Keyhole limpet hemocyanin for carcinoma in situ of the bladder: a long-term follow-up study.

OBJECTIVE: Keyhole limpet hemocyanin (KLH) is a nonspecific immunomodulator, demonstrated to be clinically effective in superficial bladder cancer. The present study investigated the clinical efficacy of intravesical KLH in patients with carcinoma in situ (CIS) with a long-term follow-up. METHODS: Thirteen patients with CIS grade III were treated with intravesical instillations of KLH, 20 mg for 6 weeks, then monthly for 1 year and bimonthly for 2 subsequent years. Patients not responding to 2 courses of KLH were treated with bacillus Calmete-Guérin (BCG, 81 mg Connaught strain). RESULTS: The follow-up period ranged from 12 to 84 months. Two patients were free of tumor after KLH instillations with a follow-up of 66 and 82 months, respectively. All patients who did not respond to the primary KLH course, but to the 'rescue' instillation of BCG, experienced recurrences after 42, 48, 56 and 60 months after the first KLH instillation treatment. Three patients with recurrent CIS and who were not cystectomized had recurrences after prolonged remission (4-5 years). Patients progressing despite KLH and BCG instillations underwent cystectomy. CONCLUSIONS: KLH demonstrates efficacy and induces long- term remissions against CIS in a limited number of cases. In the present study, most patients with CIS progressed over time whatever the substance instilled, whether KLH or BCG. CIS remains a very aggressive neoplasm requiring a lifelong follow-up. Further studies are necessary to define the precise role of KLH in patients with CIS.

Efficacy of prophylactic Immucothel in patients pretreated with conventional drugs to prevent recurrence of superficial bladder carcinoma.

OBJECTIVES: Fifty patients enrolled in clinical trials with Immucothel((R)) were reevaluated for their disease-free intervals. METHODS: Of the 37 evaluable patients, 16 had received mitomycin C, 3 bacillus Calmette-Guérin, 3 Adriamycin and 15 miscellaneous pretreatments prior to Immucothel. They thus served as their own controls. RESULTS: Although their prognosis was worse at the time when Immucothel therapy was started than at the time of initiation of pretreatment, the mean recurrence-free intervals of all patients increased from 17.0 months under pretreatment to 35.1 months under Immucothel. CONCLUSION: The difference was statistically significant (Wilcoxon matched-pairs signed-ranks test).

Antibody response to keyhole limpet hemocyanin (KLH) treatment in patients with superficial bladder carcinoma.

The dynamics of specific KLH-antibody production after intracutaneous and intravesical instillation was analysed. Nine patients (male, n = 7; female, n = 2, mean age 68.6 years, range 47-75) with primary superficial carcinomas of the bladder were intracutaneously immunized with 1 mg Keyhole limpet hemocyanin (KLH) after the complete resection of the tumors. Treatment was continued for 6 consecutive weeks, monthly for one year and thereafter bimonthly for 2 subsequent years, consisting of 20 mg KLH in 20 ml saline introduced intravesically. The antibodies against KLH in patient sera were determined by means of a specially developed direct enzyme-linked immunosorbent assay (ELISA; according to H. von der Kammer, Max Planck Institute for Biophysical Chemistry, Goettingen, Germany). Blood was taken for antibody-titer examination before treatment and 8 weeks after treatment. The KLH-antibody titer increased significantly (Mann-Whitney-Test P = 0.02) after KLH therapy in bladder cancer patients, however the level varied considerably from patient to patient. 6 of 9 patients (67%) presented increased serum antibody titers to KLH after immunotherapy. 4 patients (44.4%) remained free of tumor during the established follow-up period of 10-45 months (median 30.7 months). One patient without increased antibody titer to KLH was free of tumor, 2 patients however, suffered from tumor recurrence after the KLH course. 2 patients presented with tumor recurrence in spite of increased antibody titers. No evidence of tumor progression occurred in patients with recurrence after KLH therapy. 4 of 5 patients (80%) without tumor recurrence presented with a positive skin test. Of patients with tumor recurrence, 50% had a negative skin test. 44.4% KLH-treated patients had tumor recurrence The recurrence rate was 1.6. The time to recurrence was 8.75 months. KLH instillation did not induce major side effects. Positive skin test reactivity and KLH antibody response were more commonly seen in responding patients (i.e. those who remained tumor free after therapy) than in non-responders. The production of KLH antibodies, apparently is the biological response to the antigen stimulus of KLH.

Urinary interleukin-1 alpha levels are increased by intravesical instillation with keyhole limpet hemocyanin in patients with superficial transitional cell carcinoma of the bladder.

Intravesical instillation of keyhole limpet hemocyanin (KLH) is a possible treatment for decreasing tumor recurrence after transurethral resection (TUR) in patients with superficial transitional cell carcinoma of the bladder (stages pTa-pT1, grades 1-3). Our study confirms the theory that instillation of KLH stimulates production of cytokines, resulting in their secretion in urine. Interleukin-1 (IL-1) stimulates the immune cascade through a domino effect and is produced mainly by activated macrophages. The instillation program was started 5-7 days after TUR of primary superficial cell carcinoma. 20 mg KLH in 20 ml of 0.9% NaCl was instilled into the bladder each week for 6 consecutive weeks and then monthly for 1 year. When KLH is instilled into the bladder, IL-1 alpha is secreted in the urine. A specific enzyme-linked immunosorbent assay (ELISA) was used for analysis. The ELISA for IL-1 alpha was established in our laboratory and showed a detection limit of 5 pg/ml. This IL-1 alpha ELISA deviation amounts to 3-7% within a series of measurements, and 5-15% from series to series. In the therapy group the IL-1 alpha secretion ranged from 0 to 30,905 pg/24 h and in the control group from 0 (collection period) to 2,472 pg/4 h. IL-1 alpha production increased significantly after KLH instillation in bladder cancer patients; however, the level varied considerably from patient to patient. Maximum production was achieved within a period of 4-8 h, decreasing within 24 h. There was a striking difference between the amount of IL-1 alpha produced over the 24-hour period in the control group and that of the KLH group. 8 of 14 patients (57%) who responded to KLH therapy had higher urine IL-1 alpha levels after 6 weeks of KLH treatment than those who failed to respond within 12 months, but the levels were not of statistical significance. The secretion of IL-1 alpha in urine is the biological response of the bladder to the antigen stimulus of KLH. No IL-2 was detected in the urine samples. It remains to be determined whether no IL-2 cytokine was present, or whether the amount was smaller than the minimal detection limit required for the ELISA.

[Adjuvant immunotherapy with keyhole limpet hemocyanin in category PT 2 N+ and PT 3-4, No-N+, Mo renal cell carcinoma]. / Adjuvante Immuntherapie mit Keyhole Limpet Hemocyanin (KLH) beim Nierenzellkarzinom der Kategorie PT 2 N+ und PT 3-4, No-N+, Mo.

This study was a prospective randomized trial to compare adjuvant immunotherapy with Keyhole Limpet Hemocyanin (KLH) after radical nephrectomy. From January 1983 to December 1988, 50 patients underwent radical nephrectomy for category PT 2 N+ and PT 3-4, No-N+, Mo renal cell carcinoma. Postoperatively 25 patients were given adjuvant treatment with the biological response modifier, Keyhole Limpet Hemocyanin (KLH), and 25 patients were in the control group. In each group 2 patients were lost to follow-up. The mean follow-up time was 55 months. Adjuvant treatment with KLH did not appear to improve the prognosis in renal cell carcinoma patients. The 5-year survival rate was 60% in the KLH group and 56.5% in the control group. Progress was seen in 9/23 in the KLH group, 10/23 in the controls. The median survival in patients showing progress was 27 and 28 months in the two groups, respectively. Studies with a combination of low dose cyclophosphamide and KLH revealed a positive immunostimulating effect, which may provide the rationale for further research concerning different KLH doses, schedules or therapeutic combinations.