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Induction of Immunity to Prostate Cancer Antigens: Results of
a Clinical Trial of Vaccination with Irradiated Autologous
Prostate Tumor Cells Engineered to Secrete
Granulocyte-Macrophage Colony-stimulating Factor Using ex
Vivo Gene Transfer
Jonathan W. Simons, Bahar Mikhak, Ju-Fay Chang, et al.
Cancer Res 1999;59:5160-5168.
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[CANCER RESEARCH 59, 5160 –5168, October 15, 1999]
Induction of Immunity to Prostate Cancer Antigens: Results of a Clinical Trial of
Vaccination with Irradiated Autologous Prostate Tumor Cells Engineered to
Secrete Granulocyte-Macrophage Colony-stimulating Factor Using
ex Vivo Gene Transfer1
Jonathan W. Simons,2 Bahar Mikhak,3 Ju-Fay Chang,3 Angelo M. DeMarzo, Michael A. Carducci, Michael Lim,
Christine E. Weber, Angelo A. Baccala, Marti A. Goemann, Shirley M. Clift, Dale G. Ando, Hyam I. Levitsky,
Lawrence K. Cohen, Martin G. Sanda, Richard C. Mulligan, Alan W. Partin, H. Ballentine Carter, Steven Piantadosi,
Fray F. Marshall, and William G. Nelson
Johns Hopkins Oncology Center, Brady Urological Institute, and Johns Hopkins University School of Medicine, Baltimore, Maryland 21287 [J. W. S., B. M., A. M. D., M. A. C.,
M. L., C. E. W., A. A. B., M. A. G., H. I. L., A. W. P., H. B. C., S. P., F. F. M., W. G. N.]; University of Michigan Medical Center, Ann Arbor, Michigan 48019 [M. G. S.]; Howard
Hughes Medical Institute, Children’s Hospital of Boston, and Harvard University School of Medicine, Boston, Massachusetts 02115 [L. K. C., R. C. M.]; and Cell Genesys, Inc.,
Foster City, California 94404 [J-F. C., S. M. C., D. G. A.]
ABSTRACT
Vaccination with irradiated granulocyte-macrophage colony-stimulating factor (GM-CSF)-secreting gene-transduced cancer vaccines induces
tumoricidal immune responses. In a Phase I human gene therapy trial,
eight immunocompetent prostate cancer (PCA) patients were treated with
autologous, GM-CSF-secreting, irradiated tumor vaccines prepared from
ex vivo retroviral transduction of surgically harvested cells. Expansion of
primary cultures of autologous vaccine cells was successful to meet trial
specifications in 8 of 11 cases (73%); the yields of the primary culture cell
limited the number of courses of vaccination. Side effects were pruritis,
erythema, and swelling at vaccination sites. Vaccine site biopsies manifested infiltrates of dendritic cells and macrophages among prostate tumor vaccine cells. Vaccination activated new T-cell and B-cell immune
responses against PCA antigens. T-cell responses, evaluated by assessing
delayed-type hypersensitivity (DTH) reactions against untransduced autologous tumor cells, were evident in two of eight patients before vaccination and in seven of eight patients after treatment. Reactive DTH site
biopsies manifested infiltrates of effector cells consisting of CD45RO1
T-cells, and degranulating eosinophils consistent with activation of both
Th1 and Th2 T-cell responses. A distinctive eosinophilic vasculitis was
evident near autologous tumor cells at vaccine sites, and at DTH sites.
B-cell responses were also induced. Sera from three of eight vaccinated
men contained new antibodies recognizing polypeptides of 26, 31, and 150
kDa in protein extracts from prostate cells. The 150-kDa polypeptide was
expressed by LNCaP and PC-3 PCA cells, as well as by normal prostate
epithelial cells, but not by prostate stromal cells. No antibodies against
prostate-specific antigen were detected. These data suggest that both
T-cell and B-cell immune responses to human PCA can be generated by
treatment with irradiated, GM-CSF gene-transduced PCA vaccines.
INTRODUCTION
New PCA4 treatments are needed urgently for the more than 40,000
men in the United States who die from metastatic PCA annually.
Several new PCA treatment approaches aim to eradicate PCA cells by
inducing systemic immunity to antigens expressed by PCA cells
Received 2/25/99; accepted 8/17/99.
The costs of publication of this article were defrayed in part by the payment of page
charges. This article must therefore be hereby marked advertisement in accordance with
18 U.S.C. Section 1734 solely to indicate this fact.
1
This work was supported by a National Cancer Institute, NIH, Special Projects of
Research Excellence Grant for Prostate Cancer CA58236 and by the CaP CURE Foundation.
2
To whom requests for reprints should be addressed, at The Brady Urological Institute,
Marburg 409, The Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, Maryland 21287. Phone: (410) 614-1662; Fax: (410) 614-3695.
3
These authors contributed equally to this paper.
4
The abbreviations used are: PCA, prostate cancer; DC, dendritic cell; DTH, delayedtype hypersensitivity; GM-CSF, granulocyte-macrophage colony-stimulating factor; PSA,
prostate-specific antigen; PSMA, prostate-specific membrane antigen; RCR, replicationcompetent retrovirus.
(1–11). Because many such antigens may also be present in normal
prostate epithelial cells as well as PCA cells, one major therapeutic
challenge for induction of anti-PCA immune responses may be the
need to overcome immune tolerance against normal prostate antigens.
GM-CSF-secreting cancer cell vaccines, generated from cancer
cells by ex vivo gene transfer, have been shown to elicit tumoricidal
antitumor immune responses in a variety of animal tumor models
(12–23), including preclinical models of PCA (24, 25), and in human
clinical trials (26, 27). Irradiated GM-CSF-secreting cancer cell vaccines induce antitumor immune responses by recruiting antigen-presenting cells, such as DCs, to immunization sites. DCs, the most
potent immunostimulatory antigen-presenting cells known, activate
antigen-specific CD41 and CD81 T-cells by priming them with
oligopeptides processed from the dying cancer cells (28). Recent
preclinical studies have suggested that CD41 T-cells activated by
GM-CSF-secreting cancer cell vaccines do not merely facilitate cancer cell destruction by CD81 T-cell cells (28). Rather, vaccination
simultaneously elicits both Th1 and Th2 CD41 T-cell responses,
leading to cancer cell killing by a variety of mechanisms (28). In a
clinical trial of this treatment approach for malignant melanoma, both
T-cell and B-cell immune responses against melanoma antigens were
detected (26). Experience from previous melanoma vaccine clinical
trials, using irradiated allogeneic melanoma cell lines as vaccines, has
indicated that vaccination-associated B-cell responses elicited by vaccination include the generation of new antibodies recognizing
polypeptides present in both normal and neoplastic cells (29).
To determine whether GM-CSF-secreting PCA vaccines might
elicit T-cell and B-cell immune responses against normal and neoplastic prostate cells in men with PCA, we conducted a clinical trial
of this treatment strategy. The clinical translation involved tumor
resection by radical prostatectomy, establishment of primary PCA
cultures, and ex vivo gene transfer. This was the first NIH Office of
Recombinant DNA Activities-approved trial of human gene therapy
for PCA. Eight men with PCA were treated by intradermal injections
of irradiated PCA vaccine cells, and then monitored for treatmentassociated side effects, for signs of PCA progression after vaccination,
and for evidence of induction of T-cell and B-cell immune responses.
Results indicated that this new PCA immunotherapy treatment approach, featuring vaccination with GM-CSF-secreting autologous
prostate tumor cells, was feasible, safe, and capable of eliciting
systemic immune responses against PCA antigens.
MATERIALS AND METHODS
Selection of Patients for Treatment with Genetically Modified PCA
Vaccines. Candidates for enrollment into the Phase I clinical trial included
men with adenocarcinoma of the prostate who had undergone a radical pros5160
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IRRADIATED GM-CSF GENE-TRANSDUCED PCA VACCINES
tatectomy with curative intent and were found to have metastatic PCA at
surgery despite careful preoperative staging. Before surgery, men who were
considered for treatment provided informed consent to permit immediate
postoperative establishment of primary autologous PCA cultures as a first step
in PCA vaccine preparation. Further processing of the primary PCA cultures,
including retroviral gene transfer, proceeded only after histopathological identification of PCA lymph node metastasis, PCA seminal vesicle invasion, or
both. Additional eligibility criteria for enrollment into the trial included the
following: age, $18 years; Eastern Cooperative Oncology Group performance
status of 0 or 1; suitable candidacy for radical prostatectomy; serum direct
bilirubin, #2.0 mg/dl; serum creatinine, #2.0 mg/dl; WBC count, $3500/
mm3; platelet count, $100,000/mm3; no previous history of cancer; no previous history of autoimmune diseases; seronegativity for antibodies to HIV; no
recent immunotherapy; and no recent immunosuppressive therapy (including
oral or topical corticosteroids, cytotoxic chemotherapy, or radiation therapy).
Design of the Phase I Trial of Genetically Modified PCA Vaccine
Therapy. The three primary end points of the Phase I study were as follows:
(a) to evaluate the safety of intradermal vaccination of cultured, lethally
irradiated, autologous (PCA) vaccines transduced with the MFG-S-GM-CSF
vector to secrete human GM-CSF at 150-1500 ng/million cells/24 h; (b) to
describe and quantitate the acute and long term toxicities of treatment with ex
vivo GM-CSF gene-transduced prostate vaccines; and (c) to assay in vitro and
in vivo the contribution of effects of vaccines to the induction of antitumor
immune responses to (PCA). Patients were treated at two vaccine dose levels:
1 3 107 and 5 3 107 autologous GM-CSF-transduced prostate vaccines. The
trial was designed to evaluate three patients enrolled for dose level 1, and five
patients were to be enrolled for dose level 2 if dose escalation was permitted
by the safety rules of the trial. Patients were considered evaluable for safety
and toxicity using National Cancer Institute Common Toxicity Criteria if they
completed three full courses of vaccination. Vaccinations were administered
every 21 days. Patients were vaccinated until exhaustion of the supply of
vaccine, but no fractional doses were permitted. In the event that a patient
accrued at dose level 2 had sufficient GM-CSF gene-transduced autologous
vaccine yields for three full dose treatments at dose level 1, but not three full
dose treatments at dose level 2, the trial rules permitted treatment at dose level
1. Dose level 2 represented the estimated upper limit of vaccine cell yield in
over 20 clinical trial simulations of stage T2b tumors (2– 4-g tumors) using
radical prostatectomy specimens.5 If no dose-limiting toxicities were observed
at dose level 2 after a total Phase I accrual of 8 patients, a 30-patient Phase II
study was planned based on Phase I safety, review by the FDA, and Office of
Recombinant DNA Activities review.
The Phase I trial proceeded in three stages. Stage I involved surgical harvest of
prostate tumor cells, cultivation of primary tumor explants, ex vivo gene transfer
with a replication-defective retrovirus containing cDNA encoding GM-CSF, lethal
irradiation of the genetically modified prostate tumor cells, and formulation for
intradermal administration as vaccines (see below and Refs. 24 and 27).
In stage II of the trial, men were subjected to treatment with the PCA vaccines
at two dose levels. For dose level 1, men were treated with 1 3 107 PCA vaccine
cells, administered as two intradermal injections of 0.5 3 107 cells/0.5 ml of
HBSS, every 21 days until the vaccine cell supply was exhausted. A patient was
evaluable for toxicity if he completed three vaccinations. Vaccine injections were
given in the limbs, with at least 5 cm separating inoculation sites. Different limbs
were used in different treatment cycles.
For stage III of the trial, vaccinated men were monitored for treatmentassociated side effects, including the possible appearance of RCR in the
peripheral blood, after each vaccine injection and then monthly for 3 months,
every 3 months for 9 months, and yearly thereafter. A thorough evaluation for
the appearance of autoimmune diseases, including autoimmune serology studies, was conducted every 6 months after completion of the vaccination course.
All toxicities, including autoimmune toxicities, were graded using the National
Cancer Institute Common Toxicity Criteria. At follow-up visits, vaccinated
men were also assessed for (PCA) progression, using serum PSA determinations. Radiographic imaging studies were also used as needed. The plasma
pharmacokinetics of absorbed GM-CSF following vaccine administration was
monitored as described previously (27, 30). Vaccinated men were also monitored for induction of T-cell and B-cell immune responses (see below).
5
S. M. Clift and J. W. Simons, unpublished data.
The rationale for choosing dose level 1 at 1 3 107 cells was based on four
facts. First, it was based on preclinical studies showing efficacy against
preestablished tumors in this vaccine cell dose range in the hormone-refractory
Dunning rat (PCA) model (24, 25). Second, the cell dose range was found to
be safe in renal cell carcinoma patients in a Phase I study using MFG-GM-CSF
gene-transduced tumor vaccines (27). Third, in clinical trial simulations, autologous prostate cell vaccines could be generated consistently in the dose
level 1 range following gene transfer with the MFG-GM-CSF vector in
patients undergoing anatomical radical prostatectomy. (24).5 Fourth, this vaccine cell dose range secreting GM-CSF conferred an objective clinical response in metastatic renal cell carcinoma patients (27).
The Phase I clinical study was reviewed and approved by The Johns
Hopkins Joint Committee on Clinical Investigation, by the Johns Hopkins
University School of Medicine Biosafety Committee, by the Food and Drug
Administration, and by the NIH Office of Recombinant DNA Activities.
Preparation of GM-CSF-secreting Autologous PCA Vaccine Cells Using Retroviral Gene Transfer. Excised prostate tumors were mechanically
dissociated into 0.1– 0.5-cm fragments, suspended in a transport medium,
sealed, and shipped in a thermally secure container to Somatix Therapy Corp.
(Alameda, CA). Tumor fragments were mechanically disaggregated into a
suspension and then cultivated in serum-free medium (24). At the time of
initial plating, cell viablility was consistently 70 – 80% by trypan blue exclusion. The expansion rate in primary culture was consistent with that described
previously by Sanda et al. (24) using serum-free media. The doubling times
ranged from 4 to 12 days. No fetal bovine serum or collagenase was used in
cell disaggregation, shipping, or cryopreservation. Primary cultures were transduced with the replication-defective retrovirus containing cDNA encoding
GM-CSF (MFG-GM-CSF) as described previously (24, 27, 30). Genetically
modified PCA vaccine cells (GVAX, Cell Genesys, Inc., Foster City, CA)
were then lethally irradiated (with 15 Gy), assessed for GM-CSF secretion by
ELISA (R&D Systems, Minneapolis, MN), evaluated for MFG-GM-CSF
integration by quantitative Southern blot analysis (24), tested for microbial
contaminants and for RCR (27, 30), and stored in liquid nitrogen. Immediately
before administration as vaccines, the cells were thawed, washed three times
with HBSS, and checked for viability by trypan blue exclusion.
Analyses of Immune Responses Elicited by Vaccine Treatment. Assessment of T-cell and B-cell immune responses induced by vaccination with
irradiated GM-CSF-secreting PCA cells included histopathological and immunohistochemical studies of vaccine site biopsies, DTH testing using unmodified autologous PCA cells, and immunoblot analyses of serum antibodies
appearing after vaccination.
For each man treated with PCA vaccines, a skin biopsy was obtained before
vaccination, and then vaccine site biopsies were performed 3 days following
the first and final vaccine inoculations. Biopsy specimens were dissected such
that samples could be formalin fixed and paraffin embedded and also snap
frozen without formalin fixation. Tissue sections cut from formalin-fixed
samples were stained with H&E. Vaccine cells were detected by immunohistochemical staining for cytokeratins (using antikeratin antibodies AE1 and
AE3; Roche Molecular Biochemicals, Indianapolis, IN; Ref. 31), for PSA
(using antibody 5/26, Immunotech, Inc., Westbrook, ME), and for prostatespecific acid phosphatase (using rabbit antiserum A 0627, Dako Corp., Carpinteria, CA). Infiltrating inflammatory cells were detected and characterized by
immunohistochemical staining for CD68 (a macrophage marker; antibody
KP1, Dako; Ref. 32), for CD1a (a Langerhans cell marker; antibody O10,
Immunotech; Ref. 33), for S-100 (a Langerhans cell and melanocyte marker;
rabbit antiserum Z 311, Dako), for CD56 (a natural killer cell marker; antibody
123C3 against NCAM, Zymed Laboratories, Inc., South San Francisco, CA;
Refs. 34 and 35), for leukocyte common antigen (LCA; antibodies PD7/26/16
and 2B11, Dako; Ref. 36), for CD3 (a T-cell marker; rabbit antiserum A 0452,
Dako; Ref. 37), for CD4 (a helper T-cell marker, antibody 1F6, Novocastra,
Vector Laboratories, Inc., Burlingame, CA), for CD8 (a cytotoxic T-cell
marker; antibody C8 144B, Dako; Ref. 38), for CD45RO (a marker for
activated or memory T-cells; antibody UCHL1, Dako; Ref. 39), for CD20 (a
B-cell marker; antibody L26, Dako; Ref. 40), for Ki-67 (a marker of proliferation; antibody MIB-1, Immunotech; Ref. 41), and with Diff Quick (a stain
that detects eosinophils and neutrophils; Aloegiance, Columbia, MD). Frozen
sections were stained for eosinophil major basic protein using an immunohistochemical technique (antibody BMK13, Research Diagnostics, Inc., Flanders,
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IRRADIATED GM-CSF GENE-TRANSDUCED PCA VACCINES
NJ; Ref. 42). Evaluation of the stained vaccine site biopsy sections was
assessed by three observers (B. M., J. W. S., and A. M. D).
DTH testing was accomplished by intradermal administration of irradiated (15
Gy) autologous prostate tumor cells (1 3 106 cells in 0.2 ml of HBSS) that had
been propagated ex vivo in serum-free medium but had not been exposed to the
MFG-GM-CSF retrovirus or fetal bovine serum in handling. DTH target cells
were derived at the second passage of primary cultures of autologous prostate
tumor cell explants using identical methods of primary cell culture as described
above; they were not permanently established cell lines (24, 27). These DTH target
cells were cryopreserved in a buffer containing human serum albumin. DTH
reactivity was assessed by measuring the extent of induration at 48 h at the DTH
injection site as described previously (27). DTH site biopsies (5 mm) were
obtained at 48 h and processed in a manner similar to the vaccine site biopsies. In
addition to DTH testing using autologous prostate tumor cells, DTH testing using
seven defined common recall antigens was also undertaken (Multitest CMI panel,
Pasteur-Merieux-Connaught, Swiftwater, PA).
Sera obtained from vaccinated men were analyzed for the presence of
induced antibody responses against PCAs antignes by using the sera to stain
immunoblots containing protein extracts from cultured PCA cells as well as
from other cultured human cells. LNCaP PCA cells (43), PC-3 PCA cells (44),
DU 145 PCA cells (45), A549 lung carcinoma cells (46), LS-174T colon
carcinoma cells (47), KLE endometrial carcinoma cells (48), Jurkat T-cell
leukemia cells (49), and MDA-MB-435 breast carcinoma cells (50, 51) were
propagated in vitro in DMEM or Ham’s F-12 growth medium (JHR Bioscience, Lenexa, KS) containing 10% FCS. Primary cultures of human prostate
epithelial cells, prostate stromal cells, prostate smooth muscle cells, and lung
fibroblasts were obtained from the Clonetics Corp. (Walkersville, MD). To
prepare protein extracts, cultured cells were harvested, collected by centrifugation at 1000 rpm for 10 min using a Beckman CS-6R centrifuge (Beckman,
Palo Alto, CA), washed extensively with PBS, and then subjected to lysis in 10
mM Tris-HCl at pH 7.4, 1 mM EDTA, 10% glycerol, 1% NP40, 1 mM
phenylmethylsulfonyl fluoride, and 1% protease inhibitor cocktail set III
(Calbiochem, La Jolla, CA) for 1 h at 4°C. The cell lysates were then clarified
by centrifugation at 600 3 g and subjected to protein quantification using the
BCA assay (Pierce, Rockford, IL). Lysates containing 25–35 mg of protein
were electrophoresed on 4 –20% gradient polyacrylamide gels (Norvex, San
Diego, CA) in the presence of SDS and transferred electrophoretically to
nitrocellulose membranes (Norvex). The resultant nitrocellulose membrane
blots were first treated with a blocking solution (10% nonfat dry milk and 0.5%
Tween 20 in PBS) overnight at 4°C, next exposed to sera recovered from
vaccinated men (at a 1:1000 dilution in PBS containing 0.05% Tween 20) for
2 h at room temperature, and then washed extensively with PBS containing
0.1% Tween 20. Human serum antibodies adhering to blotted proteins were
detected by incubation of the blots with horseradish peroxidase-conjugated
goat antihuman IgM 1 IgG 1 IgA (Zymed) at a dilution of 1:3000 in PBS
containing 0.05% Tween 20 for 1 h at room temperature. After further washing
in PBS with 0.1% Tween 20, horseradish peroxidase activity was detected
using an ECL kit (Amersham Pharmacia Biotech, Arlington Heights, IL).
Human serum antibodies directed specifically against PSA were assayed using
immunoblots containing purified PSA (Calbiochem) in an identical manner.
RESULTS
Generation of GM-CSF-secreting Autologous Prostate Tumor
Cell Vaccines Using ex Vivo Gene Transfer. After radical prostatectomy, 11 men with PCA were found to have metastatic cancer and
were eligible for participation in the Phase I clinical trial. For each of
the 11 men, autologous prostate tumor cells were placed in primary
cultures using 2–5 grams of prostate tumor tissue dissected from
radical prostatectomy resection specimens. The accrual of the Phase I
trial was 8 patients evaluated for toxicities after a minimum of three
vaccinations given every 2 weeks. Primary cultures were successfully
established in 8 of 11 patients (73%; see Table 1). Prostate tumor cell
expansion via propagation in vitro to cell yields adequate for treatment at the assigned dose level was somewhat less successful. For
patients accrued in the trial at dose level 1 (1 3 107 cells/vaccination),
sufficient cells were expanded in three of four primary culture attempts (75%); one primary culture failed to be established at dose
level 1. When dose level 1 was found to be clinically safe in three
treated patients, a total of seven patients were accrued for dose level
2 (5 3 107 cells/vaccination). Sufficient cells were recovered in only
three of seven patients’ primary cultures to allow three vaccinations at
dose level 2. Thus, only three patients were treated at dose level 2.
Two patients had tumors that failed to be established in primary
culture, and the remaining two patients accrued at dose level 2 had
sufficient vaccine cell yields to specifications to be treated at dose
level 1. As a result, primary prostate tumor cell culture yields in this
trial permitted five patients to be treated at dose level 1 and three to
be treated at dose level 2 (Table 2). On average, .90% of the entire
prostate tumor tissue was placed into primary culture, making it
unlikely that total cell yield could be significantly increased by
procuring more primary tumor at surgery (Table 2).
In contrast to the suboptimal success rate in expanding prostate
tumor cell numbers in primary cultures, genetic modification of PCA
cells to achieve high level secretion (.140 ng/106 cells over 24 h) of
GM-CSF using ex vivo retroviral gene transfer was remarkably effective (eight of eight attempts, or 100%; see Table 1). Previous studies
using preclinical models have suggested a minimum threshold of .35
ng of GM-CSF/106 cells over 24 h secreted by vaccine cells might be
required to elicit therapeutic antitumor immune responses (12). Transduction of the prostate tumor cells by the replication-defective retrovirus MFG-GM-CSF resulted in viral integration to a copy number of
between 1 and 4 per haploid genome as assessed by quantitative
Southern blot analysis (not shown; see Ref. 24). Resultant GM-CSF
secretion by the prostate tumor cells increased from ,0.2 ng/106 cells
over 24 h to between 143 and 1403 ng/106 cells over 24 h (Table 2).
Vaccine Administration. Eight men were treated with irradiated
GM-CSF-secreting prostate tumor cell vaccines at 2 dose levels (five
at dose level 1 and three at dose level 2). Up to six intradermal
vaccinations were administered every 3 weeks. Skin reactions (see
Fig. 1), including discomfort, erythema, swelling, and pruritis, were
common after vaccine treatment (Table 3). The maximum level of
erythema and induration, up to 4 cm in diameter, typically appeared
within 24 – 48 h of vaccination and resolved without intervention in
5–7 days. Mild low-grade fevers, chills, and malaise were noted by a
few men as a consequence of vaccine inoculation (Table 3). No severe
or dose-limiting cutaneous or systemic side effects were observed. No
significant alterations in serum electrolyte and chemistry values or in
hematology counts, including WBC counts, total eosinophil counts,
and total neutrophil counts, were seen. Plasma GM-CSF pharmacokinetic analyses failed to show any vaccine-associated rise in plasma
GM-CSF levels. No RCR was detected in any vaccine cell preparation
or in blood from any of the vaccinated men at any time.
Assessment of PCA treatment efficacy was not a primary end point of
the Phase I clinical trial of GM-CSF-secreting autologous prostate tumor
cell vaccines. With eight fully evaluable patients enrolled and treated, the
trial did not have adequate statistical power to estimate a treatmentassociated response rate. The median serum PSA before radical prostatectomy was 28.85 ng/ml (with a range of 6.7–75 ng/ml), and the median
serum PSA at first vaccination was 0.65 ng/ml (with a range of 0.1–30.4
ng/ml; see Table 1). Ultimately, all eight vaccinated patients manifested
a rising serum PSA, showing PCA progression.
Recruitment of Immune Effector Cells to Vaccine Sites. Intradermal injection was chosen for the mode of vaccination because of
the abundance of Langerhans cells, the skin DCs, which constitute the
critical antigen-presenting cells for priming immune responses to
irradiated GM-CSF-secreting tumor cells (28). Vaccine site biopsies
were obtained 3 days after the first and final vaccine inoculations.
Extensive histopathological and immunohistochemical analyses of
these vaccine site biopsies were undertaken to characterize immune
effector cell infiltrates appearing as a consequence of vaccination (26,
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IRRADIATED GM-CSF GENE-TRANSDUCED PCA VACCINES
Induction of T-cell Immune Responses against Prostate Tumor
Antigens. The T-cell epitopes that were recognized by infiltrating
CD-31 T-cells on newly induced DTH sites following vaccination with
GM-CSF gene-transduced autologous prostate vaccines are not known at
this time. Several new reports suggest that PCA patients may even have
preexisting CD-4 and CD-8 T-cells against many potential PCA associated antigens, including PSA and PSMA (8, 52) In previous tumor
vaccine studies, in which defined peptide antigens were not known,
tumor antigen-specific T-cell responses were assessed using cutaneous
DTH testing against antigens present in autologous tumor cells (26, 27,
53–58). For this study, irradiated autologous prostate tumor cells served
as DTH target cells. These prostate tumor cells were propagated in
serum-free media and cryopreserved in a buffer containing human serum
albumin. Thus, the prostate tumor DTH cells were largely free of contaminating xenoproteins, such as collagenase or proteins present in bovine sera, which have been reported to confound interpretations of DTH
skin tests in some other cancer vaccine trials (57). DTH reactivity was
measured as the bidimensional extent of induration at the intradermal
DTH injection site at 48 h.
Vaccinated men were subjected to prostate tumor DTH testing before
vaccination, after three vaccine treatments, and at the end of the vaccine
course. All vaccinated men were also subjected to DTH testing for
reactivity against seven common recall antigens, as described previously
(27). Each of the vaccinated men appeared immunocompetent, as evidenced by DTH reactivity against one or more of the recall antigens,
before beginning treatment with PCA vaccines. In addition, all vaccinated men displayed normal levels of T-cell receptor z chains in circu-
Table 1 Characteristics of patients
Characteristic
Value
No. enrolled in study (including those without metastatic
PCA)
No. clinically eligible
No. treated with metastatic PCA
No. of successful PCA cell cultures (sufficient for vaccine
preparation)/no. of culture attempts
No. of successful GM-CSF gene transductions/no. of
transduction attempts
Median age of treated patients (range), yr
Mean age of treated patients, yr
21
11
8
8/11
8/8
51 (46–64)
53
Median PSA level presurgery for treated patients (range),
ng/ml
Mean PSA level presurgery for treated patients, ng/ml
Median PSA level for treated patients at 1st vaccination
(range), ng/ml
Mean PSA level for treated patients at 1st vaccination,
ng/ml
28.85 (6.7–75)
30.85
0.65 (0.1–30.4)
6.08
Table 2 GM-CSF secretion by PCA vaccine cells following MFG-GM-CSF gene
transfer
Patient no.
Dose level
GM-CSF secretion ng/106
PCA vaccine cells/24 ha
Total
vaccinations
1
2
3
4
5
6
7
8
1
1
1
1
2
1
2
2
143
197
349
607
1403
240
520
233
6
6
6
5
6
3
6
3
a
GM-CSF secretion before MFG-GM-CSF transduction, ,0.2 ng/106 PCA vaccine
cells/24 h; average GM-CSF secretion after transduction, 461.5 ng/106 PCA vaccine
cells/24 h.
27). Autologous prostate tumor cells, characterized by positive immunohistochemical staining for cytokeratins, were present in all vaccine site biopsies evaluated (see Fig. 2B). Acanthosis, a thickening of
the stratum spinosum of the epidermis often associated with autoimmune diseases or malignancy, was apparent in each of the vaccine site
biopsies (Fig. 2A). The severity of acanthosis, graded by a pathologist
(A. M. D.), appeared to increase from the first vaccine site biopsy to
the last for each of the vaccinated men.
Inflammatory cell infiltrates were present in each of the vaccine site
biopsies compared to pretreatment biopsies. The magnitude of the inflammatory cell response surrounding intradermal deposits of tumor
vaccine appeared to be greater in dose level 2 patients compared to the
dose level 1 cohort. Langerhans cells, the skin DCs, were evident at the
junction of the epidermis and dermis and also in the dermis near vaccine
cells in one vaccine site biopsy examined (Fig. 2C). Macrophages were
also detected (Fig. 2D). Neutrophils and eosinophils, usually present near
vaccine cells in the dermis, increased in abundance from ,1 to 37.5%
and from ,0.5 to 15% of inflammatory cells, respectively, in skin
biopsies from vaccine sites versus skin biopsies from similar locations
obtained before vaccination. Eosinophils infiltrating the vaccine sites
showed evidence of activation and massive levels of degranulation (Fig.
3). After repeated vaccinations, the fraction of eosinophils (assessed as
the ratio of eosinophils to CD31 T-cells) at vaccine sites increased. In
areas of acanthosis, dermal blood vessels manifest a striking eosinophilic
vasculitis, with characteristic subendothelial eosinophils (Fig. 2F). Small
blood vessels near vaccine cells were also typically surrounded by eosinophils, often accompanied by other mononuclear inflammatory cells,
including CD31 T-cells (Fig. 2E). CD31 T-cells also appeared near
DCs and macrophages recruited to vaccine sites. Frequent CD81 T-cells
were consistently present in the dermis following vaccination.
Fig. 1. Vaccine site appearance 72 h after inoculation of irradiated autologous GMCSF-secreting PCA cells. Pt, patient.
Table 3 Toxicities accompanying vaccination with irradiated with GM-CSF-secreting
autologous PCA cells
Fully evaluable cycles
Systemic side effectsa
Low-grade fever (grade 2 or less)
Chills
Malaise
Acute vaccine site effects
Injection site erythema/swelling (grade 2 or less)
Site tenderness (1–3 days)
Pruritus (grade 2 or less)
Pain during injection
a
Dose level 1
(5 patients)
Dose level 2
(3 patients)
26
15
0/26
0/26
1/26
2/15
3/15
4/15
26/26
5/26
3/26
26/26
15/15
5/15
10/15
15/15
Graded using NCI Common Toxicity Criteria.
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IRRADIATED GM-CSF GENE-TRANSDUCED PCA VACCINES
Fig. 2. Vaccine site biopsy photomicrographs
showing skin infiltration by immune effector cells
72 h after vaccination. Immunohistochemical staining for various antigens was accomplished as described in “Materials and Methods.” A, inflammatory cell infiltrates apparent after H&E staining; B,
cytokeratin-positive vaccine cells; C, CD1a-positive DCs in the epithelium and dermis; D, CD68positive macrophages; E, CD3-positive T-cells; F,
eosinophils, neutrophils, and other mononuclear inflammatory cells evident after H&E staining.
lating CD31 T-cells (not shown; see Ref. 59). Reactive prostate tumor
DTH tests were present before vaccination in two of eight men. Following vaccination, seven of eight patients manifested positive DTH tests to
challenge with irradiated, untransduced autologous prostate cell targets
range (5–23 mm). Of the six of eight patients with no positive DTH to
challenge with autologous prostate cells prior to vaccination, five of six
became positive after treatment. In the case of the two of eight patients
with a pretreatment positive DTH reaction to their autologous tumor prior
to treatment, patient 3 (dose level 1) showed a 2-fold increase in induration (6 to 12 mm) following vaccination, whereas patient 5 (dose level
2) manifested no appreciable increase in DTH from 8 mm following
vaccination. The study was too small to ascertain any statistically significant differences in DTH induction sizes associated with vaccine treatment at dose level 1 versus dose level 2. The magnitude of reactivity of
DTH could not be clearly ascribed to total number of vaccinations or
GM-CSF levels. The largest DTH conversion (3 to 25 mm) was observed
in patient 8, who received only three vaccinations at dose level 2 (Table
2). Interestingly, the largest DTH reactivity appeared in patient 8, who
had a history of clinical prostatitis.
Histopathological and immunohistochemical analysis of prostate tumor DTH site biopsies taken from two patients after vaccination revealed
abundant inflammatory infiltrates not evident in skin biopsies obtained
before vaccination. Perivascular cuffing by infiltrating lymphocytes,
characteristic of DTH reactions, was present in all reactive DTH site
biopsies (Fig. 4A). DTH site biopsies also disclosed ingress of macrophages (Fig. 4B) and of natural killer cells (Fig. 4C). Extensive eosinophil
infiltrates and a subendothelial eosinophilic vasculitis, reminiscent of the
vaccine site biopsies, were present in reactive DTH site biopsies taken
after vaccination. T-cells were also present at DTH sites. In the DTH site
biopsies, some 80% of the CD31 T-cells expressed CD45RO, indicative
of T-cell activation after vaccination (Fig. 4D). Similar to the vaccine site
biopsies, the prostate tumor DTH site biopsies displayed an increasing
abundance of eosinophils relative to T-cells as the vaccine treatment
course proceeded. Few B-cells were evident at the DTH sites.
Pre- and postvaccine peripheral blood samples were also tested for
proliferation and cytokine release (IL-2, GM-CSF, and g IFN) in
response to recombinant PSA, using candida as a positive control. All
patients demonstrated responsiveness to candida, but none showed
evidence of PSA-specific T-cell recognition.6 Due to low yields of
6
H. I. Levitsky and J. W. Simons, unpublished observations.
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IRRADIATED GM-CSF GENE-TRANSDUCED PCA VACCINES
was expressed by both normal and neoplastic prostate epithelial cells
and by prostate smooth muscle cells, but not by prostate stromal cells,
lung fibroblasts, or WBCs (Fig. 6A). The 150-kDa polypeptide was
also expressed by a number of human cancer cell lines (Fig. 6B).
Characterization of the precise epitope(s) recognized by the induced
antibodies is ongoing. Using the same immunoblot analysis approach,
no antibodies against PSA were detected (not shown). Despite the
induction of new antibodies in three of eight patients, none of the eight
patients developed any clinically detectable lymphadenopathy.
DISCUSSION
Fig. 3. Eosinophil degranulation at the vaccine site. Vaccine site biopsy obtained 72 h
after vaccine inoculation was stained for eosinophil major basic protein (MBP) using an
immunohistochemical technique (see “Materials and Methods”).
autologous tumor cells in early passage, autologous tumor cells were
not available to assess the priming of responses to undefined tumorassociated antigens.
Induction of B-Cell Immune Responses against Prostate Tumor
Antigens. Although few B-cells appeared to be present at prostate
tumor vaccine sites or at prostate tumor DTH sites, immunoblot
analyses using sera from the eight treated men, obtained before and
after vaccination, disclosed the appearance of increased titers of
antibodies recognizing prostate tumor antigens in sera from three of
the men as a consequence of vaccine treatment (Fig. 5, patients 1, 6,
and 7). New antibodies at 1:1000 titer were observed in patients 1 and
6 (dose level 1) and patient 7 (dose level 2), 2 weeks following final
vaccination (Fig. 5). All three of these patients had negative DTH skin
reactivity to challenge with autologous prostate cells prior to vaccination with GM-CSF gene-transduced PCA vaccines. The induced
immunoglobulins recognized polypeptides of 26, 31, and 150 kDa in
extracts from LNCaP PCA cells (Fig. 5). The 150-kDa polypeptide
The results of the Phase I clinical trial of irradiated GM-CSF-secreting
autologous prostate tumor vaccine therapy indicated that such treatment
was safe and induced both B-cell and T-cell immune responses against
PCA cell-associated antigens. A major difficulty for future clinical development of this autologous treatment approach was the low yield of
autologous PCA vaccine cells recovered (often 5 3 107 or less) using cell
culture approaches to expand PCA cell numbers. This approach appears
clinically impractical for large Phase II studies to assess efficacy given
the cell culture technology of primary cultures used in this study. Retroviral transfer of GM-CSF cDNA to permit high level secretion of GMCSF was not limiting. Nonetheless, with limited numbers of autologous
PCA vaccine cells likely available from most men with localized PCA,
and no PCA vaccine cells likely available from most men with advanced
PCA, exploration of higher vaccine doses and different vaccination
schedules in future clinical trials will not be possible. Allogeneic PCA
vaccines, prepared from PCA cell lines genetically modified to secrete
high levels of GM-CSF, may offer a solution to this clinical development
problem. Preclinical studies have suggested that antigens from irradiated
GM-CSF-secreting cancer vaccine cells are presented to T-cells on MHC
molecules expressed by host antigen-presenting cells (see Refs. 60 and
61); such vaccine cells thus do not necessarily need to be MHC-matched
with host T-cells to be effective at eliciting potent antitumor immunity.
Rather, the vaccine cells need to express tumor antigens expressed by
metastatic PCA clones in patients, and they need to secrete sufficient
paracrine GM-CSF to recruit bone marrow-derived antigen-presenting
cells (DCs and macrophages) to sites of vaccination (60, 61). The PCA
Fig. 4. Infiltration of immune effector cells at
DTH reaction sites at 48 h. Immunohistochemical
staining for immune effector cell antigens was accomplished as described in in “Materials and Methods.” A, vasculitis evident by H&E staining; B,
CD68-positive macrophages; C, CD56-positive
natural killer cells; D, CD45RO-positive T-cells.
These photomicrographs are representative of postvaccination DTH cellular infiltrates against autologous prostate cell targets at both dose levels.
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IRRADIATED GM-CSF GENE-TRANSDUCED PCA VACCINES
Fig. 5. Anti-PCA antibody responses induced by
vaccination. Patient sera were used to probe immunoblots containing electrophoretically separated
LNCaP polypeptides as described in “Materials and
Methods.” Lanes A, immunoblots probed with patient sera obtained before vaccination; Lanes B,
immunoblots probed with patient sera collected 2
weeks after administration of the final vaccine dose.
Fig. 6. Expression of a 150-kDa polypeptide recognized by serum from a vaccinated patient (patient 7;
see Fig. 5). Immunoblots containing electrophoretically separated polypeptides from various cells were
probed with serum recovered from patient 7 before
(PRE) and after (POST) vaccination. A, Lane 1,
LNCaP PCA cells; Lane 2, normal prostate stromal
cells; Lane 3, normal prostate epithelial cells; Lane
4, normal prostate smooth muscle cells; Lane 5,
normal lung fibroblasts; Lane 6, peripheral blood
leukocytes. B, Lane 1, PC-3 PCA cells; Lane 2,
LNCaP PCA cells; Lane 3, A549 lung carcinoma
cells; Lane 4, LS-174T colon carcinoma cells; Lane
5, DU 145 PCA cells; Lane 6, KLE endometrial
carcinoma cells; Lane 7, Jurkat T-cell leukemia
cells; Lane 8, MDA-MB-435s breast carcinoma
cells.
cell lines LNCaP and PC-3, which contain a number of common PCAs,
express the newly identified 150-kDa polypeptide recognized by sera
from men treated with autologous PCA vaccines. Based on data from this
Phase I trial, a Phase II clinical trial of irradiated GM-CSF-secreting
LNCaP and PC-3 vaccines, using vaccine cell doses higher than that
possible with autologous PCA vaccines, is currently under way.7 GMCSF gene-transduced allogeneic PCA vaccines appear to permit long
schedules of booster vaccinations, given the inexhaustible supply of the
permanently established tumor cell lines.7
Tumor-specific cytotoxic CD81 T-cells recognize tumor antigens
presented on class I MHC molecules to target cancer cells for destruction. For many men with advanced PCA, class I MHC low or
negative PCA cells may be present (62– 65). Such cells would likely
7
J. W. Simons and W. G. Nelson, unpublished data.
be difficult to eradicate with tumor-specific cytotoxic CD81 T-cells
alone. Fortunately, Hung et al. (28) have recently reported that vaccination with irradiated GM-CSF-secreting cancer vaccines activate
tumor-specific CD41 T-cells to simultaneously produce Th1 and Th2
responses. Both CD81 T-cell effectors and non-MHC-dependent
immune effectors of antitumor immunity are elicited by GM-CSF
gene-transduced vaccine treatment. Immune response data collected
during the conduct of the Phase I trial of irradiated GM-CSF-secreting
PCA vaccines supports in man the conclusions Hung et al. (28)
derived in mice. Notably, DCs and macrophages were recruited for
antigen processing by paracrine GM-CSF secretion at tumor vaccination sites (Figs. 2 and 3). Following PCA antigen presentation in vivo,
postvaccination reactive DTH site biopsies indicated the participation
of degranulating eosinophils as well as circulating T-cells in vaccination induced immune responses to autologous PCA cell DTH tar-
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IRRADIATED GM-CSF GENE-TRANSDUCED PCA VACCINES
gets (Fig. 4). Architecturally, the concerted immunological response
appears to include eosinophil accumulation and degranulation in the
subendothelial space of small blood vessels immediately adjacent to
depositions of DTH tumor antigen. Identical pictures of postvaccination DTH response to autologous untransduced tumor target cells have
been reported in clinical trials of renal cell carcinoma and melanoma
using GM-CSF gene-transduced autologous tumor vaccines (26, 27).
GM-CSF gene-transduced PCA vaccines increased antibody titers
against prostate tumor cell line-associated antigens. This suggests that
B-cells participated in the immune response following treatment.
Increasing titers of antibodies to PCA antigens were detected among
three of the men treated with irradiated GM-CSF-secreting autologous
PCA cell vaccines. These antibody responses are reminiscent of
antibody responses reported for a clinical trial of irradiated GM-CSFsecreting autologous melanoma cell vaccines (26). To our knowledge,
this is the first report of induction of new antibody responses to PCA
antigens in patients using cytokine gene-modified tumor vaccines,
peptide-pulsed DCs, or any other strategy of immunotherapy. One of
the antigen epitopes, present in a 150-kDa polypeptide, was expressed
in normal prostate epithelial cells, as well as in PCA cells. However,
it is unclear why the majority of patients (5 of 8) did not elicit
detectable antibodies following treatment. The lack of yield of autologous PCA cells has not permitted testing of these antibodies against
antigens expressed by each patient’s tumor. Of interest, the newly
identified 150-kDa antigen was also expressed by a number of nonPCA human cancer cell lines. The molecular identification of the
150-, 31-, and 26-kDa polypeptides containing antigenic epitopes
recognized by sera from vaccinated men is currently under way.8 It
will be critical to define the PCA tumor-associated antigens for
B-cells and T-cells in future clinical trials using new, sensitive technologies for antigen discovery.
GM-CSF gene-transduced PCA vaccines represent only one of several
new approaches to active specific immunotherapy of PCA, which are in
early clinical development. Examples of new approaches involve vaccinations with defined peptide antigens, such as PSA (66), vaccinations
with carbohydrate antigens (67), vaccinations with vaccinia vectors expressing PSA (68), and infusions with GM-CSF-activated autologous
DCs loaded ex vivo with defined prostate-specific peptides (69) or even
amplified tumor RNA (70). Some of these approaches in Phase I studies
have reported anecdotal evidence of clinical activity (67, 69). To our
knowledge, this is the first report of new antibody responses to normal
prostate epithelial antigens following immunotherapy. In addition, despite the limitations in autologous cell yields, which compromised dose
escalation, the expression of GM-CSF in the context of autologous PCA
vaccine cells did recruit antigen-presenting cells at the vaccination site
and induce systemic T-cell responses at DTH sites histologically identical
to those discovered in mice treated with GM-CSF gene-transduced vaccines. Extensive clinical efficacy testing of each of these approaches is
required. Our data, and data from other approaches, now seem to suggest
that systemic immune responses to human PCA can be generated against
a tumor type that has been conventionally viewed as being nonimmunogenic, and refractory to immunotherapy. Efficacy testing appears particularly justified as adjuvant therapy, in which immunotherapy is most
favored at effecting curative antitumor immune responses following
surgery or radiation therapy.
ACKNOWLEDGMENTS
We gratefully acknowledge the significant contributions of Drs. Michael
Amey, Hayden Braine, Thomas Hendrix, Donald S. Coffey, Jan Drayer, Joel
Nelson, Gordon Parry, Joseph Rokovich, and James Zabora, as well as the
8
J.-F. Chang, unpublished data.
contributions of Sujatha Ayyagari, Michelle Bartkowski, Barbara Starklauf,
Devon Young, Elizabeth Clawson-Simons, and Kimberly Heaney to the completion of the clinical trial and the preparation of the manuscript.
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