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Original Article Efficacy analysis of triple-negative breast cancer patients treated with dendritic cell-cytokine-induced killer cell immunotherapy

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Int J Clin Exp Med 2019;12(12):13221-13229
www.ijcem.com /ISSN:1940-5901/IJCEM0100059
Original Article
Efcacy analysis of triple-negative
breast cancer patients treated with dendritic
cell-cytokine-induced killer cell immunotherapy
Yunqing Xie1, Kai Huang2, Shaofeng Lin3, Xiaowei Lin1, Qingfeng Zheng3, Qiuhong Zheng1
1Fujian Provincial Key Laboratory of Tumor Biotherapy, Departments of 2Breast Surgery, 3Chest Surgery, Fujian
Cancer Hospital & Fujian Medical University Cancer Hospital, Fuma Road 420, Fuzhou 350014, China
Received July 24, 2019; Accepted October 9, 2019; Epub December 15, 2019; Published December 30, 2019
Abstract: Background: To examine the efcacy of dendritic cell-cytokine-induced killer (DC-CIK) cell immunotherapy
combine with chemotherapy with or without radiotherapy for triple-negative breast cancer (TNBC) patients following
surgery. Methods: Sixty-seven TNBC patients were selected between December 2008 and February 2012 for this
retrospective study. Twenty-ve patients who received an infusion of DC-CIK cells were placed in the DC-CIK group
while an additional 42 patients were in the non-DC-CIK group. Results: The 3-year disease-free survival (DFS) rate
was signicantly improved in the DC-CIK group versus the non-DC-CIK group (P=0.021). The 5-year DFS rate was
improved from 20.08% to 39.32% although it approached statistical signicance (P=0.052). A subgroup analysis
showed that the 3-year and 5-year DFS rate were signicantly higher in the DC-CIK group, including advanced
TNM stage TNBCs compared with the non-DC-CIK group (P=0.026, P=0.042, respectively). The 3-year OS rate for
the advanced-stage subgroup in the DC-CIK group was signicantly higher compared with the non-DC-CIK group
(P=0.025). Although compared with the non-DC-CIK group, the improvement of 5-year OS rate with DC-CIK treat-
ment in the advanced-stage subgroup approached statistical signicance (P=0.051), the 5-year OS rate was still
improved from 22.72% to 41.56%. Conclusions: Advanced TNM stage TNBC patients may benet from an adjuvant
infusion of DC-CIK cells concurrent with conventional therapy to prevent disease relapse and improve OS.
Keywords: Cytokine-induced killer cell, dendritic cell, adjuvant immunotherapy, triple-negative breast cancer
Introduction
Currently, breast cancer is the leading cancer
affecting females worldwide. In 2012, nearly
one million new cases were diagnosed, and
among these cases, more than 170,000 in-
volved triple-negative breast cancer (TNBC) [1].
TNBC is dened as being negative for estrogen
receptor (ER), human epidermal growth factor
receptor-2 (HER-2), and progesterone rece-
ptor (PR) expression in immunohistochemistry
assays [2]. In general, TNBC represents 10-20%
of all breast cancers and it exhibits biological
behavior that is distinct from other breast can-
cers [3]. In particular, the clinical pathological
features of TNBC include a more aggressive
phenotype and a higher risk of metastatic
recurrence compared with other types of breast
cancer. It has been reported that up to 30% of
TNBC cases progress to metastatic breast can-
cer [4].
When distant metastasis events are detected
in TNBC patients, they mainly affect lung, liver,
brain, bone, and skin tissues and the prognosis
is very poor [5]. Due to the absence of endo-
crine and HER-2 targets, TNBC is less likely to
respond to conventional therapies such as anti-
HER-2 or hormone therapies, and chemothera-
py is currently the primary treatment for TNBC.
However, this therapy is only benecial for
approximately 20% of TNBC patients who are
sensitive to chemotherapy [6]. In addition, the
recurrence rate among patients with residual
TNBC is high (30-40%) [7]. The greatest risk of
recurrence is generally between 1 and 3 years
after treatment, and a sharp decrease in sur-
vival is observed within the rst ve years after
treatment [8]. Targeted therapies have been
Efcacy of DC-CIK cell immunotherapy for TNBC
13222 Int J Clin Exp Med 2019;12(12):13221-13229
developed, including poly ADP ribose poly-
merase (PARP) inhibitors and monoclonal anti-
bodies (e.g., cetuximab, erlotinib, and dasat-
inib), although clinical trials are ongoing to
conrm the anti-tumor efcacy of these poten-
tial treatments [9].
More recently, immunotherapy has been con-
sidered as a possible therapy when contraindi-
cations for surgery, radiotherapy, and chemo-
therapy exist [10]. Several previous studies
have investigated the safety and efcacy of
various immunotherapy approaches, as well as
their potentially curative effects [11, 12]. In
particular, dendritic cells (DCs) represent anti-
gen-presenting cells which can induce naive T
cells to have a specic and cytotoxic response
[13]. In addition, cytokine-induced killer (CIK)
cells represent a heterogeneous population of
cells which can be induced by multiple cyto-
kines [10]. Several reports have described the
benets of DC-CIK cell immunotherapy [14,
15]. Moreover, the advantages of DC-CIK cul-
tures include enhanced cell proliferation and
cytokine secretion and high tumoricidal activi-
ty. Thus, the infusion of DC-CIK cells currently
represents a novel and effective treatment for
cancer. Our own work and that of other labora-
tories have demonstrated that DC-CIK immuno-
therapy enhances immune function and the
microenvironment of breast cancer patients
with PR and ER nuclear staining <1% and HER-2
staining scored as 0 to 2+ at our pathology
department. Twenty-ve patients underwent
adjuvant DC-CIK therapy while the remaining
43 patients did not (the DC-CIK group and con-
trol group, respectively) (Table 1).
Chemotherapy with or without radiotherapy
treatment
All of the TNBC patients underwent four 21-day
cycles of anthracyline and paclitaxel-bas-
ed chemotherapy after surgery. Intravenous
administration of epirubicin (60 mg/m2) was
performed on day 1, followed by a 3-h intrave-
nous infusion of 175 mg/m2 paclitaxel on day
2. Patients with lymph node metastasis or dis-
tant metastasis received sequential intensity-
modulated radiation therapy before nishing
their chemotherapy regimen, with irradiation of
50 Gy/25f applied outside the axillary +/- lym-
phatic drainage area. The tumor bed received
10-16 Gy.
Generation of CIK cells and DC from peripheral
blood
Percoll density gradient centrifugation was per-
formed to isolate peripheral blood mononucle-
ar cells (PBMCs) from 50 mL heparinized whole
blood samples. The lymphocytes were collect-
Table 1. Characteristics of the cohort examined
Characteristic DC-CIK
(n=25)
non-DC-CIK
(n=42) p-value
Patient age 0.798
<50 y 18 29
≥50 y 713
Median age, y (range) 45 (31-75) 46 (32-60)
KPS (mean ± SD) 87.60±5.97 86.67±5.70 0.527
TNM 0.353*
I-IIA 11 19
IIB-IV 14 23
Surgery 1.000*
No 0 1
Yes 25 41
Chemotherapy 0.525*
No 0 2
Yes 25 40
Radiotherapy 0.071*
No 12 29
Yes 13 13
*Fisher’s Exact Test.
that are otherwise compromised by the abil-
ity of tumor cells to evade detection [16,
17]. However, limited data are available
regarding the effects of DC-CIK immuno-
therapy on TNBC patients [18, 19]. Th-
erefore, a retrospective analysis of the
effect of adjuvant DC-CIK immunotherapy
combined with chemotherapy with or with-
out radiotherapy on TNBC patients after sur-
gery (n=25) was conducted and clinical out-
come was evaluated.
Methods
Patients’ clinical features
Approval for this study was obtained from
the Ethics Committee of our institute and
written consent was obtained from each
participating patient. Between December 1,
2008 and February 28, 2012, 67 TNBC
patients who underwent surgery and re-
ceived chemotherapy with or without radio-
therapy at Fujian Cancer Hospital were
enrolled in this study. TNBC was conrmed
Efcacy of DC-CIK cell immunotherapy for TNBC
13223 Int J Clin Exp Med 2019;12(12):13221-13229
ed, plated at a concentration of 2×106 into 75
cm2 culture asks (BD, USA), and incubated
under 5% CO2 at 37°C. After 1-2 h, complete
GT-T551 medium supplemented with 50 ng/
mL interleukin-4 (IL-4) (Amoytop) and 100 ng/
mL granulocyte-macrophage colony-stimulat-
ing factor (GM-CSF) (Amoytop, China) was
added to each culture ask. The medium was
replenished every 3 days. On day 5, the medi-
um was supplemented with 500 U/mL tumor
necrosis factor-α (TNF-α; Peprotech, USA) and
100 µg/mL WT1 antigen (Miltenyi Biotec,
Germany). Mature tumor antigen-pulsed DCs
were harvested at day 7.
The suspended cells that were previously col-
lected were transferred to a 75 cm2 culture
ask that was pre-coated with 50 µg (5 µg/mL)
CD3 monoclonal antibody (Takara, Japan). On
day 1, complete GT-T551 medium (Takara) sup-
plemented with interferon (IFN)-1000 U/mL
(Novoprotein, Xiamen, China) and 1000 U/mL
IL-2 (Sihuanpharm, Beijing, China) was added
to adjust the cell density to 5×106 cells/mL.
Every 3 days, the cells received fresh medium
containing IL-2 (500 U/mL). On day 7, the CIK
cells were mixed with tumor antigen-pulsed
DCs at a ratio of 1:10. The mixed DC-CIK cells
were maintained in complete GT-T551 medium
supplemented with IL-2 (500 U/mL).
DC-CIK treatment schedule
Bacterial contamination and endotoxin tests
were conducted prior to performing transfu-
sions. Results <0.06 EU were needed within 48
h of testing to proceed. Briey, DC-CIK cells
were harvested on day 12 and added to a 0.9%
normal salt solution (Hai Wang, Fuzhou, China).
The DC-CIK cells were then administered at
2-5×109 cells a day for 4 d via intravenous infu-
sion during the intervals of chemotherapy. One
cycle was dened as four transfusions, and it
included 1-2×1010 cells. The interval of each
cycle extended over at least 14 d.
Follow-up
All patients completed follow-up examinations
that were required every three months for the
rst two years, every six months for the next
three years, and then annually thereafter until
the 28th of February 2017. Both clinical and
laboratory examinations or telephone consulta-
tions were conducted. Physical examinations
and blood tests were also performed at each
follow-up visit. A colonoscopy, chest/abdominal
computed tomography (CT) scan, and ultra-
sound scans of the liver and abdomen were
performed every 6-12 months. Positron emis-
sion tomography-computed tomography (PET-
CT) was used to monitor suspected metastasis
or tumor recurrence. Short-term efcacy was
evaluated based on assigned Karnofsky perfor-
mance scale (KPS) scores.
Statistical analysis
Statistical analyses were performed with SPSS
16.0. Data are presented as the mean ± stan-
dard deviation (SD) and were compared with
the Kaplan-Meier method. The Cox proportion-
al hazard regression model was used for multi-
variate analysis. A p-value <0.05 was statisti-
cally signicant.
Results
Baseline patient characteristics
Sixty-seven TNBC patients were histologically
conrmed and agreed to participate in this
study. Twenty-ve patients were assigned to
the DC-CIK group and 42 patients were
assigned to the non-DC-CIK group. The clinical
and demographic characteristics of the two
groups did not signicantly differ (P>0.05)
(Table 1).
Adverse effects of DC-CIK cell transfusions
Among the patients who underwent DC-CIK cell
transfusions, one patient (4%) experienced a
mild fever and chills, while another patient
experienced an allergic reaction, anaphylactic
shock, hypotension, and chest tightness. Both
patients recovered with symptomatic treat-
ment. None of the patients in the cohort exhib-
ited problems with hepatic or renal function.
Assessment of KPS scores
The baseline KPS scores for the DC-CIK
and non-DC-CIK groups were 87.6±5.97 and
86.07±5.70, respectively (P=0.53). After treat-
ment, the KPS scores for the two groups we-
re 83.02±4.32 and 72.67±5.01, respectively
(P<0.05).
OS and DFS estimates
Kaplan-Meier estimates of 3-year DFS rates for
the DC-CIK and non-DC-CIK groups were signi-
Efcacy of DC-CIK cell immunotherapy for TNBC
13224 Int J Clin Exp Med 2019;12(12):13221-13229
cantly improved (P=0.021 Figure 1), and the
5-year DFS rates for the DC-CIK and non-DC-
CIK groups were improved from 20.08% to
39.32%, although it only approached statistical
signicance (P=0.052; Figure 2). Kaplan-Meier
estimates of 3-year and 5-year OS rates for the
two groups had no statistical signicance
(P=0.106, P=0.137, respectively; Figures 3, 4).
Subgroup analysis
A subgroup analysis was performed to investi-
gate whether TNM stage affects the prognosis
of postoperative TNBC patients with or without
DC-CIK treatment. TNBC patients in the early
stage group (which included TNM stages I and
IIA) did not appear to benet from DC-CIK treat-
ment based on their 3-year and 5-year DFS
rates (Figures 5, 6, P=0.755, P=0.934, respec-
tively) as well as 3-year and 5-year OS rates
(Figures 7, 8, P= 0.784, P=0.945, respec-
tively).
Figure 1. Kaplan-Meier estimates of 3-year DFS for
the DC-CIK and non-DC-CIK groups.
Figure 2. Kaplan-Meier estimates of 5-year DFS for
the DC-CIK and non-DC-CIK groups.
Figure 3. Kaplan-Meier estimates of 3-year OS for
the DC-CIK and non-DC-CIK groups.
Figure 4. Kaplan-Meier estimates of 5-year OS for
the DC-CIK and non-DC-CIK groups.
Figure 5. Kaplan-Meier estimates of 3-year DFS for
patients with TNM stage I or IIA TNBC.
Efcacy of DC-CIK cell immunotherapy for TNBC
13225 Int J Clin Exp Med 2019;12(12):13221-13229
In contrast, the 3-year DFS rate and 5-year DFS
rate for the advanced-stage group (which
included TNM stages IIB, III, and IV), was sig-
nicantly affected by DC-CIK treatment (Fig-
ures 9, 10, P=0.026, P=0.042 respectively).
The 3-year OS rate was also signicantly
improved for the advanced-stage group (Figure
11, P=0.025). Although compared with non-
DC-CIK group, the improvement of 5-year OS
rate with DC-CIK treatment in the advanced-
stage subgroup had only borderline statistical
signicance (Figure 12, P=0.051), the 5-year
OS rate was still improved from 22.72% to
41. 56%.
Discussion
TNBC exhibits biological behaviors, including
an invasive phenotype, which is distinct from
other breast cancers. Currently, anthracycline-
based chemotherapy and radiotherapy are the
primary treatments for TNBC, while endocrine
Figure 6. Kaplan-Meier estimates of 5-year DFS for
patients with TNM stage I or IIA TNBC.
Figure 7. Kaplan-Meier estimates of 3-year OS for pa-
tients with TNM stage I or IIA TNBC.
Figure 8. Kaplan-Meier estimates of 5-year OS for pa-
tients with TNM stage I or IIA TNBC.
Figure 9. Kaplan-Meier estimates of 3-year DFS for
patients with TNM stage IIb, III, or IV TNBC.
Figure 10. Kaplan-Meier estimates of 5-year DFS for
patients with TNM stage IIb, III, or IV TNBC.
Efcacy of DC-CIK cell immunotherapy for TNBC
13226 Int J Clin Exp Med 2019;12(12):13221-13229
and targeted therapeutic targets have not been
identied. For early stage TNBC, surgical treat-
ment combined with radiotherapy improves
local control and is currently the best treatment
available. However, for patients with advanced
stage TNBC, radiotherapy has not signicantly
affected prognosis [20]. Moreover, neopathy of
radiotherapy remains a cause of increased
mortality [21]. The potential side effects of che-
motherapy should also be considered, and
these include immunosuppression and toxicity
to kidneys, liver, lung, and heart. Unfortunately,
these side effects remain difcult to overcome.
Consequently, immunotherapy represents an
attractive option for cancer treatment due to its
low toxicity and high specicity [22]. Moreover,
it has been demonstrated that cell immuno-
therapy combined with conventional treatment
can improve treatment outcomes [23]. The
mechanism responsible for this improvement
may derive from the synergistic effects of the-
se two approaches. For example, chemothera-
py not only kills and/or slows the growth of can-
cer cells, but it can also increase the sensitivity
of tumor cells’ response to immune effector
cells. Meanwhile, immunotherapy can restore
an immune system which is compromised by
chemotherapy and can also stimulate antitu-
mor immunity [24]. Currently, DC-CIK cell treat-
ment is widely used for the treatment of cancer
patients. Antigen-presenting DCs are able to
activate naive CD4+ T helper cells and they
have overcome immune tolerance and immu-
nosuppression in many cancer patients [25].
CIK cells mediate cytotoxicity that can directly
eradicate tumor cells, while secretion of Th1
cytokines, such as IFN-, IL-2, and IL-12, by CIK
cells can modulate the immune system to
reduce tumor recurrence and metastasis [26].
Correspondingly, the incubation of DCs with
CIK cells has led to an increase in Th1 cyto-
kine secretion and stronger cytotoxicity [27].
Furthermore, many studies have also reported
the successful application of DC-CIK immuno-
therapy as an adjuvant treatment to chemo-
therapy and radiotherapy to colon cancer [28],
hepatocellular cancer [29], and gastric cancer
[30].
In this retrospective study, adjuvant DC-CIK
therapy was associated with fewer adverse
effects and an improved 5-year DFS rate from
20.08% to 39.32% in TNBC patients, although
it only approached statistical signicance
(P=0.052). However, the 5-year OS rates did
not signicantly improve in the DC-CIK group
compared with the non-DC-CIK group, and this
result is inconsistent with the results reported
by Pan et al. [19]. Therefore, a larger sample
size is needed to further investigate these
ndings since the sample size in our study and
in the Pan et al. study are both small. In the
subgroup analysis that was conducted based
on TNM stage, the advanced-stage subgroup
exhibited a signicant improvement in their
3-year and 5-year DFS rate with DC-CIK thera-
py. The 3-year OS rate was signicantly affect-
ed by DC-CIK treatment for this group, and the
5-year OS was also improved albeit without sta-
tistical signicance. The relatively small sample
size of the present study may have contributed
to the absence of a statistical result. Moreover,
the early-stage subgroup did not exhibit signi-
Figure 11. Kaplan-Meier estimates of 3-year OS for
patients with TNM stage IIb, III, or IV TNBC.
Figure 12. Kaplan-Meier estimates of 5-year OS for
patients with TNM stage IIb, III, or IV TNBC.
Efcacy of DC-CIK cell immunotherapy for TNBC
13227 Int J Clin Exp Med 2019;12(12):13221-13229
cant improvements in their 5-year DFS and OS
rates. Thus, the present results indicate that
patients with advanced stage TNBC (e.g., IIb, III,
and IV) may greatly benet from adjuvant
DC-CIK treatment, and this observation is con-
sistent with previously reported results for
advanced cancers [28-31].
Due to the limitations associated with a retro-
spective study, a randomized, double-blind,
parallel-group, multicenter prospective trial
needs to be conducted to further examine and
conrm the present results. Additional studies
are also needed to examine the effects of using
a combination of several alternative therapy
modalities to achieve a more comprehen-
sive tumor treatment. These modalities could
include conventional therapies, cell immuno-
therapies, and antibody-based immunothera-
pies, including those targeting programmed
cell death 1 (PD-1) and cytotoxic T-lymphocyte-
associated protein 4 (CTLA-4) immune pro-
teins. For example, pembrolizumab and ipilim-
umab are monoclonal antibodies which have
been developed to target PD-1 and CTLA-4,
respectively. Despite having different targets,
and distinct cellular mechanisms, both induce
an expansion of CD8+ T cells to mobilize the
body’s immune system to kill tumors [32].
Nanda et al. recently showed consistent bene-
ts of pembrolizumab treatment for metastatic
TNBC patients, with a total remission rate of
18.5% achieved [33]. Thus, PD-1 may repre-
sent a new target in treatments of TNBC.
However, only 20-30% of TNBC cases have
been found to be positive for programmed
death-ligand 1 expression [34]. Consequently,
additional combinational treatment options are
being considered and developed for TNBC. Of
particular interest is the capacity for cell immu-
notherapies to improve immune function.
Furthermore, cell immunotherapies in combi-
nation with antibody-based immunotherapies
could provide more effective treatment.
Conclusions
Among the 67 TNBC patients examined, 25
underwent DC-CIK therapy combined with che-
motherapy with or without radiotherapy, while
the remaining patients did not undergo DC-CIK
therapy yet still received chemotherapy with or
without radiotherapy and served as the control
group. There were several ndings made based
on these two groups. First, the KPS score for
the DC-CIK group was signicantly higher than
the KPS score for the non-DC-CIK group.
Second, patients in the DC-CIK group had a
lower risk of cancer recurrence despite no sig-
nicant improvement in their 3-year and 5-year
OS rate. Third, a subgroup analysis showed
that the advanced stage TNBC patients who
received chemotherapy with or without radio-
therapy after surgery beneted from DC-CIK
therapy. For example, the 3-year and 5-year
DFS rate for these patients signicantly
improved compared with the non-DC-CIK group.
The 3-year OS rate was also signicantly
improved for these advanced stage patients,
and the 5-year OS rate also improved although
the improvement approached statistical signi-
cance. Thus, adjuvant DC-CIK cell therapy may
represent a useful strategy for the treatment of
cases involving advanced stage cancer.
Acknowledgements
This study was supported in part by grants
from: Natural Science Foundation of Fujian
Province (2016J01514); The Fujian Science
and Technology Plan (2017Y0022) Project sup-
ported by the National Clinical Key Specialty
Construction Program.
This study was approved by the ethics commit-
tee of Teaching Hospital of Fujian Medical
University, Fujian Provincial Tumor Hospital and
was carried out in accordance with the
Declaration of Helsinki of the World Medical
Association. All enrolled patients provided writ-
ten informed consent.
Disclosure of conict of interest
None.
Address correspondence to: Qiuhong Zheng, Fujian
Provincial Key Laboratory of Tumor Biotherapy,
Fujian Medical University Cancer Hospital, Fuzhou
350014, Fujian, China. Tel: +86-0591-83660063-
8416; Fax: +86-0591-83660011; E-mail: niu-
niu2000130@hotmail.com; Qingfeng Zheng, De-
partment of Chest Surgery, Fujian Medical Univer-
sity Cancer Hospital, Fuma Road 420, Fuzhou
350014, Fujian, China. Tel: +86-0591-83660063-
5310; E-mail: zhqf@msn.com
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