Open Access

The effect of chemotherapy combined with recombination mutant human tumor necrosis factor on advanced cancer

  • Xing Liu1Email author,
  • Xiang-fu Zhang1,
  • Zhi-weng Zheng1,
  • Huishan Lu1,
  • Xinyuan Wu1,
  • Changmin Huang1,
  • Chuan Wang1 and
  • Guoxiang Guang1
Journal of Translational Medicine20042:33

https://doi.org/10.1186/1479-5876-2-33

Received: 27 May 2004

Accepted: 14 October 2004

Published: 14 October 2004

Abstract

Background

Past studies suggested that tumor necrosis factor (TNF) assisted anti-tumor treatment and intensified the sensitivity of chemotherapy. However its clinical application has been curbed because of its low purity, high dosage, and strong toxicity. This research, through perspective random clinical control experiment, observed the therapeutic effect of the treatment of late malignant tumor through the injection of recombinant mutant human tumor necrosis factor (rmhTNF) combined with general chemotherapy and its adverse reactions.

Methods

105 patients with advanced malignant tumor were randomly divided into trial group, 69 patients, and control group, 36 patients. Injection of rmhTNF 4 × 106u/m2 was given to the trial group, from the 1st to 7th days, the 11th to 17th days combined with chemotherapy course. The chemotherapy plan was as follows: CAP for patients with the NSCLC; FAM for patients with gastric cancer; FC for patients with colorectal cancer. One treatment cycle lasted for 21 days and two cycles were scheduled. The control group was given only the same chemotherapy as the trial group.

Results

In the trial group there was 1 CR case and 12 PR cases, and the response rate is 13/69 (18.84%); in the control group 1 PR case, the response rate 1/36 (2.78%). The response rate of the trial group was significantly higher than that of the control group (P = 0.022). The response rate for NSCLC in the trial group was 8/17 (47.06%), and 1/6 (16.67%) in the control group. The response rates for gastric cancer and colorectal cancer in the trial groups also were higher than those of the control groups. After the treatment the KPS is 89.00 ± 9.92 in the trial group, and 84.17 ± 8.84 in the control group, with a significant difference between the two groups (P = 0.028). The adverse reactions of rmhTNF injection included: pain in the injection area, chill, hardening and swelling and redness in the injection area, fever, ostealgia and myosalgia, and cold-like symptoms. All these adverse reactions were mild and bearable.

Conclusions

The administration of rmhTNF injection in combination with general chemotherapy is an effective and secure means in treating advanced malignant tumor.

Keywords

Tumor Tumor necrosis factor Biological therapy Chemotherapy Complex therapy

Tumor necrosis factor (TNF) is a polypeptide produced by monocytic macrophages and T-lymphocytes stimulated by endotoxin[1]. It has been well shown in vivo or in vitro that TNF assists anti-tumor treatment and intensified the sensitivity of chemotherapy to many different kinds of tumor cells [25]. However its clinical application has been curbed because of its low purity, high dosage, and strong toxicity. Via the cooperation between the Forth Military Medical University and Shanghai Celstar Bio-pharmaceutical Holding Co. Ltd, an injection of recombinant mutant human tumor necrosis factor (rmhTNF) which is a genetic engineering TNF of a high activity and low toxicity, has been produced by rebuilding natural TNF with protein engineering technics. Phase I clinical trial (tolerance test) showed that the patients had good tolerance. and the toxicity of rmhTNF was slight As a participant of the Phase II and Phase III clinical study of rmhTNF, we observed the therapeutic effect of the treatment of late malignant tumor through the injection of recombinant mutant human tumor necrosis factor combined with general chemotherapy and its toxicity in a multi-center, random clinical control Phase II and Phase III clinical study of rmhTNF during October 2000 ~ May 2002. The results are reported as below.

1. Materials and Methods

1.1 Patients

105 patients from our department with advanced malignant tumors diagnosed via pathologic or cytological examinations were randomly collected, of which 23 were non-small cell lung cancer, 50 gastric cancers and 32 were colorectal cancers. Moreover, 79 of them were males and 26 of them were females. The range of their ages was 25~70, with the median age 52 years old. All of them were during their later phases of either recrudescent or metastatic cancers, had no sugary indexes and were taking conservative medicine treatment. KPS scoring for them before treatment were ≥ 60, neutrophil ≥ 2.0 × 109/L, PLT ≥ 100 × 109/L and Hb ≥ 90 g/L. They had almost normal functions of the heart, liver and kidney and at least had one evaluable tumor focus. They had not taken any other anti-tumor treatment one month before the experiment and they had a prospective survival time > 3 months. All of the patients were well informed and written consents were signed. Then they were randomly divided into two groups, i.e. the trial group of 69 patients and the control group of 36 patients, the conditions of the two groups were comparable (P >0.05, see Table 1). In the individual group of three tumors, the stage of the disease is of no significant difference (P >0.05, see Table 1).
Table 1

The General Data of the Trial and Control Group

Item

 

Trial group (n = 69)

Control group (n = 36)

P

Sex

   

0.362

   Male

 

50

29

 

   Female

 

19

7

 

Median age (year)

 

52

51

0.437

Type of tumors

   

0.638*

   NSCLC

 

17

6

 

   Gastric cancer

 

32

18

 

   Colorectal cancer

 

20

12

 

KPS ( )

 

85.31 ± 6.07

86.69 ± 7.81

0.334

Clinical stage

   

0.630

   III

 

11

8

 

   IV

 

58

28

 

   NSCLC

III

5

3

0.621*

 

IV

12

3

 

   Gastric cancer

III

4

3

0.684

 

IV

28

15

 

   Colorectal cancer

III

2

2

0.620*

 

IV

18

10

 

*The p value is calculated by Fisher exact chi-square because n < 30 or some cells have expected count less than 1.

1.2 Source of drugs

Injection of rmhTNF which was in powder form of 500 × 105u/tube (number 00061) was made and provided by the Forth Military Medical University and was stored at 4°C in refrigerator.

1.3 Treatment protocol

For the trial group, injection of rmhTNF 4 × 106u/m2 was given from the 1st to 7th days, the 11th to 17th days combined with chemotherapy course. The chemotherapy plan was as follows: CAP (CTX 750 mg/m2, d1, ADM 40 mg m2, d1, DDP 30 mg m2, d1-d3) for patients with the non-small cell lung cancer; FAM (5-FU500 mg/ m2, d1-d5, ADM 40 mg/ m2, d1, MMC 6 mg/ m2, d1) for patients with gastric cancer; FC (5-FU 500 mg/ m2, d1-d5, CF 100 mg/ m2, d1-d5) for patients with colorectal cancer. One treatment cycle lasted for 21 days and two cycles were scheduled. For the control group, only the same chemotherapy as the trial group was given. Signs, symptoms and adverse reactions were carefully observed during the treatment. Weekly examinations of blood routine were performed before and after treatment, while liver and kidney functions, urine routine, EEG, liver ultrasonic and chest X-ray examinations were performed before and after every treatment cycle. CT examinations of the evaluable tumor focuses were performed one time before treatment, when treatments were finished and after 4 weeks of the finish.

1.4 Evaluation of response and toxicity

1.4.1 Evaluation of response

Complete response (CR) is that, the disappearance of all lesions and no appearance of new disease for at least 4 weeks. Partial response (PR) is defined as a reduction by at least 50% in the sum of the products of the two longest diameters of all lesions maintained for at least 4 weeks with no appearance of new disease. Minimal response (MR) is different from PR with a reduction by at least 25%, but not more than 50%. Stable disease (SD) is a less than 25% reduction or less than 25% increase in the sum of the products of the two perpendicular diameters of all measured lesion with no appearance of new disease. Progression disease (PD) is that, an increase greater than 25% over the size present at entry into the study or, for patients who respond, the size at time of maximum regression, or the appearance of new areas of malignant disease. CR+PR were rated as response rate.

1.4.2 Toxicity

The toxicity was followed the WHO acute and sub-acute toxic rating

2. Results

2.1 Response to treatment

After two treatment cycles, the trial group had 1 CR case, 12 PR cases, 11 SD cases and 18 PD cases, and the response rate was 13/69(18.84%). The control group, on the other hand, had 1 PR case, 4 MR cases, 19 SD cases and 12 PD cases, and had a response rate 1/36 (2.78%). The response rate of the trial group was significantly higher than that of the control group (P = 0.022, see Table 2).
Table 2

The Response Rate in the Trial and Control Group after Two Treatment Cycles

Group

n

CR

PR

MR

SD

PD

Response rate

P

Trial

69

1

12

11

27

18

13/69 (18.84%)

0.022

Control

36

0

1

4

19

12

1/36 (2.78%)

 
The response rate for NSCLC of the trial group was 8/17 (47.06%), higher than that of the control group 1/6 (16.67%) but without statistic significance (P = 0.208). The response rates for gastric cancer was 12.50% (4/32), while for the controls were 0.00% (0/18) without statistic significance (P = 0.283). The response rates for colorectal cancer was 5.00% (1/20), while no response case in the controls group (0/12), but there was still no statistic significance (P = 1.000, see Table 3).
Table 3

The Response Rate in the Trial and Control Group for Different Type of Tumors

 

Group

n

CR

PR

MR

SD

PD

Response rate

p*

NSCLC

Trial

17

1

7

3

4

2

47.06% (8/17)

0.208

 

Control

6

0

1

1

3

1

16.67% (1/6)

 

Gastric cancer

Trial

32

0

4

6

13

9

12.50% (4/32)

0.283

 

Control

18

0

0

2

9

7

0.00 (0/18)

 

Colorectal cancer

Trial

20

0

1

2

10

7

5.00% (1/20)

1.000

 

Control

12

0

0

1

7

4

0.00 (0/12)

 

*The p value is calculated by Fisher exact chi-square because n < 30 or some cells have expected count less than 1.

2.2 Life quality

Before the treatment there was no significant difference of the general status (KPS) between the two groups (P > 0.05). After the treatment the KPS was 89.00 ± 9.92 in the trial group, and 84.17 ± 8.84 in the control group, with a statistic significant difference (p = 0.028, see Table 4).
Table 4

Before and after Treatment, KPS Value in the Trial and Control Group

Group

Trial (n = 69)

Control (n = 36)

P

Before treatment ( )

85.31 ± 6.07

86.69 ± 7.81

0.334

After treatment ( )

89.00 ± 9.92

84.17 ± 8.84

0.028

2.3 Toxicity

Fever, cold-like symptoms, ostealgia and myosalgia, chill, pain in the injection area, hardening and swelling and redness in the injection area were much more happened in the trail group compared with the control group (P < 0.01 = , while there were no significant differences between the two groups on the frequencies of anemia, leukopenia, thrombocytopia and nausea / vomiting (P > 0.05). No abnormalities correlated with drugs were found in liver or kidney functions, urine routine, EEG and blood pressure (see Table 5).
Table 5

Toxicity in the Trial and Control Group

Toxicity

Trial (n = 69)

Control (n = 36)

P*

 

0

I

II

III

IV

0

I

II

III

IV

 

Anemia

37

16

8

7

1

21

9

4

1

1

0.665

Leukopenia

28

23

9

9

0

17

13

4

2

0

0.570

Thrombocytopia

59

5

2

2

1

31

3

1

1

0

0.557

Nausea / Vomiting

32

16

19

2

0

18

4

11

2

1

0.476

Fever

52

12

5

0

0

36

0

0

0

0

0.000

Eruption

67

2

0

0

0

36

0

0

0

0

0.274

Cold-like symptoms

47

19

3

0

0

36

0

0

0

0

0.000

Ostealgia / Myosalgia

46

21

2

0

0

36

0

0

0

0

0.000

Chill

38

31

0

0

0

36

0

0

0

0

0.000

Pain in injection area

13

41

15

0

0

36

0

0

0

0

0.000

Hardening, swelling and redness in injection area

42

17

10

0

0

36

0

0

0

0

0.000

*The p value is calculated by Fisher exact chi-square because n<30 or some cells have expected count less than 1.

3. Case report

A 54-year-old man hospitalized at August 27, 2001 with complains of "left chest pain accompanied by cough and hard breath for half a month". Physical examination after hospitalization showed: enlarged lymph node of 3 × 3 cm above the right clavicle, hard and immobile. Chest CT on September 27, 2001 (see Figure 1) showed: conglomeration of a size of 5.5 × 4.2 cm at the left lower hilus pulmonis, large amount of accumulation of fluid in the left thoracic cavity, enlarged lymph nodes in the mediastinum. Biopsy of the lymph node above the right clavicle showed: transferred adenocarcinoma. Cancer cells were found in the fluid in the thoracic cavity after centrifugation. The diagnosis was "Adenocarcinoma on the left lower lung, stage T4N3M0IIIb". Chemotherapy of protocol CAP + rmhT NF injection (i.m.) was given from October 4 to November 14, 2001. Two weeks later, a clear relief of hard breath and cough was found. After two periods of therapy (November 16, 2001), physical examination showed shrinkage of lymph node of 0.5 × 0.5 cm above the right clavicle, and Chest CT (see Figure 2) showed: clear shrinkage of conglomeration of 3.0 × 2.5 cm at the left lower hilus pulmonis, small amount of accumulation of fluid in the left thoracic cavity. A callback of CT one month later showed: conglomeration was of the size of 4.0 × 2.8 cm. The curative effect was confirmed as "PR".
Figure 1

Chest CT before treatment (27-Sep-2001) show that conglomeration of a size of 5.5 × 4.2 cm at the left lower hilus pulmonis, large amount of accumulation of fluid in the left thoracic cavity, enlarged lymph nodes in the mediastinum.

Figure 2

Chest CT after treatment (16-Nov-2001) show that clear shrinkage of conglomeration of 3.0 × 2.5 cm at the left lower hilus pulmonis, small amount of accumulation of fluid in the left thoracic cavity.

4. Discussion

Tumor necrosis factor (TNF) is a polypeptide produced by monocytic macrophages and T-lymphocytes stimulated by endotoxin. It can act as modulator to immunity and induces anti-tumor effects in hosts. It also has direct cytotoxic effects and inhibitory effects on cellular growth. It can kill the tumor cell without notable toxic effect on the normal cells [1]. Studies have shown that the anti-tumor mechanism of the tumor necrosis factor includes 1) killing the tumor cell directly [3]; 2 inducing the apoptosis of tumor cells [3]; 3) reversing more drug resistance of tumor cell and improving the sensitiveness of chemotherapy [3]; 4) destroying the blood supply of tumor tissue [4]; 5) increasing the killing effects of immune-effect cells on the tumor cells [3]. However, its clinical application has been curbed because of its low purity, high dosage, and strong toxicity. Studies have also shown that, a higher anti-tumor effect and lower toxicity were got by modified some structure of TNF. Nakamura [6] prepared a novel recombinant tumor necrosis factor-α (TNF) mutant (mutant 471), in which 7 N-terminal amino-acids were deleted and Pro8Ser9Asp10 was replaced by Arg-Lys-Arg, and compared its biological activity with that of wild-type recombinant TNF. Mutant 471 had a 7-fold higher anti-tumor activity against murine L-M cells in vitro, and a higher binding activity to TNF receptors on L-M cells, than wild-type TNF. Kamijo[7] reported that TNF(C-Phe), in which the C-terminal leucine of TNF molecule was replaced by phenylalanine, was 20-times as potent in induction of differentiation of human myelogenous leukemia cells (U-937 cells) as the parent TNF(N-Met). The rmhTNF has been obtained successfully from hTNF-α by gene engineering technology which was mutated by deleting 7 amino acids at the N-terminus, replacing Pro8Ser9Asp10 by Arg-Lys-Arg, and substituting Leu157 with Phe [8]. Phrase I clinical trial indicated that, all of 32 patients who were randomly grouped into six groups were treated with different dose: 2.5 × 105u/m2, 5 × 105u/m2, 1 × 106u/m2, 2 × 106u/m2, 3 × 106u/m2, 4 × 106u/m2, were well tolerable.

The present study has shown that shortly after the combined chemotherapy with rmhTNF, 24/69 (34.78%) of the focuses were more or less absorbed or subsidized, of which there were 1 CR case and 12 PR cases, with the response rate was 13/69 (18.84%), while in the control group only 5/36 (13.89%) cases had reduced focuses with only 1 PR case and the response rate 1/36 (2.78%). The response rate of the trial group was significantly higher than that of the control group (P = 0.022). Analysis of the therapeutic effects in different kind of diseases showed that the response rate for NSCLC of the trial group was 8/17 (47.06%), higher than that of the control group 1/6 (16.67%), which also means that TNFα has suppressive effects on lung adenocarcinoma[9]. The reason why there was no statistic significance (P > 0.05) between the two groups may be due to too small samples in this investigation. The response rates for gastric cancer and the colorectal cancer were both quite low, i.e. 4/32 (12.50%) and 1/20 (5.00%), respectively, while for the controls were 0/18 and 0/12, respectively (0.00%) and without statistic significance (P > 0.05). Such a result may be mainly due to the fact that most of the patients had taken combined chemotherapy before and that samples in both groups were quite small. It was thought [2] that the anti-tumor activity of TNF may co-activate some chemotherapy drugs. Results of the present study showed that the combined therapy of TNF and chemotherapy may be still effective on previously chemotherapy drug resistant tumors, which also means that TNF has co-activating effects on chemotherapy drugs. Moreover, after two treatment cycles, scoring for the general status (KPS) was 89.00 ± 9.92 in the trial group and 84.17 ± 8.84 in the control group, with a statistic significant difference (P = 0.028). It shows that the combined rmhTNF chemotherapy may benefit the quality of the patients' life.

It has already been reported[25, 10, 11] that the toxicity of TNF in phase I or II clinical trials are mainly chill, fever, local redness, swelling and pain, hypotension, nausea, vomiting, myalgia, fatigue and diarrhea, while pulmonary hemorrhage and severe hepatic dysfunction also have been observed[12]. But there are no reports on the toxicity of rmhTNF. The present study showed that some of the patients had pain in the injection area, chill and hardening, swelling and redness in the injection area of which the incidences were 81.2%(56/69), 44.9%(31/69) and 39.1% (27/69), respectively, but of a low degree and the patients had good tolerance. The symptoms of fever, ostealgia and myosalgia and cold-like symptoms were more in the trail group than that in the control group, all of which were of grade I or II. They mainly happened when the drugs were given at the 3rd or 5th times, and can be relieved after taking 25 mg metacen, and can disappear automatically after the finish of the therapy. There were no significant differences between the two groups on the number of cases which showed marrow suppression or nausea / vomiting, and on the degree of those symptoms. There were no cases which showed rmhTNF-correlated abnormal liver or kidney functions, urine routine, EEG and blood pressure.

In summary, combined therapy of rmhTNF and chemotherapy has co-activating and sensitivity improving effects on the treatment of advanced malignant tumors, and may increase the recent responsive effectiveness with an improvement of the general status and quality of patients' lives. The main adverse reactions of the local injection of rmhTNF are pain in the local injection area, chill, hardening and swelling and redness in the injection area, fever, ostealgia and myosalgia and cold-like symptoms, all of which were of light to moderate degree and are tolerable.

Declarations

Authors’ Affiliations

(1)
Department of Oncology, Union Hospital of Fujian Medical University

References

  1. Xian-Zhong Gao, Shu-Xu Xu: Current diagnosis and therapy of tumors [M]. 1973, Beijing, Science and Technology Press, 118-Google Scholar
  2. Min-Li Huang, Hong Sun, You-ji Feng: The study of Tumor-Necrosis Factor and chemotherapy on Gynecologic Carcinoma. Chin J Cancer Biother. 1995, 2 (3): 202-Google Scholar
  3. Lee KY, Chang W, Qiu D: PG 490 (triptolide) cooperates with tumors necrosis factor alpha to induce apoptosis in tumor cells[J]. J Biol Chem. 1999, 274 (19): 13451-13455. 10.1074/jbc.274.19.13451.View ArticlePubMedGoogle Scholar
  4. Lasek W, Giermasz A, Kuc K: Potentiation of the anti-tumor effect of actinomycin D by tumor necrosis factor alpha in mice: correlation between in vitro and vivo results[J]. Int J Cancer. 1996, 66 (3): 374-379.View ArticlePubMedGoogle Scholar
  5. Libutti SK, Barlett DJ, Franker DL: Technique and results of hyperthermic isolated hepatic perfusion with tumor necrosis factor and melphalan for the treatment of unresectable hepatic malignancies[J]. J Am Coll Surg. 2000, 191 (5): 519-530. 10.1016/S1072-7515(00)00733-X.View ArticlePubMedGoogle Scholar
  6. Nakamura S, Kato A, Masegi T: A novel recombinant tumor necrosis factor alpha mutant with increased anti-tumor activity and lower toxicity[J]. Int J Cancer. 1991, 48 (5): 744-748.View ArticlePubMedGoogle Scholar
  7. Kamijo R, Takeda K, Nagumo M: Induction of differentiation of human monoblastic and myeloblastic leukemia cell lines by TNF muteins[J]. Biochem Biophys Res Commun. 1989, 160 (2): 820-827.View ArticlePubMedGoogle Scholar
  8. Zhang ying-qi, Zhao ning, Li bo: Preparation of a novel recombinant human tumor necrosis factor-α by gene engineering technology[J]. Chin J Cell Mol Immunol. 2002, 18 (4): 402-405.Google Scholar
  9. Yi Su, Ya-Mei Wu: The study of synergistic cytotoxicity of tumor necrosis factor and interleukin-2 against lung adenocarcinoma cell[J]. Chinese Journal of Cancer. 2000, 19 (8): 779-781.Google Scholar
  10. Liddil JD, Dorr RT: Schedule dependent toxicity of tumor necrosis factor in rodents. Cancer drug Deliv. 1987, 4 (3): 159-167.View ArticlePubMedGoogle Scholar
  11. Budd GT, Green S, Baker LH: A Southwest Oncology Group phase H trial of recombinant tumor necrosis factor in metastatic breast cancer. Cancer. 1991, 68 (8): 1694-1695.View ArticlePubMedGoogle Scholar
  12. Schilling PJ, Murray JL, Markowitz AB: Novel tumor necrosis factor toxic effects. Cancer. 1992, 69: 256-260.View ArticlePubMedGoogle Scholar

Copyright

© Liu et al; licensee BioMed Central Ltd. 2004

This article is published under license to BioMed Central Ltd. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Advertisement