Daily intravenous infusions of Corynebacterium parvum in twenty patients with disseminated cancer: a preliminary report of clinical and biologic findings

Effects of Lactobacillus casei on Pseudomonas aeruginosa infection in normal and dexamethasone-treated mice

A single intraperitoneal injection of Lactobacillus casei YIT 0003 into normal or dexamethasone-treated mice led to nonspecific resistance against intraperitoneal challenge with lethal doses of Pseudomonas aeruginosa PAO 3047. The enhanced resistance was retained for 14 days (P less than 0.05) after injection with living L. casei. In contrast, the statistically significant duration of the enhanced resistance in mice treated intraperitoneally with living L. acidophilus YIT 0075 was only 5 days. The in vivo killing activity of peritoneal exudate cells (PECs) against P. aeruginosa 5 and 7 days after intraperitoneal injection of living L. casei was significantly higher than in the case of PECs elicited by L. acidophilus. In the case of intravenous injection of heat-killed L. casei before intraperitoneal challenge with P. aeruginosa, there were no survivors in the late period after administration of L. casei. A high correlation existed between the patterns of in vivo killing of P. aeruginosa by PECs and survival rate of mice injected intravenously with heat-killed L. casei. The reduced in vivo killing activity of PECs from dexamethasone-treated mice against P. aeruginosa infection was also augmented by the intraperitoneal injection of heat-killed L. casei. These results indicate that L. casei possesses a resistance-enhancing capacity against P. aeruginosa infection in vivo. Differences in the duration of the enhanced resistance caused by L. casei and by L. acidophilus may be due to differences in chemical composition and/or physicochemical properties of the cell walls of the two kinds of bacteria.

The effect of treatment with Corynebacterium parvum on the development and growth of experimental hematogenic metastases of schwannoma in the rat

Single i.v. administration of Corynebacterium parvum 5 days before i.v. injection of 10(6) tissue cultured syngeneic schwannoma cells in Lewis rats resulted in extension of survival time (P less than 0.05). There was a significant decrease in metastatic tumor incidence for lung, heart, and kidney and decreased lung tumor growth with approximately 50% of the lung tumor burden of untreated controls (P less than 0.05). Rats treated similarly with C. parvum 10 days after tumor cell injection showed no enhanced survival; to the contrary, their survival was shortened. Moreover, tumor incidence in the post-treated group was not significantly different from the control but significantly increased in comparison to the pretreated group. Enhanced lung tumor growth resulted in a final tumor burden about twice that of untreated controls (P less than 0.05).

Complement and cancer: activation of the alternative pathway as a theoretical base for immunotherapy

Activation of the APC is pointed out as the common factor in all sufficiently studied cancer treatments employing nonspecific, active immunotherapy. This chapter outlines the molecular biology of both APC and classical pathway of complement, summarizes the alternative pathway's biologic activities especially in relation to the C3/C5 convertase C3b,Bb, and its implications in the mechanism of host defense against malignancies, particularly relating to the activated macrophage. The many involvements of the APC in the various agents used for nonspecific active immunotherapy are reviewed, and possible clinical implications outlined. It is concluded that activation of the APC can be proposed as the specific theoretical basis so far lacking for this treatment modality and that it is accordingly feasible to attempt to monitor clinical application of this principle by fine-tuning of APC activation in cases of human cancer.

Levamisole as adjuvant to chemotherapy of ovarian cancer. Results of a randomized trial and 4-year follow-up

The results of a randomized trial, stratified according to age and stage of disease, in 140 patients with ovarian cancer are presented. The drug, levamisole, or a placebo was given as adjuvant to cytotoxic chemotherapy for 12 months after maximal surgical reduction of tumor. Because of severe side effects, levamisole treatment was discontinued in 8 of 69 patients (marked neutropenia in 5, severe skin rashes in 3). There were no significant differences in the survival curve and mean duration of survival between levamisole-treated and placebo-treated groups during the 4 years of follow-up, except for patients with Stage II disease. Among these latter patients, the survival rate became progressively much lower in the levamisole-treated group and the difference reached statistical significance after the second year of follow-up (P less than 0.01). In view of the inconclusive evidence that levamisole provides a beneficial effect (in fact, there is concern of a deleterious effect) and the serious side effects, the drug should not be used in patients with ovarian cancer.

Immunology of head and neck cancers

Despite the ever growing collection of data concerning the function of the immune system in patients with epidermoid carcinoma of the head and neck, the precise mechanism by which these tumors effect the body's surveillance against foreign antigen is as yet unidentified. If these specific immunological characteristics of the cancer cell can be identified, laboratory analysis of these "markers" could lead to detection and treatment of cancer in its earliest stages. Included in this chapter is a review of the embryological development of the immune system, a description of the components of the immune system and their responses to invasion by tumor antigen. Measurements of immuno responsiveness of the individual are important in determining the pretreatment state of immuno-competence and in predicting prognosis following treatment. Measurements of T-lymphocyte functions and their response to immuno-manipulations can also aid in predicting which patients will benefit from immunotherapy. Finally, categorization of the multiple forms of immunotherapy including active, specific and non-specific, and adoptive mechanisms are discussed. More recent methods of related immunotherapy trials will also be mentioned. As of this writing, the trials of immunochemotherapy have not produced any conclusive results due to the lack of multi-institutional trials and limited quantities of immunotherapeutic agents for these clinical trials.

Clinical Phase I investigation of intravenous oil attached mycobacterial components as immunotherapeutic agents

The toxicity and immunological effects of suspensions of mycobacterial cell wall skeleton (CWS) and trehalose dimycolate (TDM) attached to oil droplets and given intravenously in doses of 100 to 200 micrograms/M2 every one or two weeks was investigated. The major limiting side effect was fever and chills at a dose of 2 mg/M2. There was no major hematopoietic, renal, hepatic toxicity, or pulmonary toxicity. Intravenous therapy with CWS/TDM/Oil was associated with complete regression of a bronchial squamous cell arcinoma in one of three patients receiving 2000 micrograms/M2 weekly. The continued development and clinical study of surface attached purified and/or synthetic microbial adjuvants is a promising area of investigation.

Methotrexate alone or with regional subcutaneous Corynebacterium parvum in the treatment of recurrent and metastatic squamous cancer of the head and neck

Patients with advanced, incurable squamous cancer of the head and neck were randomly assigned to treatment with weekly methotrexate alone or methotrexate with Corynebacterium parvum given subcutaneously in weekly bilateral doses in sites around the neck. The addition of C. parvum did not alter the response rate, response duration, survival (either median or long-term) or severity of toxic effects compared to treatment with methotrexate alone. Response rates were higher for patients without distant metastases, ambulatory patients, and those younger than age 65 years. Median survival was improved for responders to chemotherapy and for those initially ambulatory. C. parvum given subcutaneously has no place in the treatment of far advanced cancer of the head and neck.

Levamisole as an adjuvant to chemotherapy in extensive bronchogenic carcinoma: a Veterans Administration Lung Cancer Group Study

A randomized trial of 381 patients with extensive lung cancer compared immunochemotherapy with levamisole (150 mg/m2 orally three times a week), cyclophosphamide (700 mg/m2 IV every three weeks) and CCNU (70 mg/m2 orally every six weeks) with the same chemotherapy without levamisole. When disease progressed, doxorubicin hydrochloride or doxorubicin hydrochloride plus levamisole was used. Hematologic toxicity required reduction of the levamisole dosage to 2.5 mg/kg (100 mg/m2) three times a week, every other week. When corrections are made for all variables, levamisole itself had a negative influence on survival. Patients given 150 mg/m2 had a shorter median time to treatment failure (P = 0.02), lower response rate (P = 0.02) more toxicity (P = 0.08), and shorter median survival (P = 0.08). Patients with 10% or greater weight loss had significantly shorter survival (P = 0.006). The regimen with the reduced dosage of levamisole also was more toxic (P = 0.05) but otherwise did not differ from the control regimen. The cause of the adverse effect of levamisole is unknown. It did not occur because of an excess of toxic deaths or because smaller doses of cytotoxic drugs were given to patients treated with levamisole. Neither the initial lymphocyte count nor the Candida skin test reactions had a significant effect on the study endpoints when correction was made for dominant prognostic factors such as the initial performance status and weight loss.

Actinomycin-D plus 5-(3,3-dimethyl-1-triazeno)-imidazole-4-carboxamine (DTIC) with or without intravenous Corynebacterium parvum in metastatic malignant melanoma

Chemotherapy and chemoimmunotherapy of Stage IV B malignant melanoma were compared in 88 patients. Chemotherapy consisted of DTIC 250 mg/M2 of the body surface area daily x five days and actinomycin-D 2 mg/M2 on day 1 repeated every 3--4 weeks. Chemoimmunotherapy consisted of the same regimen plus C. parvum 2 mg/M2 I.V. daily for 14 days before every third cycle of chemotherapy, plus 2 mg/M2 I.V. daily on days 7 and 14 of each 21--28 day chemotherapy cycle. There was 32 evaluable chemotherapy and 33 evaluable chemoimmunotherapy patients and the groups were well balanced for clinical and pathologic as well as prognostic variables. The complete and partial remission rates, remission and survival durations, and hematologic and gastrointestinal toxicities were different in the two randomized groups being 6 and 3%, 9 and 9%, 7.6 and 12 months, 8.8 and 6.0 months, 20 and 16%, and 62 and 70%, respectively for these parameters. This difference was not statistically significant. Therefore, it can be concluded that the results of chemotherapy with actinomycin-D plus DTIC were not substantially different from those reported using DTIC alone, and that we cannot recommend the addition of actinomycin-D to DTIC for palliative management in these patients. Furthermore, C. parvum immunotherapy did not add to chemotherapy in terms of remission rate, remission duration, or survival for patients with Stage IV B malignant melanoma.

Clinical trial of Corynebacterium parvum (intra-lymph-node and intravenous) and radiation therapy in the treatment of head and neck carcinoma

Fifty-seven patients with previously untreated squamous cell carcinoma of the head and neck region of all clinical stages were entered a trial to evaluate the effectiveness of Corynebacterium parvum combined with radiation therapy in improving local and survival results. Twenty-nine patients were randomized to receive radiation therapy alone, and 28 patients were randomized to receive radiation therapy combined with C. parvum. The C. parvum was administered into the tumor-bearing lymph nodes of the neck or into the cervical node region in non-node-positive patients (4 mg/m2) and by intravenous routes (at 2, 2, 4, 4 and 4 mg/M2) at days -10, -7, and -3 before, and at +7 and +14 days after the start of radiation therapy. The study began in July 1975 and was terminated after 2 1/2 years of patient accession. The statistical analysis showed that those receiving C. parvum were not doing better than controls and, in fact, in some subgroups there was concern that they might be doing less well. Pertinently, analysis showed that those receiving C. parvum would not experience the 25% point improvement in disease-free survival frequency which had been stipulated in the design of the protocol.

Antitumor effect of heat-killed Aspergillus fumigatus mycelium in a mouse model

A suspension of heat-killed Aspergillus fumigatus mycelium inhibited the growth of a chemically-induced mouse bladder tumor (MBT). Tumor growth was inhibited when the mycelium was injected into mice in a mixture with the tumor cells, when injected into growing tumors, and when introduced IP at the time tumor cells were injected into the hind leg muscle. In the concentrations that affected tumor growth no toxicity of the fungus preparation was observed. The fungal suspension was more effective against MBT than a Corynebacterium parvum strain known to be a potent biologic response modifier. A significant increase in the number of mouse peritoneal exudate cells (PEC) was noted following inoculation with the mycelium. The induced PEC were cytotoxic to the tumor cells in vivo, suggesting that at least part of the tumor inhibition by the mycelium is host-mediated.

A study of reactions to Corynebacterium parvum (C. parvum) in the brain and dermis of the rat

A comparative analysis was made of the histological changes caused by Corynebacterium Parvum (C. parvum) infected into the brain and dermis of normal and C. parvum presensitized rats. Control rats were injected with saline. It was shown that for approximately 3 days after the intracerebral injection the brain reacted with a polymorphonuclear cell infiltration. This reaction was replaced in order by lymphocytes, macrophages, and finally by epithelioid cells progressing to granuloma. The histological changes were similar but more intense in the dermis than in the brain. Lymphocytes reached a peak by day 7, macrophages by day 3, and epithelioid cells by day 18. In comparison to the dermis, the cellular infiltration in the brain is more delayed, less intense and of longer duration. Intracerebral saline induced a moderate lymphocytic infiltrate, and in C. parvum presensitized rats a more intense macrophagic response. It is concluded that the brain of the rat, especially in presensitized animal, mounts an inflammatory response to C. parvum which is morphologically similar to that seen in the skin.

Organ distributions and clearance studies of 99mtechnetium-labeled Corynebacterium parvum in patients with leukemia

The clearance, metabolism and localization of Corynebacterium parvum (C. parvum) labeled with 99mtechnetium (99mTc) given intravenously was studied in various leukemia patients to develop the method and to evaluate reticuloendothelial systems (RES) function. A computer program was utilized to characterize the clearance. C. parvum 0.05 mg was labeled aseptically with 10 mCi of 99mTc with a reducing agent. It was injected intravenously over 5 s and clearance was characterized over the next 60 min. The low dose of C. parvum did not cause any symptoms. The blood or plasma clearance time (t 1/2) was in the range of 0.65 to 1.96 min, in eight patients. By whole body imaging, the distribution of C. parvum was found mainly in the liver, and to a much lesser extent in the spleen, lungs, and bone marrow. Nonparticulate 99mTc (which was not sedimented by centrifugation of blood samples at 3000 rpm for 30 min) appeared rapidly in the blood after i.v. injection accounting for more than half of the radioactivity in a few minutes. In vitro incubation of 99mTc labeled C. parvum with saline, whole blood, serum or leukocytes revealed that the release of free 99mTc resulted from the combined action of serum and leukocytes. The rapid clearance will limit the utility of this preparation in characterizing RES function in man and its modification by disease or therapy.

Evaluation of vindesine and MER in colorectal cancer

Vindesine, a derivative of vinblastine, was administered to 39 patients with advanced colorectal cancer refractory to 5-fluorouracil alone or in combination with other chemotherapeutic agents. The initial dose of vindesine was 4 mg/m2 administered intravenously (IV) over 30 minutes every two weeks. Tumor regression of more than 50% was seen in 2 and stable disease in 13 of 33 patients evaluable for response. Prior treatment with vincristine did not seem to influence response to vindesine. The median survival time was four months. The major toxic effect of vindesine was peripheral neuropathy, which occurred in 35% of patients who received two or more courses of treatment. Methanol extract residue of BCG (MER) was administered IV to 20 of 39 patients receiving vindesine without randomization in order to evaluate toxicities associated with IV MER. The most common toxic reactions to MER were fever and chills, while malaise and headaches were less common. Transient respiratory distress associated with appearance of reticulonodular pulmonary infiltrates occurred in 1 patient. Thus, MER at a dose of less than 1 mg/m2 did not seem to significantly influence the response rate to vindesine or the survival of patients. However, it appeared to ameliorate the myelosuppression caused by vindesine.

Single versus multiple human-equivalent doses of C. parvum in mice: neutralization of the anti-metastatic effect

The murine dose of i.v. C. parvum (466 microgram) was compared with a single, low, human-equivalent dose of 70 microgram and with repeated weekly low doses. All treatments increased the antibody titre against C. parvum (CP). However, repeated doses stimulated a much higher titre than single doses. In all treated animals spleen weight peaked at 2 weeks and then fell. A single low dose caused a 3-fold increase, a single high dose or multiple low doses a 6-fold increase. Liver weight changes followed a similar pattern. Hepatosplenomegaly was prolonged by multiple doses. The effects of these treatments on Lewis tumour metastases were studied. A single high dose and a single low dose on the day of tumour implantation (Day 0) were equally effective at inhibiting pulmonary metastases. Repeated low doses starting on Day 0 were no more effective than a single dose. The effect of CP on survival after primary-tumour excision on Day 10 was observed. Low dose CP on Day 7 doubled the harmonic mean of survival time. Repeated doses were no more effective than a single dose. Low-dose prophylaxis up to 2 weeks before tumour significantly inhibited metastases. However, when repeated low-dose prophylaxis was combined with a single low dose on Day 0, the anti-metastatic effect was abrogated. This neutralization of the anti-metastatic effect of CP given on Day 0 was found to persist after a 13-week treatment-free interval. Possible mechanisms for this phenomenon are discussed.

Cyclophosphamide plus 5-(3,3-dimethyl-1-triazeno)-imidazole-4-carboxamide (DTIC) with or without Corynebacterium parvum in metastatic malignant melanoma

One hundred twenty patients with metastatic malignant melanoma were randomized to receive either cyclophosphamide, 600 mg/m2 IV, on day 1 plus DTIC 200 mg/m2 IV days 1 through 5, or the same chemotherapy plus C. parvum 5 mg/m2 IV on day 8 and day 15. Therapy was repeated every 21 days. Although responses were observed in 13.8% of patients on cyclophosphamide plus DTIC versus 25.5% of patients on cyclophosphamide plus DTIC plus C. parvum, the median duration of remission was 15.6 weeks on chemotherapy and 13.0 weeks on chemotherapy plus C. parvum. Furthermore, survival was similar on both regimens (6.1 months versus 5.7 months, respectively). Favorable prognostic factors included metastatic disease confined to skin or lymph nodes (33% responses), performance status greater than 70% (24% response rate), and administration of three or more courses of chemotherapy (31% response rate). The dose limiting toxicity was myelosuppression, which was equal on both regimens. Chills and fever were common in response to C. parvum, and, rarely hypotension, cyanosis, or immune nephritis was observed. The addition of C. parvum to chemotherapy with cyclophosphamide plus DTIC is not recommended.

Subcutaneous Corynebacterium parvum in bladder cancer: a controlled study of its immunological effects

Fourteen out of 26 patients with invasive bladder cancer were randomly assigned to receive weekly subcutaneous injections of Corynebacterium parvum (CP) in addition to standard treatment. Peripheral blood T lymphocyte percentage, K cell activity, mitogen responsiveness, and monocyte and polymorph leucotaxis were measured at intervals over a period of 1 to 2 years. The only consistent difference between the CP-treatment patients and the controls was a slightly higher level of K cell activity in the former, who, however, fared rather worse than the controls in terms of survival.

An evaluation of Corynebacterium parvum during remission maintenance therapy in pediatric patients with acute lymphoblastic leukemia

The biologic impact and clinical toxicity of Corynebacterium parvum administered at a dose of 5 mg/M2 by intravenous or subcutaneous routes were evaluated in 18 children receiving combination chemotherapy for maintenance of acute lymphoblastic leukemia (ALL) in remission. Several nonspecific immunologic and hematologic parameters were evaluated. Patients were also monitored for changes in cutaneous sensitivity to histamine. No changes in any parameter were observed in patients after only one course of C parvum injection. However, after 6-10 courses, glass-adherent peripheral blood leukocytes of C parvum-treated patients augmented the response of PHA-stimulated autologous lymphocytes. In all nine patients studied who received C parvum injection subcutaneously for at least six months, there were significant increases in the mean bone marrow myelocyte-erythrocyte (ME) volumes compared to pretreatment values. These results suggest that periodic evaluations are desirable in patients receiving repeated administration of C parvum, since changes in immunologic and hematologic responses may be demonstrable only after several injections. In contrast to the reported experience in adults, subcutaneous C parvum administration children was not well tolerated, whereas intravenous infusion was generally well tolerated.

Toxicity manifestations following intravenous Corynebacterium parvum administration to patients with ovarian and cervical carcinoma

Manifestations of clinical toxicity were evaluated following 341 courses of intravenous Corynebacterium parvum adjuvant immunotherapy in patients with ovarian and cervical carcinoma. Most patients exhibited symptoms of minor toxicity, which decreased in intensity as subsequent courses of therapy were administered. Temperature elevations to 38.5 degrees C. were the most objectively measured signs of toxicity but temperature elevations greater than 38.5 degrees C. occurred following only 20.5 per cent of the infusions. Blood pressure alterations were not a serious problem and no serious central nervous system or renal toxicity was noted. The minor side effects should not preclude the use of C. parvum as an immunopotentiating agent if it is shown to be beneficial in the treatment of human malignant disease.

A preliminary study of intralesional, intralymph node, intravenous and intraperitoneal Corynebacterium parvum treatments in patients with advanced cancer

Twenty-one patients with squamous cell carcinoma of oral cavity and/or cervical lymph node and four patients with soft tissue sarcomas were given intralesional (2-4 mg/m2) and intralymph node (2-4 mg/m2) C. parvum injections followed by 5 intravenous (2-4 mg/m2) C. parvum treatments and conventional therapies. Seven patients with Stage III ovarian carcinomas were given intraperitoneal (2-4 mg/m2) C. parvum injections followed by conventional therapies. The local and systemic effects of the C. parvum treatments were described and the anti-tumor effects were evaluated in this series of patients.

Immunology, tumor markers, and breast cancer

Although our knowledge of immunologic processes in breast cancer is still inadequate, many preliminary studies described here may yield valuable information after long-term patient follow-up. At present, there is no specific tumor marker diagnostic of breast cancer, but markers such as CEA, ferritin, immune complexes, and specially estrogen receptors have strong potential as prognostic indicators. As a group, breast cancer patients, as do those with other malignancies, demonstrate reduced immunologic capacity, therefore assays of nonspecific immune function may not be relevant. Assays of "specific" reactivity to breast tumor antigens, however, warrant further investigation as clinical tools. Application of immunotherapy to breast cancer is relatively recent and few trials have more than preliminary data. Determination of estrogen receptors should be included in future clinical immunotherapy protocols so that true evaluation of immunologic responses may benefit, hopefully, from our awareness of the endocrine milieu.

Phase I studies of C. parvum given intravenously: effects of dexamethasone on its biologic and toxic properties

Three biologic effects were clearly associated with C. parvum infusions: a) granulocytosis with lymphomonocytopenia, b) increase in responsiveness to phytohemmagglutinin and c) increase of specific antibodies to C. parvum antigens. Addition of dexamethasone moderately altered the kinetics of leukocyte changes without affecting other properties. Side effects after intravenous administration of C. parvum (2.5 mg/m2) consisted primarily of chills and fever which lasted for periods of 6-24 hours. Side effects occurred in 77% of the infusions. Addition of dexamethasone (4 mg IVP) reduced significantly the frequency (only 22% of patients) and intensity (fever 102 F and chills for only 30-60 minutes) of side effects. Clearly, dexamethasone of the dosage employed did not abrogate C. parvum effects while reducing significantly its toxic properties.

In vitro cytotoxicity of peritoneal macrophages activated with Mycobacterium smegmatis

Incorporation of 3H-TdR into EL4 leukemic cells in vitro was inhibited by peritoneal exudate cells (PEC) harvested from syngeneic C57BL/6J mice given an intraperitoneal (i.p.) injection of 1x10(7) viable Mycobacterium smegmatis ATCC 607 (Smeg) 4 days before. This phenomenon was also observed in the following five systems of PEC from animals and syngeneic tumor cells: C57BL/6J mice and B16 melanoma; DBA/2 mice and P815 mastocytoma; SWM/Ms mice and K5 fibrosarcoma; BALB/c, nu/nu mice and KKN-1 fibrosarcoma; and strain 2 guinea pigs and line-10 hepatoma. The in vitro cytotoxicity of the PEC activated by viable Smeg was much higher than those activated by dead-Smeg, viable BCG or proteose peptone. The activity of the adherent fraction of the PEC was stronger than that of the nonadherent one, and not influenced by either anti-theta or anti-mouse lymphocyte rabbit sera. The PEC induced with Smeg 4 days before contained a large population of mononuclear cells (88.9%) and a significant level of polymorphonuclear cells (PMN) (3.2%), and showed a much higher cytotoxicity than the PEC induced with Smeg 3 hr before, which contained a much larger population of PMN (71.9%), suggesting that PMN were not the effector cells in this system. In vitro and in vivo treatment with macrophage-inhibitors such as carrageenan, trypan blue and cytochalacin B, reduced the activity of the PEC. All of these facts suggested macrophages as the effector. Viable macrophages were required for the growth inhibition of EL4 in vitro: gamma-ray irradiated or freeze-thawed macrophages were ineffective. Kinetic studies revealed that inhibition of 3H-TdR incorporation into EL4 cells started within 3 hr of incubation together with the activated macrophages at an effector to target (E/T) ratio of 5, and the incorporation decreased gradually with the lapse of incubation time. On the other hand, 51Cr release from labelled EL4 was undetected when the E/T ratio was 5 but detected at on E/T of 10 or more. Even at the higher E/T ratio, at least 10 hr were needed until the release of 51Cr, suggesting that the activated macrophages produced growth inhibition of tumor cells followed by cell destruction.

Assessment of the role of surgery for control of lung cancer

When morphologically stratified, the classification of patients according to surgical stage provides an objective basis for evaluating the results of surgical treatment. In a review of 794 patients according to surgical staging criteria, the data supported concepts regarding differences in the behavior of each cell type as well as major differences in survival between each stage of disease. The overall cumulative five-year survival was 37% for squamous cell carcinoma, 27% for adenocarcinoma, and 27% for undifferentiated large cell carcinoma. Fewer than 1% of patients with undifferentiated small cell carcinoma survived. Survival for patients with surgical Stage I disease was 53%, for Stage II 29%, and for Stage III 16%. The results of surgical treatment for patients with limited disease extent are much better than is generally realized. Fifty to 60% of such patients in this series survived five years. Survival studies by surgical stage permit resonable estimates of the presence of occult metastatic disease and supply insights necessary to the design and appropriate selection of adjunctive therapeutic programs.

An analysis of the factors allowing promotion (rather than inhibition) of tumour growth by Corynebacterium parvum

The following factors were found to determine whether C. parvum (CP) treatment promoted rather than inhibited the growth of methylcholanthrene-induced fibrosarcoma cells injected into CBA mice. (1) The dose of tumour cells. Promotion occurred only with low doses, around the TD50. (2) The route of injection of CP. Greater promotion was caused by intravenous (IV) than by subcutaneous (SC) administration. Addition of irradiated tumour cells to SC CP resulted in tumour inhibition. (3) The dose of CP. Promotion increased with increasing dose of either SC or IV CP. (4) The time of CP injection relative to tumour challenge. Promotion only occurred when CP was given before tumour cells, except when using IV CP and very few tumour cells. With increasing doses of tumour cells, first post-treatment with IV CP and then pre-treatment became inhibitory. The effect of CP on established immunity to tumour cells was also studied. Mice were immunized by tumour amputation. The resistance to tumour challenge thus generated could be abrogated by CP given before challenge, most effectively by a high dose IV. The data are interpreted according to the following hypothesis. (1) CP suppresses the expression of cell-mediated immunity to tumour antigens. (2) This is caused by trapping of anti-tumour effector cells at the site of CP deposition. (3) Promotion can only occur when CP is given before effector cells have reached the tumor site.

Immunological monitoring and immunotherapy in carcinoma of the lung

One hundred and seven patients with carcinoma of the lung underwent immunologic testing, and 62 of these patients were randomized to an immunotherapy protocol comparing the effects of Pasteur strain BCG, either alone or combined with allogeneic tumor cells, to the effects of no immunotherapy. Patients with residual disease left at the time of surgery or with metastatic disease at the time of diagnosis showed no increase in survival as a result of this form of immunotherapy. An insufficient number of patients with less advanced disease, in whom we would expect the most beneficial effect, have been entered in this study. In general, we were unable to document substantial effects of immunotherapy on the immunologic parameters tested. Only in recall antigen skin testing was there a statistically significant increase in reactivity in the immunotherapy groups. Tests of general immune status appeared to have a predictive value in monitoring lung cancer patients. Anergic patients had a poorer prognosis than did patients who demonstrated skin test reactivity. Patients with normal percentages of lymphocytes (T cells) forming rosettes with sheep erythrocytes at 29 degrees C were generally normal in other tests of immune competence. In serial studies of rosette formation, all patients who developed recurrent disease had a pattern of depressed or falling rosette values, and these abnormalities occurred an average of 3.1 months prior to clinical detection of recurrence. Patients with large-cell anaplastic carcinoma were found to have a significantly higher incidence of depressed rosette levels than the other histologic types. Both large and small-cell anaplastic patients had significantly depressed lymphocyte proliferation by mitogens and allogeneic cells. Although lung cancer patients have been described as immunologically depressed, they are capable of recognizing tumor-associated antigens. When tested in leukocyte migration inhibition assays with tumor-associated antigens, the majority of the patients in our study were found to be reactive. The use of a 3 M KCl extract of pleural effusion cells from a patient with pulmonary adenocarcinoma has given good reactivity and specificity in lung cancer patients of all histologic types. In addition, these patients have been shown to respond in a mixed lymphocyte/tumor interaction to tumor-associated antigens (Dean, 1976b).

Complement activation in vivo in cancer patients receiving C. parvum immunotherapy

Serum complement levels were assayed in 26 patients with disseminated cancer, who received immunotherapy with infusion of C. parvum. Complement activation, indicated by the consumption of C3 or C4 or both, was found in 46% of the patients. Serum samples showed direct correlation between decreased C3 and conversion of C3 proactivator, whereas such conversion did not occur when C4 alone was decreased. It is concluded that the bypass (properdin) pathway was activated in patients in whom C3 consumption was detected, while the classical (C1) pathway was activated in the patients with C4 consumption unaccompanied by C3 decrease. Direct correlation was observed between delayed cutaneous hypersensitivity reactions to recall antigens and the incidence of C. parvum-associated complement activation.

Immunotherapy of leukemia

The data reviewed in this paper indicate that immunotherapy is effective in prolonging remission and survival in acute and chronic leukemia. The acute lymphocytic leukemias may or may not respond to immunotherapy and further work is needed in this area. No studies of immunotherapy in chronic lymphocytic leukemia have been done, but this will be an important area for investigation, since there is often profound immunodeficiency in this disease. The malignant lymphomas are another fertile area for this type of research, since they have a high response rate, tumor-associated immunodeficiency, and at least differentiation antigens if not tumor-specific antigens. The scientific basis for the use of immunotherapy in leukemia includes the demonstration of a relationship of rate and duration of remission and survival to immunocompetence, the demonstration of unique tumor-associated antigens on leukemia cells, and the demonstration of immune responses to these antigens which can be boosted by immunization. At the present time, active nonspecific immunotherapy with BCG and MER and active specific immunotherapy have been proved effective in acute myelogenous leukemia. Careful attention should be given to dose, schedule, route, and so forth. Other types of immunotherapy remain to be explored.