Advanced renal cell carcinoma treated with granulocyte-macrophage colony-stimulating factor gene therapy: A clinical course of the first Japanese experience

A phase I study of granulocyte-macrophage colony-stimulating factor (GM-CSF) gene-transduced tumor vaccine for patients with metastatic renal cell carcinoma (RCC) was initiated in 1998, as the first cancer gene therapy in Japan. The study is still ongoing, but the first patient is presented here as a case report. The patient was a 60-year-old man with Stage IV CRC with multiple lung metastases. After surgical resection of the tumor, autologous tumor cells were transduced and cultured to produce GM-CSF. The patient received a total of 2.2 x 108 gene-transduced autologous vaccine cells by subcutaneous injection. During the course of vaccination, growth of the largest metastatic mass slowed to some extent; however, multiple new lesions developed. About 1 month after the start of low-dose IL-2 therapy, rapid and remarkable regression in a large lung hilar metastatic mass was noticed. The patient died of progressive disease 7 months after the start of GM-CSF gene therapy. Careful histological examination by autopsy revealed that the responding mass was infiltrated by CD8 positive dominant T lymphocytes, and did not exhibit vasculitis or any other changes associated with active autoimmune disease.     

Phase I trial of a B7-1 (CD80) gene modified autologous tumor cell vaccine in combination with systemic interleukin-2 in patients with metastatic renal cell carcinoma

PURPOSE: A reason that the immune system may fail to reject tumors is that T cells encounter tumor antigen derived peptides on the surface of tumor cells in a tolerizing rather than activating context since tumor cells do not express T cell co-stimulatory molecules such as B7-1 (CD80). In preclinical models over expression of B7-1 on the surface of tumor cells has been shown to activate T cells which kill tumor cells. We conducted a phase I clinical trial testing this approach in patients with metastatic renal cell carcinoma. MATERIALS AND METHODS: Resected tumors from 15 patients were disaggregated and adapted to tissue culture, transduced with the B7-1 gene and injected subcutaneously as a vaccine. The dose of the vaccine was escalated in 3 separate cohorts of patients, and systemic interleukin-2 (IL-2) was administered as an adjuvant designed to enhance the proliferation of the vaccine activated T cells. RESULTS: Of the 15 patients 9 had measurable disease, 2 had a partial response and 2 had stable disease. Perivascular T cell infiltrates at autologous tumor delayed type hypersensitivity skin test sites developed in 3 of the 4 patients with stable disease or partial response. Although the patients experienced the usual and expected toxicity from the IL-2, there was no significant toxicity observed with the vaccine. CONCLUSIONS: The B7-1 gene modified autologous tumor cell vaccine is safe and can be combined with systemic IL-2 with acceptable toxicity. Immunological and clinical responses were observed in some of the patients. A phase II trial is reasonable to determine the efficacy of this approach.     

Expression of the SART3 tumor rejection antigen in renal cell carcinoma

PURPOSE: We recently reported that SART3 tumor rejection antigen is recognized by HLA class I restricted cytotoxic T lymphocytes from patients with esophageal cancer. We now investigate the expression of SART3 antigen in renal cell carcinoma to identify an appropriate molecule that may be used in specific immunotherapy of renal cell carcinoma. MATERIALS AND METHODS: Renal cell carcinoma and nontumorous kidney tissues were obtained at surgery. A section of each sample was minced with scissors and stored at -80C until use. SART3 antigen expression was examined in uncultured renal cell carcinoma and nontumorous kidney tissues. We also evaluated the ability of derived peptides to include cytotoxic T lymphocytes in peripheral blood mononuclear cells from patients with renal cell carcinoma. RESULTS: The SART3 antigen was detected in all renal cell carcinoma cell lines, primary cultures of renal cell carcinoma and nontumorous kidney tissues, and in the cytosol of 57% and 15% of renal cell carcinoma and nontumorous kidney tissues, respectively. HLA-A2402 restricted and tumor specific cytotoxic T lymphocytes (KE4) used in cloning of the SART3 gene were significantly cytotoxic to cells from renal cell carcinoma cell lines and primary cultures of renal cell carcinoma tissue but they did not lyse normal cells, including those from primary cultures of nontumorous kidney tissue. The SART3 peptides derived from positions 109-118 and 315-323 induced HLA-A24 restricted cytotoxic T lymphocytes to renal cell carcinoma cells from peripheral blood mononuclear cells of patients with renal cell carcinoma. CONCLUSIONS: The SART3 antigen and derived peptides may be applied to the specific immunotherapy of HLA-A24+ renal cell carcinoma.     

慢性肾功能衰竭患者血清粒系集落刺激因子水平观察

为了解血清粒系集落刺激因子（Ｇ－ＣＳＦ）的代谢途径，用自行建立ＥＬＩＳＡ法检测了６１例慢性肾功能衰竭（ＣＲＦ）患者及６０例健康对照者Ｇ－ＣＳＦ水平。结果表明８６．９ＣＲＦ患者血清Ｇ－ＣＳＦ水平明显升高，其原因可能是由于Ｇ－ＣＳＦ的排泄障碍，在体内堆积之敌。     

Clinical and immunological characteristics of patients with serologic progression of prostate cancer achieving long-term disease control with granulocyte-macrophage colony-stimulating factor

PURPOSE: We describe the clinical and immunological characteristics of patients with biochemically relapsed prostate cancer who achieved long-term disease control with GM-CSF (Leukine). MATERIALS AND METHODS: A total of 30 patients with prostate cancer and nonmetastatic recurrent disease, as manifested by increasing PSA between 0.4 and 6.0 ng/ml after prior definitive therapy, were enrolled in a phase II trial. Patients received 250 microg/m2 GM-CSF daily subcutaneously on days 1 through 14 of a 28-day cycle until PSA or objective progression. The patient and disease characteristics of patients who remained without evidence of disease progression beyond 4 years were examined. Additionally, flow cytometry was performed in peripheral blood to characterize monocyte and dendritic cells. RESULTS: Seven of 29 evaluable patients (24%) remained free of disease progression at a median of 5.1 years (range 4.5 to 5.6 or greater) from the start of GM-CSF therapy. Patients on long-term GM-CSF tended to have lower initial T stage, Gleason score and pretreatment PSA. An increase in the number of circulating monocytes and dendritic cells was observed after 14 days of GM-CSF treatment. These values returned to baseline during the 14-day off period. CONCLUSIONS: GM-CSF modulates PSA in androgen dependent, biochemically relapsed cases. A substantial proportion of patients achieve long-term disease control. The clinical characteristics described may help select patients for future clinical trials with GM-CSF or other immunomodulators. Additional investigation is required to define the immunological mechanism of GM-CSF in prostate cancer.     

肾细胞癌VEGF表达和MVD检测的临床意义

目的 探讨肾细胞癌（RCC）组织中血管内皮细胞生长因子（VEGF）的表达与肿瘤间质微血管密度（MVD）检测的临床意义。方法 采用免疫组化方法对65例肾细胞癌（RCC）及10例正常肾组织进行VEGF单克隆抗体及CD34单克隆抗体染色，观察RCC的VEGF表达与MVD之间的相关性。结果 VEGF的表达与肿瘤间质微血管密度之间存在正相关性，二者均与RCC的病理分级、临床分期及远处转移显著相关（P〈0.05，P〈O．001）。结论 VEGF与MVD可客观准确反映RCC的生物学行为，上述二项指标可作为评估RCC恶性程度、转移及预后的重要指标。     

重组人粒细胞巨噬细胞集落刺激因子凝胶剂对深Ⅱ度烧伤创面溶痂及愈合影响的临床研究

目的通过临床对比研究,探讨重组人粒细胞巨噬细胞集落刺激因子(recombinant human granulocyte-macrophage colony-stimulating factor,rhGMCSF)凝胶剂对深Ⅱ度烧伤创面溶痂及愈合的作用及其机制。方法以2008年12月-2010年12月收治的符合选择标准的58例深Ⅱ度烧伤患者作为试验对象。男36例,女22例;年龄12～67岁,平均32.4岁。热液烫伤38例,火焰烧伤20例。受伤至治疗时间为1～3d,平均2.1d。采用随机双盲、自身对照方法,分为给予rhGMCSF凝胶剂治疗组(试验组)及不含rhGMCSF的凝胶剂基质治疗组(对照组)。两组用药面积比较差异无统计学意义(P>0.05),具有可比性。用药后观察创面情况,于2、6、10、14、18d计算创面溶痂率,记录完全溶痂时间及创面愈合时间。结果与对照组相比,试验组用药4d后黄白色坏死组织或痂皮逐渐变软;6d后坏死组织易浮动而脱落或痂皮边缘翘起,基底红白相间,深层肉芽组织增长迅速;8d时痂皮基本溶解。用药2d后试验组创面溶痂率即高于对照组,除用药后18d,其余各时间点两组创面溶痂率比较差异均有统计学意义(P<0.05)。试验组完全溶痂时间为(7.71±2.76)d,较对照组(14.71±3.63)d明显缩短(t=13.726,P=0.000);创面愈合时间为(18.41±2.47)d,亦较对照组(23.58±3.35)d明显缩短(t=15.763,P=0.000)。结论 rhGMCSF凝胶剂与单纯凝胶剂基质相比能促进深Ⅱ度烧伤创面坏死组织脱落,加快创面愈合。     

肾细胞癌中血管内皮生长因子的表达

目的 探讨肾癌组织中血管内皮生长因子的表达及其与肾癌生物学行为的关系。方法 应用单克隆鼠抗-VEGF抗体通过免疫组化SP法研究肾癌中血管内皮生长因子的表达。结果 60例肾癌组织中35例(58.3％)血管内皮生长因子阳性。血表达与组织学分级(P<0.05)和TNM分期(P<0.05)均明显相关。 结论 血管内皮生长因子表达对肾癌生物学行为有重要影响,设法抑制血管内皮生长因子有望成为肾癌治疗的另一有效方法。     

Collecting duct renal cell carcinoma: clinical study of a rare tumor.

PURPOSE: Collecting duct carcinoma is a rare type of renal cell carcinoma that affects younger patients, and is associated with aggressive regional and distant spread. The clinical and pathological features of 6 patients with collecting duct carcinoma treated at a single institution are described. MATERIALS AND METHODS: There were 6 patients with collecting duct carcinoma included in the University of California School of Medicine, Los Angeles, Kidney Cancer Database. Demographic, clinical, pathological and survival data were gathered. RESULTS: Average patient age plus or minus standard deviation was 56 +/- 11 years, and 5 of 6 had TNM stage IV disease. The average survival of these patients was 11.5 months (range 7 to 17). There was 1 patient who had TNM stage I disease and survived without evidence of disease at 5 years. Transient response to chemotherapy was seen in 1 patient. CONCLUSIONS: Collecting duct carcinoma is associated with poor prognosis. For the majority of patients surgical treatment will not result in a cure. Previously recommended chemotherapy and/or immunotherapy appears to have a limited role in treatment of this disease, and early detection may be the best method for prolonging patient survival.     

Using tumor markers to predict the survival of patients with metastatic renal cell carcinoma

PURPOSE: Approximately 30% of renal cell carcinomas (RCCs) present as metastatic disease. Molecular markers have the potential to characterize accurately the biological behavior of tumors and they may be useful for determining prognosis. MATERIALS AND METHODS: A custom tissue array was constructed using clear cell RCC from 150 patients with metastatic RCC who underwent nephrectomy prior to immunotherapy. The tissue array was stained for 8 molecular markers, namely Ki67, p53, gelsolin, carbonic anhydrase (CA)9, CA12, PTEN (phosphatase and tensin homologue deleted on chromosome 10), epithelial cell adhesion molecule and vimentin. Marker status and established clinical predictors of prognosis were considered when developing a prognostic model for disease specific survival. RESULTS: On univariate Cox regression analysis certain markers were statistically significant predictors of survival, namely CA9 (p <0.00001), p53 (p = 0.0072), gelsolin (p = 0.030), Ki67 (p = 0.036) and CA12 (p = 0.043). On multivariate Cox regression analysis that included all markers and clinical variables CA9 (p = 0.00002), PTEN (p <0.0001), vimentin (p = 0.0032), p53 (p = 0.028), T category (p = 0.0025) and performance status (p = 0.0013) were significant independent predictors of disease specific survival and they were used to construct a combined molecular and clinical prognostic model. The bias corrected concordance index (C-index) of this combined prognostic model was C = 0.68, which was significantly higher (p = 0.0033) than that of a multivariate clinical predictor model (C = 0.62) based on the UCLA Integrated Staging System (T category, histological grade and performance status). CONCLUSIONS: In patients with clear cell RCC a prognostic model for survival that includes molecular and clinical predictors is significantly more accurate than a standard clinical model using the combination of stage, histological grade and performance status.     

Combined small cell carcinoma and sarcomatoid squamous cell carcinoma in the renal pelvis

We report here a case of combined small cell carcinoma and sarcomatoid squamous cell carcinoma in the renal pelvis. A 61-year-old female presented with right flank discomfort, microhematuria and progressive renal dysfunction. Following diagnosis of right renal pelvic carcinoma, radical nephroureterectomy with lymph node dissection was performed through a midline incision. The tumor was pathologically diagnosed to be combined small cell carcinoma and sarcomatoid squamous cell carcinoma in the renal pelvis. The patient had no evidence of recurrence or metastasis, 16 months postoperatively. Small cell carcinoma or sarcomatoid squamous cell carcinoma of the renal pelvis is very rare. We believe this is the first such case to be reported in the world.     

粒细胞集落刺激因子和干细胞因子对骨髓单个核细胞的动员效率及其机制

目的 联合应用粒细胞集落刺激因子(G-CSF)和干细胞因子(SCF)动员骨髓单个核细胞,评价其动员效果,探讨CXCL12/CXCR4信号通路在骨髓单个核细胞动员中的作用及机制.方法 将昆明小鼠随机分为两组,治疗组皮下注射重组鼠G-CSF 100μg/(kg·d)和重组鼠SCF25μg/(kg·d),连续使用5d;对照组皮下注射等剂量的生理盐水.每组于不同时间点取小鼠骨髓,分离培养骨髓单个核细胞,计数成纤维样细胞集落形成单位(CFU-F)的个数;应用流式细胞仪分选CD34+ CXCR4+单个核细胞(MNCs);应用酶联免疫吸附试验(ELISA)法测定骨髓细胞外液CXCL12a的水平;采用逆转录-聚合酶链反应(RT-PCR)检测骨髓CXCL12 mRNA表达变化.结果 应用G-CSF/SCF后,骨髓及外周血中单个核细胞计数较对照组明显增加(P<0.01),CFU-F形成能力显著增强(P<0.05);流式分选表明CD34+ CXCR4+细胞占骨髓CD34+单个核细胞总数的(44.6±8.7)%;RT-PCR和EUSA检测示骨髓CXCL12 mRNA表达下降,骨髓细胞外液CXCL12蛋白也显著下降,两者变化一致.结论 G-CSF/SCF可有效地诱导骨髓单个核细胞动员,其机制可能是通过破坏骨髓CXCL12/CXCR4信号通路平衡,下调CXCL12/CXCR4间相互作用,以促进骨髓单个核细胞动员.     

Tumor VEGF expression correlates with tumor stage and identifies prognostically different groups in patients with clear cell renal cell carcinoma

ObjectivesVascular endothelial growth factor (VEGF) is a potent inducer of tumor angiogenesis and represents the key element in the pathogenesis of clear cell renal cell carcinoma (ccRCC). The aim of this study was to investigate the use of tumor VEGF expression as a parameter to identify tumor stage and prognostically different patient groups.Methods and materialsWe retrospectively collected clinical data of 137 patients treated with partial or radical nephrectomy at our institutions for organ-confined, locally advanced, and metastatic ccRCCs between 1984 and 2013. Tumor cell VEGF immunohistochemical expression was compared with pathological and clinical features including age, sex, tumor stage, and Fuhrman grade. Comparison of VEGF expression levels between tumor stages was performed via Kruskal-Wallis nonparametric test. Survival analysis was conducted via Kaplan-Meier product-limit method, and Mantel-Haenszel log-rank test was employed to compare survival among groups.ResultsMedian age at diagnosis was 61 years (range: 33–85 y). Tumor stage was pT1N0M0 in 67 patients (49%), pT2N0M0 in 5 (4%), and pT3N0M0 in 25 (18%), while 40 patients (29%) had metastatic tumors at diagnosis. Fuhrman nuclear grade was G1 in 22 patients (16%), G2 in 60 (44%), G3 in 33 (24%), G4 in 13 patients (9%), and unknown in 9 patients. Tumor VEGF was differentially expressed among different stages (P<0.001) and in low (G1–2) and high (G3–4) Fuhrman grade tumors (P<0.001). No significant differences were found when stratifying by sex (P = 0.06) or age (P = 0.29). Median overall survival (OS) from partial or radical nephrectomy was 161 months (range: 1–366). We observed a significantly longer OS in patients with low (<25%) vs. high (>25%) VEGF expression levels (median OS 206 vs. 65 mo, P<0.001).ConclusionsOur data show that tumor cell VEGF expression is significantly associated with tumor stage and Fuhrman grade and is able to predict patient outcome, suggesting a potential use of this parameter in identifying prognostically different patients with ccRCC.     

Thymidine phosphorylase levels as a prognostic factor in renal cell carcinoma

OBJECTIVE: To investigate the relationship between thymidine phosphorylase (TP), a vascular growth factor, and established prognostic factors for renal cell carcinoma (RCC), e.g. histological grade or Tumour-Node-Metastasis (TNM) classification. PATIENTS AND METHODS: TP levels were measured in RCC tissue (tumour TP) and in adjacent non-neoplastic kidney tissue (normal tissue TP), using a sandwich-type enzyme-linked immunosorbent assay. The 59 patients, diagnosed with organ-confined RCC before surgery and who had undergone radical nephrectomy, were divided into two groups according to their prognosis after surgery. Group 1 (nine patients) had a poor prognosis and group 2 (50) had no evidence of disease within a 65-month follow-up. The relationships among TP level, TNM classification, histological subtypes, V factor and prognosis, and of tumour TP to normal tissue TP levels were investigated. Multiple regression analysis was used to determine the importance of factors associated with increased TP levels. RESULTS: Normal tissue TP levels correlated with histological grade (r = 0.31, P < 0.01); in patients with venous invasion or with a poor prognosis, the levels were significantly higher than in those without (P < 0.05 and < 0.001, respectively). The normal tissue TP levels were also significantly higher in the non-clear cell than in the clear cell subtype. Multiple regression analysis showed that the independent factor associated with elevated normal tissue TP levels was histological grade (R2 = 0.189, P < 0.01). There was no correlation between tumour TP and other factors. CONCLUSION: Normal tissue TP levels in localized hypervascular RCC were associated with histological grade. These data suggest that normal tissue TP levels could be a prognostic factor.     

A postoperative prognostic nomogram predicting recurrence for patients with conventional clear cell renal cell carcinoma

PURPOSE: Few published studies have simultaneously analyzed multiple prognostic factors to predict recurrence after surgery for conventional clear cell renal cortical carcinomas. We developed and performed external validation of a postoperative nomogram for this purpose. We used a prospectively updated database of more than 1,400 patients treated at a single institution. MATERIALS AND METHODS: From January 1989 to August 2002, 833 nephrectomies (partial and radical) for renal cell carcinoma of conventional clear cell histology performed at Memorial Sloan-Kettering Cancer Center were reviewed from the center's kidney database. Patients with von Hippel-Lindau disease or familial syndromes, as well as patients presenting with synchronous bilateral renal masses, or distant metastases or metastatic regional lymph nodes before or at surgery were excluded from study. We modeled clinicopathological data and disease followup for 701 patients with conventional clear cell renal cell carcinoma. Prognostic variables for the nomogram included pathological stage, Fuhrman grade, tumor size, necrosis, vascular invasion and clinical presentation (ie incidental asymptomatic, locally symptomatic or systemically symptomatic). RESULTS: Disease recurrence was noted in 72 of 701 patients. Those patients without evidence of disease had a median and maximum followup of 32 and 120 months, respectively. The 5-year probability of freedom from recurrence for the patient cohort was 80.9% (95% confidence interval 75.7% to 85.1%). A nomogram was designed based on a Cox proportional hazards regression model. Following external validation predictions by the nomogram appeared accurate and discriminating, and the concordance index was 0.82. CONCLUSIONS: A nomogram has been developed that can be used to predict the 5-year probability of freedom from recurrence for patients with conventional clear cell renal cell carcinoma. This nomogram may be useful for patient counseling, clinical trial design and effective patient followup strategies.