Dendritic cell therapy

What are DENDRITIC CELLS?

• Dendritic Cells (DCs) are known as antigen presenting cells. They are special key regulators of the Immune system capable of activating the
  T-Cells and stimulating the growth and differentiation of B-Cells. Dendritic cells identify specific protein markers known as peptides on the surface of foreign or invading cells. DCs then present these peptide markers to other cells in the immune system so that they can seek out cells that carry this specific marker and destroy them.

What is DENDRITIC CELL THERAPY?

• Dendritic Cell Therapy harnesses the action of Dendritic Cells by identifying specific antigens on the cancer cells circulating in the blood of an individual, allowing the immune system to seek out the cancer cells to destroy them. It also stimulates memory cells providing long lasting immunity.
• Dendritic Cell Therapy is not a genetic therapy.
• Dendritic Cell Therapy does not involve the use of genotoxic (chemo) drugs.

How is the DENDRITIC CELL THERAPY made?

• Individualized dendritic therapies are created by isolating the DendriticCells and Circulating Tumor Cells (CTCs) from a fresh blood sample of a cancer patient. The CTCs are analyzed to identify the most frequently expressed protein (epitope) on the surface of these cells. This cancer protein is then imprinted on to the dendritic cells. The dendritic cell population is then augmented into millions, and the final preparation is created for administration to the patient.

What is the goal of DENDRITIC CELL THERAPY?

• The goal of the Dendritic Cell Therapy is to prime dendritic cells to teach T cells and B cells to recognize the cancer epitopes. Eventually, the CD28 T cells and CD28B cells form memory cells that respond faster when the same cancer epitope re-appears.. If the DENDRITIC CELL THERAPY is effective, it will provide the patient with long-term immunity against the cancer cells.
• Immune Frame testing is done prior to Dendritic Cell Therapy administration to establish the baseline immune system status and repeated as follow-up testing to monitor the immune system’s response. Dendritic Cell Therapy “boosters” can be made in the future for the patient if the dendritic cells or the CD28 T cells or CD28 B cells lose potency or memory.

What kind of cancers can be treated with DENDRITIC CELL THERAPY?

• Solid tumors only

What kind of cancers will not respond to DENDRITIC CELL THERAPY?

• Hematologic malignancies
• Testicular Cancer
• Compartmentalized cancers (isolated in an organ ex: brain)
• Central Nervous System cancers – Dendritic cells do not usually pass through the blood brain barrier to reach the target. Therefore, CNS cancers must be biopsied in order to create the therapy and consequently are less likely to work as well as it does with other types of cancer.

At what cancer stage should a patient consider DENDRITIC CELL THERAPY?

• Any stage can be considered if the cancer is stable and the patient is not on any concurrent chemotherapy, radiation or immunosuppressive therapies.
• Also appropriate for the patient that is currently in remission and seeking to reduce the likelihood of a cancer recurrence.

Are there any contraindications to DENDRITIC CELL THERAPY?

• Current treatment with chemotherapy or radiation.
• Recent radiation or chemotherapy - the patient will need to wait a minimum of three (3) weeks.
  • This therapy requires a fully usable immune system to be effective so this time frame is only an estimate and may be longer depending on the status of the patient, and their immune system’s ability to restore itself. Careful evaluation needs to be done by the healthcare provider before recommending this therapy to insure optimal response.
• Recent blood transfusions – the patient will need to wait 120 days
• Immune Suppression Medication – the patient must wait at least 14 days
• Active Autoimmune Disease: Patients are not eligible for the therapy
• Cachexia
• Pregnancy or breastfeeding
• Children (under the age of 18)
• Active infections – (includes active Lyme and coinfections)
  • Indicators:
    • WBC >10,000
    • Lymph > 20%
    • CRP >3.0
• High inflammation:
  • Indicators:
    • CRP>3.0)
    • Sed Rate >29 mm
    • AGP- a1-acid glycoprotein >110
    • ANC <2500 (indicator of immune insuciency)
    • Hemoglobin <8.5
• Tregs (CD25 + CTLA4) are present on the pre-Immune Frame (any %)
• High TNF-a on the pre–Immune Frame (should be under 5%)
• Radioactive Seeds: Patients are not eligible for the therapy
• Gamma Delta T Cell Therapy (GDTC): Patients are not eligible for the therapy

Why can’t DENDRITIC CELL THERAPY be done on children?

Dendritic Cells have not been evaluated in children. They have an immature immune system and we do not know the effect of the immune system and development of self-tolerance. Additionally, children have an active thymus gland and their immune system is under development. Therefore, it is not recommended.

Is DENDRITIC CELL THERAPY safe?

• Multiple studies, including human trials and clinical experience have established the DENDRITIC CELL THERAPY as generally safe.
• There are over 800 clinical trials on DC’s with over 200 active trials currently underway.

Are there studies on DENDRITIC CELL THERAPY?

• https://www.intechopen.com/books/biology-of-myelomonocytic-cells/
  dendritic-cells-location-function-and-clinical-implications
• https://www.nature.com/subjects/dendritic-cells
• https://pubmed.ncbi.nlm.nih.gov/31810551/
• https:/www.ncbi.nlm.nih.gov/pubmed/10073291

What happens if the patient’s immune system doesn’t respond?

If there is not a successful response by the patient’s immune system by the end of the third dose (based on follow up Immune Frame results) you can either start a new DC therapy cycle with a dierent antigen OR change the therapeutic strategy altogether. The particular level of response will be dependent on the status and health of the patient as well as if the patient adhered to the pre and post therapy guidelines. Resuming immune inhibiting/cytotoxic treatments will impact the ultimate outcome of therapy since they directly impact the memory cells. It’s recommended that your patient sign and disclaimer relative to this if they are planning on resuming other therapies.

What is the administration schedule of DENDRITIC CELL THERAPY?

• One dose every 21 days for three total doses and two follow up tests:
  • Therapy Infusions are on Days 0, 21 and 42
  • Follow up Immune Frame and Oncotrace are drawn on Day 63
    

Important:

• Remember that day “0” is counted as Day 1 in terms of counting for dose infusions as well as for mandatory follow up tests.
• These are live cells and need to be kept cold. Watch tracking closely to ensure the therapy will be arriving during oce hours.
• Upon receipt, immediately complete your quality control check and put it in the refrigerator. Do not freeze.
• It is highly recommended to infuse on the day of delivery (Day 6 = Tuesday) and if that is not possible then the next morning (Day 7 = Wednesday). Do not intentionally wait to infuse.
• Shipment from the lab is on a Thursday (Day 1) administration must occur by Wednesday (Day 7) of the following week at the absolute latest.
• After Thursday (Day 8) the cells may not be viable and should not be
  administered unless confirmed by the lab that they are still viable.

Is the administration timeline flexible for DENDRITIC CELL THERAPY?

It is recommended to follow the recommended administration schedule to ensure that the patient receives the highest viability/eect.

• Both doctors and patients need to schedule the administration of all three doses in advance to receive dose one (1) in order to avoid any delays with the additional two doses that will be upcoming.
• Should there be an unexpected delay, the therapy can be requested to be shipped and administered up several weeks late without loss of
  efficacy. Be sure to ask the lab if this is the case with your particular patient. If the therapy has already shipped this option is no longer available.
• If the administration schedule was altered at all, then the follow up tests are 21 days after Dose 3 (considering the delay was within reasonable limits).

What is included in the DENDRITIC CELL THERAPY package and what is the cost?

• Package Price: 8000 Euro
• Package Includes:
  • All three (3) doses of the Dendritic Cell Therapy
  • 1 Follow up Immune Frame after the third dose (Day 63)
  • 1 Follow up Oncotrace after the third dose (Day 63)
• Package DOES NOT include:
  • Initial (baseline) Immune Frame or Oncotrace tests
  • Additional follow up Immune Frames (past the Day 63 one)

What are the mandatory prerequisite tests required to establish baseline for DENDRITIC CELL THERAPY?

• Initial (Pre) Immune Frame – Initial/Baseline immune status
• Initial Oncotrace – (Baseline CTC)

Reminder: the initial baseline tests are not included in the cost of the actual therapy)

How much blood is required for DENDRITIC CELL THERAPY?

• Initial Immune Frame (Baseline test) (Draw 15-25 ml of blood) 1 vial
• Initial Oncotrace (Baseline test) (Draw 15 ml) 1 vial
• Dose 1, 2, and 3 of DENDRITIC CELL THERAPY (Draw 70-80 ml of blood) 3 vials
• Follow up Immune Frame (Draw 15-25 ml of blood) 1 vial

Note: if ordering the Oncotrace, Immune Frame and the three doses of the therapy at the same time then 80 ml of blood (3 vials) will be sucient.

It is highly recommended to evaluate the baseline Oncotrace and the initial Immune Frame prior to ordering the therapy to verify the patient’s eligibility. 30 ml of blood (1 vial) is sucient for both tests if ordered at the same time.

What are the mandatory follow-up tests for DENDRITIC CELL THERAPY?

• Mandatory Follow-Up Testing: Day 63 (which is 63 days from Dose 1)
• Immune Frame for verification of immune response
• Oncotrace for the follow up cell (CTC) count

Important relative to placing a packaged follow up test order:

• The Day 63 follow up tests are not ordered in the doctor’s portal
• These are ordered via a “letterhead order.”
• Simply write on your clinic’s letterhead the patient's name and that you are ordering the Oncotrace and Immune Frame for the specific follow up (ie Dendritic Cell Therapy - Day 63)
• Include the letterhead order with the patient’s blood sample.
• Also email the letterhead order to
  info@rgcc-international-northamerica.com

Note: Additional information on Letterhead Orders is in the Orientation Guide. You can download this document from the Resources section of the Doctor’s Portal.

Important: It is highly recommended to run a follow-up Immune Frame test every 6 months for at least 2 years to monitor CD80, CD86 and CD28 levels to
determine if a repeat of the therapy or a change in therapy becomes necessary. These tests are optional and not included in the original therapy package.

What pre-medications are required for DENDRITIC CELL THERAPY?

• Mandatory: 4 mg dexamethasone I.V. in a 20-50 ml rapid drip saline solution or slow bolus push.
• Optional but highly recommended: IV H2 inhibitors: Famotidine, Cimetidine, Nizatidine given at least 60 min before IV. The reason for the H2 blocker is to decrease any chance of headache, nausea, vomiting, and diarrhea. This is rare but very unsettling if it happens to your patient.
• Optional: Paracetamol (Acetaminophen), PO 500 mg, three times per day for up to three days starting an hour before the application, in order to counteract headache that could develop.

What needs to be avoided PRIOR to the pre-Immune Frame and the actual DENDRITIC CELL THERAPY administration?

Pre-Therapy Administration: The patient must be o ALL cytotoxic and free radical producing therapies. If drawing for cellular therapies, the patient must be off ALL immune suppressing therapies as well.

• Natural Substances (IV): cytotoxic substances like Vitamin C or Ozone at least 14 days.
• Natural Substances (oral supplements): Class 1 or 3 cytotoxic substances (per patient’s Onconomics Plus results) at least 14 days
• Methylene Blue: at least 14 days
• Off Label Medications: Ivermectin-FenBen-Itraconazole: 21 days
• Chemotherapy (non-platinum derivative): at least 14 days
• Chemotherapy (platinum derivative): at least 21 days
• MOAB or SMW drugs for at least 14 days
• Blood Transfusions: at least 120 days
• Radiation: at least 14 days
• Scans with Contrast: at least 14 days
• Surgery (simple/routine): at least 7-10 days
• Surgery (brain or extensive): minimum of 30 days based on time of recovery. Could be longer if slow recovery or if the person had some type of adverse reaction. Must be evaluated on a case-by-case basis.
• Fever: at least 14 days
• Hyperthermia (local/concentrated/microwave ablation): at least 30 days due to increase in cellular debris released into the bloodstream.
• Hyperthermia (generalized/systemic): no waiting
• Hyperbaric Therapy: 14 days
• Cryoablation: no waiting
• Immune Suppression Medication (All pre-Cellular Therapies – VAXO-Q-RE, Vaccine Prep, Dendritic Cells, DendroCov): at least 14 days
• Mistletoe: 14 days
• Radioactive Seeds: Patients are not eligible for therapies due to the prolonged and undetermined time of the radiation exposure
• Gamma Delta T Cell Therapy (GDTC): Patients are not eligible for therapies due to the potential interaction with RGCC therapies.

Note: The purpose of these guidelines is to ensure the highest level of effectiveness of each therapy by removing treatments that interfere with and/or diminish the effectiveness of that therapy. Adherence to these guidelines will improve therapy effectiveness and patient outcomes.

Reason: The breakdown of the CTC caused by these substances creates debris that could interfere with the development of the memory cells. Allowing time for the body to clear the debris will increase the eectiveness of the therapy.

What DOES NOT need to be avoided for the DENDRITIC CELL THERAPY?

• Hormone Suppression Therapy (applies to most but not all since there are exceptions ex: Verzenio requires 3 days based on ½ life x 5)
• Checkpoint inhibitors (can be beneficial)
• Mild Hyperthermia (Infrared Sauna)
• SOT therapy (can be beneficial if given at least 14 days prior)

What needs to be avoided AFTER the DENDRITIC CELL THERAPY?

• The patient must stay off ALL cytotoxic, or free radical producing, and immunosuppressive therapies 21 days after the administration of the therapy.
• Advise patient to avoid contracting Parvo 19 (parvovirus B19). This will most likely completely destroy the cellular immunity that the therapy had created, and they will have to start over, after they show that they are now immune to Parvo 19.

The above is not an exhaustive list of problematic substances, so how can you decide what might interfere with the development of memory cells?

In deciding what might or might not interfere with the development of the memory cells, ask yourself if the product has a direct or indirect effect on the CTC (in either being directly cytotoxic or in the generation of free radicals). Those are the problem substances since they create inflammation and debris in the blood sample (the scientists call it noise). Example: Artemisinin breaks down DNA so it works directly as a cytotoxin so it must be avoided. So do
 substances like Ivermectin, Ozone, Colloidal Silver, and Curcumin.

However, substances that work indirectly through the metabolism of cells (starving cancer) like Salicinium or Metformin only need to be avoided for 7 days after the administration of the therapy.

Additionally, substances like Flavonoids (ALL - including Quercetin and Resveratrol) and products like modified citrus pectin also work indirectly so they also only need to be avoided for the 7 days after administration of the therapy.

Are there any possible adverse reactions with DENDRITIC CELL THERAPY?

• Flu-like symptoms
• Fatigue
• Fever
• Injection site reaction (skin rash)
• *Urticaria (hives)
• Tumor Lysis Syndrome (TLS) with large volume of tumors
• Pain at surgical sites
• Increase in systolic blood pressure (usually 10-20 mm)

*Note: There has never been any reported severe life-threatening anaphylactic reaction from this procedure. However, there is no guarantee that this will not happen, however rare it may be.

What are the expected results after DENDRITIC CELL THERAPY?

The end result of Dendritic Cell therapy is the decrease of CTCs and the follow up Immune Frame is showing the activation of the immune system.

1. Baseline: Patient is not eligible for Dendritic Cell therapy if the pre–Immune
   Frame shows:
   • High Tregs (CD25 + CTLA4) (Any % will interfere with memory cell development)
   • High TNF-a (over 5%)
2. Monitoring Progress: Follow up Immune Frame for Dendritic Cells is at Day 63.
   • Any rise of markers except for CD25, CTLA4 and TNF-a is an indication of activation
3. Final Outcome: Day 63 – Immune Frame expected results:
   • T&B cells should be steadily present
   • CD 80 should be over 15%
   • CD 86 should be over 10%
   • CD 28 – B & T line should be above 0 (even barely is ok)
4. Booster is necessary:
   • See below for the booster policy. The ultimate goal is to develop a long-term immune response:
     • >15 on both CD80 & CD86 dendritic cells and
     • >1.0 on CD28 memory cells

Important: These numbers may not be reached until the 6 month follow up Immune Frame.

Is there anything that can be done to help obtain optimal results on the follow up Immune Frame?

Yes, you can recommend various nutrients to help improve the results on the Immune Frame. Please see our Immune Frame Comprehensive Guide.

What is the Booster policy for the DENDRITIC CELL THERAPY?

• If Day 63 Immune Frame results were not on target (per guidelines) the lab first recommends you consider a change in therapy (SOT, DC with a
  new epitope target, or conventional treatment).
• If a booster is desired, then a repeat of the Immune Frame (not included in package) must be repeated on Day 210 (plus/minus one week).
• If the results on Day 210 (plus/minus one week) still do not show the targeted numbers (per guidelines) then a booster can be requested.
• Boosters will not be approved prior to the Day 210 (plus/minus one week) Immune Frame results being posted.
• The booster request must be made in writing within 15 Days from the Day 210 Immune Frame results.
• The one time, one dose booster will be for the same epitope target of the original therapy
• Patient must not have undergone other cytotoxic therapies (radiation or chemotherapy)
• Patient must not have undergone other conventional immune therapies

When is a new DENDRITIC CELL THERAPY order required instead of a
booster?

• It has been over 15 days from Day 210 Immune Frame.
• Memory cells have started dropping (to know this information patient will require an optional follow up Immune Frame between Day 63 and Day 210). Important: Optional Immune frames are not included in the package price of the therapy.
• Patient has undergone conventional cytotoxic or immune therapy since receiving the original DC therapy (this will automatically require a retargeting and even if within the booster timeline it will not be considered a booster).
• Important: a new Dendritic Cell Therapy is subject to the current pricing.

If based on the above you believe your patient requires a booster, please follow the below steps:

1. Submit booster request to support@rgcc-international-northamerica.com
2. Include in your email your rationale for the booster request. Ex. Day 210 follow up the patients CD 80/86 cells did not meet the desired percentage number.
3. Include the exact dates of the therapy administration.
4. Include what therapies (conventional and alternative) the patient received post blood draw for the therapy.
5. Include what therapies (conventional and alternative) the patient received post therapy administration (if any).
6. Provide the required completed follow-up forms.
7. Provide any recent scan/test results relative to the patient's current cancer status.

How to Administer DENDRITIC CELL THERAPY

Important: It is critical that doses be administered on the recommended intervals to ensure optimum response. There is a synchronization eect needed and it is essential the doses be added at the designated time, or the therapy will not work as intended.

First steps:

• Take the patient’s Dendritic Cell therapy vial out of the refrigerator and allow it to come up to ambient room temperature while the pre-medications are being given. Even warming to low normal body temperature (90-95 degrees) by holding in your hands can be very helpful as well.
• Check the vial number and match it to patient’s name.
• Inspect the vial. The cells are suspended in solution and are ready for administration. The solution should be colorless without any sign of precipitation. **In case of any color changes or any precipitation DO NOT ADMINISTER. Immediately notify RGCC by email at info@rgcc-international-northamerica.com and call 1-800-813-1372.

PRE-MEDS: Administer pre-medications prior to each dose of the DENDRITIC CELL THERAPY.

• Start with about a 250-500ml bag of saline
• Start the IV line with Catheter to the patient
• If using an H2 Inhibitor: Administer the IV form of any H2 inhibitors: Cimetidine, Nizatidine, or Famotidine-give at least 45-60 minutes before the IV. If giving orally, it needs to be given 6 hours before the IV.
• Ready 4 mg dexamethasone I.V. in a 20-50 ml rapid drip saline solution or very slow bolus push
• If using Paracetamol (Acetaminophen), PO 500 mg starting an hour before administration and up to three times per day for up to three days after administration to help counteract the headache that could develop.

Note: The use of Dexamethasone is to help prevent the likely severe damage to the surrounding tissue if the patient experienced an extravasation during the administration of the therapy.

Day 1 – 1st Dose

• Before the pre-medications are finished prepare 250-500 ml IV saline
• Remove the security tape carefully, remove cap, wipe the stopper with a sterile alcohol swab
• Leave the bottle in an upright position to remove the sample, REASON: (the inside rims on rubber seal can sometimes cause cells to stick)
• Use a 10 ml syringe with a 21-gauge 2-inch needle and very slowly remove the 5-7 ml of cells
• Slowly and gently push the cells into the 250-500 ml saline bag, (remember these are live cells and are fragile). Pull back 1 to 2 times partially filling the 10 ml syringe with saline to remove all cells from the syringe
• Gently swirl/tilt the prepared IV solution a few times to mix well (do not shake)
• Now you’re ready to infuse the Dendritic Cell drip into the patient. Drip rate should last approximately 45 minutes to 1.5 hours
• This drip should not cause any pain or discomfort to the patient. In some cases, during the IV or shortly thereafter, the patient may begin to experience a slight fever (99-100), slight headache, or chills. This is generally a good thing but monitor the patient while in your oce and instruct them to call you if the fever rises over 102 degrees over the next several days

Day 21 – 2nd dose - Administer exactly the same as dose 1.

Day 42 – 3rd dose - Administer exactly the same as dose 1 and 2.

Day 63 – Mandatory Follow up Immune Frame and Oncotrace – (Included in
package)

Advanced FAQs from practitioners

Q: Why did DENDRITIC CELL THERAPY change from two doses to three doses?

A: From Dr. Papasotiriou, the analysis of data after long term application shows the following:

If we rely on the Immune-Frame after each step, especially between the 1st and 2nd dose, we may lose the window of actual boosting the immune response simply because the peak is taking place on day 21 and 28. If we delay further, we may permanently lose this time opportunity.

The risk of delay is the same between doses 2 and 3 but still measurable, thus the reason you might choose to run an optional Immune Frame. Therefore, it is best to have a straight algorithm of application and tests during the process of Dendritic Cells application.

Q: Can scans look worse after DENDRITIC CELL THERAPY?

A: Yes. Dendritic Cell Therapy is a personalized treatment and therefore the magnitude of the response varies significantly from person to person. The
result of the Dendritic Cells is the generation of antibodies and specialized cells that will attack the tumor. Because this is an immunotherapy, it is not uncommon to witness an increase in tumor mass due to the inflammation that the immune system causes while attacking the cancer cells or even a rise in some cancer markers in serum due to cancer cells are being killed and cancer proteins being released to the blood. This is known as pseudo-progression and is common in immunotherapies.

To see if the Dendritic Cells are activating the immune system to attack the cancer, and for how long, it is recommended to check specific immune markers. In RGCC we use the Immune Frame. It is required to have an Immune Frame before undergoing the Dendritic Cell Therapy to see the baseline levels, and then you can follow the response again using this test to evaluate immune activation.

Q: Can test markers go up after DENDRITIC CELL THERAPY?

A: Yes. Cancer markers like PSA can go up after the therapy is administered due to cancer cells being killed and the cancer proteins being released in the blood.

Q: Can DENDRITIC CELL THERAPY be done to a person with a large tumor?

A: The goal is to activate the immune system against the patient’s cancer cells. The Dendritic Cell therapy should only be administered after careful evaluation of each patient’s current health status. Patients with tumors in highly vascularized areas such as the lungs or liver, as well as those with a single large tumor or multiple tumors (measuring over 5 cm singularly or in total) are at high risk for an inflammatory effusion known as Tumor Lysis Syndrome which can cause severe symptoms.

Q: What antigen/protein is targeted in MBC with DENDRITIC CELL THERAPY?

A: The targets will vary (RGCC does not provide that information) with each MBC case. This is one major reason you cannot use the therapy from patient A on patient B with MBC or vice versa.

Q: When the cancer mutates to hide from this target, is another one substituted or does DENDRITIC CELL THERAPY become an obsolete option?

A: The CD80, CD86 and CD28 memory cell count will slowly go down over the months/years as the cancer mutates away from the original target. This is the reason for the constant (every 6 months) follow-up Immune Frames over months and years. At this point the lab will need a new blood sample to create a new Dendritic Cell Therapy for these new mutated cancer cells, this is called a “Retargeting” which creates the antibodies against the new epitope of the new cancer cells/tumor. This is why the therapy can be used to help patients with two or more primary cancers at the same time.

Q: Can DENDRITIC CELLS be used with Brain or Spinal cancers?

A: Not easily and it’s not recommended. The reasons are that when administering primed DENDRITIC CELL THERAPY into the CSF (which means that we inject cells in a level of 10^6 cells and above) you will automatically be altering the consistency of the CSF (since none or up to 1 cell per cc should be present). Hence, the fluid itself may cause severe problems for the patient.