|
Advertisement |
|
|
||
 |
|
|||||
|
|||||
|
 |
||||||
|
||||||
|
||||||
|
Originally published as JCO Early Release 10.1200/JCO.2004.06.043 on December 22 2003 © 2004 American Society of Clinical Oncology. Immunopharmacologic Analysis of an Autologous, Hapten-Modified Human Melanoma VaccineFrom the Department of Medicine, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA. Address reprint requests to David Berd, MD, Thomas Jefferson University, 1015 Walnut St, Suite 1024, Philadelphia, PA 19107; e-mail: d_berd{at}mail.jci.tju.edu
PURPOSE: We have previously reported a clinical trial of a human cancer vaccine consisting of autologous tumor cells modified with the hapten, dinitrophenyl (DNP), in patients with clinical stage III melanoma. Here we present a follow-up report expanded to 214 patients with 5-year follow-up. PATIENTS AND METHODS: Two hundred fourteen patients with clinical stage III melanoma (117 patients with stage IIIC and 97 patients with stage IIIB) who were melanoma-free after standard lymphadenectomy were treated with multiple intradermal injections of autologous, DNP-modified vaccine mixed with bacille Calmette-Guérin. Four vaccine dosage schedules were tested sequentially, all of which included low-dose cyclophosphamide. Patients were tested for delayed-type hypersensitivity (DTH) to autologous melanoma cells, both DNP-modified and unmodified, and to control materials. RESULTS: The 5-year overall survival (OS) rate of the 214 patients was 44%. DTH responses to unmodified autologous melanoma were induced in 47% of patients. The OS of this DTH-positive group was double that of DTH-negative patients (59.3% v 29.3%; P < .001). In contrast, positive DTH responses to DNP-modified autologous melanoma cells and to purified protein derivative developed in almost all patients but did not affect OS. Surprisingly, the OS after relapse was also significantly longer in patients who developed positive DTH to unmodified tumor cells (25.2% v 12.3%; P < .001). Finally, the development of DTH was dependent on the schedule of administration of the vaccine, specifically, the timing of an induction dose administered at the beginning of the treatment program. CONCLUSION: This study underscores the importance of the immunopharmacology of the autologous, DNP-modified vaccine and may be relevant to other cancer vaccine technologies.
Progress in the development of an effective therapeutic human cancer vaccine has been disappointingly slow. Despite a number of seemingly positive clinical trials published over the past 20 years [1-6], oncologists remain skeptical about the results, and no cancer vaccine is likely to obtain marketing approval in the United States in the near future. Paradoxically, the theoretical and experimental bases for active immunotherapy of malignant tumors have become more firmly established as progress in the clinic has languished. Animal models continue to indicate that established, albeit small, tumors can be made to regress by active immunization [7]. A number of human tumor-associated antigens have been discovered, from which immunogenic peptides have been identified and synthesized [2,4]. T cells that can modulate antitumor immunity have been rediscovered as regulatory T cells with a characteristic phenotype and cytokine production profile [8]. A major impediment to progress in this area has been a dearth of information on what may be called the immunopharmacology of cancer vaccines. Little is known about optimum vaccine doses, schedules of administration, or routes of administration. There are no standard, widely accepted immunologic tests for monitoring vaccine efficacy; as characterized in a recent editorial [9], it has not been easy to determine whether a vaccine works. We have been conducting clinical trials with a cancer vaccine consisting of autologous, intact tumor cells modified with the hapten, dinitrophenyl (DNP). The rationale for this approach consists of the value of the autologous tumor cell as a source of tumor rejection antigens [10-12] and the ability of haptenization to render immunogenic proteins to which the host is otherwise unresponsive [13-15]. Previously we reported the preliminary immunologic and clinical results of clinical trials in which 77 patients with clinical stage III melanoma were treated postoperatively with the autologous, DNP vaccine [16]. Here we present an updated report expanded to 214 patients, almost all of whom have completed 5-year follow-up. We confirm our previous finding that patients who developed positive delayed-type hypersensitivity (DTH) to unmodified, autologous tumor cells had significantly longer durations of relapse-free survival (RFS) and overall survival (OS). In addition, we show that this response was a significant determinant of survival, even in patients who eventually experienced relapse, because it affected their pattern of relapse. Finally, we present evidence that the schedule of administration of the DNP vaccine, in particular, the timing of what we are calling an induction dose, affects both immunologic and clinical end points.
Patients The study population consisted of 214 patients with clinical stage III melanoma. Metastatic masses were  2.5 cm in diameter but were completely resectable. The clinical characteristics of these patients are listed in Table 1. One hundred seventeen patients (55%) had stage IIIC disease by virtue of one or more of the following characteristics: four or more positive nodes, in-transit metastases, gross extranodal extension, or ulceration of the primary lesion; the other 97 patients had stage IIIB disease [17]. Assessment of the pathology of the primary lesions and the lymph nodes was done at the hospitals where the surgeries were performed.
The protocols were approved by the institutional review board of Thomas Jefferson University. Patients had to be entered onto the protocol within 30 days of lymphadenectomy. The major entry criteria were as follows: completion of standard lymphadenectomy, including, when necessary, excision of in-transit metastases; no clinically evident metastases as determined by physical examination and imaging studies (computed tomography of the chest, abdomen, and pelvis); age 16 years; no systemic antimelanoma therapy within 8 weeks of study entry; and not taking corticosteroids or other immunosuppressive drugs. After the completion of vaccine treatments, patients were evaluated by history and physical examination at the Thomas Jefferson University Hospital every 2 months in years 1 and 2, every 3 months in year 3, and every 6 months in years 4 and 5. No patients were lost during the 5-year follow-up period. Because of early relapse and the need for additional antitumor therapy, 24 patients did not complete the intended course of vaccine administration. However, because all patients who received at least one vaccine injection were considered assessable, these 24 patients were included in the analysis. There were no drop-outs from the trial.
Tumor Processing and Vaccine Preparation On the day that a patient was to be treated, an aliquot of cells was thawed, washed, and irradiated to 25 Gy. Then the cells were washed again and modified with DNP by the method of Miller and Claman [19]. This involves a 30-minute incubation of tumor cells with dinitrofluorobenzene (DNFB), followed by washing with saline. Each vaccine fell within a specified dose range of live (trypan blue–excluding) tumor cells suspended in 0.2 mL of Hanks solution with human serum albumin. In addition, there were variable numbers of lymphocytes and dead cells in all specimens [18].
Vaccine Administration
Vaccine Dosage Schedules
For Schedules A, B, and C, patients received baseline skin testing and then were sensitized with DNFB by topical application of a 1% solution in acetone corn oil on 2 consecutive days in the same site on the ventral upper arm; cyclophosphamide 300 mg/m2 was administered by intravenous rapid infusion 3 days before DNFB application. The first vaccine injection was given 2 weeks later. For Schedule D, DNFB sensitization was omitted. For Schedule A, DNP vaccine mixed with BCG was administered every 4 weeks for a total of eight doses; cyclophosphamide 300 mg/m2 was administered 3 days before the first and second doses. All vaccine injections were given into the same site. For Schedule B, vaccine was administered weekly for 6 weeks; after a 4-week re-evaluation period, vaccine was again administered weekly for 6 weeks. The first three vaccines of each course were DNP-modified and the last three were unmodified. BCG was admixed only with the first and fourth vaccine of each course. All of the DNP vaccine injections were given into one area, and all of the unmodified vaccine injections were given into a second area. Cyclophosphamide 300 mg/m2 was administered 3 days before the start of each vaccine course. Schedule C was identical to Schedule B, except that all vaccines were DNP-modified and all were mixed with BCG. Schedule D was a simplified regimen in which DNFB presensitization was omitted, and only one series of six weekly DNP-modified vaccines was administered.
Rationale for Dosage Schedules
DTH Testing DTH testing was performed before the treatment program was initiated and posttreatment (see Results). Analyses were performed by determining the maximum DTH response exhibited by each patient to each of the test reagents.
Statistics
Effect of Patient-Related Variables on Survival Figure 1 shows the RFS and OS of all 214 patients treated postlymphadenectomy with autologous, DNP vaccine. The data are essentially complete, because all but four surviving patients have completed the 5-year follow-up. The 5-year RFS and OS rates are 33% and 44%, respectively. Univariate analysis of known prognostic variables (Tables 1 and 3) indicated that the major determinant of survival was the number of positive nodes; eg, the 5-year OS rates of patients with a palpable mass only versus those with a mass plus three or more microscopically positive nodes were 61.9% and 21.4%, respectively. However, the presence of metastatic disease in two nodal sites and extranodal extension were significant independent predictors of OS as confirmed by the multivariate analysis (Table 4). It should be noted that only grossly evident extranodal extension was recorded, because processing of the mass precluded a routine examination for microscopic invasion of the entire lymph node capsule. Finally, neither the presence of in-transit metastases nor ulceration of the primary tumor alone were significant determinants of survival in DNP vaccine–treated patients, although both were previously shown to be important variables in large series of patients treated with surgery alone [21].
Effect of Vaccine Dosage Schedule on Survival Table 5 lists the range of vaccine doses administered. The dose of vaccine was defined by the number of live tumor cells, ie, tumor cells that excluded the supravital dye, trypan blue. These live cells were proliferation-incompetent as shown by failure to incorporate a radioactive DNA precursor after in vitro incubation (data not shown). Subsequently we found that dead tumor cells also may have contributed to the immunogenicity of the vaccine [18], so we summarized the number of dead and total (live plus dead) cells administered as well. Univariate analysis (Table 6) indicated that none of these cell dosage parameters significantly affected RFS or OS. However, schedule C seemed to be associated with lower 5-year RFS and OS, although the difference was of borderline statistical significance only for RFS.
Effect of Vaccine-Induced DTH Responses on Survival Table 5 provides a summary of the DTH responses induced by administration of DNP vaccine. For each patient, the maximum DTH response to each material is tabulated. For most patients, DTH to unmodified autologous melanoma cells was tested at only one posttreatment time point (week 10 for study A, week 11 for studies B and C, week 9 for study D). Sixty-eight patients had a second DTH test to unmodified tumor cells. In studies A, B, and C (n = 34), the follow-up DTH test was performed after a median interval of 1.9 months; in study D (n = 34), the follow-up DTH test was performed after a median interval of 9.5 months. For each patient, there was a tight correlation between DTH responses elicited at the two time points; eg, for DTH to mechanically dissociated tumor cells, the squared multiple r = 0.690 (P < .001). These data suggest that the DTH responses shown in Table 5 were durable as well as reproducible. Pretreatment positive DTH responses to autologous melanoma cells, either DNP-modified or unmodified, were observed in only 23 patients (8%) and were generally small (median, 6 mm). We tested for DTH to both autologous melanoma cells that had been dissociated with enzymes (collagenase and DNAse) and to melanoma cells that had been mechanically dissociated only. The two preparations usually elicited similar DTH responses, as indicated by regression analysis (Fig 2). However, 30 patients (14%) developed an apparent DTH response to the enzymes themselves, as measured by skin testing with enzyme-treated autologous peripheral-blood mononuclear cells, so we analyzed only their DTH response to mechanically dissociated melanoma cells. Thirty percent of these enzyme-reactive patients also exhibited positive DTH to mechanically dissociated cells. It is noteworthy that DTH to the enzymes was induced in 60% of patients treated with dosage schedule B, which included immunization with unmodified as well as DNP-modified melanoma cells, but in only 7% of patients treated by dosage schedules A, C, and D, in which all vaccine cells were hapten-modified.
Virtually all patients developed positive DTH to DNP-modified autologous melanoma cells and to PPD after DNP vaccine treatment, and the intensity of these response was similar among the four dosage schedules (P = .507 and P = .103, respectively, Kruskal-Wallis test). In contrast, the DTH response to DNP-modified autologous lymphocytes was significantly lower in patients treated with schedule D as compared with A, B, and C (P < .001). This difference was likely due to the omission of DNFB contact sensitization in schedule D, which might have primed patients for a T-cell response to DNP-modified normal tissue antigens. DTH responses to unmodified autologous melanoma were induced less frequently and were smaller. Schedules A and D generated significantly larger responses to unmodified tumor cells than schedules B and C (P < .001). Only three patients exhibited positive DTH to unmodified, autologous peripheral-blood mononuclear cells; these responses could have represented the induction of autoimmunity, but because no patients developed changes in the number of circulating leukocytes or clinical signs of autoimmunity, they were more likely artifactual. Univariate analyses of the effect of the DTH responses on survival are shown in Table 6. The group of patients who developed positive DTH to unmodified, autologous melanoma cells had a doubling of both RFS and OS, which was highly significant (P < .001; Fig 3). In contrast, the magnitudes of the DTH response to DNP-modified melanoma cells and PPD were not predictive of longer survival (Fig 4).
Finally, as shown in Table 7, a positive DTH response to unmodified tumor cells remained statistically significant for both RFS and OS in multivariate analyses that included the previously determined important patient-related variables: sex, number of positive lymph nodes, and presence or absence of extranodal extension. None of the other treatment-related parameters tested in this model (DTH responses to DNP-modified tumor cells, DTH to PPD, or number of tumor cells per vaccine dose) had significant effects on survival.
Timing of the Vaccine Induction Dose Because the development of positive DTH to unmodified melanoma cells was so important to clinical outcome, we performed retrospective analyses to determine why dosage schedules B and C were inferior to A and D in regard to stimulation of that immune response. All four dosage schedules included the following procedures: baseline skin testing performed by intradermal injection of 1 x 106 irradiated, autologous, DNP-modified tumor cells without BCG into the ventral forearm; administration of low-dose cyclophosphamide; and multiple intradermal injections of DNP-modified melanoma cells mixed with BCG beginning 3 days after cyclophosphamide administration. One difference between schedules was the timing of the baseline skin tests. A majority of patients (n = 122) received baseline skin testing 3 to 8 days before cyclophosphamide administration (day -3 to -8), whereas 78 patients received baseline skin testing on the day of cyclophosphamide administration (day 0) or one day after (day +1). The remaining 14 patients received baseline skin testing 12 to 14 days before cyclophosphamide administration or not at all.
DTH responses to autologous, unmodified melanoma cells that developed after a course of DNP vaccine were significantly larger in patients who had received baseline skin testing on day -3 to -8 than in those who had been skin-tested on day 0 or day +1 (Fig 5; P < .001). The percentage of patients who developed a positive DTH (
Surprisingly, this variable influenced survival as well. Five-year OS was 51% in the group that had baseline skin testing on day -3 to -8 versus 33% in the group with baseline skin testing on days 0 or +1 (P = .007; Fig 6). A similar dichotomy was observed for 5-year RFS (40% v 22%, respectively; P = .005). This effect remained significant in a multivariate analysis that included the known prognostic variables: number of positive nodes, presence of extranodal extension, and sex (hazard ratio for skin test on day 0 or +1 v days -3 to -8 = 1.618; range, 1.117 to 2.343; P = .011).
These data indicate that what we have considered merely a baseline skin test may serve as an induction dose of vaccine. The timing of the induction dose relative to administration of cyclophosphamide apparently determines whether the subsequent course of DNP vaccine results in tumor immunity or unresponsiveness.
Relapse Sites and Postrelapse Survival
The 5-year postrelapse survival rate was 16.1%. We performed an analysis of the patient-related and treatment-related variables that might determine postrelapse survival in these patients. As expected, postrelapse survival was significantly higher in patients who experienced relapse late (> 6 months postlymphadenectomy) versus early (
Of 85 patients who received combination chemotherapy (73 with the Dartmouth regimen [23]) for postrelapse metastases, the responses of 80 were documented: 18 patients (23%) had complete or partial responses, and these responders lived longer. For some patients, it was possible to resect the metastases and produce a new DNP-modified vaccine. The 29 patients who received DNP vaccine re-treatment lived significantly longer after experiencing relapse than those who did not, but this effect was impossible to separate from the beneficial effect of having a resectable metastasis to begin with.
Unexpectedly, 5-year postrelapse survival was significantly greater in patients who had developed a positive DTH response (
Toxicity All patients developed reactions at the vaccine injection sites consisting of pruritic papules that progressed to pustules, sometimes with small ulcerations. The intensity of the reactions was ameliorated by reducing the dose of BCG. Less than 5% of patients noted fever or chills after vaccine administration, and no patient experienced a decrease in performance status attributable to vaccine administration. We observed no clinical evidence of autoimmunity. No patients developed depigmentation after treatment.
Our approach to active immunotherapy of cancer is based on two principles: first, autologous tumor cells are the optimal source of tumor antigens; second, hapten modification is an effective way to increase their immunogenicity. The first premise is strongly supported by the classic literature of tumor immunology [10] as well as by more recent work suggesting that antigens shared by tumors of the same histology may not make effective vaccines [11]. Hapten modification is a venerable immunologic trick that allows the generation of an immune response against proteins that are otherwise not immunogenic [24]. Several animal models confirm that immunization with hapten-modified tumor cells confers protection against challenge with unmodified tumor cells [25]. Most recently, Sojka et al [13], using the highly metastatic 410.4 murine mammary carcinoma, reported that administration of a vaccine consisting of irradiated tumor cells haptenized with DNP caused significant prolongation of RFS, whereas an unmodified vaccine was ineffective. The molecular basis of the hapten effect has been elucidated by Martin et al [20]. They have demonstrated that immunization of mice with trinitrophenyl peptides induced cytotoxic T cells that recognized unmodified peptides. They hypothesized that haptenization increases the binding of autoreactive T cells to self peptides, and, once activated, these T cells react with unmodified peptides as well. Previously, we reported the immunologic and clinical results of 77 patients with clinical stage III melanoma treated with autologous, DNP-modified vaccine after lymphadenectomy [16]. This article represents a final update of the initial studies, the sample size having been increased to 214 patients and almost all surviving patients having completed the planned 5-year follow-up. There are two major findings, each of which provides insight into the immunopharmacology of the vaccine: first, the development of a positive DTH response to unmodified, autologous melanoma cells after vaccine administration is a significant determinant of clinical outcome; second, the development of a positive DTH response is, to a great extent, determined by schedule of vaccine administration. Patients who developed a positive DTH to unmodified melanoma cells had 5-year RFS and OS that were double those of patients with negative DTH responses (59% v 29%, respectively). This effect size is actually larger than what we originally reported, and we interpret it as indicating that the vaccine works by inducing T-cell–mediated immunity to as yet unidentified melanoma antigens. However, we have performed additional analyses to be certain that interpretation of these data was not obscured by technical or statistical artifacts. The major technical artifact in the use of autologous tumor cells for DTH testing is the presence of immunogenic contaminants, especially heterologous serum and the enzymes used for tumor dissociation. We did not use serum in the preparation of the vaccines, but the cells were exposed to collagenase (bacterial origin) and DNAse (bovine origin). In a previous study in which patients were administered an autologous melanoma vaccine that was not hapten-modified, we observed large DTH responses to both collagenase and DNAse in almost all patients after treatment [26], apparently owing to trace amounts of enzyme remaining on the cells after the tumor dissociation process. To avoid that problem, the patients described in this article were skin-tested with autologous tumor cells obtained by mechanical dissociation (without enzymes) as well as with enzymatically dissociated cells, and the two preparations produced almost identical responses. Surprisingly, only 14% of patients who received DNP-modified vaccine developed DTH to the enzymes, as measured by skin testing with enzyme-coated autologous peripheral-blood mononuclear cells, and most of them had been treated by dosage schedule B, which included immunization with unmodified as well as DNP-modified melanoma cells. These data suggest that DNP modification of tumor cells either removes the contaminating enzymes or renders them nonimmunogenic. Statistical artifacts interfering with interpretation of DTH results are more subtle. It is possible that patients who developed positive responses survive longer because they are healthier to begin with. We have addressed this issue by analyzing the effect of other immunologic parameters on clinical outcome and by performing multivariate analyses. In contrast to the significant effect of DTH to unmodified melanoma cells, survival was not affected by the responses to DNP-modified tumor cells or to PPD. Moreover, a positive DTH response to unmodified tumor cells remained a statistically significant determinant of both RFS and OS in multivariate analyses that included the important patient-related variables: sex, number of positive lymph nodes, and presence or absence of extranodal extension. An unexpected finding was the significant effect of DTH to unmodified tumor cells on postrelapse survival. Patients who had developed positive DTH after their initial vaccine administration had a 5-year postrelapse survival rate that was double that of patients who had negative DTH responses (25% v 12%, respectively). This finding can be at least partially explained by the observation that patients with positive DTH to unmodified melanoma cells had a significantly higher likelihood of experiencing relapse with tumors that were resectable. Thus it is possible that the induction of antitumor immunity changes the biology of the disease so that the growth of metastases is modulated even when not prevented.
It is noteworthy that several other investigators have now reported that DTH is a meaningful measure of tumor immunity in cancer patients undergoing immunotherapy. Chang et al [27] found that eight of 10 and four of 10 patients developed The second major finding of this study was the importance of the vaccine dosage schedule on the immunologic response. Patients treated on schedules A and D developed significantly greater DTH responses to unmodified, autologous melanoma cells than those treated on schedules B and C. This difference was not due to variations in vaccine dose, but rather to the schedule of administration—apparently, to the timing of what we are calling an induction dose. This is defined as the intradermal injection of DNP-modified autologous melanoma cells without BCG before or simultaneously with cyclophosphamide. When these protocols were designed, the purpose of this injection was to serve as a baseline skin test, so therefore its timing was not considered critical. However, a retrospective analysis indicated that patients who received baseline skin testing 3 to 8 days before cyclophosphamide administration (day -3 to -8) subsequently developed significantly larger DTH responses than those who received baseline skin testing on the day of cyclophosphamide administration (day 0) or one day after (day +1). Moreover, the timing of the induction dose seemed to affect clinical outcome in that 5-year OS was significantly greater in the day -3 to -8 group, even after a multivariate analysis. Given the number of treatment variables that differentiated the four dosage schedules, the induction dose phenomenon should be viewed as a hypothesis until more definitive clinical data are obtained. However, it is of interest that it has been reproduced in an animal model: in the 410.4 murine mammary carcinoma model described above, the administration of an induction dose 7 days before cyclophosphamide further increased RFS (M.B. Mokyr, personal communication, 2002). Moreover, there is a plausible immunologic explanation for this phenomenon based on melanoma-specific regulatory T cells (Tr) [8]. Administration of the induction dose (autologous melanoma cells without adjuvant) could induce the expansion of Tr cells, which are killed or functionally inhibited by the administration of cyclophosphamide 3 to 8 days later. Then, administration of vaccine 3 days after cyclophosphamide would allow the presentation of tumor antigens with an adjuvant in the absence of specific Tr. These events could increase the probability of generating an effective cell-mediated immune response. An assessment of the clinical effectiveness of the autologous, DNP-modified melanoma vaccine requires a randomized trial. However, as phase II data, the results (44% 5-year OS) seem promising when compared with the outcomes of most published surgical series of patients with clinically detectable nodal metastases, which report 5-year survivals of 20% to 25% [30-32]. Even in the more recent large data analysis that formed the basis of the newest American Joint Committee on Cancer staging system, patients with stage IIIC disease, who comprised the majority of our patients, were reported to have 5-year OS of only approximately 25% [17]. Additional evidence that the DNP vaccine can induce clinically meaningful antitumor immunity is provided by our study of patients with measurable metastases, in which six of 83 patients had documented clinical responses [6]. The findings resulting from this work on an autologous, hapten-modified vaccine may be applicable to other human cancer vaccines. Whether vaccines are composed of whole cells, cellular extracts, purified proteins, peptides, or DNA, an understanding of their immunopharmacology is necessary for their clinical development. After all, vaccines are drugs, thus the way they are administered (eg, dose, schedule, and route of administration) is likely to be as important to their efficacy as their composition. These variables are best analyzed by using an immunologic end point that makes biologic sense and that is strongly predictive of clinical outcome.
The following authors or their immediate family members have indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. Owns stock (not including shares held through a public mutual fund: David Berd, AVAX Technologies Inc. Acted as a consultant within the last 2 years: David Berd, AVAX Technologies Inc. Received more than $2,000 a year from a company for either of the last 2 years: David Berd, AVAX Technologies Inc.
We thank Carmella Clark and Jason Kuchar for technical assistance and Ellen Bloome, research nurse.
Authors' disclosures of potential conflicts of interest are found at the end of this article.
1. Vermorken JB, Claessen AME, van Tinteren H, et al: Active specific immunotherapy for stage II and stage III human colon cancer: A randomised trial. Lancet 353:345-350, 1999[CrossRef][Medline] 2. Rosenberg SA, Yang JC, Schwartzentruber DJ, et al: Immunologic and therapeutic evaluation of a synthetic peptide vaccine for the treatment of patients with metastatic melanoma. Nature Med 4:321-327, 1998[CrossRef][Medline] 3. Leong SPL, Enders-Zohr P, Zhou Y-M, et al: Recombinant human granulocyte macrophage-colony stimulating factor and autologous melanoma vaccine mediate tumor regression in patients with metastatic melanoma. J Immunother 22:166-174, 1999 4. Marchand M, Van Baren N, Weynants P, et al: Tumor regressions observed in patients with metastatic melanoma treated with an antigenic peptide encoded by gene MAGE-3 and presented by HLA-A1. Int J Cancer 80:219-230, 1999[CrossRef][Medline] 5. Nestle FO, Alijacic S, Gilliet M, et al: Vaccination of melanoma patients with peptide- or tumor lysate-pulsed dendritic cells. Nat Med 4:328-332, 1998[CrossRef][Medline] 6. Berd D, Sato T, Cohn H, et al: Treatment of metastatic melanoma with autologous, hapten-modified melanoma vaccine: Regression of pulmonary metastases. Int J Cancer 94:531-539, 2001[CrossRef][Medline]
7. Bilsborough J, Uyttenhove C, Colau D, et al: TNF-mediated toxicity after massive induction of specific CD8+ T cells following immunization of mice with a tumor-specific peptide. J Immunol 169:3053-3060, 2002
8. Dieckmann D, Plottner H, Berchtold S, et al: Ex vivo isolation and characterization of CD4(+)CD25(+) T cells with regulatory properties from human blood. J Exp Med 193:1303-1310, 2001
9. Wolchok JD, Chapman PB: How can we tell when cancer vaccines vaccinate? J Clin Oncol 21:586-587, 2003 10. Prehn RT, Main JM: Immunity to methylcholanthrene-induced sarcomas. J Natl Cancer Inst 18:769-778, 1957 11. Ramarathinam L, Sarma S, Maric M, et al: Multiple lineages of tumors express a common tumor antigen, P1A, but they are not cross-protected. J Immunol 155:5323-5329, 1995[Abstract]
12. Tamura Y, Peng P, Daou M, et al: Immunotherapy of tumors with autologous tumor-derived heat shock protein preparations. Science 278:117-120, 1997 13. Sojka DK, Felnerova D, Mokyr MB: Anti-metastatic activity of hapten-modified autologous tumor cell vaccine in an animal tumor model. Cancer Immunol Immunother 51:200-208, 2002[CrossRef][Medline] 14. Martin S, Von Bonin A, Fessler C, et al: Structural complexity of antigenic determinants for class I MHC- restricted, hapten-specific T cells: Two qualitatively differing types of H-2Kb-restricted TNP epitopes. J Immunol 151:678-687, 1993[Abstract] 15. Weigle WO: The production of thyroiditis and antibody following injection of unaltered thyroglobulin without adjuvant into rabbits previously stimulated with altered thyroglobulin. J Exp Med 122:1049-1062, 1965[Abstract]
16. Berd D, Maguire HC Jr, Schuchter LM, et al: Autologous, hapten-modified melanoma vaccine as post-surgical adjuvant treatment after resection of nodal metastases. J Clin Oncol 15:2359-2370, 1997
17. Balch CM, Buzaid AC, Soong S-J, et al: Final version of the American Joint Committee on Cancer staging system for cutaneous melanoma. J Clin Oncol 19:3635-3648, 2001 18. Berd D, Sato T, Mastrangelo MJ: Effect of the dose and composition of an autologous, hapten-modified melanoma vaccine on the development of delayed-type hypersensitivity responses. Cancer Immunol Immunother 51:320-326, 2002[CrossRef][Medline] 19. Miller SD, Claman HN: The induction of hapten-specific T cell tolerance by using hapten-modified lymphoid cells: I. Characteristics of tolerance induction. J Immunol 117:1519-1526, 1976[Medline] 20. Martin S, Weltzien HU: T cell recognition of haptens, a molecular view. Int Arch Allergy Immunol 104:10-16, 1994[CrossRef][Medline]
21. Balch CM, Soong S-J, Gershenwald JE, et al: Prognostic factors analysis of 17,600 melanoma patients: Validation of the American Joint Committee on Cancer melanoma staging system. J Clin Oncol 19:3622-3634, 2001 22. Mitchell MS: Relapse in the central nervous system in melanoma patients successfully treated with biomodulators. J Clin Oncol 7:1701-1709, 1989[Abstract] 23. McClay EF, Mastrangelo MJ, Berd D, et al: Effective combination chemo/hormonal therapy for malignant melanoma: Experience with three consecutive trials. Int J Cancer 50:553-556, 1992[Medline] 24. Weigle WO: The relationship among acquired immunological tolerance and its termination and tolerance to self and autoimmunity. Int Arch Allergy Appl Immunol 27:368-369, 1965[Medline] 25. Cavallo G, Forni G: Cell reactivity toward syngeneic neoplastic cells in mice hypersensitized to DNP. Eur J Cancer 10:103-106, 1974 26. Berd D, Maguire HC Jr, McCue P, et al: Treatment of metastatic melanoma with an autologous tumor-cell vaccine: Clinical and immunologic results in 64 patients. J Clin Oncol 8:1858-1867, 1990[Abstract]
27. Chang AE, Redman BG, Whitfield JR, et al: A phase I trial of tumor lysate-pulsed dendritic cells in the treatment of advanced cancer. Clin Cancer Res 8:1021-1032, 2002
28. Lee P, Wang F, Kuniyoshi J, et al: Effects of interleukin-12 on the immune response to a multipeptide vaccine for resected metastatic melanoma. J Clin Oncol 19:3836-3847, 2001
29. Disis ML, Schiffman K, Gooley TA, et al: Delayed-type hypersensitivity response is a predictor of peripheral blood T-cell immunity after HER-2/neu peptide immunization. Clin Cancer Res 6:1347-1350, 2000 30. Balch CM, Soong S-J, Murad TM, et al: A multifactorial analysis of melanoma: III. Prognostic factors in melanoma patients with lymph node metastases (stage II). Ann Surg 193:377-388, 1981[Medline] 31. Karakousis CP, Seddiq MK, Moore R: Prognostic value of lymph node dissection in malignant melanoma. Arch Surg 115:719-722, 1980[Abstract] 32. Coit DG, Rogatko A, Brennan MF: Prognostic factors in patients with melanoma metastatic to axillary or inguinal lymph nodes: A multivariate analysis. Ann Surg 214:627-636, 1991[Medline] Submitted June 11, 2003; accepted September 16, 2003. Related Editorial
This article has been cited by other articles:
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
||||||||
|
TOP
ABSTRACT
INTRODUCTION
6 months), who experienced relapse in soft tissue versus viscera, and whose first relapse was resectable versus nonresectable (
