The role of therapeutic apheresis in the treatment of cancer: a review

M. Rigdon Lentz
Therapeutic Apheresis. -1999. -Vol. 3, no. 1. -R. 40-48.
Columbia Southern Hills Medical Center, Nashville, Tennessee, U.S.A.

It is now well understood that immunosuppression is the hallmark of malignant

tumours in humans. Clinical cancer is characterized by State of immunosuppression
or immunological tolerance, manifested by depression of cellular immunity in the
presence of circulating blocking factors to cause tolerance to neoantigenam as a
result of immune effects of different hormones such as estrogen, progesterone and
human horiogonadotropin- (-HCG); the presence of suppressive t-cells; the
presence of factors that enhance the migration of leukocytes; immune adhesion
reduction of red blood cells.
The degree of suprescii is directly proportional to the stage and extent of a tumor
process. Mechanism which defines immunotolerantnost and immunotolerantnosti
acquired the status provides alien proteins of tumor cells, called soluble factors in
blood and Extracellular Fluid spaces, violate the ability of cellular immunity
influence tumor cell antigens [M.R. Lentz, 1990]. It must be remembered that the
majority of vertebrate animals do not develop cancer throughout their lives, despite
the mathematical probability of each of us 4-6 tumor cells every day.

History of immunosuppression in cancer.

Over the past 40 years, many researchers have identified soluble blood factors,
immunosuppressive serum, ascitic and pleural fluid in human tumors. Primary
observations have been performed M.G.Wittaker and others. (1971) and Suciu-Foca
N etc. (1973), which demonstrated that immune deficiency identified in vitro caused
by circulating blocking factors. The lack of defined the progression of the disease
and the level of these factors increased in proportion to the extent of this
progression. This implies a direct correlation between the prevalence of tumors and
the degree of immune deficiency.
M.R.Lichtenstein (1942) found that pregnancy is also accompanied by increased
immunotolerantnost to antigens of the fetus, when cellular immunity response
below the normal level.
R.W.Rosenstein, etc. (1981) identified and partially identified the suppressive factors
of Splenocytes in specific gaptenovoj sensitivity in mice. These factors are proteins
of 65,000-70,000 Daltons and adsorbirovalis by macrophages.
R.W.Baldwin, etc. (1972) found that the serum of rats with gepatomoj-induced
aminoazokrasitelem, incubation with effector cells inhibits their cytotoxic effects on
tumor cells. K.E.Hellstrom and i. Hellstrom (1974) described the cytotoxicity of
autologous serum ingibici mononuclear cells in vitro. E. Murray (1978) found
blocking the cytotoxic activity of lymphocytes in the serum of patients with
melanoma and the reason for that was a glycoprotein with 15.000 Daltons.
It was identified that supressivny factor secreted by the tumor. W.F.Sample, etc.
(1971) found that the serum of cancer patients whose blood showed reduced
activity, suppressed the ability of fitogemaggltininovu to fitoaggltinacii normal
lymphocyte from normal serum of healthy individuals.
Many researchers have found immunosuppressive factors of serum of cancer
patients in direct proportion to the degree of prevalence of tumors. The inhibitors
were similar and in pregnant women, which defined the same immunotolerantnost
to antigens of the fruit.
Finally, specific inhibitors of tumor necrosis factor (TNF and ) in serum and serum
ultrafiltrate were M.R.Lentz and others. in 1990 year.

The paradigm of immune regulation

Decrease of inhibitors of immune reactions in blood and extracellular fluids by
Apheresis can be very useful in cancer patients.

Cytokines tumor necrosis factor (TNF), interleukins IL-1 and IL-6

and their receptors
TNF is a plejotropnym citokinom, produced to combat damage or infection. These
molecules are the main effectors of inflammatory and immune responses in
animals. There are two forms of TNF- TNF and TNF . TNF plays an important and
pivotal role as mediator of resistance against viruses, bacteria, fungi, and cancer
cells. It is important to note, however, that the over-production of these cytokines
may lead to different pathological States, including systemic toxicity and septic
shock.
Identified 2 types of TNF receptor (TNFR). One of them-TNFR2 (type a, 75.000
Daltons or UTR Antigen). Another receptor, called TNFR1 (type b, 55,000 Daltons).
Both of these receptors have a high degree of affinity with TNF or TNF.
Many groups of researchers have identified TNF binding proteins in human serum
and urine and which can neutralize their biological activity. These proteins sTNFR1
and sTNFR2. These soluble forms are specific to each of the two types of TNFR and
discover at the level 1-2 ng/ml in serum and urine of healthy individuals.
Elevated levels of serum or plasma sTNFR found in pathological conditions such as
Meningococcemia, endotoxemia, and HIV infection. High levels were also found in
the plasma and ascitic fluid of patients with infections and malignant tumors. ..
However, when the level of less than 6.5 sTNFR ng/ml was 10.6-month median
survival, and at the level of more than 6.5 ng/ml-3.6 months.
Interleukin 1 (IL-1).
There are two forms of IL-1, IL-1 and 1 IL. These cytokines are produced mainly
mononuklearnymi by phagocytes, as well as a number of other cell types, including
keratocity the skin, some epithelial cells and some cells of the central nervous
system. These cytokines have diverse effects on different types of cells. They also
regulate the production of a large number of other proteins, including other
cytokines IL-2, TNF and colony stimulating factors.
IL-1 and 1 IL-are important mediators of inflammation and immune responses in
animals. Due to the earlier appearance of IL-1 during inflammatory reactions and
because of the various effects of IL-1 and 1 IL, these cytokines are considered to
play an important role in the development of pathological conditions including
chronic inflammation, septic shock and defects in hematopoiesis.
Effects of IL-1 produced by linking these cytokines with two different cell membrane
receptors, IL-1R type 1 or 2. In particular, the type 1 receptor-protein 80.000 Dalton
found on lymphocytes and polymorphonuclear leukocytes of ....
Found and various types of inhibitors of IL-1 and made from the urine of patients
with myeloid leukemia-protein of 25,000 Daltons. Produce IL-1r monocytes,
fibroblasts, macrophages and neutrophil. Cytokines regulating the production of IL-1
, include IL-13, IL-16, IL-4, IFN- , granulocite-macrophage colony stimulating factor
(GMCSF) and tumor growth factor (TGF ). The latter stimulates the production of IL-
1, IL-1r . In experiments shown that IL-1r blocks the activity of IL-1 both in vitro
and in vivo.
Shows possible therapeutic effect of IL-1r in treating sepsis, rheumatoid arthritis,
cachexia, chronic myeloid leukemia and the reactions of rejection of the
transplanted bone marrow.

Interleukin 6 (IL-6)
Is t-lymphocytes, macrophages, fibroblasts, monocitarnymi gepatocitami, vascular
endothelial cells, the cells of cardiac myxomas, bladder cancer, myeloma,
astrogliomy, glioblastoma. The influence of IL-6 on various cells varied stimulation
of differentiation in lymphocytes and antibody secretion, activation of IL-2 t-
lymphocytes, the acceleration of the cytotoxic t lymphocyte differentiation, and
growth factor of mature thymocytes and peripheral t-lymphocytes, cells, hybridoma
cells, myeloma, plasmacytoma, keratinocytes, mezangialnah cells, hematopoietic
cells and others. These different effects indicate that IL-6 plays a major role in the
mediation of the inflammatory and immune response to infections, lesions and
malignant tumors. Elevated levels of IL-6 is associated with various diseases,
including autoimmune diseases, mesangial proliferative Glomerulonephritis,
psoriasis and cancer.
Biological activity of IL-6 binding starts with the cytokine receptor complex affine
with two-membrane lectin. IL-6R (80.000 Daltons) and glycoprotein 130,000 Dalton
and make up this set. Soluble forms of IL-6R (50,000 Daltons) were found in the
urine of healthy, myeloma cells in culture, t-cell Lymphoma (Lymphoma virus HTLV)
and serum HIV-positive HIV-infected ... more

Experiments on animals
In 1982, we have developed a system of molecules from the blood Apheresis
poluselektivnogo less than 150 000 Daltons. We used a porous membrane in the flat
track modules in parallel layers. Membranes were made of polycarbonate and 5 m
thickness were with 0.05 m size pores. Sieving coefficient of albumin (69.000
Daltons) was 40% for IgG-8%. This process is called "ultraferez" (more correctly-
cascade plasmapheresis!).
First, procedures were performed on pregnant animals with known gestational age
to test a hypothesis that removal of blocking factors could induce childbirth. Each of
the 6 pregnant sheep was a ultraferezna procedure which they all suffered no
apparent side effects. However, all of them started labour and they gave birth to a
normal baby.

6 dogs were selected then induced malignant tumors. 5 have been swelling breasts
and 1-osteosarcoma. Was ultraferez to call the inflammatory process in tumors
after removal of the blocking factor.
After 1 treatment in dogs tumors were observed gmperemi, local heat, swelling,
softening.
After 2-3 treatments in the tumors were determined by local hemorrhages,
coagulation necrosis, visible when a biopsy.
After 5 treatments of tumors regressed. Residual tumor masses were rezecirovany
and there remained only the scar. Dogs were observed until their death (1-4 years)
and there was no sign of recurrence of tumors.
Clinical research
The first phase of these works has been approved by the US Food and Drug
Administration (FDA) in 1985, and held at the University of California, Irvine.
Each of the 16 patients had a variety of solid tumors, and they have all accepted
methods of treatment have failed. It was held on the 12 month ultrafereza
procedures that were transferred.
Removal of plasma ultrafiltrate volume stood at 10 ml/BW (5-25 mL/kg). The volume
removed 3 times a week and poorly to ultrafiltrate volume, prepared from fresh-
frozen plasma normal healthy donors. Duration of the procedure was 1:0 (from 30
minutes before 2:0). The frequency and the volumes were sufficient to induce and
maintain the inflammatory processes in tumors.
Patients has increased pulsating pain in the area of cancer, local hyperemia and
fever, pain and softening of skin tumors, with the rise of the level of c-reactive
protein (CRP) and lactate dehydrogenase (LDH).
In 1 patient with metastatic melanoma after 7 procedures for removal capacity
guaranteed 250 ml of ultrafiltrate has developed specific hemorrhagic necrosis and
Lysis syndrome tumors.
Clinical result initially reduced diameter measured tumors (by palpation or Rg-
logical).
Complete cure was full as disappearance or Rg-logical measurable tumours.
Partial result-decreasing diameter at 50% or more or histologically detected necrosis
or reparative fibrosis at 50% or more compared to the reference level.
The minimum result-reduction or necroses biopsy is less than 50%.
Stabilization is defined by the absence of cancer growth, compared with the initial
state before treatment.
In 14 of the 16 patients experienced redness, swelling and softening of the tumors.
The metastases disappeared in a patient with metastatic adenokarcinomoj, two
patients with melanoma, three-cancer with metastatic breast and one patient with
bladder cancer disappeared dysuria, frequent urge to urinate and a 50% decreased
the size of the tumor when a cystoscopy.
In 3 patients developed Lysis syndrome tumors with full its necrosis (2-1 and
melanoma with neoplastic tumor of the Wilm's).
In 6 of the 16 patients had tumour at 50% or more.
The 3-decrease by less than 50%.
The 2-piece is stabilization of the tumor.
Some patients in this phase of the study had multiple melanoma of skin with
repeated biopsimi. By 12:0 am after the first procedure has not yet been seen
softening and swelling of the tumor. Determined by hypertrophy of vascular
endothelial tumor and perivaskulrnoe accumulation of monocytes in the form of
coupling. Then lymphocytes were infiltrating the fabric, disrupted structure of tumor
cells and their nuclei. Identified coagulation and hemorrhagic necrosis of tumor
mass. Necrosis progressed until the complete disappearance of tumors.
The FDA gave approval for additional studies that were conducted in the Nac. The
medical centre, hospital, J. Kennedy in Palm Springs, California in 64 patients. Tumor
were breast, kidney, prostate, melanoma, nemelcockletocny lung cancer, ovarian
cancer, endometrial cancer, Wilm's tumour, colon cancer, Sarcoma of soft tissues,
osteogennaya Carcinoma, orogovevaij Carcinoma of head and neck, lung, cervix.
For this research we determined soluble TNFR inhibitor in serum and serum
ultrafiltrate these patients. This inhibitor is neutralized killer lymphocytes and
cytotoxicity of macrophages, and producirovals and sekretirovals tumor cells,
stromal tumor cells and vascular endothelial cells of the tumor. We also found a
significant increase of the inhibitor in serum of pregnant women.
Other researchers found the inhibitors to IL-1 and IL-6 in the form of low molecular
fraction of proteins, to ultrafereze. We are working on the identification of possible
specific inhibitor of -interferon (IFN) and molecules that appear from TNF-
inhibitors that affect blasttransformaci. Each of these molecules in size less than
100,000 Daltons and destroyed ultrafereze.
We studied the biological role of TNF inhibitors, based on their ability to inhibit
recombinant TNF when L-929 cells in vitro. Then we have identified these molecules
by ELISA (R&D Sistems Inc., Minneapolis, MN U.S.A.). Using these molecules, we
have confirmed a direct correlation between the degree of reduction and TNFR1
TNFR2 and degree of tumor regression in clinical courses Apheresis of low-
molecular-weight proteins in patients with tumors of mammary glands.
Ultrafereza methods were studied using hollow fibre devices which were found to
be more effective.

We have completed the pilot issledoyvani this method for metastatic melanoma,
cancer of the breast and colon cancer and found a significant effect.
This type of tumor-specific inflammation in tumor necrosis when combined with
signs of systemic toxicity has not been clinically studied in our earlier studies to
stimulate tumor immunity in sverhfiziologieskih doses of exogenous
proinflammatory cytokines.
We found a clear difference between anticipated and actual postafereznym-TNFR1
and TNFR2 indicating that TNFR2 can be reduced to a greater extent than TNFR1 in
tumor tolerance.
We continue to work to create more effective systems and devices for better control
of concentration of inhibitors in order to achieve a maximum of clinical effect.
Recently, D.H.Murmn et al (1998) found a indoleamine 2-3-dioxygenase (IDO)-
enzyme, tryptophan, kataboliziruij secreted by the trofoblastom and by
macrophages, and have suggested that the presence of this enzyme allows the
placenta to destroy the tryptophan-essential amino acid required in the production
of TNF. So it will not be a surprise that this enzyme may be detected and in cancer
cells. This could be another possible complementary mechanism suppressing the
immune protection.

Auto-immune disease.
Immunologic Pharmaceutical Corporation (Seattle, WA, U.S.A) has developed a
preparation consisting of two molecules sTNFR2 and Fc receptor. Studies have
demonstrated the ability of the material to stop immune inflammation in patients
with rheumatoid arthritis and dose-dependence between the high concentration of
infuziruemogo inhibitor and curative effect. This information corresponds to our
observations and to increase inflammation, destroying native antigen [the tumor] at
lower concentrations TNFR2 method ultrafereza. However, it is clear that great care
should be observed at the introduction of these materials for clinical use in the
treatment of autoimmune diseases and shall be conditioned for specific points in
such therapy, to their level in the blood has been restored to normal [to avoid
provoking tumours!].

Conclusion
It became clear that the soluble inhibitors of cellular immunity, specific inhibitors of
proinflammatory cytokines are activated in these clinical situations in which tumor
tissue antigens are tolerant to the effects of the immune system.
There is no doubt that inflammation may be stimulated removal of these inhibitors
and if removing them is sufficiently complete, it can be achieved by the complete
destruction of the tumor. And alien [and aberrant own] antigens can be eliminated.
It was clear from our clinical studies that complete destruction of tumors is possible
up to restore the ability of cell destruction and reduce the possibility of the
recurrence of the tumor.
This is the fundamental for the future of cancer research.

Address correspondence and reprint requests to Dr. m. Rigdon Lentz,

397 Wallace Rd., Suit 314, Nashville, TN 37211, U.S.A.

THERAPEUTIC PLASMAPHERESIS PROTOCOLS IN ONCOLOGY

Valery Voinv.A., Orlov, S.v., Karchevskyy K.s., Warriors A.v.
Spbmu name akad. I.p. Pavlova, St. Petersburg.
There is a lot of evidence for detoxification and efferent therapy in cancer patients:
1. in the preoperative preparation of the 2-3 sessions of plasmapheresis with laser
irradiation of blood. Especially in cases with obstructive jaundice and inflammatory
complications from tumors.
2. support of chemoradiotherapy-plasmapheresis sessions over 5, 10, 15 and 20
sessions of radiation for a month.
3. accompanying courses of chemotherapy for the purpose of detoxication-the 2-3
sessions of plasmapheresis in volume of up to 0.3 ORC with laser irradiation of blood
after each cycle of chemotherapy. Substitution of kristalloidnymi solutions,
expressed in gipoproteinemii to add protein solutions (albumin, plasma). A total of
over 6 months may take up to 12-15 sessions of plasmapheresis.
4. intensive plasmapheresis programs conducted through the day during the month
(up to 12 sessions) with the removal of up to 0.5 ORC and replacement with donor
plasma/w ratio of 0.8: 1 with laser irradiation of blood for inhibitors of killernoj
activity of lymphocytes and killer cytolytic activity of macrophages to activate
cellular immunity.
(Published in the Anthology: "proceedings of the twelfth Conference of the Moscow
society of gemafereza, m., 2004, p. 9).