Interleukin-2 Based Home Therapy of Metastatic Renal Cell Carcinoma: Risks and Benefits in 215 Consecutive Single Institution Patients

Abstract

Purpose In 215 consecutive patients with advanced metastatic renal cell carcinoma seen at a single institution the efficacy and tolerance of different subcutaneous recombinant interleukin-2 based home therapies were assessed. Materials and Methods Treatment consisted of subcutaneous recombinant interleukin-2 alone and subcutaneous recombinant interleukin-2 in combination with recombinant interferon-alpha 2 with or without intravenous 5-fluorouracil. Results Overall objective response rate in 215 patients was 33 percent (95 percent confidence interval 26 to 39 percent). Among 16 patients receiving recombinant interleukin-2 alone there was 1 partial remission (overall response 6 percent). In 79 patients receiving recombinant interleukin-2 and interferon-alpha 2 in combination 6 complete and 16 partial remissions occurred (overall response 28 percent). Of 120 patients receiving a combination of recombinant interleukin-2, recombinant interferon-alpha 2 and 5-fluorouracil 13 achieved a complete and 34 a partial remission (overall response 39 percent). Of all patients 5 percent achieved long-lasting remissions and remain disease-free. Multivariate analyses identified pretreatment erythrocyte sedimentation rate greater than 70 mm. per hour and lactic dehydrogenase greater than 280 units per 1. as independent prognostic factors of major significance (p less than or equal to 0.0001) in metastatic renal cell carcinoma. Additionally, neutrophil count greater than 6,000/microliter, hemoglobin less than 100 gm./l., extrapulmonary metastases and bone lesions were identified as minor (p less than or equal to 0.006) prognostic variables. Patients were assigned to 1 of 3 risk categories according to cumulative risk score defined as the function of the sum of all 6 independent variables. In 116 intermediate risk patients 2-year survival was 65 percent (median survival not reached after 32 months) with recombinant interleukin-2, recombinant interferon-alpha 2 and 5-fluorouracil, as opposed to 27 percent 2-year survival (median survival 15 months) with recombinant interleukin-2 and interferon-alpha 2 (p less than 0.0001), and 0 percent (median survival 4.8 months) with single agent recombinant interleukin-2. In the majority of patients systemic toxicity of subcutaneous recombinant interleukin-2 based protocols was limited to grade 1 or 2 constitutional symptoms, that is fever, chills, malaise and anorexia, which allowed for outpatient therapy. Conclusions The present outpatient recombinant interleukin-2 triple drug combination protocol was as effective as the most aggressive intravenous recombinant interleukin-2 regimen available. Combination home therapy eliminated the need for inpatient and/or intensive care as required for intravenous cytokine administration and, thereby, it substantially improved the therapeutic index and cost-effectiveness of recombinant interleukin-2 therapy in metastatic renal cell carcinoma stratified for risk.