Human lymphoblastoid interferon in the treatment of small cell lung cancer

Interferon-alpha is a predisposing risk factor for carbamazepine-induced hyponatremia: A case of syndrome of inappropriate antidiuresis caused by interferon-alpha therapy

A 31-year-old man had been treated with carbamazepine (CBZ) for 6 years and warfarin with bucolome for 2 years before developing hyponatremia 7 days after an injection of interferon-alpha 2b and starting oral ribavirin for chronic hepatitis C virus infection. Despite the hyponatremia, urinary osmolality exceeded plasma osmolality, and urinary excretion volume decreased markedly after water loading. Restriction of water intake and administration of dimethylchlortetracycline improved the hyponatremia, and lithium therapy maintained the normonatremia for one year. The hyponatremia recovered 6 months after the interferon-alpha 2b therapy was completely stopped. In the present case, the syndrome of inappropriate antidiuresis may have been caused by the effect of interferon-alpha 2b on the renal distal tubules that had been sensitized by CBZ. Patients on CBZ therapy should be carefully observed for the development of hyponatremia when they are started on interferon-alpha 2b injections.

Interferon trials in small cell lung cancer at one institution: a comparison of results obtained before and after initiation of systematic treatment trials using IFN-alpha in combination with other modalities

Chemotherapy became the primary treatment for small cell lung cancer (SCLC) in the early 1970s. The standard drug combinations were first vincristine, adriamycin, and cyclophosphamide (VAC) and then, from the early 1980s, etoposide-platinum combinations. Despite a good initial objective response, however, patients usually suffer a rapid relapse. Treatment development has, therefore, focused on ways to overcome drug resistance, and on the addition of cytokines to the chemotherapeutic arsenal. Interferon (IFN) was one of the first cytokines found to have anticancer effects, and it was introduced into the combined modality regimens used to treat SCLC in the early 1980s in an attempt to overcome the problem of early relapse. The role of IFN was investigated with the aim of establishing how best to combine it with other treatments for SCLC. In this paper, we review the impact of IFN on the outcome for 714 SCLC patients who were treated in randomized IFN trials at one institution over a period of 20 years and IFN trials conducted at other institutions during the same period. The parameters we used at our institution to measure outcome tended to improve during the period when patients were being treated in our three randomized IFN trials, compared with the period when patients received only standard treatment in a nonclinical trial setting. However, the differences were not statistically significant. During this period, IFN was used as maintenance therapy, concomitantly with chemotherapy, and combined with other treatment modalities. Our experience is that IFN-alpha is most effective when administered as low-dose maintenance treatment. Other IFN trials published during the same period were small and heterogeneous. Results were inconsistent and added little new information, although it has been shown that high pretreatment levels of serum vascular endothelial growth factor (VEGF) predict a poor response to treatment and consequently a poor outcome. The recently confirmed antiangiogenic properties of IFN deserve to be investigated in studies of maintenance treatment, in combination with other biologic agents. Patient should be selected according to criteria based on pretreatment assessment of biologic markers, such as VEGF and basic fibroblast growth factor (bFGF). Our studies, all at one institution, pioneered the biologic treatment of solid tumors and developed a solid basis of knowledge for future studies of biologic agents in cancer treatment.

Phase II trial of recombinant IFN-alpha2a with etoposide/cisplatin induction and interferon/megestrol acetate maintenance in extensive small cell lung cancer

Previous data suggested interaction of cisplatin with interferon (IFN) in non-small cell lung cancer and a possible effect of IFN in maintaining remission in small cell lung cancer (SCLC). This study was designed to further examine the effect of IFN in the treatment of extensive disease (ED) SCLC. Forty previously untreated patients with performance status (PS) of 0-2 (Zubrod scale) were treated with etoposide (100 mg/m2 for 3 days), cisplatin (25 mg/m2 for 3 days) (EP), and recombinant IFN-alpha2a (rIFN-alpha2a) (5 x 10(6) U/m2 for 3 days) for six cycles (induction), followed by rIFN-alpha2a (5 x 10(6) U/m2) thrice weekly and megestrol acetate (40 mg q.i.d.) as maintenance therapy for 6 months or until progressive disease or intolerable toxicity was documented. Patients were 25 men (62%) and 15 women (38%), median age 58 (28-76), median Zubrod performance status 1 (0-2). Major sites of metastasis include liver (55%), bone (42%), bone marrow (25%), and adrenal gland (18%). Of 40 eligible patients accrued to this trial, 35 were evaluable for response, and 37 were evaluable for toxicity. There were 3 complete and 28 partial responses, for an overall response rate of 89%. With 39 of 40 patients followed until death, median survival (Kaplan-Meier) is estimated at 46 weeks (95% CI range 35-55). Twenty patients completed six cycles of induction, and 16 received maintenance therapy, median 2 cycles (range 1-3). Major toxicity during induction included grade 4 granulocytopenia in 24%, grade 2-3 nausea or vomiting or both in 41%, grade 2 fatigue in 24%, grade 2 anorexia in 22%, and grade 2-3 renal insufficiency in 9% of 175 total courses of chemotherapy administered. Toxicity during the maintenance phase was notable for grade 2-3 fatigue in 43%, grade 2-3 anorexia in 24%, grade 2-3 weight loss in 10%, and grade 3-4 anemia in 17% of 30 courses. There were no treatment-related deaths. The addition of rIFN-alpha2a to EP in induction chemotherapy of ED SCLC, followed by rIFN-alpha2a and megestrol acetate maintenance therapy, was reasonably well tolerated. The complete and overall response rates and duration of remission and survival appear to be similar to those generally obtained with EP alone in similar patients.

Biological response modifiers

Biological response modifiers (BRMs) of current clinical interest may be divided into two categories: immunomodulating agents and colony stimulating factors (CSFs). The first are employed to potentiate the host defences towards the tumor but results have proved disappointing in non-small cell lung cancer (NSCLC). With regard to the second, the real dose increment which may be ascribed to CSFs is not sufficient to overcome chemoresistance of NSCLCs. CSFs can, however, reduce the hematologic toxicity of chemotherapy, which represents the most significant result.

Characterisation and properties of a small cell lung cancer cell line and xenograft WX322 with marked sensitivity to alpha-interferon

Controversy exists as to whether interferons usefully influence the growth of epithelial carcinomas. A small cell lung carcinoma (SCLC) cell line, WX322, has been derived which is greater than 1000-fold more sensitive to alpha-interferon (IFN) when grown in agar than other reported SCLC cell lines. The WX322 line has been characterised to prove its epithelial origin and its chemosensitivity compared with that of the NCI-H69 small cell line. The WX322 cell line expresses neuroendocrine and epithelial markers and possesses a morphology consistent with SCLC origin. A concentration of 5 IU ml-1 of IFN produced 50% inhibition of colony formation in agar in the WX322 line, whereas a concentration of greater than 10(5) IU ml-1 was required to produce a comparable effect with the NCI-H69 cell line. In contrast, WX322, possessed similar sensitivity to NCI-H69 cells when exposed to a range of cytotoxic agents. Analysis of the cell cycle indicated that IFN increased the percentage of cells in the G0/G1 phase for the WX322 cell line but increased the percentage in S phase for the NCI-H69 line. Growth of the xenograft, from which the cell line was derived, was also inhibited by IFN at doses greater than 10(5) IU/mouse/day. The WX322 cell line whether grown in agar or as a xenograft shows an unusually high sensitivity to IFN and provides an interesting model for studying mechanisms of IFN cytotoxicity to epithelial cells.

Aerosol application of interferon-alpha in the treatment of bronchioloalveolar carcinoma

10 patients with locally advanced bronchioloalveolar carcinoma were treated with interferon-alpha as an inhaled aerosol. Initial doses ranged between 1 and 10 MU daily or thrice weekly and were then increased to 20 MU daily. Treatment was continued until disease progression or excessive toxicity occurred, 9 patients were evaluable for toxicity. In 1 case treatment had to be stopped after 2 weeks due to fever, fatigue and progressive dyspnoea. 2 patients developed fever, 1 had malaise, fatigue and loss of appetite and 2 had dose-dependent transient dyspnoea. According to standard criteria no tumour responses could be detected. In 6 out of 8 evaluated for response to interferon, radiological stabilisation of disease for 7-43 weeks (median 15) was observed. These results point to the feasibility of aerosol inhalation of interferon-alpha, but also to its limited antitumour activity in locally advanced bronchioloalveolar carcinoma.

The role of interferons in the treatment of malignant neoplasms

Interferons (IFNs) are proteins with a wide range of biological effects. IFNs have antiviral and antiproliferative properties. They modulate both the immune system and the expression of cell phenotype. In the past decade, the IFNs have received intense clinical scrutiny. Alpha IFN is the best studied and displays activity in many neoplastic diseases; it has shown the most promise in the hematological cancers although several solid tumors, including epidemic Kaposi's sarcoma, renal cell carcinoma, and melanoma, respond. No neoplastic disease, however, has been cured by the IFNs. IFN seems to be most active in the setting of minimal residual disease, and clinical studies evaluating its role in the adjuvant setting are under way. Other areas of research include trials combining IFN with cytotoxic drugs or other biological response modifiers, and maintenance IFN to prolong remissions following successful induction therapy.

Behavioral assessment of patients treated with alpha-interferon

To document behavioral effects of interferon (IFN) with daily consecutive assessments we developed an easily administered procedure for bedside testing. It included assessment of mental control and affective behavior, and a self-assessment questionnaire. The method was evaluated in 9 lung cancer patients before and during the treatment with alpha-IFN and the results were supplemented with those obtained by a neuropsychological test battery of one of the patients. The latter tests covered memory, visuoperceptual, visuoconstructional, speech, language, intellectual and psychomotor functions, reading, writing, and calculation. The bedside method was capable of revealing the essential effects of IFN on human behavior, i.e. irritability, slowing of behavior, dyscoordination, and motor perseveration. Consequently, the bedside testing method is recommended for frequently repeated clinical assessments of aberrant behavior of patients treated with IFN, while neuropsychological test batteries serve better for testing situations requiring more detailed and quantified data of localization value.

Small cell lung carcinoma. A phase II evaluation of r-interferon-gamma

Twelve previously untreated patients with small cell lung carcinoma (SCLC) were treated with r-interferon-gamma (Immuneron, Biogen S.A., Geneva, Switzerland). The planned dose was 1 mg (28 X 10(6) mu)/ms daily for 5 days, followed by 0.5 mg/m2 three times a week for 3 weeks or until progression, whichever was first. Eight patients were fully evaluable, and there were no responses. In four of the eight, the disease remained stable for 1 month, and four progressed before this time. Toxic reactions included pyrexia, headache, and malaise, which were mild to moderate. Ten patients subsequently received conventional chemotherapy, which resulted in three complete and four partial responses. The mean duration of response to chemotherapy was 8 months. It is concluded that r-interferon-gamma, at the dose and schedule used, has no significant clinical activity in small cell lung carcinoma.

Recombinant interferon A (IFL-rA) therapy of small cell and squamous cell carcinoma of the lung. A phase II study

Recombinant interferon A (50 x 10(6) U/m2 three times weekly) was given to 17 patients with SCCL and 13 patients with SQL. The minimal scheduled duration of therapy was 12 weeks. Fifteen and 11 patients, respectively, were evaluable for response. All 15 patients with SCCL showed progressive disease after a period of 2.5 weeks (median; range 1-13). One patient with SQL obtained a partial remission lasting 14 months and six patients showed no change for 14-20 weeks, while the remaining patients showed progression during the initial 12 week period. Toxicity was shown to be significant and only one patient completed therapy without dose reduction. The major cause of dose reduction was fatigue and anorexia (18 patients). Fourteen patients experienced a median weight loss of 6%. Haematological and hepatological toxicity was found in six and 19 patients, respectively. In most cases parameters of marrow and liver function were reversible in spite of continuing interferon treatment.

The effects of alpha and gamma interferons on human lung cancer cells grown in vitro or as xenografts in nude mice

We have compared the effects of alpha and recombinant gamma interferons (IFNs) on the growth of human lung cancer cell lines in vitro. There was a diversity of response amongst the lines studied, the most sensitive being COR-L23 (a large cell anaplastic carcinoma line) and POC (a small cell line). In these two lines, IFN-gamma was found to be more potent than IFN-alpha. During cell growth of line POC in the presence of IFN-gamma no significant shift in cell cycle distribution occurred. When lines COR-L23 and POC were grown as xenograft tumours in nude mice, daily injection of 4 X 10(5) units per mouse per day of IFN-gamma produced no discernible retardation of tumour growth.

Small cell lung cancer 1973-1983: early progress and recent obstacles

The recognition that the vast majority of patients with small cell lung cancer have distant metastatic disease at the time of diagnosis led to the use of systemic chemotherapy and consequent major improvements in survival in the early to mid-1970's. In the past five years, however, the pace of therapeutic advances has slowed. Recently evaluated treatment strategies, including more intensive induction chemotherapy, "late intensive" therapy of responding patients, alternation of chemotherapeutic regimens, integration of chest irradiation with drug therapy, large field irradiation, and reappraisal of the value of surgical resection, are discussed in this review. Advances in understanding of the cell biology of small cell lung cancer which may eventually lead to new forms of treatment are summarized.

Interferons and cancer therapy

A variety of human interferons, alpha, beta and gamma are now recognised. Three types of alpha-interferon have been submitted to clinical assessment. Overall, the results have been disappointing. Attention is now directed towards their use in combination with conventional cytotoxic agents.

Increased expression of human monocyte HLA-DR antigens and Fc gamma receptors in response to human interferon in vivo

The expression of class II MHC encoded antigens (HLA-DR) and Fc gamma receptors by peripheral blood monocytes from untreated patients with small cell carcinoma of the bronchus was compared with that of normal donors. Fc gamma receptor expression was found to be elevated in these patients in comparison with normal. In contrast HLA-DR antigen expression by patients' monocytes was somewhat depressed in comparison with normal. Continuous intravenous infusion of a total of 400 megaunits/m2 of human lymphoblastoid interferon-alpha (IFN-alpha) over a 5 day period markedly increased both monocyte HLA-DR antigen expression and Fc gamma receptor expression in comparison with that of untreated patients and normal donors. The initial increases declined somewhat but were still evident after 3 weeks of intermittent intramuscular IFN-alpha therapy.