Lung cancer spread to adrenal glands life expectancy

If You Have Adrenal Cancer

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What is an adrenal tumor?

Tumors can start any place in the body. An adrenal tumor starts when cells in the adrenal glands grow out of control and crowd out normal cells. This makes it hard for the body to work the way it should.

Most tumors found in the adrenal glands are called adenomas. These are not cancer (benign) and don’t cause problems. Adenomas are sometimes found by accident when someone has tests for other reasons.

If an adrenal tumor is cancerous, the cancer cells can spread to other parts of the body. Cancer cells in the adrenal glands can sometimes travel to lymph nodes and other organs. When cancer cells do this, it’s called metastasis (pronounced meh-TAS-tuh-sis). To doctors, the cancer cells in the new place look just like the ones from the adrenal glands.

Cancer is always named for the place where it starts. Many cancers found in the adrenal glands did not start there. In these cases, the cancer has spread from other organs, so it is not considered or treated like adrenal cancer. For example, if lung cancer spreads to the adrenal gland, it is still called lung cancer.

The adrenals

The adrenals are small glands that are right above the kidneys. The kidneys are inside the upper part of the belly.

The adrenals have 2 parts called the cortex and medulla. The main job of the adrenals is to make certain hormones. For example, some adrenal hormones help the body deal with stress and control blood pressure. Other adrenal hormones help develop sex organs and control puberty.

When Non–Small Cell Lung Cancer Spreads: What to Expect

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Non–small cell lung cancer, or NSCLC, is the most common kind of lung cancer, making up about 80 to 85 percent of all cases. It is referred to as metastatic NSCLC when it has spread from the lungs to other parts of the body.

There are different subtypes of NSCLC, depending on which type of lung cell they originated in. But they are usually grouped together because the approach to treatment and the prognosis are often similar. These subtypes include adenocarcinoma, squamous cell carcinoma, and large cell carcinoma.

Treatment of metastatic NSCLC has improved dramatically in just the past decade, says David Graham, MD, of the Levine Cancer Institute in Charlotte, North Carolina. “Ten or fifteen years ago, the chances of living two years with metastatic NSCLC were pretty darn small. Now the odds of being around for two years are better than the odds of not being around for two years.” More often than not, patients survive two to five years, he says. “It’s definitely a lot better than it was.”

Recognizing the Symptoms of Metastatic NSCLC

Many cases of NSCLC are not discovered until after the cancer has metastasized. But careful attention to early symptoms can lead to early diagnosis, when treatment is more likely to be effective.

Symptoms of NSCLC include a cough that does not go away, coughing up blood, and chest pain that gets worse with deep breathing or laughing. Weight loss, loss of appetite, shortness of breath, and fatigue are also possible indications of NSCLC, but they can also be caused by other conditions. None are specific to NSCLC, which is why diagnosis is often delayed.

As with many other cancers, the danger increases when NSCLC spreads. Tumor cells can break away from tumors in the lungs and travel through the bloodstream to other parts of the body. Metastatic NSCLC cells, Dr. Graham says, are most likely to spread to lymph nodes in the middle of the chest, the liver, adrenal glands, bones, and possibly the brain.

Symptoms of metastatic NSCLC depend on the area of the body the cancer has spread to. If it has spread to the bones, it can cause bone pain in the back or hips. If they spread to the brain, these errant cells can also cause headaches, weakness, numbness of an arm or leg, dizziness, and seizures.

If NSCLC spreads to the liver, it can lead to yellowing of the skin and eyes, and if it spreads to the skin or lymph nodes, it can cause lumps near the surface of the body, according to the American Cancer Society. Lung cancer that has spread to the adrenal glands often causes no symptoms, but you may experience dizziness, weakness, and fatigue.

What Are the Treatment Options?

While there’s currently no cure for metastatic NSCLC, treatments are available that can ease your symptoms and help you live longer and feel better — what Taofeek Owonikoko, MD, an oncologist at the Winship Cancer Institute of Emory University in Atlanta, refers to as the quantity and quality of life.

Treatment options depend on many factors, including the areas the cancer has spread to and the particular characteristics of the cancer. Ten years ago, patients’ cells were examined to see whether they had small-cell lung cancer or NSCLC. “Now we want to find the specific alterations in the cancer cell,” says Dr. Owonikoko. “If there are specific mutations, the particular treatment would be dictated by that.”

For example, doctors will now order tests to determine whether the cancer cells have mutations in three genes — known as EGFR, ALK, and ROS1.

“We have specific targeted therapies that will take advantage of changes associated with those genetic markers,” says Graham. “They offer a treatment opportunity we wouldn’t have otherwise.” Each of those genes is associated with a pathway in the cells that spurs cancer growth.

Doctors can now treat those cancers with drugs to block the pathways and therefore slow growth rather than having to turn immediately to more invasive surgery, radiation, or chemotherapy.

Such treatments are known as targeted therapies because they are directed at a particular genetic target.

Some people are also candidates for immunotherapy, one of the newest and most significant advances in the treatment of metastatic NSCLC (and other cancers).

Cancer cells have devised all kinds of clever biological tricks to hide from the body’s immune system, which would otherwise attack them. Immunotherapy, using drugs called checkpoint inhibitors, makes the cancer cells visible to the immune system, which is then mobilized into action.

Treatment of cells in the bones, liver, brain, and elsewhere might require conventional cancer treatments that is, surgery, radiation, or chemotherapy.

The Outlook for Metastatic NSCLC

The length of time a person with metastatic NSCLC will live, and what kind of life he or she will have, are related to the particular mutations that are present in their tumor cells, and whether the effects of the mutations are able to be treated with immunotherapy.

Because of advancements in treatment, survival rates for people with metastatic NSCLC are improving. Those who respond to treatment can live four or five years, says Owonikoko. “Overall, the prognosis has improved,” he says, “but it’s still not where we want it to be.” Clinical trials are constantly being conducted to find ways to improve treatments and quality of life for people with metastatic NSCLC — ask your doctor whether you may be a candidate for such a trial.

Metastatic lung cancer

Metastatic lung cancer occurs when lung cancer cells break away from a tumor and travel to other parts of your body through the blood or lymph system. Lung cancer can be metastatic at the time of diagnosis or following treatment. Because symptoms do not develop when lung cancer is present, it is common for the cancer to metastasize before it is diagnosed.

Even though the cancer may have formed a tumor in a new location in the body, it is still named after the part of the body where it started. For example, if lung cancer spreads to the brain, it is called metastatic lung cancer. The most common sites of metastases for lung cancer are the other lung, adrenal gland, bones, brain and liver. If you have been treated for lung cancer and now have cancer cells in any of these areas, it is most likely that the lung cancer has spread.

Metastatic lung cancer is not the same as recurrent lung cancer. Recurrent lung cancer is cancer that returns to the same part of the same lung after treatment, rather than traveling to other parts of the body. If cancer develops in the lung that wasn’t previously affected, it is almost always a new metastasized cancer, not a recurrence. In all cases, a metastatic tumor is always caused by cancer cells migrating from another part of the body.

Metastatic lung cancer treatment options

In general, metastatic cancers are treated based on the original site of the cancer. The drugs used to treat your lung cancer may be used for metastases. The cancer cells themselves have not changed but simply are living in a new place.

Drug therapy is used to treat most cases of lung cancer that has spread to your liver. Options for brain metastases include radiation therapy, chemotherapy and/or steroids. Surgery is an option in very specific cases.

Radiation therapy or drug therapy are options for lung cancers that have spread to bone. Drugs would be used if you are not experiencing pain or there is no danger of bone breakage. Radiation therapy would be used if you have pain or your bone is fragile.

Next topic: What are the stages of lung cancer?

Metastatic Non-Small-Cell Lung Carcinoma Successfully Treated with Pre-operative Chemotherapy and Bilateral Adrenalectomy

Abstract

Metastatic non-small-cell lung cancer is a common condition with a dismal prognosis. Although palliative chemotherapy improves survival and quality of life, nearly all patients die of progressive disease. Metastatic involvement of adrenal glands is not rare, but usually reflects widespread dissemination. Selected patients with single adrenal metastasis may be cured with surgery, although the level of evidence comes from single cases reports and short retrospective series. Here we report a patient with bilateral adrenal metastases from previously resected non-small-cell lung cancer, who remains free of disease four years after pre-operative chemotherapy and bilateral adrenalectomy.

INTRODUCTION

Metastatic non-small-cell lung cancer (NSCLC) is considered an incurable disease in most cases. In this setting, only salvage resection of single brain metastases may be judged as a standard surgery in selected patients with controlled primary tumour (1,2). Lung carcinoma commonly metastasizes to adrenal glands (3,4). Although adrenalectomy has been reported in several single cases and small series of selected patients with metastatic NSCLC, the precise role of this approach remains controversial (5). Bilateral involvement of adrenal glands is not uncommon, but usually is associated with diffuse systemic spread. In a computerized Medline search in English medical literature about adrenalectomy for metastatic lung cancer, we have retrieved only two cases of bilateral involvement of adrenal glands surgically removed (6,7). We report here another highly selected patient successfully treated with pre-operative chemotherapy followed by adrenalectomy for metastases to both adrenal glands.

CASE REPORT

A 54-year-old Caucasian man complained of right chest pain and dry cough during the last 4 months. He was an active smoker of 20 cigarettes per day and he had no relevant medical history. Thorax and abdomen CT scan showed a peripheral mass of 3×4 cm in right upper pulmonary lobe with chest wall invasion. Bronchoscopy was normal and a CT-guided biopsy was performed revealing large cell carcinoma. On December 1999, right upper lobectomy with chest wall en block resection was performed. The histopathological study showed a poorly differentiated adenocarcinoma (Fig. 1) measuring 8×5 cm with invasion of parietal pleura, ribs and muscle, and bronchial and chest wall margins free of disease: stage IIB (pT3pN0).

Figure 1.

Low power view of intraalveolar tumor growth (A). High power view of poorly differentiated adenocarcinoma filling alveolar space. Notice PAS positive droblets (B). Please note that a colour version of this figure is available as supplementary data at http://jjco.oxfordjournals.org.

Figure 1.

Low power view of intraalveolar tumor growth (A). High power view of poorly differentiated adenocarcinoma filling alveolar space. Notice PAS positive droblets (B). Please note that a colour version of this figure is available as supplementary data at http://jjco.oxfordjournals.org.

Three months later he noted pain in the right hypochondrium and a CT scan showed bilateral enlargement of adrenal glands (Fig. 2), with two masses of 7 cm in the right side and 5×2 cm in the left side, without any other evidence of disease. A CT scan-guided biopsy of the right adrenal mass was performed demonstrating infiltration of large cell carcinoma. In April 2000, he started chemotherapy with cisplatin 100 mg/m2 on day 1 and gemcitabine 1200 mg/m2 on days 1 and 8, every 21 days. After three courses of chemotherapy he achieved a partial response and a CT scan done after the sixth cycle showed radiological complete response (Fig. 3). In October 2000, bilateral subcostal laparotomy was performed. At surgery, both adrenal glands seemed to be fibrous, with thrombosis of their veins and the spleen surface looked granular. Bilateral adrenalectomy and splenectomy was accomplished with no post-operative complications. Immediately after surgery, hormonal replacement was started with daily hydrocortisone and fludrocortisone. Pathological examination of the adrenals revealed hemorrhagic fibrosis in both glands and microscopic foci of large cell carcinoma in only the left gland (Fig. 4). Spleenic parenchyma was within normal limits.

Figure 2.

Gross metastatic involvement of both adrenal glands before neoadjuvant chemotherapy.

Figure 2.

Gross metastatic involvement of both adrenal glands before neoadjuvant chemotherapy.

Figure 3.

Abdominal CT scan after six chemotherapy cycles showing near complete response. Notice major shrinking of both adrenals and density changes only in the left one.

Figure 3.

Abdominal CT scan after six chemotherapy cycles showing near complete response. Notice major shrinking of both adrenals and density changes only in the left one.

Figure 4.

Low power view of left adrenal and tumor tissue. Notice dense lymphoid infiltration of both (A). Isolated small nests of tumor cells in the midst of inflammation and fibrosis (B). Please note that a colour version of this figure is available as supplementary data at http://jjco.oxfordjournals.org.

Figure 4.

Low power view of left adrenal and tumor tissue. Notice dense lymphoid infiltration of both (A). Isolated small nests of tumor cells in the midst of inflammation and fibrosis (B). Please note that a colour version of this figure is available as supplementary data at http://jjco.oxfordjournals.org.

After surgery recovery, two more cycles of cisplatin and gemcitabine with the same schedule were administered. Treatment was finished on February 2001, the patient has been followed up every three months by physical exam, biochemistry, tumour markers and CT scans, and to date he remains free of disease.

DISCUSSION

Treatment of choice for patients with stage IV lung carcinoma and good performance status is palliative chemotherapy. Although chemotherapy improves survival and quality of life in these patients (8), virtually all patients will die of progressive disease. Some patients with stage IV NSCLC have a solitary metastasis as the only sign of advanced disease, creating a medical dilemma for clinicians. For these patients a surgical approach might be considered but, unfortunately, only a resection of single brain metastases (2) has clearly demonstrated in randomized trials to have any impact on survival.

Adrenal glands are one of the most frequent sites of spread from NSCLC. In some necropsy series around one-third of patients had metastases in adrenal glands (4). Usually, adrenal metastases are associated with more extensive disease, but it is not exceptional to first appear as a single synchronous or metachronous metastasis. Some authors have hypothesized that adrenal involvement in NSCLC could be as a consequence of both lymphogenous and hematogenous dissemination (9). This theoretical lymphatic route of spreading may reaffirm the role of surgery for isolated adrenal metastasis, on the assumption that it was a regional disease. Moreover, both open and laparoscopic adrenalectomy have become safe techniques in the hands of expert surgeons (7,10).

Currently, less than one hundred unilateral adrenalectomies for metastatic NSCLC have been published in English language medical literature. Most of them have been reported as single cases, although some reference institutions have communicated their cumulative experience with a number of patients (5,10,11–18). Based on the available information, it is very difficult to extract true conclusions and even more to establish general recommendations for the management of these patients. Probably, there are selection and publication biases in favour of patients with a good outcome. It may explain that patients of large series have generally shorter survival than those reported as single cases (5). Mediastinal nodal involvement and a short disease-free interval seem to be important prognostic factors and may predict poor outcome after adrenalectomy (5,10). However, the majority of authors recommend adjuvant chemotherapy after surgery, with an attempt to reduce or delay relapses, despite being, until recent times, an unproven treatment for completely resected NSCLC (19). Perhaps the most important conclusion is that some patients may survive a long time without relapse after resection of isolated adrenal metastases. For bilateral adrenal involvement the lack of evidence for surgery is more obvious, with only two cases reported so far. The first patient (6), as in our case, with a favourable long-term relapse-free survival (more than 9 years), but the other one with a worse prognosis died 13 months after surgery (7).

The alternative to surgery for patients with metastatic NSCLC is systemic chemotherapy. Combination chemotherapy with a platinum compound and a new agent is considered now the standard of care for patients with advanced-stage NSCLC (20). However, median overall survival of NSCLC patients treated with chemotherapy is about 8 months nowadays, with less than 10% alive at two years. Taking into account that chemotherapy may play an important role in patients with adrenal metastases, as a palliative alternative or adjuvant to surgery, the neoadjuvant approach can be reasonable in particular cases. Patients with synchronous metastases and those with large or bilateral involvement could be treated with chemotherapy after an extensive radiological staging and, in case of response, salvage surgery may be a realistic option.

In our patient, rapid progression after lung surgery with large, bilateral and symptomatic involvement of the adrenal glands invited us to propose systemic chemotherapy. Because of the excellent response to chemotherapy without widespread dissemination and no nodal disease at resection, salvage surgery with two cycles more with adjuvant intent was offered.

With this case report we want to point out that, in selected cases, surgery may change the natural history of some patients with ill-starred prognosis with conventional treatments. However, we do not think that this approach may be considered a standard option for all patients with adrenal metastasis. It could be considered as a highly selected individualized approach based on age, co-morbidity, performance status, disease-free interval since lung surgery, prognostic factors derived from pathological stage of lung carcinoma, previous experience of the surgeon and patient’s wishes. Multidisciplinary evaluation by expert surgeons and oncologists seems crucial in the management of selected patients with potentially resectable stage IV NSCLC, such as this one.

1 Wronski M , Arbit E , Burt M , Galicich JH . Survival after surgical treatment of brain metastases from lung cancer: a follow-up study of 231 patients treated between 1976 and 1991, J Neurosurg, 1995, vol. 83 (pg. 605-16) 2 Patchell RA , Tibbs PA , Walsh JW , Dempsey RJ , Maruyama Y , Kryscio RJ , et al. A randomized trial of surgery in the treatment of single metastases to the brain, N Engl J Med, 1990, vol. 322 (pg. 494-500) 3 Abrams HL , Sprio R , Goldestein N . Metastases in carcinoma: analysis of 1000 autopsied cases, Cancer, 1950, vol. 3 (pg. 74-85) 4 Marabella P , Takita H . Adenocarcinoma of the lung: clinico-pathological study, J Surg Oncol, 1975, vol. 7 (pg. 205-12) 5 Beitler AL , Urschel JD , Velagapudi SRC , Takita H . Surgical management of adrenal metastases from lung cancer, J Surg Oncol, 1998, vol. 69 (pg. 54-57) 6 Urschel JD , Finley RK , Takita H . Long-term survival after bilateral adrenalectomy for metastatic lung cancer: a case report, Chest, 1997, vol. 112 (pg. 848-50) 7 Hasan R , Harold KL , Matthews BD , Kercher KW , Sing RF , Heniford BT . Outcomes for laparoscopic bilateral adrenalectomy, J Laparoendosc Adv Surg Tech A, 2002, vol. 12 (pg. 233-6) 8 Non-Small Cell Lung Cancer Collaborative Group Chemotherapy in non small cell lung cancer: A meta-analysis using updated data on individual patients from 52 randomized clinical trials, BMJ, 1995, vol. 311 (pg. 899-909) 9 Karolyi P . Do adrenal matastases from lung cancer develop by lymphogenous or hematogenous route?, J Surg Oncol, 1990, vol. 43 (pg. 154-6) 10 Sarela AI , Murphy I , Coit DG , Conlon KC . Metastasis to the adrenal gland: the emerging role of laparoscopic surgery, Ann Surg Oncol, 2003, vol. 10 (pg. 1191-6) 11 Abdel-Raheem MM , Potti A , Becker WK , Saberi A , Mehdi SA . Late adrenal metastasis in operable non-small-cell lung carcinoma, Am J Clin Oncol, 2002, vol. 25 (pg. 81-3) 12 Bretcha-Boix P , Rami-Porta R , Mateu-Navarro M , Hoyuela-Alonso C , Marco-Molina C . Surgical treatment of lung cancer with adrenal metastasis, Lung Cancer, 2000, vol. 27 (pg. 101-5) 13 Porte HL , Roumilhac D , Graziana JP , Eraldi L , Cordonier C , Puech P , et al. Adrenalectomy for a solitary adrenal metastasis from lung cancer, Ann Thorac Surg, 1998, vol. 65 (pg. 331-5) 14 Reyes L , Parvez Z , Nemoto T , Regal AM , Takita H . Adrenalectomy for adrenal metastasis from lung carcinoma, J Surg Oncol, 1990, vol. 44 (pg. 32-4) 15 Raviv G , Klein E , Yellin A , Schneebaum S , Ben-Ari G . Surgical treatment of solitary adrenal metastases from lung carcinoma, J Surg Oncol, 1990, vol. 43 (pg. 123-4) 16 Kirsch AJ , Oz MC , Stoopler M , Ginsburg M , Steinglass K . Operative management of adrenal metastases from lung carcinoma, Urology, 1993, vol. 42 (pg. 716-9) 17 Ayabe H , Tsuji H , Hara S , Tagawa Y , Kawahara K , Tomita M . Surgical management of adrenal metastasis from bronchogenic carcinoma, J Surg Oncol, 1995, vol. 58 (pg. 149-54) 18 Kim SH , Brennan MF , Russo P , Burt ME , Coit DG . The role of surgery in the treatment of clinically isolated adrenal metastasis, Cancer, 1998, vol. 82 (pg. 389-94) 19 The International Adjuvant Lung Cancer Trial Collaborative Group Cisplatin-based adjuvant chemotherapy in patients with completely resected non-small-cell lung cancer, N Eng J Med, 2004, vol. 350 (pg. 351-60) 20 American Society of Clinical Oncology Treatment of unresectable non-small-cell lung cancer guideline: update 2003, J Clin Oncol, 2004, vol. 22 (pg. 330-53) © 2006 Foundation for Promotion of Cancer Research

Targeted Treatments

One of the most exciting developments in lung cancer medicine is the introduction of targeted treatments. Unlike chemotherapy drugs, which cannot tell the difference between normal cells and cancer cells, targeted therapies are designed specifically to attack cancer cells by attaching to or blocking targets that appear on the surfaces of those cells. People who have advanced lung cancer with certain molecular biomarkers may receive treatment with a targeted drug alone or in combination with chemotherapy. These treatments for lung cancer include:

Erlotinib (Tarceva and others). A targeted treatment called erlotinib has been shown to benefit some people with non-small cell lung cancer. This drug blocks a specific kind of receptor on the cell surface—the epidermal growth factor receptor (EGFR). Receptors such as EGFR act as doorways by allowing substances in that they can encourage a cancer cell to grow and spread. Lung cancer cells that have a mutation on the EGFR are likely to respond to treatment with erlotinib instead of chemotherapy. For patients who have received chemotherapy, and are in need of additional treatment, erlotinib can be used even without the presence of the mutation.

Afatinib (Gilotrif). In 2013, the FDA approved afatinib for the initial treatment of metastatic NSCLC in patients with the same EGRF gene mutations or deletions as those who can be treated successfully with erlotinib.

Gefitinib (Iressa). In 2015, the FDA approved gefitinib for the first-line treatment of patients with NSCLC whose tumors harbor specific types of EGFR gene mutations, as detected by an FDA-approved test.

Bevacizumab (Avastin). Just like normal tissues, tumors need a blood supply to survive. Blood vessels grow in several ways. One way is through the presence of a substance called vascular endothelial growth factor (VEGF). This substance stimulates blood vessels to penetrate tumors and supply oxygen, minerals, and other nutrients to feed the tumor. When tumors spread throughout the body, they release VEGF to create new blood vessels.

Bevacizumab works by stopping VEGF from stimulating the growth of new blood vessels. (Because normal tissues have an established blood supply, they are not affected by the drug.) When combined with chemotherapy, bevacizumab has been shown to improve survival in people with certain types of non-small lung cancer, such as adenocarcinoma and large cell carcinoma.

Crizotinib (Xalkori). A treatment that has shown benefits for people with advanced non–small cell lung cancer who have the ALK gene mutation. Crizotinib works by blocking ALK and stopping the growth of the tumor.

Ceritinib (Zykadia). This was approved in 2014 for people with metastatic ALK-positive lung cancer who cannot tolerate crizotinib or whose cancer continued to grow while being treated with crizotinib.

Because the genes of cancer cells can evolve, some tumors may become resistant to a targeted treatment. Medications to meet those challenges are being studied now in clinical trials, which often offer important treatment options for people with lung cancer.

Immunotherapy

Immunotherapy has recently emerged as a new treatment option for certain lung cancers. While any cancer treatment can cause side effects, immunotherapy is generally well-tolerated; this is in part due to its mechanism of action.

Our immune system is constantly working to keep us healthy. It recognizes and fights against danger, such as infections, viruses, and growing cancer cells. In general terms, immunotherapy uses our own immune system as a treatment against cancer.

In March 2015, the FDA approved the immunotherapy nivolumab (Opdivo) for the treatment of metastatic squamous NSCLC which was unsuccessfully treated with chemotherapy. Nivolumab works by interfering with a molecular “brake” known as PD-1 that prevents the body’s immune system from attacking tumors.

In 2016, the FDA approved a new immunotherapy called pembrolizumab (Keytruda) for the treatment of advanced NSCLC as an initial therapy. Its therapeutic activity is similar to that of nivolumab. Patients are tested for a protein known as PDL-1 and if a sufficient quantity is identified they may qualify for this treatment.

Additional approaches to immunotherapy for lung cancer have shown promise in early clinical trials and are now in late-phase development. Treatments for NSCLC have advanced the furthest; however, a number of new immune-based treatments for SCLC are also in clinical development. These treatments fall into four main categories:

  • Monoclonal antibodies are lab-generated molecules that target specific tumor antigens (a substance that the immune system sees as being foreign or dangerous).
  • Checkpoint inhibitors target molecules that serve as checks and balances in the regulation of immune responses.
  • Therapeutic vaccines target shared or tumor-specific antigens.
  • Adoptive T-cell transfer is an approach in which T-cells (a type of white blood cell) are removed from the patient, genetically modified or treated with chemicals to enhance their activity, and re-introduced into the patient with the goal of improving the immune system’s anticancer response.

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