Original Article Meta-analysis of chemotherapy and dendritic cells with cytokine-induced killer cells in the treatment of non-small-cell lung cancer

Transcription

1 Int J Clin Exp Med 2015;8(8): /ISSN: /IJCEM Original Article Meta-analysis of chemotherapy and dendritic cells with cytokine-induced killer cells in the treatment of non-small-cell lung cancer Chenhong Zheng 1,3*, Ganjun Yu 2*, Hui Wang 4*, Airong Tang 5, Peiliang Geng 3, Huiming Zhang 3, Zhiquan Zhu 3, Fang Li 3, Xiaohua Xie 1 1 Department of Comprehensive Surgery, South Building, Chinese PLA General Hospital, Beijing , China; 2 Institute of Immunology, National Key Laboratory of MedicalImmunology & Second Military Medical University, 800 Xiangyin Road, Shanghai , China; 3 Department of Chinese PLA General Logistics, No. 2 Clinic, Management Support Bureau, Beijing , China; 4 Department of Plastic Surgery, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China; 5 Department of General Medicine, Beijing Tieying Hospital, Beijing , China. * Equal contributors. Received April 26, 2015; Accepted July 10, 2015; Epub August 15, 2015; Published August 30, 2015 Abstract: Background: Non-small-cell lung cancer (NSCLC) is one of the most fatal cancers, which leads to large number of people dead. Followed by surgery, chemotherapy and radiotherapy, chemotherapy combined dendritic cells with cytokine-induced killer cells (DC-CIK) immunotherapy has been applied in NSCLC for some time, but little consistent beneficial results are provided. So, it is essential to weigh the pros and cons of the new therapeutic method. Methods: We searched the randomized controlled trials of NSCLC mainly by PubMed database. Terms combination of cytokine-induced killer cells, tumor and cancer were used. After evaluating the heterogeneity of selected studies, then we performed the meta-analysis. Pooled risk ratios (RRs) were estimated and 95% confidence intervals (CIs) were calculated using a fixed-effect model. Sensitivity analysis was also performed. Results: Six eligible trials were enrolled. Efficiency and safety of chemotherapy followed by DC-CIK immunotherapy (experimental group) and chemotherapy alone (control group) were compared. 1-year overall survival (OS) (P=0.02) and progression free survival (PFS) (P=0.005) in the experimental group were significantly increased compared with the control. Disease control rate (DCR) (P=0.006) rose significantly in experimental group. However, no significant differences between the two groups were observed in 2-year OS (P=0.21), 2-year PFS (P=0.10), overall response rate (ORR) (P=0.76) and partial response (PR) (P=0.22). Temporary fever, anemia, leukopenia and nausea were the four major adverse events (AEs) treated by chemotherapy. The incidence of anemia, leukopenia and nausea in the experimental group was obviously lower than the control group. Temporary fever rate was higher in experimental group than that in the control, but could be alleviated by taking sufficient rest. Conclusions: Chemotherapy combined with DC- CIK immunotherapy showed superiority in DCR, 1-year OS and PFS, and no more AEs appeared, however, there was no significant improvement in ORR, PR, 2-year OS and PFS. As a whole, the combination therapy is safer but modest in efficacy for advanced NSCLC patients. Keywords: Dendritic cells, cytokine-induced killer cells, DC-CIK, immunotherapy, NSCLC, chemotherapy Introduction Lung cancer, especially NSCLC, has been considered one of most commonly diagnosed and devastating disease in the world [1]. NSCLC was regarded as one of the leading killers in the causes of mortality worldwide and possess about 80% to 85% of all lung cancer cases [2]. So far, the most widely applied cancer treatments are still surgery, radiation and chemotherapy; however, these methods have some side effects and often fail to completely remove minimal residual cancer cells, including small lesions and metastatic cells. What s worse, five-year survival rate keeps very poor [3], then drug resistance and adverse effects still remain, thus, the more effective and safer treatments are urgently required to improve the quality and duration of life [4]. Then immunotherapy appears. Dendritic cells with cytokineinduced killer cell (DC-CIK) therapy has been

2 widely used as an important component of cancer treatments [5]. The CIK cell is developed on the basis of LAK (Lymphokine-activated killer, LAK). LAK cells are IL-2-activating cytotoxic effector lymphocyte, and CIK cells areaquired by incubating mononuclear cells from peripheral blood, bone marrow or cord blood with additions, such as interleukin (IL)-2, IL-1, CD3 monoclonal antibody and interferon (IFN)-γ [6]. CIK and LAK are both heterogeneous. LAK cells mainly consist of CD3 - CD56 + natural killer (NK) cells, and CD3 + CD56 - T cells while CIK cells are mainly have 88% CD3 + CD56 + T cells [7]. The main components of them are the main contributors to the cytolytic properties respectively. They were first described as higher proliferation and more advantages in antitumor activities than LAK cells by Schmidt Wolf et al [8]. Though CD3 + CD56 + cells are derived from CD3 + CD56 - T cells, they were demonstrated that they had enhanced cytotoxicity against various tumor cells compared with CD3 + CD56 - cells and expanded up to 1000-fold in cultures [9]. CIK cells have been proven to take advantages over LAK cells and primary cytotoxic T cells (CTL), like higher proliferation rate, greater efficacy but few side-effects, and non-mhcrestricted killing [10]. Therefore, CIK cell-based therapy shows more promising clinical prospects for many types of cancers in clearing minimal residual cancer cells. More and more current clinical trials have proved this point. Since the first clinical trial of CIK immunotherapy for cancer patients was reported in 1999 [11], CIK cells therapy was widely used in various types of solid tumors, such as breast cancer, liver cancer, kidney cancer, colorectal cancer and non-small-cell lung cancer (NSCLC). Several clinical trials have shown encouraging results. They demonstrated that CIK immunotherapy may prevent recurrence, improve progression-free survival rates (PFS), and promote the quality of life (QoL) [12, 13]. However, clinical studies of CIK immunotherapy are still at its start and lack a certification provided by multicenter studies with large samples. Therefore, we performed a systematic review and metaanalysis of randomized phase II and III clinical trials to assess the efficacy and safety of DC-CIK immunotherapy in the treatment of patients with NSCLC. We aim to evaluate the effect of CIK-based therapy on the survival and QoL of cancer patients, as well as the toxicity. Methods Search strategy Articles published in English from PubMed, EMBASE, and Web of Science were collected for studies which could be enrolled in this metaanalysis from 2003 to Keywords like Dendritic Cells with Cytokine-Induced Killer Cells or DC-CIK immunotherapy, Non-Small- Cell Lung Cancer or NSCLC, and chemotherapy were used in conjunction. Inclusion criteria and study selection All the randomized studies of patients with NSCLC as one of two arms of therapeutic regimens: DC-CIK-based immunotherapy and chemotherapy alone were considered. The study selection was as follows: (1) studies were published in English and performed in human (2) studies should be randomize controlled trials (3) all the trials had not to be confounded by other treatments in either group. Data collection To collect the potential relevant articles, all the full articles and available abstracts were scanned and analyzed by two independent reviewers (Chenhong Zheng and Ganjun Yu). Divergences were discussed with a third investigator (Hui Wang). The following information was cross-checked and collected: the first and last authors names, the published year and journal, the place of the performed study, the study design (mode of randomiation, description of withdraws, blinding information), the number of sample size, the median age of patients, the treatments that patients received, the study period and the NSCLC stages. The randomization integrity were assessed by checking the patterns of treatment allocation and the balanced baseline characteristics. To ensure that the follow-up of surviving patients was balanced by treatment group and was current, we checked all the available data. Measures of curative outcome Clinical responses such as the median survival time (MST), the overall survial (OS) and progres Int J Clin Exp Med 2015;8(8):

3 Figure 1. Flow diagram of the study selection process Table 1 showed the characteristics of the whole selected trials. sion free survival (PFS) were evaluated in prognosis. Partial response (PR), overall response rate (ORR) and disease control rate (DCR) were assessed in treatment efficacy. MST is the time at which half of the patients are expected to be alive, denoting how long patients survive with cancer in general or after a certain treatment. OS was defined as the time from the start of the treatment to the time of death from any case. PFS was defined as the length of time during and after treatment for which a patient lived with a disease that did not worsen. ORR was defined as the sum of partial and complete response rates, while the DCR as the sum of stable disease, partial response and complete response rates. All the criteria were defined according to the World Health Organization (WHO). Then we evaluated the toxicity, QoL and subsets of the T-lymphocyte in patients of the studies. Toxicity was assessed in accordance with the criteria of the National Cancer Institute (NCI) Common Toxicity Criteria (CTC). QoL was assessed on the basis of the Karnofsky performance status (KPS) or Lung Cancer Symptom Scale (LCSS). The results were provided by the articles included or calculated according to the data in an article. Statistical analysis sion tests of the respective tests. Heterogeneity between the trials was assessed to determine which model might be most suitable. The Cochran Q-test was performed when the homogeneity of the results of studies was considered at a predefined significance threshold of P>0.1 or I 2 <50%. The odds ratios (OR) were the principal measurements of effect and were presented with a 95% confidence interval (CI). Results Selection results Sixteen publications were final- We did Statistical analysis with Review Manager Version 5.2 (Cochrane Collaboration). P<0.05 was considered statistically significant. All reported P-values resulted from two sided ver- ly considered eligible by refer- ring to pr-defined inclusion criteria. The reasons for study inclusion/exclusion are graphically described in Figure 1. The characteristics and quality of the studies are presented in Tables 1 and 2, respectively. Bias of the included studies are presented in Figure 2. Risk of bias summary: review authors judgements about each risk of bias item for each included study are presented in Figure 3. After strict selection, the clinical trials included in the paper is shown in Figure 1. So, 6 articles reporting clinical trials of DC-CIK cell-based immunotherapy and chemotherapy for NSCLC were used in our meta-analysis. All patients in the immuno-ct- and CT-treated groups received for cycles of chemotherapy after surgery, except for stage I patients. In the immuno group, patients were treated with CIK cells that were activated by Ag-loaded DC after chemotherapy. PBMC were collected from NSCLC patients after surgery and chemotherapy. For culture of CIK cells, PBMC were cultured with anti-cd3 antibody (Ab) to stimulate CIK cell growth, recombinant human interleukin (IL)-1α and recombinant human interferon (IFN)-γ and recombinant human IL-2 and IFN-γcontaining medium was added to the culture system. IL-4 and granulocyte-macrophage colo Int J Clin Exp Med 2015;8(8):

4 Table 1. Clinical information of the eligible trails for the meta-anlysis First author Nation Journal Study type Sample size Chemo-DC-CIK Chemo Hui Li [14] China Cytotherapy Case control Lili Yang [15] China Cancer Immunol Immunother Case control Min Zhao [16] China Experimental and Therapeutic Medicine Case control Runbo Zhong [17] China Cancer Immunol Immunother Case control Shengbin Shi [18] China Tumori Case control Junping Zhang [19] China Chinese-German Journal of Clinical Oncology Case control Chemo, chemotherapy; Chemo-DC-CIK, chemotherapy and DC-CIK therapy. NR not reported. Table 2. Patient information for the eligible trials (χ 2 tests) (P>0.05) Features Chemo- Chemo-DC-CIK χ 2 P-value Gender Male Female Category Adenocarcinoma Squamouscinoma Large-cell carcinoma Stage IIIa IIIb IV ny-stimulating factor (GM-CSF) were cultured for DC, to facilitate DC growth. To stimulate DC, autologous tumor lysate was added and cocultured with DC. For CIK cell activation, after CIK cell culture, CIK cells were co-cultured with DC loaded with tumor Ag. Efficacy assessment: DCR, ORR The analysis of DCR also demonstrated favorable results for the CIK cell therapy arm, with the RR being 1.3 (95% CI , P=0.002) (Figure 4). However, the ORR for the chemotherapy combined with CIK group was 53.69%, which did not differ significantly from the ORR of 44.44% for the chemotherapy-alone group (RR 1.15, 95% CI , P=0.45) (Figure 5). Prognosis evaluation: OS and TPP Patients in the CIK group were associated with prolonged 1 year TTP compared with the non- CIK group (OR 1.87, 95% CI , < ) (Figure 6). Furthermore, the results of the pooled analysis showed that patients in In most trials, nausea and peripheral nerve toxicity could be seen within 24 h after CIK cell transfusion. On the whole, the analysis showed that the incidence of Nausea (RR 0.63, 95% CI , P=0.008). However, the Peripheral nerve toxicity group. (RR 1.43, 95% CI , P=0.45) for the chemotherapy combined with CIK group did not differ significantly from in the chemotherapy group (Figure 8). Immuno response The analysis showed that the ratio of CD3, CD4, NK, CD3 + CD56 + cells was significantly increased in the CIK group compared with the non- CIK group, which was reflected by pooled R of for CD3 cells (95% CI-0.73 to -0.18, P=0.001), CD4 R of (95% CI-7.94 to -6.42, P<0.001), NK R of (95% CI-6.91 to -3.06, P<0.001), CD3 + CD56 + cells R of (95% CI-7.36 to -5.28, P<0.001). Furthermore, the percentage of CD8 T cells was significantly decreased in the CIK group compared with the non-cik group (OR 5.97, 95% CI , P<0.001) (Figure 9). Sensitivity analysis the CIK group had a significantly improved half-year survival (RR 1.16, 95% CI , P=0.01), 1-year survival (RR 1.57, 95% CI , P=0.04) and 2-year survival (RR 1.30, 95% CI , P=0.002) and the 3-year survival (RR 1.51, 95% CI , P=0.0007) (Figure 7). Toxicity analysis We performed sensitivity analyses to examine the stability of the results of this meta-analysis Int J Clin Exp Med 2015;8(8):

5 Figure 2. Funnel plot of comparison: 1 OS, outcome: 1.3 OS 2 Y. Figure 3. Risk of bias summary: review authors judgements about each risk of bias item for each included study. The pooled ORs were not altered qualitatively when each study was excluded, suggesting our results are statistically reliable. Discussion Immunotherapy has become the most promising approach for cancer therapy, as the Science has commented that cancer immunotherapy is the top 1 of the ten scientific and technological breakthroughs in 2013 [20]. Due to CIK (Cytokine-induced killer) cell treatment play a central role in cell-mediated immunity, anti-tumor cells activity included, which is a subset of immunotherapy, has attracted more and more attention and made gratifying achievements. The effect of cellular immunotherapy based on CIK cells, which generates form nonmajor histocompatibility complex (MHC) restricted cytotoxic lymphocytes through peripheral blood lymphocytes plus interleukin (IL)-2, IL-1, anti-cd3 monoclonal antibody, and interferon gamma (IFN-γ). Dendritic cells (DC) specialized antigenpresenting cells can be found in body, which exists in most tissues. When countering with antigens, dendritic cells can be show its constitutive patrol activities from immune-organs, which could kill cells. Accumulated studies have been shown that DC (Dendritic cell) -activated CIK (Cytokine-induced killer) cell treatment play a critical role in anti-tumor therapeutic strategies [21, 22]. Compared with the CIK treatment, DC-CIK treatment have demonstrated that which could be increasing the anti-tumor activities than CIK treatment both in vivo and in vitro [23, 24]. Furthermore, More and more studies have proven that DC-CIK has powerful anti-tumor properties and a good potential for clinical application [25]. Clinic studies also have proven that DC-CIK treatment display more immune response, safety, and survival and quality of life outcomes than common chemotherapies alone in colorectal cancer [26, 27]. Assessment of safety and efficacy of this approach for the treatment of other types of tumors is under way. This meta-analysis focus on the chemotherapy combined with DC-CIK in NSCLC treatment. Until up-to now, the number of DC-CIK therapy clinical trials about NSCLC are published for Int J Clin Exp Med 2015;8(8):

6 Figure 4. Forest plot of the comparison of disease control rate (DCR). P values are from P for the effect modification evaluation of heterogeneity within or across the groups of regimens. CI, confidence interval; RR, risk ratio; DC/CIK, DC-CIK immunotherapy; Chemo, chemotherapy; Con, control group; Exp, experimental group. A fixed-effect metaanalysis model (Mantel-Haenszel method) was used. Figure 5. Forest plot of the comparison of overall response rate (ORR), P values are from P for the effect modification evaluation of heterogeneity within or across the groups of regimens. CI, confidence interval; RR, risk ratio; DC/CIK, DC-CIK immunotherapy; Chemo, chemotherapy;con, control group; Exp, experimental group. A fixed-effect metaanalysis model (Mantel-Haenszel method) was used. Figure 6. Forest plot for 1 year TTP. Chemo, chemotherapy; Chemo-DC-CIK, chemotherapy and DC-CIK therapy. about 20 articles. Due to the quality of publish reports may influence confidence and bias of the meta-analysis, we enrolled six reports in our meta-analysis Int J Clin Exp Med 2015;8(8):

7 Figure 7. Forest plot of the comparison of overall survival (OS). 0.5, 1-, 2-year and 3-year overall survival (OS) between the non-dc-cik and DC-CIK groups. P values are from P for the effect modification evaluation of heterogene Int J Clin Exp Med 2015;8(8):

8 ity within or across the groups of regimens. CI, confidence interval; RR, risk ratio; DC/CIK, DC-CIK immunotherapy; Chemo, chemotherapy; Con, controlgroup; Exp, experimental group. The fixed effects meta-analysis model (Mantel- Haenszel method) was used. Figure 8. Forest plot for the toxicity. Comparison of the toxicity (Nausea and Peripheral nerve toxicity) between the non-dc-cik and DC-CIK groups. P values are from P for the effect modification evaluation of heterogeneity within or across the groups of regimens. CI, confidence interval; RR, risk ratio; DC/CIK, DC-CIK immunotherapy; Chemo, chemotherapy; Con, control group; Exp, experimental group. A fixed-effect meta-analysis model (Mantel-Haenszel method) was used. Our analysis demonstrated that DCR had favorable results for the CIK cell therapy arm, But the ORR for the chemotherapy combined with CIK did not differ significantly from the chemotherapy-alone group. Patients in the CIK group were associated with prolonged 1 year TTP compared with the non-cik group. Furthermore, the results of the pooled analysis showed that patients in the CIK group had a significantly improved half-year survival, 1-year survival, and 2-year survival, and the 3-year survival. Nausea and peripheral nerve toxicity for the chemotherapy combined with CIK group did not differ significantly from in the chemotherapy group. There are advantages over the conventional treatments using DC-CIK cells immunotherapy as follows: Firstly, It is more accurate to kill tumor cells. Compared with chemotherapy and radiotherapy killing all cells together, DC-CIK therapy is more like precision-guided missiles that can accurately kill tumor cells without killing innocent cells. Therefore, the side effects of the treatment to the patients are relatively small. Secondly, the possibility of developing drug-resistance is less, so it could be applied to clinics for a long time [28]. Last, but the most important, it could still play an important role in immune surveillance after killing tumor cells, and protecting the body all his lifetime. In contrast to other tumor biotherapies, DC-CIK cells therapy is of broad applicability, slight side effects and stability. Though the approach currently has some limitations, such as low levels of cell number persisted in vivo after infusion, low affinity for tumor-specific antigen and relatively long time frame required to isolate and Int J Clin Exp Med 2015;8(8):

9 14535 Int J Clin Exp Med 2015;8(8):

10 Figure 9. Forest plot for the immunophenotype assessment. Pre-DC-CIK-chemotherapy and post-dc-cik-chemotherapy. P values are from P for the effect modification evaluation of heterogeneity within or across the groups of regimens. CI, confidence interval; DC/CIK, DC-CIK immunotherapy; Chemo, chemotherapy; Con, control group; Exp, experimental group. A fixed-effect meta-analysis model (Mantel-Haenszel method) was used. expand target T cell clones, some clinical trials has made it a potential candidate for cancer therapy. Here we introduce and summarize the studies about DC-CIK cells applying to cancer immunotherapy. Acknowledgements This work was supported by grants from the Army Technology Research Program of China (BWS12J051). Disclosure of conflict of interest None. Address correspondence to: Dr. Xiaohua Xie, Department of Comprehensive Surgery, South Building, PLA General Hospital of China, Beijing , China. n4xxh@126.com References [1] Siegel R, Naishadham DJemal A. Cancer statistics, CA Cancer J Clin 2012; 62: [2] Herbst RS, Heymach JVLippman SM, Lung cancer. N Engl J Med 2008; 359: [3] Zheng YW, Li RM, Zhang XW, Ren XB. Current adoptive immunotherapy in non-small cell lung cancer and potential influence of therapy outcome. Cancer Invest 2013; 31: [4] Kobayashi KHagiwara K. Epidermal growth factor receptor (EGFR) mutation and personalized therapy in advanced nonsmall cell lung cancer (NSCLC). Target Oncol 2013; 8: [5] Hui KM. CIK cells--current status, clinical perspectives and future prospects--the good news. Expert Opin Biol Ther 2012; 12: [6] Wang W, Meng M, Zhang Y, Wei C, Xie Y, Jiang L, Wang C, Yang F, Tang W, Jin X, Chen D, Zong J, Hou Z, Li R. Global transcriptome-wide analysis of CIK cells identify distinct roles of IL-2 and IL-15 in acquisition of cytotoxic capacity against tumor. BMC Med Genomics 2014; 7: 49. [7] Pievani A, Borleri G, Pende D, Moretta L, Rambaldi A, Golay J, Introna M. Dual-functional capability of CD3+CD56+ CIK cells, a T-cell subset that acquires NK function and retains TCR-mediated specific cytotoxicity. Blood 2011; 118: [8] Schmidt-Wolf IG, Negrin RS, Kiem HP. Blume KGWeissman IL, Use of a SCID mouse/human lymphoma model to evaluate cytokine-induced killer cells with potent antitumor cell activity. J Exp Med 1991; 174: [9] Joshi PS, Liu JQ, Wang Y, Chang X, Richards J, Assarsson E, Shi FD, Ljunggren HG, Bai XF. Cytokine-induced killer T cells kill immature dendritic cells by TCR-independent and perforindependent mechanisms. J Leukoc Biol 2006; 80: [10] Wang X, Yu W, Li H, Yu J, Zhang X, Ren X, Cao S. Can the dual-functional capability of CIK cells be used to improve antitumor effects? Cell Immunol 2014; 287: [11] Schmidt-Wolf IG, Finke S, Trojaneck B, Denkena A, Lefterova P, Schwella N, Heuft HG, Prange G, Korte M, Takeya M, Dorbic T, Neubauer A, Wittig B, Huhn D. Phase I clinical study applying autologous immunological effector cells transfected with the interleukin-2 gene in patients with metastatic renal cancer, colorectal cancer and lymphoma. Br J Cancer 1999; 81: [12] Mesiano G, Todorovic M, Gammaitoni L, Leuci V, Giraudo Diego L, Carnevale-Schianca F, Fagioli F, Piacibello W, Aglietta M, Sangiolo D. Cytokine-induced killer (CIK) cells as feasible and effective adoptive immunotherapy for the treatment of solid tumors. Expert Opin Biol Ther 2012; 12: [13] Schmeel LC, Schmeel FC, Coch CSchmidt-Wolf IG. Cytokine-induced killer (CIK) cells in cancer immunotherapy: report of the international registry on CIK cells (IRCC). J Cancer Res Clin Oncol 2015; 141: [14] Li H, Wang C, Yu J, Cao S, Wei F, Zhang W, Han Y, Ren XB. Dendritic cell-activated cytokine-induced killer cells enhance the anti-tumor effect of chemotherapy on non-small cell lung cancer in patients after surgery. Cytotherapy 2009; 11: [15] Yang L, Ren B, Li H, Yu J, Cao S, Hao X, Ren X. Enhanced antitumor effects of DC-activated CIKs to chemotherapy treatment in a single cohort of advanced non-small-cell lung cancer patients. Cancer Immunol Immunother 2013; 62: [16] Zhao M, Li H, Li L, Zhang Y. Effects of a gemcitabine plus platinum regimen combined with a dendritic cell-cytokine induced killer immunotherapy on recurrence and survival rate of non-small cell lung cancer patients. Exp Ther Med 2014; 7: Int J Clin Exp Med 2015;8(8):

11 [17] Zhong R, Teng J, Han B, Zhong H. Dendritic cells combining with cytokine-induced killer cells synergize chemotherapy in patients with late-stage non-small cell lung cancer. Cancer Immunol Immunother 2011; 60: [18] Shi SB, Ma TH, Li CH, Tang XY. Effect of maintenance therapy with dendritic cells: cytokine-induced killer cells in patients with advanced non-small cell lung cancer. Tumori 2012; 98: [19] Zhang J, Mao G, Han Y, Yang X, Feng H, Jia L. The clinical effects of DC-CIK cells combined with chemotherapy in the treatment of advanced NSCLC. The Chinese-German Journal of Clinical Oncology 2012; 11: [20] Couzin-Frankel J. Breakthrough of the year Cancer immunotherapy. Science 2013; 342: [21] Zhang Y, Wang J, Wang Y, Lu XC, Fan H, Liu Y, Zhang Y, Feng KC, Zhang WY, Chen MX, Fu X, Han WD. Autologous CIK cell immunotherapy in patients with renal cell carcinoma after radical nephrectomy. Clin Dev Immunol 2013; 2013: [22] Li XD, Xu B, Wu J, Ji M, Xu BH, Jiang JT, Wu CP. Review of Chinese clinical trials on CIK cell treatment for malignancies. Clin Transl Oncol 2012; 14: [23] Qu HQ, Zhou XS, Zhou XL, Wang J. Effect of DC- CIK cell on the proliferation, apoptosis and differentiation of leukemia cells. Asian Pac J Trop Med 2014; 7: [24] Pan Y, Tao Q, Wang H, Xiong S, Zhang R, Chen T, Tao L, Zhai Z. Dendritic cells decreased the concomitant expanded Tregs and Tregs related IL-35 in cytokine-induced killer cells and increased their cytotoxicity against leukemia cells. PLoS One 2014; 9: e [25] Wang YY, Wang YS, Liu T, Yang K, Yang GQ, Liu HC, Wang SS, Yang JL. Efficacy study of CyberKnife stereotactic radiosurgery combined with CIK cell immunotherapy for advanced refractory lung cancer. Exp Ther Med 2013; 5: [26] Zhu H, Yang X, Li J, Ren Y, Zhang T, Zhang C, Zhang J, Li J, Pang Y. Immune response, safety and survival and quality of life outcomes for advanced colorectal cancer patients treated with dendritic cell vaccine and cytokine-induced killer cell therapy. Biomed Res Int 2014; 2014: [27] Shi SB, Tang XY, Tian J, Chang CX, Li PQi JL. Efficacy of erlotinib plus dendritic cells and cytokine-induced killer cells in maintenance therapy of advanced non-small cell lung cancer. J Immunother 2014; 37: [28] Thanendrarajan S, Kim YSchmidt-Wolf I. New adoptive immunotherapy strategies for solid tumours with CIK cells. Expert Opin Biol Ther 2012; 12: Int J Clin Exp Med 2015;8(8):