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10.1245/s10434-006-9239-x
Annals of Surgical Oncology 14:1295-1304 (2007)
© 2007 Society of Surgical Oncology
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Original Article

Low-dose Interleukin-2 Administered Pre-operatively to Patients with Gastric Cancer Activates Peripheral and Peritumoral Lymphocytes But Does Not Affect Prognosis

Giovanni Carlo Cesana1, Fabrizio Romano1, Gaia Piacentini1, Marco Scotti1, Ambrogio Brenna2, Giorgio Bovo2, Massimo Vaghi3, Giacomo Aletti4, Roberto Caprotti1, Howard Kaufman5 and Franco Uggeri1

1 Department of General Surgery, University of Milano-Bicocca, S. Gerardo Hospital, via Donizzetti 106, Monza 20052, Milan, Italy
2 Department of Pathology, University of Milano-Bicocca, S. Gerardo Hospital, via Donizzetti 106, Monza 20052, Milan, Italy
3 Department of Clinical Oncology, University of Milano-Bicocca, S. Gerardo Hospital, via Donizzetti 106, Monza 20052 Milan, Italy
4 Department of Mathematics, University of Milan, Milan, Italy
5 Laboratory of Tumor Immunology, Department of Surgery, Columbia University, New York, NY, USA

Correspondence: Address correspondence and reprint requests to: Giovanni Carlo Cesana, E-mail: giovanni.cesana{at}gmail.com


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: There is evidence that cancer is immunogenic under certain situations. IL-2 is described to stimulate an effective antitumor immune response in vitro and in vivo. The ability of cancer patients to undergo surgical resection is still the most important prognostic factor for many solid tumors, including gastric adenocarcinoma. The host immune system may be further compromised by surgical procedures leading to a generalized state of immunodepression in the post-operative period. The aim of this randomized case–control study is to evaluate the effects of pre-operative low-dose IL-2 treatment on patients with gastric adenocarcinoma who undergo surgery.

Methods: Sixty-eight patients with gastric adenocarcinoma were enrolled in the study and randomized in two groups: 36 patients were pre-treated with IL-2 and 32 underwent surgery without any treatment. Total peripheral WBC, neutrophils, CD3+ T, CD4+ T, CD8+ T and NK cells were obtained before and after surgery, at different times. Peritumoral infiltration was analyzed on all surgical specimens. Overall survival and relapse-free survival were studied with a median follow-up of 51 months.

Results: Low-dose IL-2 treatment resulted in an increase peritumoral lymphocytic and eosinophilic infiltrations and in a minor decrease in CD3+ T and CD4+ T cells after surgery (P < 0.05). A stepwise multivariate analysis revealed that overall survival and relapse-free survival were affected only by stage of tumor and age of patients.

Conclusions: According to our data low-doses of IL-2 administered pre-operatively to patients with gastric cancer activate peripheral and peri-tumoral lymphocytes but did not affect prognosis.

Key Words: Clinical trial • Gastric carcinoma • Interleukin-2 • Treatment


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Gastric adenocarcinoma is the third most common cancer (8.7%; 876,000 new cases in year 2000), and the second most common cause of death due to cancer worldwide (10.4%; 647,000 deaths in year 2000).1,2 There is an overall decreasing trend in incidence of gastric adenocarcinoma, but an increase of cancers localised to the cardia.3–6 The geographical distribution of stomach cancer is characterised by wide international variations. High-risk areas include Japan, Central and South America and Eastern Asia.1 Italy is a medium-risk area (11,000 deaths in year 1998), with wide variations among the different regions.7

Surgery is still the major prognostic factor for gastric cancer. Patients who are not resected have a poor prognosis with survival ranging from 3 to 11 months. For those patients undergoing resection and lymphadenectomy, the factors that affect prognosis include the location of the tumor, the gross pathologic type and the TNM classification.8 There is evidence that surgical operations can cause a variety of immunological disturbances in man both in vivo and in vitro.9 Post-operative changes in the systemic immune response are proportional to the degree of surgical trauma leading to a generalized state of immunosuppression, which is implicated in the development of septic complications and providing a "fertile soil" for tumor cell metastasis.10–12

Interleukin-2 (IL-2) was first described as a T cell growth factor.13,14 It is produced by activated T cells and stimulates the growth and function of T cells and NK cells. IL-2 was first used in patients with advanced cancer, and some clinical responses were seen,15 allowing FDA to licence IL-2 as a therapy in metastatic melanoma and metastatic renal cell carcinoma. However, extremely high doses were given in the initial cancer trials (up to 150 million units per day) resulting in severe toxicity, including capillary leak syndrome, hypotension and pulmonary edema. Many of the first patients treated on this high dose regimen required hospitalization in an intensive care unit. Because of its central role in T cell immunity, IL-2 was also one of the first immune-based therapies to be tested in patients with HIV. In these studies an intermediate dose was given. Kovacs et al.16 administered 18 million units per day for 5 days every 8 weeks by continuous intravenous infusion in the hospital. The results were significant in patients with baseline CD4 counts >200 cells/mm3. In addition, the infusion of IL-2 was still associated with side effects such as fever and flu-like symptoms. Subsequent trials of intermittent intermediate dose IL-2 have mainly used subcutaneous administration, since this seems to have similar efficacy with less severe side effects and allows outpatient administration.17 In addition, some have argued for low dose, continuous IL-2 rather than intermittent IL-2 at higher doses.18

In recent years many trials were conducted with different IL-2 regimens in solid tumors other than melanoma and renal cell carcinoma with variable results.19 IL-2 was also used to improve the anti-tumor activity of other forms of immunotherapy,20–27 chemotherapy28–33 and surgery.34–40 Immunotherapy may thus also be a potentially promising alternative strategy for gastric cancer. In early clinical trials, systemic immunotherapy included both active vaccination directed against defined tumor-associated antigens expressed in gastric carcinoma cells41 and passive administration of IL-2 with some evidence of regression of metastatic gastric cancer.42,43 Other studies have applied immunotherapy in the adjuvant setting with equally promising results. For example, OK-432, a streptococcal preparation, demonstrated marginal improvement in survival for patients with stage III gastric cancer44 and a meta-analysis of centrally randomized controlled clinical trials indicated a significant survival benefit with combination of OK-432 and chemotherapy compared to chemotherapy alone (P < 0.05).45 Additional data suggesting a biological and clinical benefit of subcutaneous, preoperative administration of low-dose IL-2 in colon cancer46–48 encouraged us to evaluate low-dose IL-2 therapy in the neoadjuvant setting for patients with gastric adenocarcinoma who undergo surgery and to evaluate its effects on systemic and tumor infiltrating lymphocyte numbers. We also sought to determine if neoadjuvant low-dose IL-2 could influence the clinical outcome for patients undergoing gastric resection for cancer. Preliminary data on this trial were published in 2004 with limited follow-up, in order to report the biological, histological and clinical preliminary results.35 We now present the definitive results with the full accrual of patients and a median follow-up of 51 months.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patients Characteristics
Patients with assessable gastric cancer, who met eligibility criteria for IL-2 administration and surgical procedures, were enrolled in this study between October 1999 and July 2003. The inclusion criteria were: performance status according to Karnofsky score 80–100%, indication and eligibility for a surgical procedure with curative intent, histologically confirmed adenocarcinoma, and no weight loss. Exclusion criteria were: presence of distance metastasis and concurrent treatment with agents having influence on the immune system; to exclude the possible influence of blood transfusion on the immune response, patients needing to be transfused prior to surgery were not included in the study. Patients were randomized in two groups: one was treated before surgery with low doses IL-2 (cases), the other underwent surgery without having been treated (controls). The clinical protocol was approved by the ethical committee and all patients were required to give written informed consent.

Study Design
Low-dose IL-2 was administered subcutaneously at 9,000,000 UI twice a day for 3 days. Patients underwent gastric surgery 36 h after the last dose. Toxicity was measured according to WHO criteria. The clinical outcome was determined by a follow-up evaluation which consisted of physical examination, hematological and blood chemistry panels, blood tests for carcinoembryonic antigen and carbohydrate antigen 19-9. These assessments were repeated every 3 months for the first post-operative year and then every 6 months. Either abdominal ultrasonography or computed tomography was performed every 6 months, as was chest radiography. Bone scintigraphy, barium enema radiography, and computed tomography of the chest or brain were performed only when metastasis to these sites was suspected. After detection of recurrent disease, appropriate therapy was given.

Peripheral Blood Counts
Total peripheral WBC, neutrophils, total lymphocytes (CD3+), T helper lymphocytes (CD4+), cytotoxic lymphocytes (CD8+) and natural killers (NKs) counts were assessed by flow cytometric assay (Beckton Dickinson, San Josè, CA, USA). Blood samples were drawn in the morning at 8 a.m. at baseline and on 7th, 14th and 50th day after surgery.

Characterization and Quantification of Peritumoral Infiltration
Neutrophilic, lymphocytic and eosinophilic infiltrations were analyzed on all surgical specimens. The specimens were fixed in 10% formaldehyde solution and then embedded in paraffin. Slices of embedded specimens were stained with hematoxylineosin and Giemsa and evaluated by the same pathologist. The density of infiltration was analyzed by a 10 high power microscopic fields (400x). Peritumoral infiltration’s density was graded according to the classification of Ropponen modified49 and four grades were established: negative (0: 0 cells/field), weak (+: 1–30 cells/field), moderate (++: 30–50 cells/field), dense (+++: >50 cells/field). Few specimens were further characterized by immunohistochemistry (IHC) as T cells with polyclonal rabbit anti-human CD3 (DAKO) or B cells with monoclonal mouse anti-human CD79a (DAKO).

Statistical Analysis
Data are expressed as mean and standard deviation (SD) for absolute numbers and percentages. Statistical analysis was done using Student’s t-test to assess differences between the different study groups. P < 0.05 was considered significant. Association and correlation between variables were assessed with adjustments to other variables via linear models. Stepwise multivariate analysis on Cox and logit models were performed when appropriate. Kaplan–Meier curves were done to analyze overall survival and relapse-free survival in cases and controls.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Patients Characteristics
Sixty-eight patients were eligible and provided consent to participate in the study. They were randomized in two groups. The first group (n = 36) was treated with low doses IL-2 before surgery (cases), the second (n = 32) underwent surgery without any treatment (controls). Patients’ age, sex, site of tumor, type and grading of tumor, stage of tumor, type of surgical intervention and total months of follow up, were not significantly different in the two groups (Table 1Go). Thirty patients (44.1% of the total), 15 cases and 15 controls, underwent partial gastrectomy; 38 (55.9%), 21 cases and 17 controls, underwent total gastrectomy. The surgical choice was determined by tumor site. Total gastrectomy was preferred to partial gastrectomy when the tumor was localized to the cardia.


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  		TABLE 1. Summary of patients characteristics
 
Low-dose IL-2 Therapy is Well Tolerated by Treated Patients
The side effects have been previously reported.35,50 Pre-operative administration of low-dose IL-2 resulted in very mild toxicity. Twenty-five patients (36.7% of the total) had fever (grades I and II according to WHO criteria) associated with common flu-like symptoms on the 1st day after IL-2 administration. All patients had skin erythema at the injection site which spontaneously disappeared in a few days. As already reported, low-dose IL-2 therapy did not induce fluid retention or major toxicity, including capillary leak syndrome, hypotension or pulmonary edema. No cardiovascular, neurological, or surgical complications related to IL-2 administration occurred during anaesthesia or surgery.

IL-2 Impact on Peripheral Blood Leukocytes Counts
At baseline, total WBC (7,192 ± 2,747 cells/mm3), neutrophils (4,539 ± 2,627 cells/mm3), CD3+ T cells (1,129 ± 417 cells/mm3), CD4+ T cells (692 ± 302 cells/mm3), CD8+ T cells (432 ± 228 cells/mm3) and NK cells (243 ± 174 cells/mm3) were in the normal range without significant differences between cases and controls (Fig. 1Go). Only four patients had a WBC count greater than 10,000 mm–3 at baseline (two cases and two controls) and nine patients had counts less than 5,000 mm–3 (four cases and five controls). No patients with CD4+ T cells counts less than 200 mm–3 were enrolled in the study. Total WBC and neutrophils were significantly increased in cases on the 50th day after surgery (P < 0.05). Surgical intervention resulted in decreased numbers of peripheral blood lymphocytes in CD3+ T, CD4+ T, CD8+ T and NK cell subsets (Fig. 1Go). The difference between CD3+ T cell number before surgery and 7 days after was –367 cells/mm3 for controls and –71 cells/mm3 for cases. The difference between CD4+ T cell number before surgery and 7 days after was -195 cells/mm3 for controls and –43 cells/mm3 for cases. The decrease in cell number 7 days after surgery resulted significantly higher in controls compared to cases (P < 0.05) for CD3+ T and CD4+ T cells. Although we noted a trend of decreasing in controls’ CD8+ T cell and NK cell number 200% greater than in cases’, this difference did not reach statistical significance. After the 7th postoperative day, lymphocyte counts rebounded in both treated and controls groups following similar kinetics (Fig. 1Go).


Figure 1
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  		FIG. 1. Total WBC, neutrophils, CD3+ T, CD4+ T, CD8+ T and NK cells counts were assessed by flow cytometry on peripheral blood samples preoperatively (Pre-op) and on days 7, 14 and 50 after surgery. A significantly higher number (P < 0.05) of total WBC and neutrophils was noted in cases (continuous line) compared to controls (dashed line) on 50th day after surgery. Seven days after surgery, the decrease in CD3+ and CD4+ T cell number was significantly lower (P < 0.05) in cases than in controls.

 
Local Peritumoral Response to IL-2 Treatment
IL-2 pre-treatment resulted in a significant increase (P < 0.05) of lymphocytic and eosinophilic peritumoral infiltration (Fig. 2Go). An example of semiquantitative analysis of the peritumoral infiltration is shown in Fig. 3Go. Figure 3AGo represents a negative lymphocytic peritumoral infiltration: almost 0 cells per field. Figure 3BGo represents a dense lymphocytic peritumoral infiltration: more than 50 cells per field. More than an half of controls (56.3%) had no peritumoral lymphocytic infiltration, 34.4% weak, 3% moderate (only one control) and 6.3% dense (two controls). Most of cases resulted in a weak (44.4%) or moderate (30.5%) lymphocytic infiltration, 11.1% dense and only 14% (five cases) had none. Neither cases nor controls had a dense eosinophilic peritumoral infiltration. Most controls (68.8%) had no eosinophilic infiltration, 28.1% weak and 3.1% (one control) moderate. 47.2% of cases had a negative eosinophilic infiltration, 36.1% weak and 16.7% moderate. Lymphocytic infiltration resulted to be mostly composed by T cells (60% of the total) and in a lower percentage by B cells (40%). T lymphocytes were characterized by a widespread distribution among tumor cells (Fig. 3CGo). B cells were instead organized at the periphery of the tumor in a characteristic nodular shape (Fig. 3DGo). No difference between cases and controls was noted in lymphocytic subpopulations or in inflammatory and neutrophilic infiltration.


Figure 2
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  		FIG. 2. Grade of peritumoral infiltration. Peritumoral infiltration was graded through a semiquantitative method (see Fig. 3Go). Grade’s averages of peritumoral infiltration resulted significant increased in patients treated with low-dose IL-2 (black bars) compared to controls (white bars), for lymphocytes (P = 0.0003) and eosinophils (P = 0.0249).

 

Figure 3
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  		FIG. 3. Peritumoral lymphocytic infiltrations. Paraffin-embedded specimens were sliced and stained with hematoxylineosin. The density of infiltration was analyzed by a 10 high power microscopic fields (400x) and graded in a semiquantitative way: negative (A) almost 0 cells/field; weak: almost 1–30 cells/field; moderate: almost 30–50 cells/field; dense (B) more than 50 cells/field. Specimens were further characterized by IHC for T cells (C) and B cells subpopulations (D).

 
Overall Survival in Gastric Cancer Patients Pre-treated with Neoadjuvant Low-dose IL-2
A stepwise multivariate analysis demonstrated that overall survival was dependent on stage of cancer, age and type of surgical intervention, in that order (Table 2Go). In total 60% of patients were alive at the end of the study (21 cases out of 36 and 20 controls out of 32) with a mean survival of 55 ± 15 months. The mean age was 67 ± 10 years for those patients who were alive at the completion of the trial compared to 72 ± 8 years for those patients who died before the end of the study. As shown in Fig. 4Go there was no significant difference in overall survival between cases (dark line) and controls (light line). All fifteen patients (eight cases and seven controls) with stage 1 (S1) adenocarcinoma were alive at the end of the study with a mean survival of 48 ± 14 months. Twelve patients with stage 2 (S2) adenocarcinoma (nine cases and five controls) had a mean survival of 39 ± 23 months and 57% of them resulted to be alive at the end of the study (six cases and two controls). Twenty-eight patients had stage 3 (S3) adenocarcinoma (14 cases and 14 controls) and 50% of them were alive at the end of the study (five cases and nine controls) with a mean survival of 25±19 months. Eleven patients had stage 4 (S4) adenocarcinoma (five cases and six controls) and 36% of them were alive at the end of the study (two cases and two controls) with a mean survival of 24±21 months. Patients who underwent partial gastrectomy (15 cases and 15 controls) had a better survival than those who underwent total gastrectomy (21 cases and 17 controls): 37±20 months versus 29±21 months.


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  		TABLE 2. Summary of overall survival multivariate stepwise selection
 

Figure 4
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  		FIG. 4. Kaplan–Meier curves show that there is no significant difference in overall survival (A) and in relapse-free survival (B), between patients treated with low-dose IL-2 (dark line) and controls (light line).

 
Relapse-free Survival in Gastric Cancer Patients Treated with Neoadjuvant Low-dose IL-2
A stepwise multivariate analysis demonstrated that relapse-free survival depended only on tumor stage and age of patients, but was not influenced by type of surgical intervention or neoadjuvant low-dose IL-2 administration (Table 3Go). A 47% of patients treated with low-dose IL-2 relapsed by the end of the study with an average relapse-free survival of 49±14 months compared to 50% of controls who had a relapse-free survival of 46±17 months. Thirty-five patients out of 68 (51%) did not relapse by the end of the study and had a mean relapse-free survival of 48±15 months. The mean age was 65±10 years for those patients without relapse compared to 72±8 years for those who relapsed by the end of the study. There was no difference in relapse-free survival between cases and controls (Fig. 4Go). S1 patients had a mean relapse-free survival of 45±19 months with only two patients out of 15 (13%) presenting with recurrent disease or death by the end of the study (0/8 cases, 0%; 2/7 controls, 28%). S2 patients had a mean relapse-free survival of 33±23 months with 8/14 patients (57%) presenting disease or death by the end of the study (5/9 cases, 55%; 3/5 controls, 60%). S3 patients had a mean relapse-free survival of 25±19 months, with 15/23 patients (65%) presenting with recurrent disease or death by the end of the study (9/14 cases, 64%; 6/14 controls, 43%). S4 patients had a mean relapse-free survival of 21±20 months with 8/11 patients presenting with recurrent disease or death by the end of the study (3/5 cases, 60%; 5/6 controls, 83%).


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  		TABLE 3. Summary of relapse-free survival multivariate stepwise selection
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Although there is evidence that cancer is immunogenic under certain situations, the host immune system is not able to mount an effective immune response against most established tumors, allowing tumors to grow and to spread systemically. The reason why the immune system is defective is not entirely known but it has been suggested that the induction of central and/or peripheral tolerance might lead to clonal deletion and inactivation of self-reactive lymphocytes.51 Peripheral tolerance results once mature lymphocytes exit primary lymphoid organs and recent data has implicated regulatory T cells as being responsible for inducing and maintaining peripheral tolerance.52 Despite the difficulties in initiating tumor-specific immunity in cancer patients, the administration of high-dose IL-2 in metastatic melanoma and renal cell carcinoma patients results in objective clinical responses in 15–20% of patients and the majority of complete responders appear to be resistant to tumor recurrence with median follow-up data extending to 17 years.53–57 Paradoxically, IL-2 has been reported to promote the activity of suppressive regulatory T cells and such cells are elevated in patients with cancer. The mechanism of IL-2 anti-tumor activity, however, is complex and more recent studies suggest that high-dose IL-2 may actually inhibit regulatory T cells activity in responding patients, and thus may limit peripheral immune tolerance.58

The ability of cancer patients to undergo surgical resection is still the most important prognostic factor for many solid tumors, including gastric adenocarcinoma. The host immune system may be further compromised by surgical procedures leading to a generalized state of immunodepression in the postoperative period.10–12 In our study we confirmed this in gastric cancer patients and noted that this was especially profound during the first 7 days after operation (Fig. 1Go). Our data demonstrated a decrease in total peripheral blood lymphocytes below 1,000 cells/mm3 (805±446 lymphocytes/mm3) 7 days after surgery starting from a mean baseline value of 1,172±428 lymphocytes/mm3 for those patients who were not pre-treated with IL-2. We also observed a specific decrease in CD4+ T, CD8+ T and NK cell counts after operation (Fig. 1Go). This decrease after tumor manipulation during surgery might provide a fertile environment for residual tumor cells to grow or for micrometastasis to develop. It is not known if improvements in surgical technique and keeping tumor manipulation to a minimum during operation will prevent the decrease in lymphocyte depletion post-operatively. While adjuvant and neoadjuvant chemotherapy have demonstrated a survival benefit for patients with gastric cancer,59 in this study we considered the hypothesis that neoadjuvant IL-2 could abolish the post-operative decrease in peripheral and peritumoral lymphocytes and if these conditions can improve prognosis in those patients who undergo surgical intervention for gastric cancer.

In this trial, IL-2 was administered subcutaneously and in low doses to avoid significant toxicity and complications during anesthesia or surgery. Seven days after operation we noted a minor decrease in peripheral blood CD3+ T cells, CD4+ T cells, CD8+ T cells and NK cells in patients pre-treated with low-dose IL-2 compared to control patients (Fig. 1Go). This minor decrease was statistically significant for CD3+ and CD4+ T cells (P < 0.05). While we also observed a trend toward decreasing in CD8+ T cells and NKs in control patients, this did not reach statistical significance due to the high variability within the population. After 7 days, lymphocyte counts in IL-2-treated and control patients increased at a similar rate suggesting that the activity of IL-2 is most pronounced in the first week after surgery. In general, surgical trauma induces lymphopenia with a slow rebound depending on the type and severity of trauma. IL-2 appears to set a higher starting point for the lymphocyte rebound after trauma.

In addition to peripheral blood lymphocytes, we also analyzed the local peritumoral cellular infiltrates. Our data suggested that there was an increase in lymphocytic and eosinophilic infiltration in patients pre-treated with IL-2 compared to controls (see Fig. 2Go). These data imply that IL-2 might act to abolish the post-operative decrease in peripheral blood lymphocytes and also increase the local accumulation of lymphocytes and eosinophils within the tumor. This is consistent with data from melanoma patients where IL-2 has been shown to induce lymphocytic infiltration into tumors of patients who achieved clinical responses.60 An increased in eosinophilic infiltrates have also been reported in patients with colon cancer pre-treated with IL-2.61 The activity of IL-2 on peritumoral lymphocytes and eosinophils is perhaps not unexpected and may result from direct action on the IL-2 receptor, which is expressed by both activated lymphocytes and eosinophils,62 and an indirect action due to an IL-2-mediated cascade of cytokines and chemokines that results in lymphocyte and eosinophil migration and proliferation. The presence of peritumoral infiltrating lymphocyte is a well described phenomenon in cancer patients and typically relates to a better prognosis as reported in patients with primary malignancies of the lung,63 liver,64 ovary,65 colon,66,67 genitourinary tract68 and stomach.69 IL-2 seems not to modify the composition of lymphocytic infiltration, which resulted to be mostly made by T cells, widespread diffused into the tumor (Fig. 3CGo), and by B cells, peripherally organized in a nodular shape (Fig. 3DGo).

Although the changes in lymphocyte frequency with neoadjuvant IL-2 were interesting, we did not notice an improvement in relapse-free or overall survival. Stepwise multivariate analyses were made to evaluate factors that influenced survival and found that tumor stage and patient age were the only predictors of response in our patients (see Tables 2Go, 3Go). It was not unexpected that a better prognosis was related with a low tumor stage and younger age at presentation. Although less significant, overall survival also appeared to be affected by the type of surgical intervention. Total gastrectomy resulted in a worse prognosis than partial gastrectomy and this might relate to the fact that total gastrectomy was chosen more frequently for cardia tumors, which have been described as being more aggressive than tumors affecting other parts of the stomach.2 In addition these results might also relate to the fact that gastrectomy is a bigger procedure and may lead to more profound immunosuppression, although we did not find this in our study. The fact that relapse-free survival did not depend on the type of surgical intervention might have been related to appropriate selection of patients for surgical intervention and good operative technique.

According to our data low doses of IL-2 administered pre-operatively to patients with gastric cancer activate peripheral and peritumoral lymphocytes but did not affect prognosis and Kaplan–Meier analysis suggested no differences between cases and controls (Fig. 4Go). Comparing these findings with our preliminary data,35 in which a trend was seen favoring IL-2 treated patients, the current trial, with a median follow-up of 51 months, seems to confirm that low-dose IL-2 does not improve relapse-free or overall survival in patients with gastric cancer. The reasons for the lack of therapeutic effectiveness is not entirely clear but we would propose several points for consideration. First, we know that only selected melanoma and renal cell carcinoma patients have a significant benefit from high-dose IL-2 therapy and for this reason we may require a much larger study to detect a benefit in patients with gastric carcinoma. Second, we utilized a low-dose IL-2 regimen and most studies with IL-2 have found that high-dose therapy is superior to low-dose treatment regimens.70 Finally, the influence of IL-2 on regulatory T cells may be critical for influencing clinical outcome and we did not directly examine these cells in the current study. While many reports suggest that these regulatory T cells are elevated in cancer patients, there is some data suggesting that high-dose IL-2 may be associated with a decrease to normal levels of this population after exposure to high-dose IL-2.58 Thus, further investigation with high-dose IL-2 and careful monitoring of regulatory T cell populations may provide further insights into the utility of IL-2 and other forms of immunotherapy for patients with gastric cancer.


   ACKNOWLEDGMENTS
 
The authors are indebted to Dr Howard Kaufman, Edwin C. and Anne K. Weiskopf Associate Professor of Clinical Surgical Oncology at Columbia University College of Physicians & Surgeons (New York, NY, USA), for his scientific support.

Received for publication April 20, 2006. Accepted for publication September 7, 2006.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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