Safety of Lienal Polypeptide Injection Combined with Chemotherapy in Treating Patients with Advanced Cancer

Objective: To assess the safety of Liena polypeptide injection (produced by JILIN FSENS PHARMACEUTICAL CO.,LTD) combined with chemotherapy in treating patients with advanced cancers. Method: A consecutive cohort of patients with advanced cancers were treated with Liena polypeptide injection combined with chemotherapy. And chemotherapy for patients with advanced cancers were adopted from regimens suggested by NCCN guideline. Liena polypeptide injection was intravenously injected at a dosage of 2ml plus 100ml normal saline for continuous 7 days during chemotherapy as one course. After at least two courses of treatment, safety and side effects were evaluated. Results: There were 20 female and 14 male patients with advanced cancer recruited into this study, including 10 patients with breast, 8 patients with colorectal, 8 patients with lung, 4 patients with gastric, and 1 patient with esophageal cancer, as well as 1 patient with non-Hodgkin’s lymphoma, 1 patient with low pharyngeal and 1 patient with urethral cancer. The median age of patients was 59 (40-82) years. Incidences of Grade 1 to 2 myelosuppression was observed in 5/34 patients, and Grade 1 to 2 elevation of hepatic enzyme was recorded in 3/34 patients. Adverse effects on the gastrointestinal tract were documented in 5/34 patients, and were Grade 1. No Grade 3-4 toxicities were diagnosed. No treatment related death was found. Conclusions: Liena polypeptide injection combined with chemotherapy was safe in treating several sites of tumors, that mainly included lung, colorectal and breast cancer. However, further study should be conducted to clarify the effectiveness of this treatment.


Safety of Lienal Polypeptide Injection Combined with Chemotherapy in Treating Patients with Advanced Cancer
Xin-En Huang*, Lin Wang, Zhu-Qing Ji, Meng-Yan Liu, Ting Qian, Li Li as immunotherapy are mostly considered (Cheng M et al, 2013;Peng XH et al, 2008). Surgery, which involves removal of the tumor and the surrounding tissue, remains the most common treatment for various types of cancer. However, it could not be used to treat leukemia and lymphoma. Moreover, the combination of surgery with other therapies is necessary because most neoplasms could metastasize to other organs (Brannon-Peppas L et al, 2004;Ozols RF et al., 2006;Arruebo M et al, 2007). Chemotherapy is widely used to treat cancer with advanced stage. However, chemical substances is reported to suppress the immune system by diminishing immune cells, and is associated with various toxicities (Shurin MR et al, 2012).
Cancer immunotherapy is used to activate the immune system to treat cancer. The activity of immune cells, eg., macrophages, natural killer cells, dendritic, and T-cells, is enhanced by various immune activators, including cytokines, and immunological regimens (Rosenberg SA et al., 2004;Rosenberg SA et al., 2001;Serda RE et al., 2013). These immunological activators could increase anticancer activity by generating T helper 1 (Th1) cells and cytotoxic T-lymphocytes (CTLs).
According to this background, we hypothesize that liena polypeptide injection combined with chemotherapy could be established as an optimal schedule in treating Chinese patients with cancer.

Eligiblility criteria
Patients recruited in this study were required to be pathologically/ cytologically diagnosed with cancer in Jiangsu Cancer Hospital & Research Institute; to sign an informed consent before treatment; to expose to long term chemotherapy or supportive care; to have a score of karnofsky performance status (KPS) ≥ 60 with expectancy life span more than 3 moths; to be classified with no contraindications for chemotherapy; to have a routine blood test performed 0 to 3 days before chemotherapy and normal hematopoietic function as evidenced by white blood cell count 3000/ul and platelet count 100000/ul, normal hepatic function test (aspartate aminotransaminase and alanine aminotransferase less than 1.5 times of the upper limit of normal values), renal function test (serum total bilirubin<1.5mg/dl and creatinine<1.5mg/ dl). Exclusion criteria included history of alcoholic intoxication, diabetes, and patients who were pregnant or nursing. Chemotherapy was administered according to NCCN guideline. Liena polypeptide injection was intravenously injected at a dosage of 2ml plus 100ml normal saline for continuous 7 days during chemotherapy as one course. After at least two courses of treatment, safety and side effects were evaluated.

Toxicity Evaluation
The incidence rates of toxicity in this study were assessed at baseline and respectively after two cycles of treatment, the grade of toxicities was determined according to The National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE; version 3).

Results
There were 20 female and 14 male patients with advanced cancer recruited into this study, including 10 patients with breast, 8 patients with colorectal, 8 patients with lung, 4 patients with gastric, and 1 patient with esophageal cancer, as well as 1 patient with non-Hodgkin's lymphoma, 1 patient with low pharyngeal and 1 patient with urethral cancer (table 1). The median age of patients was 59 (40-82) years. Incidences of Grade 1 to 2 myelosuppression was observed in 5/34 patients, and Grade 1 to 2 elevation of hepatic enzyme was recorded in 3/34 patients. Adverse effects on the gastrointestinal

Discussion
Cancer is a group of diseases with deregulated growth of abnormal cells. The reason for this uncontrolled growth is a series of mutations that cause aberrant expression of gene products essential for regulating proliferation, survival, and growth activities of cells; and further, cause basic biological changes of cells: the ability to respond to growth signals, engage cell death programs to eliminate unnecessary, excess or damaged cells, and the formation of new blood vessels and ability to invade tissue. Thus, clinicians and researchers try to find effective therapeutic approaches that could eliminate cancerous cells, meanwhile protecting normal, healthy tissues. In the field of cancer treatment in China, significant progress is made in recent years. However, most current treatments for cancers still involving surgery or chemo-, radiation, and hormone therapies. And chemical substances is associated with suppressing immune system by destroying immune cells, and with various toxicities (Kalyanaraman B et al., 2002;Naumov GN et al., 2003). Further, the development of drug resistance is linked with current treatments, and could be due to abnormalities in drug transporters or detoxifying enzymes that affect the interaction between chemotherapeutic agent and its target. Defects in DNA repair mechanisms and the apoptotic or cell death pathway could also lead to the development of cancer drug resistance. Thus, chemotherapy is moderately accepted by Chinese cancer patients due to no sufficient effectiveness and severe toxicities. And, the prognosis remains poor for Chinese patients with advanced cancer.
Immunotherapy is considered as an important treatment option for cancer patients. According to several studies, tumor-specific cellular and humoral immune responses occur in patients with cancer. However, immune evasion is a main problem in cancer patients, and it was reported that impairment of CD4+ T cells was a mechanism for this immune evasion (Alisa A et al., 2005 ) . Several results from the analysis of mRNA arrays revealed that MHC class II is one of the most highly expressed genes in cancer tissue, compared with benign adjacent tissues. These MHC II molecules induce CD4+ T cell anergy (Crispe IN et al., 2006). And further, increases in immunosuppressive myeloid and lymphoid cell populations, suppression of natural killer cells, and impair the effector function of cellular immune responses in cancer patients (Arihara F et al., 2013;Chen Z et al., 2009;Hoechst B et al., 2009;Ilkovitch D et al., 2009). On the other hand, immunosuppressive cell populations, eg., T regulatory cells (Tregs) and myeloid-derived suppressor cells, are also considered to be important factors in cancer evasion. The number of Tregs in cancer patients is elevated in peripheral blood and cancer tissue (Ormandy LA et al., 2005), and the accumulation of infiltrated Tregs within the tumor was found to be correlated with disease progression and poor prognosis (Chen KJ et al., 2011;Gao Q et al., 2007 ). On this background, the combination of chemotherapy with immunotherapy is commonly attempted, and among these considerations, cytokines, peptides vaccines, and monoclonal antibodies, etc were being developed as potential treatments or approved cancer therapies that could improve the immune response against cancers. Interferon (IFN), a well known cytokine which induces an antitumor response by enhancing cytotoxicity, tumor antigen presentation and lymphocyte proliferation, and by blocking angiogenesis, was used in patients with cancer (Rougier P et al., 2007;Belardelli F et al., 2002;Singh RK et al., 1995), and demonstrated some clinical efficacy with good tolerance (Sun HC et al., 2006;Lin SM et al., 2004). IFN was also used in combination with chemotherapy, with cisplatin and 5-fluorouracil (5-FU), for advanced cancer (Patt YZ et al., 2003;Komorizono Y et al., 2003). It was reported that the complete response reached 16% and partial response 36%in cancer patients with portal venous invasion and treated by a combination of 5-FU and IFN (Obi et al., 2006). The combination of IFN and granulocytemacrophage colony-stimulating factor was tested and found to be effective in selected advanced cancer patients, suggesting that IFN could induce apoptosis and inhibit cell growth (Vadrot N et al., 2006). Another important cytokine with immunostimulatory functions is IL-2. The effect of IL-2 was clinically tested in patients with several cancer sites, eg., melanoma and renal cancer, for its ability to stimulate the proliferation and activity of T cells that would cause tumor regression (Rosenberg SA et al., 1998;. However, the utility of therapeutic peptides is limited by their susceptibility to degradation and poor tumor penetration in vivo (Talmadge JE et al., 1998). Thus, Lienal polypeptide is clinically tested in this study on the background that few previous reports were found.
In this study, our purpose is to assess the safety of Liena polypeptide injection (produced by JILIN FSENS PHARMACEUTICAL CO.,LTD) combined with chemotherapy in treating patients with advanced cancers. We recruited 20 female and 14 male patients with advanced cancer recruited into this study, including 10 patients with breast, 8 patients with colorectal, 8 patients with lung, 4 patients with gastric, and 1 patient with esophageal cancer, as well as 1 patient with non-Hodgkin's lymphoma, 1 patient with low pharyngeal and 1 patient with urethral cancer. Liena polypeptide injection was intravenously injected at a dosage of 2ml plus 100ml normal saline for continuous 7 days during chemotherapy as one course. After at least two courses of treatment, safety and side effects were evaluated. Incidences of Grade 1 to 2 myelosuppression was observed in 5/34 patients, and Grade 1 to 2 elevation of hepatic enzyme was recorded in 3/34 patients. Adverse effects on the gastrointestinal tract were documented in 5/34 patients, and were Grade 1. No Grade 3-4 toxicities were diagnosed. No treatment related death was found. In conclusion, our current study suggested that Liena polypeptide injection combined with chemotherapy was safe in treating several sites of tumors, that mainly included lung, colorectal and breast cancer. However, further study should be conducted to clarify the effectiveness of this treatment.