In vitro assessment of cell-mediated immunity in patients with renal cell carcinoma

Adjuvant treatment for renal cell carcinoma

Despite significant advances in the diagnosis, staging and treatment of patients with renal cell carcinoma, recurrence rates following surgical resection of locally aggressive tumours remain high. In an effort to delay disease progression and improve survival, the concept of adjuvant therapy has been proposed. Optimal adjuvant therapy for surgically resected renal cell carcinoma remains to be defined and the evaluation of adjuvant therapies will require properly controlled and adequately powered randomised trials. Promising preliminary results have been seen with active immunotherapies and agents that target critical signalling pathways, and there are several Phase III trials of these novel treatment options that are underway. In addition, classification of patients into high- and low-risk subgroups on the basis of a prognosis profile will serve as a useful means to guide clinicians in improving the selection of patients who are likely to derive benefit from adjuvant therapy. This will lead to a future area of investigation, which will be the identification of patients within the target population that should respond to a given treatment. This review will discuss the role and current status of adjuvant therapies for renal cell carcinoma.

Surgery for metastatic renal cell cancer

Renal cell carcinoma (RCC) often presents in its metastatic form, or progresses after curative treatment. While the management of metastatic RCC has historically been mainly surgical, contemporary approaches often incorporate systemic immunotherapy. This review examines the current indications and scope of surgical treatment of patients with metastatic RCC. Surgery is sometimes indicated for symptom palliation at either the primary or secondary sites. However, other less invasive therapies may be equally effective, and should be considered carefully. Cytoreductive surgery prior to immunotherapy appears to confer a survival advantage, but only selected patients are suitable for this treatment regimen. Primary immunotherapy followed by surgical removal of the tumour in partial responders is an alternative treatment strategy, which has not yet been evaluated as in randomized trials. As immunotherapy develops further, the precise timing and role of surgery in multimodality treatment will need to be carefully evaluated. Occasionally, the complete surgical excision of metastases, and the primary tumour, if present, is feasible and this may prolong survival. Empirically, it would seem that such patients should also be treated with adjuvant immunotherapy, as eventual relapse is frequent. Surgery with the aim of inducing spontaneous tumour regression is not justifiable, given the rarity of this phenomenon.

Immunotherapy of metastatic renal cell cancer

BACKGROUND

The management of metastatic renal cancer remains a therapeutic challenge. Conventional cytotoxic chemotherapy is rarely effective, and the most promising approaches appear to lie in the field of immunotherapy.

METHODS

The authors review the literature regarding current and investigational immunotherapy approaches to the management of metastatic renal cancer.

RESULTS

The mechanism of action, methods of delivery, efficacy, and side effect profile of the cytokines IL-2 and interferon alfa are discussed. The role of investigational approaches such as tumor vaccines, antibody-based therapy, lymphocyte infusions, and bone marrow transplantation is addressed. The rationale for nephrectomy as an adjunctive procedure to immunotherapy is also discussed.

CONCLUSIONS

Ongoing laboratory investigation of the cause of the immune deficit in patients with metastatic renal cell cancer will result in the development of novel therapies to enhance tumor cell recognition as well as host antitumor response. Translation of laboratory findings into the clinic will be facilitated by the presence of an already well-developed infrastructure for the performance of clinical trials for patients with this difficult diagnosis.

Novel therapies for renal cell carcinoma

Metastatic renal cell cancer remains a disease which is difficult to treat medically. Prognosis often depends more on intrinsic disease features than on treatment choices. In this review, we examine novel therapies and scientific directions surrounding the RCC treatment problem. Reports relating chromosomal aberrations and of comparative gene expression analyses relating to RCC, are reviewed briefly. The central role of the von Hippel Lindau protein in clear cell RCC pathogenesis is evident. The limited contribution of conventional cytotoxic chemotherapy is mentioned. Some clinically applied agents whose clinical results are highlighted include 5-FU, retinoids, thalidomide, razoxane and IL-12. Features of the pathophysiology of von Hippel Lindau protein are described, with attention to potential novel therapies targeting HIF-1alpha, VEGF, TGF-beta1 and TGF-alpha pathways. Immunotherapy is being explored in many angles. Most basic are cytokine therapies incorporating new IL-2 and IFN-alpha schedules. Newer cytokine-based drugs include pegylated forms and IL-12. Allogeneic mini-transplantation has generated much interest. Tumour-associated antigens are being used to direct therapy using both identified and non-identified epitopes. A variety of tumour-cell vaccine and dendritic-cell vaccine clinical approaches are discussed. Finally, nephrectomy for known metastatic disease has been demonstrated to be helpful in retrospective and now prospective trials. Resection of metastases is also discussed. We are optimistic that the further clinical development among these novel therapies will improve the outlook for metastatic RCC.

Spontaneous regression of brain metastasis secondary to renal cell carcinoma

Spontaneous regression of malignant tumors is a rare event. A case involving brain metastasis from renal cell carcinoma (RCC) is presented. Nine years after the diagnosis of metastasis the patient is alive without evidence of recurrence. We have only found three previous RCC cases in the literature involving spontaneous regression of brain metastasis (4, 16, 17).

Clinical studies on cell-mediated immunity in patients with renal cell carcinoma: interleukin-2 and interferon-gamma production of lymphocytes

The authors examined interleukin-2 (IL-2) production and interferon gamma (IFN gamma) production of peripheral blood mononuclear cells in 28 patients with renal cell carcinoma and 17 control subjects. The peripheral blood was obtained prior to the initiation of therapeutic procedures. The patients were divided into two groups according to tumor size, less than or equal to 5 cm and greater than 5 cm. The production of IL-2 and IFN gamma was measured by immunoradiometric assay. As a result, in the patients with tumors greater than 5 cm, IL-2 and IFN gamma production was impaired. However, in the patients with tumors less than or equal to 5 cm, IFN gamma production was enhanced, though IL-2 production was not significantly different from that of the control subjects. There was no significant correlation between IL-2 production and IFN gamma production.

Antibodies to cultured tumor cells detected in sera of renal cell carcinoma patients by a quantitative avidin-biotin method

Antibodies reacting with the tumor cell line RC-Pa were measured by a quantitative avidin-biotin complex method. Sera of renal cell carcinoma patients, patients with other types of cancer and healthy donors were analyzed. Of 71 sera from renal cell carcinoma patients 67 (94 per cent) were classified as showing renal cell carcinoma, while 32 of 36 sera (89 per cent) from healthy subjects were classified as showing no renal cell carcinoma. Four of 21 serum specimens (19 per cent) from individuals with other than renal cancer were misclassified. Furthermore, sera from renal carcinoma patients immunized with a mixture of autologous tumor cells and Corynebacterium parvum showed a marked increase in reactivity compared to those from patients receiving progesterone. The results indicate that this assay might become useful to detect or monitor renal cell carcinoma.

Autologous mixed lymphocyte tumor cell culture in patients with renal cell carcinoma

Cell-mediated immunity was studied by measurement of lymphocyte response to autologous tumor cells in 19 surgically treated patients with histologically proved (mixed lymphocyte tumor cell culture) renal cell carcinoma. Tumor stage was low in 9 patients and high in 10, while grade was low in 11 and high in 8. Of 8 patients in whom a positive lymphocyte response was detected 6 had high and 2 had low stage tumors (p less than 0.05), while the grade of disease was low in 7 and high in 1 (p less than 0.05). Furthermore, the more advanced and undifferentiated the tumor the more significant the decrease in lymphocyte response (p less than 0.05). Lymphocyte response was positive in 5 of 8 patients with low stage and low grade tumors but negative in 7 with high stage and high grade disease. However, no correlation between the lymphocyte response and the degree of microscopic lymphocytic infiltration in and around the tumor was found. This study confirms that the specific immunological defense mechanism of patients with renal cell carcinoma against the tumors remains well at an earlier stage of tumor development, especially in cases with well differentiated malignancy, and showed attenuation in parallel with pathological spread or in poorly differentiated tumors.

Treatment of renal cancer patients by transcatheter embolization and its effects on lymphocyte proliferative responses

The effects of transcatheter embolization on lymphocyte proliferation in patients with renal cancer were investigated. Prognosis was good in 12 patients who underwent preoperative transcatheter embolization and 2 of 5 patients with distant metastases survived for 2 years or more. The remaining 9 patients underwent transcatheter embolization as a conservative procedure and 4 of 7 with distant metastases survived more than 1 year. Lymphocyte response to phytohemagglutinin before treatment in the presence of autologous or homologous serum was significantly lower in all patients than in healthy persons (p less than 0.01 and less than 0.05, respectively). The response after transcatheter embolization decreased slightly only in the presence of autologous serum for a short interval but recovered to the pre-treatment level 1 month after embolization. However, only in the presence of autologous serum was the response significantly higher at 2 months after nephrectomy than before treatment in patients who underwent preoperative transcatheter embolization (p less than 0.05). The serum inhibitory factor levels changed in inverse proportion to the post-treatment lymphocyte response. In patients who underwent preoperative transcatheter embolization the serum inhibitory factors essentially disappeared 2 months after nephrectomy.

Spontaneous regression of metastases of renal cancer: A report of two cases including the first recorded regression following irradiation of a dominant metastasis and review of the world literature

Two cases of spontaneous regression of lung metastases are presented. One is the first report of regression of metastases after irradiation of a dominant metastasis. The world literature is reviewed, and 67 documented cases have been found including the two now reported. Attention is drawn to the use of immunotherapy in the treatment of advanced renal cancer.

Active specific immunotherapy of stage IV renal carcinoma with aggregated tumor antigen adjuvant

Active-specific immunotherapy of human malignancy with a vaccine consisting of admixtures of modified tumor antigens and an adjuvant such as tuberculin has not been fully explored, despite preliminary reports of clinical success and conceptual support from animal studies. Three years ago, we designed a prospective study using aggregated soluble tumor antigens admixed with tuberculin or phytohemagglutinin as an adjuvant (TAA) in order to treat patients with Stage IV renal carcinoma. Autologous tumor vaccines were used initially in 24 patients with operatively accessible tumor, although most patients eventually were switched to allogeneic preparations. Scarifications with Bacillus-Calmette Guerin were used in order to ensure maximum reactivity to tuberculin and patients received no other therapy while in the study. Two patients achieved complete remission and 2, partial remission. The overall survival rate for the 30 patients entered is equivalent to reported survival rates for patients with extensive disease treated with aggressive surgery with or without chemotherapy. We believe these results offer strong preliminary evidence of efficacy of this particular type of therapy in an advanced human malignancy.

Spontaneous regression of renal cell carcinoma metastases after preoperative embolization of primary tumor and subsequent nephrectomy

Preoperative arterial embolization and infarction of a large renal cell carcinoma followed by radical nephrectomy seven days later led to spontaneous regression of pulmonary metastases. However, a cerebral metastatic deposit manifested itself fourteen months after surgery, requiring craniotomy. Presently, the patient is alive and well with no evidence of disease twenty-one months after his original surgery. The immunologic implications of this favorable response to treatment are discussed, and immunologic testing of similar cases is encouraged.

T lymphocytes inhibiting factors in renal cancer: evaluation of differences between arterial and renal venous blood levels of E rosette forming cells

The cellular immune response has been reported to be impaired in patients with renal cancer and to be increased by removal of the tumor bulk. T lymphocyte levels in the vein of the neoplastic kidney were investigated in 4 patients to assess the presence of a T lymphocyte inhibiting factor produced by the tumor. T lymphocyte levels resulted in significantly decreased tumorous venous blood, whether compared to arterial, contralateral or peripheral blood. A similar result was not found in 10 control patients. Some hypotheses on the nature of this T lymphocyte inhibition are discussed.

Recognition of virally transformed cells by lymphocytes from patients with prostatic cancer

Data presented describe the first assay using human peripheral blood lymphocytes (PBL) against two unique virally transformed cell lines in vitro. Human cells transformed by a cytomegalovirus (CMV-Mj) isolated from normal human prostate tissue were used as target cells in microcytoxicity assays with lymphocytes from 100 patients. Three target cell types were used: control human embryonic lung cells (HEL), transformed HEL cells (CMV-Mj-HEL-2), and transformed HEL cells retrieved from tumors induced in athymic nude mice (CMV-Mj-HEL-2, T-1) by injection of CMV-Mj-HEL-2 cells. PBL preparations from 84% of all patients tested significantly killed CMV-Mj-HEL-2, T-1 cells. However, only PBL from patients with prostatic carcinoma were cytotoxic for CMV-Mj-HEL-2 cells significantly more often than for control HEL. The implications of this approach are discussed.

Cell-mediated immunity in patients with renal cell carcinoma as measured by leukocyte migration inhibition test

The cell-mediated immune (CMI) response to tumor-associated antigens present in 3 M KCL extracts of renal cell carcinoma tissue was measured in patients with renal cell carcinoma (RCC) by the leukocyte migration inhibition (LMI) test. Of 30 patients with histologically proved RCC, 19 (63%) gave a positive LMI test; whereas, 2 of 28 (7%) of the normal donors, 13 of 43 (30%) patients with other cancers, and 5 of 14 (36%) benign kidney disease patients gave positive tests. Thirteen per cent of RCC patients reacted to a normal kidney extract. Although 33% gave a positive response to a lung carcinoma extract, the incidence of reactivity was less than that observed with the lung cancer patients. These results suggest that a CMI response to a renal carcinoma-associated antigen was measured by the LMI test. Correlation of the LMI data with the stage of disease and clinical status indicated that 71% of patients that had a localized tumor and were clinically free of disease one year postnephrectomy lost their tumor-directed CMI response. Patients with distant metastasis (Stage D) were LMI positive provided they had not received radiation or hormone therapy at the time of testing. These results suggest that the demonstration of CMI, as measured by the leukocyte migration inhibition test, correlates with the presence of active disease.

T and B lymphocyte levels in renal cancer patients: influence of preoperative transcatheter embolization and radical nephrectomy

The mean percentage of T and B lymphocytes in peripheral blood was tested in 6 patients with renal cancer before and after preoperative transcatheter embolization and radical nephrectomy. While no significant difference was found in B lymphocyte levels compared to those in healthy control subjects a clear impairment in circulating T lymphocyte levels was observed in renal cancer patients who had not been treated. This reduction in T lymphocyte levels persisted after embolization but there was a significant increase after radical nephrectomy.

Adenosine deaminase activity in patients with renal adenocarcinoma

Erythrocyte and lymphocyte adenosine deaminase (ADA) levels were studied in 31 patients with renal cell carcinoma (RCC). Decreased lymphocyte ADA levels occurred in patients with RCC. Erythrocyte ADA levels were reduced only in blood type B and O patients. Nephrectomy resulted in a rise in lymphocyte and erythrocyte ADA levels. Progression of clinical disease was associated with a fall in lymphocyte ADA values in all patients and with a rise in erythrocyte levels only in blood type A patients. Our results suggest that changes in erythrocyte and lymphocyte ADA levels in RCC patients are acquired and may offer insight into host-tumor interactions.

Aggressive versus conservative management of stage IV renal cell carcinoma

Improved modalities to treat metastatic renal cell carcinoma will require an aggressive surgical and chemotherapeutic approach. Nephrectomy with hormonal and non-hormonal chemotherapy does improve median survival and 3-year survival significantly. The use of xenogeneic specific immune ribonucleic acid and Bacillus Calmette-Guerin offers promising immunotherapeutic modalities that may be combined with surgical and chemotherapeutic regimens. Early diagnosis of metastatic disease is important to evaluate properly the results of various modalities of treatment and possibly to improve the efficiency of these modalities. The management of solitary metastatic nodules should involve aggressive resection of the primary and metastatic nodule. Adjuvant hormonal and non-hormonal chemotherapy should be considered in all stages of the disease.

Regression of renal cell hepatic metastasis following removal of primary lesions

Although spontaneous regression of metastatic renal cell carcinoma occurs it is so uncommon that it should not be considered the primary basis for recommending removal of the asymptomatic primary lesion. Such a recommendation should be made when other treatment modalitis are available to augment the factors influencing the patient-tumor interface. Spontaneous regression of a documented solitary liver metastatic lesion is reported. Removal of the residual hepatic lesion failed to prolong the patient's life.

Nephrectomy for renal cell carcinoma with metastases

The percentage of patients with renal cell carcinoma who also have identifiable metastases when first seen is increasing. In the past metastases were considered justification for excluding nephrectomy in the management of the patient. However, numerous opportunities for therapy which are abetted by removal of the primary tumor are presented. It is concluded, depending on several variables, that the advantages of nephrectomy usually justify the procedure.

Immunotherapy of disseminated renal cell carcinoma with transfer factor

Ten patients with disseminated renal cell carcinoma have been treated with transfer factor as an immunostimulant. In 5 patients with metastatic disease evident at the time of initial diagnosis treatment involved removal of the primary tumor followed by transfer factor therapy. Of these patients 3 had a temporary stabilization of metastatic disease. Three patients with recurrent metastatic disease after previous nephrectomy were treated, 2 of whom showed a temporary stabilization of metastatic disease. There were 2 additional patients without clinically evident metastases but at a high risk for recurrent disease who were treated and remain free of disease. We used 5 immunologic parameters to evaluate the clinical effects of transfer factor. No objective clinical regression was noted in any patient treated with measurable disease.

The role of adjunctive nephrectomy in patients with metastatic renal cell carcinoma

The results of therapy for 78 patients with disseminated renal cell carcinoma are evaluated. Symptoms related to the primary tumor were noted in only 28 per cent of the patients and were not difficult to manage in those patients not undergoing nephrectomy. Adjuctive nephrectomy, therefore, is a more appropriate term than palliative nephrectomy when referring to removal of the primary tumor as part of an aggresive combined therapeutic approach. Of patients receiving an adjunctive nephrectomy those with osseous metastases only had a better 1-year survival rate (36 per cent) than those with metastases to other sites (18 per cent). Complete regression of metastases was noted in 12 per cent of patients treated with medroxyprogesterone acetate and adjunctive nephrectomy. The role of adjunctive nephrectomy combined with embolic infarction, hormonal therapy, chemotherapy and/or immunotherapy is discussed.