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Introduction Cell based immunotherapies have been in practice in Japan for the past two decades with established clinical trials on its efficacy in both solid tumours and hematological malignancies including gastric cancer, ovarian cancer , lung cancer and liver cancer. [1,2,3,4] In India, NCRM has been providing Autologous Immune Enhancement Therapy (AIET) using autologous Natural Killer (NK) cells and activated T Lymphocytes for Cancer since 2005 following the established protocols practiced by the Biotherapy Institute of Japan. Significant outcome achieved after AIET in advanced pancreatic cancer, Acute Myeloid leukemia (AML) in Indian patients have already been reported. [5, 6] Here we report our experience in few more patients and present the hurdles overcome and lessons learned in translating the technology from Japan to India Case Details: Case 1: A 54 year-old female presented with Stage IV recurrent ovarian malignancy in 2010 with a history of previous surgery and chemotherapy for ovarian malignancy in June 2009. The CA-125 level of 243 U/ml. CT scan revealed lesions in the liver, spleen, along the greater curvature of body of stomach and in the perisplenic region, between the medial aspect of liver and stomach and in the right inguinal region. She was suggested six cycles of chemotherapy with Doxorubicin (50 mg) and Carboplatin (450 mg) along with AIET. After proper informed consent, the peripheral blood was withdrawn and the in vitro expansion of the NK cells, activated T Lymphocytes from the peripheral blood was performed using the protocol reported earlier. [7] Average cell count after the in vitro expansion was 1.2 X 108 cells. Six transfusions of the in vitro expanded NK cells and activated T lymphocytes were administered following which the CA-125 decreased to 4.7 U/mL. CT scan taken in December 2010 showed a regression of the lesions in the spleen and perisplenic peritoneal deposits, stable hepatic lesions and resolution of perigastric peritoneal deposits with a marked decrease in the size of the inguinal lymph nodes from and no recurrence in the pelvic region. There was also improvement in appetite and quality of life of the patient. There were no adverse reactions following the AIET infusions. [8] The latest follow-up in May 2012 revealed static non progressive disease with all the parameters including tumor markers within normal range. Case 2: A 15 year old girl presented with complaints of diffuse bone pain for 3 months, intermittent fever for 1 month and increasing pallor in October 2004. On examination, she was found to have pallor with hepatosplenomegaly. A low haemoglobin level (9.3 mg/dl), low platelets (21000) and a WBC count of 13600 with 83% lymphoblasts was revealed in her blood picture. Bone marrow examination and flow cytometry were suggestive of Acute Lymphoblastic Leukemia – CD 10+ CD 19+. Cytogenetics revealed Philadelphia chromosome and BCR-ABL positivity. Qualitative BCR-ABL was done serially to assess disease status. She was started on chemotherapy as per UK MRC protocol – Regimen B along with Imatinib Mesylate (in view of her BCR-ABL positivity) and prophylactic cranial radiotherapy of 12 Gy at the end of delayed intensification. She had persistent disease with low positive BCR-ABL at 0.04% at the end of delayed intensification. As there were no matched HLA donors as she had high risk disease she was suggested for AIET using autologous natural killer (NK) cells (CD3-CD56+) in January 2007. 562 x 106 in vitro expanded NK cells were infused to the patient intravenously and four weeks later, the BCR-ABL in the PB turned negative. She completed her treatment in October 2007. She has been on regular follow up for the last five years and she continues to be in remission. Case 3: A female patient aged 64 years with advanced serous papillary Adenocarcinoma of both ovaries with liver metastasis underwent omentectomy and resection of the liver nodule in the month of January 2011 and completed 6 cycles of chemotherapy with Paclitaxel and Carboplatin, completed in April 2011. In April 2011, non-enhancing lesions in the Left lobe of the liver and a left gastric node were revealed in the CT scan of the whole abdomen. The patient was suggested for radiofrequency ablation and maintenance chemotherapy along with AIET. The patient was administered five transfusions of AIET using autologous NK cells and activated T lymphocytes. 140 ml of peripheral blood (PB) was withdrawn in May 2011 from which two transfusions of AIET with the average NK cell count being 618 millions and T cell count being 331 million were administered. However when 140 ml of PB was withdrawn for the second time in June 2011 for two more transfusions, the peripheral blood mononuclear cells (PBMNCs) count were alarmingly lower though she had a WBC count of 4600 cells, and the expansion of NK cells, T lymphocytes was not marked following which her report which was received from a Hospital in Thailand revealed that she had Auto-immune Hemolytic anemia (AIHA) for which she was prescribed steroids. It has already been reported that the functional profile of NK cell is lower in AIHA patients. [9] Also the limiting factor of steroid administration is also to be considered. The average NK cell count of the third and fourth was 3.9 million while activated T cell count was 4.2 million. When the PB was withdrawn for the fifth transfusion, the NK, T lymphocytes expansions were higher leading to transfusion of a cell count of 103 million and activated T lymphocytes of 329 million. On the whole, the immune cells expansion in this patient was lesser compared to other patients and this can be attributed to the association of AIHA.[10] Nevertheless there were no adverse effects after the AIET and the patient continues to be stable as per the latest follow-up in August 2012. Hurdles overcome and lessons learned: As with translation of any therapy, there were hurdles during the initial translation of the AIET technology from the Biotherapy Institute of Japan to India. As AIET was new to our team of scientists, they were trained initially for two years by the Japanese experts and there is a constant interaction with frequent information exchange among the Indian technical team and the Japanese team till date. The hurdle faced in the use of Laboratory reagents is that their efficacy might vary according to the manufacturer and to put aside the doubt and to ensure that the same results obtained in Japan are reproduced in India, all the laboratory reagents used in India are the same used in Biotherapy institute obtained from Japan. Biotherapy Institute constantly monitors quality of the reagents by assessing their effects on primary cell cultures and cell lines which are maintained in that Institute. The hurdle in infrastructure requirements were overcome by establishing a laboratory in India with similar specifications and equipments as that in Japan with even more stringent protocols to suit the Indian conditions. With these lessons learned in translating the technology of AIET from Japan to India and following the significant outcomes in the various patients mentioned above and more than 60 others, future studies are underway to analyze the methods by which the in vivo efficacy of NK cells can be enhanced and analyzing the synergistic effects when AIET is combined with Monoclonal antibodies. Conclusion: AIET technology was successfully translated from Japan to India overcoming various hurdles and since 2005 several patients in India have been administered AIET with no adverse reactions of any kind, which falls in line with the earlier reports from the literature. Significant increase in disease free survival or static non-progressive disease could be accomplished in patients with ovarian cancer, Acute Lymphoblastic leukemia, Acute Myeloid Leukemia, advanced in-operable pancreatic cancer, prostate cancer with multiple metastasis and breast cancer with metastasis, we have experienced. An increase in awareness about this least toxic method of Cancer treatment among physicians and the public for an early referral is necessary. Further studies on prevention of cancer using in vitro expanded autologous immune cells are underway. References: 1.Takayama T, Sekine T, Makuuchi M, Yamasaki S, Kosuge T, Yamamoto J, Shimada K, Sakamoto M, Hirohashi S, Ohashi Y, Kakizoe T. Adoptive immunotherapy to lower postsurgical recurrence rates of hepatocellular carcinoma: a randomised trial. Lancet. 2000 ;356(9232):802-7. 2.Kimura H, Yamaguchi Y. A phase III randomized study of interleukin-2 lymphokine-activated killer cell immunotherapy combined with chemotherapy or radiotherapy after curative or noncurative resection of primary lung carcinoma. Cancer. 1997;80(1):42-9. 3.Kono K, Takahashi A, Ichihara F, Amemiya H, Iizuka H, Fujii H, Sekikawa T, Matsumoto Y: Prognostic significance of adoptive immunotherapy with tumor-associated lymphocytes in patients with advanced gastric cancer: a randomized trial. Clin Cancer Res. 2002; 8 : 1767-71. 4.Fujita K, Ikarashi H, Takakuwa K, Kodama S, Tokunaga A, Takahashi T, Tanaka K. Prolonged disease-free period in patients with advanced epithelial ovarian cancer after adoptive transfer of tumor-infiltrating lymphocytes. Clin Cancer Res. 1995;1(5):501-7.5.Sivaraman G, Pandian A, Baskar S, Senthil KR, Senthilnagarajan R, Dedeepiya V, Abraham S. Autologous Immune Enhancement therapy for advanced carcinoma of pancreas a case report. PASRM 2008-004. J Stem Cells Regen Med. 2008; 4(1):136.Damodar S, Terunuma H , Sheriff AK , Farzana L , Manjunath S , Senthilkumar R , Shastikumar G , Abraham S , Wang FS. Autologous Immune Enhancement Therapy (AIET) for a Case of Acute Myeloid Leukemia (AML) - Our Experience. PASRM 2006-001. J Stem Cells Regen Med. 2006, 1(1): 40-417.Takada M, Terunuma H, Deng X, Dewan MZ, Saji S, Kuroi K, Yamamoto N, Toi M. Refractory lung metastasis from breast cancer treated with multidisciplinary therapy including an immunological approach. Breast Cancer 18:64-7, 2011. 8.Manjunath SR, Ramanan G, Dedeepiya VD, Terunuma H, Deng X, Baskar S, Senthilkumar R, Thamaraikannan P, Srinivasan T, Preethy S, Abraham SJ. Autologous immune enhancement therapy in recurrent ovarian cancer with metastases: a case report. Case Rep Oncol. 2012 Jan;5(1):114-8. 9.Conte R, Dinota A, Tazzari PL, Belletti D, Sermasi G. Analysis of natural killer cells in patients with idiopathic autoimmune hemolytic anemia. Vox Sang 56:270-3, 198910.Dedeepiya VD, Terunuma H, Deng X, Baskar S, Manjunath SR, Senthilkumar R, Murugan P, Thamaraikannan P, Srinivasan T, Preethy S, Abraham SJ. A comparative analysis of in vitro expansion of natural killer cells of a patient with autoimmune haemolytic anaemia and ovarian cancer with patients with other solid tumours. Oncol Lett. 2012 Feb;3(2):435-440. |
