C l i n i c a l V a l u e o f I m m u n o c h e m o t h e r a p y w i t h OK-432 or P S - K f o r S t o m a c h C a n c e r P a t i e n t s Shigeru FUJIMOTO,Makoto TAKAHASItI,T o m o h i t o MINAMI, Hiroaki ISHIGAMI, Masaru MIYAZAKI and Kenjiro ITOH A B S T R A C T : A prospective clinical trial was undertaken in 121 patients with stomach cancer to compare i m m u n o c h e m o t h e r a p y with 5-fluorouracil and FT-207 combined with OK-432 or PS-K, immunostimulators, and plain chemotherapy with 5-fluororacil and FT-207. O f the 121 patients who received immunochemotherapy, 67 patients (group A) had undergone curative removal of the tumor. The other 54 patients had undergone noncurative tumor removal or had recurrence after non-curative tumor removal and they were divided into two groups (groups B and C) on the basis of lymphocyte reactivity induced with P H A . Although group A exhibited a significant increase in PHA-induced lymphocyte transformation and a trifling increase in lymphocyte counts, its survival rate within a 36 month period did not differ from that of the peer controls. Group B, composed of 21 patients showing improvement of PHA-induced lymphocyte transformation, significantly prolonged its survival compared to the peer controls. The survival of group C, composed of 33 patients showing a gradual drop in PHA-induced lymphocyte transformation, was not prolonged compared to the peer control patients; and they showed significant decreases in lymphocyte counts. The overall survival of group B and group C was not superior to that of the 48 peer controls. K E Y W O R D S : immunochemotherapy, OK-432, PS-K, stomach cancer, survival, PHA-induced lymphocyte transformation, DNCB skin Test. ~
INTRODUCTION A considerable amount of information has been accumulated concerning immunotherapy for cancer. H u m p h r y et al.7, s reported that immunotherapy with a tumor "vaccine" affected favorably the clinical course of patients with malignant tumor. Furthermore, it was reported by Seigler et a1.16,17 and Morton et al.l~ 11 that the results o f B C G immunotherapy in patients with advanced malignant tumor are encouraging. Above all, Everson and Cole 2 described that the disappearance of the primary tumor was associated with the development of abscesses. It is generally recognized that host immune response to the infection is also responsible for tumor regression. OK-432, a drug which was prepared from streptococcus haemolyticus by Okamoto et a1.,12,18 is one of the drugs used for immunotherapy in Japan. Sakurai et al. 15 have reported that pretreatment with OK-432 prolonged significantly the life-span of tumor-bearing rats. O n the other hand, Yoshikumi et al. TMreported recently that protein polysaccharide, PS-K, isolated Coriolns versicolor belonging to the Basidiomycetes class was effective From the First Department of Surgery, School of Medicine, Chiba University, Chiba, Japan JAPANESEJOURNALOF SURGERY,VOL. 9, No. 3, pp. 190-196, 1979
Volume 9
Number 3
Clinical Value of lmmunochemotherapy
191
against mouse sarcoma 180 by stimulating cellular immunity. We in the First Department of Surgery, Chiba University Hospital, Japan, initiated from December, 1973, immunochemotherapy with OK-432 or PS-K as an adjuvant to surgery. The purpose of this paper is to evaluate adjuvant immunochemotherapy with OK-432 or PS-K to patients with stomach cancer. MATERIALS AND METHODS
The patients included in this study were treated by the authors in our surgical department of Chiba University Hospital. One hundred and twenty-one patients with curatively and non-curatively resected stomach cancer were admitted in this study. In every case, the diagnosis was confirmed by histological examination. The patients ranged in age from 24 to 67 years with a mean of 54.7. Immunologic Evaluation : Immunologic evaluations of all patients were performed by lymphocyte blastogenesis, lymphocyte count, and skin tests prior to immunochemotherapy and/or surgery. These were also performed during the lapse of the clinical course. T h e peripheral lymphocyte blastogenesis was measured by aH-thymidine uptake in a modified method 6 of the whole blood culture by Park and Good. 14 Briefly, 50/21 of heparnized blood was diluted with 100 /21 of Roswell Park Memorial Institute m e d i u m 1640 (Grand Island Biological Company, Grand Island, New York, U.S.A.) containing 100/2g of phytohemagglutinin-M (PHA-M) (Difco Laboratories, Detroit, Michigan, U.S.A.). The cultures were kept in a CO2 incubator for 48 hours at 37~ with 0.5 r of 3ttthymidine added at the midpoint of the incubation period. The cultures were harvested on 25 m m diameter filter p a p e r (pore size 1.2/i, Millipore Corporation, Bedford, Massachusetts, U.S.A.) by dissolution of erythrocytes with 3 ml of distilled water. Following this, the filter was treated with two washes each of 0.9% NaC1 solution and 5 % ice-cold trichloroacetic acid. The filter was placed for 12 hours in a counting vial with 0.2 ml of 0.3N-KOH and then counted in a liquid scintillation counter after addition of 10 ml of Bray solution. Triplicate cultures with and without P H A were always carried out and varied less than 15% from the mean. T h e term "stimulation index" was used to describe lymphocyte blastogenesis, that is, stimulation index =
C P M obtained by cultures with P H A C P M obtained by cultures without P H A
As a skin test, the D N C B reaction procedure (a slight modification of Eilber and Morton's method 1) was put into practice. Treatment Undergone: Seventy-nine of 121 patients had been treated with PS-K and the other 42 with OK-432. PS-K or OK-432 was used in combination with chemotherapy as reported previously.4 O f these, 9 cases were eliminated for one of the following reasons: 1) conspicuous lack of doses of PS-K or OK-432 because of some aversion to the drugs; 2) failure to return for followup. T h e 79 patients who were treated with PS-K received orally 60 to 120 mg/kg/day and were given 731 g of PS-K as an average total dose. The 42 patients who were treated with OK-432 received intravenously or subcutaneously 0.2 KE/day* as an initial * KE is an abbreviation for "Klinische Einheit."
192
Jpn. J. Surg. Sept. 1979
Fujimoto et al.
dose, and their average total dose amounted to 108 KE. These treatments began on about day 10 after operation. T h e treatment with PS-K continued for at least 8 to 12 months. The OK-432 therapy continued daily without interruption until discharge and then was further continued at a once a week outpatient rate. These 121 patients were compared with similar peer patients receiving the previousreported chemotherapy 4 without PS-K or OK-432. This plain chemotherapy with orally administered 5-FU and/or FT-207, as an adjuvant to surgical treatment, has been performed since 1970 in our surgical department. 4 The 109 peer patients included in this study received consecutively 5-FU and/or FT-207 for at least 12 months. The 121 patients treated by PS-K or OK-432 were divided into 3 groups. Group A: 67 patients having undergone curative removal of the tumor and receiving immunochemotherapy. Group B: 21 patients with non-curatively resected stomach cancer receiving the drugs, and showing improvement of PHA-induced lymphocyte transformation. Group C: 33 patients with non-euratively resected stomach cancer receiving the drugs, but dying before any improvement o f PHA-induced lymphocyte transformation could be determined. Out of the 109 peer patients 61 patients were chosen for control of group A and 48 for control of groups B and C. ~.ESULTS
Survival Statistics
The survival of 67 patients in group A is compared to 61 peer control patients treated - -
i
i
i
100 [] "~\-~ 80
L
~ Group A
R----! Control .
.
.
~
B 4o
2o
1
r
Months after Operation Fig. 1. Survival curve for the patients who had undergone curative removal of the tumor.
Volume 9
Number 3
Clinical Value of Immunochemotherapy i
100 .iv---
~- ~ o o N----N o-----o
80
193 l
Group B Group C Groups B & C Control
60
k,
\
40
20
0 Fig. 2.
'It 6 12 Months after Operation
18
Survival curve for the patients with non-curatively resected or recurrent stomach cancer.
by chemotherapy only (Fig. 1). The survival rate in group A is unchanged from that of the peer controls (X 2 tests at 12, 24 and 36 months indicated by P < 0 . 2 , P < 0 . 5 and P < 0 . 8 , respectively). Survival data of 21 patients in group B and 33 patients in group C are shown in Fig. 2. These data are compared to a control group of patients treated with chemotherapy only. The higher survival rate in group B was observed. Comparing the 50~o survival point, there was a life prolongation from 5.0 months to 10.8 months (X 2 tests at 6, 9 and 12 months indicated P < 0 . 0 1 ,
INTRODUCTION A considerable amount of information has been accumulated concerning immunotherapy for cancer. H u m p h r y et al.7, s reported that immunotherapy with a tumor "vaccine" affected favorably the clinical course of patients with malignant tumor. Furthermore, it was reported by Seigler et a1.16,17 and Morton et al.l~ 11 that the results o f B C G immunotherapy in patients with advanced malignant tumor are encouraging. Above all, Everson and Cole 2 described that the disappearance of the primary tumor was associated with the development of abscesses. It is generally recognized that host immune response to the infection is also responsible for tumor regression. OK-432, a drug which was prepared from streptococcus haemolyticus by Okamoto et a1.,12,18 is one of the drugs used for immunotherapy in Japan. Sakurai et al. 15 have reported that pretreatment with OK-432 prolonged significantly the life-span of tumor-bearing rats. O n the other hand, Yoshikumi et al. TMreported recently that protein polysaccharide, PS-K, isolated Coriolns versicolor belonging to the Basidiomycetes class was effective From the First Department of Surgery, School of Medicine, Chiba University, Chiba, Japan JAPANESEJOURNALOF SURGERY,VOL. 9, No. 3, pp. 190-196, 1979
Volume 9
Number 3
Clinical Value of lmmunochemotherapy
191
against mouse sarcoma 180 by stimulating cellular immunity. We in the First Department of Surgery, Chiba University Hospital, Japan, initiated from December, 1973, immunochemotherapy with OK-432 or PS-K as an adjuvant to surgery. The purpose of this paper is to evaluate adjuvant immunochemotherapy with OK-432 or PS-K to patients with stomach cancer. MATERIALS AND METHODS
The patients included in this study were treated by the authors in our surgical department of Chiba University Hospital. One hundred and twenty-one patients with curatively and non-curatively resected stomach cancer were admitted in this study. In every case, the diagnosis was confirmed by histological examination. The patients ranged in age from 24 to 67 years with a mean of 54.7. Immunologic Evaluation : Immunologic evaluations of all patients were performed by lymphocyte blastogenesis, lymphocyte count, and skin tests prior to immunochemotherapy and/or surgery. These were also performed during the lapse of the clinical course. T h e peripheral lymphocyte blastogenesis was measured by aH-thymidine uptake in a modified method 6 of the whole blood culture by Park and Good. 14 Briefly, 50/21 of heparnized blood was diluted with 100 /21 of Roswell Park Memorial Institute m e d i u m 1640 (Grand Island Biological Company, Grand Island, New York, U.S.A.) containing 100/2g of phytohemagglutinin-M (PHA-M) (Difco Laboratories, Detroit, Michigan, U.S.A.). The cultures were kept in a CO2 incubator for 48 hours at 37~ with 0.5 r of 3ttthymidine added at the midpoint of the incubation period. The cultures were harvested on 25 m m diameter filter p a p e r (pore size 1.2/i, Millipore Corporation, Bedford, Massachusetts, U.S.A.) by dissolution of erythrocytes with 3 ml of distilled water. Following this, the filter was treated with two washes each of 0.9% NaC1 solution and 5 % ice-cold trichloroacetic acid. The filter was placed for 12 hours in a counting vial with 0.2 ml of 0.3N-KOH and then counted in a liquid scintillation counter after addition of 10 ml of Bray solution. Triplicate cultures with and without P H A were always carried out and varied less than 15% from the mean. T h e term "stimulation index" was used to describe lymphocyte blastogenesis, that is, stimulation index =
C P M obtained by cultures with P H A C P M obtained by cultures without P H A
As a skin test, the D N C B reaction procedure (a slight modification of Eilber and Morton's method 1) was put into practice. Treatment Undergone: Seventy-nine of 121 patients had been treated with PS-K and the other 42 with OK-432. PS-K or OK-432 was used in combination with chemotherapy as reported previously.4 O f these, 9 cases were eliminated for one of the following reasons: 1) conspicuous lack of doses of PS-K or OK-432 because of some aversion to the drugs; 2) failure to return for followup. T h e 79 patients who were treated with PS-K received orally 60 to 120 mg/kg/day and were given 731 g of PS-K as an average total dose. The 42 patients who were treated with OK-432 received intravenously or subcutaneously 0.2 KE/day* as an initial * KE is an abbreviation for "Klinische Einheit."
192
Jpn. J. Surg. Sept. 1979
Fujimoto et al.
dose, and their average total dose amounted to 108 KE. These treatments began on about day 10 after operation. T h e treatment with PS-K continued for at least 8 to 12 months. The OK-432 therapy continued daily without interruption until discharge and then was further continued at a once a week outpatient rate. These 121 patients were compared with similar peer patients receiving the previousreported chemotherapy 4 without PS-K or OK-432. This plain chemotherapy with orally administered 5-FU and/or FT-207, as an adjuvant to surgical treatment, has been performed since 1970 in our surgical department. 4 The 109 peer patients included in this study received consecutively 5-FU and/or FT-207 for at least 12 months. The 121 patients treated by PS-K or OK-432 were divided into 3 groups. Group A: 67 patients having undergone curative removal of the tumor and receiving immunochemotherapy. Group B: 21 patients with non-curatively resected stomach cancer receiving the drugs, and showing improvement of PHA-induced lymphocyte transformation. Group C: 33 patients with non-euratively resected stomach cancer receiving the drugs, but dying before any improvement o f PHA-induced lymphocyte transformation could be determined. Out of the 109 peer patients 61 patients were chosen for control of group A and 48 for control of groups B and C. ~.ESULTS
Survival Statistics
The survival of 67 patients in group A is compared to 61 peer control patients treated - -
i
i
i
100 [] "~\-~ 80
L
~ Group A
R----! Control .
.
.
~
B 4o
2o
1
r
Months after Operation Fig. 1. Survival curve for the patients who had undergone curative removal of the tumor.
Volume 9
Number 3
Clinical Value of Immunochemotherapy i
100 .iv---
~- ~ o o N----N o-----o
80
193 l
Group B Group C Groups B & C Control
60
k,
\
40
20
0 Fig. 2.
'It 6 12 Months after Operation
18
Survival curve for the patients with non-curatively resected or recurrent stomach cancer.
by chemotherapy only (Fig. 1). The survival rate in group A is unchanged from that of the peer controls (X 2 tests at 12, 24 and 36 months indicated by P < 0 . 2 , P < 0 . 5 and P < 0 . 8 , respectively). Survival data of 21 patients in group B and 33 patients in group C are shown in Fig. 2. These data are compared to a control group of patients treated with chemotherapy only. The higher survival rate in group B was observed. Comparing the 50~o survival point, there was a life prolongation from 5.0 months to 10.8 months (X 2 tests at 6, 9 and 12 months indicated P < 0 . 0 1 ,
