastatic pancreatic cancer and produce an evidence-based practice guideline. METHODS: A systematic review of the literature was performed. The MEDLINE, CANCERLIT, and Cochrane Library databases were searched using the following medical subject heading search terms: 'pancreatic neoplasms', 'chemotherapy, adjuvant', 'radiotherapy', 'immunotherapy', combined with the text words: 'chemotherapy', 'radiotherapy', 'radiation', 'immunotherapy', combined with terms for the following study designs or publication types: practice guidelines, meta-analyses and randomized controlled trials. The Physician Data Query clinical trials database and the proceedings of the annual meetings of the American Society of Clinical Oncology (1996 to 2001) and the American Society for Therapeutic Radiology and Oncology (1999 to 2001) were searched for reports of new or ongoing trials. Relevant literature was selected and reviewed independently, and the reference lists from these sources were searched for additional trials. Interpretation of evidence was resolved by consensus. RESULTS: Eight randomized trials were obtained that met the inclusion criteria. CONCLUSIONS: Recommendations are to offer combined chemotherapy and radiotherapy to suitable patients. The preferred chemotherapeutic agent to combine with radiotherapy is bolus or infusional 5-fluorouracil, but the optimal mode and duration of 5-fluorouracil delivery is unclear. Chemotherapy alone with gem-citabine is an acceptable alternative.

Adenocarcinoma↗

Capecitabine monotherapy and in combination with immunotherapy in the treatment of metastatic renal cell carcinoma.

This prospective trial aimed to evaluate the therapeutic effects and systemic toxicities of capecitabine monotherapy and capecitabine treatment combined with biological response modifiers in patients with metastatic renal cell carcinoma. Fifty-four patients suffering from metastatic renal cell carcinoma progressing under first-, second- or third-line treatment entered the trial. Capecitabine was given orally at a dose of 2500 mg/m2 daily divided into two doses for 14 days, followed by a 7-day rest in the monotherapy as well as in the combination treatment. This schedule was repeated in 3-week cycles. The combination therapy consisted of capecitabine and an immunotherapy treatment, which consisted either of interferon (IFN)-gamma1b (100 mg/day) administered consecutively 5 times weekly during weeks 1 and 2, and recombinant interleukin (IL)-2 (4.5 MU/day) administered on 4 consecutive days during weeks 3 and 4, every 6 weeks, or IFN-alpha (6 MioIE/day) administered 3 times a week. Fifty-two patients are now evaluable for response and 54 patients for toxicity. We observed a partial response to treatment in five patients (9.6%), minor response in five patients (9.6%), stable disease in 32 patients (61.6%) and only 10 patients (19.2%) showed continued disease progression despite treatment. Outpatient capecitabine was well tolerated. We did not observe any WHO grade IV toxicities. We conclude that capecitabine monotherapy and capecitabine treatment in combination with biological response modifiers appear to be effective regimens with favorable toxicity profiles in patients with advanced renal cell carcinoma. Capecitabine monotherapy seems to be superior than the combination treatment because of its easier application form.

Aged↗

MER immunotherapy and combination chemotherapy for advanced, recurrent Hodgkin's disease. Cancer and Leukemia Group B study.

The effects of chemotherapy and chemoimmunotherapy in previously treated advanced Hodgkin's disease were evaluated in a randomized study of 167 patients by CALGB. Combination chemotherapy consisted of treatment with one of three regimens with further randomization of MER (methanol extraction residue BCG) immunotherapy or no MER during chemotherapy. CVPP (CCNU, vinblastine, procarbazine, prednisone) was compared to a new combination, BAVS (bleomycin, Adriamycin, vincristine, streptozotocin), and to a third regimen consisting of alternating cycles of CVPP and BAVS. At the current analysis there is no significant difference in complete responses among the chemotherapy regimens. MER did not improve complete response frequency and was associated with significantly poorer survival for patients previously treated with chemotherapy. There was also no benefit with MER for patients with at least one pretreatment positive skin test. Because of the documented lack of therapeutic benefit and the morbidity of painful ulcers, MER treatment has been discontinued.

Adult↗

Potentiation of the therapeutic index of interleukin-2 immunotherapy by combination with taurine in a syngeneic murine tumour model.

BACKGROUND: Administration of interleukin-2 (IL-2) is limited by the induction of the vascular leak syndrome (VLS). AIMS: To examine the effect of taurine on the toxicity and antitumour activity of IL-2 in a B16 melanoma pulmonary metastases model. METHODS: B16 melanoma cells were injected into female C57BL/6 mice. Macroscopic melanoma pulmonary foci were established by day 10 in untreated mice. Treated mice were randomised into treatment by rIL-2 alone, rIL-2 plus taurine or taurine alone. Control animals received saline. Mice were sacrificed on day 18. Lung metastases were counted in a blinded fashion with the aid of a dissecting microscope. Wet to dry lung weight was measured following lung removal. In another experiment animals were treated as above (n = 15 per group) and survival following treatment monitored. RESULT: Treatment with IL-2 and taurine significantly reduced lung nodules compared with IL-2 alone. Host survival was significantly enhanced. The wet to dry (w/d) ratios of lung weights in the group receiving IL-2/taurine were significantly less than IL-2 alone. Bronchoalveolar lavage protein fluid was reduced indicating reduced pulmonary injury. CONCLUSION: These findings indicate that the combination of taurine with IL-2 augments the efficacy of this immunotherapy while reducing its associated dose-limiting toxicity.

Animals↗

[The therapeutic effects of OK-432 combined adoptive immunotherapy (AIT) against liver metastases of breast cancer].

We studied the effect of OK-432 combined AIT in 24 cases of liver metastases of breast cancer. Eleven of the 16 patients (69%) who received intraarterial transfer responded to this therapy. On the other hand, no patients responded to intravenous or intraportal transfer. The minimum cell number for a therapeutic response was 10(9) cells. Four patients had abscopal effects after therapy. The serum CEA level paralleled the therapeutic effects. There were no severe side effects accompanying this therapy. These results indicate that intra-arterial OK-432 combined AIT should be the first choice therapy against liver metastases of breast cancer.

Biological Products↗

Evaluation of Livingston's chemotherapy combined with immunotherapy in treatment of small cell lung carcinoma.

The comparative studies presented in this work aimed at evaluation of isoprinosine in the combined cytostatic and irradiation treatment of small cell lung cancer. The comparison was performed between three groups of patients: 1. treated by the method of Livingston et al., 2. treated by the method of Livingston et al. in a combination with isoprinosine, 3. treated by the same method but the cycle of treatment was shortened from 3 weeks to 8 days with the parallel application of isoprinosine as immunotherapeutic and stimulator of the hematopoietic system. It was found that the mean time of complete and partial remission and the mean survival time was longer in the second and third group of patients. The mean survival time in the first group amounted to 3 weeks, in the second to 43 weeks and in the third to 49 weeks. It was also shown that post-chemotherapy complications were less frequent and less intensive.

Adult↗

Therapeutic cancer vaccines: at midway between immunology and pharmacology.

The pursuit of active specific immunotherapy of cancer re-emerged vigorously in the 90s. More than 50 vaccines are currently under clinical testing, and more than 400 clinical trials have been conducted. This wave of enthusiasm is rooted in fundamental immunology, as new paradigms, such as the dominant tolerance through T-regulatory cells and the instructive role of the innate immune system on the adaptive immune system, opened the possibility that an efficient cancer vaccination could be achieved even without the need of cancer neoantigens, provided that antigen presentation could be increased, and that regulatory circuits could be controlled. However, recent failures in some large trials have brought disappointment and have highlighted the differences between experiments in young, healthy mice with small transplanted tumours, and clinical testing in aged, ill patients with advanced spontaneous tumours, driving the attention to issues such as tumour editing, tumour-induced immunosuppression, and immunosenescence. The molecular basis of these phenomena is only partially known. Additionally, the inherent complexity of the immune system as a network of multiple interactions and redundant control loops among a huge diversity of components sets another barrier to the translation of in vitro reductionist knowledge into rationally designed clinical trials. All this calls for a new therapeutic paradigm in cancer vaccines, moving beyond the analogy with the classic drug-target approach, and targeting the immune system regulation as a whole, and its interaction with the tumour, in all its complexity. Early mathematical modelling of cancer immunotherapy has suggested how to go about it. This re-evaluation of the cancer vaccine landscape, suggests that future successful cancer immunotherapy will be combined immunotherapy, will be exquisitely schedule-dependent and will need new experimental models allowing for the exploration of the mechanisms of resistance and tumour escape, such as tumour editing and tumour induced immunosuppression, in the context of the physiology of the immune system of the elderly. These shifts will put cancer vaccines closer to pharmacology than to conventional preventive vaccinology, or at least at the midway. A change in the design and the ultimate goals of the clinical trials will also be needed, identifying long term stabilization of the disease and quality of life as main endpoints, again closer to the clinical management of most chronic noncommunicable diseases.

Animals↗

Graft versus leukemia. VI. Adoptive immunotherapy in combination with chemoradiotherapy for spontaneous leukemia-lymphoma in AKR mice.

A three-step treatment plan incorporating adoptive immunotherapy and chemoradiotherapy was used to treat AKR (H-2k) mice bearing spontaneous leukemia-lymphoma (SLL). 1) Leukemic mice were treated with chemoradiotherapy for immunosuppression and leukemia cytoreduction. 2) To introduce a graft-versus-leukemia reaction against residual malignant cells, the immunosuppressed AKR mice were given immunocompetent cells from H-2 mismatched DBA/2 (H-2d) donors. 3) To "rescue" the AKR hosts from incipient graft-versus-host disease, the mismatched DBA/2 cells were killed with combination chemotherapy, and cells from allogeneic H-2 matched RF (H-2k) donors were administered to restore hematopoiesis. Leukemic AKR mice thus treated had significant prolongation of their median survival time and a higher 60-day survival rate post treatment than did untreated controls, chemoradiotherapy controls, or control mice that received chemoradiotherapy plus cells from syngeneic donors. Therefore, adoptive immunotherapy may be useful as an adjunct to conventional therapy for treatment of SLL in AKR mice.

Amphotericin B↗

Tumor growth suppression by a mouse/human chimeric anti-CEA antibody and lymphokine-activated killer cells in vitro and in SCID mouse xenograft model.

The mouse/human chimeric antibody Ch F11-39, recently generated by ourselves, shows the same high specificity and affinity for carcinoembryonic antigen (CEA) as those of its parental mouse monoclonal antibody. Ch F11-39 is capable of mediating antibody-dependent cell-mediated cytotoxicity (ADCC) with human peripheral blood lymphocytes (PBL). Interleukin-2 (IL-2) modulates the function of immunocytes, in particular inducing lymphokine-activated killer (LAK) cells and enhancing ADCC. In the present study, we therefore tested the combination immunotherapy of Ch F11-39 with LAK cells in vitro and in severe combined immunodeficiency (SCID) mice bearing human CEA-producing tumors. In vitro experiments using human gastric tumor cell lines, Ch F11-39 effectively mediated ADCC against CEA-positive MKN-45 cells, but not against CEA-negative cells. The specificity of ADCC for Ch F11-39 was demonstrated by experiments with irrelevant target cells or irrelevant antibody. ADCC activity of PBL with Ch F11-39 was enhanced by double after preincubation with IL-2 at 10 U/ml. The concentration of Ch F11-39 required for 50% maximal cell killing was about 0.25 microgram/ml at 10 U/ml of IL-2. Increasing ADCC was triggered by IL-2 earlier (1 day) than the generation of LAK cells (3 days). Control human IgG blocked the ADCC, suggesting that the enhancement of ADCC by IL-2 may be caused by activation of effector cells expressing Fc receptors. In vivo anti-tumor activity of combined immunotherapy was estimated using SCID mice inoculated s.c. with 1 x 10(7) MKN-45 cells. The i.v. administration of LAK cells and i.p. administration of Ch F11-39 and IL-2 produced a marked growth inhibition of MKN-45 tumors in SCID mice (about 50% reduction in tumor size as compared to the control untreated group, measured 15 days after treatment). In summary, the enhanced antitumor activity of Ch F11-39 with LAK cells suggests that it might be a useful immunotherapeutic reagent for CEA-expressing tumors.

Animals↗

Treatment of advanced primary lung cancer associated with malignant pleural effusion by the combination of immunotherapy and chemotherapy.

Twelve patients with advanced primary lung cancers associated with malignant pleural effusion were treated with intrathoracic instillation of recombinant interleukin-2 with or without in-vitro-sensitized cells. Two cases achieved complete response, and 7 partial response. The adverse effects seen in the protocol were marginal, and the protocol was well-tolerated and feasible. Furthermore, 4 cases were treated with the combination of systemic chemotherapy and adoptive immunotherapy. Of these, 3 cases responded well to the therapy and have shown a complete response for more than 20 months, indicating that adoptive immunotherapy together with chemotherapy might be a beneficial treatment for advanced lung cancer patients.

Adenocarcinoma↗

Bowen's disease (squamous cell carcinoma in situ) in immunosuppressed patients treated with imiquimod 5% cream and a cox inhibitor, sulindac: potential applications for this combination of immunotherapy.

BACKGROUND: Patients with chronic lymphocytic leukemia (CLL) often have a protracted course. However, all these patients are immunosuppressed and may have a high incidence of cutaneous malignancies. OBJECTIVE: To determine if combination therapy using topical imiquimod cream 5% and the oral cyclooxygenase (COX) inhibitor are useful in the therapy of squamous cell carcinoma in situ (SCC in situ)/Bowen's disease in patients with long-standing CLL. METHODS: Five CLL patients with head and neck cutaneous SCC in situ, which met criteria for Bowen's disease, were treated with topical 5% topical imiquimod cream and an oral COX inhibitor, sulindac 200 mg twice a day. RESULTS: All patients showed clinical resolution and histologic clearing of the tumors after 16 weeks of therapy. CONCLUSION: The local immune modulator, 5% imiquimod, in combination with a COX inhibitor, with its many potential antitumor effects may stimulate the innate and possibly the adaptive immune responses to clear these malignancies.

Adjuvants, Immunologic↗

Combination cytokine immunotherapy with tumor necrosis factor alpha, interleukin 2, and alpha-interferon and its synergistic antitumor effects in mice.

The antitumor activity of combination therapy with recombinant human tumor necrosis factor alpha (rhTNF-alpha), recombinant human interleukin 2 (rhIL-2), and recombinant hybrid alpha-interferon A/D (rhIFN-alpha A/D) was assessed against established weakly immunogenic (MCA-106) and nonimmunogenic (MCA-102) sarcomas at both s.c. and visceral (hepatic) sites. C57BL/6 mice were treated with a single i.v. dose of rhTNF-alpha followed by rhIL-2 (75,000 units) and rhIFN-alpha A/D (75,000 units) i.p. twice daily for 5 consecutive days. Substantial improvements were observed when the combination of rhTNF-alpha, rhIL-2, and rhIFN-alpha A/D was administered, as measured by regression of tumor, prolongation of survival, and improved cure rates, compared with any combination of two cytokines or any cytokine alone against the MCA-106 sarcoma. These findings were consistent in both the s.c. and single hepatic tumor models. For example, treatment of the MCA-106 s.c. tumor bearers with the triple cytokine combination resulted in cures of 16 of 18, 17 of 18, and 12 of 18 mice receiving rhTNF-alpha dosages of 2, 4, and 6 micrograms, respectively, compared with 2 of 18, 7 of 18, and 9 of 18 at 2, 4, and 6 micrograms of rhTNF-alpha plus rhIL-2 without rhIFN-alpha A/D. Established 10-day single liver tumor weights when treated with the triple combination therapy were 54 and 25 mg in treatment groups receiving 2 and 4 micrograms of rhTNF-alpha, compared with 376 and 302 mg with the same amounts of rhTNF-alpha alone (P less than 0.004). Mice bearing hepatic sarcomas treated with triple cytokine combination therapy had cure rates of 50% and 67% at rhTNF-alpha doses of 2 and 4 micrograms, compared with no survivors with rhTNF-alpha alone. No improved antitumor effects resulted from therapy with any cytokine alone or in combination against the nonimmunogenic MCA-102 sarcoma. Possible in vivo mechanisms by which these three cytokines synergize are discussed.

Animals↗