title: Adjuvant therapeutic vaccination in patients with non-small cell lung cancer made lymphopenic and reconstituted with autologous PBMC: first clinical experience and evidence of an immune response.
abstract: BACKGROUND
  Given the considerable toxicity and modest benefit of adjuvant chemotherapy for non-small cell lung cancer (NSCLC), there is clearly a need for new treatment modalities in the adjuvant setting. Active specific immunotherapy may represent such an option. However, clinical responses have been rare so far. Manipulating the host by inducing lymphopenia before vaccination resulted in a magnification of the immune response in the preclinical setting. To evaluate feasibility and safety of an irradiated, autologous tumor cell vaccine given following induction of lymphopenia by chemotherapy and reinfusion of autologous peripheral blood mononuclear cells (PBMC), we are currently conducting a pilot-phase I clinical trial in patients with NSCLC following surgical resection. This paper reports on the first clinical experience and evidence of an immune response in patients suffering from NSCLC.
  
  
  METHODS
  NSCLC patients stages I-IIIA are recruited. Vaccines are generated from their resected lung specimens. Patients undergo leukapheresis to harvest their PBMC prior to or following the surgical procedure. Furthermore, patients receive preparative chemotherapy (cyclophosphamide 350 mg/m2 and fludarabine 20 mg/m2 on 3 consecutive days) for induction of lymphopenia followed by reconstitution with their autologous PBMC. Vaccines are administered intradermally on day 1 following reconstitution and every two weeks for a total of up to five vaccinations. Granulocyte-macrophage-colony-stimulating-factor (GM-CSF) is given continuously (at a rate of 50 microg/24 h) at the site of vaccination via minipump for six consecutive days after each vaccination.
  
  
  RESULTS
  To date, vaccines were successfully manufactured for 4 of 4 patients. The most common toxicities were local injection-site reactions and mild constitutional symptoms. Immune responses to chemotherapy, reconstitution and vaccination are measured by vaccine site and delayed type hypersensitivity (DTH) skin reactions. One patient developed positive DTH skin tests so far. Immunohistochemical assessment of punch biopsies taken at the local vaccine site reaction revealed a dense lymphocyte infiltrate. Further immunohistochemical differentiation showed that CD1a+ cells had been attracted to the vaccine site as well as predominantly CD4+ lymphocytes. The 3-day combination chemotherapy consisting of cyclophosphamide and fludarabine induced a profound lymphopenia in all patients. Sequential FACS analysis revealed that different T cell subsets (CD4, CD8, CD4CD25) as well as granulocytes, B cells and NK cells were significantly reduced. Here, we report on clinical safety and feasibility of this vaccination approach during lymphoid recovery and demonstrate a patient example.
  
  
  CONCLUSIONS
  Thus far, all vaccines were well tolerated. The overall trial design seems safe and feasible. Vaccine site reactions associated with infusion of GM-CSF via mini-pump are consistent with the postulated mechanism of action. More detailed immune-monitoring is required to evaluate a potential systemic immune response. Further studies to exploit homeostasis-driven T cell proliferation for the induction of a specific anti-tumor immune response in this clinical setting are warranted.
authors.affiliation: Department of Surgery, Grosshadern Medical Center, Ludwig-Maximilians-University, Marchioninistrasse 15, 81377 Munich, Germany. dominik.ruettinger@med.uni-muenchen.de
authors.forename: Dominik
authors.initials: D
authors.lastname: Rüttinger
authors.forename: Natasja K
authors.initials: NK
authors.lastname: van den Engel
authors.forename: Hauke
authors.initials: H
authors.lastname: Winter
authors.forename: Marcus
authors.initials: M
authors.lastname: Schlemmer
authors.forename: Heike
authors.initials: H
authors.lastname: Pohla
authors.forename: Stefanie
authors.initials: S
authors.lastname: Grützner
authors.forename: Beate
authors.initials: B
authors.lastname: Wagner
authors.forename: Dolores J
authors.initials: DJ
authors.lastname: Schendel
authors.forename: Bernard A
authors.initials: BA
authors.lastname: Fox
authors.forename: K-W
authors.initials: KW
authors.lastname: Jauch
authors.forename: Rudolf A
authors.initials: RA
authors.lastname: Hatz
mesh_terms: D000277:Adjuvants, Pharmaceutic / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D000368:Aged; D001706:Biopsy; D001772:Blood Cell Count; D019496:Cancer Vaccines / Q000008:administration & dosage / Q000009:adverse effects / Q000276:immunology / Q000627:therapeutic use*; D002289:Carcinoma, Non-Small-Cell Lung / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000276:immunology / Q000473:pathology; D005260:Female; D016178:Granulocyte-Macrophage Colony-Stimulating Factor / Q000008:administration & dosage / Q000276:immunology; D006801:Humans; D007109:Immunity / Q000276:immunology*; D007150:Immunohistochemistry; D007271:Injections, Intradermal; D007963:Leukocytes, Mononuclear / Q000276:immunology*; D008175:Lung Neoplasms / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000276:immunology / Q000473:pathology; D008231:Lymphopenia / Q000150:complications / Q000276:immunology*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D013902:Radiography, Thoracic; D014611:Vaccination
chemical_list: D000277:Adjuvants, Pharmaceutic; D019496:Cancer Vaccines; D016178:Granulocyte-Macrophage Colony-Stimulating Factor