Active specific immunotherapy of malignant melanoma with anti-idiotypic monoclonal antibodies

In this study, we have utilized the human high molecular weight-melanoma associated antigen (HMW-MAA) as a target for active specific immunotherapy with mouse anti-idiotypic (anti-id) monoclonal antibodies (mAb) in patients with malignant melanoma. After having summarized the characteristics of HMW-MAA which account for its selection as a target for immunotherapy, we describe the development and characterization of mouse anti-id mAb MK2-23 which bears the internal image of HMW-MAA. Furthermore, we describe the results of the first clinical trial performed with mouse anti-id mAb MK2-23 in patients with malignant melanoma.     

Adenovirus-mediated expression of melanoma antigen gp75 as immunotherapy for metastatic melanoma

Melanocyte differentiation antigens, such as the brown locus protein gp75, are potential biological targets for immunotherapy. We investigated whether expression of the murine gp75 cDNA mediated by an adenovirus (Ad) vector could induce melanoma rejection using this model self antigen that usually induces tolerance, and whether Ad vector-directed production of interleukin-2 (IL2) might augment this response. To evaluate this approach, Ad vectors were constructed containing the murine gp75 cDNA (Ad.gp75) and the human IL2 cDNA (Ad.IL2). Efficacy was evaluated in C57BI/6 mice challenged i.v. with 10(5) B16 cells, using the number of lung metastases as the efficacy parameter. Naive control mice developed 175 +/- 12 metastases by day 14. Controls receiving intranasal Ad.IL2 1 day after B16 cell injection, intraperitoneal (i.p.) mitomycin-C-treated B16 cells +/- i.p. Ad.IL2 before B16 cell challenge and Ad.beta gal-treated mice had similar numbers of metastases as controls (P > 0.1). In marked contrast, preimmunization with intradermal Ad.gp75 provided dramatic reduction in the number of lung metastases (52 +/- 7, 29% of control). Addition of regional (intranasal delivery to the lung) Ad.IL2 to intradermal Ad.gp75 preimmunization 1 day following tumor challenge provided further protection (18 +/- 6, 10% of control). Depletion of CD4+ and CD8+ T-cell subsets effectively blocked the protective effect seen following immunization. Adoptive transfer of macrophage-depleted splenocytes from Ad.gp75-immunized mice similarly afforded significant protection against B16 tumor cell challenge. Further, serum obtained 21 days following Ad.gp75 immunization showed no detectable anti-gp75 antibody by immunoprecipitation. These results suggest that immunization with Ad.gp75 induces cellular immune responses that are capable of rejecting B16 melanoma in a host that is usually tolerant to gp75 antigen.     

Immunochemical detection of cyclobutane thymine dimers in epidermal Langerhans cells of ultraviolet B-irradiated hairless mice

Integrity of sensory and motor function is essential in the maintenance of continence. The pudendal nerve assumes a central role being a mixed sensory and motor nerve. Neuropathic changes may therefore lead to incontinence and stretch injury to the pudendal nerve has been implicated as an aetiological factor. However pudendal neuropathy, altered anal sensation and perineal descent do not always correlate in the same patient. To investigate this further we evaluated the effect of a simulated defaecation strain on pelvic floor neurological function in a group of patients with constipation and incontinence. Pudendal nerve terminal motor latency (PNTML) and anal electrosensitivity (AS) were measured at rest and after a simulated defaecation strain of 1 minute. At rest PNTML correlated with AS (r = 0.461, P = 0.003). Twenty-five patients had perineal descent of more than 1 cm on straining, and 13 had descent below the ischial tuberosities. After 1 minute of straining AS was significantly (P < 0.001) blunted and PNTML was significantly (P < 0.001) prolonged both changes returning to normal after 3 minutes. AS was significantly (P = 0.01) more blunted in patients with perineal descent of more than 1 cm. PNTML was significantly (P = 0.01) more prolonged in patients with perineal descent of more than 2 cm. Age was significantly correlated with AS (r = 0.45, P = 0.004) and PNTML (r = 0.49, P = 0.002). Anal sensation and PNTML are acutely affected by defaecation straining, and changes may occur in patients without perineal descent. Functional changes occur equally in constipated and incontinent patients.     

Differential responses to chemoimmunotherapy in patients with metastatic malignant melanoma

An open, multicentre non-randomised study was performed to evaluate the activity and toxicity of combination chemoimmunotherapy, consisting of cisplatin, interleukin-2 and interferon-alpha, in metastatic malignant melanoma. Between March 1992 and September 1993, 28 patients with pathologically proven metastatic malignant melanoma, bidimensionally measurable disease and an Eastern Co-operative Oncology Group score < or = 1 were treated with the combination chemoimmunotherapy. The regimen consisted of cisplatin (100 mg/m2 on day 0), interleukin-2 (Proleukin, Chiron, Middlesex, U.K.) 18 x 10(6)IU/m2/d continuous intravenous infusion on days 3-7 and 17-22, with interferon-alpha (Roferon-A, Roche, Hertfordshire, U.K.) 9 x 10(6) U/d subcutaneously on days 3, 5, 7, 17, 19, 21 during the interleukin-2 infusions. The treatment cycle lasted 28 days. Among 27 assessable patients, 5 patients achieved partial responses, for an overall response rate of 18% (95% CI 6-37%). Median progression-free survival was 44 days (range 8-279) and median overall survival was 264 days (range 41-1432). Differential responses were noted in 41% of patients and responses were more frequent in non-visceral disease (skin, lymph node and soft tissue disease) (P = 0.04). These results indicate that differential responses to chemoimmunotherapy are common in patients with metastatic melanoma. This may account for the broad range of response rates reported in the literature.     

Immunity to jellyfish venoms: suppression of venom-induced immune responses in ultraviolet B-irradiated mice

Lymph node and spleen cells from mice immunized with sea nettle (Chrysaora quinquecirrha) venom exhibited a proliferative response after exposure to the homologous antigen or that of a related jellyfish, Physalia (Portuguese man-o'-war). Native venom was a more effective stimulant than heated, non-lethal venom. Ultraviolet light treatments administered to the skin either before or after venom sensitization suppressed the proliferative response of these internal immune cells.     

Nitric oxide and peroxynitrite released by ultraviolet B-irradiated human endothelial cells are possibly involved in skin erythema and inflammation

In this study we attempted to demonstrate whether endothelial cell nitric oxide synthase (eNOS) and xanthine oxidase (XO) could be activated to release nitric oxide (NO) and peroxynitrite (ONOO-) following exposure to ultraviolet B (UVB) radiation and to define whether this light-induced response could be involved in the pathogenesis of sunburn erythema and inflammation. Treatment of human endothelial cells with UVB (290-320 nm) radiation (up to 100 mJ/cm2) resulted in an increase of both NO and ONOO- release that was inhibited by NG-monomethyl-L-arginine (L-NMMA). Treatment of cell cytosol with various doses of UVB radiation (up to 20 mJ/cm2) resulted in a threefold increase of XO activity that was inhibited (approximately 90% by oxypurinol. In reconstitution experiments, when purified eNOS was added to purified XO, an almost fourfold increase in ONOO- production at 20 mj/cm2 UVB radiation was observed. UVB radiation (100 mg/cm2) decreased cell membrane fluidity, indicating changes in the physicochemical characteristics of the membranes. In in vivo experiments, when human volunteers were subjected to UVB light, a protection factor (PF) of 3.90 +/- 0.85 was calculated when an emulsified cream formulation containing nitro-L-arginine (L-NA; 2%) and L-NMMA (2%) was applied to their skin. The present studies indicate that UVB radiation acts as a potent stimulator of eNOS and XO in human endothelial cells. The cytotoxic effects of NO and ONOO- may be the main factors in the integrated response of the skin leading to vasodilatation, the first key event of erythema production and the inflammation process.     

Immunizing patients with metastatic melanoma using recombinant adenoviruses encoding MART-1 or gp100 melanoma antigens

BACKGROUND: The characterization of the genes encoding melanoma-associated antigens MART-1 or gp100, recognized by T cells, has opened new possibilities for the development of immunization strategies for patients with metastatic melanoma. With the use of recombinant adenoviruses expressing either MART-1 or gp100 to immunize patients with metastatic melanoma, we evaluated the safety, immunologic, and potential therapeutic aspects of these immunizations. METHODS: In phase I studies, 54 patients received escalating doses (between 10(7) and 10(11) plaque-forming units) of recombinant adenovirus encoding either MART-1 or gp100 melanoma antigen administered either alone or followed by the administration of interleukin 2 (IL-2). The immunologic impact of these immunizations on the development of cellular and antibody reactivity was assayed. RESULTS: Recombinant adenoviruses expressing MART-1 or gp100 were safely administered. One of 16 patients with metastatic melanoma receiving the recombinant adenovirus MART-1 alone experienced a complete response. Other patients achieved objective responses, but they had received IL-2 along with an adenovirus, and their responses could be attributed to the cytokine. Immunologic assays showed no consistent immunization to the MART-1 or gp100 transgenes expressed by the recombinant adenoviruses. High levels of neutralizing antibody were found in the pretreatment sera of the patients. CONCLUSIONS: High doses of recombinant adenoviruses could be safely administered to cancer patients. High levels of neutralizing antibody present in patients' sera prior to treatment may have impaired the ability of these viruses to immunize patients against melanoma antigens.     

Prognostic factors in metastatic melanoma

BACKGROUND: Each year, 6000 people die in the United States from metastatic melanoma. Further study of factors affecting the prognosis of patients with this disease is needed. METHODS: The authors analyzed response and survival data from 635 patients who had entered three Eastern Cooperative Oncology Group trials for metastatic melanoma. RESULTS: Factors associated with poorer survival after study entry included poor performance status and the presence of symptoms, such as reduced appetite, fever, or nausea/vomiting. Male patients had poor survival, as did patients entering the study less than 1 year after a documented recurrence to study entry. As expected, characteristics of the initial primary disease (treatment and symptoms) had little association with survival after entering the advanced disease protocol. Two summary measures of the extent of metastatic involvement had a strong influence on survival. These were the number of nonbone metastases and the clinician's assessment as to the most significant metastatic site. Patients with the liver as their clinically most significant metastatic site had a poorer prognosis than those otherwise classified, including those with central nervous system metastases. The prognosis also worsened with an increasing number of sites of nonbone metastases, including skin and soft tissue. Tumor response occurred in only 11% of the patients. Patients with poor performance status and those with lung involvement had a significantly lower response rate than did others. Although the frequency of response was low, patients with objective responses survived significantly longer than did the nonresponders (based on an analysis appropriately adjusted for the time of response using a time-dependent proportional-hazards model). CONCLUSIONS: These results provide useful guidelines for the design and analysis of clinical trials in metastatic melanoma.     

Critical analysis of treatment of stage II and stage III melanoma patients with immunotherapy

Over the past 8 years, 244 patients with Stage II or III melanoma have been treated by cutaneous injection of a crude acellular homogenate of allogeneic melanoma cells (V-I) or a more concentrated fraction (V-II), followed in most patients by exchanges of WBC between paired partners. Patients with Stage III disease exhibited an overall response rate of 24% and prolongation of survival compared with control data. Stage II patients also had prolonged survival and reduced rate of recurrence over historic peers' data. Breakdown of subgroup data revealed that V-II plus exchange of WBC is similar to V-I plus exchange or V-II alone. However, recent experience of LTF suggests a higher response rate than in either V-I or V-II groups, particularly when autochthonous tumor is used for cross-immunization. The most meaningful immunologic data resulted from analysis of DNCB and MIF data. Patients negative to DNCB rarely respond to immunotherapy. A positive pretreatment MIF or positive conversion following treatment correlates with response, whereas, conversion of positive to negative predicts poor clinical performance.     

Systemic treatment of metastatic melanoma with chemotherapy

This article reviews the use of systemic chemotherapy for the treatment of metastatic melanoma, including single-agent chemotherapy, combination chemotherapy with and without tamoxifen, and biochemotherapy.     

Metastatic cutaneous melanoma promoted by ultraviolet radiation in mice with transgene-initiated low melanoma susceptibility

An inbred-strain (C57BL/6) transgenic (Tyr-SV40E) mouse model of ultraviolet radiation (UVR)-induced metastatic cutaneous melanoma was produced without the use of chemical carcinogens and without resulting in other skin malignancies. Expression of this transgene occurs specifically in melanocytic-lineage cells. In untreated hemizygous mice of transgenic line 12 there are no skin melanomas, and the oncogenic sequence, which is expressed at a very low level, functions solely as a weak initiating stimulus. UVR [including 65% ultraviolet B (280-320 nm wavelength)] supplied the necessary promoting stimulus leading to melanomas. Of various trial protocols, eight were successful and involved exposure of 112 mice for a limited time on each of 3-10 days starting at 2-3 days of age and totalling 1.1-3.7 J/cm2 UVR. Fourteen of these animals developed a total of 15 invasive skin melanomas on the head and body, arising between 37-115 weeks of age and, therefore, often after a relatively long latency. The tumors were melanotic and in five of the mice they yielded macrometastases in regional and distant sites. The single most favorable protocol (1.9 J/cm2 total UVR, at 0.38 J/cm2/day for 5 days starting at 3 days of age) led to the highest incidence of melanoma (5 of 19 mice) and one of the lowest mortality rates (2 of 19). No melanomas occurred in UVR-treated nontransgenic C57BL/6 controls. Benign skin keratoacanthomas arose and often regressed in treated transgenic as well as nontransgenic mice. This new transgenic mouse model introduces many novel possibilities for experimental analysis of the melanoma-promoting mechanisms of UVR and also of the ability of specific genetic changes to impede or facilitate the UVR effect.     

Immunological reactions of skin melanoma patients to nonspecific and adaptive immunotherapy

Patients with malignant skin melanoma were given different kinds of immunotherapy; nonspecific immunotherapy with BCG vaccine, adaptive immunotherapy with methotrexate or phytohemagglutinin activated autolymphocytes, and also a combination of polychemotherapy with BCG. The state of cell immunity was determined prior to, during and at the end of the therapy, in accordance with the courses. As a result of the conducted therapy an increased level of cell immunity was observed, that usually corresponded to clinical development of the disease. At the same time, the increase in immune response indices due to continuous administration of BCG vaccine is not related with the clinical course, while the persistent anergy or reduced level of cell immunity during this kind of therapy is a poor prognostic sign.     

Risk and outcome in metastatic malignant melanoma patients receiving DTIC, cisplatin, BCNU and tamoxifen followed by immunotherapy with interleukin 2 and interferon alpha2a

Combined chemo-/immunotherapy has shown high objective response rates and a significant though small proportion of long-term complete responders in metastatic malignant melanoma. The purpose of this study was to determine response rates, freedom from treatment failure (FFTF) and overall survival in patients with advanced metastatic malignant melanoma treated with combined chemo-/immunotherapy, and to determine the value of a prognostic model for prediction of treatment outcome, FFTF and survival. Sixty-nine patients with metastatic malignant melanoma received combined chemo-/immunotherapy consisting of up to four cycles of DTIC (220 mg m(-2) i.v. days 1-3), cisplatin (35 mg m(-2) i.v. days 1-3), BCNU (150 mg m(-2) i.v. day 1, cycles 1 and 3 only) and tamoxifen (20 mg orally, daily). Two cycles of chemotherapy were followed by 6 weeks of outpatient immunotherapy with combined interleukin 2 (20 x 10(6) IU m(-2) days 3-5, weeks 1 and 4; 5 x 10(6) IU m(-2) days 1, 3, 5, weeks 2, 3, 5, 6) and interferon-alpha (6 x 10(6) IU m(-2) s.c. day 1, weeks 1 and 4; days 1, 3, 5, weeks 2, 3, 5, 6). All patients were evaluated on an intention-to-treat basis. Of 69 patients entered in the study, seven achieved complete remissions and 20 reached partial remissions with an objective response rate of 39% (95% confidence interval 28-52%). Median survival was 11 months, median FFTF was 5 months. Seven patients achieved ongoing long-term remissions, with maximum survival of 58 + months, and maximum FFTF of 58 + months. By Kaplan-Meier survival analysis and two-proportional Cox regression analysis, pretreatment performance status and serum lactic dehydrogenase were statistically significant and independent predictors of survival; risk groups could be defined as (a) the absence of both or (b) the presence of either one or both of these risk factors. Whereas survival and response were significantly influenced by patient risk, no influence could be demonstrated for FFTF. This combined outpatient chemo-/immunotherapy is feasible and results in objective response rates and survival similar to earlier trials. Pretreatment risk, as defined by serum lactate dehydrogenase (LDH) and performance status, has a significant impact on treatment outcome and patient survival.     

多西他赛联合塞替派与多西他赛联合卡培他滨治疗转移性乳腺癌的随机、对照临床研究

目的:比较多西他赛联合塞替派方案和多西他赛联合卡培他滨方案治疗转移性乳腺癌的临床疗效及其安全性.方法:选择北京大学临床肿瘤学院乳腺肿瘤内科2006年8月至2008年9月收治的女性乳腺癌患者共46例,采用多西他赛联合塞替派(A组)或卡培他滨(B组)方案进行随机、对照临床治疗试验,A组第1,8天多西他赛35 mg/衬静脉滴注,第1天塞替派60-65 m岁扩静脉滴注,B组第1,8天多西他赛35 mg/耐静脉滴注,第1~14天卡培他滨1000 mg/m2,口服,每日2次.21 d为1个周期,至少应用2个周期.结果:多西他赛联合塞替派组22例,多西他赛联合卡培他滨组24例,两组患者基线情况一致.可评价疗效多西他赛联合塞替派组21例,多西他赛联合卡培他滨组22例.两组疗效分别为部分缓解9.52%..27.27% (2/21例,6/22例),稳定52.38% vs31.82% (11/21例,7/22例),进展38.10%..40.91% (8/21例,9/22例),疾病控制率分别为61.90% vs.59.09%(13/21例,13/22例),中位无进展生存期分别为7.9个月(95% CI 0.77~15.03)vs.8.3个月(95% C14.01~12.59),1年生存率分别为88.2%..81%,P值均＞0.05,每两组间差异无统计学意义.无化疗相关死亡病例.多西他赛联合塞替派组和多西他赛联合卡培他滨组最常见的不良反应为骨髓抑制,主要不良反应Ⅲ~Ⅳ度发生率分别为白细胞减少45.45% vs..26.09%,中性粒细胞减少45.45%..21.74%,血小板减少9.09% vs.0%,手足综合征0% vs.13.04%.P值均＞0.05,每两组间差异无统计学意义.结论:多西他赛联合塞替派方案治疗转移性乳腺癌有一定近期疗效,不良反应可耐受,可以作为经济、有效的解救方案.     

Intratumoral oxygen tension in metastatic melanoma

Tumour hypoxia can lead to a decrease in the biological effectiveness of radiation and alkylating agents. Few data are available on oxygen tension (PO2) in melanoma. In 20 patients with past history of melanoma, PO2 was evaluated in normal tissues and suspected metastatic lesions (nodes and skin metastases). Oxygen tension was measured using a needle probe technique (KIMOC-6650 histograph, Eppendorf, Germany), the day before the surgical removal of the suspected metastatic lesion. Histological confirmation of the malignant origin of the removed lesion was obtained in 18 cases. In two cases invasion by the known melanoma was not seen histologically. The median PO2 for normal tissues was 40.5 mmHg. For tumours, the median PO2 was 11.6 mmHg, and it was 17.1 mmHg in nodes and 6.7 mmHg in skin metastases. Very low values (< 2 mmHg) accounted for 20% of the recorded values in nodes and 15% in skin metastases. When analysed according to the node size (< or > or = 3 cm in diameter), the median PO2 was 10.4 mmHg in large nodes (six patients) and 53.3 mmHg in small nodes (six patients). For the two non-tumoral lesions, the median PO2 values were 20.9 and 25.1 mmHg, with no values below 10 mmHg. Thus a decrease in PO2 values, probably corresponding to tumour hypoxia, was found in most of the metastatic tumours when compared with normal tissues. The prognostic value of these PO2 measurements in melanoma remains to be demonstrated in the tumour response to radiotherapy or alkylating agents. However, tumour hypoxia can already be investigated as a target for new treatment modalities in metastatic melanoma.     

Acute cholecystitis from metastatic melanoma to the gall-bladder in a patient with a low-risk melanoma

OBJECTIVES: An investigation was conducted to determine whether ongoing transmission of Mycobacterium tuberculosis was occurring in a California state prison. METHOD: Prison pharmacy records were used to identify cases of active tuberculosis (TB). RESULTS: Ten of the 18 cases of active TB treated at the facility during 1991 were diagnosed at the prison that same year (an incidence of 184 per 100,000). Three inmates were infectious for a total of 7 months while imprisoned. The prevalence of TB skin test-positivity among inmates was 30%, and the incidence of new infection attributable to incarceration was 5.9 per 100 inmates per year. CONCLUSIONS: Transmission of M. tuberculosis may be occurring in the California prison system.     

The treatment of metastatic melanoma with chemotherapy and biologics

The majority of adults over the age of 65 y develop osteoarthritis (OA), a joint disease characterized by degeneration of articular cartilage and subchondral sclerosis. Early in the disease, the articular cartilage surface begins to change histologically from a smooth to a rough or fibrillated appearance. A prerequisite for any chondroprotective pharmacological intervention is detection of OA in its preclinical phase. Current diagnostic imaging modalities, such as radiographs or (nuclear) magnetic resonance imaging, either cannot directly image the cartilage surface or lack sufficient resolution to detect surface fibrillations. We have developed an ultrasonic technique that can be used to characterize these surface fibrillations directly. We present our in vitro results with validation by laser-based confocal microscopic imaging.