Critical Analysis of Treatment of Stage and Stage Melanoma Patients With Immunotherapy WILLIAM R. JEWELL, M.D., JAMES H. THOMAS, M.D., JOHN M. STERCHI, M.D.*, PAUL A. MORSE, PH.D., LOREN J. HUMPHREY, M.D.
Over the past 8 years, 244 patients with Stage II or III melanoma have been treated by cutaneous injection of a crude acellular homogenate of allogeneic melanoma cells (V-I) or a more concentrated fraction (V-II), followed in most patients by exchanges of WBC between paired partners. Patients with Stage III disease exhibited an overall response rate of 24% and prolongation of survival compared with control data. Stage II patients also had prolonged survival and reduced rate of recurrence over historic peers' data. Breakdown of subgroup data revealed that V-II plus exchange of WBC is similar to V-I plus exchange or V-II alone. However, recent experience with LTF suggests a higher response rate than in either V-I or V-II groups, particularly when autochthonous tumor is used for cross-immunization. The most meaningful immunologic data resulted from analysis of DNCB and MIF data. Patients negative to DNCB rarely respond to immunotherapy. A positive pretreatment MIF or positive conversion following treatment correlates with response, whereas, conversion of positive to negative predicts poor clinical performance. S EVERAL CLINICAL TRIALS
have demonstrated suc-
cessful treatment of micro and macro metastases of melanoma using a variety of immunotherapeutic techniques. Morton et al. have recorded regression of approximately 90Wo of subcutaneous and cutaneous melanoma nodules directly injected with Bacillus Calmette Guerin (BCG).1' In addition, several other noninjected nodules were noted to regress. Seigler also has shown, using a complex multiple treatment program ofactive specific and nonspecific immune stimulation, that melanoma-bearing hosts can be benefited by immune manipulation.16 Presented at the Annual Meeting of the Southern Surgical Association, December 8-10, 1975, The Homestead, Hot Springs, Virginia. * Current address: Bowman Gray School of Medicine, Winston Salem, North Carolina. Supported in part by John A. Hartford Foundation, Inc., and the American Cancer Society, ACS-IM-45. Reprint requests: William R. Jewell, M. D., Department of Surgery, University of Kansas Medical Center, 39th and Rainbow Boulevard, Kansas City, Kansas 66103.
From the Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas
Sumner and Foraker were the first to demonstrate that adoptive techniques can be effective.20 One of two patients transfused with whole blood removed from another melanoma patient who had complete "spontaneous regression" also had complete disappearance of all tumor. Nadler and Moore cross-immunized paired patients with each other's tumors.13 After the tumor implants were rejected or removed, patients' whole white blood cells (WBC) were cross-exchanged. One hundred thirteen patients with melanoma were treated in this fashion and 23 had objective tumor regression. 14 Krementz later confirmed this observation using a similar system.9 Humphrey et al. demonstrated that an acellular tumor homogenate could be used instead of whole melanoma cells to immunize paired melanoma patients, thereby reducing the potential hazard of tumor inoculation.6 This report summarizes 8 years of experience with active and adoptive immunotherapeutic techniques used to treat patients with disseminated and recurrent melanoma, and most recently, used to treat patients with a high risk of developing recurrence after surgery for primary operable melanoma. Materials and Methods Over the past 8 years, 224 patients, 180 with Stage III (proven disseminated or recurrent disease) and 44 patients with Stage II (nodal metastases from primary disease of the torso or extremities present but no known disease following surgery) have been treated by active stimulation with allogeneic acellular melanoma preparation alone or in combination with exchange of WBC. Recently, 11 patients with Stage I1 or Stage III disease paired
543
JEWELL AND OTHERS
544
TABLE 1. Sex and Primarv Sites of 44 High-Risk Melanomas from K UMC Compared with 230 Patients from Ellis Fischel
Male/Female Ratio Head and Neck Lower Extremity Trunk Upper Extremity
Ellis Fischel
KUMC
1.15:1 34* 29 19 15
1.59:1 9 23 44 23
* Results expressed as per cent of total.
Ann. Surg. * May 1976
study were completely staged with scans, x-rays, and when necessary, surgery, into Stage II or Stage III groups. Previously prepared randomization cards were then used to select the type treatment for each patient. Patients in the LTF group were paired with nonmelanoma partners and were cross-immunized with each other's tumor or allogeneic tumor of identical histologic type if autochthonous tumor was not available. The immunizing dose used in the LTF group consisted of 20 mg of tumor, minced finely enough to pass through an 18-gauge needle. The tumor was treated with Cobalt-60 to 2500 R prior to injection. Patients received the minced radiated tumor at two-week intervals. After three injections, patients underwent leukophoresis of one pint of blood and the separated WBCs were used to prepare LTF by freezing and thawing 6 times followed by dialysis against distilled water and ultrafiltration to concentrate the volume to 1.0 ml. Following skin testing for hypersensitivity, 1.0 ml was given intramuscularly. The paired patients then were restimulated by tumor injection and donated and received 1.0 ml of LTF every two weeks for total doses ranging from two to 15, determined by partner availability. All 224 patients were observed for clinical response and survival. Response was defined as 50% reduction in diameter of measurable tumor or clearly measurable regression less than 50%, which was sustained for at least three months and no new tumor development. Survival was measured by the life table method as described by Cutler and Ederer.3 All patients for the last 4 years have been evaluated for cutaneous delayed hypersensitivity reactions to dinitrochlorobenzene (DNCB) as described by Catalona.2 All patients were sensitized by topical application of 2000 micrograms of DNCB in 0.1 ml of acetone. A spontaneous flare at the sensitization site at two weeks or a positive reaction to a challenge of 50 micrograms of DNCB at a separate site was interpreted as positive. In addition, patients were treated with four recall antigens: mumps (Lilly, 2 units), PPD (Parke Davis, 5 units), ,Monilia (Hollister-Stier, 1/100), and Trichophyton (Hollister-Stier, 1/20). Responses to intradermal injection of 0.1 ml of antigen exceeding 1.0 cm induration were considered positive. Several in vitro tests have been used over the past 8 years. Serologic immunity evaluated by complement fixa-
with patients with other types of malignancies have been treated by cross-immunization with radiated tumor cells followed by cross-transfusion of lymphocyte transfer factor (LTF) as described by Smith et al.17 The acellular homogenates used for immunization have been previously reported.7 Briefly, the first preparation, Vaccine I (V-1), was prepared by finely mincing tumor and preparing a 20% W/V suspension of melanoma tissue removed surgically or at autopsy in phosphate buffer solution (PBS). The suspension was rendered acellular by rapid freezing and thawing. This homogenate was later refined by centrifuging three times at slower speeds and finally at 102,000 x g for 30 minutes. The final supernatant fraction, termed Vaccine II (V-II), was concentrated 10:1 by Diaflo vacuum filtration. Most patients receiving V-1 were given 4 weekly injections of 1.0 ml, intracutaneously and subcutaneously, followed by 4 or 5 cross-transfusions of WBC and serum, equivalent to one pint of blood each. Patients treated with V-I1 received 8 weekly injections of 1.0 ml each, followed by booster injections at three-month intervals. Following immunization with V-II, patients either received no further treatment or were paired and cross-transfused with WBC alone from three pints of blood, or more recently WBC from 6 pints of blood prepared by leukophoresis on a Latham cell separator. The tumor equivalencet of V-I is 0.20 grams tumor per ml, and V-II is 2.0 grams tumor per ml. Because it appeared that regression of tumor and increased survival could be produced by immunotherapy with no clinical evidence of harm, i.e., enhanced tumor growth, graft-versus-host reaction, anaphylaxis, etc., it seemed reasonable to study patients with no known disease but with a greater than 50% chance of developing recurrence. Forty-four patients have been entered in this study to date. Forty-two were treated with Vaccine I1 with or without WBC exchange, and two with LTF. The 2. Response Rate in Patients with Stage III Melanoma Treated distribution of the primary site and sex of these patients TABLE bv Active Immunization With and Without Exchange of WBC or LTF is given in Table 1. All of the patients had either 21% 7/33* V-1 plus Exchange positive regional nodes or were judged to be high risk 20% V-Il 8/40 only because of the primary site, i.e., anorectal or scalp. 28% 9/32 V-Il plus Exchange The most recent study was undertaken to evaluate V-II 33% 3/9 LTF plus WBC exchange versus LTF. All patients in this sub24% 27/1 14 Total
t Weight of tumor required to produce
1
ml of vaccine.
* Only data from patients with measurable disease are
presented.
Vol. 183 . No. 5
IMMUNOTHERAPY FOR MELANOMA
545
lymphocyte counts increase in responding patients and decrease in patients with unrelenting progression. 15 The incidence of delayed cutaneous hypersensitivity reaction (DHR) at the site of vaccine injection increased from 0 80 10,o with V-I to 62% with V-I1.7 UCLA x Responses were seen in all four treatment groups. IMMUNOTHERAPY \ -J 60 pt. to V-II plus exchange of WBC appears higher Response **\g34 605 \ KUMC \ than V-1 plus exchange or V-II only. However, the difIMMUNOTHERAPY ferences are too small to be significant with these sample *034pt. sizes. 40 Survival data of 34 consecutive patients with Stage III 24 treated with V-II plus exchange, 7 with vacdisease, --ELLS FISCHEL and 3 with LTF are shown in Fig. 1. These II cine only 30pt. 20 data are compared to a similar group of patients treated with immunotherapy at UCLA by Morton et al.,1" and Stage III patients from Ellis Fischel Hospital.10 Unlike 0 the UCLA group, none of these patients underwent 24 30 18 12 6 surgery to "debulk" the tumor mass. It can be seen in TIME, MONTHS FIG. 1. Survival of Stage III melanoma patients treated at the Fig. 1 that survival at 24 months is equal to that reported University of Kansas Medical Center (KUMC) with immunotherapy by Morton and approximately twice the rate expected without "debulking" surgery compared to patients treated at UCLA from the Ellis Fischel data. Analysis of data from the l00 -\
-
with Immunotherapy and Ellis Fischel control data.
tion, immunodiffusion, and by activity of sera against primary culture growth of identical but allogeneic tumor has been reported previously by Humphrey et al. and will not be reiterated here.7 Recently, patients have been evaluated by measuring total peripheral lymphocyte counts (TLC) and the per cent distribution of thymus-dependent (TDL) and bursadependent (BDL) lymphocytes. Sheep red blood cell (RBC) rosette formation as reported by Mendes was used for TDL assay and antibody-coated sheep RBC were used for BDL analysis.12 Complement-dependent (EAC) and noncomplement-dependent (EA) fractions were also recorded. Lymphocyte sensitization was monitored with a migration inhibition factor (MIF) by a modification of the test described by Soborg and Bendixen.18 Patients' peripheral leukocytes were placed in capillary tubes with and without allogeneic melanoma antigen (V-II preparation, see above). Inhibition of migration of leukocytes by 20% or more in the antigen-versus-nonantigen tubes was regarded as positive.
100
80
60 -J -i
* C/) o
*KUMC
44pt.
0
40 0
ELLIS
0 FISCHEL
54pt. 20
Results Clinical response rates of measurable lesions in 114 patients with disseminated melanoma are shown in Table 2. Sixty-six patients with no measurable lesions are excluded from these data. All responses were noted in 0 intradermal or subcutaneous disease except one patient 3 2 4 5 with a 3 cm lesion of the frontal bone which disappeared TIME, YEARS while on LTF therapy. Several laboratory studies based FIG. 2. Survival of high-risk melanoma patients from University of on these patients have been previously reported, in- Kansas Medical Center (KUMC) compared to historic control data cluding the observation that in general, total peripheral from Ellis Fischel.
Ann. Surg. * May 1976
JEWELL AND OTHERS
546
to obtain autochthonous tumor from patients randomized to the LTF group.
60 0
U-
0
\
KUMC
44pt.
w 40
cr 011
*
-
_
20
0
1
MD ANDERSON 54pt.
2 3 TIME YEARS ,
FIG. 3. Recurrence of melanoma in high-risk melanoma patients at KUMC versus control data from M.D. Anderson Hospital.
high-risk group (Fig. 2) appears to demonstrate increased survival over historic control levels.10 This observation is substantiated further by an apparent decrease in recurrence rate compared to data reported by Gutterman et al.5 (Fig. 3). Preliminary results of the current study designed to evaluate the relative efficacy of V-I1 plus exchange versus LTF are shown in Table 3. Three patients have had complete disappearance of tumor in the LTF group but none of the V-Il group have responded. All three LTF responses occurred in patients where autochthonous tumor was used for immunization. In the 6 nonresponders, autochthonous tumor was not available and allogeneic tumor was substituted. Every effort is now being made TABLE 3. Comparison of Stage 11 and Stage III Patients Randomized to Treatment wit/ V-1l Pluis Exchange of WBC or LTF Number
Immunologic Evaluation Critical analysis of 32 consecutive patients with Stage III disease reveals that all 7 patients in this subgroup exhibiting response to immunotherapy were DNCB positive, and also had a positive response to at least one recall antigen prior to the onset of therapy. In those patients demonstrating unrelenting progression, only 5 of 25 were DNCB positive. However, only 4 of these 25 were negative to all recall antigens. Therefore, DNCB appears to be a better predictive test of response than recall antigens. All 44 Stage II patients had a positive DHR to DNCB. Total lymphocyte counts, TDL and BDL data are presented in Table 4. It is apparent that patients with Stage III disease have a striking reduction of TLC, TDL, and BDL. Stage II patients also have decreased counts, but to a lesser degree than in Stage III. Lymphocytes from 67 patients were tested for MIF activity (Table 5) in an attempt to correlate MIF activity with clinical course. Patients sequentially tested were scored as favorable if there was objective tumor regression or stabilization of disease for 6 months in Stage III disease or no recurrence in 1 year in Stage II disease. Progression of disease in shorter periods of time were scored as unfavorable. These data suggest that a sustained positive reaction or conversion of negative to positive correlates with a favorable clinical course, whereas a continued negative reaction or conversion of positive to negative predicts an unfavorable course. Because these tests were performed with allogeneic antigen no inference as to melanoma specificity is possible.
Discussion It appears that immunotherapy can beneficially affect the course of patients with malignant melanoma. Clear regression of measurable tumor was seen in 24% of patients studied. It is doubtful that this overall response rate can be explained by "spontaneous regression." Survival is a difficult parameter to evaluate. However, comparison with historic control data appears to indicate TABLE 4. Peripheral Lymphocyte Colnts in Patients wt'ithi Stage 11 and Stage Ill Disease. Resullts are Expressed as Cell Counts/mm3 I One Standard Deviation
Response Total
V-11 plus Exchange of WBC Stage III Stage II LTF Stage III Stage II
Lymphocyte 9 8
0
9 2
3
Control Stage II Stage III
Number
Count
TDL
BDL
10 44 32
2736 ± 951 2091 ± 556 1592 ± 727
1455 ± 505 1090 ± 392 631 ± 524
1195 ± 431 859 ± 242 667 ± 303
Vol. 183 * No. 5
IMMUNOTHERAPY FOR MELANOMA
TABLE 5. Correlation of Clinical Response to Migration inhlibition Factor Data (67 Patients Tested)
Positive 45 Patients Negative 22 Patients
Not Retested
Retest Positive
Negative
23 9
16 (7/9)* 9 (7/2)
6 (1/5) 4 (1/3)
* Values in parentheses represent the number of patients with a favorable clinical course over the number of patients with unrelenting progression of disease.
evidence of favorable response in Stage 11 and Stage III patients. The Stage I1 series reported has several unfavorable characteristics. There is a strong male predominence. Almost one half of the series consists of torso primary lesions with positive regional nodes. All head and neck melanomas were from the scalp or neck while over half of the control series head and neck lesions were from the face. Bias, therefore, in this group appears directed against the treated group. On the other hand, the risk of treatment if present at all must be subtle. No untoward reactions to the therapy were noted, unlike BCG injection where serious reactions and even fatalities have been reported.19 It is discouraging that most of the Stage III patients ultimately developed progressive disease, and were put on chemotherapy protocols. The 42% of the 34 patients studied for survival alive at 2 years are of considerable interest. If there is any measureable survival at 5 years the interpretation of these data would be considerably strengthened. In many respects these results closely parallel those previously reported by Morton et al. despite the fact that they employ an apparently different concept of immune stimulation." However, the possibility that the results obtained in this report were due to nonspecific stimulation rather than specific active or adoptive effects cannot be completely excluded. At this time there is no test system that will measure host antitumor activity specifically in the presence of nonspecific protein and HLA antigen effects that are probably evoked by allogeneic tumor vaccine preparations. The MIF data which demonstrated that most patients have activity initially and others can be converted by combined active and adoptive manipulation is of interest, but does not prove anti-melanoma specificity. Currently we are attempting to employ sequential skin testing as described by Burdick et al.,' lymphocyte blastogenesis as suggested by Vetto, et al.,2' and MIF, using autochthonous antigen preparations to avoid the pitfalls of the allogeneic human system. These data also support Morton's view that immune deficiency is a function of tumor burden. All of our Stage 1I patients were positive when tested forDHR toDNCB, compared to a 39% positive response rate in Stage III patients. Also, there is a clear decline of TLC, TDL, and BDL as the disease progresses. Conversely, response
547 to immunotherapy appears related to a positive reaction to DNCB and increased levels of TLC15 and, therefore, low tumor burden. The results with LTF appear most interesting. As we have reported previously, the LTF patients had a higher response rate than the V-II plus exchange group.8 In addition, all of the responses occurred where autochthonous tumor was used to cross-immunize the LTF donor partner. Also, the LTF patients had a higher conversion rate measured by MIF and conversion of recall antigen DHR than V-II plus exchange patients.8 These results imply individual tumor specificity as has been suggested recently in colon tumors by Elias and Elias.4 This critical point should be clarified as quickly as possible.
References 1. Burdick, J. F., Wells, S. A., Jr. and Herberman, R. B.: Immunologic Evaluation of Patients with Cancer by Delayed
Hypersensitivity Reactions. Surg. Gynecol. Obstet., 141:779,
1975. 2. Catalona, W. J., Taylor, P. T., Rabson, A. S. and Chretien, P. B.: A method for Dinitrochlorobenzene Contact Sensitization: A Clinicopathological Study. N. Engl. J. Med., 286:399, 1972. 3. Cutler, S. J. and Ederer, F.: Maximum Utilization of the Life Table Method in Analyzing Survival. J. Chron. Dis., 8:699, 1958. 4. Elias, E. G. and Elias, L. L.: Some Immunologic Characteristics of Carcinoma of the Colon and Rectum. Surg. Gynecol. Obstet., 141:715, 1975. 5. Gutterman, J. U., Mavligit, G., McBride, C., et al.: Active Immunotherapy with BCG for Recurrent Malignant Melanoma. Lancet, 1:1208, 1973. 6. Humphrey, L. J., Lincoln, P. M. and Griffen, W. O., Jr.: Immunologic Response in Patients with Disseminated Cancer. Ann. Surg., 168:374, 1968. 7. Humphrey, L. J., Boehm, B., Jewell, W. R. and Boehm, 0. R.: Immunologic Response of Cancer Patients Modified by Immunization with Tumor Vaccine. Ann. Surg., 176:554, 1972. 8. Jewell, W. R., Thomas, J. H., Morse, P. and Humphrey, L. J.: Comparison of Allogeneic Tumor Vaccine with Leukocyte Transfer and Transfer Factor Treatment of Human Cancer. Ann. N.Y. Acad. Sci., (In Press). 9. Krementz, E. T. and Samuels, M. S.: Tumor Cross Transplantation and Cross Transfusion in the Treatment of Advanced Malignant Disease. Bull. Tulane Univ. Med. Fac., 26:263, 1967. 10. Knutson, C. O., Hori, J. M. and Spratt, J. S., Jr.: Melanoma. In Current Problems in Surgery. Chicago, Year Book Medical Publishers, 1-55, 1971. 11. Morton, D. L., Eilber, F. R., Holmes, E. C., et al.: BCG Immunotherapy of Malignant Melanoma: Summary of a Seven-Year Experience. Ann. Surg., 180:635, 1974. 12. Mendes, N. F., Tolnai, M. E., Silveira, N. P., et al.: Technical Aspects of the Rosette Tests Used to Detect Human Complement Receptor (B) and Sheep Erythrocyte-Binding (T) Lymphocytes. J. Immunol., 111:860, 1973. 13. Nadler, S. H. and Moore, G. E.: Clinical Immunologic Study of Malignant Disease; Response to Tumor Transplants and Transfer of Leukocytes. Ann. Surg., 164:482, 1966. 14. Nadler, S. H. and Moore, G. E.: Immunotherapy of Malignant Disease. Arch. Surg., 99:376, 1969. 15. Pendergrast, W. J., Jr., Boehm, 0. R. and Humphrey, L. J.: Effect of Immunotherapy on Peripheral Lymphocyte Count. Arch. Surg., 103:184, 1971. 16. Seigler, H. F., Shingleton, W. W., Metzgar, R. S., et al.: Non-
JEWELL AND OTHERS
548
Ann. Surg. o May 1976
Specific and Specific Immunotherapy in Patients with MelaSurgery, 72:162, 1972. 17. Smith, G. V., Morse, P. A., Jr., Deraps, G. D., et al.: Immunotherapy of Patients with Cancer. Surgery, 74:59, 1973. 18. Soborg, M. and Bendixen, G.: Human Lymphocyte Migration as a Parameter of Hypersensitivity. Acta Med. Scand., 181:247, 1967. 19. Sparks, F. C., Silverstein, M. J., Hunt, J. S., et al.: Complica-
tions of BCG Immunotherapy in Patients with Cancer. N. Engl. J. Med., 289:827, 1973. 20. Sumner, W. C. and Foraker, A. G.: Spontaneous Regression of Human Melanoma, Clinical and Experimental Studies. J. Cancer, 13:79, 1960. 21. Vetto, R. M., Burger, D. R., Vandenbark, A. A. and Nolte, J.: Influence of Serum Blocking Factors on Cancer Patients Undergoing Immunotherapy. Am. J. Surg., 130:237, 1975.
DiSCUSSION
than to rely on comparing your data to historical controls, which is always fraught with danger?
noma.
DR. WARREN H. COLE (Asheville, North Carolina): I think their work is really very exciting, and I've been following it ever since they started it several years ago. Some of their important figures got a little bit lost in the numerous figures that Dr. Humphrey gave you. Therefore I would like to call your attention to page 13 in the program, where they say their one-year survival following immunotherapy is 100% versus 58% expected, and their two-year survival is 85% versus 44% expected. To me this is very remarkable, and indicates that immunotherapy has great
possibilities. In attempts to conceive of mechanisms to improve on the immunologic have found it stimulating to speculate on the causes of the regression in spontaneous regression; and here I have been studying the 176 cases which Dr. Everson and I reported on several years ago. After studying these cases, I became convinced that the major cause response, I
was a
stimulation, primarily accidental, of the immune reaction, which
is only one ofthe many ways to obtain improved immunologic response. Part of the work carried out by Dr. Humphrey and Dr. Jewell has been a stimulation of the immune system, but this is probably better illustrated by administration of BCG, which they have used, but I think Dr. Morton has probably used that much more extensively than anybody else. There are several other known methods of stimulating a patient's immune response, and that's what gives me optimism, thinking we do have a few other ways of stimulating our immunologic response. I believe these various possibilities should be explored. These include other bacterial products, irradiated tumor cells, the enzyme neuraminidase, and a few others. It's now obvious that one method of immunologic trial is effective in one patient and not in another. We are finding that out almost every day. Before we find a really effective mechanism, it appears that we might be justified in trying one method after another in a patient, until we find one which is reasonably effective. And this regimen would stimulate the procedure of trying numerous antibiotics to destroy an infection. Anyway, its's very obvious to me that the immunologic treatment of cancer is now possible, and has great promise. So I would agree with that statement that Dr. Humphrey made just before he closed. Obviously, we can't supplant the old reliables of surgery, radiation, and chemotherapy, but I believe we are about reaching the point where these can be supplemented by immunotherapy. Now, the point of my remarks leads to an important question, which I would like to put to Dr. Humphrey and Dr. Jewell: Do they think that the immunologic treatment would be more effective in Stage I disease, given just after definitive treatment, such as operative resection of a tumor,.when the patient still has some protective immunologic reaction of his own? Well, I really think so, but I'd like to ask the experts about this question. DR. WARD 0. GRIFFEN, JR. (Lexington, Kentucky): In the manuscript Dr. Jewell and Dr. Humphrey indicated that Vaccine I had a dose of 0.2 gm/ml of tumor, whereas Vaccine 11 had 2 gm/ml. Is the difference in response between V-I and V-Il simply a dose response? Secondly, no mention was made about debulking. I guess this is a corollary to Dr. Cole's question. If you can remove a great deal of the tumor, can you improve the ability of the patient to bring his own
immunologic capacity into play? And thirdly, do you think you are now ready to have randomized trials of your own various techniques of immunologic therapy, rather
DR. JAMES C. DRYE (Louisville): I think immunotherapy is a field which should be pursued. We have tried chemicals, radiation, and surgery, and I think this avenue is well worth exploring. The results of chemotherapy and surgery have been only partially successful. This immunotherapy approach may improve our results. I arise to present a case of mine treated by an immunology method except I used blood from a patient who had been treated 8 or 10 years before and had no evidence of recurrence. I would first like to give the past history of my patient. This patient had acute rheumatic fever at the age of about 12. This was followed by St. Vitus dance, or chorea, and apparently some injury to the heart. However, he had at the time I first saw him no symptoms of heart disease. At the age of 15 he had a thyroidectomy, and from the history it seems that he was severely toxic. He made a good recovery from this and takes 4 gm of thyroid a day. He developed petit mal at the age of ten or 12. This has been controlled by Dilantin and phenobarbital. Several years ago the patient was vacationing in Rome, and a pop bottle which was being carried by blew up and tore out his right eye, and this was enucleated. He came to me in March, 1967. He had a melanoma on the medial surface of the tibia about six inches above the ankle. I removed this with an excision biopsy with about a 3 mm margin, and it came back as melanoma on fixed sections. The next morning I removed about a 6 cm diameter of skind down to the periosteum, and took the fascia of the underlying muscle, and did a skin graft. This was in March, 1967. In August of '67 he returned to me complaining of being short of breath. He had a flat percussion note and I could hear no breath sounds. I stuck a needle in his chest and removed 1500 cc of fluid. I was required to reaspirate him every five or seven days and removed 1000 to 1500 cc of fluid each time. I injected nitrogen mustard, not a cancericidal dose, because I had begun to believe that chemotherapy agents were practically useless; all they did was make a patient sick. But I hoped to obliterate the pleural space, so that he would not get this collection of fluid, and breathe better; but this didn't work either. By then I has become quite fond of this patient, and I lay awake at night thinking; What can I do? There ought to be something. Dr. Condict Moore, who is a member of this society, had a patient who was operated on for melanoma eight years before and apparently recovered. I transfused 250 ml of blood from this patient to my patient at the same time removing another 1500 cc of fluid from his chest. I repeated the transfusion a week later. This patient never again had any pleural fluid collection, and became completely asymptomatic. In August of '68 he developed evidence of heart failure due to mitral stenosis from his rheumatic fever. Dr. Allan Lansing, of Louisville, operated on the man. There was no evidence of any pleural involvement, and nothing in the lungs. The x-rays at the time I first saw him were
highly suggestive of a
mass
in his left
upper
lobe. Dr. Lansing
could see or feel nothing, and the patient recovered from his heart
operation. I saw this patient ten days ago. He is alive, well, healthy and doing well. He has no symptoms. Honestly and very humbly, I don't know whether I cured a diagnosis or cured the disease, and that it may recur. We all know that melanoma is extremely unpredictable. This man might have gotten along as well without any treatment. I really don't know.
Over the past 8 years, 244 patients with Stage II or III melanoma have been treated by cutaneous injection of a crude acellular homogenate of allogeneic melanoma cells (V-I) or a more concentrated fraction (V-II), followed in most patients by exchanges of WBC between paired partners. Patients with Stage III disease exhibited an overall response rate of 24% and prolongation of survival compared with control data. Stage II patients also had prolonged survival and reduced rate of recurrence over historic peers' data. Breakdown of subgroup data revealed that V-II plus exchange of WBC is similar to V-I plus exchange or V-II alone. However, recent experience with LTF suggests a higher response rate than in either V-I or V-II groups, particularly when autochthonous tumor is used for cross-immunization. The most meaningful immunologic data resulted from analysis of DNCB and MIF data. Patients negative to DNCB rarely respond to immunotherapy. A positive pretreatment MIF or positive conversion following treatment correlates with response, whereas, conversion of positive to negative predicts poor clinical performance. S EVERAL CLINICAL TRIALS
have demonstrated suc-
cessful treatment of micro and macro metastases of melanoma using a variety of immunotherapeutic techniques. Morton et al. have recorded regression of approximately 90Wo of subcutaneous and cutaneous melanoma nodules directly injected with Bacillus Calmette Guerin (BCG).1' In addition, several other noninjected nodules were noted to regress. Seigler also has shown, using a complex multiple treatment program ofactive specific and nonspecific immune stimulation, that melanoma-bearing hosts can be benefited by immune manipulation.16 Presented at the Annual Meeting of the Southern Surgical Association, December 8-10, 1975, The Homestead, Hot Springs, Virginia. * Current address: Bowman Gray School of Medicine, Winston Salem, North Carolina. Supported in part by John A. Hartford Foundation, Inc., and the American Cancer Society, ACS-IM-45. Reprint requests: William R. Jewell, M. D., Department of Surgery, University of Kansas Medical Center, 39th and Rainbow Boulevard, Kansas City, Kansas 66103.
From the Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas
Sumner and Foraker were the first to demonstrate that adoptive techniques can be effective.20 One of two patients transfused with whole blood removed from another melanoma patient who had complete "spontaneous regression" also had complete disappearance of all tumor. Nadler and Moore cross-immunized paired patients with each other's tumors.13 After the tumor implants were rejected or removed, patients' whole white blood cells (WBC) were cross-exchanged. One hundred thirteen patients with melanoma were treated in this fashion and 23 had objective tumor regression. 14 Krementz later confirmed this observation using a similar system.9 Humphrey et al. demonstrated that an acellular tumor homogenate could be used instead of whole melanoma cells to immunize paired melanoma patients, thereby reducing the potential hazard of tumor inoculation.6 This report summarizes 8 years of experience with active and adoptive immunotherapeutic techniques used to treat patients with disseminated and recurrent melanoma, and most recently, used to treat patients with a high risk of developing recurrence after surgery for primary operable melanoma. Materials and Methods Over the past 8 years, 224 patients, 180 with Stage III (proven disseminated or recurrent disease) and 44 patients with Stage II (nodal metastases from primary disease of the torso or extremities present but no known disease following surgery) have been treated by active stimulation with allogeneic acellular melanoma preparation alone or in combination with exchange of WBC. Recently, 11 patients with Stage I1 or Stage III disease paired
543
JEWELL AND OTHERS
544
TABLE 1. Sex and Primarv Sites of 44 High-Risk Melanomas from K UMC Compared with 230 Patients from Ellis Fischel
Male/Female Ratio Head and Neck Lower Extremity Trunk Upper Extremity
Ellis Fischel
KUMC
1.15:1 34* 29 19 15
1.59:1 9 23 44 23
* Results expressed as per cent of total.
Ann. Surg. * May 1976
study were completely staged with scans, x-rays, and when necessary, surgery, into Stage II or Stage III groups. Previously prepared randomization cards were then used to select the type treatment for each patient. Patients in the LTF group were paired with nonmelanoma partners and were cross-immunized with each other's tumor or allogeneic tumor of identical histologic type if autochthonous tumor was not available. The immunizing dose used in the LTF group consisted of 20 mg of tumor, minced finely enough to pass through an 18-gauge needle. The tumor was treated with Cobalt-60 to 2500 R prior to injection. Patients received the minced radiated tumor at two-week intervals. After three injections, patients underwent leukophoresis of one pint of blood and the separated WBCs were used to prepare LTF by freezing and thawing 6 times followed by dialysis against distilled water and ultrafiltration to concentrate the volume to 1.0 ml. Following skin testing for hypersensitivity, 1.0 ml was given intramuscularly. The paired patients then were restimulated by tumor injection and donated and received 1.0 ml of LTF every two weeks for total doses ranging from two to 15, determined by partner availability. All 224 patients were observed for clinical response and survival. Response was defined as 50% reduction in diameter of measurable tumor or clearly measurable regression less than 50%, which was sustained for at least three months and no new tumor development. Survival was measured by the life table method as described by Cutler and Ederer.3 All patients for the last 4 years have been evaluated for cutaneous delayed hypersensitivity reactions to dinitrochlorobenzene (DNCB) as described by Catalona.2 All patients were sensitized by topical application of 2000 micrograms of DNCB in 0.1 ml of acetone. A spontaneous flare at the sensitization site at two weeks or a positive reaction to a challenge of 50 micrograms of DNCB at a separate site was interpreted as positive. In addition, patients were treated with four recall antigens: mumps (Lilly, 2 units), PPD (Parke Davis, 5 units), ,Monilia (Hollister-Stier, 1/100), and Trichophyton (Hollister-Stier, 1/20). Responses to intradermal injection of 0.1 ml of antigen exceeding 1.0 cm induration were considered positive. Several in vitro tests have been used over the past 8 years. Serologic immunity evaluated by complement fixa-
with patients with other types of malignancies have been treated by cross-immunization with radiated tumor cells followed by cross-transfusion of lymphocyte transfer factor (LTF) as described by Smith et al.17 The acellular homogenates used for immunization have been previously reported.7 Briefly, the first preparation, Vaccine I (V-1), was prepared by finely mincing tumor and preparing a 20% W/V suspension of melanoma tissue removed surgically or at autopsy in phosphate buffer solution (PBS). The suspension was rendered acellular by rapid freezing and thawing. This homogenate was later refined by centrifuging three times at slower speeds and finally at 102,000 x g for 30 minutes. The final supernatant fraction, termed Vaccine II (V-II), was concentrated 10:1 by Diaflo vacuum filtration. Most patients receiving V-1 were given 4 weekly injections of 1.0 ml, intracutaneously and subcutaneously, followed by 4 or 5 cross-transfusions of WBC and serum, equivalent to one pint of blood each. Patients treated with V-I1 received 8 weekly injections of 1.0 ml each, followed by booster injections at three-month intervals. Following immunization with V-II, patients either received no further treatment or were paired and cross-transfused with WBC alone from three pints of blood, or more recently WBC from 6 pints of blood prepared by leukophoresis on a Latham cell separator. The tumor equivalencet of V-I is 0.20 grams tumor per ml, and V-II is 2.0 grams tumor per ml. Because it appeared that regression of tumor and increased survival could be produced by immunotherapy with no clinical evidence of harm, i.e., enhanced tumor growth, graft-versus-host reaction, anaphylaxis, etc., it seemed reasonable to study patients with no known disease but with a greater than 50% chance of developing recurrence. Forty-four patients have been entered in this study to date. Forty-two were treated with Vaccine I1 with or without WBC exchange, and two with LTF. The 2. Response Rate in Patients with Stage III Melanoma Treated distribution of the primary site and sex of these patients TABLE bv Active Immunization With and Without Exchange of WBC or LTF is given in Table 1. All of the patients had either 21% 7/33* V-1 plus Exchange positive regional nodes or were judged to be high risk 20% V-Il 8/40 only because of the primary site, i.e., anorectal or scalp. 28% 9/32 V-Il plus Exchange The most recent study was undertaken to evaluate V-II 33% 3/9 LTF plus WBC exchange versus LTF. All patients in this sub24% 27/1 14 Total
t Weight of tumor required to produce
1
ml of vaccine.
* Only data from patients with measurable disease are
presented.
Vol. 183 . No. 5
IMMUNOTHERAPY FOR MELANOMA
545
lymphocyte counts increase in responding patients and decrease in patients with unrelenting progression. 15 The incidence of delayed cutaneous hypersensitivity reaction (DHR) at the site of vaccine injection increased from 0 80 10,o with V-I to 62% with V-I1.7 UCLA x Responses were seen in all four treatment groups. IMMUNOTHERAPY \ -J 60 pt. to V-II plus exchange of WBC appears higher Response **\g34 605 \ KUMC \ than V-1 plus exchange or V-II only. However, the difIMMUNOTHERAPY ferences are too small to be significant with these sample *034pt. sizes. 40 Survival data of 34 consecutive patients with Stage III 24 treated with V-II plus exchange, 7 with vacdisease, --ELLS FISCHEL and 3 with LTF are shown in Fig. 1. These II cine only 30pt. 20 data are compared to a similar group of patients treated with immunotherapy at UCLA by Morton et al.,1" and Stage III patients from Ellis Fischel Hospital.10 Unlike 0 the UCLA group, none of these patients underwent 24 30 18 12 6 surgery to "debulk" the tumor mass. It can be seen in TIME, MONTHS FIG. 1. Survival of Stage III melanoma patients treated at the Fig. 1 that survival at 24 months is equal to that reported University of Kansas Medical Center (KUMC) with immunotherapy by Morton and approximately twice the rate expected without "debulking" surgery compared to patients treated at UCLA from the Ellis Fischel data. Analysis of data from the l00 -\
-
with Immunotherapy and Ellis Fischel control data.
tion, immunodiffusion, and by activity of sera against primary culture growth of identical but allogeneic tumor has been reported previously by Humphrey et al. and will not be reiterated here.7 Recently, patients have been evaluated by measuring total peripheral lymphocyte counts (TLC) and the per cent distribution of thymus-dependent (TDL) and bursadependent (BDL) lymphocytes. Sheep red blood cell (RBC) rosette formation as reported by Mendes was used for TDL assay and antibody-coated sheep RBC were used for BDL analysis.12 Complement-dependent (EAC) and noncomplement-dependent (EA) fractions were also recorded. Lymphocyte sensitization was monitored with a migration inhibition factor (MIF) by a modification of the test described by Soborg and Bendixen.18 Patients' peripheral leukocytes were placed in capillary tubes with and without allogeneic melanoma antigen (V-II preparation, see above). Inhibition of migration of leukocytes by 20% or more in the antigen-versus-nonantigen tubes was regarded as positive.
100
80
60 -J -i
* C/) o
*KUMC
44pt.
0
40 0
ELLIS
0 FISCHEL
54pt. 20
Results Clinical response rates of measurable lesions in 114 patients with disseminated melanoma are shown in Table 2. Sixty-six patients with no measurable lesions are excluded from these data. All responses were noted in 0 intradermal or subcutaneous disease except one patient 3 2 4 5 with a 3 cm lesion of the frontal bone which disappeared TIME, YEARS while on LTF therapy. Several laboratory studies based FIG. 2. Survival of high-risk melanoma patients from University of on these patients have been previously reported, in- Kansas Medical Center (KUMC) compared to historic control data cluding the observation that in general, total peripheral from Ellis Fischel.
Ann. Surg. * May 1976
JEWELL AND OTHERS
546
to obtain autochthonous tumor from patients randomized to the LTF group.
60 0
U-
0
\
KUMC
44pt.
w 40
cr 011
*
-
_
20
0
1
MD ANDERSON 54pt.
2 3 TIME YEARS ,
FIG. 3. Recurrence of melanoma in high-risk melanoma patients at KUMC versus control data from M.D. Anderson Hospital.
high-risk group (Fig. 2) appears to demonstrate increased survival over historic control levels.10 This observation is substantiated further by an apparent decrease in recurrence rate compared to data reported by Gutterman et al.5 (Fig. 3). Preliminary results of the current study designed to evaluate the relative efficacy of V-I1 plus exchange versus LTF are shown in Table 3. Three patients have had complete disappearance of tumor in the LTF group but none of the V-Il group have responded. All three LTF responses occurred in patients where autochthonous tumor was used for immunization. In the 6 nonresponders, autochthonous tumor was not available and allogeneic tumor was substituted. Every effort is now being made TABLE 3. Comparison of Stage 11 and Stage III Patients Randomized to Treatment wit/ V-1l Pluis Exchange of WBC or LTF Number
Immunologic Evaluation Critical analysis of 32 consecutive patients with Stage III disease reveals that all 7 patients in this subgroup exhibiting response to immunotherapy were DNCB positive, and also had a positive response to at least one recall antigen prior to the onset of therapy. In those patients demonstrating unrelenting progression, only 5 of 25 were DNCB positive. However, only 4 of these 25 were negative to all recall antigens. Therefore, DNCB appears to be a better predictive test of response than recall antigens. All 44 Stage II patients had a positive DHR to DNCB. Total lymphocyte counts, TDL and BDL data are presented in Table 4. It is apparent that patients with Stage III disease have a striking reduction of TLC, TDL, and BDL. Stage II patients also have decreased counts, but to a lesser degree than in Stage III. Lymphocytes from 67 patients were tested for MIF activity (Table 5) in an attempt to correlate MIF activity with clinical course. Patients sequentially tested were scored as favorable if there was objective tumor regression or stabilization of disease for 6 months in Stage III disease or no recurrence in 1 year in Stage II disease. Progression of disease in shorter periods of time were scored as unfavorable. These data suggest that a sustained positive reaction or conversion of negative to positive correlates with a favorable clinical course, whereas a continued negative reaction or conversion of positive to negative predicts an unfavorable course. Because these tests were performed with allogeneic antigen no inference as to melanoma specificity is possible.
Discussion It appears that immunotherapy can beneficially affect the course of patients with malignant melanoma. Clear regression of measurable tumor was seen in 24% of patients studied. It is doubtful that this overall response rate can be explained by "spontaneous regression." Survival is a difficult parameter to evaluate. However, comparison with historic control data appears to indicate TABLE 4. Peripheral Lymphocyte Colnts in Patients wt'ithi Stage 11 and Stage Ill Disease. Resullts are Expressed as Cell Counts/mm3 I One Standard Deviation
Response Total
V-11 plus Exchange of WBC Stage III Stage II LTF Stage III Stage II
Lymphocyte 9 8
0
9 2
3
Control Stage II Stage III
Number
Count
TDL
BDL
10 44 32
2736 ± 951 2091 ± 556 1592 ± 727
1455 ± 505 1090 ± 392 631 ± 524
1195 ± 431 859 ± 242 667 ± 303
Vol. 183 * No. 5
IMMUNOTHERAPY FOR MELANOMA
TABLE 5. Correlation of Clinical Response to Migration inhlibition Factor Data (67 Patients Tested)
Positive 45 Patients Negative 22 Patients
Not Retested
Retest Positive
Negative
23 9
16 (7/9)* 9 (7/2)
6 (1/5) 4 (1/3)
* Values in parentheses represent the number of patients with a favorable clinical course over the number of patients with unrelenting progression of disease.
evidence of favorable response in Stage 11 and Stage III patients. The Stage I1 series reported has several unfavorable characteristics. There is a strong male predominence. Almost one half of the series consists of torso primary lesions with positive regional nodes. All head and neck melanomas were from the scalp or neck while over half of the control series head and neck lesions were from the face. Bias, therefore, in this group appears directed against the treated group. On the other hand, the risk of treatment if present at all must be subtle. No untoward reactions to the therapy were noted, unlike BCG injection where serious reactions and even fatalities have been reported.19 It is discouraging that most of the Stage III patients ultimately developed progressive disease, and were put on chemotherapy protocols. The 42% of the 34 patients studied for survival alive at 2 years are of considerable interest. If there is any measureable survival at 5 years the interpretation of these data would be considerably strengthened. In many respects these results closely parallel those previously reported by Morton et al. despite the fact that they employ an apparently different concept of immune stimulation." However, the possibility that the results obtained in this report were due to nonspecific stimulation rather than specific active or adoptive effects cannot be completely excluded. At this time there is no test system that will measure host antitumor activity specifically in the presence of nonspecific protein and HLA antigen effects that are probably evoked by allogeneic tumor vaccine preparations. The MIF data which demonstrated that most patients have activity initially and others can be converted by combined active and adoptive manipulation is of interest, but does not prove anti-melanoma specificity. Currently we are attempting to employ sequential skin testing as described by Burdick et al.,' lymphocyte blastogenesis as suggested by Vetto, et al.,2' and MIF, using autochthonous antigen preparations to avoid the pitfalls of the allogeneic human system. These data also support Morton's view that immune deficiency is a function of tumor burden. All of our Stage 1I patients were positive when tested forDHR toDNCB, compared to a 39% positive response rate in Stage III patients. Also, there is a clear decline of TLC, TDL, and BDL as the disease progresses. Conversely, response
547 to immunotherapy appears related to a positive reaction to DNCB and increased levels of TLC15 and, therefore, low tumor burden. The results with LTF appear most interesting. As we have reported previously, the LTF patients had a higher response rate than the V-II plus exchange group.8 In addition, all of the responses occurred where autochthonous tumor was used to cross-immunize the LTF donor partner. Also, the LTF patients had a higher conversion rate measured by MIF and conversion of recall antigen DHR than V-II plus exchange patients.8 These results imply individual tumor specificity as has been suggested recently in colon tumors by Elias and Elias.4 This critical point should be clarified as quickly as possible.
References 1. Burdick, J. F., Wells, S. A., Jr. and Herberman, R. B.: Immunologic Evaluation of Patients with Cancer by Delayed
Hypersensitivity Reactions. Surg. Gynecol. Obstet., 141:779,
1975. 2. Catalona, W. J., Taylor, P. T., Rabson, A. S. and Chretien, P. B.: A method for Dinitrochlorobenzene Contact Sensitization: A Clinicopathological Study. N. Engl. J. Med., 286:399, 1972. 3. Cutler, S. J. and Ederer, F.: Maximum Utilization of the Life Table Method in Analyzing Survival. J. Chron. Dis., 8:699, 1958. 4. Elias, E. G. and Elias, L. L.: Some Immunologic Characteristics of Carcinoma of the Colon and Rectum. Surg. Gynecol. Obstet., 141:715, 1975. 5. Gutterman, J. U., Mavligit, G., McBride, C., et al.: Active Immunotherapy with BCG for Recurrent Malignant Melanoma. Lancet, 1:1208, 1973. 6. Humphrey, L. J., Lincoln, P. M. and Griffen, W. O., Jr.: Immunologic Response in Patients with Disseminated Cancer. Ann. Surg., 168:374, 1968. 7. Humphrey, L. J., Boehm, B., Jewell, W. R. and Boehm, 0. R.: Immunologic Response of Cancer Patients Modified by Immunization with Tumor Vaccine. Ann. Surg., 176:554, 1972. 8. Jewell, W. R., Thomas, J. H., Morse, P. and Humphrey, L. J.: Comparison of Allogeneic Tumor Vaccine with Leukocyte Transfer and Transfer Factor Treatment of Human Cancer. Ann. N.Y. Acad. Sci., (In Press). 9. Krementz, E. T. and Samuels, M. S.: Tumor Cross Transplantation and Cross Transfusion in the Treatment of Advanced Malignant Disease. Bull. Tulane Univ. Med. Fac., 26:263, 1967. 10. Knutson, C. O., Hori, J. M. and Spratt, J. S., Jr.: Melanoma. In Current Problems in Surgery. Chicago, Year Book Medical Publishers, 1-55, 1971. 11. Morton, D. L., Eilber, F. R., Holmes, E. C., et al.: BCG Immunotherapy of Malignant Melanoma: Summary of a Seven-Year Experience. Ann. Surg., 180:635, 1974. 12. Mendes, N. F., Tolnai, M. E., Silveira, N. P., et al.: Technical Aspects of the Rosette Tests Used to Detect Human Complement Receptor (B) and Sheep Erythrocyte-Binding (T) Lymphocytes. J. Immunol., 111:860, 1973. 13. Nadler, S. H. and Moore, G. E.: Clinical Immunologic Study of Malignant Disease; Response to Tumor Transplants and Transfer of Leukocytes. Ann. Surg., 164:482, 1966. 14. Nadler, S. H. and Moore, G. E.: Immunotherapy of Malignant Disease. Arch. Surg., 99:376, 1969. 15. Pendergrast, W. J., Jr., Boehm, 0. R. and Humphrey, L. J.: Effect of Immunotherapy on Peripheral Lymphocyte Count. Arch. Surg., 103:184, 1971. 16. Seigler, H. F., Shingleton, W. W., Metzgar, R. S., et al.: Non-
JEWELL AND OTHERS
548
Ann. Surg. o May 1976
Specific and Specific Immunotherapy in Patients with MelaSurgery, 72:162, 1972. 17. Smith, G. V., Morse, P. A., Jr., Deraps, G. D., et al.: Immunotherapy of Patients with Cancer. Surgery, 74:59, 1973. 18. Soborg, M. and Bendixen, G.: Human Lymphocyte Migration as a Parameter of Hypersensitivity. Acta Med. Scand., 181:247, 1967. 19. Sparks, F. C., Silverstein, M. J., Hunt, J. S., et al.: Complica-
tions of BCG Immunotherapy in Patients with Cancer. N. Engl. J. Med., 289:827, 1973. 20. Sumner, W. C. and Foraker, A. G.: Spontaneous Regression of Human Melanoma, Clinical and Experimental Studies. J. Cancer, 13:79, 1960. 21. Vetto, R. M., Burger, D. R., Vandenbark, A. A. and Nolte, J.: Influence of Serum Blocking Factors on Cancer Patients Undergoing Immunotherapy. Am. J. Surg., 130:237, 1975.
DiSCUSSION
than to rely on comparing your data to historical controls, which is always fraught with danger?
noma.
DR. WARREN H. COLE (Asheville, North Carolina): I think their work is really very exciting, and I've been following it ever since they started it several years ago. Some of their important figures got a little bit lost in the numerous figures that Dr. Humphrey gave you. Therefore I would like to call your attention to page 13 in the program, where they say their one-year survival following immunotherapy is 100% versus 58% expected, and their two-year survival is 85% versus 44% expected. To me this is very remarkable, and indicates that immunotherapy has great
possibilities. In attempts to conceive of mechanisms to improve on the immunologic have found it stimulating to speculate on the causes of the regression in spontaneous regression; and here I have been studying the 176 cases which Dr. Everson and I reported on several years ago. After studying these cases, I became convinced that the major cause response, I
was a
stimulation, primarily accidental, of the immune reaction, which
is only one ofthe many ways to obtain improved immunologic response. Part of the work carried out by Dr. Humphrey and Dr. Jewell has been a stimulation of the immune system, but this is probably better illustrated by administration of BCG, which they have used, but I think Dr. Morton has probably used that much more extensively than anybody else. There are several other known methods of stimulating a patient's immune response, and that's what gives me optimism, thinking we do have a few other ways of stimulating our immunologic response. I believe these various possibilities should be explored. These include other bacterial products, irradiated tumor cells, the enzyme neuraminidase, and a few others. It's now obvious that one method of immunologic trial is effective in one patient and not in another. We are finding that out almost every day. Before we find a really effective mechanism, it appears that we might be justified in trying one method after another in a patient, until we find one which is reasonably effective. And this regimen would stimulate the procedure of trying numerous antibiotics to destroy an infection. Anyway, its's very obvious to me that the immunologic treatment of cancer is now possible, and has great promise. So I would agree with that statement that Dr. Humphrey made just before he closed. Obviously, we can't supplant the old reliables of surgery, radiation, and chemotherapy, but I believe we are about reaching the point where these can be supplemented by immunotherapy. Now, the point of my remarks leads to an important question, which I would like to put to Dr. Humphrey and Dr. Jewell: Do they think that the immunologic treatment would be more effective in Stage I disease, given just after definitive treatment, such as operative resection of a tumor,.when the patient still has some protective immunologic reaction of his own? Well, I really think so, but I'd like to ask the experts about this question. DR. WARD 0. GRIFFEN, JR. (Lexington, Kentucky): In the manuscript Dr. Jewell and Dr. Humphrey indicated that Vaccine I had a dose of 0.2 gm/ml of tumor, whereas Vaccine 11 had 2 gm/ml. Is the difference in response between V-I and V-Il simply a dose response? Secondly, no mention was made about debulking. I guess this is a corollary to Dr. Cole's question. If you can remove a great deal of the tumor, can you improve the ability of the patient to bring his own
immunologic capacity into play? And thirdly, do you think you are now ready to have randomized trials of your own various techniques of immunologic therapy, rather
DR. JAMES C. DRYE (Louisville): I think immunotherapy is a field which should be pursued. We have tried chemicals, radiation, and surgery, and I think this avenue is well worth exploring. The results of chemotherapy and surgery have been only partially successful. This immunotherapy approach may improve our results. I arise to present a case of mine treated by an immunology method except I used blood from a patient who had been treated 8 or 10 years before and had no evidence of recurrence. I would first like to give the past history of my patient. This patient had acute rheumatic fever at the age of about 12. This was followed by St. Vitus dance, or chorea, and apparently some injury to the heart. However, he had at the time I first saw him no symptoms of heart disease. At the age of 15 he had a thyroidectomy, and from the history it seems that he was severely toxic. He made a good recovery from this and takes 4 gm of thyroid a day. He developed petit mal at the age of ten or 12. This has been controlled by Dilantin and phenobarbital. Several years ago the patient was vacationing in Rome, and a pop bottle which was being carried by blew up and tore out his right eye, and this was enucleated. He came to me in March, 1967. He had a melanoma on the medial surface of the tibia about six inches above the ankle. I removed this with an excision biopsy with about a 3 mm margin, and it came back as melanoma on fixed sections. The next morning I removed about a 6 cm diameter of skind down to the periosteum, and took the fascia of the underlying muscle, and did a skin graft. This was in March, 1967. In August of '67 he returned to me complaining of being short of breath. He had a flat percussion note and I could hear no breath sounds. I stuck a needle in his chest and removed 1500 cc of fluid. I was required to reaspirate him every five or seven days and removed 1000 to 1500 cc of fluid each time. I injected nitrogen mustard, not a cancericidal dose, because I had begun to believe that chemotherapy agents were practically useless; all they did was make a patient sick. But I hoped to obliterate the pleural space, so that he would not get this collection of fluid, and breathe better; but this didn't work either. By then I has become quite fond of this patient, and I lay awake at night thinking; What can I do? There ought to be something. Dr. Condict Moore, who is a member of this society, had a patient who was operated on for melanoma eight years before and apparently recovered. I transfused 250 ml of blood from this patient to my patient at the same time removing another 1500 cc of fluid from his chest. I repeated the transfusion a week later. This patient never again had any pleural fluid collection, and became completely asymptomatic. In August of '68 he developed evidence of heart failure due to mitral stenosis from his rheumatic fever. Dr. Allan Lansing, of Louisville, operated on the man. There was no evidence of any pleural involvement, and nothing in the lungs. The x-rays at the time I first saw him were
highly suggestive of a
mass
in his left
upper
lobe. Dr. Lansing
could see or feel nothing, and the patient recovered from his heart
operation. I saw this patient ten days ago. He is alive, well, healthy and doing well. He has no symptoms. Honestly and very humbly, I don't know whether I cured a diagnosis or cured the disease, and that it may recur. We all know that melanoma is extremely unpredictable. This man might have gotten along as well without any treatment. I really don't know.
