Identification of the immune response against tumour antigens in patients with lung adenocarcinoma

Lung cancer is the most common cause of cancer mortality in men in the
developed world and one of the leading causes in women. In the Netherlands,
around 9000 new cases of lung cancer occur annually. The male-female ratio in
the occurrence of lung cancer is 80%-20%. Each year around 9000 patients die
from lung cancer in the Netherlands. The two major forms of lung cancer are
non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). NSCLC
comprises about 80 % of all lung cancers. Smoking is the main (environmental)
risk factor that is associated with the development of lung cancer.
Establishing the mechanisms involved in the development of lung cancer has been
the subject of intensive investigation in recent years.

Determining the stage of disease is critical for treatment recommendations and
prognosis. Lung cancer patients are staged according to the TNM classification
system. Patients with stage I and stage II non small cell lung cancer are, when
operable, treated with complete surgical resection. Patients with advanced
disease (stage III/IV) are generally treated with chemotherapy, radiotherapy or
a combination of both. This treatment is palliative, mostly has a partial
respons and quick progression of disease occurs regularly. Unfortunately, the
majority of lung cancer patients present with advanced disease. Therefore, the
five-year survival for non small cell lung cancer patients is low (14%)

Recent research has therefore focused on new anticancer therapies regarding
lung cancer. Recently, immunotherapy has been shown to have great potential as
a new anticancer therapy in several malignancies (melanoma, vulva carcinoma).
Whether immunotherapy can be used in the treatment of lung cancer, depends on
whether a specific immune response can be found in these patients and on which
tumorantigens are involved. XAGE-1B is a member of the family of cancer testis
(CT) antigens and appears to evoke an immune response in patients with
lungadenocarcinoma. So far, XAGE-1B specific systemic or local cellular immune
responses have not been studied in patients with lung adenocarcinoma or other
types of NCSLC.

This is an exploratory study to assess the presence, specificity, type and
strength of systemic and local specific cellular immune responses in patients
with lung adenocarcinoma at different time-points during routine diagnostic
work-up and treatment. This study will be performed in order to delineate the
immunological setting in which potential vaccines could be used as treatment
options for lung cancer patients.

All patients presented at the Department of Pulmonology with lung
adenocarcinomas, undergoing routine diagnostic work-up and treatment will be
asked to participate in our study. So far, XAGE-1B expression has only been
reported in lung adenocarcinomas. It has been observed that around 30% of lung
adenocarcinomas are positive for XAGE-1B (Nakagawa CCR 2005; our own
non-published observations). For the primary study objective we aim to include
at least 15 patients with XAGE-1B expressing tumours. Therefore, we plan to
recruit at least 60 patients with adenocarcinomas in order to investigate the
presence of a XAGE-1B specific systemic or local immune responses.. Following
informed consent the following materials will be collected:

For the analysis of systemic and local specific T-cells and for the analysis of
tumour-antigen expression and immune-infiltrate

- From all patients, we will collect heparin blood samples (70 ml) taken at a
maximum of 2 weeks before treatment. From those patients that will undergo
chemotherapy (stage II/IV lung adenocarcinoma patients), we will also collect
70 ml of blood 2-4 weeks after the last dose of the chemotherapy schedule. The
heparinized blood samples will be collected via venapunction at outpatient
clinical visit. This blood will be collected together with the routine regular
venapunctions.

- From those patients who will undergo mediastinal staging by endoscopic
ultrasound guided fine needle aspiration (FNA), we will collect mediastinal
lymph node aspirates.

- From those patients that undergo bronchoscopy or CT-guided biopsy during
diagnostic work-up, fresh biopsy material will be obtained.

- From those patients that undergo lung surgery after diagnostic work-up, fresh
tumour resection tissue will be obtained.

The collection of all materials will be performed during the standard
outpatient visits and clinical admissions as part of routine diagnostic
procedures and treatment of lung cancer patients. In addition to this, we will
ask patients for an additional 70 ml of blood prior to treatment. After
treatment with chemotherapy, we will also ask for an additional 70 ml of blood.
We will collect these blood samples by venapunction during routine outpatient
clinical visits. Furthermore, we will ask lung cancer patients who are staged
by endoscopic ultrasound guided fine needle aspiration, for permission to
perform 2 additional lymph node punctions next to the regular 4 punctions that
are routinely performed during these procedures. These two extra nodal
aspirates will prolong the procedure, which normally takes 15-20 minutes, with
an estimated 4 minutes and does not pose an increased risk for the patient.