Phenotypes and lymphokine-activated killer activity of pleural cavity lymphocytes of lung cancer patients without malignant effusion

Albumin Paclitaxel Combined with Intrapleural Infusion of Bevacizumab + Lobaplatin for the Second-Line Treatment of Patients with Non-Squamous Non-Small Cell Lung Cancer

Objective

To investigate the clinical efficacy and safety of albumin paclitaxel combined with intrapleural bevacizumab + lobaplatin for patients with non-squamous non-small cell lung cancer (NS-NSCLC) with malignant pleural effusion (MPE) and analyze prognostic factors.

Methods

A total of 126 NS-NSCLC patients were included in the study. Control group with 64 cases received intrapleural infusion of lobaplatin + intravenous albumin paclitaxel, and treatment group with 62 cases received additional intrapleural bevacizumab perfusion. Analysis was performed by collecting data about MPE, progression-free survival (PFS), overall survival (OS), and scores of quality of life.

Results

In the treatment and control groups, objective response rate (ORR) was 51.6% and 31.3% (χ² = 5.39, P=0.02), and disease control rate (DCR) was 91.9% and 71.9% (χ² = 8.49, P=0.004), respectively. The main adverse reactions (≥grade 3) in the treatment group were thrombocytopenia, peripheral neurotoxicity, proteinuria, neutropenia, and nausea/vomiting, and in the control group, they were weakness, nausea/vomiting, anemia, and peripheral neurotoxicity. In the control and treatment groups, the median PFS was 6.2 (95% confidence interval (CI): 5.86–6.56) and 5.1 (95% CI: 4.956–5.191), and the median OS was 14.4 (95% CI: 12.681–16.113) and 10.6 months (95% CI: 8.759–12.391). The score of quality of life for treated patients was significantly higher than those before treatment and the control group, and the parameters included general health status (GH), role physical (RP), body pain (BP), social function (SF), and vitality (VT); pH, CD4+/CD8+ values, and vascular endothelial growth factor (VEGF) in the pleural effusion significantly affected the PFS and OS (P < 0.05). Bevacizumab administration in patients with bloody pleural effusion did not increase the risk of pleural hemorrhage.

Conclusion

The combination of albumin paclitaxel and intrapleural bevacizumab + lobaplatin is effective and may reverse the adverse events in patients with NS-NSCLC and MPE. The change of CD4+/CD8+ ratio before and after treatment is an independent and prognostic factor for patients with NS-NSCLC and MPE.

Generation and differentiation of IL-17-producing CD4+ T cells in malignant pleural effusion

IL-17-producing CD4(+) T (Th17) cells have been found to be increased in some human cancers; however, the possible implication of Th17 cells in regulating antitumor responses in malignant pleural effusion (MPE) remains to be elucidated. In the current study, distribution and phenotypic features of Th17 cells in both MPE and peripheral blood from patients with lung cancer were determined by flow cytometry or double immunofluorescence staining. The impacts of cytokines on Th17 cell generation and differentiation were explored. The chemoattractant activity of chemokines CCL20 and CCL22 for Th17 cells in vitro was also observed. It was found that the increased Th17 cells could be found in MPE compared with blood. The in vitro experiments showed that IL-1β, IL-6, IL-23, or their various combinations could promote Th17 cell generation and differentiation from naive CD4(+) T cells. MPE was chemotactic for Th17 cells, and this activity was partly blocked by anti-CCL20 and/or CCL22 Abs. Our data also showed that the accumulation of Th17 cells in MPE predicted improved patient survival. It could be concluded that the overrepresentation of Th17 cells in MPE might be due to Th17 cell differentiation and expansion stimulated by pleural proinflammatory cytokines and to recruitment of Th17 cells from peripheral blood induced by pleural chemokines CCL20 and CCL22. Furthermore, the accumulation of Th17 cells in MPE predicted improved patient survival. These data provide the basis for developing immune-boosting strategies based on ridding the cancer patient of this cell population.

Pleural macrophages are the dominant cell population in the thoracic cavity with an inflammatory cytokine profile similar to peritoneal macrophages

Numerous human macrophage (mphi) subpopulations with different behavior have been identified in adults. It is well known that peritoneal mphi are activated by abdominal surgery and subsequently contribute to a systemic inflammatory response that leads to immune suppression, increased morbidity and mortality. Information on the role of pleural mphi in adults is scarce and information on their role in children is lacking. We investigated the behavior of pleural versus peritoneal mphi in children and adolescents. As a first step, we compared the cellular composition of the pleural and peritoneal surface in children and adolescents. Pleural and peritoneal lavages were performed in 21 patients undergoing non-contaminated laparoscopic and thoracoscopic surgical procedures. We observed a significantly higher percentage of mphi in the pleural compared to the peritoneal cavity with less lymphocytes, a small amount of polymorphonuclear cells (PMNs) and other cells. To further study the mphi inflammatory response, we measured the spontaneous and LPS triggered cytokine release of isolated pleural versus peritoneal mphi (IL-1beta, IL-6, and IL-10). The pattern of cytokine release was similar in both, pleural and peritoneal mphi. Directly after lavage, they showed a strong activation, with no difference between stimulated and non-stimulated cells. After 24 h resting, mphi of both compartments reacted to LPS with a similar significant increase in the cytokine release. In conclusion, our results demonstrate that pleural mphi represent the dominant cell population in the pleural cavity of the young. They show a similar inflammatory response as peritoneal mphi and should be considered to play a major role in the local inflammatory response to thoracic surgery.

CD4+CD25+ regulatory T lymphocytes in malignant pleural effusion

BACKGROUND

Active suppression by CD4(+)CD25(+) regulatory T lymphocytes plays an important role in the downregulation of T-cell responses to foreign and self-antigens.

OBJECTIVE

To analyze whether the CD4(+)CD25(+) regulatory T lymphocytes exist and function normally in malignant pleural effusion.

METHODS

The percentages of CD4(+)CD25(+) T lymphocytes in pleural effusion and peripheral blood from patients with lung cancer with malignant effusion, pleural lavage and peripheral blood from patients with lung cancer without effusion, and peripheral blood from healthy control subjects were determined by flow cytometry. The expressions of forkhead transcription factor Foxp3 and cytotoxic lymphocyte-associated antigen-4 were also examined. CD4(+)CD25(+) and CD4(+)CD25(-) T cells from pleural effusion and peripheral blood were isolated, and were cultured to observe the effects of CD4(+)CD25(+) cells on proliferation response of CD4(+)CD25(-) T cells in vitro.

MAIN RESULTS

There were increased numbers of CD4(+)CD25(+) T cells in malignant pleural effusion from patients with lung cancer compared with pleural lavage from patients with lung cancer without pleural effusion, and that these cells have constitutive high-level expression of Foxp3 and cytotoxic lymphocyte-associated antigen-4. Furthermore, CD4(+)CD25(+) T cells mediate potent inhibition of proliferation response of CD4(+)CD25(-) T cells, and anticytotoxic lymphocyte-associated antigen-4 monoclonal antibody could reduce the inhibitory activity of CD4(+)CD25(+) T cells.

CONCLUSIONS

The increased CD4(+)CD25(+) T cells found in malignant pleural effusion express high levels of Foxp3 transcription factor and potently suppress the proliferation of CD4(+)CD25(-) T cells, and cytotoxic lymphocyte-associated antigen-4 is involved in the suppressive activity of pleural CD4(+)CD25(+) T cells.

Prognostic value of CD4+ lymphocytes in pleural cavity of patients with non-small cell lung cancer

BACKGROUND

For patients with non-small cell lung cancer the TNM staging system and other conventional prognostic factors fail to predict accurately the outcome of treatment and survival. This study attempts to determine the prognostic value for survival of the proportions of CD4+ lymphocytes in the pleural cavity (PLY) of patients with resectable non-small cell lung cancer.

METHODS

Lymphocytes in the pleural cavity separated from 51 patients with non-small cell lung cancer were examined by flow cytometry to measure the proportions of CD4+ PLY. Univariate and multivariate analyses were performed to assess the association between the proportion of CD4+ PLY and survival.

RESULTS

The 5 year survival rate of patients with percentage CD4+ PLY of ⩽30% was 84% whereas that of patients with %CD4+ PLY >30% was 26.9%. The difference in survival between the %CD4+ PLY ⩽30% and %CD4+ PLY >30% groups was significant (p<0.0001). The %CD4+ PLY in those who survived for 5 years was significantly lower than that in the patients who died within 5 years (p<0.0001). The difference in survival between patients with stage IA and IB lung cancer with %CD4+ PLY ⩽30% and those with %CD4+ PLY >30% was also significant (p =0.015). Multivariate analysis showed that the proportion of CD4+ PLY (hazard ratio=6.9, 95% CI 0.045 to 0.47) and nodal status (hazard ratio=22.7, 95% CI 0.006 to 1.806) are significant and independent prognostic factors for the survival of patients with lung cancer.

CONCLUSIONS

The proportion of CD4+ PLY may help to select patients who are likely to have a poorer prognosis after surgery and therefore may be suitable for consideration of adjuvant treatments. These results need confirmation in a larger prospective study.

Prognostic value of CD4+ lymphocytes in pleural cavity of patients with non-small cell lung cancer

BACKGROUND

For patients with non-small cell lung cancer the TNM staging system and other conventional prognostic factors fail to predict accurately the outcome of treatment and survival. This study attempts to determine the prognostic value for survival of the proportions of CD4+ lymphocytes in the pleural cavity (PLY) of patients with resectable non-small cell lung cancer.

METHODS

Lymphocytes in the pleural cavity separated from 51 patients with non-small cell lung cancer were examined by flow cytometry to measure the proportions of CD4+ PLY. Univariate and multivariate analyses were performed to assess the association between the proportion of CD4+ PLY and survival.

RESULTS

The 5 year survival rate of patients with percentage CD4+ PLY of < or = 30% was 84% whereas that of patients with %CD4+ PLY > 30% was 26.9%. The difference in survival between the %CD4+ PLY < or = 30% and %CD4+ PLY > 30% groups was significant (p < 0.0001). The %CD4+ PLY in those who survived for 5 years was significantly lower than that in the patients who died within 5 years (p < 0.0001). The difference in survival between patients with stage IA and IB lung cancer with %CD4+ PLY < or = 30% and those with %CD4+ PLY > 30% was also significant (p = 0.015). Multivariate analysis showed that the proportion of CD4+ PLY (hazard ratio = 6.9, 95% CI 0.045 to 0.47) and nodal status (hazard ratio = 22.7, 95% CI 0.006 to 1.806) are significant and independent prognostic factors for the survival of patients with lung cancer.

CONCLUSIONS

The proportion of CD4+ PLY may help to select patients who are likely to have a poorer prognosis after surgery and therefore may be suitable for consideration of adjuvant treatments. These results need confirmation in a larger prospective study.

Evidence for cytotoxic T lymphocyte response against human lung cancer: reconstitution of antigenic epitope with peptide eluted from lung adenocarcinoma MHC class I

BACKGROUND

Cancer-associated, major histocompatibility complex (MHC)-restricted peptide antigens have been elucidated in human melanomas and ovarian, breast, and renal carcinomas; but relatively little is known about lung cancer antigens.

METHODS

To work toward delineation of lung cancer-associated antigens, we developed tumor infiltrating lymphocytes (TILs), peripheral blood mononuclear cell-derived cytolytic T cell lines (CTL), autologous lung cancer cell lines, and normal lung cell lines from 17 patients undergoing lung cancer resections. The TILs and CTL lines were subsequently evaluated for markers of activation and specific lysis of autologous or allogeneic lung cancer cell lines or both.

RESULTS

Freshly isolated TILs contained a more activated T cell population compared with the patients' peripheral blood T cells as evidenced by an increased expression of HLA-DR, CD25, and CD45RO. TILs isolated from 15 patients lysed allogeneic lung cancer lines. TILs lysed autologous lung cancer but not autologous normal lung or Epstein-Barr virus transformed B cell lines (B-LCL) in 4 of 8 cases tested, suggesting tumor specificity. A CTL line (RHPBL57.1) was generated from peripheral blood mononuclear cells of an HLA-A24(+) patient by stimulation against an established HLA-A24(+) allogeneic lung cancer cell line. RHPBL57.1 lysed the lung cancer cell line in an HLA-A24-restricted manner. Moreover, RHPBL57.1 specifically lysed autologous B-LCL pulsed with peptides, eluted from MHC class I and isolated from the HLA-A24(+) lung cancer cell line.

CONCLUSIONS

TILs isolated from patients with lung cancer are predominantly an activated population of T cells with evidence of tumor and MHC class I-restricted lysis. Furthermore, we provide evidence for a lung cancer-associated, MHC class I-bound peptide antigen(s) that reconstitutes the epitope recognized by a lung cancer specific CD8(+) T cell line derived from a patient with lung cancer.

T lymphocyte activation in myasthenic thymoma

The functional and phenotypic characteristics of lymphocytes separated from myasthenic thymoma (Th-L) were compared with those of lymphocytes separated from non-thymomatous thymus associated with thymoma (NTh-L) of the same patients and NTh-L of myasthenia gravis (MG) patients without thymoma. We examined whether Th-L and NTh-L of MG patients reacted to interleukin-2 (IL-2) to develop lymphokine-activated killer (LAK) activity and/or cytolytic activity against K562 (natural killer (NK) activity), and the phenotypic changes in such cells during incubation. Ten MG patients with thymoma and six MG patients without thymoma, and four non-MG thymoma patients were included in this study. Th-L and NTh-L of MG patients reacted with IL-2 to develop LAK and NK activities. The LAK activity developed from Th-L was significantly higher than that from NTh-L, and the LAK activity developed from Th-L was as high as that from peripheral blood lymphocytes (PBL) in MG patients without thymoma. The proportions of CD3+ cells, CD4+/CD8- cells, and CD4-/CD8+ cells in Th-L of MG patients increased significantly during incubation. On the other hand, the proportion of CD4+/CD8+ cells in Th-L of MG patients decreased significantly. The proportions of CD4+/CD8- cells, CD4-/CD8+ cells, and CD4+/CD8+ cells in NTh-L of MG patients with and without thymoma exhibited no change during incubation. These findings suggest that CD4+/CD8+ Th-L of MG patients may have a higher potential to react to IL-2 than NTh-L, and that the former cells might develop LAK activity like that of PBL on maturation to CD4+/CD8- cells and CD4-/CD8+ cells. Our findings also suggested that Th-L might play an important role in the pathogenesis of MG with thymoma.

OK-432 develops CTL and LAK activity in mononuclear cells from regional lymph nodes of lung cancer patients

We examined the effect of OK-432 on induction of cytotoxic T lymphocytes (CTL) directed against autologous tumor cells (ATC) and lymphokine-activated killer (LAK) cells from mononuclear cells separated from regional lymph node cells (RLMNCs) of 49 lung cancer patients. We also examined the phenotypic changes of RLMNCs during incubation with or without OK-432. Significant CTL activity and LAK activity against ATC developed from RLMNCs after stimulation with OK-432 or IL-2. Sequential treatment with OK-432 plus IL-2 or IL-2 plus OK-432 also developed significant CTL activity and LAK activity from RLMNCs. The CTL activity produced by OK-432 alone was as high as the CTL activity developed by IL-2 alone, OK-432 plus IL-2, or IL-2 plus OK-432. There was no significant difference in the CTL activities achieved by these four treatments. The proportion of CD25+ cells in RLMNCs after incubation with OK-432 was twice that before incubation. Although OK-432 increased IL-2 receptor expression on RLMNCs, it showed no synergistic effect with IL-2 in developing CTL and LAK activity. After incubation with OK-432, the proportion of HLA-DR + cells was also increased significantly. Moreover, the proportions of HLA-ABC+ and HLA-DR+ (class I and class II major histocompatibility complex antigens) cells in ATC were significantly larger than in Daudi cells. OK-432 alone could develop CTL activity against ATC from the RLMNCs of lung cancer patients that was as high as that developed by IL-2 alone or by sequential treatment with OK-432 plus IL-2 or IL-2 plus OK-432. The CTL developed from the RLMNCs of lung cancer patients may recognize class I and/or II antigens on the surface of ATC. These results indicated that treatment with OK-432 might be therapeutically useful for lung cancer patients as a CTL inducer rather than a LAK inducer.

Elevation of interleukin-10 levels in malignant pleural effusion

STUDY OBJECTIVE

Human immunity has been found to have two major components, cellular and humoral immunity. T-helper type 1 (Th1) pathway favors cellular immunity and Th2 pathway favors humoral immunity. Early determination toward Th1 and Th2 cells in the immune response is dependent on the balance between interleukin-12 (IL-12), which favors Th1 responses, and IL-4, which favors Th2 responses. IL-2 and interferon-gamma (IFN-gamma) are produced in the Th1 pathway, and IL-4 and IL-10 are produced in the Th2 pathway. Lack of cellular immunity, IL-2, and IFN-gamma had been reported in malignant pleural effusions. However, to our knowledge, there are no previous reports on other cytokine components involving Th1 or Th2 pathway. The present study was designed to answer these questions.

DESIGN

Cytokine levels in peripheral blood and pleural fluid of 21 patients with malignant pleural effusion, including IL-4, IL-10, and IL-12, were analyzed with enzyme-linked immunosorbent assays. Lymphocyte subpopulations of peripheral blood and pleural effusion were also studied by using flow cytometry.

MEASUREMENTS AND RESULTS

The results showed a significant increase in IL-10 level as compared with blood samples. IL-4 and IL-12 were below minimal detectable concentrations both in the blood and the effusion. The ratio of pleural helper T cells was significantly higher than in the blood (p = 0.0002). The ratio of pleural natural killer (NK) cells was significantly lower than in the blood (p = 0.0001). The ratio of pleural suppressor T cells was lower than blood with borderline significance (p = 0.0522). No significant change in B-lymphocyte ratio between blood and pleural effusion was found (p = 0.2471). There was no correlation between difference in IL-10 level and lymphocyte subpopulation of pleural effusion and blood samples.

CONCLUSIONS

Helper T-cell subpopulations were increased while NK and suppressor T-cell subpopulations were decreased in malignant pleural effusions. The decrease in NK cell subpopulations with elevated IL-10 and minimal IL-12 concentration in neoplastic pleural effusion would suggest the usage of IL-12 or antibody of IL-10 to improve local cellular immunity. Further study is needed.

Myasthenia gravis induces the activation and maturation of lymphocytes in thymoma

The biological differences between lymphocytes separated from thymoma patients with myasthenia gravis (MG) and those separated from thymoma patients without MG was examined. We investigated whether lymphocytes in thymoma (Th-L) of patients with and without MG could react to interleukin-2 (IL-2) to develop cytolytic activity against K562 and lympho kine-activated killer (LAK) activity, and their phenotypic changes during incubation with IL-2. Sixteen thymoma patients who consisted of eight patients with MG and eight patients without MG were investigated. Th-L of all MG patients could react to IL-2 to develop LAK activity. Th-L of all of MG patients also developed cytolytic activity against K562 target cells. Cytolytic activity against K562 and LAK activity from Th-L of the MG patients were significantly higher than those from Th-L of the patients without MG (P < 0.01, P < 0.01). The proportions of CD3+ and CD4-/CD8+ cells of Th-L of MG patients increased significantly during the incubation period with IL-2 (P < 0.05, P < 0.05). The proportion of CD4+/CD8+ cells of Th-L of patients with MG decreased significantly (P < 0.05) during incubation with IL-2. On the other hand, there was no significant phenotypic change in Th-L of the patients without MG. These results indicate that MG induces the functional and phenotypic activation and functional and phenotypic maturation of Th-L.

Granulocyte-macrophage colony-stimulating factor augments lymphokine-activated killer activity from pleural cavity mononuclear cells of lung cancer patients without malignant effusion

The role of recombinant granulocyte-macrophage colony-stimulating factor (GM-CSF) in augmentation of lymphokine-activated killer (LAK) cell induction by interleukin-2 (IL-2) from pleural cavity mononuclear cells (PCMNCs) was examined in sixteen patients with resectable primary lung cancer not associated with malignant effusion. None of the patients had received any anticancer therapy prior to this study. Incubation of PCMNCs of patients without malignant effusion with GM-CSF for 4 days in the presence of IL-2 resulted in a significant increase in LAK activity against natural killer-resistant Daudi cells. This result was obtained by using the 4 h 51Cr-release assay. PCMNCs and blood mononuclear cells (BMNCs) were harvested simultaneously from pleural cavity lavage fluid and peripheral blood in lung cancer patients. The LAK activity developed from PCMNCs and BMNCs following incubation with IL-2 for 4 days, but the LAK activity from PCMNCs was significantly lower than that from BMNCs (P < 0.05). Incubation of PCMNCs with GM-CSF augmented the LAK activity from PCMNCs to a level as high as that from BMNCs. These results suggest that the combined use of GM-CSF with IL-2 may result in augmentation of LAK activity developed from PCMNCs of lung cancer patients without malignant effusion.