Med. Oncol. & Tumor Pharmacother. Vol. 8, No. 4, pp. 223-228, 1991
0736--0118/91 $3.00 + .00 Pergamon Press Ltd
Printed in Great Britain
REVIEW MONOCLONAL
ANTIBODIES
IN THE MANAGEMENT
OF CARCINOMA
PATIENTS
MARIO ROSELLI,*[[ C A R L O U. CASCIANI,* F I O R E L L A G U A D A G N I , t O R E S T E B U O N O M O , * BENIAMINO IORIO,* A L E S S A N D R A DIODATI,* VINCENZO VITTORINI,* J O H N W. GREINER,~. DAVID COLCHER$w and J E F F R E Y SCHLOM$ *Department of Surgery, II University of Rome, Schoot of Medicine, Rome, Italy; ~-Regina Elena Cancer Institute, Rome, Italy; :~Laboratory of Tumor Immunology and Biology, National Cancer Institute, NIH, Bethesda, MD 20892, U.S.A. (Received 7 Muy 199l; accepted 12 May 199 l) The use of monocionai antibodies (MAbs) in the clinical management of carcinoma patients is reported in the present review. Among the various MAbs generated, MAb B72.3 (LTIB, National Cancer Institute, U.S.A.) has been extensively used in clinical trials either for antigen identification (TAG-72) in sera, or for tumor localization in carcinoma patients. Serum assay results, in colorectai cancer patients, showed the usefulness of the MAb B72.3 in monitoring the clinical course of the malignant disease. Its specific tumor localization (70% of the biopsy specimens) and the immunoscintigraphy studies, after in vivo administration, have also been discussed. The positive results obtained, markedly contributed in the development of a new intraoperative methodology termed "radioimmunoguided surgery".
Key words: Monoclonal antibody, B72.3, TAG-72, Radioimmunoguided surgery, Colorectal cancer.
There are several different ways to use MAbs for clinical management of neoplastic patients, including clinical diagnosis using serum assays, immunocytopathological analyses of effusions or fine-needle aspiration specimens, immunoscintigraphy and, with additional development, site-directed immunotherapy. Their diagnostic applications may provide a good opportunity to preselect patients for the immunotherapy on the basis of the localization of the MAb to primary as well as metastatic tumor lesions through imaging studies. In the past few years a high-molecular weight mucin-like glycoprotein, termed TAG-72 (Tumor Associated Glycoprotein-72), has been identified and characterized using the murine IgG~ MAb B72.3. tT-~STAG-72 antigen is found in high percentages of colorectal, stomach, ovary, pancreas, breast and non-small cell lung adenocarcinomas.~9-2~ This pancarcinoma antigen is rarely expressed in most normal adult human tissues, 2~ with the exception of secretory phase endometrium, 22 and transitional colonic mucosa. 23 Recently, the development of second generation anti TAG-72 MAbs, using the purified TAG-72 as immunogen and designated CC (for Colon Cancer), :4 enabled the possibility of improving the detection of TAG-72 antigen in t h e
INTRODUCTION
Since hybridoma technology has been developed t several monoclonal antibodies have been generated which are currently under investigation either for diagnosis or therapy of carcinoma patients. At the present time, many of these MAbs have already been used in various aspects of patient management and in better understanding the biology of carcinoma cell populations. 2-~5 These MAbs have also led to the identification and/or characterization of novel tumor-associated antigens (TAAs) expressed by human neoplasia. Several basic principles appear to pertain to the vast majority of TAAs, since a given carcinoma associated antigen is usually expressed in more than one type of carcinoma, i.e. not all tumors within a given tumor type, and not all cells within a tumor lesion, wilt express a given TAA. In fact, there is not only antigenic heterogeneity among carcinoma cell populations, but also a temporal modulation of tumor antigens, t6 .{Actual address; Dept of Pathology, University of Nebraska Medical Center, Omaha, NE, U.S.A. ]lTo whom reprints should be addressed: Mario Roselli M.D., Dept of Surgery, II University of Rome; c/o S. Eugenio Hospital, P.te Dell'Umanesimo 10, 00144 Rome, Italy. 223
224
Mario Roselli et al.
serum and other body fluids of carcinoma patmnts.-Using the new double-determinant immunoradiometric assay, CA 72-4, approximately 40% of patients with carcinoma of the ovary, colon, pancreas, stomach, and lung have circulating serum TAG-72 levels greater than the suggested cut-off limit (i.e. 6 U/ml). Only 3.5% and 6.7% of sera from normal volunteers and patients with benign gastrointestinal (GI) disease, respectively, have TAG-72 levels greater than 6 U/ml. 2(' Presented here is a review from previously published w o r k s 7-t1"16-22'24-26"3335-45 0 n the use of specific MAbs in the diagnosis of carcinoma.
Sera from 9 of 11 (82%) of these patients had elevated TAG-72 levels and 6 of 11 (55%) had elevated C E A levels. The increase of one or both marker serum levels correlated with the clinical status in 10 of 11 (91%) patients with recurrence. This study showed that T A G - 7 2 serum m a r k e r is present in a considerable n u m b e r of patients where C E A cannot be detected at the time of diagnosis and/or at the time of recurrence of the disease. Therefore, the m e a s u r e m e n t of both T A G - 7 2 and C E A may improve the m a n a g e m e n t of G I adenocarcinoma patients, due to the c o m p l e m e n t a r i t y which exists between these tumor markers.
TUMOR TARGETING
SERUM ASSAY Serum assays using a specific M A b may be useful, not only to detect the presence of occult carcinoma lesions, but also to identify those patients who may be good candidates for immunotherapy, and to monitor the efficacy of standard therapy. At this time the main application of tumor markers is monitoring tumor activity, and one of the most used serum assays is the well-known C E A . 27-3t In fact, during therapy, C E A serum levels may give aq accurate estimate of the effectiveness of treatment~ An early detection ot: relapse, evidenced by an elevation of the t u m o r marker serum level, may lead to a different therapeutic strategy at a time that might precede clinical evidence of tumor recurrence. Moreover, C E A serum levels can provide diagnostic as well as prognostic information of patients with carcinoma. 27-3. Recently, Guadagni and colleagues 26 compared the presence of elevated levels of TAG-72 in patients with primary carcinoma of the GI tract with that of C E A . Sera from 82 patients with diagnosed G I carcinomas were evaluated for the presence of T A G - 7 2 and C E A prior to surgery. As shown in Fig. 1, 39% and 42% of the patients had elevated serum levels of TAG-72 ( > 6 U/ml) and C E A (>5 ng/ml), respectively. In addition, a substantial percentage of patients (16%) where C E A was not detected, scored positively for TAG-72; conversely, approximately 17% of patients with undetected T A G - 7 2 levels had elevated C E A levels, suggesting the complementarity between the two markers. F u r t h e r m o r e , elevated levels of either m a r k e r were found in sera of 82% of patients with advanced GI cancer, which is an increase of 24% over the measurement of C E A alone. Serum T A G 72 and C E A levels were also monitored in 31 patients (21 colon, and 10 stomach tumors) for varying lengths of time after resection of the carcinoma; 11 patients developed recurrent disease.
Several studies were carried out to define the specific tumor localization of in vivo administration of radiolabeled MAb B72.3 in colorectal cancer patients. ~ ' ~ > ~ 5 A quantitative evaluation of its reactivity was also obtained by direct analyses of biopsy materials: tumor and normal tissue r e m o v e d for staging. At the present time, M A b B72.3 has been administered to more than 100 patients at the National Institutes of Health Clinical Center and to several hundred patients worldwide. A p p r o x i m a t e l y one week prior to surgery, patients were given radiopharmaceutical ~-~lI-B72.3 M A b both intravenously (i.v.) or intraperitoneally (i.p.) for the radioimmunolocalization of metastatic disease, t3LIB72.3 M A b administered i.v. localized in t u m o r
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Fig. 1. Pre-surgery serum TAG-72 and CEA levels in patients diagnosed with GI carcinoma. The closed (O) circles represent serum TAG-72 and CEA values in patients with colorectal carcinoma. Open (9 circles are values for patients with gastric carcinoma. Dashed (---) lines represent the cutoff serum levels for TAG-72 (6 U/ ml) and CEA (5 n~ml).
Clinical value of MAbs lesions with a Radiolocalization Index greater than 3 times as compared with normal tissues (see Table 1), in approximately 70% of the colorectal carcinoma lesions examined after surgery. 13~I-B72.3 M A b administered i.p. also selectively localized carcinoma lesions with over 100 times higher percent injected dose/g (%~D/g) in tumors as compared with normal tissue in selected patients, in terms of gamma-scanning, positive localization was seen in approximately 50% of the cases. This discrepancy between the RI indices and gamma-scanning is most likely due to the fact that gamma-cameras are not set for the 13tI but for other radionuclides. This impairs image resolution and, in some cases, detection of small lesions (i.e. less than 2 cm) by gammascanning techniques. Iodine, for a variety of reasons, is not a good radionuclide for diagnostic imaging as well as therapeutic purposes. Therefore, the scan results may be improved by using other radionuclides, such as ~)')mTc, ~l~In and ~23I, that are considered more suitable for gamma-scanning. 32 The initial immunoscintigraphy studies, however, did demonstrate the ability of B72.3 M A b to selectively localize different carcinoma lesions at many organ sites. A n o t h e r important observation which comes from the initial t u m o r targeting trial using 131I-B72.3 M A b was the development of human anti-mouse Ig antibodies ( H A M A ) . 33 The presence of H A M A in these patients represents two different problems. The first is the inability to administer to patients multiple injections of a MAb. Serum H A M A also interferes with established R I A s which use mouse antibodies to measure such tumor antigens as T A G - 7 2 and C E A . 34"35 This interference
225
is usually represented by an unexpected elevation in the level of the antigen being studied, without any correlation to the status of the disease. Therefore, different treatments have been established to abolish the artifact due to H A M A , 34'35 thus allowing the continued use of tumor markers for evaluating the patients' clinical course.
RADIOIMMUNOGUIDED SURGERY T u m o r detection can also be achieved by a new interesting approach: the intraoperative use of a gamma-sensitive probe. Recently, the Ohio State University College of Medicine group has developed an intraoperative gamma-detecting p r o b e ( G D P , N e o p r o b e Corporation, Columbus, Ohio), 36 which has been shown to be useful in the localization of t u m o r lesions at laparotomy using monoclonal antibody labeled with the low-energy y-emitter iodine 125. 37`38 This new technique has been termed "radioimmunoguided surgery" (RIGS). R I G S , first reported in 1985, was developed to improve the identification of both primary and recurrent carcin o m a lesions too small to be detected by current external imaging techniques such as c o m p u t e d i o m o g r a p h y (CT) and immunoscintigraphy. C o l ~ orectal carcinoma patients with locally advanced, or metastatic disease, are still potentially eligible for surgical cure; thus, accurate determination of the extent of t u m o r within the a b d o m e n is crucial for the successful treatment of patients. In addition, there is a large group of patients with elevated serum t u m o r
Table 1. Localization of ~3~I-B72.3 IgG to carcinoma lesions and normal organs RI* Malignant lesions
RI Normal organs
Anatomic site
i0
Positive RI totalt
Liver Colon Small intestine Lymph node Lung Peritoneum Pelvis Soft tissue Spleen Other Total
4 5 3 4 3 18 1 2 3 0 43
24 10 t 7 6 18 1 3 0 5 75
1 2 3 2 2 8 0 3 1 2 24
25/29 12/17 4/7 9/13 8/11 26/44 1/2 6/8 1/4 7/7 99/142
10
Positive RI total-~
20 35 20 19 6 29 9 53 1 21 198
0 0 2 2 0 2 0 1 0 1 8
0 0 0 .0 0 0 0 0 4 0 4
0/20 0/35 2/22 2/21 0/6 2/31 0/9 1/54 4/5 1/22 12/210
*The % ID/g of every biopsy specimen was divided by the % ID/g of the normal tissue(s) used as standard to determine the Radiolocalization Indices (RI). ?>3 are considered positive for MAb localization. [Modified from Colcher et al. s]
226
Mario
Roselli
et al.
markers but no evidence of disease who undergo exploratory laparotomy. Intraoperative definition of all tumor sites in such patients is frequently difficult because of adhesions and concerns in obtaining a large number of frozen section biopsy specimens from areas that are only marginally suspicious. In this context, the RIGS technique plays an important role. In fact, the i.v. administration of radiolabeled monoclonal antibody to the patient and the subsequent exploratory laparotomy, by a hand-held gamma-detecting probe, are used to examine the abdominal cavity in order to identify cancer cells tagged by the antibody. The surgeon can easily scan the abdominal cavity in a few minutes. Furthermore, superficial tumor lesions located on, or near a body cavity orifice can be detected externally, and probedirected biopsies performed. The original study -v' showed the advantages of this new surgical procedure in detecting intra-abdominal cancer. In a preliminary study, 3* eight of nine patients diagnosed with primary colorectal cancer localized L:5I-B72.3 MAb. In the same trial '-~5l-B72.3 MAb was also localized in 47 of 57 carcinoma sites in patients with recurrent colorectal cancer. Subclinical tumor, unidentified by inspection and palpation, was detected by RIGS in 26% of the patients with recurrept disease (see Table 2). At the present time ~esI is the isotope being used to label monoclonal antibodies, although the use of other radionuclides such as ~ I n , 99mTc or w-~l are still being considered. In theory, their emission energy make these radionuclides very promising because preoperative external scintillation scans could also be performed; thus providing additional information to the surgeon before the patient is explored. The external scan would perhaps demonstrate more accurately the extent of the tumor and identify patients with antigen-positive tumors prior to surgery. The G D P would then be used intraoperatively to identify both clinically obvious tumors as well as subclinical tumors not detected by the traditional diagnostic methods. This method of tumor detection may have the potential to improve the potential therapeutic results of surgery and it may also provide information to improve radioimaging and the selection of patients for subsequent MAb-mediated therapeutic trials. With further improvements in antibody engineering and modification it is anticipated that RIGS will become even more effective. The advent of new antibodies or new molecules that clear the blood pool more quickly will decrease the time between the injection of the radiolabeled antibody and surgical procedure, overcoming, therefore, the major problem of this technique. The use of monoclonal antibodies with higher affinity, cocktails of antibodies, along with improved
Table 2. RIGS in recurrent colorectal cancer Location of recurrence
Liver Pelvis Implants Lymph nodes Local recurrence Lung Second primary
Percent sites localized* 68.4 100 88.9 80 75 100 100
(13/19) (12/12) (8/9) (8/10) (3/4) (2/2) (l/I)
*Indicates a tumor:normal ratio (No. localized/Total No.) [Modified from Sickle-Santanello et ell. (38)] isotope selection and labeling methodology, will add significantly to the successful use of this new surgical technique.
NEW APPROACHES Several innovations have recently been obtained which may enhance the diagnostic and therapeutic efficacy of monoclonal antibodies. We have already discussed the possibility of using different radionuclides; thus, various studies are ongoing 39 using new chelate chemistries for the more efficient coupling of [3- and c,-emitters, considered more suitable for therapy than iodine, to MAb B72.3. A different approach to improve radiopharmaceutical delivery to tumor cells is the dose fractionation which will enable the administration of a high dose of radioactivity not tolerated as a single injection. 4~ Furthermore, the development of new molecules such as the recombinant/chimeric B72.3 (y84 and u should eliminate or reduce the human anti-murine IgG response since constant regions of these molecules are human. *l'42 These new constructs should make possible multiple dose regimens. Recently, advances in technology involving the cloning of Ig genes led to the development of modified forms of lgG, such as Single Chain Antibody (SCA). This new molecule is composed of a variable-chain amino acid sequence (VL) of an lg tethered to a variable heavy chain (VH) sequence by a linker peptide. Experiments performed in athymic mice have been encouraging for its potential usefulness in future clinical applications in the management of c a n c e r ) 3 Finally, studies have been performed to overcome antigen heterogeneity in carcinoma lesions. Besides the use of high-energy radionuclides to kill several cell diameters, another approach could be the use of multiple antibodies cocktails. 4a Antigenic heterogeneity can also be modulated using Biological Response Modifiers
Clinical value o f M A b s
such as interferons (lENs). It has been already shown that either IFN-c~ or -y can selectively upregulate tumor antigen expression, and these findings appear to have important implications in the more efficient use of many MAbs for tumor diagnosis and therapy. 45
12.
1
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0736--0118/91 $3.00 + .00 Pergamon Press Ltd
Printed in Great Britain
REVIEW MONOCLONAL
ANTIBODIES
IN THE MANAGEMENT
OF CARCINOMA
PATIENTS
MARIO ROSELLI,*[[ C A R L O U. CASCIANI,* F I O R E L L A G U A D A G N I , t O R E S T E B U O N O M O , * BENIAMINO IORIO,* A L E S S A N D R A DIODATI,* VINCENZO VITTORINI,* J O H N W. GREINER,~. DAVID COLCHER$w and J E F F R E Y SCHLOM$ *Department of Surgery, II University of Rome, Schoot of Medicine, Rome, Italy; ~-Regina Elena Cancer Institute, Rome, Italy; :~Laboratory of Tumor Immunology and Biology, National Cancer Institute, NIH, Bethesda, MD 20892, U.S.A. (Received 7 Muy 199l; accepted 12 May 199 l) The use of monocionai antibodies (MAbs) in the clinical management of carcinoma patients is reported in the present review. Among the various MAbs generated, MAb B72.3 (LTIB, National Cancer Institute, U.S.A.) has been extensively used in clinical trials either for antigen identification (TAG-72) in sera, or for tumor localization in carcinoma patients. Serum assay results, in colorectai cancer patients, showed the usefulness of the MAb B72.3 in monitoring the clinical course of the malignant disease. Its specific tumor localization (70% of the biopsy specimens) and the immunoscintigraphy studies, after in vivo administration, have also been discussed. The positive results obtained, markedly contributed in the development of a new intraoperative methodology termed "radioimmunoguided surgery".
Key words: Monoclonal antibody, B72.3, TAG-72, Radioimmunoguided surgery, Colorectal cancer.
There are several different ways to use MAbs for clinical management of neoplastic patients, including clinical diagnosis using serum assays, immunocytopathological analyses of effusions or fine-needle aspiration specimens, immunoscintigraphy and, with additional development, site-directed immunotherapy. Their diagnostic applications may provide a good opportunity to preselect patients for the immunotherapy on the basis of the localization of the MAb to primary as well as metastatic tumor lesions through imaging studies. In the past few years a high-molecular weight mucin-like glycoprotein, termed TAG-72 (Tumor Associated Glycoprotein-72), has been identified and characterized using the murine IgG~ MAb B72.3. tT-~STAG-72 antigen is found in high percentages of colorectal, stomach, ovary, pancreas, breast and non-small cell lung adenocarcinomas.~9-2~ This pancarcinoma antigen is rarely expressed in most normal adult human tissues, 2~ with the exception of secretory phase endometrium, 22 and transitional colonic mucosa. 23 Recently, the development of second generation anti TAG-72 MAbs, using the purified TAG-72 as immunogen and designated CC (for Colon Cancer), :4 enabled the possibility of improving the detection of TAG-72 antigen in t h e
INTRODUCTION
Since hybridoma technology has been developed t several monoclonal antibodies have been generated which are currently under investigation either for diagnosis or therapy of carcinoma patients. At the present time, many of these MAbs have already been used in various aspects of patient management and in better understanding the biology of carcinoma cell populations. 2-~5 These MAbs have also led to the identification and/or characterization of novel tumor-associated antigens (TAAs) expressed by human neoplasia. Several basic principles appear to pertain to the vast majority of TAAs, since a given carcinoma associated antigen is usually expressed in more than one type of carcinoma, i.e. not all tumors within a given tumor type, and not all cells within a tumor lesion, wilt express a given TAA. In fact, there is not only antigenic heterogeneity among carcinoma cell populations, but also a temporal modulation of tumor antigens, t6 .{Actual address; Dept of Pathology, University of Nebraska Medical Center, Omaha, NE, U.S.A. ]lTo whom reprints should be addressed: Mario Roselli M.D., Dept of Surgery, II University of Rome; c/o S. Eugenio Hospital, P.te Dell'Umanesimo 10, 00144 Rome, Italy. 223
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serum and other body fluids of carcinoma patmnts.-Using the new double-determinant immunoradiometric assay, CA 72-4, approximately 40% of patients with carcinoma of the ovary, colon, pancreas, stomach, and lung have circulating serum TAG-72 levels greater than the suggested cut-off limit (i.e. 6 U/ml). Only 3.5% and 6.7% of sera from normal volunteers and patients with benign gastrointestinal (GI) disease, respectively, have TAG-72 levels greater than 6 U/ml. 2(' Presented here is a review from previously published w o r k s 7-t1"16-22'24-26"3335-45 0 n the use of specific MAbs in the diagnosis of carcinoma.
Sera from 9 of 11 (82%) of these patients had elevated TAG-72 levels and 6 of 11 (55%) had elevated C E A levels. The increase of one or both marker serum levels correlated with the clinical status in 10 of 11 (91%) patients with recurrence. This study showed that T A G - 7 2 serum m a r k e r is present in a considerable n u m b e r of patients where C E A cannot be detected at the time of diagnosis and/or at the time of recurrence of the disease. Therefore, the m e a s u r e m e n t of both T A G - 7 2 and C E A may improve the m a n a g e m e n t of G I adenocarcinoma patients, due to the c o m p l e m e n t a r i t y which exists between these tumor markers.
TUMOR TARGETING
SERUM ASSAY Serum assays using a specific M A b may be useful, not only to detect the presence of occult carcinoma lesions, but also to identify those patients who may be good candidates for immunotherapy, and to monitor the efficacy of standard therapy. At this time the main application of tumor markers is monitoring tumor activity, and one of the most used serum assays is the well-known C E A . 27-3t In fact, during therapy, C E A serum levels may give aq accurate estimate of the effectiveness of treatment~ An early detection ot: relapse, evidenced by an elevation of the t u m o r marker serum level, may lead to a different therapeutic strategy at a time that might precede clinical evidence of tumor recurrence. Moreover, C E A serum levels can provide diagnostic as well as prognostic information of patients with carcinoma. 27-3. Recently, Guadagni and colleagues 26 compared the presence of elevated levels of TAG-72 in patients with primary carcinoma of the GI tract with that of C E A . Sera from 82 patients with diagnosed G I carcinomas were evaluated for the presence of T A G - 7 2 and C E A prior to surgery. As shown in Fig. 1, 39% and 42% of the patients had elevated serum levels of TAG-72 ( > 6 U/ml) and C E A (>5 ng/ml), respectively. In addition, a substantial percentage of patients (16%) where C E A was not detected, scored positively for TAG-72; conversely, approximately 17% of patients with undetected T A G - 7 2 levels had elevated C E A levels, suggesting the complementarity between the two markers. F u r t h e r m o r e , elevated levels of either m a r k e r were found in sera of 82% of patients with advanced GI cancer, which is an increase of 24% over the measurement of C E A alone. Serum T A G 72 and C E A levels were also monitored in 31 patients (21 colon, and 10 stomach tumors) for varying lengths of time after resection of the carcinoma; 11 patients developed recurrent disease.
Several studies were carried out to define the specific tumor localization of in vivo administration of radiolabeled MAb B72.3 in colorectal cancer patients. ~ ' ~ > ~ 5 A quantitative evaluation of its reactivity was also obtained by direct analyses of biopsy materials: tumor and normal tissue r e m o v e d for staging. At the present time, M A b B72.3 has been administered to more than 100 patients at the National Institutes of Health Clinical Center and to several hundred patients worldwide. A p p r o x i m a t e l y one week prior to surgery, patients were given radiopharmaceutical ~-~lI-B72.3 M A b both intravenously (i.v.) or intraperitoneally (i.p.) for the radioimmunolocalization of metastatic disease, t3LIB72.3 M A b administered i.v. localized in t u m o r
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Fig. 1. Pre-surgery serum TAG-72 and CEA levels in patients diagnosed with GI carcinoma. The closed (O) circles represent serum TAG-72 and CEA values in patients with colorectal carcinoma. Open (9 circles are values for patients with gastric carcinoma. Dashed (---) lines represent the cutoff serum levels for TAG-72 (6 U/ ml) and CEA (5 n~ml).
Clinical value of MAbs lesions with a Radiolocalization Index greater than 3 times as compared with normal tissues (see Table 1), in approximately 70% of the colorectal carcinoma lesions examined after surgery. 13~I-B72.3 M A b administered i.p. also selectively localized carcinoma lesions with over 100 times higher percent injected dose/g (%~D/g) in tumors as compared with normal tissue in selected patients, in terms of gamma-scanning, positive localization was seen in approximately 50% of the cases. This discrepancy between the RI indices and gamma-scanning is most likely due to the fact that gamma-cameras are not set for the 13tI but for other radionuclides. This impairs image resolution and, in some cases, detection of small lesions (i.e. less than 2 cm) by gammascanning techniques. Iodine, for a variety of reasons, is not a good radionuclide for diagnostic imaging as well as therapeutic purposes. Therefore, the scan results may be improved by using other radionuclides, such as ~)')mTc, ~l~In and ~23I, that are considered more suitable for gamma-scanning. 32 The initial immunoscintigraphy studies, however, did demonstrate the ability of B72.3 M A b to selectively localize different carcinoma lesions at many organ sites. A n o t h e r important observation which comes from the initial t u m o r targeting trial using 131I-B72.3 M A b was the development of human anti-mouse Ig antibodies ( H A M A ) . 33 The presence of H A M A in these patients represents two different problems. The first is the inability to administer to patients multiple injections of a MAb. Serum H A M A also interferes with established R I A s which use mouse antibodies to measure such tumor antigens as T A G - 7 2 and C E A . 34"35 This interference
225
is usually represented by an unexpected elevation in the level of the antigen being studied, without any correlation to the status of the disease. Therefore, different treatments have been established to abolish the artifact due to H A M A , 34'35 thus allowing the continued use of tumor markers for evaluating the patients' clinical course.
RADIOIMMUNOGUIDED SURGERY T u m o r detection can also be achieved by a new interesting approach: the intraoperative use of a gamma-sensitive probe. Recently, the Ohio State University College of Medicine group has developed an intraoperative gamma-detecting p r o b e ( G D P , N e o p r o b e Corporation, Columbus, Ohio), 36 which has been shown to be useful in the localization of t u m o r lesions at laparotomy using monoclonal antibody labeled with the low-energy y-emitter iodine 125. 37`38 This new technique has been termed "radioimmunoguided surgery" (RIGS). R I G S , first reported in 1985, was developed to improve the identification of both primary and recurrent carcin o m a lesions too small to be detected by current external imaging techniques such as c o m p u t e d i o m o g r a p h y (CT) and immunoscintigraphy. C o l ~ orectal carcinoma patients with locally advanced, or metastatic disease, are still potentially eligible for surgical cure; thus, accurate determination of the extent of t u m o r within the a b d o m e n is crucial for the successful treatment of patients. In addition, there is a large group of patients with elevated serum t u m o r
Table 1. Localization of ~3~I-B72.3 IgG to carcinoma lesions and normal organs RI* Malignant lesions
RI Normal organs
Anatomic site
i0
Positive RI totalt
Liver Colon Small intestine Lymph node Lung Peritoneum Pelvis Soft tissue Spleen Other Total
4 5 3 4 3 18 1 2 3 0 43
24 10 t 7 6 18 1 3 0 5 75
1 2 3 2 2 8 0 3 1 2 24
25/29 12/17 4/7 9/13 8/11 26/44 1/2 6/8 1/4 7/7 99/142
10
Positive RI total-~
20 35 20 19 6 29 9 53 1 21 198
0 0 2 2 0 2 0 1 0 1 8
0 0 0 .0 0 0 0 0 4 0 4
0/20 0/35 2/22 2/21 0/6 2/31 0/9 1/54 4/5 1/22 12/210
*The % ID/g of every biopsy specimen was divided by the % ID/g of the normal tissue(s) used as standard to determine the Radiolocalization Indices (RI). ?>3 are considered positive for MAb localization. [Modified from Colcher et al. s]
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markers but no evidence of disease who undergo exploratory laparotomy. Intraoperative definition of all tumor sites in such patients is frequently difficult because of adhesions and concerns in obtaining a large number of frozen section biopsy specimens from areas that are only marginally suspicious. In this context, the RIGS technique plays an important role. In fact, the i.v. administration of radiolabeled monoclonal antibody to the patient and the subsequent exploratory laparotomy, by a hand-held gamma-detecting probe, are used to examine the abdominal cavity in order to identify cancer cells tagged by the antibody. The surgeon can easily scan the abdominal cavity in a few minutes. Furthermore, superficial tumor lesions located on, or near a body cavity orifice can be detected externally, and probedirected biopsies performed. The original study -v' showed the advantages of this new surgical procedure in detecting intra-abdominal cancer. In a preliminary study, 3* eight of nine patients diagnosed with primary colorectal cancer localized L:5I-B72.3 MAb. In the same trial '-~5l-B72.3 MAb was also localized in 47 of 57 carcinoma sites in patients with recurrent colorectal cancer. Subclinical tumor, unidentified by inspection and palpation, was detected by RIGS in 26% of the patients with recurrept disease (see Table 2). At the present time ~esI is the isotope being used to label monoclonal antibodies, although the use of other radionuclides such as ~ I n , 99mTc or w-~l are still being considered. In theory, their emission energy make these radionuclides very promising because preoperative external scintillation scans could also be performed; thus providing additional information to the surgeon before the patient is explored. The external scan would perhaps demonstrate more accurately the extent of the tumor and identify patients with antigen-positive tumors prior to surgery. The G D P would then be used intraoperatively to identify both clinically obvious tumors as well as subclinical tumors not detected by the traditional diagnostic methods. This method of tumor detection may have the potential to improve the potential therapeutic results of surgery and it may also provide information to improve radioimaging and the selection of patients for subsequent MAb-mediated therapeutic trials. With further improvements in antibody engineering and modification it is anticipated that RIGS will become even more effective. The advent of new antibodies or new molecules that clear the blood pool more quickly will decrease the time between the injection of the radiolabeled antibody and surgical procedure, overcoming, therefore, the major problem of this technique. The use of monoclonal antibodies with higher affinity, cocktails of antibodies, along with improved
Table 2. RIGS in recurrent colorectal cancer Location of recurrence
Liver Pelvis Implants Lymph nodes Local recurrence Lung Second primary
Percent sites localized* 68.4 100 88.9 80 75 100 100
(13/19) (12/12) (8/9) (8/10) (3/4) (2/2) (l/I)
*Indicates a tumor:normal ratio (No. localized/Total No.) [Modified from Sickle-Santanello et ell. (38)] isotope selection and labeling methodology, will add significantly to the successful use of this new surgical technique.
NEW APPROACHES Several innovations have recently been obtained which may enhance the diagnostic and therapeutic efficacy of monoclonal antibodies. We have already discussed the possibility of using different radionuclides; thus, various studies are ongoing 39 using new chelate chemistries for the more efficient coupling of [3- and c,-emitters, considered more suitable for therapy than iodine, to MAb B72.3. A different approach to improve radiopharmaceutical delivery to tumor cells is the dose fractionation which will enable the administration of a high dose of radioactivity not tolerated as a single injection. 4~ Furthermore, the development of new molecules such as the recombinant/chimeric B72.3 (y84 and u should eliminate or reduce the human anti-murine IgG response since constant regions of these molecules are human. *l'42 These new constructs should make possible multiple dose regimens. Recently, advances in technology involving the cloning of Ig genes led to the development of modified forms of lgG, such as Single Chain Antibody (SCA). This new molecule is composed of a variable-chain amino acid sequence (VL) of an lg tethered to a variable heavy chain (VH) sequence by a linker peptide. Experiments performed in athymic mice have been encouraging for its potential usefulness in future clinical applications in the management of c a n c e r ) 3 Finally, studies have been performed to overcome antigen heterogeneity in carcinoma lesions. Besides the use of high-energy radionuclides to kill several cell diameters, another approach could be the use of multiple antibodies cocktails. 4a Antigenic heterogeneity can also be modulated using Biological Response Modifiers
Clinical value o f M A b s
such as interferons (lENs). It has been already shown that either IFN-c~ or -y can selectively upregulate tumor antigen expression, and these findings appear to have important implications in the more efficient use of many MAbs for tumor diagnosis and therapy. 45
12.
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