|GENITOURINARY CANCER SYMPOSIUM: ORIGINAL ARTICLE
|Year : 2014 | Volume
| Issue : 3 | Page : 338-341
Dendritic cell vaccine treatment of advanced de novo colorectal cancer in renal transplant patients
J Ying1, X Yang2, F Hao2, X Xin2, X Wu3, Y Pang1
1 Department of Oncology, Tianjin Union Medicine Centre, Tianjin, China
2 Department of Oncology, Tianjin Union Medicine Centre, Tianjin; Shanghai Claison Biotechnology Co. Ltd., Shanghai, China
3 Department of Oncology, Institute of Oncology, Tianjin Union Medicine Centre, Tianjin, China
|Date of Web Publication||10-Dec-2014|
Department of Oncology, Tianjin Union Medicine Centre, Tianjin
Source of Support: Tianjin Municipal Science and Technology
Commission (No. 12ZCDZSY17100), Conflict of Interest: None
Objective: The clinical outcome, especial the immunologic responses to cancer and graft, of dendritic cell (DC) vaccine in the treatment of advanced de novo colorectal cancer (CRC) in renal transplant patients was investigated in this study. Materials and Methods: 7 patients were received 1 cycle tumor lysate pulsed autologous DC vaccine. The positive cell-mediated cytotoxicity responses to DC vaccine against CRC cell in two out of 7 patients were seen by delayed type hypersensitivity (DTH) test. The positive cell-mediated cytotoxicity responses to DC vaccine against normal kidney cell in all 7 patients were not seen by DTH tests and no notable change of renal function during and after vaccination. Conclusions: DC vaccine has emerged as a promising new strategy in the treatment of advanced de novo CRC in renal transplant patients and DC vaccines have become an attractive therapeutic option, developing immune responses specific against CRC cell, achieving clinical efficacy without graft failure.
Keywords: Dendritic cell vaccine, de novo colorectal cancer, graft failure, renal transplantation
|How to cite this article:|
Ying J, Yang X, Hao F, Xin X, Wu X, Pang Y. Dendritic cell vaccine treatment of advanced de novo colorectal cancer in renal transplant patients. Indian J Cancer 2014;51:338-41
|How to cite this URL:|
Ying J, Yang X, Hao F, Xin X, Wu X, Pang Y. Dendritic cell vaccine treatment of advanced de novo colorectal cancer in renal transplant patients. Indian J Cancer [serial online] 2014 [cited 2019 Sep 22];51:338-41. Available from: http://www.indianjcancer.com/text.asp?2014/51/3/338/146792
| » Introduction|| |
An increased incidence of malignancy is a severe long-term complication of successful renal transplantation,  which is thought to be impaired immune surveillance, direct neoplastic action of immunosuppressive agents and infection with oncogenic viruses.  There is evidence that renal transplant recipients are 2-3 times more likely to develop colorectal cancer (CRC) than the general population. ,,
The prognosis of renal transplant recipients with advanced stage CRC is very poor.  CRC tends to progress faster after diagnosis in renal transplant recipients compared with the general population. De novo CRC in renal transplant recipients has a high recurrence rate and poor survival rate when the cancer is advanced. Such faster progression in advanced stage suggests a role for immunosuppression included increased host susceptibility to tumor genesis and cancer progression. 
The decreased survivals for advanced CRC were considered as due to immunosuppressive drugs, but also ineffective treatment.  Recipients with advanced CRC did not receive adequate adjuvant chemotherapy due to incompatibility with immunosuppressants. Although surgery to remove the primary tumor is important treatment, other combined methods are necessary in CRC management. Some advanced CRC recipients in the transplant group refused chemotherapy due to their general bad condition or the risk of infection. Furthermore, concerns over graft failure with severe side-effect of chemotherapy led to modified chemotherapy in advanced stage CRC; although, it was still uncertain whether the graft failure was related to chemotherapy. 
Cancer therapy has now moved into the area of immunotherapy. Non-specific immunotherapy has been surpassed by modalities that produce a specific and potent immune response against identifiable tumor-associated antigens, so called active specific immunotherapy.  Approaches that come under this heading include dendritic cells (DC) vaccines. DCs can be further boosted by the use of immunostimulatory cytokines.  In contrast to chemotherapy, DC vaccine of CRC is not associated with any serious side-effects. ,,, DC vaccine has the ability to start and amplify antigen-specific anti-tumor responses. ,, Once the immune system generates T-cells specific for a particular antigen of CRC cell, a group of immune memory cells that remember this antigen will remain in the body. In the case of a second threat from the same antigen, an immune response will be mounted much faster than the first one vaccination, stimulates the immune system to kill residual cancer cells that persist in the body and could result in the cancer recurring and metastasis. With advances in molecular biology and the identification of tumor-associated antigens, many new strategies have been developed in trying to overcome the limits of chemotherapy and to aid in the fight to cure patients of metastatic and micrometastatic CRC. ,,
DC vaccine is an appealing therapeutic modality for CRC because of its potential to selectively target tumor cells rather than normal tissue. Therefore, DC vaccine might provide an alternative treatment for those de novo CRC in renal transplant patients without graft failure. We conducted a study to evaluate the safety and immunologic responses using a DC vaccine in 7 patients with CRC who had previously undergone renal transplantation.
| » Materials and Methods|| |
This study was carried out in 7 patients who developed CRC after renal transplantation followed by immunosuppressive therapy. All cases were advanced stage with histological proven CRC and referred to the Department of Oncology, Tianjin Union Medicine Center, Tianjin, China, From April 2011 to April 2012. The study protocol was approved by the Hospital's Ethical Committees and class III medical techniques of "treatment with autologous immune cells (T-cells, NK-cells)" in accordance with the policy by the Minister of Health of China. Written consent was obtained from all patients at study entry.
Preparation of tumor antigen and normal kidney tissue antigen
Patient tumor tissue specimens from the tissue bank of our hospital (available for 4 patients), were then mechanically dissociated and filtered. The cells were crushed by the ultrasonic and centrifuged with a 600 Χ g for 30 min. The supernatant was collected as tumor lysate for sensitizing DCs and delayed type hypersensitivity (DTH) test.
The tumor tissue of the other 3 patients could not be available, so colon tumor cell lines HCT-116 were used instead. The cells were plated at 3 Χ 10 6 /mL, cultured for 24 h at 37C and then crushed by the ultrasonic and centrifuged with a 600 g for 30 min. The supernatant was collected as tumor lysate for sensitizing DCs and DTH test.
Preparation of DC vaccines
Generation of DCs
0All procedures were performed according to the standard method widely reported. ,, Patients underwent leukapheresis using the Fresenius KABI System. The leukapheresis product was enriched for monocytes, peripheral blood mononuclear cells were isolated over the Ficoll, washed, suspended in culture medium (X-Vivo 15, 200 mM 2% L-glutamine, 1% autologous heat-inactivated plasma) at 3 Χ 10 6 cells/mL and separated by 90 min adherence to plastic Corning dishes (Corning USA). Non-adherent cells were removed and adherent cells were subsequently cultured for 7 days with 500 U/ml recombinant human granulocyte macrophage colony-stimulating factor (rhuGM-CSF; R and D, USA) and 250 U/mL recombinant human interleukin-4 (rhuIL-4; R and D, USA) added on days 0, 3 and 6 of culture. On culture day 6, autologous tumor lysate was added at 40 ΅g/mL. On culture day 7, tumor necrosis factor was added at 10 ng/mL for the maturation for 24 h. On culture day 8, DCs were harvested, viable cells were enumerated and administered if they met the following release criteria: Viability >70%, no organisms on gram stain, cultured samples with no bacterial growth and endotoxin levels of <5 EU/kg. Cells were washed twice, 1 Χ 10 7 cells were resuspended in 4 mL NS for 2 syringe for bilateral inguinal region 24 points intradermal injection, or 1 Χ 10 7 cells were resuspended in 100 mL NS for intravenous injection. The remainder of the DCs was frozen in 90% autologous serum/10% dimethyl sulfoxide DMSO at 1-2 Χ 10 7 DCs/mL for further use.
DC phenotypic analysis
Aliquots of the cultured cells were subjected to phenotypic analysis at the time of cryopreservation. The expressions of the cell surface antigens CD14, CD83, CD86 and HLA2DR were analyzed. Antibodies against CD14, CD83, CD86 and HLA2DR (BD, USA) were used together with relevant iso-type controls. For four color analyses of DCs, cells were labeled simultaneously with lineage cocktail and four of the relevant DC cell surface markers. Flow cytometric analysis (FCM) was performed on a FACS Calibur flow cytometer (BD Bioscience). Data were analyzed by using CellQuest software (BD Bioscience).
To test the cell-mediated cytotoxicity response, 40 ΅g/mL lysate tumor cells were administered intradermally into the forearm one week after the whole cycle of DC vaccination. A positive DTH skin-test reaction was defined as >5 mm diameter in duration after 48 h.
Patients receive one cycle vaccination with a total of three immunizations once a week with tumor lysate pulsed autologous DCs. The vaccine was administered both intradermally (i.d.) 24 points injection of 1.0 Χ 10 7 cells/4 mL near the inguinal region on the bilateral thigh and 1.0 Χ 10 7 cells/100 mL infusion intravenously at the same time. The toxicity and adverse events were mainly evaluated.
Renal function monitoring
The renal functions were tested one week after the whole cycle of DC vaccination. Notable changes in serum creatinine (SCr) level, defined as an increase of ≥0.5 mg/dL for patients with a normal baseline SCr level (i.e., <1.4 mg/dL), an increase of ≥1.0 mg/dL in patients with an abnormal baseline SCr level (i.e., ≥1.4 mg/dL), or a doubling of any SCr level. 
Statistical package for the social sciences software program (version 8.0) has been used for data analysis. Students t-test has been done. P < 0.05 is considered as a significant difference.
| » Results|| |
Characteristics of patients
The characteristics of patients who developed de novo CRC subsequent to transplantation are summarized in [Table 1]. There are 7 patients, 5 were male and 2 were female. The average age was 56.3 7.5 years (range:45-63 years) and the average time to develop cancer after kidney transplantation was 9.1 3.1 years (range:5-13 years). All 7 patients were received post-transplantation immunosuppressant regimen. None of the 7 patients were suffered rejection prior to or during the treatment of cancer.
Out of 7 patients 5 patients received primary tumor resection; the other 2 cases with adenocarcinoma confined histologically did not receive primary tumor resection because of the advance of the cancer. Out of the 7 patients, 4 cases had received FOLFOX4 chemotherapy for 3-6 cycles, 2 cases had received oral Xeloda treatment and 1 case had received no adjuvant chemotherapy. 7 cases were all stage 4 CRC, 4/7, 2/7 and 1/7 with metastasis in abdomen, liver and bone, respectively, showed in [Table 1].
Phenotype changes of DC vaccine
The immune Phenotype of DC vaccine was tested by FCM. 8 days after culture, the expressions of the cell surface antigens CD83, CD86 and HLA2DR were increased, CD14 were significantly decreased compare with that of before culture, as shown in [Table 2] (P < 0.05).
Clinical outcome and toxicity
All 7 patients received 1 cycle of DC vaccine. The positive cell-mediated cytotoxicity responses to DC vaccine were seen in 4 out of 7 patients. Toxicity of DC vaccine consisted of mild flu-like symptoms. 3 patients had normal body temperature, 3 patients had a fever below 38.1C, 1 patient had severed fever 41.0C and relieve after 5 mg dexamethasone injection and physical cooling. After the end of the study, the patients have been surveyed for 4.6 1.7 months (range:2-7 months), showed in [Table 1].
Function monitoring of graft kidney
In fearing of impairment of graft kidney by the immune stimulating activity, the renal function was monitored. No signs of renal failure during the immunization and no notable decrease of renal function were observed, after the cycle of DC vaccination, showed in [Table 1].
| » Discussion|| |
It is well-accepted that the incidence of malignancy is much higher in patients who underwent renal transplantation than in those who did not. Yet, some of the tumors may arise in renal recipients might have already presented at the time of renal transplantation, but not detected, with no relation to renal transplantation. As a general rule, tumors detected within the 1 st year after renal transplantation are considered as pre-existed. In the 7 CRC patients showed in this paper, the onset interval from renal transplantation was at least 5 years. Such patients should be considered as "de novo" group. 
It is suggested that de novo CRC transplant recipients have a worse 5-year survival rate than the general population because of long time immunosuppression, which results in a more aggressive tumor biology. ,,,, CRC patients who underwent renal transplantation usually develop more advanced colon cancer with a worse disease-related survival rate than those who did not undergo renal transplantation. It is supported by the fact that the incidence of tumors is higher in patients treated with immunosuppressants following renal transplantation due to chronic renal failure than in the normal population. The causes for this difference might be explained by the immunological abnormalities induced by immunosuppressants. It indicates that CRC in transplant recipients are biologically more aggressive, thus resulting to a worse prognosis in such patients than in the general population. Immunosuppression should take responsibility for the poor prognosis of CRC patients after renal transplantation. Hence, since a higher degree of morbidity might be encountered, transplantation patients should receive immunotherapy to reconstruct immune function destroyed by long time intake of immunosuppression agent besides standard oncology treatment, including neo-adjuvant therapy, if their general condition is good and the organ graft functions well.
As the knowledge about immune-competences improved, immunotherapy used today, such as DC vaccine, is specific and active. ,, The aim of active specific immunotherapy is to establish a highly selective and potent cellular immune response, specifically directed against the patient's cancer cells. Dendritic cells (DCs) are the most potent antigen presenting cells with an ability to prime both a primary and secondary immune response to tumor cells. Therapeutic cancer DC vaccines developed for CRC have shown benefits in phase III trials by extending the disease-free survival period and overall survival. It is believed that DC vaccines may play an adjuvant role in CRC by consolidating the responses to conventional therapy.  In our study, the positive cell-mediated cytotoxicity response to DC vaccine against cancer cell were observed in 4 out of 7 patients without decrease of renal function.
Chemotherapy - the conventional treatments for CRC - are associated with high toxicities and a significant negative effect on patients' quality-of-life. The advanced de novo CRC in renal transplant patients are tend to refused chemotherapy due to their bad general condition and server toxicities of chemotherapy. In contrast to chemotherapy, DC vaccines stimulates the body's immune system and natural resistance to cancer, thus offering a gentler means of cancer treatment that is less damaging to the rest of the body. DC vaccination prompts the immune system to kill residual cancer cells that could result in the cancer recurring.
In our studies, all 7 patients received 1 cycle of DC vaccine. The only uncomfortable are mild flu-like symptoms. Patients exhibited very good compliance. After the end of the study, patients have been surveyed for 2-7 months.
Thus, DC vaccine has emerged as a promising new strategy and an attractive therapeutic option in the treatment of advanced de novo CRC in renal transplant patients, developing immune responses specific against CRC cell, achieving clinical efficacy without graft failure. 
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[Table 1], [Table 2]