Seminars in Surgical Oncology 7:217-220 (1991)
lmmunotherapy for Malignant Melanoma: A Review and Update J. MICHAEL C. McGEE, MD From the Department of Surgery, University of Oklahoma College of Medicine, Tulsa
Several different approaches to the application of specific active immunotherapy for the adjuvant therapy of melanoma have developed independently. Specific active immunotherapy refers to autologous or allogenic inoculation or transplantation of tumor cells or cell products into patients with cancer. Several different types of tumor vaccines have been studied and have been combined with different immunotherapeutic modalities. This report will include a review of several of those different techniques and will also review the observed 5-year survival rates for a melanoma tumor homogenate (concentrated) vaccine, developed by L. J. Humphrey and colleagues. KEYWORDS:five-year survival rates, tumor vaccine, melanoma, active specific immunotherapy, tumor homogenate
INTRODUCTION Melanoma, first described in 1787, is increasing in incidence. Although much has been learned abou; its histology, diagnosis, and staging, its biologic properties such as induction, progression, and rates of spontaneous regression remain mysterious. Much effort has gone into elucidating the optimal management, but there remains much pessimism. Recent studies have looked at the extent of resection, if, when, and where to dissect lymph node-bearing areas, different types of chemotherapy including the use of regional perfusion and hyperthermia, and various types of biologic response modifier therapies often referred to as immunotherapy [ 11. Nonspecific but active types of immunotherapy include Corynebacterium parvum, BCG, levamisol, and Freund’s adjuvant. Specific active immunotherapy refers to autologous or allogenic inoculation or transplantation of tumor cells or cell products into patients. These vaccines have been modified or combined with several substances and injected, usually subcutaneously or occasionally intralesionally. In 1972, one author reviewed the previous 80 years of tumor vaccines [2]. Some of these trials included patients with melanoma. The tumors were excised, ground up, and reinjected into the same patient or into other patients with gross disease. The results were not however, there were reports of complete tumor regression [2]. 0 1991 Wiley-Liss, Inc.
ADJUVANT TRIALS OF ACTIVE SPECIFIC IMMUNOTHERAPY Combinations with BCG In 1970 Morton reported a series of patients in which he injected skin metastatic nodules with BCG. In 5 patients those nodules regressed and in 2 patients, uninjected nodules also regressed. Since remote lesions were affected and antibodies were noted in the serum, it raised the possibility of enhanced tumor immunity [3,4]. In 1982, Morton reported the combination of BCG and irradiated neuraminidase-treated melanoma cells injected subcutaneously in a randomized trial of adjuvant treatment of stage I1 patients. The follow-up was 50 months, and the survival in the control group was 41%, the BCG group was 43%, and the BCG plus tumor cell vaccine group was 53% [5]. He later reported that those patients who responded to the vaccine and BCG with the elaboration of IgM antibodies had a significantly better clinical course. Morton and associates have described six different melanoma-associated antigens and have developed three different cell lines containing high concentrations of these surface antigens. When they selected 47 melanoma specimens-98% had a least one of these 6 antigens. Three of the six antigens were gangliosides, two Address reprint requests to J. Michael C. McGee, M.D., Department of Surgery, University of Oklahoma College of Medicine, 2815 South Sheridan Road, Tulsa, OK 74129.
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glycoproteins, and one lipoprotein. In preliminary results of a trial involving 55 patients, there was a higher number of antibody responders [6]. Other investigators have shown similar results with BCG and neuraminidase-treated, irradiated whole cell vaccines, and other groups are exploring vaccines with more specific melanoma-associated antigens [7-91. Siegler reported a large series in 1979 of 719 patients treated with BCG and neuraminidase-treated, irradiated whole melanoma cells. Four-year survivals were reported by stage and Clark’s level. Clark’s level I11 with 236 patients and Stage I (without nodal metastases) had an 88% rate of survival, and level 111 with 47 patients and Stage I1 (with nodal metastases) had an 82% 4-year survival rate. Similar results were noted for Clark’s level IV for both stages. Clark’s level V patients had 100% (19 Stage I patients) and 55% (26 Stage I1 patients) 4-year survival rates. They noted that Clark’s level was an important prognostic factor for Stage I patients, but not when nodal metastases had occurred. Their overall 4year survival rates for Stages I and I1 (by my calculations) were approximately 86% and 73% [lo].
Other Combinations Various other combinations of adjuvant immunotherapy have been tried. Investigators have used Levamisole with their vaccine [ I 11. Some have coupled rabbit IgG [12], and others goat IgG [13] with minimal success. Skornick added cholesterol hemisuccinate to melanoma cell cultures and irradiated them prior to injection. In 21 patients with gross disease there were seven responders and 619 who were tested showed skin reactivity [14]. Mitchell added a BCG derivative called Detox to a mechanical lysate of two melanoma cell lines in a trial involving patients with gross disease and 5/17 had remissions [ 151. Viral Oncosylates Perhaps the most promosing additions to melanoma vaccine therapy are different viral oncosylates. Use of vesicular stomatitis virus [ 16-18], Newcastle disease virus [19-211, and vaccinia virus [22-251 have been reported. In 1978, Boone reported increased rates of cellmediated immunity in vaccines obtained from cell cultures infected with vesicular stomatitis virus [ 171. In a 1979 review they asserted that infected cells retain their antigenicity even when lysed [18]. In 1977 Cassal and Murray reported increased lymphocyte cytotoxicity using a cell cultured vaccine infected with Newcastle disease virus. They observed clinical responses in 6 of 13 patients treated with their vaccine [ 19,201. In 1983 they noted only a 12% rate of progression to disseminated disease in these Stage I1 patients [2 11.
Wallack reported the short-term follow-up of patients treated with a melanoma oncolysate infected with vaccinia virus in 1987. Thirty-eight patients with Stage I1 melanoma were followed for a mean of 17 months with a 53% disease-free rate. They noted a positive correlation between levels of antimelanoma IgG antibodies and disease-free survival, whereas antimelanoma IgM antibodies showed no clear correlation [22]. In 1989 he reported another series of 39 patients in which 25/39 (64%) were disease-free at 18.5 months [23]. Hersey (1986) noted increased leukocyte dependent antibodies against melanoma cells in patients receiving a vaccinia melanoma cell lysate vaccine [24]. In 1987 they reported 2-year survival statistics. Eighty Stage I1 patients were entered into the study; 39 were followed for 2 years with 75% survival. A matched nonrandomized control showed 57% survival [25].
Tumor Homogenate Beginning in the early 1970s, Humphrey et al. began a series of clinical trials involving tumor vaccines in the form of tumor homogenates. Early results showed some clinical responses in patients with advanced disease [26,27]. In 1976 they reported the purification of their homogenized allogenic vaccine by ultracentrifugation and supernatant concentration, referring to it as concentrated cell sap. They reported a 23% response rate in patients with advanced disease. In those melanoma patients who received the newer vaccine, 5/12 had postimmunization sera that fixed complement. One of the 12 fixed complement prior to immunization. Sixty-three percent of these patients exhibited a significant delayed hypersensitivity response, and 6/18 tested showed a positive immunodiffusion test. They concluded that the concentrated supernatant following ultracentrifugation could stimulate antibody and showed increased rates of delayed hypersensitivity responses over their previous vaccine and no evidence of tumor growth [28]. In 1984 Humphrey reported projected 5-year survival rates for Stage I and Stage I1 melanoma patients receiving an adjuvant immunization schedule utilizing his newer vaccine. All patients were treated by standard surgical techniques and entered into the immunotherapy protocol within 3 months of surgery. The projected 5-year survival rate for Stage I was 90% and for Stage I1 was 68% [29]. The observed 5-year survival data are being readied for publication [30] and is 89% for Stage I and 64% for Stage 11. Two hundred thirty-eight patients were ultimately entered into the study, of which 191 were Stages I and 11. Of 129 Stage I patients, 26 were Clark’s level 2, 46 were Clark’s level 3, 54 were Clark’s level 4, and 3 were Clark’s level 5 . Out of 61 Stage I1 patients (with lymph node metastases) 1 was a Clark’s level 1, 4 were a
Immunotherapy for Malignant Melanoma
Clark’s level 2, 10 were Clark’s level 3, 22 were Clark’s level 4, 3 were Clark’s level 5 , and 21 were an unknown Clark’s level. In the 61 stage I1 patients, 24 had 1 positive node, 13 had 2 positive nodes, 6 had 3 positive nodes, 4 had 4 positive nodes, 11 had 5 or more positive nodes, and in 3 the nodal status was unknown. The 5-year survival for 129 Stage I patients was 87.5%; for 64 males it was 84% and for 65 females it was 90.7%. For 61 Stage I1 patients, the 5-year survival rate was 63.9%; for 36 males it was 66.7% and for 25 females it was 60%.Retrospectively, we broke down our Stage I (without nodal metastases) patients into a newer staging system to Stage IA, IB, 2A, and 2B based on Clark and Breslow’s levels. The 5-year survival rate for 26 Stage IA patients was 96.2%, for 46 Stage IB patients was 87%, for 54 Stage 2A patients was 83%, and 3 Stage 2B patients all survived 5 years [30]. At present there are few reported randomized studies of tumor vaccines [5,31-331. However, several studies, serving as historical controls, show 2 2 4 0 % 5-year survival rates for patients with nodal metastases [17,25,34371. Several reported series of patients receiving tumor vaccines have shown improvement over historical controls [5,21,23,25,29].
OTHER APPROACHES Another approach to improve the efficacy of tumor vaccines is pretreatment with cyclophosphamide. This drug is thought to decrease activity of suppressor cells and has shown benefit in clinical trials [38]. Other drugs thought to decrease suppressive cell activity include levamisole [39] and cimetidine [40]. Ranitidine prevented delayed hypersensitivity after blood transfusions [41]. Several authors have combined nonspecific active immunotherapy (BCG) with chemotherapy, usually DTR (5-(3,3-dimethyl- 1-triazeno)-imidazole-4-carboxamide), with one author showing improved recurrence rates [42]. A large study by Veronesi did not confirm this [35]. Other investigators have inhibited suppressor cell activity in mice by the use of monoclonal antibodies directed against the suppressed cells [43]. Antiidiotypic antibodies have shown positive clinical responses [44]. Interleukin-2 has been shown to increase cytotoxic T-cell activity [45] and has shown clinical responses in animal models and man [46]. Interferons are known to increase antigen expression and to change natural killer cell activity, macrophage tumoricidal activity, and the cytotoxic activity of sensitized T-lymphocytes [47].
DISCUSSION Although there is work being done to elucidate which melanoma-specific antigens provide the best clinical responses, it would seem that not all the important antigens are on the cell surface [6,8]. More specifically defined
219
vaccines, however, will undoubtedly provide a better clinical response. It would seem reasonable to assume that combinations of biologic response modifiers and/or certain drugs with tumor vaccines would enhance the ability of the host to respond to the presentation of allogenic tumor antigen, whether by inhibition of suppressor cell activity or by enhancement of various killer cell activities. There are many possibilities to examine as immunologic adjuvant therapies unfold.
REFERENCES 1. Das Gupta TK, Mastrangelo MJ: Editorial. Semin Oncol 15:493, 1988. 2. Currie GA: Eighty years of immunotherapy: A review of immunological methods used for the treatment of human cancer. Br J Cancer 26:141-153, 1972. 3. Morton DL, Eilber FR, Malmgren RA, et al.: Immunological factors which influence response to immunotherapy in malignant melanoma. Surgery 68: 158-164, 1970. 4. Morton DL, Eilber FR, Holmes EC, et al.: BCG immunotherapy of malignant melanoma: Summary of a seven-year experience. Ann Surg 180:635443, 1974. 5. Morton DL. Holmes EC, Eilber FR, et al.: Adjuvant immunotherapy of malignant melanoma: Results of a randomized trial in patients with lymph node metastases. In Rosenberg T (ed): “Immunotherapy of Human Cancer. ” Amsterdam: Elsevier North Holland, Inc., 1982. 6. Morton DL, Foshag LJ, Nizze JA. et al.: Active specific immunotherapy in malignant melanoma. Semin Surg OncoI5:420-425, 1989. 7. Livingston PO, Kaelin K , Pinsky CM, et al.: The serologic response of patients with Stage I1 melanoma and allogeneic melanoma vaccine. Cancer 56:2194-2200, 1985. 8. Livingston PO. Natoli El, Calves MS, et al.: Vaccines containing purified GM2 ganglioside elicit GM2 antibodies in melanoma patients. Proc Natl Acad Sci USA 84:2911-2915, 1987. 9. Bystryn JC, Oratz R, Harris MN, et al.: Immunogenicity of a polyvalent melanoma antigen vaccine in humans. Cancer 61 1065-1070, 1988. 10. Seigler HF, Cox E, Mutzner F, et al.: Specific active immunotherapy for melanoma. Ann Surg 190:36&372, 1979. 11. Shibata HR, Jerry LM, Lewis MG, et al.: Immunotherapy of human malignant melanoma with irradiated tumor cells, oral Bacillus Calmette-Guerin. and Levamisole. Ann NY Acad Sci 277~3.55-366, 1976. 12. Czajkowski NP, Rosenblatt M, Wolf PL, et al.: A new method of active immunization to autologous human tumor tissue. Lancet 2:905-909. 1967. 13. McCarthy WH, Cotton G , Carlon A, et al.: Immunotherapy of malignant melanoma. Cancer 32:97-103, 1973. 14. Skornick YG, Rong GH, Sindelar WF, et al.: Active immunotherapy of human solid tumor with autologous cells treated with cholesteryl hemisuccinate: A Phase 1 study. Cancer 58:650-654, 1986. 15. Mitchell MS. Kan-Mitchell I . Kempf RA. et al.: Active specific immunotherapy for melanoma: Phase I trial of allogeneic lysates and a novel adjuvant. Cancer Res 48:5883-5893, 1988. 16. Livingston PO, Albino AP, Chung TJC, et al.: Serological response of melanoma patients to vaccines prepared from VSV lysates of autologous and allogeneic cultured melanoma cells. Cancer 55:713-720, 1985. 17. Boone CW, Austin MG. Case R, et al.: Melanoma skin test antigen of improved sensitivity prepared from vesicular stomatitis virus-infected tumor cells. Cancer 41: 1781-1787, 1978. 18. Austin FC, Boone CW: Virus augmentation of the antigenicity of tumor cell extracts. Adv Cancer Res 30:301-345, 1979. 19. Cassal WA, Murray DR. Torbin AH, et al.: Viral oncolysate in
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the management of malignant melanoma. I. Preparation of oncolysate and measurement of immunologic responses. Cancer 40~672-679, 1977. 20. Murray DR, Cassel WA, Torbin AH, et al.: Viral oncolysate in the management of malignant melanoma. 11. Clinical Studies. Cancer 40:68&686, 1977. 21. Cassel WA, Murray DR, Phillips HS: A Phase I1 study on postsurgical management of stage I1 malignant melanoma with a Newcastle disease virus oncolysate. Cancer 52:85&860. 1983. 22. Wallack MK, Bash JA, Leftheriotis E, et al.: Positive relationship of clinical and serologic responses to vaccinia melanoma oncolysate. Arch Surg 122:146&1463, 1987. 23. Wallack MK. Bash J, Bartolucci A: Improvement in disease-free survival of melanoma patients in conjunction with serologic response in a phase IdIb Southeastern Cancer Study Group trial of vaccinia melanoma oncolysate. Am Surg 55:243-247, 1989. 24. Hersey P, Edwards A, D’Alesandro G. et al.: Phase I1 study of vaccinia melanoma cell lysates (VMCL) as adjuvant to surgical treatment of stage I1 melanoma. 11. Effects on cell mediated cytotoxicity and leucocyte dependent antibody activity: Immunological effects of VMCL in melanoma patients. Cancer Immunol Immunother 22:221-231, 1986. 25. Hersey P. Edwards A, Coates A, et al.: Evidence that treatment with vaccinia melanoma cell lysates (VMCL) may improve survival of patients with stage II melanoma: Treatment of stage I1 melanoma with viral lysates. Cancer Immunol lmmunother 25:257-265, 1987. 26. Humphrey LJ. Murray DR, Boehm OR: Effect of tumor vaccines in immunizing patients with cancer. Surg Gynecol Obstet 132:437442. 1971. 27. Humphrey LJ, Boehm B, Jewell WR, et al.: Immunologic response of cancer patients modified by immunization with tumor vaccine. Ann Surg 176:554557, 1972. 28. Jewell WR, Thomas JH. Sterchi JM, et al.: Critical analysis of treatment of stage I1 and stage 111 melanoma patients with immunotherapy. Ann Surg 183543-549. 1976. 29. Humphrey LJ, Taschler-Collins S, Goldfarb PM, et al.: Adjuvant immunotherapy for melanoma. J Surg Oncol 25:303-305, 1984. 30. Humphrey LJ, McGee JMC: Melanoma tumor vaccinefive-year follow up (In preparation). 31. McIIlmurray MB, Embleton JM. Reeves WF. et al.: Controlled trial of active immunotherapy in management of Stage I1 B malignant melanoma. Br Med J [Clin Res] 1:54&542. 1977. 32. Aranha GV, McKhann CF, Grage TB. et al.: Adjuvant immunotherapy of malignant melanoma. Cancer 43: 1297-1303, 1979. 33. Dent PB. McCulloch PB. Liao SK, et al.: Heterogeneity of melanoma-associated antigens detected by sera from patients receiv-
34. 35. 36. 37.
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ing adjuvant allogeneic tumor vaccine immunotherapy. Clin Immunol Immunopathol 23:379-391. 1982. Knutson CO, Hori JM, Spratt JS, Jr: Melanoma. In Steichen SM (ed): “Current Problems in Surgery.” Chicago: Year Book Medical Publishers, 1971, 1-55. Veronesi U, Adamus J, Aubert C, et al.: A randomized trial of adjuvant chemotherapy and immunotherapy in cutaneous melanoma. N Engl J Med 307:913-916. 1982. McCulloch PB, Dent PB. Blajchman M, et al.: Recurrent malignant melanoma: effect of adjuvant immunotherapy on survival. CMA J 117:33-36, 1977. Blois MS. Sagebiel RW, Abarbanel RM, et al.: Malignant melanoma of the skin. I. The association of tumor depth and type. and patient sex, age, and site with survival. Cancer 52:13301341, 1983. Berd D. Maguire HC, Jr, Mastrangelo MJ: Induction of cell mediated immunity to autologous melanoma cells and regression of metastases after treatment with a melanoma cell vaccine preceded by cyclophosphamide. Cancer Res 46:2572-2577, 1986. Hersey P, Ho K, Werkmeister J, et al.: Inhibition of suppressor T cells in pokeweed mitogen-stimulated cultures of T and B cells by levamisole i n vitro and in vivo. Clin Exp Immunol 46:34&349, 1981.
40. Garovoy MR. Reddich MA, Rocklin RE: Histamine induced suppressor factor inhibition of helper T cell generation and function. J lmmunol 130:357-361, 1983. 41. Nielson HJ. Hammer JH, Moesgaard F, et al.: Ranitidine prevents postoperative transfusion-induced depression of delayed hypersensitivity. Surgery 105:711-717, 1989. 42. Kaufman SD, Cosimi AB, Wood WC, et al.: Adjuvant therapy in malignant melanoma: A trial of immunotherapy, chemotherapy and combined treatment. Recent Results Cancer Res 68:38&386, 1979. 43. Drebin JA, Waltenbaugh C, Schatten S , et al.: Inhibition of tumour growth by monoclonal anti I-J antibodies. J Immunol 130:50&509, 1983. 44. O’Connell MJ, Chen z1, Yang H. et al.: Active specific immunotherapy with antiidiotypic antibodies in patients with solid tumors. Semin Surg Oncol 5:441-447, 1989. 45. Hefeneider SH. Conlon PJ, Henney CS. et al.: In vivo interleukin 2 administration augments the generation of alloreactive cytolytic T lymphocytes and resident natural killer cells. J Immunol 130:222-227, 1983. 46. Chang AE, Rosenberg SA: Overview of interleukin-2 as an immunotherapeutic agent. Semin Surg Oncol 5:385-390, 1989. 47. Nelson BE. Borden EC: Interferons: Biological and clinical effects. Semin Surg Oncol 5:391-401, 1989.
lmmunotherapy for Malignant Melanoma: A Review and Update J. MICHAEL C. McGEE, MD From the Department of Surgery, University of Oklahoma College of Medicine, Tulsa
Several different approaches to the application of specific active immunotherapy for the adjuvant therapy of melanoma have developed independently. Specific active immunotherapy refers to autologous or allogenic inoculation or transplantation of tumor cells or cell products into patients with cancer. Several different types of tumor vaccines have been studied and have been combined with different immunotherapeutic modalities. This report will include a review of several of those different techniques and will also review the observed 5-year survival rates for a melanoma tumor homogenate (concentrated) vaccine, developed by L. J. Humphrey and colleagues. KEYWORDS:five-year survival rates, tumor vaccine, melanoma, active specific immunotherapy, tumor homogenate
INTRODUCTION Melanoma, first described in 1787, is increasing in incidence. Although much has been learned abou; its histology, diagnosis, and staging, its biologic properties such as induction, progression, and rates of spontaneous regression remain mysterious. Much effort has gone into elucidating the optimal management, but there remains much pessimism. Recent studies have looked at the extent of resection, if, when, and where to dissect lymph node-bearing areas, different types of chemotherapy including the use of regional perfusion and hyperthermia, and various types of biologic response modifier therapies often referred to as immunotherapy [ 11. Nonspecific but active types of immunotherapy include Corynebacterium parvum, BCG, levamisol, and Freund’s adjuvant. Specific active immunotherapy refers to autologous or allogenic inoculation or transplantation of tumor cells or cell products into patients. These vaccines have been modified or combined with several substances and injected, usually subcutaneously or occasionally intralesionally. In 1972, one author reviewed the previous 80 years of tumor vaccines [2]. Some of these trials included patients with melanoma. The tumors were excised, ground up, and reinjected into the same patient or into other patients with gross disease. The results were not however, there were reports of complete tumor regression [2]. 0 1991 Wiley-Liss, Inc.
ADJUVANT TRIALS OF ACTIVE SPECIFIC IMMUNOTHERAPY Combinations with BCG In 1970 Morton reported a series of patients in which he injected skin metastatic nodules with BCG. In 5 patients those nodules regressed and in 2 patients, uninjected nodules also regressed. Since remote lesions were affected and antibodies were noted in the serum, it raised the possibility of enhanced tumor immunity [3,4]. In 1982, Morton reported the combination of BCG and irradiated neuraminidase-treated melanoma cells injected subcutaneously in a randomized trial of adjuvant treatment of stage I1 patients. The follow-up was 50 months, and the survival in the control group was 41%, the BCG group was 43%, and the BCG plus tumor cell vaccine group was 53% [5]. He later reported that those patients who responded to the vaccine and BCG with the elaboration of IgM antibodies had a significantly better clinical course. Morton and associates have described six different melanoma-associated antigens and have developed three different cell lines containing high concentrations of these surface antigens. When they selected 47 melanoma specimens-98% had a least one of these 6 antigens. Three of the six antigens were gangliosides, two Address reprint requests to J. Michael C. McGee, M.D., Department of Surgery, University of Oklahoma College of Medicine, 2815 South Sheridan Road, Tulsa, OK 74129.
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glycoproteins, and one lipoprotein. In preliminary results of a trial involving 55 patients, there was a higher number of antibody responders [6]. Other investigators have shown similar results with BCG and neuraminidase-treated, irradiated whole cell vaccines, and other groups are exploring vaccines with more specific melanoma-associated antigens [7-91. Siegler reported a large series in 1979 of 719 patients treated with BCG and neuraminidase-treated, irradiated whole melanoma cells. Four-year survivals were reported by stage and Clark’s level. Clark’s level I11 with 236 patients and Stage I (without nodal metastases) had an 88% rate of survival, and level 111 with 47 patients and Stage I1 (with nodal metastases) had an 82% 4-year survival rate. Similar results were noted for Clark’s level IV for both stages. Clark’s level V patients had 100% (19 Stage I patients) and 55% (26 Stage I1 patients) 4-year survival rates. They noted that Clark’s level was an important prognostic factor for Stage I patients, but not when nodal metastases had occurred. Their overall 4year survival rates for Stages I and I1 (by my calculations) were approximately 86% and 73% [lo].
Other Combinations Various other combinations of adjuvant immunotherapy have been tried. Investigators have used Levamisole with their vaccine [ I 11. Some have coupled rabbit IgG [12], and others goat IgG [13] with minimal success. Skornick added cholesterol hemisuccinate to melanoma cell cultures and irradiated them prior to injection. In 21 patients with gross disease there were seven responders and 619 who were tested showed skin reactivity [14]. Mitchell added a BCG derivative called Detox to a mechanical lysate of two melanoma cell lines in a trial involving patients with gross disease and 5/17 had remissions [ 151. Viral Oncosylates Perhaps the most promosing additions to melanoma vaccine therapy are different viral oncosylates. Use of vesicular stomatitis virus [ 16-18], Newcastle disease virus [19-211, and vaccinia virus [22-251 have been reported. In 1978, Boone reported increased rates of cellmediated immunity in vaccines obtained from cell cultures infected with vesicular stomatitis virus [ 171. In a 1979 review they asserted that infected cells retain their antigenicity even when lysed [18]. In 1977 Cassal and Murray reported increased lymphocyte cytotoxicity using a cell cultured vaccine infected with Newcastle disease virus. They observed clinical responses in 6 of 13 patients treated with their vaccine [ 19,201. In 1983 they noted only a 12% rate of progression to disseminated disease in these Stage I1 patients [2 11.
Wallack reported the short-term follow-up of patients treated with a melanoma oncolysate infected with vaccinia virus in 1987. Thirty-eight patients with Stage I1 melanoma were followed for a mean of 17 months with a 53% disease-free rate. They noted a positive correlation between levels of antimelanoma IgG antibodies and disease-free survival, whereas antimelanoma IgM antibodies showed no clear correlation [22]. In 1989 he reported another series of 39 patients in which 25/39 (64%) were disease-free at 18.5 months [23]. Hersey (1986) noted increased leukocyte dependent antibodies against melanoma cells in patients receiving a vaccinia melanoma cell lysate vaccine [24]. In 1987 they reported 2-year survival statistics. Eighty Stage I1 patients were entered into the study; 39 were followed for 2 years with 75% survival. A matched nonrandomized control showed 57% survival [25].
Tumor Homogenate Beginning in the early 1970s, Humphrey et al. began a series of clinical trials involving tumor vaccines in the form of tumor homogenates. Early results showed some clinical responses in patients with advanced disease [26,27]. In 1976 they reported the purification of their homogenized allogenic vaccine by ultracentrifugation and supernatant concentration, referring to it as concentrated cell sap. They reported a 23% response rate in patients with advanced disease. In those melanoma patients who received the newer vaccine, 5/12 had postimmunization sera that fixed complement. One of the 12 fixed complement prior to immunization. Sixty-three percent of these patients exhibited a significant delayed hypersensitivity response, and 6/18 tested showed a positive immunodiffusion test. They concluded that the concentrated supernatant following ultracentrifugation could stimulate antibody and showed increased rates of delayed hypersensitivity responses over their previous vaccine and no evidence of tumor growth [28]. In 1984 Humphrey reported projected 5-year survival rates for Stage I and Stage I1 melanoma patients receiving an adjuvant immunization schedule utilizing his newer vaccine. All patients were treated by standard surgical techniques and entered into the immunotherapy protocol within 3 months of surgery. The projected 5-year survival rate for Stage I was 90% and for Stage I1 was 68% [29]. The observed 5-year survival data are being readied for publication [30] and is 89% for Stage I and 64% for Stage 11. Two hundred thirty-eight patients were ultimately entered into the study, of which 191 were Stages I and 11. Of 129 Stage I patients, 26 were Clark’s level 2, 46 were Clark’s level 3, 54 were Clark’s level 4, and 3 were Clark’s level 5 . Out of 61 Stage I1 patients (with lymph node metastases) 1 was a Clark’s level 1, 4 were a
Immunotherapy for Malignant Melanoma
Clark’s level 2, 10 were Clark’s level 3, 22 were Clark’s level 4, 3 were Clark’s level 5 , and 21 were an unknown Clark’s level. In the 61 stage I1 patients, 24 had 1 positive node, 13 had 2 positive nodes, 6 had 3 positive nodes, 4 had 4 positive nodes, 11 had 5 or more positive nodes, and in 3 the nodal status was unknown. The 5-year survival for 129 Stage I patients was 87.5%; for 64 males it was 84% and for 65 females it was 90.7%. For 61 Stage I1 patients, the 5-year survival rate was 63.9%; for 36 males it was 66.7% and for 25 females it was 60%.Retrospectively, we broke down our Stage I (without nodal metastases) patients into a newer staging system to Stage IA, IB, 2A, and 2B based on Clark and Breslow’s levels. The 5-year survival rate for 26 Stage IA patients was 96.2%, for 46 Stage IB patients was 87%, for 54 Stage 2A patients was 83%, and 3 Stage 2B patients all survived 5 years [30]. At present there are few reported randomized studies of tumor vaccines [5,31-331. However, several studies, serving as historical controls, show 2 2 4 0 % 5-year survival rates for patients with nodal metastases [17,25,34371. Several reported series of patients receiving tumor vaccines have shown improvement over historical controls [5,21,23,25,29].
OTHER APPROACHES Another approach to improve the efficacy of tumor vaccines is pretreatment with cyclophosphamide. This drug is thought to decrease activity of suppressor cells and has shown benefit in clinical trials [38]. Other drugs thought to decrease suppressive cell activity include levamisole [39] and cimetidine [40]. Ranitidine prevented delayed hypersensitivity after blood transfusions [41]. Several authors have combined nonspecific active immunotherapy (BCG) with chemotherapy, usually DTR (5-(3,3-dimethyl- 1-triazeno)-imidazole-4-carboxamide), with one author showing improved recurrence rates [42]. A large study by Veronesi did not confirm this [35]. Other investigators have inhibited suppressor cell activity in mice by the use of monoclonal antibodies directed against the suppressed cells [43]. Antiidiotypic antibodies have shown positive clinical responses [44]. Interleukin-2 has been shown to increase cytotoxic T-cell activity [45] and has shown clinical responses in animal models and man [46]. Interferons are known to increase antigen expression and to change natural killer cell activity, macrophage tumoricidal activity, and the cytotoxic activity of sensitized T-lymphocytes [47].
DISCUSSION Although there is work being done to elucidate which melanoma-specific antigens provide the best clinical responses, it would seem that not all the important antigens are on the cell surface [6,8]. More specifically defined
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vaccines, however, will undoubtedly provide a better clinical response. It would seem reasonable to assume that combinations of biologic response modifiers and/or certain drugs with tumor vaccines would enhance the ability of the host to respond to the presentation of allogenic tumor antigen, whether by inhibition of suppressor cell activity or by enhancement of various killer cell activities. There are many possibilities to examine as immunologic adjuvant therapies unfold.
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