This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Foon, K. A. Articles by Bhattacharya-Chatterjee, M. Search for Related Content PubMed PubMed Citation Articles by Foon, K. A. Articles by Bhattacharya-Chatterjee, M. Social Bookmarking                            What's this?

Clinical and Immune Responses in Resected Colon Cancer Patients Treated With Anti-Idiotype Monoclonal Antibody Vaccine That Mimics the Carcinoembryonic Antigen

From the Division of Hematology/Oncology, Department of Internal Medicine, and Barrett Cancer Center for Prevention, Treatment and Research, University of Cincinnati Medical Center, Cincinnati, and Oncology Hematology Care, Inc, Cincinnati, OH; Division of Hematology/Oncology, Department of Internal Medicine, and Lucille Parker Markey Cancer Center, University of Kentucky Medical Center, Lexington, KY; Titan Pharmaceuticals, Inc, South San Francisco, CA; and Aquila Biopharmacueticals, Framingham, MA.

Address reprint requests to Kenneth A. Foon, MD, Barrett Cancer Center, 234 Goodman St, ML 0502 Room 1097, Cincinnati, OH 45219-2316; emailkenneth.foon{at}uc.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
PURPOSE: We generated an anti-idiotype antibody, designated CeaVac, that is an internal image of the carcinoembryonic antigen (CEA). We previously demonstrated that the majority of patients with advanced colorectal cancer generate specific anti-CEA responses. The purpose of the current study was to treat patients with surgically resected colon cancer with CeaVac to determine the immune response and clinical outcome to treatment with vaccine. We also compared the immune responses between patients treated with fluorouracil (5-FU) chemotherapy regimens plus vaccine versus vaccine alone.

PATIENTS AND METHODS: Thirty-two patients with resected Dukes' B, C, and D, and incompletely resected Dukes' D disease were treated with 2 mg of CeaVac every other week for four injections and then monthly until tumor recurrence or progression. Fourteen patients were treated concurrently with 5-FU chemotherapy regimens.

RESULTS: All 32 patients entered onto this trial generated high-titer immunoglobulin G and T-cell proliferative immune responses against CEA. The 5-FU regimens did not have a qualitative or quantitative effect on the immune response. Three of 15 patients with Dukes' B and C disease progressed at 19, 24, and 35 months. Seven of eight patients with completely resected Dukes' D disease remained on study from 12 to 33 months; one patient with resected Dukes' D disease relapsed at 9 months. One patient with incompletely resected Dukes' D disease remained on study at 14 months without evidence of progression; eight experienced disease progression at 6 to 31 months.

CONCLUSION: CeaVac consistently generated a potent anti-CEA humoral and cellular immune response in all 32 patients entered onto this trial. A number of very high-risk patients continue on study. 5-FU regimens, which are the standard of care for patients with Dukes' C disease, did not affect the immune response. These data warrant a phase III trial for patients with resected colon cancer.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
CARCINOEMBRYONIC antigen (CEA) is a M_r 180,000-glycoprotein tumor-associated antigen present on endodermally derived neoplasms of the gastrointestinal tract as well as other adenocarcinomas.¹ CEA is considered a self-antigen by the immune system, and patients with CEA-positive tumors are typically immunologically "tolerant" to CEA. CEA is an excellent tumor-associated antigen for active immunotherapy because it is typically present at high levels on the tumor cell surface. CEA is also one of the most well-characterized antigens, with its known gene sequence and its identified three-dimensional structure.² CEA is a member of the immunoglobulin (Ig) supergene family located on chromosome 19, which is thought to be involved in cell-cell interactions.³ It is also an adhesion molecule and may play a role in the metastatic process by mediating attachment of tumor cells to normal cells.^4,5 Active immunotherapy targeted to CEA might be particularly beneficial in the prevention of metastasis.

The network hypothesis of Lindenmann⁶ and Jerne⁷ offers a unique approach to transforming epitope structures into idiotypic determinants expressed on the surface of antibodies. According to the network concept, immunization with a given tumor-associated antigen will generate production of antibodies, which are termed Ab1, against this tumor-associated antigen. Ab1 is then used to generate a series of anti-idiotype antibodies against the Ab1, termed Ab2. Some of these Ab2 molecules can effectively mimic the three-dimensional structure of the tumor-associated antigen identified by the Ab1. These particular anti-idiotypes, called Ab2ß, fit into paratopes of Ab1 and express the internal image of the tumor-associated antigen. The Ab2ß can induce specific immune responses similar to those induced by the original tumor-associated antigen and, therefore, can be used as surrogate tumor-associated antigens. Immunization with Ab2ß can lead to the generation of anti–anti-idiotype antibodies (Ab3) that recognize the corresponding original tumor-associated antigen identified by Ab1. Because of the Ab1-like reactivity, the Ab3 is also called Ab1' to indicate that it might differ in its other idiotopes from Ab1.

We have generated an anti-idiotype antibody, designated CeaVac, that is an internal image of CEA.⁸ CeaVac was generated in BALB/c mice against the 8019 monoclonal antibody that binds to a highly restricted CEA epitope that has no cross-reactivity with nonspecific cross-reacting antigen and biliary glycoprotein.⁹ We have demonstrated previously that the majority of patients with advanced colorectal cancer treated with CeaVac generated a polyclonal Ig response against CEA as well as an idiotypic and CEA-specific T-cell response that is predominantly a T helper cell response.^10,11 In this report, we present data on patients with resected Dukes' B, C, and D colon cancer treated with CeaVac.

	PATIENTS AND METHODS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
Selection of Patients
All patients had CEA-positive resected colon cancer, including resected Dukes' stage D with minimal residual disease, completely resected Dukes' D, Dukes' C, and Dukes' B stages of disease. The median duration from surgical resection to first treatment with CeaVac for Dukes' D patients was 45 days (range, 13 to 340 days), and for Dukes' B and C patients was 112 days (range, 34 to 357 days). Baseline studies included a complete physical examination; computed tomography (CT) scans of the chest, abdomen, and pelvis; serum CEA level; and routine blood counts and chemistries. Staging was repeated 1 month after the fourth immunization and every 3 months thereafter for patients with Dukes' D disease and every 6 months for those with Dukes' B and C disease. All patients signed informed consent forms approved by the University of Kentucky Institutional Review Board.

Treatment Schedule
The majority of patients were treated intracutaneously with 2 mg aluminum hydroxide–precipitated CeaVac (CeaVac–Alu-Gel; Serva Fine Biochem, Inc, Garden City, Long Island, NY) every other week for four injections. Late in the study we received permission from the Food and Drug Administration to treat patients with 2 mg CeaVac mixed with 100µg QS-21 (CeaVac–QS-21; Aquila Biopharmaceuticals, Inc, Worcester, MA) subcutaneously on the same dosing schedule. Patients continued to receive a monthly vaccine booster injection and were clinically reevaluated every 3 (Dukes' D) or 6 months (Dukes' B and C) with physical examination, blood chemistries, and CT scans until the time of tumor recurrence or disease progression.

Patients were allowed to be treated concurrently with chemotherapy. A number of patients had completed chemotherapy before entry onto the trial. Patients who received fluorouracil (5-FU) chemotherapy regimens (Table 1) received chemotherapy concurrently with CeaVac. A limited number of patients completed 5-FU regimens before entry onto the trial.

Generation of the Anti-Idiotype for the Clinical Trial
Murine monoclonal antibody 8019 was used to immunize syngeneic BALB/c mice for the production of anti-idiotype antibody. Immunization of BALB/c mice, hybridoma fusion and cloning, selection of anti-idiotype (Ab2), and production of ascites in bulk quantities in mice were performed as previously described.^12,13 The Ab2 anti-idiotype CeaVac (IgG1) was purified from ascites by affinity chromatography on protein A-CL Sepharose 4B column (Pharmacia, Piscataway, NJ). The purity of the isolated Ig (> 95%) was determined by sodium dodecyl sulfate–polyacrylamide gel electrophoresis and high-pressure liquid chromatography techniques. Sterility, pyrogenicity, polynucleotides, mycoplasma, and adventitious virus contamination and retrovirus removal validation tests were performed in accordance with the United States Food and Drug Administration guidelines.

Preparation of Final Product
To augment the immunogenicity of the anti-idiotype vaccine, an adjuvant is typically required. Aluminum hydroxide and QS-21 have both been approved by the United States Food and Drug Administration for use as adjuvants in humans in experimental therapy. For this clinical trial, both adjuvants were studied. Briefly, 1 mL of 2% Alu-Gel was added to 5-mg aliquots of purified monoclonal anti-idiotype. The volume was then adjusted to 10 mL with Dulbecco's phosphate-buffered saline, and the mixture was incubated on a vortex for 1 hour at room temperature. The mixture was then centrifuged at 2,000 rpm at 25°C for 10 minutes. The amount of antibody bound in the gel layer was determined by measuring spectrophotometrically the amount of unbound antibody in the supernatant. The Alu-Gel–precipitated antibody was stored at 4°C until use. These procedures were performed aseptically in a laminar flow hood, and the final product was sterile and clearly labeled as anti-idiotype CeaVac–Alu-Gel and aliquoted into pyrogen-free, sterile glass vials.

For the purpose of mixing with QS-21, CeaVac was purified from ascites by affinity chromatography on a protein A-CL Sepharose 4B column, followed by diethylaminoethyl ion-exchange chromatography. The purity of the isolated Ig (> 99%) was determined by sodium dodecyl sulfate–polyacrylamide gel electrophoresis, high-pressure liquid chromatography, and isoelectric focusing.

The final products were tested for sterility, pyrogenicity, and general safety in guinea pigs before use. An Investigational New Drug Application was approved through the United States Food and Drug Administration (BB-IND 5055).

QS-21 is a saponin extract from bark of the South American soap bark tree Quillaja saponaria molina and represents an adjuvant approved by the United States Food and Drug Administration for use in humans in experimental vaccine therapy.

Specific Ab3 Response to Ab2
Sera from immunized patients with positive human anti-mouse antibody responses were tested for the presence of anti–anti-idiotypic antibodies. Sera were preincubated with normal murine Ig to block human antibodies against isotypic and allotypic determinants and then checked for the presence of anti–anti-idiotype (Ab3) by reaction with the immunizing anti-idiotype (CeaVac) coated onto microtiter plates. Unrelated Ab2 was used as control. After washings, the antigen-antibody reaction was tagged using ¹²⁵I-labeled anti-idiotype reagent in a homogeneous sandwich radioimmunoassay. Pretreatment, nonimmune sera and sera from normal donors were used as controls in these assays.

Inhibition of Ab1 Binding to LS174 T Cells by Patient Ab3 Sera
LS174 T cells (5 x 10⁵) in microtiter plates were reacted with different dilutions of patients' Ab3 sera or Ab1 and a fixed amount of ¹²⁵I-8019 (~ 90,000 cpm) and incubated for 2 hours at room temperature with shaking. After washing, the filter paper from the wells was counted in a gamma counter. Percentage of inhibition was calculated according to the formula:

where R_T is the average cpm of the experimental well with inhibitors Ab3 or Ab1, R_C is the average background cpm, and R_max is the average maximum binding without inhibitors.

Inhibition of the Binding Between Ab1 and Ab2 by Patient Ab3 Antibodies by Radioimmunoassay
Preimmune and hyperimmune patient sera samples were treated with unrelated murine Ig to remove anti-isotypic and allotypic reactivities. Serial dilutions of sera were then tested for inhibition in the Ab1-Ab2 binding assay. All assays were performed in triplicate. For direct binding inhibition assay between Ab1 and Ab2, purified Ab2 CeaVac was used to coat plates (500 ng/well), and the binding of radiolabeled 8019 (Ab1) to Ab2 was tested for inhibition in the presence of different patients' hyperimmune Ab3 sera and Ab1. This demonstrated whether Ab3 in patients' sera shared idiotopes with 8019 (Ab1). In addition, this inhibition assay between Ab1-Ab2 binding by Ab3 sera indicated whether Ab3 is a true anti–anti-idiotype. Inhibition greater than 20% by Ab3 sera at a 1/10 dilution was considered positive.

Detection of Anti-CEA Antibodies in Patients Immunized With Ab2 CeaVac
This assay was conducted to determine whether some of the Ab3 induced in patients by monoclonal murine Ab2 were of the Ab1 type and would bind to CEA. Purified CEA (Rougier Bio-tech, Montreal, Canada) was radioiodinated with ¹²⁵I by the chloramine T method. Radiolabeled CEA (1 x 10⁶ cpm) was reacted with 0.5 mL of each patient's serum preadsorbed on protein G-Sepharose beads. After reactions, the beads were washed and counted in a gamma-ray spectrophotometer. Preimmune sera, phosphate-buffered saline/bovine serum albumin, and Ab3 sera obtained from a patient treated with an unrelated murine monoclonal antibody for T-cell lymphoma were used as controls in these assays.

Purification of Ab3 From Hyperimmunized Patient Sera and Its Quantitation
Ab3 (anti–anti-idiotype) was purified from the immunized patient sera by an immunoadsorbent column that consisted of immunizing anti-idiotype Ig coupled to Sepharose 4B. Protein (Ab3) bound to this column was eluted with glycine hydrochloride (pH 2.7), neutralized to pH 7.0 with 1 mol/L Tris hydrochloride, and dialyzed extensively against phosphate-buffered saline. This material was then passed through a mouse Ig column to remove anti-isotypic and allotypic antibodies, concentrated, and used as purified Ab3. Human anti-mouse antibodies (HAMA) were then eluted with glycine hydrochloride (pH 2.7). The total yield of Ab3 and HAMA were quantitated by optical density at 280 nm using extinction coefficient of antibodies. Finally, the total amount of Ab3/HAMA was divided by the amount of serum used for purification to quantitate the amount of Ab3/HAMA (in milligrams per milliliter of serum).

Assay for T-Cell Proliferative Response
Peripheral-blood mononuclear cells (PBMCs) were isolated by standard Ficoll-Hypaque density gradient centrifugation method, and 5 x 10⁵ cells per well were incubated with different concentrations of CeaVac–Alu-Gel and control 4DC6–Alu-Gel (10 ng to 2µg) in RPMI medium with 5% heat-inactivated fetal calf serum and penicillin and streptomycin. 4DC6–Alu-Gel is an IgG1 anti-idiotype antibody that mimics a highly restricted T-cell antigen.^12-14 The nonspecific mitogen phytohemagglutinin-P was used as a positive control at 2µg and 1µg per well. After the cells were incubated for 5 days at 37°C in an atmosphere that contained 5% carbon dioxide, they were pulsed with [³H]thymidine (1µCi/well) for 20 hours. Data were expressed as mean counts (triplicate wells) per minute of [³H]thymidine incorporation. The SD of the data was less than 10% for each determination. Stimulation indices were determined by dividing the mean cpm of a PBMC sample by the mean cpm of the PBMC sample without a stimulant.

PBMCs were also incubated with a CEA peptide. This CEA peptide was synthesized from a region of CEA that had amino acid sequence homology to the complementarity-determining region of the Ab2 CeaVac.¹³ This CEA peptide could be substituted for CEA in biologic assays.

Assay for Circulating CEA in Serum
CEA was quantified in heat-extracted serum. For this, 1 mL of 0.2 mol/L sodium acetate buffer, pH 5.0, was added to 0.5 mL serum, vortex-mixed, incubated for 15 minutes at 90°C, and centrifuged (1,200 x g for 10 minutes). The supernatants were assayed the same day or stored frozen at -20°C. One hundred microliters of supernatant was then assayed by the enzyme immunoassay for CEA.

	RESULTS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
Clinical Outcome
None of the patients entered onto this trial had measurable disease by CT scan, although three with incompletely resected Dukes' D disease had elevated CEA levels (6 ng/mL, 16 ng/mL, and 33 ng/mL) before entry onto the study (Table 1). All nine patients with incompletely resected Dukes' D disease had evidence of residual tumor. Three of these nine patients received concurrent chemotherapy. Disease progression was observed at 6 to 31 months in eight of these patients, and two died at 14 and 20 months. One remains on study without clinical progression at 14 months. One of the eight patients with completely resected Dukes' D disease experienced recurrence at 9 months, and seven remain free of measurable disease at 12 to 33 months. One of the patients with Dukes' C1 disease relapsed at 35 months, and one patient with Dukes' B2 disease developed a second primary tumor (lung cancer). Two of eight patients with Dukes' C2 disease relapsed at 19 and 24 months, respectively.

Immune Responses
All 32 patients generated active immune responses with high-titer anti-CEA IgG responses as well as CD4 T-cell responses that were idiotype-specific. These immune responses persisted throughout the course of therapy. Although there was modest variation in the quantitative humoral immune response between different patients, the quantity in an individual patient remained constant. Most patients reached a peak anti-CEA titer after nine vaccinations, and this titer remained constant with monthly booster injections of CeaVac. Although always present, the T-cell response was variable over time, most likely because of the variability of the biologic assay, as it was performed on fresh cells. As a surrogate for CEA, we synthesized a peptide that mimics the binding region of the Ab1 to CeaVac and to CEA.¹⁵

Fourteen patients were treated with 5-FU regimens; 11 of these patients had regimens that included leucovorin. It was critical to compare the anti-CEA immune responses in patients who received 5-FU and leucovorin compared with that in those who did not receive chemotherapy because all of the high-risk Dukes' B and Dukes' C adjuvant patients in phase III trials will be treated with 5-FU and leucovorin. We found no differences in anti-CEA humoral or cellular responses in any of these patients. A representative comparison of three patients who received 5-FU and leucovorin with three who received no chemotherapy demonstrated no difference in inhibition of binding between Ab1 and the CEA-positive cell line LS174-T by patients' Ab3 sera (Fig 1). T-cell proliferative responses were also detected consistently throughout the course of therapy. Representative data from three patients who received 5-FU and leucovorin and three patients who received no chemotherapy are shown in Fig 2.

View larger version (17K): [in this window] [in a new window]   Fig 1. Inhibition of 125I-labeled Ab1 8019 binding to CEA-positive LS174 T cells by patients' Ab3 sera. Percent inhibition was calculated as described in Patients and Methods. Patients treated with 5-FU and vaccine (A) are compared with those treated with vaccine alone (B).

View larger version (17K): [in this window] [in a new window]   Fig 2. Idiotypic-specific proliferation of PBMCs isolated from patients with colorectal cancer before and during therapy with CeaVac. Stimulation indices were calculated as described in Patients and Methods. Patients treated with 5-FU and vaccine (A) are compared with those treated with vaccine alone (B).

Twenty-eight patients were treated with 2 mg CeaVac–Alu-Gel, and four patients were treated with 2 mg of CeaVac–QS-21. Comparisons were made after nine and 16 immunizations in patients treated with the different adjuvants. CEA responses were negative before treatment in all patients. Quantitation of purified Ab3 from serum was performed in selected patients, demonstrating a range of 120 to 325µg/mL serum, with somewhat higher concentrations in patients treated with QS-21 (Table 2). We also studied the isotype subclasses of the anti-CEA antibodies from patients immunized with CeaVac–Alu-Gel versus CeaVac–QS-21 and found no difference in the IgG subclasses (Table 3). Antibody-dependent cell-mediated cytotoxicity was identified in all patients tested, with no differences between those treated with CeaVac–Alu-Gel and those with CeaVac–QS-21 (data not shown).

T-cell responses were consistently observed with both adjuvants and tended to be somewhat higher with QS-21 (Table 4). T cells from all 32 patients responded to the anti-idiotype antibody CeaVac in vitro, with a brisk proliferative response. This proliferative response was consistently greater than the response to an IgG1 murine monoclonal antibody control. Eighty percent of patients' T cells also responded to a CEA peptide, which was used as a surrogate for CEA, whereas 20% responded to CeaVac, but not to the CEA peptide. T-cell testing was performed every 3 months on fresh PBMCs. Although the stimulation index varied at different time points, the patterns of response were very consistent. These data are presented in Table 4.

Toxicity
Toxicity was typically minimal, with only local reactions at the injection site with mild erythema and induration. A few patients developed large local reactions with swelling that resolved within a few days. Mild fever and chills relieved by acetaminophen occurred in only a few patients. Administration of CeaVac did not have any deleterious effects on hematopoietic, renal, or hepatic function. There was no clinical or laboratory evidence of serum sickness. No difference in toxicity was observed with either CeaVac–Alu-Gel or CeaVac–QS-21.

	DISCUSSION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
All 32 patients entered onto this trial generated high-titer Ab3 humoral responses, including responses against CEA. These Ab3 responses were sustained over the course of therapy and were quantitated in the range of 125 to 325µg/mL serum. QS-21 was used as the adjuvant in four patients, and Alu-Gel was the adjuvant in 28 patients. No major differences in antibody responses were detected, although there seemed to be a somewhat higher concentration of anti-CEA antibody in patients treated with QS-21. Also of interest was the finding that regardless of the number of injections, or whether the adjuvant was Alu-Gel or QS-21, the IgG subclasses were consistently the same, with a predominance of IgG1, IgG2, and IgG4.

Although T-cell proliferative responses were reproducibly found in all 32 patients, 80% responded to both the CeaVac and the CEA peptide in vitro, and 20% responded only to CeaVac. We interpreted this as a class II restriction. Sixteen patients were HLA typed, and eight were HLA-DR13–positive. All eight of these patients' postimmunization lymphocytes consistently proliferated in vitro against the CEA peptide. These were not isolated events, as patients were reproducibly studied every 3 months. Eight patients were HLA-DR13–negative, and three consistently did not react with the CEA peptide, whereas all of them reacted with CeaVac in vitro. However, five of eight reacted with the CEA peptide. One conclusion might be that there exists a DR13 restriction, but it is a promiscuous antigen and other class II antigens might also be able to present this peptide. Another explanation is that the three patients who did not react to the CEA peptide were reacting to a portion of CeaVac that had no homology with CEA.

Fourteen of the 32 patients received 5-FU–based regimens; 11 received 5-FU and leucovorin, and three received 5-FU and levamisole. All of these patients had qualitative and quantitative immune responses comparable to patients who did not receive 5-FU regimens. This is an important finding for phase III trials of patients with high-risk Dukes' B and C disease for whom the standard of care is treatment with 5-FU-regimens. In such trials, patients will be randomized to standard chemotherapy versus standard chemotherapy plus CeaVac. In a separate trial, we also demonstrated that administration of CeaVac in combination with irinotecan did not impair generation of the immune response to CeaVac.¹⁶

Ideally, vaccine therapy should begin immediately after surgical resection of the primary tumor or resection of metastasis. Theoretically, the sooner an immune response is generated, the greater the likelihood of eradicating micrometastatic disease. Patients were allowed to enter our trial up to 1 year from their surgery for the purpose of accrual and attempting to make a new experimental agent accessible to as many patients as possible (median durations and ranges, 45 days and 13 to 340 days for Dukes' D; and 112 days and 34 to 357 days for Dukes' B and C, respectively). In addition, this was not meant to be a survival trial, rather, an attempt to determine immune response in a relatively healthy cohort of patients and to study the effect on the immune response of chemotherapy with a 5-FU regimen administered with CeaVac.

Clinically, a number of these patients fared remarkably well. Nine patients with incompletely resected Dukes' D disease had positive surgical margins, yet a number of them continued to be stable without evidence of disease progression by either CEA level or CT scans, which were repeated every 3 months. One of these patients continues without evidence of progression at 14 months. The patient who relapsed at 31 months presented with extensive recurrent colon cancer in her pelvis. Gross disease was resected and she was placed on CeaVac but received only minimal 5-FU because of side effects. Another patient with incompletely resected abdominal lymph node Dukes' D disease who began the study with a CEA level of 16 ng/mL remained stable on study for 24 months. At 24 months, further elevation of CEA level was noted, but CT scan remained stable. This patient's clinical course is noteworthy because disease progression became evident at month 30, when enlargement of a single lymph node was noted on CT scan. Patients with completely resected Dukes' D disease have a 20% cure rate, and most patients who relapse do so within the first 2 years.^17,18 Seven of the eight patients in this category remain disease-free at a median of 16 months, two at 19 and 33 months, respectively. The patient at 33 months had two soft tissue abdominal recurrences resected within 12 months of each other before entering the CeaVac trial. The most interesting patient among those with Dukes' C2 disease is one with 22 positive lymph nodes who is disease-free at 40 months from entry onto the CeaVac study. She began CeaVac 1 year after her primary surgery and after completing 5-FU and is, therefore, 52 months disease-free. We, of course, cannot conclude that her excellent result thus far is secondary to the vaccine, chemotherapy, or favorable biology of her tumor. Of the 32 patients, two died at 14 and 20 months, respectively, both of whom had incompletely resected Dukes' D disease.

In summary, we have demonstrated the ability to break immune tolerance to CEA in 100% of 32 patients treated on this trial. The humoral and T-cell responses are vigorous and continue at the same high quantitative level as long as patients continue to receive monthly CeaVac injections. Although clinical conclusions based on results of individual patients cannot be drawn, a number of patients have fared far better than would be expected with standard therapy or no therapy. Phase III trials are currently being designed for patients with Dukes' B and C colorectal cancer and for those with resected Dukes' D disease.

	REFERENCES

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
1. Gold P, Freedman SO: Demonstration of tumor-specific antigens in human colonic carcinomata by immunological tolerance and absorption techniques. J Exp Med 121:439-462, 1965[Abstract]

2. Paxton RJ, Mooser G, Pande H, et al: Sequence analysis of carcinoembryonic antigen: Identification of glycosylation sites and homology with the immunoglobulin super-gene family. Proc Natl Acad Sci U S A 84:920-924, 1987[Abstract/Free Full Text]

3. Thompson J, Zimmerman W: The carcinoembryonic antigen gene family: Structure, expression and evolution. Tumour Biol 9:63-83, 1988[Medline]

4. Benchimol S, Fuks A, Jothy S, et al: Carcinoembryonic antigen, a human tumor marker, functions as an intercellular adhesion molecule. Cell 57:327-334, 1989[Medline]

5. Oikawa S, Inuzuka C, Kuroki M, et al: Cell adhesion activity of non-specific cross-reacting antigen (NCA) and carcinoembryonic antigen (CEA) expressed on CHO cell surface: Homophilic and heterophilic adhesion. Biochem Biophys Res Commun 164:39-45, 1989[Medline]

6. Lindenmann J: Speculations on idiotypes and homobiodies. Ann Immunol (Paris) 124:171-184, 1973[Medline]

7. Jerne NK: Towards a network theory of the immune system. Ann Immunol (Paris) 125C:373-389, 1974

8. Bhattacharya-Chatterjee M, Mukerjee S, Biddle W, et al: Murine monoclonal anti-idiotype antibody as a potential network antigen for human carcinoembryonic antigen. J Immunol 145:2758-2765, 1990[Abstract]

9. Mitchell KF: A carcinoembryonic antigen (CEA) specific monoclonal hybridoma antibody that reacts only with high molecular weight CEA. Cancer Immunol Immunother 10:1-5, 1980

10. Foon KA, Chakraborty M, John WJ, Sherratt A, Kohler H, Bhattacharya-Chatterjee M: Immune response to the carcinoembryonic antigen in patients treated with an anti-idiotype antibody vaccine. J Clin Invest 96:334-342, 1995

11. Foon KA, John WJ, Chakraborty M, et al: Clinical and immune responses in advanced colorectal cancer patients treated with anti-idiotype monoclonal antibody vaccine that mimics the carcinoembryonic antigen. Clin Cancer Res 3:1267-1276, 1997[Abstract]

12. Bhattacharya-Chatterjee M, Pride MW, Seon BK, et al: Idiotype vaccines against human T-cell acute lymphoblastic leukemia (TALL): I. Generation and characterization of biologically active monoclonal anti-idiotypes. J Immunol 5:562-573, 1987

13. Bhattacharya-Chatterjee M, Chatterjee SK, Vasile S, et al: Idiotype vaccines against T-cell leukemia: II. Generation and characterization of monoclonal idiotype cascade (Ab1, Ab2 and Ab3). J Immunol 141:1398-1403, 1988[Abstract]

14. Foon KA, Oseroff AR, Vaickus L, et al: Immune responses in patients with T-cell lymphoma treated with an anti-idiotype antibody mimicking a highly restricted T-cell antigen. Clin Cancer Res 1:1285-1294, 1995[Abstract]

15. Chatterjee SK, Tripathi PK, Chakraborty M, et al: Molecular mimicry of carcinoembryonic antigen by peptides derived from the structure of an anti-idiotype antibody. Cancer Res 58:1217-1224, 1998[Abstract/Free Full Text]

16. John W, Chatterjee M, Teitelbaum A, et al: Clinical and immune responses in patients with advanced colorectal cancer treated with an anti-idiotype (ID) mimicking carcinoembryonic antigen (CEA) combined with irinotecan. Proc Am Soc Clin Oncol 18:453a, 1999 (abstr 1748)

17. Steele G Jr, Bleday R, Mayer RJ, et al: A prospective evaluation of hepatic resection for colorectal carcinoma metastases to the liver: Gastrointestinal tumor study group protocol 6584. J Clin Oncol 9:1105-1112, 1991[Abstract]

18. Girard P, Ducreux M, Baldeyrou P, et al: Surgery for lung metastases from colorectal cancer: Analysis of prognostic factors. J Clin Oncol 14:2047-2053, 1996[Abstract/Free Full Text]

Submitted March 17, 1999; accepted May 13, 1999.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This article has been cited by other articles:

				M. R. Parkhurst, J. Joo, J. P. Riley, Z. Yu, Y. Li, P. F. Robbins, and S. A. Rosenberg Characterization of Genetically Modified T-Cell Receptors that Recognize the CEA:691-699 Peptide in the Context of HLA-A2.1 on Human Colorectal Cancer Cells Clin. Cancer Res., January 1, 2009; 15(1): 169 - 180. [Abstract] [Full Text] [PDF]

				J. Schlom, J. L. Gulley, and P. M. Arlen Paradigm Shifts in Cancer Vaccine Therapy Experimental Biology and Medicine, May 1, 2008; 233(5): 522 - 534. [Abstract] [Full Text] [PDF]

				M. C. Posner, D. Niedzwiecki, A. P. Venook, D. R. Hollis, H. L. Kindler, E. W. Martin, R. L. Schilsky, R. M. Goldberg, and for the Cancer and Leukemia Group B A Phase II Prospective Multi-institutional Trial of Adjuvant Active Specific Immunotherapy Following Curative Resection of Colorectal Cancer Hepatic Metastases: Cancer and Leukemia Group B Study 89903 Ann. Surg. Oncol., January 1, 2008; 15(1): 158 - 164. [Abstract] [Full Text] [PDF]

				J. Schlom, P. M. Arlen, and J. L. Gulley Immunotherapies with Other Therapeutic Modalities: New Paradigms for Clinical Trial Design ASCO Educational Book, January 1, 2008; 2008(1): 101 - 106. [Abstract] [Full Text] [PDF]

				P. Sabbatini and K. Odunsi Immunologic Approaches to Ovarian Cancer Treatment J. Clin. Oncol., July 10, 2007; 25(20): 2884 - 2893. [Abstract] [Full Text] [PDF]

				J. Schlom, P. M. Arlen, and J. L. Gulley Cancer Vaccines: Moving Beyond Current Paradigms Clin. Cancer Res., July 1, 2007; 13(13): 3776 - 3782. [Abstract] [Full Text] [PDF]

				G. J. Ullenhag, I. Spendlove, N. F.S. Watson, A. A. Indar, M. Dube, R. A. Robins, C. Maxwell-Armstrong, J. H. Scholefield, and L. G. Durrant A Neoadjuvant/Adjuvant Randomized Trial of Colorectal Cancer Patients Vaccinated with an Anti-Idiotypic Antibody, 105AD7, Mimicking CD55 Clin. Cancer Res., December 15, 2006; 12(24): 7389 - 7396. [Abstract] [Full Text] [PDF]

				J Pfisterer, A du Bois, J Sehouli, S Loibl, S Reinartz, A Reuss, U Canzler, A Belau, C Jackisch, R Kimmig, et al. The anti-idiotypic antibody abagovomab in patients with recurrent ovarian cancer. A phase I trial of the AGO-OVAR. Ann. Onc., October 1, 2006; 17(10): 1568 - 1577. [Abstract] [Full Text] [PDF]

				G. Chong, A. Bhatnagar, D. Cunningham, T. M. Cosgriff, P. G. Harper, W. Steward, J. Bridgewater, M. Moore, J. Cassidy, R. Coleman, et al. Phase III trial of 5-fluorouracil and leucovorin plus either 3H1 anti-idiotype monoclonal antibody or placebo in patients with advanced colorectal cancer Ann. Onc., March 1, 2006; 17(3): 437 - 442. [Abstract] [Full Text] [PDF]

				P. M. Arlen, J. L. Gulley, C. Parker, L. Skarupa, M. Pazdur, D. Panicali, P. Beetham, K. Y. Tsang, D. W. Grosenbach, J. Feldman, et al. A Randomized Phase II Study of Concurrent Docetaxel Plus Vaccine Versus Vaccine Alone in Metastatic Androgen-Independent Prostate Cancer Clin. Cancer Res., February 15, 2006; 12(4): 1260 - 1269. [Abstract] [Full Text] [PDF]

				S. Y. Chui, T. M. Clay, H. K. Lyerly, and M. A. Morse The Development of Therapeutic and Preventive Vaccines for Gastric Cancer and Helicobacter pylori Cancer Epidemiol. Biomarkers Prev., August 1, 2005; 14(8): 1883 - 1889. [Abstract] [Full Text] [PDF]

				X. Wang, E. C. Ko, L. Peng, S. D. Gillies, and S. Ferrone Human High Molecular Weight Melanoma-Associated Antigen Mimicry by Mouse Anti-Idiotypic Monoclonal Antibody MK2-23: Enhancement of Immunogenicity of Anti-Idiotypic Monoclonal Antibody MK2-23 by Fusion with Interleukin 2 Cancer Res., August 1, 2005; 65(15): 6976 - 6983. [Abstract] [Full Text] [PDF]

				S. Mosolits, G. Ullenhag, and H. Mellstedt Therapeutic vaccination in patients with gastrointestinal malignancies. A review of immunological and clinical results Ann. Onc., June 1, 2005; 16(6): 847 - 862. [Abstract] [Full Text] [PDF]

				C. Schwegler, A. Dorn-Beineke, S. Nittka, C. Stocking, and M. Neumaier Monoclonal Anti-idiotype Antibody 6G6.C4 Fused to GM-CSF Is Capable of Breaking Tolerance to Carcinoembryonic Antigen (CEA) in CEA-Transgenic Mice Cancer Res., March 1, 2005; 65(5): 1925 - 1933. [Abstract] [Full Text] [PDF]

				W. W.L. Choi, S. Srivatsa, and J. C. Ritchie Aberrant Thyroid Testing Results in a Clinically Euthyroid Patient Who Had Received a Tumor Vaccine Clin. Chem., March 1, 2005; 51(3): 673 - 675. [Full Text] [PDF]

				A. Saha, S. K. Chatterjee, K. A. Foon, F. J. Primus, S. Sreedharan, K. Mohanty, and M. Bhattacharya-Chatterjee Dendritic Cells Pulsed with an Anti-Idiotype Antibody Mimicking Carcinoembryonic Antigen (CEA) Can Reverse Immunological Tolerance to CEA and Induce Antitumor Immunity in CEA Transgenic Mice Cancer Res., July 15, 2004; 64(14): 4995 - 5003. [Abstract] [Full Text] [PDF]

				G. J. Ullenhag, J.-E. Frodin, M. Jeddi-Tehrani, K. Strigard, E. Eriksson, A. Samanci, A. Choudhury, B. Nilsson, E. D. Rossmann, S. Mosolits, et al. Durable Carcinoembryonic Antigen (CEA)-Specific Humoral and Cellular Immune Responses in Colorectal Carcinoma Patients Vaccinated with Recombinant CEA and Granulocyte/Macrophage Colony-Stimulating Factor Clin. Cancer Res., May 15, 2004; 10(10): 3273 - 3281. [Abstract] [Full Text] [PDF]

				S. Reinartz, S. Kohler, H. Schlebusch, K. Krista, P. Giffels, K. Renke, J. Huober, V. Mobus, R. Kreienberg, A. duBois, et al. Vaccination of Patients with Advanced Ovarian Carcinoma with the Anti-Idiotype ACA125: Immunological Response and Survival (Phase Ib/II) Clin. Cancer Res., March 1, 2004; 10(5): 1580 - 1587. [Abstract] [Full Text] [PDF]

				M. Lomas, W. Liauw, D. Packham, K. Williams, A. Kelleher, J. Zaunders, and R. Ward Phase I clinical trial of a human idiotypic p53 vaccine in patients with advanced malignancy Ann. Onc., February 1, 2004; 15(2): 324 - 329. [Abstract] [Full Text] [PDF]

				R L Jones, D Cunningham, G Cook, and P J Ell Tumour vaccine associated lymphadenopathy and false positive positron emission tomography scan changes Br. J. Radiol., January 1, 2004; 77(913): 74 - 75. [Abstract] [Full Text] [PDF]

				C. Casati, P. Dalerba, L. Rivoltini, G. Gallino, P. Deho, F. Rini, F. Belli, D. Mezzanzanica, A. Costa, S. Andreola, et al. The Apoptosis Inhibitor Protein Survivin Induces Tumor-specific CD8+ and CD4+ T Cells in Colorectal Cancer Patients Cancer Res., August 1, 2003; 63(15): 4507 - 4515. [Abstract] [Full Text] [PDF]

				B. K. Ko, K. Kawano, J. L. Murray, M. L. Disis, C. L. Efferson, H. M. Kuerer, G. E. Peoples, and C. G. Ioannides Clinical Studies of Vaccines Targeting Breast Cancer Clin. Cancer Res., August 1, 2003; 9(9): 3222 - 3234. [Abstract] [Full Text] [PDF]

				S. Reinartz, A. Hombach, S. Kohler, H. Schlebusch, D. Wallwiener, H. Abken, and U. Wagner Interleukin-6 Fused to an Anti-idiotype Antibody in a Vaccine Increases the Specific Humoral Immune Response against CA125+ (MUC-16) Ovarian Cancer Cancer Res., June 15, 2003; 63(12): 3234 - 3240. [Abstract] [Full Text] [PDF]

				A. Saha, S. K. Chatterjee, K. A. Foon, F. J. Primus, and M. Bhattacharya-Chatterjee Murine Dendritic Cells Pulsed with an Anti-Idiotype Antibody Induce Antigen-specific Protective Antitumor Immunity Cancer Res., June 1, 2003; 63(11): 2844 - 2854. [Abstract] [Full Text] [PDF]

				G. Pentheroudakis and N. Pavlidis Immunomodulation in colorectal cancer: disappointment or promise? Ann. Onc., March 1, 2003; 14(3): 349 - 351. [Full Text] [PDF]

				N. L. Berinstein Carcinoembryonic Antigen as a Target for Therapeutic Anticancer Vaccines: A Review J. Clin. Oncol., April 15, 2002; 20(8): 2197 - 2207. [Abstract] [Full Text] [PDF]

				G. J. Ullenhag, J.-E. Frodin, K. Strigard, H. Mellstedt, and C. G. M. Magnusson Induction of IgG Subclass Responses in Colorectal Carcinoma Patients Vaccinated with Recombinant Carcinoembryonic Antigen Cancer Res., March 1, 2002; 62(5): 1364 - 1369. [Abstract] [Full Text] [PDF]

				N. Habal, R. K. Gupta, A. J. Bilchik, R. Yee, Z. Leopoldo, W. Ye, R. M. Elashoff, and D. L. Morton CancerVax, An Allogeneic Tumor Cell Vaccine, Induces Specific Humoral and Cellular Immune Responses in Advanced Colon Cancer Ann. Surg. Oncol., June 1, 2001; 8(5): 389 - 401. [Abstract] [Full Text] [PDF]

				D. W. Grosenbach, J. C. Barrientos, J. Schlom, and J. W. Hodge Synergy of Vaccine Strategies to Amplify Antigen-specific Immune Responses and Antitumor Effects Cancer Res., June 1, 2001; 61(11): 4497 - 4505. [Abstract] [Full Text] [PDF]

				K. A. Foon and M. Bhattacharya-Chatterjee Are Solid Tumor Anti-Idiotype Vaccines Ready for Prime Time?: Commentary re: U. Wagner et al., Immunological Consolidation of Ovarian Carcinoma Recurrences with Monoclonal Anti-Idiotype Antibody ACA125: Immune Responses and Survival in Palliative Treatment. Clin. Cancer Res., 7: 1154-1162, 2001. Clin. Cancer Res., May 1, 2001; 7(5): 1112 - 1115. [Full Text]

				M. von Mehren, P. Arlen, J. Gulley, A. Rogatko, H. S. Cooper, N. J. Meropol, R. K. Alpaugh, M. Davey, S. McLaughlin, M. T. Beard, et al. The Influence of Granulocyte Macrophage Colony-Stimulating Factor and Prior Chemotherapy on the Immunological Response to a Vaccine (ALVAC-CEA B7.1) in Patients with Metastatic Carcinoma Clin. Cancer Res., May 1, 2001; 7(5): 1181 - 1191. [Abstract] [Full Text]

				K. A. Foon, J. Lutzky, R. N. Baral, J. R. Yannelli, L. Hutchins, A. Teitelbaum, O. L. Kashala, R. Das, J. Garrison, R. A. Reisfeld, et al. Clinical and Immune Responses in Advanced Melanoma Patients Immunized With an Anti-Idiotype Antibody Mimicking Disialoganglioside GD2 J. Clin. Oncol., January 14, 2000; 18(2): 376 - 376. [Abstract] [Full Text] [PDF]

				R. M. Conry, K. O. Allen, S.-w. Lee, S. E. Moore, D. R. Shaw, and A. F. LoBuglio Human Autoantibodies to Carcinoembryonic Antigen (CEA) Induced by a Vaccinia-CEA Vaccine Clin. Cancer Res., January 1, 2000; 6(1): 34 - 41. [Abstract] [Full Text]

This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Foon, K. A. Articles by Bhattacharya-Chatterjee, M. Search for Related Content PubMed PubMed Citation Articles by Foon, K. A. Articles by Bhattacharya-Chatterjee, M. Social Bookmarking                            What's this?