[CANCER RESEARCH 43, 5575-5579, November 1983] Randomized Controlled Study of Adjuvant Immunotherapy with Nocardia rubra Cell Wall Skeleton for Inoperable Lung Cancer1 Yuichi Yamamura,2 Takeshi Ogura,3 Mitsunori Sakatani, Fumio Hirao, Susumu Kishimoto, Masahiro Fukuoka, Minoru Takada, Masaaki Kawahara, Kiyoyuki Furuse, Osamu Kuwahara, Harumichi Ikegami, and Nobuya Ogawa Osa/fa University Kamiyamada, Suita, Osaka 565 [Y. Y.J; Department of Internal Medicine, Osaka University Medical School, Fukushima-ku, Osaka 553 [T. O., M. S., F. H., S. K.]; Habikino Hospital, Habikino, Osaka 583 [M. F., M. T.]: Kinki Central Hospital, /Vagasene Sakai, Osaka 591 [M. K., K. F.]; Toneyama Hospital, Toneyáma Toyonaka, Osaka 560 [0. K.]; Osaka Center for Adult Diseases, Higa$hinari-ku, Osaka 537 [H. I.]; and Department of Pharmacology, University of Ehime School of Medicine, Onsen-gun, Ehime 791-02 [N. 0.¡,Japan ABSTRACT laboratories (2). Animal experiments performed by us and others suggest that N-CWS is therapeutically effective in tumor-bearing In order to evaluate the clinical benefit of Nocardia rubra cell animals, mainly through production of specific killer T-cells as wall skeleton (N-CWS), a randomized controlled study was per well as tumoricidal macrophages (8, 12, 16, 17, 19, 20, 21). A formed with inoperable lung cancer patients entered in 5 insti preliminary Phase I study showed that N-CWS can be given to tutions from October 1978 to June 1981. Patients without pleural cancer patients in an advanced stage without serious adverse effusions were treated initially with conventional therapies such reactions (23). Thus, the present randomized controlled study as chemotherapy and/or radiotherapy, according to common was undertaken in collaboration with 4 affiliated hospitals to protocol, and then patients in performance statuses 0 to 3 were examine the adjuvant therapeutic effect of N-CWS on survival of randomized into control and N-CWS groups with stratification patients with inoperable lung cancer. into 16 categories according to 4 histológica! types and 4 clinical stages. In the N-CWS group, 400 u,g N-CWS were initially MATERIALS AND METHODS injected once or twice into the bronchial tumor using a fiberoptic bronchoscope, and subsequently 200 ng of N-CWS were in Patients. Patients with inoperable cytologically proven primary lung jected at monthly intervals into the skin from the shoulders to cancer were entered in the present trial from October 1978 to June upper arms. Of 309 patients, 118 patients in the N-CWS group 1981. The criteria for patient entry were: no history of other cancers; no and 108 patients in the control group were eligible for statistical evidence of significant dysfunction in vital organs such as heart, kidney, analysis. There was statistically no significant difference in sur lung, or liver; age younger than 76 years; and no previous treatment for vival rate between the control and the N-CWS groups. According cancer. The eligible patients were carefully graded into Stages I, II, III, and IV according to the Japan Clinical Staging System (9) which closely to histological type, significant prolongation of the survival period corresponds to the International Union Against Cancer Staging System was observed in patients with small-cell carcinoma. The 97 (7). The patients without pleural effusion were classified into 16 groups patients with pleural effusions were initially randomized into according to a combination of 4 histological types and 4 clinical stages control and N-CWS groups. In the control group, local chemo before initial conventional therapy. The patients with pleural effusion therapy with Adriamycin was performed and, in the N-CWS were treated under another protocol of local therapy. group, local administrations and monthly intracutaneous injec Biological Response Modifier. Immunological and biological charac tions of N-CWS were given. Tube thoracostomy was performed teristics of N-CWS have been reported previously (12, 16, 18, 20, 21, 23). The agent used in the present trial was a squalene-treated, freeze- in both groups. The local response rate was statistically greater in the N-CWS dried form manufactured aseptically by Fujisawa Pharmaceutical Co., Ltd. (Osaka, Japan). Informed consent for use of this agent was obtained group than in the control group, and survival period was also from all patients in the N-CWS group. prolonged significantly in the N-CWS group. The main adverse Treatment Schedule. Modality of initial conventional therapy for pa reactions to N-CWS were skin lesions in the injected sites and tients without pleural effusion was prescribed according to histological fever, but these were temporary and not serious. type and clinical stage as summarized in Table 1. In this protocol, radiotherapy for primary tumor consisting of 1000 rads/week was given generally in 6 cycles for squamous cell carcinoma and 3 cycles for INTRODUCTION localized small-cell carcinoma. Chemotherapy (CT-1) for small-cell carci Although the use of adjuvant immunotherapy has not been noma consisted mainly of cyclophosphamide (600 mg once for 4 weeks; Shionogi Pharmaceutical Co., Ltd., Osaka, Japan), 3-[(4-amino-2-methyl- extensively investigated in inoperable lung cancer, there have 5-pyrimidinyl)methyl]-1 -<2-chloroethyl)-1 -nitrosourea hydrochloride (80 to been a few reports on prolongation of survival in patients with 100 mg once for 3 to 4 weeks; Sankyo Pharmaceutical Co., Ltd., Tokyo, nonspecific immunotherapy (3, 13). Our recent studies have focused on the clinical application of N-CWS4 prepared in our Japan), and Adriamycin (40 mg once a week for 3 to 4 weeks; Kyowa Hakko Industries, Ltd., Tokyo, Japan) given in i.v. injection. In most cases, vincristine (1 mg; Shionogi Pharmaceutical Co., Ltd., Osaka, 1This study was supported by Grants for Cancer Research from the Ministry of Japan) was added i.v. once or twice a week. The main chemotherapy drugs (CT-2) for the other 3 histological types were Adriamycin (40 mg Health and Welfare and the Ministry of Education, Science, and Culture. 2 President of Osaka University Kamiyamada Suita, Osaka 565, Japan. once for 4 weeks) and methotrexate (20 mg twice a week, at 2-week 3To whom requests for reprints should be addressed. drug-free intervals; Nippon Lederle Co., Ltd., Tokyo, Japan) or vincristine ' The abbreviations used are: N-CWS, Nocardia rubra cell wall skeleton; PS, (1 mg twice a week, at 2-week drug-free intervals), all of which were performance status; i.e., transcutaneously; i.t., intratumorally; i.d., intradermal; i.e., intracutaneously; BCG, Bacillus Calmette-Guérin;ÃŒ.I.,intralesionally. given i.v. In addition, p.o. administration of Tegafur (600 mg; Taiho Received January 6,1983; accepted August 10,1983. Pharmaceutical Co., Ltd., Tokyo, Japan) was given daily to most patients NOVEMBER 1983 5575 Downloaded from cancerres.aacrjournals.org on October 1, 2021. © 1983 American Association for Cancer Research. Y. Yamamura et al. Table 1 Treatment modality of initial conventional therapy stageHistologySmall-cell Clinical carcinoma + CT-1 + CT-1 Squamous cell carcinoma RT RT RT (RT) + CT-2 AdenocarcinomaIRt" RTIIRT (RT) + CT-2IIICT-1 CT-2IVCT-1 CT-2 Large-cell carcinoma Same as adenocarcinoma a RT, radiation therapy; CT, chemotherapy. Tabte2 Distribution of characteristics ol eligible patients Response to initial Histology Clinical Stage PS therapy Squa- Adeno- mous carci- Large > Unevalu- PatientsWithoutpleuraleffusionN-CWSControlTotalWith(M/F)89/2985/23174/5222/1323/1045/23NS"(<65/65-75)63/5557/51120/10623/1222/1145/23NScell333265101cell393675Ia12noma433982333164NScell3140111IIIII4 073 50% able 2356 1770 561 43 2 1848 39 4724 7134 44 3 25104 28 5 149262349NSIV36326891019<50%87 512NS1 6743NS pleuraleffusionN-CWSControlTotalx'testSex a Classified histologically as adenosquamous cell carcinoma. 6 NS, not significant. with adenocarcinoma. Usually, these initial conventional therapies were criteria authorized by the Japan Lung Cancer Society (10), which were terminated after 8 weeks. The patients, who were still in PSs 0 to 3, graded corresponding to WHO recommendation (22). Adverse reactions were randomly assigned to the control or N-CWS group by key codes in in symptomatic manifestations in the N-CWS group were recorded sealed envelopes. Randomization was performed within 2 weeks after carefully, and abnormal laboratory findings between the N-CWS and completion of initial conventional therapy. Patients in the N-CWS group control groups were compared statistically. Survival period was calcu were given intratumoral injections with 400 to 600 ^g of N-CWS under lated from the start of initial therapy to December 31,1981, for patients fiberoptic bronchoscopy, as described by Hayata ef al. (5). In the patients without pleural effusion and to April 30, 1982, for patients with pleural with no evidence of intrabronchial tumor by endoscopy, N-CWS was effusion. Survival rate curves were derived from the method of Kaplan injected into the corresponding bronchial submucosal tissue by the same and Meier (11), and the difference between the control and N-CWS method as mentioned above. In the other patients with subpleurally groups was examined by a generalized Wilcoxon test (4). Patients in localized tumor, N-CWS was injected t.c. directly into the tumor. For control and N-CWS groups who died within 30 days after the end of the patients who refused the i.t. administration of N-CWS, 200 ^g of N-CWS initial therapy were excluded from statistical analysis. were given i.d. in the shoulder or upper arms at weekly and then monthly intervals. RESULTS Patients with histologically proven cancerous effusion were assigned in advance to either the N-CWS or the control group. Patients in PS 4 Characteristics of Patients. A total of 406 patients were were also included, because patients with pleural effusion occasionally recover from PS 4 by drainage of pleural effusion. Patients in the N-CWS entered in the trial. In the study with 309 patients without pleural group were treated locally with 40 mg of Adriamycin and 400 ^g of N- effusion, 118 patients in the N-CWS group and 108 patients in CWS at weekly intervals by tube thoracostomy.