Tadao Kakizoe

Adoptive immunotherapy to lower postsurgical recurrence rates of hepatocellular carcinoma: a randomised trial

BACKGROUND Postsurgical recurrence of hepatocellular carcinoma (HCC) is frequent and fatal. Adoptive immunotherapy is active against HCC. We assessed whether postoperative immunotherapy could lower the frequency of recurrence. METHODS Between 1992 and 1995, we did a randomised trial in which 150 patients who had undergone curative resection for HCC were assigned adoptive immunotherapy (n=76) or no adjuvant treatment (n=74). Autologous lymphocytes activated vitro with recombinant interleukin-2 and antibody to CD3 were infused five times during the first 6 months. Primary endpoints were time to first recurrence and recurrence-free survival and analyses were by intention to treat. FINDINGS 76 patients received 370 (97%) of 380 scheduled lymphocyte infusions (mean cell number per patient 7.1x10(10) [SD 2.1]; CD3 and HLA-DR cells 78% [16]), and none had grade 3 or 4 adverse events. After a median follow-up of 4.4 years (range 0.2-6.7), adoptive immunotherapy decreased the frequency of recurrence by 18% compared with controls (45 [59%] vs 57 [77%]) [corrected] patients. Time to first recurrence in the immunotherapy group was significantly longer than that in the control group (48% [37-59] vs 33% [22-43] at 3 years, 38% [22-54] vs 22% [11-34] at 5 years; p=0.008). The immunotherapy group had significantly longer recurrence-free survival (p=0.01) and disease-specific survival (p=0.04) than the control group. Overall survival did not differ significantly between groups (p=0.09). INTERPRETATION Adoptive immunotherapy is a safe, feasible treatment that can lower recurrence and improve recurrence-free outcomes after surgery for HCC.

NK105, a paclitaxel-incorporating micellar nanoparticle formulation, can extend in vivo antitumour activity and reduce the neurotoxicity of paclitaxel

Paclitaxel (PTX) is one of the most effective anticancer agents. In clinical practice, however, high incidences of adverse reactions of the drug, for example, neurotoxicity, myelosuppression, and allergic reactions, have been reported. NK105, a micellar nanoparticle formulation, was developed to overcome these problems and to enhance the antitumour activity of PTX. Via the self-association process, PTX was incorporated into the inner core of the micelle system by physical entrapment through hydrophobic interactions between the drug and the well-designed block copolymers for PTX. NK105 was compared with free PTX with respect to their in vitro cytotoxicity, in vivo antitumour activity, pharmacokinetics, pharmacodynamics, and neurotoxicity. Consequently, the plasma area under the curve (AUC) values were approximately 90-fold higher for NK105 than for free PTX because the leakage of PTX from normal blood vessels was minimal and its capture by the reticuloendothelial system minimised. Thus, the tumour AUC value was 25-fold higher for NK105 than for free PTX. NK105 showed significantly potent antitumour activity on a human colorectal cancer cell line HT-29 xenograft as compared with PTX (P<0.001) because the enhanced accumulation of the drug in the tumour has occurred, probably followed by its effective and sustained release from micellar nanoparticles. Neurotoxicity was significantly weaker with NK105 than with free PTX. The neurotoxicity of PTX was attenuated by NK105, which was demonstrated by both histopathological (P<0.001) and physiological (P<0.05) methods for the first time. The present study suggests that NK105 warrants a clinical trial for patients with metastatic solid tumours.

Cisplatin-incorporating polymeric micelles (NC-6004) can reduce nephrotoxicity and neurotoxicity of cisplatin in rats

In spite of the clinical usefulness of cisplatin (CDDP), there are many occasions in which it is difficult to continue the administration of CDDP due to its nephrotoxicity and neurotoxicity. We examined the incorporation of CDDP into polymeric micelles to see if this allowed the resolution of these disadvantages. Cisplatin was incorporated into polymeric micelles through the polymer–metal complex formation between polyethylene glycol poly(glutamic acid) block copolymers and CDDP (NC-6004). The pharmacokinetics, pharmacodynamics, and toxicity studies of CDDP and NC-6004 were conducted in rats or mice. The particle size of NC-6004 was approximately 30 nm, with a narrow size distribution. In rats, the area under the curve and total body clearance values for NC-6004 were 65-fold and one-nineteenth the values for CDDP (P<0.001 and 0.01, respectively). In MKN-45-implanted mice, NC-6004 tended to show antitumour activity, which was comparable to or greater than that of CDDP. Histopathological and biochemical studies revealed that NC-6004 significantly inhibited the nephrotoxicity of CDDP. On the other hand, blood biochemistry revealed transient hepatotoxicity on day 7 after the administration of NC-6004. Furthermore, rats given CDDP showed a significant delay (P<0.05) in sensory nerve conduction velocity in their hind paws as compared with rats given NC-6004. Electron microscopy in rats given CDDP indicated the degeneration of the sciatic nerve, but these findings were not seen in rats given NC-6004. These results were presumably attributable to the significantly reduced accumulation of platinum in nerve tissue when NC-6004 was administered (P<0.05). NC-6004 preserved the antitumour activity of CDDP and reduced its nephrotoxicity and neurotoxicity, which would therefore seem to suggest that NC-6004 could allow the long-term administration of CDDP where caution against hepatic dysfunction must be exercised.

Incorporation of water-insoluble anticancer drug into polymeric micelles and control of their particle size.

A water-insoluble anticancer drug, KRN 5500 (KRN), was incorporated into polymeric micelles forming from poly(ethylene glycol-poly(amino acid) block copolymers by physical entrapment utilizing hydrophobic interactions between this drug and the poly(amino acid) chain block of the block copolymers. Three block copolymers were examined for this incorporation; poly(ethylene glycol)-poly(beta-benzyl l-aspartate) (PEG-PBLA) and its two derivatives obtained by partial hydrolysis at the beta-benzyl l-aspartate (BLA) units (PEG-P(Asp, BLA)) and by partial cetyl ester substitution at the BLA units (PEG-P(C16, BLA)), respectively. Among these block copolymers, considerable effects of the cetyl esterification were seen on KRN yield and particle size. Considerable differences in the KRN incorporation yield and particle size were also observed between DMF and DMS used as solvent to dissolve KRN and the block copolymers. Sonication was turned out to be an effective method to obtain a polymer micelles fraction in high efficiency, and sonication was considered to work for separating intermicellar associates into dispersed micelles. A KRN incorporation procedure by dialysis using PEG-P(C16, BLA) and DMSO (as solvent) followed by sonication brought about polymeric micelles of 71 nm in weight-average diameter. This shows successful incorporation of a water-insoluble drug into polymeric micelles by optimizing block copolymer structure and incorporation conditions.

Randomized trial of dietary fiber and Lactobacillus casei administration for prevention of colorectal tumors

The epidemiologic evidence that dietary fiber protects against colorectal cancer is equivocal. No large‐scale clinical study of the administration of Lactobacillus casei has been reported. We examined whether dietary fiber and L. casei prevented the occurrence of colorectal tumors. Subjects were 398 men and women presently free from tumor who had had at least 2 colorectal tumors removed. Subjects were randomly assigned to 4 groups administered wheat bran, L. casei, both or neither. The primary end point was the presence or absence of new colorectal tumor(s) diagnosed by colonoscopy after 2 and 4 years. Among 380 subjects who completed the study, 95, 96, 96 and 93 were assigned to the wheat bran, L. casei, both and no treatment groups, respectively. Multivariate adjusted ORs for occurrence of tumors were 1.31 (95% CI 0.87–1.98) in the wheat bran group and 0.76 (0.50–1.15) in the L. casei group compared to the control group. There was a significantly higher number of large tumors after 4 years in the wheat bran group. The occurrence rate of tumors with a grade of moderate atypia or higher was significantly lower in the group administered L. casei. No significant difference in the development of new colorectal tumors was observed with administration of either wheat bran or L. casei. However, our results suggest that L. casei prevented atypia of colorectal tumors.

Endorectal Ultrasonography and Treatment of Early Stage Rectal Cancer

The purpose of this study was to evaluate the accuracy of preoperative staging by endorectal ultrasonography (EUS) and its contribution to treatment of early stage rectal cancer (ESRC). The results of EUS for 154 consecutive patients with ESRC (pTis to pT2) were compared prospectively with histologic findings, assessed according to the TNM classification. Results of treatment selection and long-term outcomes were analyzed retrospectively. There were 35 patients histologically staged as pTis, 8 as pT1-slight (invasion confined to the superficial one-third of the submucosa), 37 as pT1-massive (invasion extending to the deeper submucosa), and 74 as pT2. The equipment used was an echoendoscope GF-UM2 or GF-UM3 (Olympus, Tokyo, Japan). Sensitivity/specificity/overall accuracy rates for detection of slight submucosal invasion, massive submucosal invasion, and muscularis propria invasion were 99%/74%/96%, 98%/88%/97%, and 97%/93%/96%, respectively. Incidences of lymph node metastasis in pTis, pTis to pT1-slight, pT1, pT1-massive, and pT2 cases were 0%, 0%, 18%, 22%, and 30%, respectively. Incidences of lymph node metastasis in ESRCs staged by EUS (u) as uTis, uT1-slight, uT1-massive, uT2, and uT3 by EUS were 0%, 0%, 26%, 36%, and 64%, respectively. Sensitivity, specificity, and overall accuracy rates for detection of positive nodes in overall ESRCs were 53%, 77%, and 72%, respectively. Of the 43 patients with pTis to pT1-slight tumors, 22 underwent endoscopic polypectomy or local excision, 20 radical surgery, and 1 radical surgery after endoscopic polypectomy due to vascular invasion. All these patients are alive and all but one (who refused radical surgery due to vascular invasion after local excision and developed liver and lung metastases) are disease-free. Of the 37 patients with pT1-massive tumors, 34 underwent radical surgery and 3 transcoccygeal segmental resection. All these patients are alive disease-free except for one who died of peritoneal carcinomatosis after radical surgery. All patients with pT2 tumors underwent radical surgery. The overall 5-year survival rates for pTis, pT1, and pT2 cases were 100%, 98%, and 97%, respectively. EUS is an accurate method for evaluating invasion depth in ESRC. Patients with uTis or uT1-slight tumors staged by EUS are at low risk of positive nodes and good candidates for endoscopic polypectomy or local excision. Those with uT1-massive or uT2 lesions should be treated with a radical operation because of the high incidence of positive nodes.

Increased serum levels of basic fibroblast growth factor in patients with renal cell carcinoma

The serum level and urinary output of basic and acidic fibroblast growth factors (FGFs) were measured by sandwich enzyme immunoassay (EIA) in patients with renal cell carcinoma. In over fifty percent (16/31) of renal cell carcinoma patients, basic FGF was elevated (greater than 30 pg/ml) in their sera. There is relatively good correlation between serum levels of basic FGF and tumor stage or grade, while urinary daily output of basic FGF did not correlate with increased malignancy. The present results indicate that serum basic FGF level of patients with renal cell carcinoma is a useful diagnostic and prognostic marker for renal cell carcinoma. On the other hand, acidic FGF was not detectable in all sera and urine.

Transitional cell carcinoma of the bladder in patients with renal pelvic and ureteral cancer.

We reviewed 41 cases of transitional cell carcinoma of the renal pelvis and ureter with special reference to the coexistence or subsequent development of bladder cancer. Bladder cancer was associated with an upper urinary tract neoplasm in 20 of the 41 cases (48 per cent). Most of these patients (15 of 20) were treated by radical total cystectomy of 1-stage nephroureterocystectomy. The incidence of ureteral stump cancer after nephrectomy alone or incomplete nephroureterectomy was 64 per cent (7 of 11 patients). Twelve surgically removed specimens of the renal pelvis, ureter and/or bladder were examined extensively for the histological association of pre-neoplastic disease, such as atypical hyperplasia and carcinoma in situ. Every specimen had these changes of the urothelium adjacent to and remote from obvious tumors.

Pharmaceutical and Biomedical Differences Between Micellar Doxorubicin (NK911) and Liposomal Doxorubicin (Doxil)

The stability and biological behavior of an in vitro system of doxorubicin (DXR) entrapped in NK911, polymer micelles, was examined and compared with those of DXR entrapped in Doxil, polyethylene‐glycol‐conjugated liposomes. The fluorescence of DXR inside micelles or liposomes in an aqueous solution is known to be strongly quenched by the outer shells of the micellar or liposomal formation. Thus, by measuring the fluorescence intensity of DXR released from NK911 or Doxil, we could determine the stability of the micellar or liposomal DXR formation. Furthermore, NK911 was found to be less stable than Doxil in saline solution. In drug distribution experiments using an in vitro solid tumor model, when spheroids formed from two human colonic cancer lines, HT‐29 and WiDr, and a human stomach cancer line, MKN28, were exposed to NK911, DXR was distributed throughout the spheroids, including their center. On the other hand, when the spheroids were exposed to Doxil, DXR was distributed only to the surface of the spheroids. It has been suggested that Doxil can deliver DXR to a solid tumor more efficiently than NK911 via the EPR (enhanced permeability and retention) effect, because Doxil may be more stable in plasma than NK911. On the other hand, DXR packed in NK911 may be distributed by diffusion to cancer cells distant from the tumor vessel, because NK911 can leak out of the tumor vessel and may be able to release free DXR more easily than Doxil. It has been suggested that drug carrier systems such as liposomes and micelles should be selected appropriately bearing in mind the characteristics of the tumor vasculature and the tumor interstitium.

Cisplatin-incorporated polymeric micelles eliminate nephrotoxicity, while maintaining antitumor activity.

cis‐Diamminedichloroplatinum (II) (cisplatin, CDDP), a potent anticancer agent, was bound to the aspartic acid residues of poly(ethylene glycol)‐poly(aspartic acid) (PEG‐P(ASP)) block copolymer by ligand substitution reaction at the platinum atom of CDDP. The polymeric drug thus obtained was observed to form a micelle structure in aqueous medium, showing excellent water solubility. In the present study, in vitro and in vivo antitumor activity against several human tumor cell lines, toxicity and pharmacokinetic characteristics in rodents of CDDP‐incorporated polymeric micelles (CDDP/m) were evaluated in comparison with those of CDDP. In vitro, CDDP/m exhibited 10‐17% of the cytotoxicity of CDDP against human tumor cell lines. CDDP/m given by intravenous (i.v.) injection yielded higher and more sustained serum levels than CDDP. In vivo CDDP/m treatment resulted in higher and more sustained levels in tumor tissue than CDDP, and showed similar antitumor activity to CDDP against MKN 45 human gastric cancer xenograft. CDDP/m treatment caused much less renal damage than CDDP. These results indicate that CDDP/m treatment can reduce CDDP‐induced nephrotoxicity without compromising the anticancer cytotoxicity of CDDP.