Gynecology and Minimally Invasive Therapy 5 (2016) 127e131

Contents lists available at ScienceDirect

Gynecology and Minimally Invasive Therapy

journal homepage: www.e-gmit.com

Case report

Complete remission of relapsed cervical cancer through

immunochemoradiotherapy: Two case reports and three
proposed mechanism
Yi-Hao Lin 1, Hsin-Hong Kuo 1, Ling-Hong Tseng, Jian-Tai Qiu, Fu-Shun Chang,
Cheng-Tao Lin*
Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University College of Medicine,
Taoyuan, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: Background: In current practice, immunotherapy has been established as an adjuvant rescue therapy for
Received 1 December 2015 cervical cancer treatment after standard concurrent chemoradiotherapy (CCRT) with tumor recurrence.
Received in revised form Carcinoma of the cervix is a relatively chemotherapy-resistant disease. Patients with recurrent cervical
14 December 2015
cancer have significantly reduced life expectancy, and fewer than 20% of patients survive for 1 year.
Accepted 20 January 2016
Therefore, we tried using CCRT after priming and booster immunomodulatory therapy [i.e., immu-
Available online 3 March 2016
nochemoradiotherapy, (ICRT)].
Case reports: In the first report, a 34 year-old female diagnosed with International Federation of Gyne-
Keywords:
cervical cancer
cology and Obstetrics (FIGO) stage IIA cervical cancer with pathological proof of poorly differentiated
chemoradiotherapy squamous cell carcinoma was treated with radical surgery. Two years later, she experienced progressive
immunotherapy weakness and numbness in her right leg. Computed tomography showed a mass of 8 cm
7 cm in her
right lower pelvis and presacral area with encasement of the right middle ureter. In addition, right
hydronephrosis and a metastatic lymph node were suspected in the right iliac vessels. She received
standard CCRT with “add on” immunomodulatory agents as a radiosensitizer to augment ICRT. The
priming immunomodulatory agents included picibanil [O (i.e., OK-432)], mixed Cervarix (Glax-
oSmithKline, London, England) or Gardasil (Merck and Co., Inc., Kenilworth, NJ, USA) viral-like particle
vaccine (V) on day 1, and aldesleukin [A (i.e., interleukin-2)] on Day 2. She also started concurrent
radiotherapy and palcitaxol (80 mg/m2) on Day 2 and boostered OVA (i.e., picibanil, viral-like particle
vaccine, and aldesleukin) again on Day 4 and Day 5. After the ICRT treatment, remarkable improvements
occurred by lower sacral pain, regression of the pelvic tumor, and decreased squamous cell carcinoma
antigen (SCC-Ag) levels from 33.8 ng/mL to normal. The second case report is a 66-year-old female with
FIGO stage IIA cervical adenocarcinoma. She underwent staging surgery, followed by CCRT. She first had a
relapse on the supraclavicle node 2 years before receiving CCRT. A left axilla mass was noted 6 years
before she started the priming and booster ICRT treatment. Both patients have been disease-free for >
5 years since receiving CCRT.
Conclusion: We reported two patients with cervical cancer recurrence after conventional therapy. We
combined CCRT and ICRT to augment the host cells' immunosurveillance and reach durable response more
than 5 years mimic long-term progression-free survival. These two patients showed promising results.
Copyright © 2016, The Asia-Pacific Association for Gynecologic Endoscopy and Minimally Invasive
Therapy. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction
Conflicts of interest: The authors have no competing interests or conflicts of
interests to declare. Recurrent cervical cancer after surgery and/or radiotherapy has
* Corresponding author. Department of Obstetrics and Gynecology, Chang Gung
a high rate of mortality and morbidity. The 5-year survival rates
Memorial Hospital, 5 Fu-Shin Street, Kwei-Shan, Taoyuan 333, Taiwan.
E-mail address: [email protected] (C.-T. Lin).
reported in patients with relapsed cervical cancer after radical
1
Yi-Hao Lin & Hsin-Hong Kuo both contributed equally to this paper. surgery or radiotherapy range between 3.2% and 13%. Tumor

http://dx.doi.org/10.1016/j.gmit.2016.01.008
2213-3070/Copyright © 2016, The Asia-Pacific Association for Gynecologic Endoscopy and Minimally Invasive Therapy. Published by Elsevier Taiwan LLC. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
128 Y.-H. Lin et al. / Gynecology and Minimally Invasive Therapy 5 (2016) 127e131

recurrence is limited to the pelvis,1 which occurs in approximately intestines or bony structure (Figure 2C). These findings suggest that
one-half of patients. Curative options for these patients are either she had achieved a complete remission of cervical cancer, after
high-dose radiotherapy or pelvic exenteration.2,3 Compared to undergoing priming and booster ICRT.
pelvic exenteration, high-dose radiotherapy or concurrent chemo-
therapy (CCRT) may be more suitable for younger patients. Treat- Case 2
ment of advanced or persistent cervical cancer includes
radiotherapy and chemotherapy. However, at the present time, A 66-year-old female was diagnosed with cervical adenocarci-
there is no effective treatment for metastatic disease and re- noma, FIGO stage IIA (i.e., T2aN1M1). She underwent surgery and
currences. Experimental data from multiple cancer models have CCRT. Three years before she received CCRT, supraclavicular node
provided sufficient evidence that the effects of ionizing radiation and axilla lymph node metastatic carcinoma was noted. Metastatic
may contribute to systemic antitumor immunity.4 Therefore, we nodes and a movable mass at the left axilla were noted 6 years
attempted to use standard CCRT after priming and boosting with before she was administered the immunotherapies OK-432 and
immunomodulatory therapy [i.e., immunochemoradiotherapy, HPV 6, 11, 16, 18 or HPV 16, 18 recombinant vaccines (i.e., Gardasil or
(ICRT)] as a combination therapy to augment host cells' immuno- Cervarix, respectively). Two months later, she received another
surveillance in patients with relapsed cervical cancer. We present immunotherapy treatment with OK-432 and IL-2. She is stable now
two patients in whom this innovative approach was successful. It and has been disease-free for > 5 years. Because of successful du-
may become a novel treatment option for advanced cervical cancer rable response in relapse of cervical cancer after standard CCRT, our
or recurrent cervical cancer in the future. team was approved to complete preclinical model prime-boost
vaccination to obtain promising results.
Case Reports Thus, we reported two retrospective cases of patients who
received CCRT with mixed prime-boost “add on” OK-432 and HPV
Case 1 6, 11, 16, 18 or HPV 16, 18 recombinant vaccines (i.e., Gardasil or
Cervarix, respectively) immunomodulatory agents. Figure 3 shows
A 34 year-old female with no known systemic disease was a shrunken metastatic axillary mass at 3 months after additional
diagnosed with cervical cancer. She underwent type III radical CCRT, following ICRT in the second patient.
surgery. The pathological examination revealed poorly differenti- The Institutional Review Board of Chang Gung Memorial Hos-
ated squamous cell carcinoma, International Federation of Gyne- pital (Taoyuan, Taiwan) understood and approved our overall
cology and Obstetrics (FIGO) stage IIA (i.e., T2aN0M0). Two years treatment (approval number, 97-0505B). The patients have given
later, she was experiencing progressive weakness and numbness in their consent for their case reports to be published.
her right leg. Computed tomography (CT) showed a pelvic mass,
8 cm
7 cm, in the right lower pelvis and presacral area with Discussion
encasement of the right middle ureter. In addition, right hydro-
nephrosis and a metastatic lymph node were suspected in the right We reported two cases of local advanced cervical cancer with
iliac vessels. The patient received standard CCRT with the prime- recurrence after conventional therapy by either surgery and/or
boost “add on” immunomodulatory agents picibanil (i.e., OK-432), CCRT. We combined CCRT and/or ICRT to augment the host cells'
aldesleukin [i.e., interleukin-2 (IL-2)], levamisole, and human immunosurveillance. These two patients overall show promising
papillomavirus (HPV) 6, 11, 16, 18 recombinant vaccine (Gardasil; results, and both patients are free of disease and mimic
Merck and Co., Inc., Kenilworth, NJ, USA) or HPV 16, 18 (Cervarix; progression-free survival for more than 5 years. We currently do
GlaxoSmithKline, London, England ) were initiated as one vial not know to rescue the standard treatments and/or “add on” prime-
subcutaneous administered the immunomodulatory therapeutic boost immunotherapy for recurrent and/or metastatic cervical
regimen, respectively. Picibanil (OK-432) and aldesleukin (IL-2) are cancers have focused on pelvic exenteration. This approach,
well-studied immunomodulators for treating melanoma, gastric although morbid, remains the only curative option for locally iso-
cancer, and many other cancers.5 Levamisole and HPV 6, 11, 16, 18 lated recurrent disease. When pelvic exenteration is not generally
recombinant vaccine (i.e., Gardasil) and/or HPV 16, 18 recombinant appropriate because of metastatic disease, palliative radiation has
vaccine (i.e., Cervarix) have been used for adjuvant therapeutic been used. However, more novel discoveries about tumor immu-
vaccination. The use of levamisole as an immunostimulant has been nity and experimental data from multiple cancer models have
successful in controlling certain diseases. Levamisole is used in provided sufficient evidence that the effects of ionizing radiation
combination with a vaccine to improve its immunogenic effect may contribute to systemic antitumor immunity.4 Previous reports
in inducing dendritic cell maturation and the secretion of IL-12 and have shown consistent promising results in preclinical models of
IL-10.6 External radiation therapy (RT) was also administered in the cervical cancer therapeutic vaccines.7e12 To date, even in an adju-
first 2 months with subsequent integrated chemotherapy, after two vant setting, the efficacy of radioimmunotherapy for recurrent local
cycles of paclitaxol (80 mg/m2) and/or cisplatin (40 mg/m2). After invasive cervical cancer has not been well determined and the
completing treatment, remarkable improvements in sacral pain, concept of immunotherapy combined with chemotherapy was also
regression of the pelvic tumor, and decrease in SCC-Ag levels were halted at the preclinical stage.7 These results prompted us to
observed (Figure 1). initiate the current study. However, these results are preliminary
Figure 1 shows the SCC-Ag level of the first patient. Her SCC level and further studies are needed to substantiate the clinical utility of
remained elevated until the completion of the immunotherapy. The these methods. We propose three mechanisms.
patient also received a series of CT scans to evaluate the severity
and progression of the tumor. Images of the recurrent tumor were First mechanism: radiation therapy converts the tumor into an in
compared before ICRT. Three months after the treatment, a cystic situ vaccine
change and a decrease in the size of the tumor had occurred
(Figures 2A and 2B, respectively). Two years after she had been “Abscopal effects” may explain the lasting effect in reducing the
treated with ICRT, the masses totally regressed to achieve durable possibility of recurrence. Mole13 emphasize that all cells in the body
response and there was no definite metastasis to the soft tissues of are interdependent and damage to one cell affects the organism as
the neck, lung, chest wall, ribs, lymph nodes, or any part of a whole. Therefore, local radiation has an effect, and other local
 Y.-H. Lin et al. / Gynecology and Minimally Invasive Therapy 5 (2016) 127e131 129

Figure 1. The graph shows the change in the squamous cell carcinoma (SCC) tumor marker level in the first patient. Immunochemoradiotherapy (ICRT) was initiated, and the SCC
marker level remained elevated until the end of immunotherapy.

Figure 2. (A) Before beginning immunochemoradiotherapy (ICRT), recurrent cervical cancer is visible in the patient's right lower pelvis and presacral space. The transverse view of
the pelvis on the computed tomography (CT) image shows two large tumor masses, the sizes of which are 5.00 cm
5.50 cm and 3.64 cm
4.44 cm. (B) The recurrent tumor mass,
after priming and boosting every 3 days with OA-OA and concurrent chemoradiotherapy (CCRT). The treatment-mediated cystic change by the 3rd month after initiating ICRT and
CCRT. The transverse view of the pelvis on the CT image shows that two tumor masses remain. One tumor, 6.90 cm
4.29 cm, is a cystic mass with an irregular wall and engorged
vessels. It is in the right pelvis and has invaded the urinary bladder and rectum. The other tumor has atrophied to 3.37 cm
4.40 cm. (C) The transverse view of the pelvis on the CT
image shows that the tumor masses have vanished. OA ¼ picibanil/aldesleukin.

Figure 3. The computed tomography (CT) image of a shrunken metastatic axillary mass after additional concurrent chemoradiotherapy (CCRT), following ICRT with picibanil
(OK-432) and human papillomavirus (HPV) 6, 11, 16, 18 recombinant vaccine (Gardasil; Merck and Co., Inc. Kenilworth, NJ, USA).

therapies could influence other aspects of the body; this phe- 1994.15,16 Matzinger postulated that the immune systemdrather
nomenon could be called an “abscopal effect.”13,14 Many mecha- than differentiating “self” from “nonself”dresponds to “danger
nisms of abscopal effects have been discussed. The most accepted signals” that occur as a consequence of tissue damage. Apoptosis
mechanism is related to the immune system, especially the and necrosis induced by environmental stress, pathogens, chemo-
“danger” model of immunity originally proposed by Matzinger in therapy, and radiation can create a milieu that elicits “danger
130 Y.-H. Lin et al. / Gynecology and Minimally Invasive Therapy 5 (2016) 127e131

signals.” Based on this theory, radiation may induce cancer histocompatibility complex class I (MHC I), MHC II, CD1d, and /or
apoptosis and/necrosis, which releases exosomes and elicit an in- toll-like receptors to carry tumor-derived antigens to tumor-
flammatory response locally and thereby induce T-cell activation draining lymph nodes to complete effective signal 1 and signal 2
against tumor antigens. These antigens then circulate and may be immunization, after ICRT.8e12 To determine the type of interaction
responsible for the abscopal effects seen during RT. A similar hy- between chemotherapy and radiotherapy within the radiation field
pothesis has also been described by Demaria et al17 who demon- (i.e., supra-additivity, additivity, or infra-additivity), Steel and
strated that the abscopal effect induced in tumors treated by Peckham described isobologram analysis, which is based on the
radiation appears to be immune-mediated, and that T-cells are isoeffect concept of chemoradiotherapy interaction. Independent
required for the distant effects. Dewan also found in two preclinical doseeresponse curves for chemotherapy and radiotherapy are
carcinoma models that fractionated radiotherapy, instead of single- necessary to create a plot (i.e., isobologram).20 Other methods exist
dose radiotherapy, induces an abscopal effect when combined with to determine the types of additivity such as the median effect
anti-CTLA-4 antibody.18 principle and the response surface approach. The concept of addi-
tivity unfortunately is of limited use in clinical practice because the
Second mechanism: the combination of immunotherapy and preclinical prediction of additivity does not translate well into
chemotherapy may cause a synergistic therapeutic effect clinical outcomes. Therefore, the use of this method is limited for
forming hypotheses, which need to be confirmed empirically.
Cytotoxic chemotherapy remains one of the most widely avail- Shioyama et al21 used chemoradiotherapy and immunotherapy
able treatment options for cancer. The efficacy of chemotherapy is successfully to treat a patient with a gastrointestinal stromal tumor,
unfortunately limited; in particular, cures are rarely achieved for and their study is the only clinical study, rather than a preclinical
solid tumors. Immunotherapy is a more experimental treatment study, to discuss ICRT. Even for preclinical studies, ICRT has been a
method aimed at mobilizing the body's immune cells to attack rare subject in past decades. There are many differences between
tumor cells; however, it is also rarely curative. Few studies have this report and our report such as the sequence of immunotherapy
investigated combining chemotherapy and immunotherapy, largely and CCRT that was administered, the cancer type, and different
because the two forms of treatment are considered antagonistic in regimens. However, our report still illustrates the potential of
the standard regimen. treating cancer by priming and boosting using the ICRT regimen.
Two assumptions contribute to this view. First, most chemo- We have presented two cases of recurrent cervical cancer that
therapies kill the target cells by triggering the process of pro- was cured by innovative prime-boost immunochemoradiotherapy.
grammed cell death (i.e., apoptosis). This mode of cell death is We have demonstrated proof of the concept of concurrent radio-
regarded as nonstimulatory or tolerogenic (i.e., tolerance inducing). therapy with chemotherapy and/or immunotherapy that links
In general, chemotherapeutic agents have an immunosuppressive innate and adaptive immune cells to elicit a promising anticancer
function; however, they provide an immunomodulatory thera- response.8e10 Further studies on the efficacy between different
peutic window to elicit tumor-specific T-cells to generate an combinations of regimens or treatment methods and their mech-
excellent anticancer response. Thus, apoptosis-inducing chemo- anisms are nonetheless needed.
therapy would be expected to induce a state of nonresponsiveness
in cytotoxic T-lymphocytes that could otherwise potentially Acknowledgments
destroy tumor cells.
Second, lymphocyte depletion (i.e., lymphopenia) is a common The study was supported by grants CMRPG3C0911 and
adverse effect of many anticancer drugs and/or radiation, which is CMRPG3D1881, which were provided by Chang Gung University
assumed to be detrimental to any potential immune response. Hospital (Taoyuan, Taiwan).
However, recent studies challenge both of these assumptions, and
new mechanisms have been raised.7 References
One mechanism that has been postulated in an attempt to
explain the synergistic effects of chemotherapy and immuno- 1. Lai CH. Management of recurrent cervical cancer. Chang Gung Med J. 2004;27:
711e717.
therapy is that chemotherapeutic drugs may enhance the anti-
2. Friedlander M, Grogan M, U.S. Preventative Services Task Force. Guidelines for
tumor effects of immunotherapy by acting directly on the tumor the treatment of recurrent and metastatic cervical cancer. Oncologist. 2002;7:
and host environment, and thereby minimizes the drugs' immu- 342e347.
nosuppressive effects. Some studies have demonstrated that 3. Berek JS, Howe C, Lagasse LD, Hacker NF. Pelvic exenteration for recurrent
gynecologic malignancy: survival and morbidity analysis of the 45-year
certain drugs may modify the immunogenicity of tumor cells. Some experience at UCLA. Gynecol Oncol. 2005;99:153e159.
chemotherapeutic agents may cause tumor cells to become highly 4. Formenti SC, Demaria S. Combining radiotherapy and cancer immunotherapy:
immunogenic, while others may directly cause tumor cell death by a paradigm shift. J Natl Cancer Inst. 2013;105:256e265.
5. Ryoma Y, Moriya Y, Okamoto M, Kanaya I, Saito M, Sato M. Biological effect of
the release of a multitude of epitopes and exosomes for recognition OK-432 (picibanil) and possible application to dendritic cell therapy. Anticancer
by the immune system. This factor subsequently incites an immune Res. 2004;24:3295e3301.
response against tumor cells such as lysis by cytotoxic T-lympho- 6. Chen LY, Lin YL, Chiang BL. Levamisole enhances immune response by affecting
the activation and maturation of human monocyte-derived dendritic cells. Clin
cytes (CTLs). Moreover, chemotherapy may eliminate or reduce the Exp Immunol. 2008;151:174e181.
activity of regulatory T-cells and their tumoricidal activity. Other 7. van der Most RG, Robinson BW, Lake RA. Combining immunotherapy with
potential mechanisms include the induction of transient lympho- chemotherapy to treat cancer. Discov Med. 2005;5:265e270.
8. Lin CT, Wang CN, Lai CH. Immunotherapy for advanced or relapsed cervical
penia through chemotherapy, which may eliminate the activity of cancer. Gynecol Min Invas Ther. 2013;2:3e7.
regulatory T-cells and the stimulation of antitumor CTLs.19 9. Chen IJ, Yen CF, Lin KJ, et al. Vaccination with OK-432 followed by TC-1 tumor
lysate leads to significant antitumor effects. Reprod Sci. 2011;18:687e694.
10. Chao A, Lin CT, Lai CH. Updates in systemic treatment for metastatic cervical
Third mechanism: immunochemoradiotherapy is the future trend
cancer. Curr Treat Options Oncol. 2014;15:1e13.
11. Lin CT, Hung CF, Juang J, et al. Boosting with recombinant vaccinia increases
To study the efficacy of the combination of chemotherapy and HPV-16 E7-specific T cell precursor frequencies and antitumor effects of HPV-
radiotherapy, many researchers have developed unique analytical 16 E7-expressing Sindbis virus replicon particles. Mol Ther. 2003;8:559e566.
12. Tseng CW, Hung CF, Alvarez RD, et al. Pretreatment with cisplatin enhances E7-
paradigms. We initially used picibanil (OK-432), which triggers specific CD8þ T-cell-mediated antitumor immunity induced by DNA vaccina-
dendtritic cells to express many cell surface receptors such as major tion. Clin Cancer Res. 2008;14:3185e3192.
 Y.-H. Lin et al. / Gynecology and Minimally Invasive Therapy 5 (2016) 127e131 131

13. Mole RH. Whole body irradiation: radiobiology or medicine. Br J Radiol. 18. Dewan MZ, Galloway AE, Kawashima N, et al. Fractionated but not single-dose
1953;26:234e241. radiotherapy induces an immune-mediated abscopal effect when combined
14. Kaminski JM, Shinohara E, Summers JB, Niermann KJ, Morimoto A, with anti-CTLA-4 antibody. Clin Cancer Res. 2009;15:5379e5388.
Brousal J. The controversial abscopal effect. Cancer Treat Rev. 2005;31: 19. Haasbeek CJ, Uitterhoeve AL, van der Velden J, Gonzalez DG, Stalpers LJ. Long-
159e172. term results of salvage radiotherapy for the treatment of recurrent cervical
15. Matzinger P. Tolerance, danger, and the extended family. Annu Rev Immunol. carcinoma after prior surgery. Radiother Oncol. 2008;89:197e204.
1994;12:991e1045. 20. Seiwert TY, Salama JK, Vokes EE. The concurrent chemoradiation para-
16. Matzinger P. The danger model: a renewed sense of self. Science. 2002;296: digmdgeneral principles. Nat Clin Pract Oncol. 2007;4:86e100.
301e305. 21. Shioyama Y, Yakeishi Y, Watanabe T, et al. Long-term control for
17. Demaria S, Ng B, Devitt ML, et al. Ionizing radiation inhibition of distant a retroperitoneal metastasis of malignant gastrointestinal stromal
untreated tumors (abscopal effect) is immune mediated. Int J Radiat Oncol Biol tumor after chemoradiotherapy and immunotherapy. Acta Oncol. 2001;40:
Phys. 2004;58:862e870. 102e104.