Clinical analysis of DC-CIK combined surgery for advanced renal cell carcinoma

Yu-Yang Wang,Gai Hang,Quan Wen,Bo Chen*

1Inner Mongolia Medical University,Inner Mongolia,China.2Tongliao Hospital of Inner Mongolia Autonomous Region,Inner Mongolia,China.

Abstract:Objective:This the aim of article to investigate the clinical efficacy of DC-CIK Immunotherapy for advanced renal cell carcinoma.Method:36 patients with advanced renal carcinoma were randomly divided into two groups:DC-CIK in treatment group and IFN-α in control group.Results:after treatment with DC-CIK in the treatment group,compared with the control group after treatment with IFN-α,CT was reexamined 1 year after treatment in both groups.There were significant differences in Alt,AST,SCR and BUN(P＜0.05),CD3(+),CD4(+)and CD8(+)in the treatment group were significantly higher than those in the control group(P＜0.05),The percentage of CD3(-)CD56(+),the Count of CD3(-)CD56(+)and the percentage of Tc were significantly different(P＜0.05),and the KPS score was significantly different between the treatment group treated with DC-CIK and the control group treated with IFN-α(P＜0.05).Conclusion:DC-CIK can inhibit and kill the tumor cells,and change the activity of T cell subsets,improve the immune function and quality of life of patients with advanced renal cell carcinoma.It is an immunotherapy program worthy of wide application in clinic practice.

Keywords:DC-CIK,IFN-α,immunotherapy,renal cell carcinoma

Background

Renal cell carcinoma(RCC)is a malignant tumor of the urinary system with high incidence rate and high mortality.According to previous data,30% of patients had metastasis at the time of diagnosis,and the effect of radiotherapy,chemotherapy and hormone therapy was poor[1].In the course of long-term clinical treatment,targeted therapeutic drugs were found to be safe and effective,but they were expensive,and the side effects of passive immunotherapy including IFN-α and IL-2 were obvious[2].Active immunotherapy has less side effects,so stem cell therapy has attracted more attention in the current medical[3].cytokine-induced killer(CIK)have the characteristics of killing tumors.Antigen presenting cells play an important role in the process of cell activation[4,5].It was reported that DC-CIK could relieve T cell immunologic incompetence,enhance the inhibition cell and prolong the survival time[6].However,there are few studies on DC-CIK in the treatment of advanced renal carcinoma.In this study,36 patients with advanced renal cell carcinoma treated in our hospital were treated with two methods,and the effects were recorded and analyzed.

Methods

Gneral research information

36 patients with advanced renal cell carcinoma(RCC)who were treated in our hospital from January 2017 to September 2020-were selected as the study objects.All patients met the clinical diagnostic criteria of RCC.They were randomly divided into two groups.Treatment group:13 males and 5 females,aged from 46 to 78 years,with an average of(53 ± 11.7)years,The course of disease ranged from 5 to 21 months,with an a verage of(11.3± 3.1)months,Tumor stage:Grade III in 10 cases and grade IV in 8 cases.Control group:10 males and 8 females,aged from 47 to 76 years,with an average of(48.3 ± 12.9)years,The course of disease ranged from 5 to 23 months,with an average of(12.3 ± 3.3)months,Tumor stage:grade III in 12 cases and grade IV in 6 cases.

Selection criteria

Inclusion criteria:(1)Meeting criteria for advanced renal cancer(Stage T3 and T4 of TNM staging standard of AJCC renal cell carcinoma in 2017).(2)Expected survival greater than 7 months.(3)No major mental illness and can actively cooperate with the treatment.(4)Consent to treatment and voluntary informed consent.

Exclusion criteria:(1)Concurrent presence of other malignant tumors or medical history,physical condition not resistant to continued treatment.(2)Active autoimmune disease.(3)Patients with a previous history of organ transplantation.(4)Patients with a history of allergy to biological products.

Main reagents

(1)IFN-α(Beijing Taize Ruida Technology Co.)

(2)DC-CIK cells(Beijing Jingmeng High-Tech Co.)

Treatment

Patients in both groups underwent laparoscopic radical nephrectomy at selected time after diagnosis;

Treatment Group:DC-CIK treatment regimen

DC-CIK cells need to be induced with 50ml sterile saline before infusion,and then DC-CIK cells need to be infused with 50ml sterile saline after infusion.During cell infusion,the speed should be kept at 23～40 drops/min,which should not be too fast,and ECG monitoring should be carried out.DC-CIK cells were infused once every two days from the first week-three times in all.The number of infused cells was 4 × 109～15 ×109.

Control group:IFN-α treatment regimen

The dosage and methods of IFN-α:This topic uses the gradually increasing dosage treatment way,which reduces the patient to the medicine the adverse reaction,the treatment process is smooth.3 MIU intramuscular injections 3 times a week for 12 weeks,6 MIU per injection in week,6 MIU per injection in week 2 and 9 MIU per injection after week 3.During the treatment period,the drug was stopped when the liver and kidney function was seriously damaged or other serious adverse reactions or the white blood cell count was less than 3 ×109/L,and the treatment was resumed after recovery.

Cell phenotype was detected by flow cytometry:the ratio of CD3(+),CD4(+),CD8(+),CD3(+)and CD56(+)cells was measured by T cell subgroup test kit and flow cytometer,respectively.The immunophenotypic characteristics of DC-CIK cells were required.

efficacy indicators and evaluation criteria

Observation Index:(1)Imaging Index:CT examination(Patients need to plain and contrast enhanced abdominal CT scan and plain chest CT scan every time),CT examination re-examination to evaluate the efficacy-1 year after treatment evaluation;(2)Biochemical test comparison;(3)T cell subsets were compared before and after treatment;(4)Quality of life and adverse reactions were observed:Appetite,sleep and mental status were observed before and after treatment-1 month after treatment;There are no adverse reactions or local irritation.

All of the above monitoring measures were tested at the 3,6,and 9 months after the end of treatment.

Living quality improvement assessment criteria:

The observation indexes were normal activity time,physical activity time,daytime,bed rest time and self-care ability in Karnofsky functional state score.Significant effect for KPS score increased by more than 20 points;effective for KPS score increased by more than 10 points;ineffective for KPS score increased by less than 10 points or unchanged or decreased.

Statistical methods

SPSS20.0 software was used to analyze the data and mean ±standard deviation(±S)was used to express the measurement data in the form of normal distribution and median(interquartile distance)was used to express the data in the form of skew distribution.The comparison of the multiple sample is the means of the measurement data with normal distribution and homogeneous variance applied variance analysis,the comparison between groups applied LSD-t test,the comparison of the measurement data with non-normal distribution or uneven variance applied non-parameter test,the test level α=0.05,P＜0.05indicated that the difference was statistically significant.

Results

Patients’ characteristics

Both groups were no significant di fference between the two groups in sex,age and tumor stage(P＞0.05),the difference was not statistically significant.It can be considered that the general information of the two groups is the same.（Table 1）

Table 1 Comparison of Patients’characteristics between treatment group and control group

Liver and kidney function of the two groups were compared before and after treatment

Alt,AST,SCR and BUN in the treatment group were not statistically significant compared with those in the control group before treatment(P＞0.05).After treatment with DC-CIK,ALT,AST,SCR and BUN were compared with control group after treatment with IFN-α.The difference was statistically significant(P＜0.05).It can be considered that the treatment of advanced renal cell carcinoma with DC-CIK has no damage to the liver and kidney function of patients,which is better than IFN-α.（Table 2）

T cell subsets were compared between the two groups before and after treatment

CD3(+),CD4(+)and CD8(+)in the treatment group were not statistically significant compared with those in the control group before treatment(P＞0.05).The levels of CD3(+),CD4(+)and CD8(+)in the treatment group were significantly higher than those in the control group(P＜0.05).The increase of CD3(+),CD4(+)and CD8(+)in patients'serum can improve the patient’s immunity and achieve a satisfactory anti-tumor effect.(Table 3)

Comparison of immune function between the two groups before and after treatment

There was no significant difference in CD3(-)CD56(+)count,CD3(-)CD56(+)percentage,TC percentage and Th cell percentage between the treatment group and the control group before treatment(P＞0.05).The percentage of CD3(-)CD56(+),the Count of CD3(-)CD56(+)and the percentage of Tc in the treatment group were significantly higher than those in the control group(P＜0.05),but there was no significant difference in the percentage of helper T cell(P＞0.05).It can be considered that DC-CIK can achieve the purpose of antitumor immunity by reducing the number of CD4(+)CD25(+)high cells,increasing the proportion of CD4(+)/CD8(+)cells and reducing the apoptosis rate of Tc.(Table 4)

KSP scores were compared between the two groups before and after treatment

There was no significant difference in KPS score between the treatment group and the control group before treatment(P ＞0.05).After treatment with DC-CIK,the KPS score was significantly higher than that of the control group after treatment with IFN-α(P＜0.05).It indicates that DC-CIK not only has a better tumor-killing effect on advanced patients,but also can improve the quality of life.(Table 5)

Table 2 Comparison of liver and kidney function before and after treatment

Table 3 The activity of T cell subsets before and after treatment was compared between the two groups.

Table 4 comparison of immune function between the two groups before and after treatment

Table 5 Comparison of KPS scores before and after treatment between the two groups.

Discussion

Renal cell carcinoma(RCC)is one of the most common renal malignancies originating from renal tubular epithelial cells,accounting for 75%-78% of renal tumors.The incidence of rate in urinary system is only inferior to prostate cancer and bladder cancer,but it is the highest mortality rate of urinary system[7,8].Because renal cell carcinoma is not sensitive to radiotherapy and chemotherapy,it is not recommended to carry out conventional radiotherapy and chemotherapy on the tumor bed after operation.Therefore,immunotherapy has become an important post-operative adjuvant therapy.Immunotherapy can be divided into active and passive immunity.Active immunotherapy utilizes the immunogenicity of tumor cells and uses various effective immune methods,such as IFN-α to induce the host immune response to tumor antigens.The most representative of passive immunotherapy is adoptive cell immunotherapy,such as DC-CIK amplifying auto-immune effector cells in vitro,autologous or allogeneic immune cells with an immune response to tumor cells are reinfused into the body of cancer patients to activate the immune response of the body’s immune system to achieve the goal of killing tumor cells.Anti-tumor immunity includes cellular immunity and humoral immunity.

Dendritic cell,as a powerful major antigen presenting cell(APC)in human body,can induce antigen-specific cytotoxic lymphocyte(CTL)response,influence the proliferation of β cells and activated humoral immune response[9,10].CIK cells have tumor specificity and cytotoxic activity,but their long-term therapeutic effect is weak,while DC has obvious advantage of long-term curative effect.Therefore,DC-CIK cells enhance the specificity of immune killing,both short-term and long-term results were achieved in the removal of tumors[11].The recurrence and metastasis of renal cell carcinoma(RCC)is one of the most important postoperative problems for RCC patients.This may be related to the observation time and the small number of observation objects.The liver and kidney function was also the key index after the traditional immunotherapy because of the obvious toxic and side effects.The results showed that there were significant differences in Alt,AST,SCR and BUN(P＜0.05).It indicates that DC-CIK therapy has no damage to liver and kidney function and is more safe.

Mature DC highly expressed MHC(Major histocompatibility complex)molecules bind to the antigen,forming MHC-Iantigen complex and MHC-Ⅱantigen complex,the former presenting antigen to CD8(+)cells,these cells differentiate into cytotoxic T cells,which present the antigen to CD4(+)cells to enhance theantibody-mediated immune response.Therefore,the level of CD3(+),CD4(+)and CD8(+)in peripheral blood is an important index to reflect the immune status of the body[12].The results of this study showed that CD3(+),CD4(+)and CD8(+)in the treatment group were significantly higher than those in the control group(P＜0.05),which to improve the patient’s immunity and achieve a satisfactory anti-tumor effect.

CD3(+)CD56(+)T cells are the main immunophenotype of CIK[13].It has been found that DC-CIK cells can decrease the number of CD4(+)CD25(+)high cells and increase the ratio of CD4(+)/CD8(+)cells,thus achieving the aim of anti-tumor immunity[14].Clinical studies have shown that DC-CIK cells can significantly enhance T lymphocyte cytotoxicity,increase the ratio of CD3(+)CD56(+)cells,stimulate rapid cell proliferation and reduce T cell apoptosis[15].Results the percentage of CD3(+)CD56(+)and the Count of CD3(+)CD56(+)were significantly different between the two groups(P＜0.05).The main reason cancer cells proliferate in the body is that they evade recognition by the immune system,preventing the body from producing the cytotoxic T lymphocyte that specifically kill tumors.Tc is the main effector of cell-mediated anti-tumor immunity[16].Th1 can differentiate into Th1 or Th2,Th1 secretes IFN-γ and IL-2,which assist T lymphocyte mediated immune response,and Th2 secretes IL-4 and IL-10,which enhance antibody mediated immune response and thus exert antitumor effect[17].The percentage of Tc decreased and the difference was statistically significant(P＜0.05).With the improvement of People’s living standards,the quality of life of cancer patients,especially patients in the middle and late stages,is becoming more and more impoertent.The side effects of traditional immunotherapy and the disease itself can lead to the decrease of the quality of life of the patients.Therefore,this study found that the changes of KPS scores were statistically significant(P＜0.05).It indicates that DC-CIK not only has a better tumor-killing effect on advanced patients,but also can improve the quality of life.

In conclusion,DC-CIK is effective in the treatment of patients with advanced renal carcinoma.It can inhibit and kill tumor cells,change the activity of T cell subsets,improve the immune function and improve the quality of life.It is an immunotherapy program worthy of wide application in clinic.