Research ArticleClinical Studies

A Trial of Autologous Ex vivo-expanded NK Cell-enriched Lymphocytes with Docetaxel in Patients with Advanced Non-small Cell Lung Cancer as Second- or Third-line Treatment: Phase IIa Study

YOUNG JUN YANG, JI CHAN PARK, HOON KYO KIM, JIN HYOUNG KANG and SUK YOUNG PARK
Anticancer Research May 2013, 33 (5) 2115-2122;

Abstract

Background: New strategies are still needed to enhance the treatment outcome for advanced non-small cell lung cancer, in spite of recent remarkable developments. Cancer immunotherapy has been attractive since a long time, with diverse clinical attempts and results. In particular, natural killer (NK) cells have received considerable attention because of their potential role in immune surveillance in vivo by destroying infected or transformed cells. Major histocompatibility complex class I-related chain A/B (MICA/B) on tumor cells, known as the representative ligand for NKG2D receptor on NK cells, has been reported to be modulated by a variety of stress factors, including some chemotherapeutic agents, and it is anticipated that enhancing MICA/B expression will be contributory to anticancer treatment. With recent development of expanding autologous ex vivo NK cell-enriched lymphocytes (NKL), we designed a trial to augment the anticancer effect by co-administering NKL and docetaxel, one of the second-line agents used for treatment of patients with advanced non-small cell lung cancer (NSCLC). Patients and Methods: Eligible patients were between the age of 20 and 75 years, with an Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0 to 2, and previously received one chemotherapy or two regimens including one epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor, stage IIIB/IV, histologically- or cytologically-proven NSCLC with measurable lesions. NKL were kindly prepared and provided from NKBIO Co. (Seongnam City, Korea). Feasibility, adverse effects, progression-free survival (PFS) were evaluated and compared with the historical control of weekly docetaxel regimen. Results: Nineteen patients were enrolled before early closure. NKL production and administration were feasible in all cases, even in those with disseminated disease. No additional adverse events were observed in addition to those reported for docetaxel-alone. PFS of 3 months and 10.5% response rate (RR), with two cases of partial response, were observed and were similar to the historical control (PFS=2.9 months, RR=8.0%). Conclusion: To our knowledge, this is the first report on the combination of NKL with docetaxel in patients with advanced NSCLC. Autologous NKL production and co-administration with docetaxel were feasible without further toxicity or complication. Benefit in PFS and RR, as compared with the historical control, was not detected in this study population with advanced NSCLC. In order to determine whether the combination of NKL and chemotherapy has any anticancer effect, an additional study should be performed in patients with low tumor burden, such as those with less advanced disease or those in remission.

The treatment strategy for advanced non-small cell lung cancer (NSCLC) is tailored and the personalized therapy is based on clinical factors, pathology and molecular biology (1). Selection of appropriate primary treatment and maintenance therapy or second-line chemotherapy have achieved remarkable improvements, in the treatment outcome in patients with advanced NSCLC. However, it is unfortunate that long-term disease-free survival is still low, especially in cases of first-line regimen failure, despite current treatment modalities. Thus, new treatment options are pursued. The potential role of cancer immunotherapy has long been attractive and there have been many attempts using diverse immunotherapeutic modalities with variable clinical results. In particular, natural killer (NK) cells have received considerable attention because of their potential role in immune surveillance in vivo, together with CD8+ cytotoxic T-lymphocyte (CTL), by destroying infected or transformed cells (2-4). Pioneering of modern cancer treatment using NK cells was the report of clinical effects of lymphokine-activated killer (LAK) cells by Steven Rosenberg and colleagues (5). But these kinds of adoptive immunotherapies (LAK cells, tumor infiltrating lymphocytes (TIL), gene-modified TILs) have been proven effective in limited fields such as allogeneic stem cell transplantation and melanoma therapy. Their clinical application towards most types of solid cancer has rarely been successful, their use is not considered as standard cancer treatment. Until recently, the clinical application of NK cells has been hindered due to the difficulty in obtaining sufficient NK cell numbers ex vivo. A recent development of a novel method in expanding autologous ex vivo NK cell-enriched lymphocytes (NKL) by NKBIO Co. (Seongnam City, Korea) has renewed interest in immunotherapy using NK cells. However, adoptive immunotherapy using NK cells alone is thought to be ineffective for advanced cancer upon reviewing previous studies (6, 7). Based on previous reports and our experiments that showed that expression of major histocompatibility complex class I-related chain A/B (MICA/B), the representative ligand for NKG2D receptor, on tumor tissue can be increased by some chemotherapeutic agents, resulting in increased NK cell-mediated cytotoxicity (NKMC) (8, 9), we designed a clinical trial of the combination of NKL with chemotherapy. The aims of the present study were to investigate the feasibility, safety, and efficacy of the combination of NKL with docetaxel, an approved second-line regimen, in patients with advanced NSCLC who had previously received one or two regimens. To our knowledge, this appears to be the first report on the combination of NKL with docetaxel for patients with advanced NSCLC.

Patients and Methods

Cell line, reagents, flow cytometry. The human cervical carcinoma cell line, HeLa, was from laboratory stocks. The cell line was cultured at 37°C with 5% CO2 in RPMI-1640 medium supplemented with 10% heat-inactivated fetal calf serum. Mouse monoclonal antibody (mAb) against human MICA/B and FITC-labeled rat anti-mouse IgG were purchased (R and D Systems, Minneapolis, USA). Since docetaxel was almost insoluble in the experiment culture medium, cisplatin was used to determine effects on MICA/B expression. Cisplatin, at the indicated concentrations, was added to the HeLa cell culture media for 2 h, then cells were washed and further cultured. Twenty-two hours later, the cells were collected.

Cell-surface expression of MICA/B was detected using flow cytometry. Detached cells were washed twice in cold phosphate-buffered saline (PBS) and stained with fluorescein isothiocyanate (FITC)-labeled mouse antibody against human MICA/B for 60 min at 4°C. Fluorescence was detected using an FC500 flow cytometer (Beckman Coulter, Brea, California, USA) and data were expressed as relative ratio (RR); the fold increase of FI relative to un-treated cell. Sample size. This study design was based on superiority over treatment with docetaxel-alone by 50% in respect of PFS. The sample size was calculated by the method of Brookmeyer and Crowley (10). Based on previous results of treatment with docetaxel-alone as the historical control (median PFS=2.9 months) (11), median PFS of 4.3 months and sample size of 44 patients were required in order to have 80% power of detection and 20% significance level (α=0.2).

Patient selection and baseline assessment. Eligible patients were between the age of 20 and 75 years, with an Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0 to 2 and had previously received one line of chemotherapy or two regimens including one epidermal growth factor receptor tyrosine kinase inhibitor, stage IIIB/IV, histologically- or cytologically-proven NSCLC with measurable lesions. Other eligibility criteria included leukocyte count ≥4,000/μl and ≤12,000/μl, neutrophil count ≥2,000/μl, platelet count ≥105/μl, hemoglobin ≥9.5 g/dl, blood urea nitrogen below or equal to the upper limit of the institutional normal range (ULN), on the serum creatinine below or equal to the ULN, creatinine clearance ≥60 ml/min, serum bilirubin ≤1.5 × ULN, serum alanine aminotransferase and aspartate aminotransferase ≤2.5 × ULN. Women who were pregnant or lactating were excluded from the study. Other exclusion criteria included patients with active infection, uncontrolled heart disease, interstitial pneumonia, positivity for the hepatitis B or C virus, AIDS or positivity for HIV, autoimmune diseases or treatment with immunosuppressive drugs, past history of drug hypersensitivity, symptomatic brain metastasis, prior radiotherapy delivered to the target region, or active concomitant malignancy. This study was approved by the Institutional Review Boards at the participating centers (approval number; CIRB-0032-009) and the Korea Food & Drug Administration and all patients provided written informed consent.

Study design, treatment regimen. Eligible patients were to receive 35 mg/m2 docetaxel as a 30-min intravenous (i.v.) infusion on days 1, 8 of each cycle, followed by a two-week treatment-free period. A maximum of six cycles were allowed. Prophylactic (oral or i.v.) dexamethasone 4 mg or 8 mg was given 30 min before each docetaxel infusion. Peripheral blood was collected for preparing NKL from each patient. 320 ml of whole blood were obtained eight days before the first docetaxel infusion and peripheral blood mononuclear cells (PBMCs) were isolated from blood by density-gradient centrifugation. About a fifth of total PBMCs was used for each culturing process for day 8 of the first cycle, day 1 and 8 of the second and third cycles of treatment, while the rest were frozen and stored for planned treatment. Another 320 ml of whole blood were obtained from day 16 to 21 of the second cycle for day 1 and 8 of the fourth and fifth cycles and day 1 of the sixth cycle of treatment. A further 60 ml of whole blood was obtained on the eighth day of the fifth cycle for day 8 of the sixth cycle of treatment. Figure 1 shows the schema of the treatment schedule. Prophylactic antiemetics were permitted. In cases of progressive disease (PD), treatment was stopped; patients either abandoned treatment or were switched to a third-line regimen, depending on their general health status and/or preference. In cases of grade 3-4 hematological toxicity, a docetaxel dose reduction to 30 mg/m2 was recommended. In the event of non-hematological grade 3-4 adverse events, the decision to reduce the drug dose or remove the patient from the study was at the investigator's discretion.

Figure 1.
Figure 1.

The schema of the treatment schedule.

Expanding autologous ex vivo NKL. A novel method for expanding autologous ex vivo NKL was used by NKBIO Co. as follows; lymphocytes harvested from 60 ml of peripheral blood of a patient were suspended in 3 ml of culture fluid, admixed into 33 ml of culture fluid to which 70 μl of interleukin-2 (IL-2) (proleukin, Novartis, Cambery, UK), 200 μl of L-glutamine (Sigma, St. Louis, USA) and 3 ml of autochthonous plasma were added, then cultured in the presence of antibody to CD3, CD16, and CD56 (Becton, Dickinson and Company, NJ, USA) for four days (first culturing step). The mixed culture fluid from the first culturing step was then admixed into 60 ml of culture fluid to which 100 μl of IL-2, 1 ml of L-glutamine and 7 ml of autochthonous plasma were added, and further cultured for three days (second culturing step). 7 ml of autochthonous plasma were then added to the mixed culture fluid resulting from the second culturing step, injected into a gas- permeable culture bag containing 1000 ml of culture fluid, and further cultured for seven days (third culturing step). As a result of serial culturing, the total cell count of NKLs increased from 2.0×106-4.0×107, when separated from 60 ml of blood, to 2.0×109-1.0×1010.

The final products were evaluated for purity, viability, sterility, and cytotoxicity against K562 cell line. The number of NKLs in the final product of the 60-ml bag should be over 2.0×109 with >80% viability. NK and NKT (CD56+CD16+CD3−) cells were to compose over 50% of all cells while CD3+cells and CD19+cells were to be below 50% and 1%, respectively. The products were sterile, with an endotoxin level of <0.3 EU/ml, and free from mycoplasma and other adventitious viruses. Cytotoxicity against the K562 cell line was greater than 30%. Figure 2 shows the schematic flow procedures for NKL cell expansion.

Outcomes and statistical analysis. The primary end-point of this study was PFS. Secondary end-points included response rate (RR), overall survival (OS) and toxicity. Assessment of the tumor for a response to treatment was performed by means of computed tomography (CT) every two cycles. Unidirectional measurements were adopted on the basis of the Response Evaluation Criteria in Solid Tumors (RECIST, version 1.1) (12). Complete response (CR) was defined as the disappearance of all tumor indications. Partial response (PR) was defined as an estimated decrease of ≥30% in tumor size. Progressive disease (PD) was defined as the appearance of any new tumor lesions or an increase ≥20% in the size of existing tumor lesions. When responses did not qualify as CR, PR, or PD, they were reported as stable disease (SD). PFS was evaluated for the period from the date of randomization to the date when disease progression was first observed or death occurred. A lesion not previously irradiated that was measurable according to RECIST version 1.1 was required for evaluation of response. OS was evaluated for the period from the date of randomization to the date of death. Survival outcomes were analyzed by the Kaplan Meier estimator. A complete blood cell count and measurements of liver and renal function were assessed at least every week during the treatment. Non-hematological toxicities were also verified at least every week by patient interview and physical examination. Toxicity was described by the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4 (http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf). Case report forms captured all toxicities of grade 3 or more, any grade neuropathy or edema, and any grade event resulting in dose reduction or delay. PFS was assessed using the Kaplan Meier method and was compared by the log-rank test.

Figure 2.
Figure 2.

Schematic flow procedures for NK cell-enriched lymphocytes expansion. IL-2: Interleukin-2; CD: cluster of differentiation.

Results

Increase in HeLa cell MICA/B expression derived from cisplatin stimulation. Stimulating HeLa cells by cisplatin, the trend for increased MICA/B expression measured by flow cytometry occurred in a cisplatin-dose-dependent manner (Figure 3). Cisplatin at 5 μg/ml induced peak MICA/B expression at 24-36 hours, expression then declined (Figure 4). Cisplatin at 5 μg/ml is equivalent to the usual blood concentration when it is commonly prescribed for systemic chemotherapy. Considering the half-life of cisplatin inside a living body, MICA/B expression was measured after a series of processes: two hours of exposure to cisplatin, wash-out, and 22 h of further cultivation.

Patients. Between February 2011 and April 2012, a total of 23 patients were enrolled at three centers in Korea until this study was closed early because of a slower recruitment rate than expected (which might be related to the revised guideline about second-line and maintenance regimen) and internal affairs at NKBIO Co. Out of these, four patients did not receive study treatment because of death before their treatment was initiated (one patient), ineligibility (one patient) and consent withdrawal (two patients). Therefore, 19 patients completed at least one cycle of study treatment and were assessable for PFS, tumor response and toxicity. The baseline characteristics of the patients are given in Table I. Their median age was 67 (range=45-77) years, 63% of patients were male, ECOG performance status was 0-1 in 79% of patients and 74% had stage IV disease. Most had received prior platinum-containing regimens (95%). Four patients received EGFR tyrosine kinase inhibitor (gefitinib, n=3; erlotinib, n=1).

Figure 3.
Figure 3.

Major histocompatibility complex class I-related chain A/B (MICA/B) expression on HeLa cell surface at 24 h exposure to cisplatin, as determined by flow cytometry. The trend for increased fluorescence intensity (FI) of MICA/B occurred in a cisplatin dose-dependent manner. Cisplatin was routinely used because of the poor solubility of docetaxel in the experimental medium. Data are expressed as relative ratio (RR); the fold increase of FI relative to un-treated cell.

Figure 4.
Figure 4.

Cisplatin (5 μg/ml) induced Major histocompatibility complex class I-related chain A/B (MICA/B) expression on HeLa cell surface, as shown by flow cytometry at the indicated time. The peak increased the fluorescence intensity (FI) ratio of MICA/B occurred at 24-36 hours after exposure to cisplatin and then decreased. Cisplatin 1 and 2 mean the serial experiment number. Data are expressed as relative ratio (RR); the fold increase of FI relative to un-treated cells.

Compliance. Ex vivo culture, expansion and intravenous infusion of NKL was feasible and well-tolerated in all patients except one, for whom study treatment was delayed one week due to inadequacy of NKL expansion. The mean count of expansion of NKLs in a 60-ml bag was 2.0×109 and NK cell purity was generally over 70%. The median number of treatment cycles delivered was four (range, 1 to 6); Fourteen patients (14/19, 73.7%) received at least half of the planned therapy (three cycles) and four patients (4/19, 21%) completed the treatment (six cycles). Treatment was stopped because of PD or SD in eleven patients (11/15, 73.6%) and because of toxicity or refusal in two (2/15, 13.3%) and two (2/15, 13.3%) patients, respectively. Blood collections for NKLs were not delayed for over a week due to leukopenia or anemia. No patients experienced any signs of infusion reactions or infection related to the handling of blood products.

View this table:
Table I.

Baseline patient characteristics.

PFS, response and toxicity. All 19 patients were evaluated for tumor responses. Table II shows the most important variables for these. There were no cases of CR. Two patients achieved a PR, with an overall response rate of 10.5%. SD was obtained in 12 patients (63.2%) and PD was observed in five patients (26.3%). Therefore, the overall disease control rate was 73.7% (14 out of 19 patients). In the two PRs, one was observed after two cycles and the other after four cycles of chemotherapy. Data on efficacy are summarized in Table III. All patients were included in the survival analysis (PFS). The median follow-up period was 8.6 months (range=2.7-15.3 months). At the time of analysis (July 1, 2012), the median PFS was 2.9 months (range=1.3-6.4 months). The Kaplan Meier estimated PFS curve is shown in Figure 5. A total of 76 cycles were administered, with a median of four cycles per patient (range=2-6 cycles).

Figure 5.
Figure 5.

The Kaplan Meier estimated progression-free survival. All patients were included in the survival analysis. The median follow-up period was 8.6 months (range=2.7-15.3 months). At the time of analysis (July 1, 2012), the median PFS was 2.9 months (range=1.3-6.4 months).

All the patients were assessed for toxicity. Table IV lists all hematological and non-hematological toxicities. Grade 1 and 2 toxicities are not shown in Table IV. Common toxicities of grade 3 or higher were peripheral sensory neuropathy, nail change and hematological toxicities (anemia, leukopenia). Severe hematological toxicity was uncommon. Grade 3 anemia, leukopenia, and febrile neutropenia were noted in two, two, and one patient, respectively. There was no treatment-related death in the present study.

Discussion

Cancer immunotherapy has long been recognized as an important modality in cancer treatment, but clinical studies have had little success. Immunotherapeutic modality using NK cells is attractive due to its potential role in immune surveillance in vivo, together with CD8+ CTLs, by destroying infected or transformed cells and possibly contributes to an increased cure rate (2-4). Many activating and inhibitory receptors on NK cells have been revealed and the balance between each group of receptor signaling is known to be essential in the control of NK cell function such as NK cell-mediated cytotoxicity (NKMC), cytokine production, and antibody-dependent cell-mediated cytotoxicty (ADCC) (13-15). NKMC mediated by NKG2DR and its representative ligand MICA/B on tumor cells has special interest in terms of anticancer treatment because MICA/B expression can be modulated by various stress factors (transformation, chemotherapy, radiation, differentiation induction, etc.) and it is anticipated that enhancing MICA/B expression will contribute to anticancer treatment (16-20). However, clinical application of NK cells has been hindered by the low frequency of NK cells in peripheral blood, 5-20%, and difficulty in expanding NK cells ex vivo. Recent development of mass expansion of NKLs ex vivo by NKBIO Co. has made clinical application of NKLs possible and we designed a clinical trial of combination of NKL with chemotherapy. The purity of NK cells in NKLs was greater than 70% and the number of NK cells to be administered per each cycle was hundreds to thousands times greater, as compared with the number of NK cells in peripheral blood. We confirmed, as previously reported by many investigators, that MICA/B on HeLa cells can be increased by the stimulation with cisplatin, vinorelbine, and docetaxel, reaching a peak at 24-36 hours, and then decreasing (docetaxel was poorly-soluble in the experimental medium and most experiments were performed using cisplatin as a representative agent). Therefore, we designed a clinical trial of combination of NKL with docetaxel administered on the same day. The lowest dose of dexamethasone, as possible, was recommended because it might reduce MICA/B expression (unpublished data). We selected patients with advanced NSCLC in second- or third-line treatment as the target of combination of NKL with chemotherapy because such diseases is highly fatal, especially after first-line failure, it was convenient to evaluate the response, and defects in HLA class I are known in NSCLC. This trial was designed as a phase-II study to evaluate the feasibility and safety and compare the outcome with the historical control of weekly docetaxel regimen, one of the recommended second-line treatments; PFS=2.9 months, RR=8.0% (11). In contrast to our concern that poor performance and myelosuppression due to weekly docetaxel and previous chemotherapy might hinder proper NKL administration, NKL preparation and expansion were feasible in all cases, even in those with disseminated cancer. No adverse events related to NKL infusion and no further toxicity, as compared with weekly docetaxel, were observed on up to six repeated NKL administrations. Similar range of adverse events shown in weekly docetaxel, such as neutropenia G3-4, asthenia, nausea/vomiting, and nail change (11) were observed in this trial. In terms of clinical benefit, PFS=3 months and RR=10.5% (2/19) were comparable to the historical control of the weekly docetaxel regimen (PFS=2.9 months, RR=8.0%), but firm statistical assessment seemed inappropriate due to the small sample size. We expected 44 patients to be enrolled in order to enable statistical assessment but this trial was closed early because of slow enrollment, possibly due to revised guidelines on maintenance regimen and new second-line drugs and due to change in internal affairs of NKBIO Co. which prepared and provided NKLs. We questioned why less benefit than we expected, in terms of PFS and RR, was observed in this study. This might be related to disseminated disease and docetaxel resistance for most of the enrolled patients (14/19, 73.6%) where the environment for NKL was not appropriate. Although we were unable to determine this, it was interesting that two cases of PR were observed in the patients with less disseminated cancer, such as one with modest mediastinal and the other with supraclavicular lymphadenopathy.

View this table:
Table II.

Most important variables for all 19 patients included in the study.

View this table:
Table III.

Tumor response to docetaxel and NK cell-enriched lymphocytes (n=19).

View this table:
Table IV.

Toxic effects of docetaxel and NK cell-enriched lymphocytes (grade 3 or higher) among the 19 patients included in the study.

As a conclusion, to our knowledge, this is the first report on the combination of NKL with docetaxel in patients with advanced NSCLC. Autologous NKL production and co-administration with docetaxel were feasible without further toxicity or complications. Benefit in PFS and RR, as compared with the historical control, was not detected in this study population with advanced NSCLC, but a further study to determine whether the combination of NKL and chemotherapy has any anticancer effect needs to be performed in patients with low tumor burden, such as those with less advanced disease or those in remission.

Acknowledgements

We thank NKBIO Co. for the excellent technical assistance and stable supply of expanded NKLs.

Footnotes

  • This article is freely accessible online.

  • Received February 17, 2013.
  • Revision received March 20, 2013.
  • Accepted March 21, 2013.

References

  1. ↵
    1. Salgia R,
    2. Hensing T,
    3. Campbell N,
    4. Salama AK,
    5. Maitland M,
    6. Hoffman P,
    7. Villaflor V,
    8. Vokes EE
    : Personalized treatment of lung cancer. Semin Oncol 38(2): 274-283, 2011.
    OpenUrlCrossRefPubMed
  2. ↵
    1. Kim JY,
    2. Son YO,
    3. Park SW,
    4. Bae JH,
    5. Chung JS,
    6. Kim HH,
    7. Chung BS,
    8. Kim SH,
    9. Kang CD
    : Increase of NKG2D ligands and sensitivity to NK cell-mediated cytotoxicity of tumor cells by heat shock and ionizing radiation. Exp Mol Med 38(5): 474-484, 2006.
    OpenUrlCrossRefPubMed
    1. Mistry AR,
    2. O'Callaghan CA
    : Regulation of ligands for the activating receptor NKG2D. Immunology 121(4): 439-447, 2007.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Zitvogel L,
    2. Apetoh L,
    3. Ghiringhelli F,
    4. Kroemer G
    : Immunological aspects of cancer chemotherapy. Nat Rev Immunol 8(1): 59-73, 2008.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Rosenberg SA,
    2. Lotze MT,
    3. Muul LM,
    4. Leitman S,
    5. Chang AE,
    6. Ettinghausen SE,
    7. Matory YL,
    8. Skibber JM,
    9. Shiloni E,
    10. Vetto JT
    : Observations on the systemic administration of autologous lymphokine-activated killer cells and recombinant interleukin-2 to patients with metastatic cancer. N Engl J Med 313(23): 1485-1492, 1985.
    OpenUrlCrossRefPubMed
  6. ↵
    1. Arina A,
    2. Murillo O,
    3. Dubrot J,
    4. Azpilikueta A,
    5. Alfaro C,
    6. Pérez-Gracia JL,
    7. Bendandi M,
    8. Palencia B,
    9. Hervás-Stubbs A,
    10. Melero I
    : Cellular liaisons of natural killer lymphocytes in immunology and immunotherapy of cancer. Expert Opin Biol Ther 7(5): 599-615, 2007.
    OpenUrlCrossRefPubMed
  7. ↵
    1. Jun Wu,
    2. Lanier LL
    : Natural killer cells and cancer. Adv Cancer Res 90: 127-156, 2003.
    OpenUrlCrossRefPubMed
  8. ↵
    1. Berg M,
    2. Lundqvist A,
    3. McCoy P Jr..,
    4. Samsel L,
    5. Fan Y,
    6. Tawab A,
    7. Childs R
    : Clinical-grade ex vivo-expanded human natural killer cells up-regulate activating receptors and death receptor ligands and have enhanced cytolytic activity against tumor cells. Cytotherapy. 11(3): 341-355, 2009.
    OpenUrlCrossRefPubMed
  9. ↵
    1. Morisaki T,
    2. Onishi H,
    3. Koya N,
    4. Kiyota A,
    5. Tanaka H,
    6. Umebayashi M,
    7. Ogino T,
    8. Nagamatsu I,
    9. Katano M
    : Combinatorial cytotoxicity of gemcitabine and cytokine-activated killer cells in hepatocellular carcinoma via the NKG2D-MICA/B system. Anticancer Res 31(7): 2505-2510, 2011.
    OpenUrlAbstract/FREE Full Text
  10. ↵
    1. Brookmeyer R,
    2. Crowley J
    : A confidence interval for the median survival time. Biometrics 38: 29-41, 1982.
    OpenUrlCrossRef
  11. ↵
    1. Bria E,
    2. Cuppone F,
    3. Ciccarese M,
    4. Nisticò C,
    5. Facciolo F,
    6. Milella M,
    7. Izzo F,
    8. Terzoli E,
    9. Cognetti F,
    10. Giannarelli D
    : Weekly docetaxel as second-line chemotherapy for advanced non-small cell lung cancer: Meta-analysis of randomized trials. Cancer Treat Rev 32(8): 583-587, 2006.
    OpenUrlCrossRefPubMed
  12. ↵
    1. Eisenhauera EA,
    2. Therasse P,
    3. Bogaertsc J,
    4. Schwartzd LH,
    5. Sargente D,
    6. Fordf R,
    7. Danceyg J,
    8. Arbuckh S,
    9. Gwytheri S,
    10. Mooneyg M,
    11. Rubinsteing L,
    12. Shankarg L,
    13. Doddg L,
    14. Kaplanj R,
    15. Lacombec D,
    16. Verweijk J
    : New response evaluation criteria in solid tumours: Revised RECIST guideline (version 1.1). Eur J Cancer 45: 228-247, 2009.
    OpenUrlCrossRefPubMed
  13. ↵
    1. Farag SS,
    2. Fehniger TA,
    3. Ruggeri L,
    4. Velardi A,
    5. Caligiuri MA
    : Natural killer cell receptors: new biology and insights into the graft-versus-leukemia effect. Blood 100(6): 1935-1947, 2002.
    OpenUrlAbstract/FREE Full Text
    1. Rajalingam R
    . Human diversity of killer cell immunoglobulin-like receptors and disease. Korean J Hematol 46(4): 216-228, 2011.
    OpenUrlPubMed
  15. ↵
    1. Textor S,
    2. Dürst M,
    3. Jansen L,
    4. Accardi R,
    5. Tommasino M,
    6. Trunk MJ,
    7. Porgador A,
    8. Watzl C,
    9. Gissmann L,
    10. Cerwenka A
    : Activating NK cell receptor ligands are differentially expressed during progression to cervical cancer. Int J Cancer 123(10): 2343-2353, 2008.
    OpenUrlCrossRefPubMed
  16. ↵
    1. Xu X,
    2. Rao G,
    3. Gaffud MJ,
    4. Ding HG,
    5. Maki G,
    6. Klingemann HG,
    7. Groh V,
    8. Spies T,
    9. Caillat-Zucman S,
    10. Gattuso P,
    11. Plate J,
    12. Prinz RA
    : Clinicopathological significance of major histocompatibility complex class I-related chain A and B expression in thyroid cancer. J Clin Endocrinol Metab 91(7): 2704-2712, 2006.
    OpenUrlCrossRefPubMed
    1. Gasser S,
    2. Orsulic S,
    3. Brown EJ,
    4. Raulet DH
    : The DNA damage pathway regulates innate immune system ligands of the NKG2D receptor. Nature 436: 1186-1190, 2005.
    OpenUrlCrossRefPubMed
    1. Stern-Ginossar N,
    2. Mandelboim O
    : An integrated view of the regulation of NKG2D ligands. Immunology 128(1): 1-6, 2009.
    OpenUrlCrossRefPubMed
    1. Zhang C,
    2. Wang Y,
    3. Zhou Z,
    4. Zhang J,
    5. Tian ZP
    : Sodium butyrate up-regulates expression of NKG2D ligand MICA/B in HeLa and HepG2 cell lines and increases their susceptibility to NK lysis. Cancer Immunol Immunother 58(8): 1275-1285, 2009.
    OpenUrlCrossRefPubMed
  20. ↵
    1. Ma Y,
    2. Conforti R,
    3. Aymeric L,
    4. Locher C,
    5. Kepp O,
    6. Kroemer G,
    7. Zitvogel L
    : How to improve the immunogenicity of chemotherapy and radiotherapy. Cancer Metastasis Rev 30(1): 71-82, 2011.
    OpenUrlCrossRefPubMed
Back to top

In this issue

Print
Download PDF
Article Alerts
Email Article
Citation Tools
Reprints and Permissions
A Trial of Autologous Ex vivo-expanded NK Cell-enriched Lymphocytes with Docetaxel in Patients with Advanced Non-small Cell Lung Cancer as Second- or Third-line Treatment: Phase IIa Study
YOUNG JUN YANG, JI CHAN PARK, HOON KYO KIM, JIN HYOUNG KANG, SUK YOUNG PARK
Anticancer Research May 2013, 33 (5) 2115-2122;
Twitter logo Facebook logo Mendeley logo

Jump to section

Keywords