Activating anti-idiotypic human anti-mouse antibodies for immunotherapy of ovarian carcinoma

Front-line chemoimmunotherapy for treating epithelial ovarian cancer: Part II promising results of phase 2 study of paclitaxel-carboplatin-oregovomab regimen

In the Part I, we have discussed the background of CA125 and the development of anti-CA125 monoclonal antibody (MAb) to highlight the potential role of CA125 and anti-CA125 MAb in the management of women with advanced stage epithelial ovarian cancer (EOC). Glycosylation change either by N-link or by O-link of CA125 is supposed to play a role in the modification of immunity. Anti-CA125 MAb, which can be classified as OC 125-like Abs, M11-like Abs, and OV197-like Abs, is often used for diagnosing, screening, monitoring and detecting the mesothelin-related diseases of the abdominal cavity, particular for those women with EOC. Additionally, anti-CA125 MAb also plays a therapeutic role, named as OvaRex MAb-B43.13 (oregovomab), which has also been extensively reviewed in the Part I review article. The main mechanisms include (a) forming CA125 immune complexes to activate the antigen-presenting cells; (b) triggering induction of CA125-specific immune responses, including anti-CA125 Abs against various epitopes and CA125-specific B and T cell responses; and (c) triggering CD4 and CD8 T-cell responses specific for B43.13 to produce specific and non-specific immune response. With success in vitro, in vivo and in primitive studies, phase II study was conducted to test the effectiveness of chemoimmunotherapy (CIT) for the management of EOC patients. In the 97 EOC patients after optimal debulking surgery (residual tumor <1 cm or no gross residual tumor), patients treated with CIT had a dramatical and statistically significant improvement of both progression-free survival (PFS) and overall survival (OS) compared to those treated with chemotherapy alone with a median PFS of 41.8 months versus 12.2 months (hazard ratio [HR] 0.46, 95 % confidence interval [CI] 0.28-0.7) and OS not yet been reached (NE) versus 42.3 months (HR 0.35, 95 % CI 0.16-0.74), respectively. The current review as Part II will explore the possibility of using CIT as front-line therapy in the management of advanced-stage EOC patients after maximal cytoreductive surgery based on the evidence by many phase 2 studies.

Front-line chemo-immunotherapy for treating epithelial ovarian cancer: Part I CA125 and anti-CA125

The current standard therapy of epithelial ovarian cancer (EOC) is the combination of surgery (primary cytoreductive surgery or interval cytoreductive surgery) and platinum-based chemotherapy (mainly using paclitaxel and carboplatin either by neoadjuvant chemotherapy and/or by postoperative adjuvant chemotherapy) with/without adding targeted therapy (mainly using anti-angiogenesis agent- bevacizumab). After front-line chemotherapy, the advanced-stage EOC can be successfully controlled and three-quarters of patients can achieve a complete clinical remission. Unfortunately, nearly all patients will recur and progression-free survival (PFS) of these patients is seldom more than 3 years with a dismal median PFS of 12-18 months. With each recurrence, patients finally develop resistance to standard chemotherapy regimen, contributing to fewer than half of women who survive for more than 5 years after diagnosis with a median overall survival (OS) of 40.7 months. Due to the lower PFS and OS, particularly for those advanced-stage patients, novel therapeutic options during the front-line therapy are desperately needed to decrease the occurrence of recurrence, and the majority of them are still under investigation. It is well-known that overexpression of CA125 has been associated with attenuated cellular apoptosis, platinum chemotherapy resistance, tumor proliferation and disease progression, suggesting that anti-CA125 may play a role in the management of patients with EOC. The current review is a Part I which will focus on development of anti-CA125 monoclonal antibody, hoping that alternation of the front-line therapy by chemo-immunotherapy will be beneficial for prolonged survival of patients with EOC.

Identification and prioritization of tumour-associated antigens for immunotherapeutic and diagnostic capacity in epithelial ovarian cancer: a systematic literature review

Epithelial ovarian cancer (EOC) is a prevalent carcinoma in the female population associated with poor prognostic outcomes, in part due to the late stage of the disease at diagnosis. Aiming to identify tumour-associated antigens (TAAs) with the potential to facilitate earlier detection and targeted therapy of EOC, five scientific literature repositories were systemically searched for primary literature sources reporting the expression of a TAA in the tissue or serum of adult females diagnosed with EOC and healthy women. We identified 7120 articles of which 32 met our inclusion criteria and passed the bias-quality assessment. Subsequently, data were collated on 29 TAAs whose expression had been analysed in 2181 patients and 589 healthy individuals. Reports of CA125 and EpCAM expression were numerous while tissue expression data were available for 28 TAAs. Data were segregated into three meta-cohorts for statistical scrutiny and their capacity for diagnostic and treatment targeting was assessed. We showed that CA-125 was expressed homogenously in EOC patients while EpCAM was expressed heterogeneously. CA-125 was the most promising TAA target for both diagnosis and treatment, gaining a priority score of 12 (/12) while EpCAM gained a priority score of seven. Tissue expression of EOC TAAs was homogenous; 90% of the EOC population express any identified TAA while just 20% of healthy individuals will be positive for the same TAA. We suggest TAA profiling should be a fundamental aspect of EOC diagnosis, sitting alongside the FIGO framework, promoting reduced mortality and directing the development of TAA-targeted therapeutics.

Investigating the presence of human anti-mouse antibodies (HAMA) in the blood of laboratory animal care workers

Background

In the present study, the researchers evaluated the presence of human anti-mouse antibodies (HAMA) in a normal population and laboratory animal care providers for the first time in the world. Also, the cause of HAMA incidence in the human body through a close contact with mice was identified.

Methods

The study population consisted of 40 laboratory animal care providers aged between 24 and 57 years with a close contact with mice (e.g. taking care of mice, feeding mice, etc.) and 40 individuals of the same age as the above group with no contact with mice. HAMA was measured in both the case and control groups using sandwich enzyme-linked immunosorbent assay (ELISA) method. Data were analyzed using SPSS 18. Univariate and multivariate linear regression and independent t-test were used. The significance of results was measured based on p < 0.05.

Results

The present study revealed that the animal care providers had (p = 000) a higher titer of HAMA (4.95 ng/mL) in their blood than the control group (1.67 ng/mL). Also, the individuals in the case group (exposed to mice) were more allergic (43.6%) than those in the control group (15%) (p = 0.003).

Conclusions

The results of this study revealed that exposure to mice in laboratory care centers can cause production of HAMA in the human body but its titer is possibly lower in Iranian working staff than those in the other parts of the world.

Immunoglobulin Ihhibiting Reagent®: Evaluation of a New Method for Eliminating Spurious Elevations in CA125 Caused by HAMA

Cancer therapy utilising radiolabelled murine monoclonal antibodies frequently leads to the production of Human Anti-Mouse Antibodies (HAMA) in the recipient. HAMA interferes with “sandwich” immunoassays, such as those for tumour markers, rendering results unreliable. Published methods for eliminating HAMA from serum are not suitable for use in a laboratory which is processing a large number of assays using an automated system. We report on the use of Immunoglobulin Inhibiting Reagent (IIR) in CA125 assays from recipients of intraperitoneal radioimmunotherapy who had spuriously elevated results due to HAMA. IIR was found to be comparable to the admixture of mouse serum as a way of eliminating the effect of HAMA. IIR is ideally suited to use with an automated assay process.

Calcitonin measurement and immunoassay interference: a case report and literature review

Calcitonin (CT) is currently the most sensitive serological marker of C-cell disease [medullary thyroid carcinoma (MTC) and C-cell hyperplasia]. Starting with a report on a case that occurred at our institution, this review focuses on trying to explain the reasons behind the poor specificity and sensitivity of the various CT immunoassays. A 15-year-old patient was referred to our institution in May 2014 for moderately elevated CT levels. Thyroid ultrasonography (US) documented a colloidal goiter. Secondary causes of the hypercalcitoninemia (hyperCT) were ruled out. The mismatch between the clinical picture and the laboratory results prompted us to search for other reasons for the patient's high CT levels, so we applied the heterophilic blocking tube (HBT) procedure to the patient's sera before the CT assay. Using this pretreatment step, his serum CT concentration dropped to <1 ng/L, as measured at the same laboratory. Measuring plasma CT has an important role in screening for C-cell disease, but moderately elevated serum CT levels need to be placed in their clinical context, bearing in mind all the secondary causes of C-cell hyperplasia and the possibility of laboratory interference, before exposing patients to the risks and costs of further tests.

MUC16 (CA125): tumor biomarker to cancer therapy, a work in progress

Over three decades have passed since the first report on the expression of CA125 by ovarian tumors. Since that time our understanding of ovarian cancer biology has changed significantly to the point that these tumors are now classified based on molecular phenotype and not purely on histological attributes. However, CA125 continues to be, with the recent exception of HE4, the only clinically reliable diagnostic marker for ovarian cancer. Many large-scale clinical trials have been conducted or are underway to determine potential use of serum CA125 levels as a screening modality or to distinguish between benign and malignant pelvic masses. CA125 is a peptide epitope of a 3-5 million Da mucin, MUC16. Here we provide an in-depth review of the literature to highlight the importance of CA125 as a prognostic and diagnostic marker for ovarian cancer. We focus on the increasing body of literature describing the biological role of MUC16 in the progression and metastasis of ovarian tumors. Finally, we consider previous and on-going efforts to develop therapeutic approaches to eradicate ovarian tumors by targeting MUC16. Even though CA125 is a crucial marker for ovarian cancer, the exact structural definition of this antigen continues to be elusive. The importance of MUC16/CA125 in the diagnosis, progression and therapy of ovarian cancer warrants the need for in-depth research on the biochemistry and biology of this mucin. A renewed focus on MUC16 is likely to culminate in novel and more efficient strategies for the detection and treatment of ovarian cancer.

CA125 in ovarian cancer

A quarter of a century since its discovery, circulating CA125 antigen is recommended for clinical use in the USA for ovarian cancer screening of high-risk women with ovaries, despite its limited sensitivity and specificity. Recent findings suggest that CA125 might also serve as a predictive marker for pre-invasive ovarian carcinoma. Methods to quantify circulating CA125 evolved toward sensitive and reliable double-determinant ELISA assays. The CA125 gene, MUC16, was cloned 20 years after the protein discovery and revealed a very complex and unusual glycoprotein structure, suggesting an immunological role. Recent evidence points toward CA125 function in the induction of materno-fetal tolerance through the alteration of natural killer phenotype. Two receptors for CA125 have been described: mesothelin and galectin-1. The specific location and functional proprieties of CA125 make it a therapeutic target of choice; clinical trials have demonstrated that anti-CA125 injections are well tolerated and suggest a potential survival benefit.

Recombinant IgA Antibodies

The production of monoclonal antibodies and the development of recombinant antibody technology have made antibodies one of the largest classes of drugs in development for prophylactic, therapeutic and diagnostic purposes. Currently, all of the Food and Drug Administration (FDA)- approved antibodies are immunoglobulin Gs (IgGs). However, more than 95%of the infections are initiated at the mucosal surfaces, where IgA is the primary immune effector antibody.

Design of a bifunctional fusion protein for ovarian cancer drug delivery: single-chain anti-CA125 core-streptavidin fusion protein

We have developed a universal ovarian cancer cell targeting vehicle that can deliver biotinylated therapeutic drugs. A single-chain antibody variable domain (scFv) that recognizes the CA125 antigen of ovarian cancer cells was fused with a core-streptavidin domain (core-streptavidin-VL-VH and VL-VH-core-streptavidin orientations) using recombinant DNA technology and then expressed in Escherichia coli using the T7 expression system. The bifunctional fusion protein (bfFp) was expressed in a shaker flask culture, extracted from the periplasmic soluble protein, and affinity purified using an IMAC column. The two distinct activities (biotin binding and anti-CA125) of the bfFp were demonstrated using ELISA, Western blot and confocal laser-scanning microscopy (CLSM). The ELISA method utilized human NIH OVCAR-3 cells along with biotinylated bovine serum albumin (B-BSA) or biotinylated liposomes, whereas, the Western blot involved probing with B-BSA. The CLSM study has shown specificity in binding to the OVCAR-3 cell-line. ELISA and Western blot studies have confirmed the bifunctional activity and specificity. In the presence of bfFp, there was enhanced binding of biotinylated antigen and liposome to OVCAR-3 cells. In contrast, the control EMT6 cells, which do not express the CA125 antigen, showed minimal binding of the bfFp. Consequently, bfFp based targeting of biotinylated therapeutic drugs, proteins, liposomes, or nanoparticles could be an alternative, convenient method to deliver effective therapy to ovarian cancer patients. Peritoneal infusion of the bfFp-therapeutic complex could also be effective in locally targeting the most common site of metastatic spread.

Survival benefit associated with human anti-mouse antibody (HAMA) in patients with B-cell malignancies

BACKGROUND

About one-third of patients with relapsed B-cell malignancies develop human anti-mouse antibody (HAMA) following mouse antibody treatment. The purpose of this study was to assess the relationship between HAMA and survival in patients given a mouse anti-lymphoma monoclonal antibody (mAb), Lym-1, directed against a unique epitope of HLA-DR antigen that is up-regulated on malignant B-cells.

METHODS

ELISA was used to quantify HAMA in 51 patients with B-cell malignancies treated with iodine-131 (131I) labeled Lym-1. Sera were collected prior to and following radioimmunotherapy (RIT) with 131I-Lym-1 until documented to be HAMA negative or throughout lifetime. Univariate, then multivariate analyses including other risk factors, were used to analyze the relationship of HAMA to survival. The relationships of HAMA to prior chemotherapies and to absolute lymphocyte counts prior to RIT were also assessed.

RESULTS

Eighteen of 51 patients (35%) developed HAMA following RIT (range of ultimate maximum titers, 6.6-1,802 microg/ml). Using the time dependent Cox proportional hazards model, maximum HAMA titers were associated with survival (P=0.02). HAMA continued to be significant for survival in multivariate analyses that included known risk factors. In Landmark analysis of 39 patients that survived at least 16 weeks, median survival of patients with HAMA less than 5 microg/ml was 61 versus 103 weeks for patients with HAMA equal or greater than 5 microg/ml at 16 weeks (P=0.02). The median survival of the five patients with highest maximum HAMA titers was 244 weeks. At 16 weeks, there was an inverse correlation between the maximum HAMA titer and the number of previous chemotherapies (P<0.003). Absolute lymphocyte counts prior to 131I-Lym-1 treatment for patients that seroconverted were higher than those for patients that did not seroconvert (P=0.01).

CONCLUSIONS

Patients with B-cell malignancies that developed high HAMA titers had longer survival that was not explained by risk factors or histologic grade, suggesting the importance of the immune system.

Molecular characterization of the anti-idiotypic immune response of a relapse-free neuroblastoma patient following antibody therapy: a possible vaccine against tumors of neuroectodermal origin?

Neuroblastoma treatment with chimeric antidisialoganglioside GD2 Ab ch14.18 showed objective antitumor responses. Production of anti-idiotypic Abs (Ab2) against ch14.18 (Ab1) in some cases was positively correlated with a more favorable prognosis. According to Jerne's network theory, a subset of anti-idiotypic Abs (Ab2beta) carries an "internal image" of the Ag and induces Abs (Ab3) against the original Ag. The molecular origin of an anti-idiotypic Ab response in tumor patients was not investigated previously. To clone anti-idiotypic Abs, B cells of a ch14.18-treated neuroblastoma patient with Ab2 serum reactivity were used to construct Ab phage display libraries. After repeated biopannings on ch14.18 and its murine relative, anti-GD2 mAb 14G2a, we selected 40 highly specific clones. Sequence analysis revealed at least 10 of 40 clones with different Ig genes. Identities to putative germline genes ranged between 94.90 and 100% for V(H) and between 93.90 and 99.60% for V(L). An overall high rate of replacement mutations suggested a strong Ag-driven maturation of the anti-idiotypic Abs. Two clones that were analyzed further, GK2 and GK8, inhibited binding of ch14.18 to GD2 just as the patient's serum did. GK8 alone inhibited >80% of the patient's anti-idiotypic serum Abs in binding to ch14.18. Rabbits vaccinated with GK8 or GK2 (weaker) produced Ab3 against the original target Ag GD2. GK8 may be useful as a tumor vaccine for GD2-positive [corrected] tumors.

A pilot phase 2 study of oregovomab murine monoclonal antibody to CA125 as an immunotherapeutic agent for recurrent ovarian cancer

This prospective, open-label, pilot phase 2 study examined the clinical and immunologic effects of oregovomab (OvaRex) in heavily pretreated patients with recurrent ovarian cancer (OC). Thirteen women were administered intravenous oregovomab (2 mg) at weeks 0, 2, 4, 8, and 12, followed by quarterly doses for up to 2 years or disease progression. Concomitant chemotherapy was not permitted. Eligibility criteria included recurrence after one or more platinum-based chemotherapy regimens, CA125 >35 U/mL, evaluable or measurable disease. Tumor burden was evaluated by physical or radiologic methods pretreatment, weeks 12, 24, and every 24 weeks thereafter. Immune responses, including antibodies and T cells to oregovomab and CA125, were demonstrated in over half the patients. Stabilization of disease and survival >2 years was observed in 3 of 13 patients and coincided with robust immune responses. Shrinkage of marker lesions was not observed; however, four patients showed decreases in CA125 levels. Treatment was well tolerated without serious adverse events or discontinuations due to therapy. This pilot study supports immunologic activity and safety of oregovomab in recurrent OC. Further study of this agent in the consolidation and adjuvant setting is ongoing to establish its clinical utility.

Immunotherapy of ovarian cancer with antibodies: a focus on oregovomab

Recent advances in the molecular and cellular biology of malignancy and tumour immunology have stimulated significant progress in the application of immunotherapies as adjuvant treatments in cancer. Oregovomab (OvaRex, AltaRex) is a murine monoclonal antibody with high affinity to the ovarian cancer associated antigen CA125. Infusion of low-dose antibody results in formation of circulating immune complexes which can trigger a cellular immune response targeting CA125 and the ovarian cancer. Oregovomab has activity following initial chemotherapy and in recurrent disease settings and is in Phase III trials to establish its efficacy to prolong time to relapse in patients with advanced ovarian cancer and favourable outcomes to their front-line treatment. Additional studies of antigen processing and combination chemo-immunotherapy are ongoing. The treatment shows promise as a potential new addition to the standard care of ovarian cancer.

Interferences in hormone immunoassays

Despite the numerous potential interferences that were discussed in this article, immunoassays, in general, are robust measurement systems. There is no practical way to identify specimens a priori that are likely to have immunoassay interference. Therefore, laboratories must rely on communication from clinicians to identify suspicious test values that may be caused by assay interference. After laboratories are alerted, multiple investigations can be undertaken. The common causes of immunoassay interferences (see Box I) are dependent on the analytic format. Competitive assays are most likely to have problems with cross-reactivity, whereas immunometric assays most often have problems with heterophile antibodies. The simple steps to test for dilutional linearity, spiked recovery, heterophile antibody blocking,and testing with alternate technology can help in the evaluations of cases that are suspected to have assay interference.

A three-step strategy for targeting drug carriers to human ovarian carcinoma cells in vitro

To improve tumor-to-tissue ratios of anticancer agents in radioimmunotherapy, a three-step targeting approach was used to deliver biotinylated liposomes to human ovarian cancer cells (NIH:OVCAR-3, SK-OV-3) in vitro. Targeting was based upon the use of two antibodies specific for the CA-125 antigen that is highly expressed on NIH:OVCAR-3 cells but not expressed on SK-OV-3 cells. Briefly, the approach consists of prelabeling target cells with biotinylated anti-CA-125 antibody and FITC-labeled streptavidin (SAv) prior to administration of biotinylated liposomes containing a marker dye for visualization by confocal laser scanning microscopy (CLSM). In addition, the two anti-CA-125 antibodies (B27.1 and B43.13) were labeled with FITC and incubated with ovarian cancer cells at 37 degrees C from 30 min to 24 h to study binding and uptake kinetics. Shedding kinetics of bound antibody from tumor cells was performed using radiolabeled B27.1. Results demonstrated that both B27.1 and B43.13 specifically bound to the cell surface of OVCAR-3 cells but not to SK-OV-3 cells. Biotinylation, FITC-labeling and radiolabeling of the antibodies did not compromise immunoreactivity. Less than 6% of the bound B27.1 was shed from tumor cells by 4 h following incubation, and the antibody-antigen complex resided predominantly on the cell surface by 4 h at 37 degrees C with slow internalization by 12-24 h. Biotinylated, conventional liposomes were specifically and effectively delivered to OVCAR-3 cells prelabeled with biotinylated B27.1 and SAv. The slow internalization and shedding properties of these antibodies are useful for multistep pretargeting methods. Thus, a modified targeting strategy, utilizing a bispecific antibody and liposomes, may be feasible for radioimmunoliposomal therapy of ovarian cancer.

Functional mimicry of an anti-idiotypic antibody to nominal antigen on cellular response

One concept for immune therapy of cancer involves induction of antigen mimic antibodies to trigger the immune system into a response against the tumor cells. Anti-idiotypic antibodies (Ab2) directed against the antigen-combining site of other antibodies (Ab1) may functionally and even structurally mimic antigen and induce anti-anti-idiotypic immune response. We report here the generation of murine monoclonal antibody (mAb) WJ02 (Ab2) raised against the murine monoclonal immunoglobulin MJ01 (Ab1), which defines ovarian cancer antigen CA125. In enzyme immunoassays the binding of Ab2 to the variable region of Ab1 could be inhibited by CA125. In addition, the mimicry of mAb WJ02 to CA125 on cellular immune response was detected by human peripheral blood cells. The T cells primed by mAb WJ02 or CA125 proliferated in the presence of CA125 or mAb WJ02, respectively. Furthermore, T cells specific to mAb WJ02 could lyse ovarian cancer cells OVCAR-3 that express CA125. Finally, we proved that a patient immunized with mAb MJ01 could induce T cells that recognize mAb WJ02. In summary, we conclude that mAb WJ02 mimics CA125 on cellular response and such functional mimicry is one of the most important criteria to select Ab2 for cancer therapy.

Development and characterization of a bispecific single-chain antibody directed against T cells and ovarian carcinoma

Bispecific antibodies with specificity for tumor antigen and CD3 have been shown to redirect the cytotoxicity of T cells against relevant tumor. Our objective was to generate single-chain bispecific antibodies (bsSCA) that could retarget mouse cytotoxic T lymphocytes (CTL) to destroy human ovarian carcinoma in a xenogeneic setting. A bsSCA, 2C11 x B43.13, was constructed by genetic engineering and expressed in mammalian cells. Molecular characteristics, binding properties, and ability to retarget CTL were studied. Western blot analysis showed that the product is a 65-kDa protein. Purification of antibodies could be done by single-step affinity chromatography using protein L-agarose with an unoptimized yield of 200 microg/L. BsSCA 2C11 x B43.13 was capable of binding to mouse CD3 and human CA125 as detected by FACS analysis of EL4 and OVCAR Nu3H2 cells, respectively. It could also bridge activated splenic T cells and human ovarian carcinoma as demonstrated by a bridge FACS assay. Redirected mouse CTL could mediate human target cell lysis in a 20-h 51Cr release assay despite that they are xenogeneic. Prolonged incubation of redirected CTL and tumor targets resulted in a dramatic reduction in tumor cell number. CD28 co-stimulation enhanced redirected CTL function in both types of assays. BsSCA 2C11 x B43.13 thus can be used as a preclinical immunotherapeutic model for human ovarian cancer in a xenogeneic setting.

Human Anti-Animal Antibody Interferences in Immunological Assays

Purpose: The scope and significance of human anti-animal antibody interference in immunological assays is reviewed with an emphasis on human anti-animal immunoglobulins, particularly human anti-mouse antibodies (HAMAs).

Issues: Anti-animal antibodies (IgG, IgA, IgM, IgE class, anti-isotype, and anti-idiotype specificity) arise as a result of iatrogenic and noniatrogenic causes and include human anti-mouse, -rabbit, -goat, -sheep, -cow, -pig, -rat, and -horse antibodies and antibodies with mixed specificity. Circulating antibodies can reach gram per liter concentrations and may persist for years. Prevalence estimates for anti-animal antibodies in the general population vary widely and range from &lt;1% to 80%. Human anti-animal antibodies cause interferences in immunological assays. The most common human anti-animal antibody interferent is HAMA, which causes both positive and negative interferences in two-site mouse monoclonal antibody-based assays. Strategies to prevent the development of human anti-animal antibody responses include immunosuppressant therapy and the use of humanized, polyethylene glycolylated, or Fab fragments of antibody agents. Sample pretreatment or assay redesign can eliminate immunoassay interferences caused by anti-animal antibodies. Enzyme immunoassays, immunoradiometric assays, immunofluorescence, and HPLC assays have been designed to detect HAMA and other anti-animal antibodies, but intermethod comparability is complicated by differences in assay specificity and lack of standardization.

Conclusions: Human anti-animal antibodies often go unnoticed, to the detriment of patient care. A heightened awareness on the part of laboratory staff and clinicians of the problems caused by this type of interference in routine immunoassay tests is desirable. Efforts should be directed at improving methods for identifying and eliminating this type of analytical interference.

Immunotherapy of human ovarian carcinoma with OvaRex MAb-B43.13 in a human-PBL-SCID/BG mouse model

The monoclonal antibody (MAb) B43.13, binding to the ovarian cancer-associated antigen CA125, has been injected into more than 200 patients with ovarian cancer to detect recurrence of the disease. The follow-up of the patients revealed surprisingly long survival spans for several patients despite high CA125 levels. To investigate the therapeutic effectiveness of OvaRex MAb-B43.13 (AltaRex, Edmonton, Canada) under well-controlled conditions, the antibody was tested in a human-PBL-SCID/BG mouse model with CA125 positive human ovarian cancer cells. Mice were reconstituted with human peripheral blood lymphocytes (PBL, normal donors) by intraperitoneal (IP) injection of 2 to 3 x 10(7) PBL/mouse. OvaRex MAb-B43.13 was administered at 100 microg/mouse in phosphate buffered saline (PBS), in three different experimental set-ups. An isotype-matched control antibody (MOPC21 or MAb-170) and PBS injection served as controls. The ovarian cancer cell line NIH:OVCAR-NU-3 was injected IP at 1 x 10(6) cells/mouse or subcutaneously (SC) at 4 x 10(6) cells/mouse. Human-PBL-SCID/BG mice were either immunized before injection of tumor cells, along with tumor cells or after small tumors were established (2 weeks after transplantation). Antibody injections were repeated twice in 2-week intervals. Functional and cellular characterization of serum and PBL from these mice demonstrated the successful engraftment of a human immune system in those mice. All three experiments showed that OvaRex MAb-B43.13 treatment could (a) delay or prevent development of tumors; (b) reduce the size of small established tumors (SC tumor injection) or suppress ascites formation; (c) delay tumor growth when injected prior to tumor implantation; and (d) prolong the survival of the mice (i.p. tumor injection).

Use of encapsulated single chain antibodies for induction of anti-idiotypic humoral and cellular immune responses

The use of biodegradable poly(lactic-co-glycolic acid) (PLGA) microspheres as a cancer vaccine delivery system for induction of anti-idiotypic responses has been investigated using a single chain antibody scFv-pDL10, which recognizes the human ovarian cancer antigen CA125. Immunization of mice with scFv-pDL10 encapsulated in PLGA microspheres resulted in enhanced humoral and cellular immune responses when compared to scFv-pDL10 alone. Induced anti-idiotypic antibodies (Ab2) which mimic the original antigen CA125 compete with CA125 for the epitope. A cellular response (T2 induction) was also observed. These results raise the possibility of anti-idiotypic antibody induction by a single chain antibody, encapsulated in biodegradeble microspheres, as a potential vaccine for ovarian carcinoma.

Antibody interference in thyroid assays: a potential for clinical misinformation

Measurements of thyrotropin and of total and free thyroxine and triiodothyronine are widely used diagnostic methods for thyroid function evaluation. However, some serum samples will demonstrate a nonspecific binding with assay reagents that can interfere with the measurement of these hormones. Several recent case reports have described the presence of such interferences resulting in reported abnormal concentrations of thyroid hormones inconsistent with the patient’s thyroid state. Circulating thyroid hormone autoantibodies, described in thyroid and nonthyroid disorders, are an important class of interference factor and can bind to hormone tracers used in various immunoassays. Two additional categories of interfering antibodies may particularly interfere within two-site immunoassays for thyrotropin. These include heterophile antibodies, especially human anti-mouse antibodies, and rheumatoid factors, which can cause interferences by immunoglobulin aggregation and (or) cross-linking of both capture and signal antibodies. Here we review the nature of these disturbances; their occurrence, prevalence, and detection; and the clinical consequences of the failure to recognize such interference.

Prospects of radioimmunotherapy in epithelial ovarian cancer: results with iodine-131-labeled murine and humanized MN-14 anti-carcinoembryonic antigen monoclonal antibodies

OBJECTIVES

Epithelial ovarian cancer (EOC) is known to produce carcinoembryonic antigen (CEA), and the plasma CEA level is frequently elevated in patients with advanced stage and bulk of tumor. This study reports the results of a phase I therapy trial with intravenously administered 131I-MN-14 anti-CEA monoclonal antibody (MAb) in patients with EOC.

METHODS

Fourteen patients with advanced refractory EOC were given escalating intravenous doses (two received 30 mCi/m2, six 40 mCi/m2, and six 50 mCi/m2) of 131I-MN-14 IgG. All patients received a diagnostic study with 8 mCi (0.6 mg) of 131I-MN-14 IgG 1 week prior to their therapy infusion. Tumor targeting was assessed by external scintigraphy, toxicity according to the Radiation Therapy Oncology Group criteria, and therapy responses by CT and serum CA-125.

RESULTS

The MAb scan was positive in all 14 treated patients. Myelosuppression was the only observed treatment-related toxicity. Dose-limiting toxicity, defined as grade 4 leukopenia or thrombocytopenia of any duration, or grade 3 leukopenia or thrombocytopenia of > 2 weeks, was not seen at the 30 or 40 mCi/m2 dose levels. However, 2 of 6 patients treated at 50 mCi/m2 had a grade 4 thrombocytopenia or a grade 3 thrombocytopenia lasting 18 days. Of the 14 patients, 1 with diffuse peritoneal implants of < or = 2 cm had a complete clinical remission by CT and CA-125 for 8 months, following an initial partial remission for 10 months, both at the 40 mCi/m2 dose level. Another patient had a mixed response for 1 month.

CONCLUSION

MN-14 anti-CEA MAb is a suitable agent for tumor targeting and may have a therapeutic potential in patients with chemotherapy-refractive EOC, especially those with minimal disease.

Anti-murine antibody response to mouse monoclonal antibodies in cancer patients

Although development of human anti-murine immunoglobulin antibody (HAMA) is often seen in patients receiving murine antibodies, the variety of methods used for detecting HAMA makes it difficult to compare directly the HAMA responses measured by different assays. In the present study, several parameters of the HAMA response to two murine monoclonal antibodies were evaluated. The anti-sialosyl Tn antibody MLS102 and anti-CA125 antibody 145-9, which were labeled with 111In, were injected intravenously into 17 colorectal cancer patients and 11 ovarian cancer patients for immunoscintigraphy, respectively. HAMA was measured by enzyme-linked immunosorbent assay. There was no difference in baseline HAMA levels before antibody injection between the two groups. HAMA developed more frequently in ovarian cancer patients receiving the 145-9 antibody than in colorectal cancer patients receiving the MLS102 antibody (9/11 vs. 6/17, P < 0.05). No significant difference was observed in maximal HAMA levels between the two groups of patients. However, time to reach the maximal levels was delayed and the duration of the response seemed longer in ovarian cancer patients. Among 11 patients receiving the 145-9 antibody three patients became positive for HAMA more than 2 months after antibody injection and the other two had HAMA activity in their sera for more than 17 months. HAMA response was different between the two antibodies, and late onset or long duration of HAMA response against the 145-9 antibody suggests the importance of HAMA measurement in patients who receive a second injection of murine antibodies even after a long interval.

Radiolabeling of monoclonal antibody B43.13 with rhenium-188 for immunoradiotherapy

In this study we report a novel method for direct radiolabeling of monoclonal antibody B43.13 (MAb-B43.13) with 188Re and have evaluated the product's radiochemical, biochemical, immunochemical and selected biological properties. 188Re-MAb-B43.13 was readily prepared by the addition of generator produced perrhenate to a preformulated antibody vial after an optimal amount of supplemental stannous ion, in the form of stannous tartrate, was added. The final radiolabeled product retained its biochemical purity (as determined by size-exclusion HPLC and R/NR-SDS-PAGE), its immunoreactivity (as determined by immunoassay) and presented with a typical stability (in the presence of serum and cysteine) and biodistribution (in tumored mice) profile. The evaluation of the product for immunoradiotherapy of ovarian cancer in a clinical setting requires further studies.

OVAREX MAb-B43.13:IFN-gamma could improve the ovarian tumor cell sensitivity to CA125-specific allogenic cytotoxic T cells

Various immunological parameters were studied in 100 ovarian cancer patients injected with the OVAREX therapeutic vaccine (the functional component of which is anti-CA125 MAb-B43.13) to explain the serendipitous observation of prolonged survival after such treatment. In addition to CA125-specific humoral and cellular responses, interferon-gamma (IFN-gamma) was also found to be induced in those patients receiving the vaccine. In vitro studies indicated that the expression of MHC I, MHC II, and ICAM I in ovarian tumor cells were upregulated in response to IFN-gamma. Such tumor cells were also found to be more sensitive to CA125-specific cytotoxic T cells compared to cells that were not incubated with IFN-gamma.

1975-1995 revised anti-cancer serological response: biological significance and clinical implications

In the 1970s a considerable amount of work was carried out in an attempt to identify an anti-tumor serological response in cancer patients. These analyses have not been very informative due to the complexity and heterogeneity of the response. More recently, the availability of recombinant molecules, synthetic peptides and analytic and semi-quantitative assays has enabled a better dissection of humoral immunity. Antibodies against intracellular antigens (c-myb, c-myc, p53 and p21 ras) have been found in a significant, albeit varying, proportion of patients bearing various tumors. Association with a poor prognosis is documented for anti-p53 antibodies in breast carcinoma patients. A number of cell surface antigens, including mucins, oncoproteins and carbohydrate antigens have been found to elicit a humoral immune response and, in some instances, circulating immune complexes were observed. A protective role for or, on the other hand, masking effects of such antibodies is still controversial. An indication that a serological response can be beneficial comes from vaccination studies. A significant association between the development of an anti-tumor antigen antibody response and prolonged survival was observed following vaccination of melanoma patients with GM2 or anti-idiotypic antibodies which molecularly mimic tumor-associated antigens. It is to be hoped that in the near future the numerous ongoing immunization trials and prognostic studies demonstrate whether antibody response can exert a protective role in vivo.

Radioimmunotherapy of solid cancers: A review

Depending on radionuclide characteristics, radioimmunotherapy (RIT) relies on radioactivity to destroy cells distant from immunotargeted cells. Therefore, even heterogeneous tumors (for antigen recognition) can be treated, because not all cells have to be targeted. Substantial complete response rates have been reported in patients with non-Hodgkin's lymphoma. Much more modest results have been reported for patients with bulky solid tumors, e.g. adenocarcinomas. The radiation doses delivered by targeting antibodies are generally too low to achieve major therapeutic responses. Dose escalation is limited by myelotoxicity, and higher doses need to be delivered to neoplasms less radiosensitive than lymphomas. Various trials for both systemic and regional RIT have been reported on. Intraperitoneal administration has been applied for colorectal and ovarian carcinomas. Our own results indicate that, e.g., intraperitoneal pseudomyxoma can be treated with RIT. Myelotoxicity can be reduced by anti-antibody-enhancement, 2- and 3-step strategies, bispecific monoclonal antibodies (MAbs), and extracorporeal immunoadsorption. The radionuclide has to be selected properly for each purpose; it can be a beta-emitter, e.g. I-131, Y-90, Re-188, Re-186, Lu-177 or Sm-153, an alpha-emitter At-211 or Bi-212 or an Auger-emitter, e.g. I-125, I-123. One major problem with RIT, besides slow penetration rate into tumor tissue and low tumor-to-normal tissue ratio, is the HAMA response, which can be partly avoided by the use of humanized MAbs and immunosuppression. However, RIT will be, because of all the recent developments, an important form of cancer management.

Monoclonal antibodies used in the detection and treatment of epithelial ovarian cancer

Conventional therapy for epithelial ovarian cancer, including aggressive cytoreductive surgery followed by combination chemotherapy regimens, has failed to reduce the number of deaths caused by this disease, which remains the most lethal of gynecologic malignancies. Monoclonal antibodies, which offer the promise of high selectivity for detection and therapy, may be targeted to tumor-associated antigens, growth factors, receptors, or oncogenes. They may be used alone as immunotherapeutic agents or conjugated to chemotherapeutic drugs, toxins, or radionuclides. Radioimmunoconjugates may also be used for preoperative or intraoperative tumor localization. The authors focused on the clinical utility, technical limitations, and potential of monoclonal antibodies in the detection and treatment of epithelial ovarian cancer with emphasis on radioimmunodetection and radioimmunotherapy.

[Immunoscintigraphy in oncology]

In vivo immunotargeting of specific antigens with radiolabeled monoclonal antibodies is a new method of diagnosis which has largely improved over the past 15 years. It has been especially developed in the oncologic field. Although it is not yet a daily procedure, immunoscintigraphy has been proven a useful diagnostic tool in many situations. It gives information about the presence of lesions and their neoplastic nature. For this reason, immunoscintigraphy appears as very complementary to morphological imaging and is mainly indicated when lesions have insufficient anatomical definition. Early detection of recurrences is actually the best indication of immunoscintigraphy. However, some problems still exist, concerning the tumor/tissues uptake ratio which is not sufficient for an optimal imaging contrast, and the apparition of human anti-mouse antibodies (HAMA) in the patients. At present, many works are in progress which could resolve these problems. Ultimately, well-performed clinical trials are necessary to establish the right place for immunoscintigraphy in the diagnostic and therapeutic strategies in oncology.

Detection efficiency of colorectal carcinoma recurrence using technetium pertechnetate-anti-carcinoembryonic antigen monoclonal antibody BW 431/26

BACKGROUND

A new anti-carcinoembryonic antigen (CEA) antibody, BW 431/26 (Scintimun, Behring-Werke, Marburg, Germany), labeled with technetium pertechnetate (Tc-99m), is an intact immunoglobulin G1 monoclonal antibody that has been used to image colorectal cancer (CRC). This report is part of a prospective multicenter clinical trial initiated by the International Atomic Energy Agency to evaluate the role of this antibody in radioimmunoimaging of patients with suspected disease recurrence.

METHODS

A group of 31 consecutive patients underwent radioimmunoimaging with Tc-99m-BW 431/26 after resection of their primary CRC. Patient referral was based on either a persistent rise in serum CEA levels of unknown origin and/or questionable findings by other imaging studies. Whole-body planar scans and single photon emission computed tomography scans of selected body regions (e.g., chest, abdomen) were performed up to 24 hours after the intravenous antibody injection. Pathologic antibody concentration localizations by radioimmunoimaging were correlated with surgical, clinical, and other imaging modality findings to validate the accuracy of radioimmunoimaging in detecting CRC recurrence.

RESULTS

A total of 75 detected tumoral lesions was evaluated: 26 of 75 were of known origin (36%), and 49 of 75 were of unknown origin (65%). There were four true-negative lesions, one false-negative lesion, and no false-positive lesions; all others were true-positive lesions. Sensitivity was 96.8%, specificity 100%, and accuracy 98.6%. The study was easy to perform, without untoward side effects on patients after antibody administration.

CONCLUSIONS

Anti-CEA antibody radioimmunoimaging is a highly reliable diagnostic procedure in detecting CRC recurrence and is useful especially for the diagnosis of patients with rising CEA blood levels of unknown origin, thereby significantly affecting patient management. Radioimmunoimaging should become part of the diagnostic workup of patients suspected of having CRC recurrence.

Radiolabelled monoclonal antibodies in tumour imaging and therapy: out of fashion?

The initial enthusiasm for the development of diagnostic and therapeutic studies involving the use of monoclonal antibodies was replaced by scepticism as hopes remained unfulfilled. Against this background one needs to ask whether immunoscintigraphy (IS) serves clinical needs effectively and whether radioimmunotherapy (RIT) has a future. The current review considers these questions by reference to relevant studies. Taking colorectal cancer as an example, an appraisal is offered of the ability of IS to detect disease at an early stage and thereby to reduce mortality, and of the influence of the results of IS on patient management. It is concluded that in a limited number of cases of colorectal cancer and other solid tumors, IS will allow surgery to be performed at a stage where cure is still possible because of its ability to detect early recurrence. Turning to RIT, the results of studies in respect of various tumour types are reviewed, with due attention to reported toxicity. As regards colorectal cancer, no consistent therapeutic effects have been achieved, and myelotoxicity is typically the dose-limiting factor. Thus many questions remain to be answered, regarding antigens to be targeted, fractionation schedule, the use of "humanised" antibodies, choice of radionuclide and the use of intact immunoglobulins or fragments. These questions are considered. Overall it is concluded that the most promising application of RIT is as adjuvant therapy in patients with minimal residual disease, and a controlled multicentre trial is recommended. The development of more potent radio-immunoconjugates for therapeutic and ultimately diagnostic purposes will contribute to the improvement and development of IS by increasing its potential to influence prognosis.

Antiidiotype induction therapy: evidence for the induction of immune response through the idiotype network in patients with ovarian cancer after administration of anti-CA125 murine monoclonal antibody B43.13

The immune status of ovarian cancer patients receiving anti-CA125 murine monoclonal antibody B43.13 was evaluated by measuring antiidiotypic antibodies (Ab2), antiantiidiotypic antibodies (Ab3), antiisotypic human antimouse antibodies (HAMA), interferon-gamma, and CA125 levels in the serum. A specific assay was developed for the determination of Ab2 antibodies using chimeric MAb B43.13. Of the 50 patients studied, 26 had elevated levels of Ab2. Eleven of these 26 patients also had high titer of antiantiidiotypic (Ab3) antibodies. Eight of the 22 patients analyzed had increased interferon-gamma levels. A tentative correlation was found between survival of these patients' antiidiotype induction.

Antiidiotypic antibodies in ovarian cancer patients treated with the monoclonal antibody B72.3

Immunotherapy with monoclonal antibodies has become a hopeful approach to the adjuvant therapy of cancer patients. Recently, formation of antiidiotypic antibodies (Ab2) has been demonstrated in ovarian cancer patients after immunization with F(ab')2 fragments of the monoclonal antibody OC 125 (MAb OC 125). Preliminary results suggested that patients with high Ab2 serum concentrations had better survival rates compared to those where low or no Ab2 serum levels were detected. Beginning in 1992, 23 patients with advanced ovarian adenocarcinomas have been treated with repeated intravenous applications of the MAb B72.3, which is directed against the ovarian carcinoma associated antigen TAG-72. Five of them had been pretreated with several F(ab')2 MAb OC 125 infusions. Blood sample analysis revealed a remarkable antiidiotypic antibody (Ab2) response in 14 patients, with five patients developing high serum levels > 1000 U/ml. Ab2 serum concentrations increased with increasing number of Mab B72.3 applications. In terms of serum levels, corresponding antiidiotypic antibody responses in patients who received both the F(ab')2 MAb OC 125 and the MAb B72.3 differed considerably. We conclude that the use of MAb B72.3 may be an additional beneficial approach to the immunological therapy of ovarian cancer. Subsequent MAb B72.3 application after failure of the F(ab')2 MAb OC 125 may induce appreciable Ab2 serum concentrations and vice versa.

Cancer therapy with radiolabeled antibodies. An overview

Considerable progress has been achieved during the last two decades in the use of radiolabeled tumor-selective monoclonal antibodies in the diagnosis and therapy of cancer. The concept of localizing the cytotoxic radionuclide to the cancer cell is an important supplement to conventional forms of radiotherapy. In theory the intimate contract between a radioactive antibody conjugate and a target cell enables the absorbed radiation dose to be concentrated at the site of abnormality with minimal injury to the normal surrounding cells and tissues. A variety of approaches and combinations of this strategy are now being pursued. This synopsis attempts to summarize the theoretical and biological basis for radio-immuno-therapy (RIT), and to review present efforts to further develop this treatment. Some of the critical issues in RIT are highlighted, and novel ways of improving the therapeutic indices of these radiopharmaceuticals are outlined. The attention is focused on the results obtained in clinical trials employing RIT. Encouraging complete response rates have recently been reported in patients with non-Hodgkin's lymphoma resistant to combination chemotherapy. More modest results have been obtained in patients with solid cancers. The promises and hurdles in creating tumor-selective radiolabeled antibodies for cancer therapy are discussed, and prospects for further improvements are presented.

Dimeric recombinant IgA directed against carcino-embryonic antigen, a novel tool for carcinoma localization

Carcinoembryonic antigen (CEA) has been shown to be one of the best markers for in vivo tumor targeting of radiolabeled antibodies, despite the fact that it is localized predominantly at the apical side of human colon carcinoma cells within the fairly closed pseudolumen structures formed by these tumors. Due to this particular histological localization, a large proportion of the CEA molecules may remain inaccessible to the intravenously injected radiolabeled anti-CEA antibodies of IgG isotype, which are widely used in the clinic. In order to improve targeting, we made a recombinant dimeric IgA, which should have the capacity to translocate from the basolateral to the apical side of the pseudolumen formed by colon carcinoma cells after binding to the polyIg receptor (pIgR). A genomic chimeric mouse-human IgA2 construct was made using one of our most specific anti-CEA hybridomas, CE-25. The chimeric IgA (chIgA) was expressed in the Sp2/0 myeloma cell line. The secreted recombinant antibody was found to consist mostly of a dimeric form of IgA with a molecular weight of about 350 kDa. The dimeric chIgA was shown to translocate efficiently in vitro across a monolayer of epithelial cells expressing the pIgR and to retain full CEA binding activity.