Volume 15, Issue 1, Pages 13-24 (July 2006)

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ABSTRACT

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The treatment of melanoma with an emphasis on immunotherapeutic strategies

Abstract

Melanoma continues to be one of the most difficult to treat of all solid tumors. Many new advances have been made in the surgical management of melanoma, including new guidelines for margins of excision, as well as sentinel node biopsy for the diagnosis of lymph node micrometastases. The search continues for an effective adjuvant melanoma treatment that can prevent local and distant recurrences. Melanoma is one of the most immunogenic of all tumors, and several clinical trials testing the immunotherapy of melanoma have been conducted, including trials in interferon, interleukin-2, and melanoma vaccines. Here we discuss many of the recent clinical trials in the surgical management of melanoma, in addition to the advances that have been made in the field of immunotherapy. A new second-generation melanoma vaccine, DC-MelVac (patent # 11221/5), has recently been granted FDA approval for Phase I clinical trials and will be introduced in this review.

Keywords: Melanoma vaccines, Immunotherapy, Vaccinia melanoma oncolysate, Dendritic cells, DC-MelVac

Article Outline

• Abstract

• 1. Introduction

• 2. Clinical trials in surgical margins for melanoma

• 3. Surgery for metastatic disease

• 4. Sentinel node biopsy for cutaneous melanoma

• 5. Immunotherapeutic strategies for melanoma

• 6. Interferon α therapy

• 7. Interleukin-2 (IL-2)

• 8. Adoptive immunotherapy

• 9. CTLA-4 blockade in melanoma

• 10. Melanoma vaccines

• 11. A second generation melanoma vaccine: DC-MelVac (patent # 11221/5)

• References

• Copyright

1. Introduction

Melanoma continues to be one of the most aggressive and difficult to treat of all solid tumors. Moreover, its incidence is rising faster than that of any other cancer at a rate of 3% per year [1], with the greatest increase in elderly men. In the United States alone, there were an estimated 59,580 new cases of melanoma in 2005, a number that has risen from 55,100 in 2004 [2], [3]. The number of deaths attributable to melanoma has decreased slightly over the last 2 years from 7910 in 2004 to 7770 in 2005 [2], [3]. Despite the rising incidence of melanoma, the 5-year survival has markedly improved since the 1940s [4]. This increase in survival can be attributed to an increased awareness resulting in earlier detection [5]. Recognizing changes in skin lesions is crucial in detecting the malignancy before it has had a chance to penetrate the deeper layers of the skin or subcutaneous tissue and metastasize to regional lymph nodes.

In the late 1960s and early 1970s, Breslow [6] emphasized the importance of tumor thickness as a prognostic indicator. Thickness is determined by the total vertical height from the granular layer of the skin to the layer of deepest penetration. The Breslow staging system was the most commonly used system until 1992 when a new staging system was adopted, the American Joint Committee on Cancer (AJCC) tumor-node metastasis (TNM) system. The TNM system for melanoma, which incorporates Breslow's ideas on tumor thickness, was further revised in 2003, and is the standard staging system that is used today [7], [8].

While surgery is curative in many cases of thin melanomas, deeper lesions are often much more difficult to treat, especially once they have metastasized from the primary site. As such, scientists and physicians have been collaborating in their efforts, both in the laboratory and in clinical settings, to find an effective adjuvant treatment for patients with high-risk melanoma. Over the last decade, there have been several accomplishments in the clinical management of melanoma, including new guidelines for surgical margins and sentinel lymph node (SLN) biopsy for the detection of nodal micrometastases. In addition, immunotherapy has emerged as a potential treatment option for patients with high-risk melanoma. It is widely accepted that melanoma is among the most immunogenic of all solid tumors. Evidence in support of this fact includes the phenomenon of spontaneous regression of primary tumor, which occurs in 3–15% of melanomas with unknown primaries [9]. In addition, tumor antigen-specific antibodies are present in melanoma patients, and it has been shown that peripheral blood lymphocytes from melanoma patients are cytotoxic to melanoma cells in vitro [10], [11], [12]. This review will discuss some of the most pertinent new advances in melanoma treatment, including surgical management as well as immunotherapeutic options that have become quite sophisticated over the last decade. In addition, a new melanoma vaccine, DC-MelVac, will be introduced.

2. Clinical trials in surgical margins for melanoma

Wide local excision (WLE) remains the only potentially curative treatment for primary cutaneous melanoma. The goal of the surgeon is to prevent local recurrence and distant metastases. Secondary goals are to minimize surgical morbidity and to optimize cosmetic results. Much debate has existed over the years as surgeons have worked to achieve these objectives. The adequacy of surgical margins has been the subject of several randomized trials over the past 20 years. Melanoma is one of the few cancers in which randomized trials performed by surgeons have changed the paradigm in the operating room.

From the late 1970s until the mid-1980s, Breslow and others advocated wide excision margins of 4–5cm for primary melanoma [13], [14], [15], [16]. In an effort to potentially decrease the size of excision margins and to avoid severe scarring and skin grafting, the first randomized, prospective trial regarding adequate excision margins was conducted by the World Health Organization (WHO) Melanoma Group between 1980 and 1985. This study included 703 patients with melanoma less than or equal to 2mm in thickness. Investigators concluded that 1cm margins were adequate for lesions <1mm in depth [17]. In 1983, the Intergroup Melanoma Surgical Trial studied excision margins for lesions of intermediate depths, and concluded that 2cm margins were adequate for tumors of 1–4mm in thickness [18]. The Swedish Melanoma Study Group Trial, published in 1996, compared excision margins of 2cm versus 5cm for melanomas 0.8–2.0mm in thickness and determined that a 2cm margin of excision was adequate [19]. In a smaller study of 326 patients, the French Group for Research on Malignant Melanoma also concluded that there was no significant difference between excision margins of 2cm versus 5cm in patients with lesions <2.1mm thick [20].

Lens et al. [21] conducted a large meta-analysis of these randomized controlled trials comparing narrow versus wide excision of primary melanomas, without nodal or distant spread. Conclusions from this study stated that excision margins >1cm had no effect on disease-free survival or overall survival in patients with melanomas <2mm in thickness. Although a 1cm margin has been accepted for melanomas <1mm thick, there does not appear to be a general consensus regarding adequate surgical margins for lesions of intermediate thickness (1–4mm). In addition, much debate remains concerning the minimum surgical margins necessary for thicker lesions (>4mm) [21]. At this point in our careful review of the literature, our recommendation is that for lesions <1mm depth of invasion, a resection margin of 1cm is adequate. For lesions 1–4mm in thickness, a 2cm resection margin is acceptable, and for lesions >4mm thick, a 3cm margin of excision is adequate. We think these recommendations compare favorably with the consensus that we have concluded from our review of the literature and our own experience.

3. Surgery for metastatic disease

The prognosis for patients with metastatic melanoma has been reported to be a dismal 7–9 months after diagnosis [22], [23]. Evidence suggests that surgical excision of metastatic disease improves survival in carefully selected patients [24], [25], [26]. In addition to improving quality of life, metastatectomies may prolong survival by restoring a functional immune system [24]. This finding is based upon the hypothesis that tumors induce immunosuppressive factors that impede the immune system's antitumor responses [27]. Hsueh et al. [28] have postulated that the resection of metastatic lesions using cytoreductive surgery enhances the immune response by increasing the number of tumor-specific antibodies and lymphocytes available for immune-mediated killing.

When considering which patients would most benefit from a potentially curative resection of metastatic lesions, the factors most predictive of improved survival include good performance status, a limited extent of metastatic disease, less aggressive tumor biology, the ability to achieve complete resection, and a prolonged disease-free interval after treatment of the primary melanoma [25]. A disease-free interval of less than 1 year is highly predictive of poor outcome [29]. Preoperative evaluation includes a detailed patient history, comprehensive physical examination, and imaging studies, which may include CT scans, MRI, and 18-fluorodeoxyglucose positron emission tomography (FDG-PET). After the initial metastatic workup is completed, some physicians advocate a “watchful waiting” period, during which the patient is followed closely for 2–3 months in order to ensure that no new lesions appear that would render the patient inoperable. Surgeons at Memorial Sloan Kettering advocate a 2–3-month period of chemotherapy for patients with a single-site asymptomatic metastasis prior to resection [25]. In our practice, we generally do not administer chemotherapy during this waiting period, as no regimen has proven to provide a definitive survival benefit. It is our belief that patients do better when spared the immunosuppression and other deleterious side effects of chemotherapy while awaiting resection of metastatic lesions.

The most frequent sites of melanoma metastases are skin, soft tissue, and lymph nodes (AJCC Stage M1). When these sites represent isolated areas of spread, resection is likely to be curative as long as complete resection is possible [25]. Patients who present with a solitary pulmonary metastasis (M2 disease) are usually asymptomatic, and surgery is therefore performed with a curative, as opposed to palliative, intent. Studies have shown that 5-year survival rates of up to 20% have been achieved in carefully selected patients who present with solitary nodules, disease-free intervals of longer than 1 year, and lesions amenable to complete excision [29]. The brain is the next most common site of metastatic melanoma, occurring in 8–15% of melanoma patients [25]. Significant palliation can be achieved with surgical resection of brain lesions, with or without postoperative whole-brain radiation [30]. Melanoma represents up to one-third of all cancer metastases to the gastrointestinal tract [25]. Most patients who present with gastrointestinal metastases will present with pain, bleeding, obstruction, or other debilitating symptoms necessitating a palliative surgical procedure. Improved survival has been reported following resection of gastrointestinal metastases, provided that complete excision is achieved [31], [32]. The John Wayne Cancer Institute and Sydney Melanoma Unit have studied the effect of hepatic metastases resection on overall survival in melanoma patients, and found that in some carefully selected patients who were rendered disease free after resection, improvements in DFS and OS were observed [33].

In summary, very few patients with Stage IV melanoma are considered suitable candidates for resection of metastatic disease with curative intent. The general consensus is that the patients who have the greatest chance of improved survival after metastatectomies are those with a long disease-free interval (greater than 1 year), those with solitary metastatic lesions, and those in which complete excision of the secondary lesion is possible [25], [29]. In these patients, an aggressive surgical approach seems warranted, as their prognosis is very poor without any intervention. It is important to remember, however, that one of the most important surgical caveats in patients with Stage IV disease is still the “watchful-waiting” period in order to ensure that surgical excision of metastatic disease is indicated.

4. Sentinel node biopsy for cutaneous melanoma

Historically, the approach to clinically negative regional nodal basins has been the topic of much debate, in which some recommended observation until clinical relapse developed while others advocated elective lymph node dissection (ELND) at the time of initial diagnosis. Morton et al. [34] first introduced SLN biopsy in 1992, a selective approach to regional lymph node dissections. SLN biopsy is a minimally invasive technique that involves lymphatic mapping and biopsy to identify the approximately 20% of patients who are clinically node negative, but harbor micrometastatic disease to the regional lymph nodes and would therefore benefit from a complete lymph node dissection [34], [35], [36], [37]. SLN-negative patients are spared the morbidity of an unnecessary formal dissection of regional lymph node basins, which at one time was a topic of incredible debate.

The benefits of SLN biopsy compared to the excision of clinically negative nodes in ELND have been well explored. SLN is a less costly and less morbid procedure by which Hematoxylin and Eosin, as well as immunohistochemical analysis can detect occult metastasis to the first draining lymph node from a primary tumor site, thereby identifying patients who would benefit from a formal lymphadenectomy [37]. The National Comprehensive Cancer Network (NCCN) guidelines recommend SLN biopsy for all patients with primary melanomas >1mm thick and for particular subsets of patients with high-risk thin (<1mm), or stage IB (ulcerated) melanomas. Complete lymph node dissection is recommended for patients with nodal metastases [38].

There is no direct evidence that SLN biopsy provides any survival benefit for patients with cutaneous melanoma. The Multicenter Selective Lymphadenectomy Trial is currently investigating this dilemma. This is a multi-institutional randomized trial whose survival data is expected to be available in 2007 [34]. There is, however, indirect evidence of the survival benefit of SLN biopsy as reported by Morton et al. [39] in a matched case-control analysis. Morton postulated that patients who underwent SLN biopsy followed by immediate dissection for metastases survived longer than patients who underwent delayed dissections. The 5-, 10-, and 15-year survival rates for the patients who underwent immediate dissection were 73%, 69%, and 69%, respectively, compared to the 51%, 37%, and 32% respective survival rates in patients who underwent delayed dissections (). Morton et al. [39] had postulated that patients with thin primary tumors and micrometastatic nodal disease would benefit most from SLN biopsies.

It is our opinion that lymphadenectomy for positive SLN biopsies is an important part of the clinical approach to the melanoma patient. We strongly recommend that patients with positive SLNs have a formal lymphadenectomy of the regional lymph node basin. On the other hand, there is growing concern that SLN biopsy may in fact increase the risk of in-transit metastases (ITM) and therefore reverse any potential survival advantage that SLN biopsy followed by lymphadenectomy may provide [40], [41]. ITM are characterized by the presence of melanoma cells in the dermis or subcutaneous fat between the primary tumor and the regional lymph node basin. ITM have been notoriously difficult to treat. The best approach has been surgical resection, if possible, with the 5-year survival rates ranging from 12% to 37% [42], [43]. ITM are theorized to occur as a result of melanoma cells detaching and becoming lodged in the lymphatic channels before reaching the regional lymph node basins. Patients with thick primary tumors, ulcerative tumors, or tumors located in the lower extremity are at an increased risk of developing ITM [44], [45]. It has been hypothesized that disruption of lymphatic flow may promote intralymphatic tumor dissemination, thus causing the reported higher ITM rates among patients undergoing SLN biopsy or WLE with ELND when compared to patients treated with WLE and delayed lymph node dissections after the lymph nodes become clinically positive [40], [41].

Furthermore, Pawlik et al. [46] conducted a comparison study, which revealed that the higher incidence of ITM among patients undergoing SLN biopsy was not due to the technique of the procedure itself, but rather was a result of aggressive tumor biology. Patients with positive SLN positive are almost always going to have less favorable primary tumor characteristics, and thus have higher recurrence rates. Pawlik et al. [46] showed in their study of 1395 patients the ITM rate for positive SLN was 12% with a median primary tumor thickness of 3.0mm compared to an ITM rate of 3.5% for the negative SLN group with a median tumor thickness of 1.3mm. A recent review conducted by Kretschmer et al. [47] showed the incidence of ITM was not affected by early nodal intervention, but instead by tumor aggressiveness. Still, long-term results of a prospective, randomized trial, such as the Multicenter Selective Lymphadenectomy Trial, are anticipated to present a clearer picture concerning the role of SLN biopsy and the potential risks and benefits this technique can provide in treating patients with primary cutaneous melanoma. Despite the results of this trial, we still strongly advocate an aggressive surgical approach for positive SLN. In summary, it is our strong opinion that the ITM are related to the biology of the initial melanoma and do not reflect a failure of the SLN biopsy technique. We recommend that SLN biopsy be done in all eligible patients.

5. Immunotherapeutic strategies for melanoma

The discovery of tumor-associated antigens (TAAs) in the 1980s along with an improved understanding of the human immune system over the last century have led to the development of the exciting field of cancer immunotherapy [48]. This field has been the subject of intense investigation over the last two decades. In fact, the manipulation of the immune system as a treatment for cancer has taken many shapes and forms throughout the history of cancer treatment, dating as far back as the 1800s. Ian Davis et al. [49] addressed this topic in a recent review article on cancer immunotherapy. The authors described “Coley's mixed toxins,” an extract of Streptococcus and Serratia, which was the only known systemic cancer therapy up until the mid 1930s. It was hypothesized that these toxins induced the immune system to fight cancer via a cytokine cascade [49]. This concept of employing microorganisms as boosters of the immune response resurfaced in the 1960s. During that time, it was shown that Bacilli Calmette-Guerin (BCG) and Corynebacterium parvum (C. parvum) could generate immune responses against tumors [50], [51]. Specific work with these organisms performed by Morton and colleagues demonstrated a decreased size of primary lesions, regression of distant metastases, as well as increased survival in certain patients with cutaneous melanoma [10], [52].

The use of certain viruses as immunologic modifiers in the treatment of specific cancers began to gain popularity in the 1970s. For example, influenza virus-modified tumor lysates were studied as potential treatments for patients with osteosarcoma [53] and sarcoma [54]. As these therapies employed a rather pathogenic virus, Wallack et al. [55] performed studies to establish an alternative virus for tumor cell modification. Vaccinia modifies membrane-associated tumor antigens and it aids in their re-expression, thereby enhancing the immunogenicity of cancers [56]. In addition, vaccinia enhances the expression of antigen-chaperoned heat shock proteins [57], [58] and specifically helps the induction of tumor-specific cytotoxic T lymphocytes (CTLs) [59]. Its safety has been well established in the vaccination of millions of people against smallpox. The incorporation of vaccinia virus into a melanoma vaccine has been explored by several laboratories [60], [61], [62], [63], [64].

Recently, several scientists have taken different approaches in developing immunologic therapies for the treatment of melanoma. These approaches include interferon therapy [65], [66], [67], [68], allogenic whole-cell vaccines [69], recombinant viral vectors [70], adoptive immunotherapy combined with lymphodepletion [71], [72], and allogenic cell lysates [61], [63], [64], [73], [74], to name a few. The in vitro manipulation of dendritic cells (DCs) is currently a popular method in the study of tumor immunotherapy. Regarding melanoma vaccines in particular, investigators have studied vaccines composed of melanoma-associated antigen-pulsed DCs [75], [76], [77], tumor-lysate-pulsed DCs [78], [79], [80], [81], [82], [83], fusion of DCs with whole tumor cells [84], [85], and in vivo DC manipulation [86], [87]. This review will describe the aforementioned immunotherapeutic strategies and will address some of the major clinical trials that have tested these strategies over the last few decades.

6. Interferon α therapy

In 1957, Drs. Lindenmann and Isaac first described a unique class of molecules, now known as interferons, that could “interfere” with virus replication within cells via a complex sequence of events [88]. Studies by Bart et al. [89] published in 1980 demonstrated promising anti-melanoma effects of interferon alpha (IFN-α) on murine B16 melanoma cell lines. These findings led investigators to study the anti-tumor effects of this cytokine in humans. The Eastern Cooperative Oncology Group (ECOG) has conducted several clinical trials on the efficacy of IFN-α as adjuvant treatment for high-risk melanoma patients, reporting somewhat inconsistent results on overall survival benefit and recurrence-free survival [65], [67], [68], [90], [91]. Nevertheless, in 1995, ECOG Trial 1684 resulted in the FDA approval of high dose IFN-α for the adjuvant treatment of melanoma patients with thick lesions or node-positive disease [68]. Despite several sophisticated clinical trials, much controversy still exists regarding appropriate patient selection, dosing regimens, and risks of significant toxicities associated with IFN-α. Many practitioners in North America continue to use IFN-α as a conventional treatment for high-risk melanoma patients. This is not the consensus worldwide, however, for European oncologists do not recommend interferon therapy for melanoma outside the scope of clinical trials [92]. The reasons for this discord are many, including inconsistent study results, severe IFN-related toxicities, as well as patient selection debates. Despite these controversies, IFN-α remains the only FDA-approved immunotherapeutic treatment for high-risk melanoma patients. Yet, researchers continue to search for the ideal IFN-α2b treatment regimen that will prove effective against melanoma without causing significant organ toxicities [93]. It is apparent from clinical experience that despite FDA approval, high-dose IFN-α is not considered to be the gold standard for adjuvant therapy of high risk, Stages I and II melanoma.

7. Interleukin-2 (IL-2)

IL-2 was first discovered in 1976 as a 15-kd immune-modulating glycoprotein produced by helper T-lymphocytes [94]. IL-2 was found to have potent activating effects on T cells, natural killer (NK) cells and lymphokine-activated killer (LAK) cells and generated much interest among researchers for its possible use in the immunotherapy of certain metastatic tumors. Studies showing the effectiveness of IL-2 therapy in mice [95] led to the first clinical trials in patients with metastatic cancer in 1984 by Rosenberg et al. [97], [98]. Further trials at the National Cancer Institute (NCI) led to the development of a standard dosing schedule of IL-2 therapy, which has produced some partial and complete responses in a very small number of patients, of which many ultimately developed recurrent disease [99].

Several multi-organ toxicities are associated with high-dose IL-2, the most dangerous of which is “capillary leak syndrome”, in which patients experience marked edema and hypotension with a high cardiac output and low peripheral resistance, similar to septic shock [100]. Efforts to reduce the morbid effects of high-dose IL-2 therapy, including the co-administration of NSAIDs and antihistamines, have produced minor improvements. The nitric oxide inhibitor, Ng-monomethyl-l-arginine (NMA) may have a role in the prevention of IL-2-related hypotension [101]. Corticosteroids should not be used, as their immunosuppressive effects may curb the benefits of IL-2 [100]. Studies testing the effectiveness of low-dose IL-2 regimens have failed to show a clinical benefit in melanoma patients [102], [103]. Other attempts to improve the therapeutic index of IL-2 in metastatic melanoma patients have included combining IL-2 with other cytokines [104], [105] or with chemotherapeutic agents [106], [107], [108]. Initial findings have been promising in a few small trials, but their effectiveness has yet to be proven on a larger scale. The FDA approved the use of high-dose IL-2 for melanoma patients with metastatic disease in 1998. Nevertheless, treatment with this cytokine produces significant morbidities and should only be used in carefully selected patients in treatment centers that are equipped to safely monitor and treat the deleterious side effects of high-dose IL-2.

8. Adoptive immunotherapy

Adoptive cell transfer (ACT) immunotherapy involves the in vitro selection of autologous, highly avid tumor-specific lymphocytes (TIL) that are activated and numerically expanded before being transferred back to the tumor-bearing host [71]. The transfer of TIL together with IL-2 and a single dose of cyclophosphamide proved to be effective in the regression of lung and liver metastases in animal models in the 1980s [109], [110]. Since then, several clinical trials involving adoptive immunotherapy have been conducted on patients with refractory metastatic melanoma [111], [112], [113], [114]. These trials have produced inconsistent clinical responses, with a major problem being the ability to generate TIL with durable in vivo longevity [96], [114]. Recent studies have shown that TIL with longer telomeres have a more sustained persistence in vivo after adoptive transfer [115]. Other investigators have shown that TIL transduced with the Bcl-2 gene persist longer in vivo after withdrawal of IL-2 compared with control T cells [116]. The persistence of adoptively transferred T lymphocytes in vivo correlates with objective clinical responses, including the regression of metastatic lesions. It has recently been reported that 51% of patients with metastatic melanoma treated with ACT therapy following non-myeloablative chemotherapy experienced objective clinical responses, including three ongoing clinical responses with durations ranging from 2 months to 2 years [71].

The toxicities associated with lymphodepleting chemotherapy and cell transfer are many and can be severe. In addition to the transient anemia, thrombocytopenia, and leukopenia experienced by many patients, others suffer from opportunistic infections, autoimmune manifestations, and respiratory complications [71]. It has been reported that one patient who experienced substantial cancer regression died 1 year after treatment from an Epstein–Barr virus lymphoproliferative disease [71]. While results of clinical trials regarding lymphodepletion and cell transfer therapy are promising, the management of patients receiving this treatment is complicated and can only be performed in quaternary centers. At this time, there are a limited number of medical institutions that are properly equipped with the technology and personnel to safely and effectively administer this complex and potentially hazardous method of melanoma treatment. Nonetheless, the fact that immunologic manipulations such as ACL do produce some clinical efficacy gives hope that immunotherapy will eventually be operative in the treatment of melanoma.

9. CTLA-4 blockade in melanoma

The activation and proliferation of T cells is imperative for immunotherapy to be effective in the treatment of melanoma. The immunoregulatory action of cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) inhibits CD-28 dependent T-cell activation, decreases IL-2 production, and halts cell cycle progression [117], [118], [119], [120]. Efforts have been made to alter the immunoregulation of CTLA-4 by blocking its activity with monoclonal antibodies, and some trials have produced promising results, including the regression of metastatic lesions [121].

10. Melanoma vaccines

Paul Ehrilich was the first to describe a vaccine approach for the treatment of malignancies using murine models in the early 1900s [122]. It was not until the 1980s, however, when TAAs were identified, that investigators began to once again have an intense interest in vaccination strategies for cancer, including melanoma. Since then, there has been a resurgence in the science of cancer immunotherapy.

Vaccines can be categorized as either univalent or polyvalent. Univalent vaccines stimulate the immune system to mount a response against a particular antigen or carbohydrate moiety. Different methods of antigen delivery have been tested, including direct injection of a synthetic peptide into the host [123], recombinant adenoviruses encoding for either MART-1 or gp100 [70], and plasmid vectors encoding specific antigens [124], [125]. While these strategies have been well tolerated by patients, and some have experienced regression of their disease, statistically significant clinical responses remain to be seen in Phase III clinical trials.

Polyvalent vaccines enable the host to mount an immune response against multiple tumor antigens. These vaccines are advantageous in that they are not HLA-restricted, and therefore many patients can potentially benefit from their antitumor effects. Polyvalent vaccines include those that are comprised of allogenic whole cells, autologous tumor cells [126], [127], [128], shed tumor antigens [129], [130], and tumor lysates. Allogenic cellular melanoma vaccines are prepared from live, irradiated melanoma cell lines possessing numerous MAAs. Morton et al. [131] have reported results from phase II clinical trials, which revealed improved OS among vaccinated patients who mounted either humoral or cellular immune responses as compared to non-vaccinated, matched historical controls. In addition, regression of metastatic disease has been reported, primarily in patients with metastases less than 2cm in diameter [131]. However, results from the matched-pair analyses of Phase II trials were not confirmed in a recent Phase III trial of Stage IV melanoma patients, in which no overall survival benefit was seen in the vaccine arm. This study was stopped early [132]. Results from a recent Phase III trial of this allogenic cellular melanoma vaccine for patients with Stage III disease are anticipated in the next 1–2 years [132].

Melacine, an allogenic melanoma cell lysate vaccine comprised of two mechanically disrupted melanoma cell lines and combined with a DETOX adjuvant, has been tested extensively in clinical trials [133], [134], [135], [136], [137]. A multicenter phase III comparison of Melacine plus low-dose cyclophosphamide versus a chemotherapy regimen demonstrated no significant difference in response rate or survival. However, Melacine produced fewer toxicities and has been approved for use in Canada in patients with late-stage melanoma [134]. A randomized phase III trial conducted by the Southwest Oncology Group compared the effects of Melacine in resected, intermediate-thickness, node-negative melanoma patients to observation alone. Results showed no evidence of improved DFS among patients in the vaccine arm. However, there was a significant benefit in a smaller subset of patients who expressed either the HLA-A2 or HLA-C3 haplotype [135], [136].

Over the last decade, DCs have gained popularity in the immunotherapy of melanoma. These cells are attractive as cancer vaccine adjuvants because they are potent antigen presenting cells capable of initiating active specific immunotherapy by presenting tumor antigens to naïve T cells. However, vaccines composed of peptide-pulsed DCs have produced inconsistent results in clinical trials [75], [138], [139], [140], [141]. Co-culturing immature DCs with tumor lysates, as opposed to using single peptides for pulsing, exposes the DCs to a greater variety of antigens with multiple HLA restrictions, thereby increasing the likelihood that a patient's immune system will recognize the presented antigens and elicit a meaningful immune response. In the first reported Phase I trial of its kind, Nestle et al. [142], successfully demonstrated that autologous DCs pulsed with either HLA-restricted peptides or autologous tumor lysate could safely induce specific antitumor immunity in vivo in a small subset of patients. This trial set the stage for several other tumor lysate-pulsed DC melanoma vaccine studies [80], [143], [144], [145], [146], [147], [148].

There is controversy as to whether vaccine therapy for melanoma may be worthwhile because it cannot be used in advanced disease, as one would test the use of chemotherapeutic agents. Nevertheless, it is our strong opinion that melanoma vaccines can work if properly applied to patients with a high likelihood of micrometastatic disease, or in patients with previously resected, advanced melanoma who now exhibit no evidence of disease. It is important to emphasize, however, that these vaccines cannot be tested in patients with established advanced melanoma because their immune system is inoperative, and cell kill would be minimal.

11. A second generation melanoma vaccine: DC-MelVac (patent # 11221/5)

The work of Wallack et al. [55] on the active specific immunotherapy of melanoma has been in development for the past three decades, beginning with the introduction of vaccinia virus as a safe alternative to influenza virus in producing oncolytic immunity against cancer. Since that time, encouraging results have emerged from several clinical trials testing the immunological and clinical responses of high-risk melanoma patients to a vaccinia melanoma oncolysate (VMO) vaccine [63], [64], [74], [149], [150], [151], [152]. The details of these trials are summarized in Table 1.

Table 1.

Wallack et al. vaccinia oncolysate clinical trials.


Study	Objectives	# Patients	Stagea	Responses	References
Autologous VO preliminary trial 1975–1977	Toxicity	29	Advanced cancers	9 responded	[55]
Allogenic VMO preliminary trial (France) 1977–1979	Feasibility	12	II and III	4/12 showed longer survival than predicted	[149]
VMO preliminary trial (USA) 1977–1979	Toxicity and feasibility	12	I and II	8 responded, all had anti-melanoma antibodies	[150]
VMO phase I 1982–1983	Dose response	48	I and II	24 NEDb	[151]
				24 recurred
				2mg dose most effective
VMO phase II surgical adjuvant trial 1988–1993	Survival	39	I and II	21 NED	[152]
				Significantly increased DFSc
				Anti-MAAd antibodies correlated with survival
VMO vs. vaccinia	Randomized, placebo-controlled	250	II	First interim analysis: No increased DFS or OSe	[64], [74]
Phase III 1988–1993	Randomized, placebo-controlled	250	II	Second interim analysis: males 44–57 years had survival advantage	[64], [74]

Stage refers to staging system used at the time of the corresponding trial.

NED=no evidence of disease.

DFS=disease free survival.

MAA=melanom-associated antigens.

OS=overall survival.

During the past several years, our laboratory has made important modifications to the first generation VMO vaccine, and has developed a potentially more efficacious and potent second-generation, DC melanoma vaccine (DC-MelVac). The original vaccine did not contain a cell line that expressed the HLA-A2 allele. This was a significant drawback, considering that a majority of melanoma patients are HLA-A2+ [153]. DC-MelVac consists of five human melanoma cell lines that now contain the HLA-A2 allele, HLA Class II antigens, among others. The polyvalent melanoma cell lysate contains more than 10 MAAs, and is therefore expected to elicit immune responses in a large number of melanoma patients.

Another immune-enhancing element of DC-MelVac is a modified vaccinia virus whose genome expresses a recombinant IL-2 gene (rIL-2VV). The rIL-2VV provides continuous secretion of low-dose IL-2 while avoiding the organ toxicities associated with higher doses of the cytokine. It has been confirmed in murine models that rIL-2VV replicates inside the host and produces IL-2, thereby increasing lymphocyte activity. In addition, mice receiving rIL-2VV had a significantly reduced tumor burden and increased survival when compared to mice receiving vaccinia oncolysate alone [154], [155].

Perhaps the most significant addition to the VMO vaccine is the incorporation of VMO-pulsed autologous DCs. DCs possess potent antigen-presenting capabilities that have produced clinical benefits in melanoma patients when combined with vaccines [141], [142], [143]. The second-generation melanoma vaccine exploits the powerful immunogenicity of autologous DCs that are pulsed ex vivo with a polyvalent rIL-2VMO. DC-MelVac received FDA approval in February 2005, and we are eagerly anticipating the initiation of a Phase I clinical trial in the near future.

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Surgery Research Laboratory, Department of Surgery, Saint Vincent's Catholic Medical Centers/New York Medical College, 153 West 11th Street, Cronin Building, Room 667, New York, NY 10011, USA

Corresponding author. Metropolitan Hospital Center, New York Medical College, 1901 1st Avenue. Rm. 12A1, New York NY 10029. Tel.: +12124236614; fax: +12124237913.

PII: S0960-7404(06)00020-X

doi:10.1016/j.suronc.2006.05.003

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