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Abstract
Pancreatic cancer (PC) is a lethal disease representing the seventh most frequent cause of death from cancer worldwide. Resistance of pancreatic tumors to current treatments leads to disappointing survival rates, and more specific and effective therapies are urgently needed. In recent years, immunotherapy has been proposed as a promising approach to the treatment of PC, and encouraging results have been published by various preclinical and clinical studies. This review provides an overview of the latest developments in the immunotherapeutic treatment of PC and summarizes the most recent and important clinical trials.
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Chimeric antigen receptors for treatment of glioblastoma: a practical review of challenges and ways to overcome them. Cancer Gene Ther 2016; 24:121-129. [PMID: 27767090 DOI: 10.1038/cgt.2016.46] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 09/05/2016] [Indexed: 12/28/2022]
Abstract
Glioblastoma (GBM) is by far the most common and the most aggressive of all the primary brain malignancies. No curative therapy exists, and median life expectancy hovers at around 1 year after diagnosis, with a minute fraction surviving beyond 5 years. The difficulty in treating GBM lies in the cancer's protected niche within the blood-brain barrier and the heterogeneity of the cancer cells, which possess varying degrees of susceptibility to various common modalities of treatment. Over time, it is the tumor heterogeneity of GBM and the ability of the cancer stem cells to evolve in response treatment that renders the cancer refractory to conventional treatment. Therefore, research has increasingly focused on treatment that incorporates knowledge of GBM molecular biology to therapeutic strategies. One type of therapy that shows great promise is the area of T-cell immunotherapy to target GBM-specific tumor antigens. One attractive strategy is to use T cells that have undergone genetic modification to express a chimeric antigen receptor capable of interacting with tumor antigens. In this article, we will review chimeric antigen receptor T-cell therapy, their advantages, drawbacks, challenges facing their use and how those challenges may be overcome.
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53
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Yang F, Jin H, Wang J, Sun Q, Yan C, Wei F, Ren X. Adoptive Cellular Therapy (ACT) for Cancer Treatment. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 909:169-239. [PMID: 27240459 DOI: 10.1007/978-94-017-7555-7_4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Adoptive cellular therapy (ACT) with various lymphocytes or antigen-presenting cells is one stone in the pillar of cancer immunotherapy, which relies on the tumor-specific T cell. The transfusion of bulk T-cell population into patients is an effective treatment for regression of cancer. In this chapter, we summarize the development of various strategies in ACT for cancer immunotherapy and discuss some of the latest progress and obstacles in technical, safety, and even regulatory aspects to translate these technologies to the clinic. ACT is becoming a potentially powerful approach to cancer treatment. Further experiments and clinical trials are needed to optimize this strategy.
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Affiliation(s)
- Fan Yang
- Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China.,Key Laboratory of Cancer Immunology and Biotherapy, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China.,Key Laboratory of Cancer Prevention and Therapy, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China.,Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China
| | - Hao Jin
- Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China.,Key Laboratory of Cancer Immunology and Biotherapy, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China.,Key Laboratory of Cancer Prevention and Therapy, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China
| | - Jian Wang
- Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China.,Key Laboratory of Cancer Immunology and Biotherapy, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China.,Key Laboratory of Cancer Prevention and Therapy, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China
| | - Qian Sun
- Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China.,Key Laboratory of Cancer Immunology and Biotherapy, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China.,Key Laboratory of Cancer Prevention and Therapy, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China
| | - Cihui Yan
- Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China.,Key Laboratory of Cancer Immunology and Biotherapy, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China.,Key Laboratory of Cancer Prevention and Therapy, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China
| | - Feng Wei
- Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China.,Key Laboratory of Cancer Immunology and Biotherapy, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China.,Key Laboratory of Cancer Prevention and Therapy, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China
| | - Xiubao Ren
- Department of Immunology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China. .,Key Laboratory of Cancer Immunology and Biotherapy, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China. .,Key Laboratory of Cancer Prevention and Therapy, Tianjin, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China. .,Department of Biotherapy, Tianjin Medical University Cancer Institute and Hospital, Huanhuxi Road, Tiyuanbei, Hexi District, Tianjin, 300060, Tianjin, China.
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54
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Künkele A, Taraseviciute A, Finn LS, Johnson AJ, Berger C, Finney O, Chang CA, Rolczynski LS, Brown C, Mgebroff S, Berger M, Park JR, Jensen MC. Preclinical Assessment of CD171-Directed CAR T-cell Adoptive Therapy for Childhood Neuroblastoma: CE7 Epitope Target Safety and Product Manufacturing Feasibility. Clin Cancer Res 2016; 23:466-477. [PMID: 27390347 DOI: 10.1158/1078-0432.ccr-16-0354] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 06/13/2016] [Accepted: 06/28/2016] [Indexed: 11/16/2022]
Abstract
PURPOSE The identification and vetting of cell surface tumor-restricted epitopes for chimeric antigen receptor (CAR)-redirected T-cell immunotherapy is the subject of intensive investigation. We have focused on CD171 (L1-CAM), an abundant cell surface molecule on neuroblastomas and, specifically, on the glycosylation-dependent tumor-specific epitope recognized by the CE7 monoclonal antibody. EXPERIMENTAL DESIGN CD171 expression was assessed by IHC using CE7 mAb in tumor microarrays of primary, metastatic, and recurrent neuroblastoma, as well as human and rhesus macaque tissue arrays. The safety of targeting the CE7 epitope of CD171 with CE7-CAR T cells was evaluated in a preclinical rhesus macaque trial on the basis of CD171 homology and CE7 cross reactivity. The feasibility of generating bioactive CAR T cells from heavily pretreated pediatric patients with recurrent/refractory disease was assessed. RESULTS CD171 is uniformly and abundantly expressed by neuroblastoma tumor specimens obtained at diagnoses and relapse independent of patient clinical risk group. CD171 expression in normal tissues is similar in humans and rhesus macaques. Infusion of up to 1 × 108/kg CE7-CAR+ CTLs in rhesus macaques revealed no signs of specific on-target off-tumor toxicity. Manufacturing of lentivirally transduced CD4+ and CD8+ CE7-CAR T-cell products under GMP was successful in 4 out of 5 consecutively enrolled neuroblastoma patients in a phase I study. All four CE7-CAR T-cell products demonstrated in vitro and in vivo antitumor activity. CONCLUSIONS Our preclinical assessment of the CE7 epitope on CD171 supports its utility and safety as a CAR T-cell target for neuroblastoma immunotherapy. Clin Cancer Res; 23(2); 466-77. ©2016 AACR.
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Affiliation(s)
- Annette Künkele
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington
| | - Agne Taraseviciute
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington.,Fred Hutchinson Cancer Research Center, Seattle, Washington.,Seattle Children's Hospital, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Laura S Finn
- Seattle Children's Hospital, Department of Pathology, University of Washington, Seattle, Washington
| | - Adam J Johnson
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington
| | - Carolina Berger
- Fred Hutchinson Cancer Research Center, Seattle, Washington.,Department of Medicine, University of Washington, Seattle, Washington
| | - Olivia Finney
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington
| | - Cindy A Chang
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington
| | - Lisa S Rolczynski
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington
| | - Christopher Brown
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington
| | - Stephanie Mgebroff
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington
| | - Michael Berger
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Julie R Park
- Seattle Children's Hospital, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Michael C Jensen
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington. .,Seattle Children's Hospital, Department of Pediatrics, University of Washington, Seattle, Washington.,University of Washington, Department of Bioengineering, Seattle, Washington
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55
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Patel S, Jones RB, Nixon DF, Bollard CM. T-cell therapies for HIV: Preclinical successes and current clinical strategies. Cytotherapy 2016; 18:931-942. [PMID: 27265874 DOI: 10.1016/j.jcyt.2016.04.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 04/19/2016] [Indexed: 12/21/2022]
Abstract
Although antiretroviral therapy (ART) has been successful in controlling HIV infection, it does not provide a permanent cure, requires lifelong treatment, and HIV-positive individuals are left with social concerns such as stigma. The recent application of T cells to treat cancer and viral reactivations post-transplant offers a potential strategy to control HIV infection. It is known that naturally occurring HIV-specific T cells can inhibit HIV initially, but this response is not sustained in the majority of people living with HIV. Genetically modifying T cells to target HIV, resist infection, and persist in the immunosuppressive environment found in chronically infected HIV-positive individuals might provide a therapeutic solution for HIV. This review focuses on successful preclinical studies and current clinical strategies using T-cell therapy to control HIV infection and mediate a functional cure solution.
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Affiliation(s)
- Shabnum Patel
- Institute for Biomedical Sciences, The George Washington University, Washington, DC, USA; Department of Microbiology, Immunology, and Tropical Medicine, The George Washington University, Washington, DC, USA; Program for Cell Enhancement and Technologies for Immunotherapy, Children's National Health System, Washington, DC, USA
| | - R Brad Jones
- Department of Microbiology, Immunology, and Tropical Medicine, The George Washington University, Washington, DC, USA
| | - Douglas F Nixon
- Department of Microbiology, Immunology, and Tropical Medicine, The George Washington University, Washington, DC, USA
| | - Catherine M Bollard
- Department of Microbiology, Immunology, and Tropical Medicine, The George Washington University, Washington, DC, USA; Program for Cell Enhancement and Technologies for Immunotherapy, Children's National Health System, Washington, DC, USA.
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56
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Paul S, Roy A, Deka SJ, Panda S, Trivedi V, Manna D. Nitrobenzofurazan derivatives of N'-hydroxyamidines as potent inhibitors of indoleamine-2,3-dioxygenase 1. Eur J Med Chem 2016; 121:364-375. [PMID: 27267006 DOI: 10.1016/j.ejmech.2016.05.061] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 11/16/2022]
Abstract
Tryptophan metabolism through the kynurenine pathway is considered as a crucial mechanism in immune tolerance. Indoleamine 2,3-dioxygenase 1 (IDO1) plays a key role in tryptophan catabolism in the immune system and it is also considered as an important therapeutic target for the treatment of cancer and other diseases that are linked with kynurenine pathway. In this study, a series of nitrobenzofurazan derivatives of N'-hydroxybenzimidamides (1) and N'-hydroxy-2-phenylacetimidamides (2) were synthesized and their inhibitory activities against human IDO1 enzyme were tested using in-vitro and cellular enzyme activity assay. The optimization leads to the identification of potent compounds, 1d, 2i and 2k (IC50 = 39-80 nM), which are either competitive or uncompetitive inhibitors of IDO1 enzyme. These compounds also showed IDO1 inhibition potencies in the nanomolar range (IC50 = 50-71 nM) in MDA-MB-231 cells with no/negligible amount of cytotoxicity. The stronger selectivity of the potent compounds for IDO1 enzyme over tryptophan 2,3-dioxygenase (TDO) enzyme (312-1593-fold) also makes them very attractive for further immunotherapeutic applications.
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Affiliation(s)
- Saurav Paul
- Department of Chemistry, Indian Institute of Technology Guwahati, Assam 781039, India
| | - Ashalata Roy
- Department of Chemistry, Indian Institute of Technology Guwahati, Assam 781039, India
| | - Suman Jyoti Deka
- Department of Bioscience and Bioengineering, Indian Institute of Technology Guwahati, Assam 781039, India
| | - Subhankar Panda
- Department of Chemistry, Indian Institute of Technology Guwahati, Assam 781039, India
| | - Vishal Trivedi
- Department of Bioscience and Bioengineering, Indian Institute of Technology Guwahati, Assam 781039, India
| | - Debasis Manna
- Department of Chemistry, Indian Institute of Technology Guwahati, Assam 781039, India.
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57
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Zhang H, Ye ZL, Yuan ZG, Luo ZQ, Jin HJ, Qian QJ. New Strategies for the Treatment of Solid Tumors with CAR-T Cells. Int J Biol Sci 2016; 12:718-29. [PMID: 27194949 PMCID: PMC4870715 DOI: 10.7150/ijbs.14405] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 01/16/2016] [Indexed: 01/11/2023] Open
Abstract
Recent years, we have witnessed significant progresses in both basic and clinical studies regarding novel therapeutic strategies with genetically engineered T cells. Modification with chimeric antigen receptors (CARs) endows T cells with tumor specific cytotoxicity and thus induce anti-tumor immunity against malignancies. However, targeting solid tumors is more challenging than targeting B-cell malignancies with CAR-T cells because of the histopathological structure features, specific antigens shortage and strong immunosuppressive environment of solid tumors. Meanwhile, the on-target/off-tumor toxicity caused by relative expression of target on normal tissues is another issue that should be reckoned. Optimization of the design of CAR vectors, exploration of new targets, addition of safe switches and combination with other treatments bring new vitality to the CAR-T cell based immunotherapy against solid tumors. In this review, we focus on the major obstacles limiting the application of CAR-T cell therapy toward solid tumors and summarize the measures to refine this new cancer therapeutic modality.
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Affiliation(s)
- Hao Zhang
- 1. Laboratory of Viral and Gene Therapy, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai 200438, China
| | - Zhen-Long Ye
- 1. Laboratory of Viral and Gene Therapy, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai 200438, China
| | - Zhen-Gang Yuan
- 1. Laboratory of Viral and Gene Therapy, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai 200438, China
| | - Zheng-Qiang Luo
- 2. Xinyuan Institute of Medicine and Biotechnology College of Life Science, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Hua-Jun Jin
- 1. Laboratory of Viral and Gene Therapy, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai 200438, China
| | - Qi-Jun Qian
- 1. Laboratory of Viral and Gene Therapy, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai 200438, China;; 2. Xinyuan Institute of Medicine and Biotechnology College of Life Science, Zhejiang Sci-Tech University, Hangzhou 310018, China;; 3. Ningbo NO.5 Hospital (Ningbo Cancer Hospital), Ningbo 315201, China
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58
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Abstract
Tumor cells could fundamentally be recognized and eliminated by the immune system but malignant cells are able to escape the immune surveillance system. The idea of immunotherapy of cancer is to activate, modulate and amplify the host immune response or to genetically equip the immune repertoire of patients with anti-tumor specificities and effectors. In recent years, a variety of promising immunotherapy strategies have been developed, such as bispecific, multispecific and immunoregulatory antibodies, gene-modified T lymphocytes and tumor vaccines. Some drugs have already been approved and others are available for patients in clinical trials. This article presents the current anti-tumor immune strategies and their molecular basis. Even though further research is needed in some areas, such as the establishment of biomarkers for targeted therapy, duration of therapeutic activity and compatibility of combined strategies, cancer immunotherapy is likely to be a key component in oncological treatment concepts in the very near future.
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Affiliation(s)
- K Dietrich
- III. Medizinische Klinik und Poliklinik, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland,
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59
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Canter RJ, Grossenbacher SK, Ames E, Murphy WJ. Immune targeting of cancer stem cells in gastrointestinal oncology. J Gastrointest Oncol 2016; 7:S1-S10. [PMID: 27034806 DOI: 10.3978/j.issn.2078-6891.2015.066] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The cancer stem cell (CSC) hypothesis postulates that a sub-population of quiescent cells exist within tumors which are resistant to conventional cytotoxic/anti-proliferative therapies. It is these CSCs which then seed tumor relapse, even in cases of apparent complete response to systemic therapy. Therefore, therapies, such as immunotherapy, which add a specific anti-CSC strategy to standard cytoreductive treatments may provide a promising new direction for future cancer therapies. CSCs are an attractive target for immune therapies since, unlike chemotherapy or radiotherapy, immune effector cells do not specifically require target cells to be proliferating in order to effectively kill them. Although recent advances have been made in the development of novel systemic and targeted therapies for advanced gastro-intestinal (GI) malignancies, there remains an unmet need for durable new therapies for these refractory malignancies. Novel immunotherapeutic strategies targeting CSCs are in pre-clinical and clinical development across the spectrum of the immune system, including strategies utilizing adaptive immune cell-based effectors, innate immune effectors, as well as vaccine approaches. Lastly, since important CSC functions are affected by the tumor microenvironment, targeting of both cellular (myeloid derived suppressor cells and tumor-associated macrophages) and sub-cellular (cytokines, chemokines, and PD1/PDL1) components of the tumor microenvironment is under investigation in the immune targeting of CSCs. These efforts are adding to the significant optimism about the potential utility of immunotherapy to overcome cancer resistance mechanisms and cure greater numbers of patients with advanced malignancy.
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Affiliation(s)
- Robert J Canter
- 1 Division of Surgical Oncology, Department of Surgery, 2 Laboratory of Cancer Immunology, Department of Dermatology, 3 Department of Dermatology, University of California Davis School of Medicine, Sacramento, CA 95817, USA
| | - Steven K Grossenbacher
- 1 Division of Surgical Oncology, Department of Surgery, 2 Laboratory of Cancer Immunology, Department of Dermatology, 3 Department of Dermatology, University of California Davis School of Medicine, Sacramento, CA 95817, USA
| | - Erik Ames
- 1 Division of Surgical Oncology, Department of Surgery, 2 Laboratory of Cancer Immunology, Department of Dermatology, 3 Department of Dermatology, University of California Davis School of Medicine, Sacramento, CA 95817, USA
| | - William J Murphy
- 1 Division of Surgical Oncology, Department of Surgery, 2 Laboratory of Cancer Immunology, Department of Dermatology, 3 Department of Dermatology, University of California Davis School of Medicine, Sacramento, CA 95817, USA
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60
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Maus MV, Levine BL. Chimeric Antigen Receptor T-Cell Therapy for the Community Oncologist. Oncologist 2016; 21:608-17. [PMID: 27009942 DOI: 10.1634/theoncologist.2015-0421] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 01/27/2016] [Indexed: 12/31/2022] Open
Abstract
UNLABELLED : The field of cancer immunotherapy has rapidly progressed in the past decade as several therapeutic modalities have entered into the clinic. One such immunotherapy that has shown promise in the treatment of cancer is the use of chimeric antigen receptor (CAR)-modified T lymphocytes. CARs are engineered receptors constructed from antigen recognition regions of antibodies fused to T-cell signaling and costimulatory domains that can be used to reprogram a patient's T cells to specifically target tumor cells. CAR T-cell therapy has demonstrated sustained complete responses for some patients with advanced leukemia, and a number of CAR therapies are being evaluated in clinical studies. CAR T-cell therapy-associated toxicities, including cytokine release syndrome, macrophage activation syndrome, and tumor lysis syndrome, have been observed and effectively managed in the clinic. In patients with significant clinical responses, sustained B-cell aplasia has also been observed and is a marker of CAR T-cell persistence that might provide long-term disease control. Education on CAR T-cell therapy efficacy and safety management is critical for clinicians and patients who are considering this novel type of treatment. In the present report, the current landscape of CAR T-cell therapy, the effective management of patients undergoing treatment, and which patients are the most suitable candidates for current trials are discussed. IMPLICATIONS FOR PRACTICE The present report describes the current status of chimeric antigen receptor (CAR) T lymphocytes as an immunotherapy for patients with relapsed or refractory B-cell malignancies. CAR T cells targeting CD19, a protein expressed on many B-cell malignancies, typically induce high complete response rates in patients with B-cell leukemia or lymphoma who have very limited therapeutic options. Recent clinical trial results of CD19 CAR T-cell therapies and the management of CAR T-cell-associated adverse events are discussed. The present report will therefore inform physicians regarding the efficacy and safety of CAR T cells as a therapy for B-cell malignancies.
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Affiliation(s)
- Marcela V Maus
- Cellular Immunotherapy Program, Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bruce L Levine
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, Pennsylvania, USA Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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61
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Kim MG, Kim D, Suh SK, Park Z, Choi MJ, Oh YK. Current status and regulatory perspective of chimeric antigen receptor-modified T cell therapeutics. Arch Pharm Res 2016; 39:437-452. [DOI: 10.1007/s12272-016-0719-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 02/04/2016] [Indexed: 10/22/2022]
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62
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Weinmann H. Cancer Immunotherapy: Selected Targets and Small-Molecule Modulators. ChemMedChem 2016; 11:450-66. [PMID: 26836578 DOI: 10.1002/cmdc.201500566] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 01/13/2016] [Indexed: 01/01/2023]
Abstract
There is a significant amount of excitement in the scientific community around cancer immunotherapy, as this approach has renewed hope for many cancer patients owing to some recent successes in the clinic. Currently available immuno-oncology therapeutics under clinical development and on the market are mostly biologics (antibodies, proteins, engineered cells, and oncolytic viruses). However, modulation of the immune system with small molecules offers several advantages that may be complementary and potentially synergistic to the use of large biologicals. Therefore, the discovery and development of novel small-molecule modulators is a rapidly growing research area for medicinal chemists working in cancer immunotherapy. This review provides a brief introduction into recent trends related to selected targets and pathways for cancer immunotherapy and their small-molecule pharmacological modulators.
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Affiliation(s)
- Hilmar Weinmann
- Bayer Pharma AG, Drug Discovery, Medicinal Chemistry Berlin, Muellerstrasse 178, 13353, Berlin, Germany.
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63
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Tsai AK, Davila E. Producer T cells: Using genetically engineered T cells as vehicles to generate and deliver therapeutics to tumors. Oncoimmunology 2016; 5:e1122158. [PMID: 27467930 PMCID: PMC4910704 DOI: 10.1080/2162402x.2015.1122158] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 11/11/2015] [Accepted: 11/14/2015] [Indexed: 12/27/2022] Open
Abstract
Adoptive cell transfer (ACT) is an emerging anticancer therapy that has shown promise in various malignancies. Redirecting antigen specificity by genetically engineering T cells to stably express receptors has become an effective variant of ACT. A novel extension of this approach is to utilize engineered T cells to produce and deliver anticancer therapeutics that enhance cytotoxic T cell function and simultaneously inhibit immunosuppressive processes. Here, we review the potential of using T cells as therapeutic-secreting vehicles for immunotherapies and present theoretical and established arguments in support of further development of this unique cell-based immunotherapy.
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Affiliation(s)
- Alexander K Tsai
- Marlene and Stewart Greenebaum Cancer Center, University of Maryland , Baltimore, Baltimore, MD, USA
| | - Eduardo Davila
- Marlene and Stewart Greenebaum Cancer Center, University of Maryland, Baltimore, Baltimore, MD, USA; Department of Microbiology and Immunology, University of Maryland, Baltimore, Baltimore, MD, USA
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64
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Gorczynski RM, Erin N, Zhu F. Serum-derived exosomes from mice with highly metastatic breast cancer transfer increased metastatic capacity to a poorly metastatic tumor. Cancer Med 2016; 5:325-36. [PMID: 26725371 PMCID: PMC4735763 DOI: 10.1002/cam4.575] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 09/09/2015] [Accepted: 10/05/2015] [Indexed: 12/12/2022] Open
Abstract
Altered interaction between CD200 and CD200R represents an example of “checkpoint blockade” disrupting an effective, tumor‐directed, host response in murine breast cancer cells. In CD200R1KO mice, long‐term cure of EMT6 breast cancer, including metastatic spread to lung and liver, was achieved in BALB/c mice. The reverse was observed with 4THM tumors, an aggressive, inflammatory breast cancer, with increased tumor metastasis in CD200R1KO. We explored possible explanations for this difference. We measured the frequency of circulating tumor cells (CTCs) in peripheral blood of tumor bearers, as well as lung/liver and draining lymph nodes. In some cases mice received infusions of exosomes from nontumor controls, or tumor bearers, with/without additional infusions of anticytokine antibodies. The measured frequency of circulating tumor cells (CTCs) in peripheral blood was equivalent in the two models in WT and CD200R1KO mice. Increased metastasis in EMT6 tumor bearers was seen in vivo following adoptive transfer of serum, or serum‐derived exosomes, from 4THM tumor bearers, an effect which was attenuated by anti‐IL‐6, and anti‐IL‐17, but not anti‐TNFα, antibody. Anti‐IL‐6 also attenuated enhanced migration of EMT6 cells in vitro induced by 4THM serum or exosomes, or recombinant IL‐6. Exosome cytokine proteomic profiles responses in 4THM and EMT6 tumor‐bearing mice were regulated by CD200:CD200R interactions, with attenuation of both IL‐6 and IL‐17 in 4THM CD200tg mice, and enhanced levels in 4THM CD200R1KO mice. We suggest these cytokines act on the microenvironment at sites within the host, and/or directly on tumor cells themselves, to increase metastatic potential.
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Affiliation(s)
- Reginald M Gorczynski
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Faculty of Medicine, Department of Immunology, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Nuray Erin
- Department of Medical Pharmacology, School of Medicine, Akdeniz University, Antalya, Turkey
| | - Fang Zhu
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Makkouk A, Chester C, Kohrt HE. Rationale for anti-CD137 cancer immunotherapy. Eur J Cancer 2016; 54:112-119. [PMID: 26751393 DOI: 10.1016/j.ejca.2015.09.026] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 09/21/2015] [Accepted: 09/21/2015] [Indexed: 11/29/2022]
Abstract
The consideration of the complex interplay between the tumour microenvironment (TME) and the immune response is the key for designing effective immunotherapies. Therapeutic strategies that harness co-stimulatory receptors have recently gained momentum in the clinic. One such strategy with promising clinical applications is the targeting of CD137, a member of the tumour necrosis factor receptor superfamily. Its expression on both innate and adaptive immune cells, coupled with its unique ability to potentiate antitumour responses through modulating the TME and to ameliorate autoimmune responses, has established it as an appealing target. In this review, we will discuss the various CD137-targeted immunotherapeutics that have reached clinical development, with a focus on recent advances and novel modalities such as CD137 chimeric antigen receptors and CD137 bispecific antibodies. We will also highlight the effect of CD137 targeting on the TME and discuss the importance of probing TME changes for predicting and testing the efficacy of CD137-mediated immunotherapy.
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Affiliation(s)
- Amani Makkouk
- Department of Medicine, Division of Oncology, Stanford University, Stanford, CA 94305 USA
| | - Cariad Chester
- Department of Medicine, Division of Oncology, Stanford University, Stanford, CA 94305 USA; Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford, CA 94305 USA
| | - Holbrook E Kohrt
- Department of Medicine, Division of Oncology, Stanford University, Stanford, CA 94305 USA.
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66
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Hammill JA, VanSeggelen H, Helsen CW, Denisova GF, Evelegh C, Tantalo DGM, Bassett JD, Bramson JL. Designed ankyrin repeat proteins are effective targeting elements for chimeric antigen receptors. J Immunother Cancer 2015; 3:55. [PMID: 26673402 PMCID: PMC4678647 DOI: 10.1186/s40425-015-0099-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 10/23/2015] [Indexed: 11/29/2022] Open
Abstract
Background Adoptive cell transfer of tumor-specific T lymphocytes (T cells) is proving to be an effective strategy for treating established tumors in cancer patients. One method of generating these cells is accomplished through engineering bulk T cell populations to express chimeric antigen receptors (CARs), which are specific for tumor antigens. Traditionally, these CARs are targeted against tumor antigens using single-chain antibodies (scFv). Here we describe the use of a designed ankyrin repeat protein (DARPin) as the tumor-antigen targeting domain. Methods We prepared second generation anti-HER2 CARs that were targeted to the tumor antigen by either a DARPin or scFv. The CARs were engineered into human and murine T cells. We then compared the ability of CARs to trigger cytokine production, degranulation and cytotoxicity. Results The DARPin CARs displayed reduced surface expression relative to scFv CARs in murine cells but both CARs were expressed equally well on human T cells, suggesting that there may be a processing issue with the murine variants. In both the murine and human systems, the DARPin CARs were found to be highly functional, triggering cytokine and cytotoxic responses that were similar to those triggered by the scFv CARs. Conclusions These findings demonstrate the utility of DARPins as CAR-targeting agents and open up an avenue for the generation of CARs with novel antigen binding attributes.
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Affiliation(s)
- Joanne A Hammill
- Department Pathology and Molecular Medicine, McMaster Immunology Research Centre, McMaster University, Hamilton, ON Canada
| | - Heather VanSeggelen
- Department Pathology and Molecular Medicine, McMaster Immunology Research Centre, McMaster University, Hamilton, ON Canada
| | - Christopher W Helsen
- Department Pathology and Molecular Medicine, McMaster Immunology Research Centre, McMaster University, Hamilton, ON Canada
| | - Galina F Denisova
- Department Pathology and Molecular Medicine, McMaster Immunology Research Centre, McMaster University, Hamilton, ON Canada
| | - Carole Evelegh
- Department Pathology and Molecular Medicine, McMaster Immunology Research Centre, McMaster University, Hamilton, ON Canada
| | - Daniela G M Tantalo
- Department Pathology and Molecular Medicine, McMaster Immunology Research Centre, McMaster University, Hamilton, ON Canada
| | - Jennifer D Bassett
- Department Pathology and Molecular Medicine, McMaster Immunology Research Centre, McMaster University, Hamilton, ON Canada
| | - Jonathan L Bramson
- Department Pathology and Molecular Medicine, McMaster Immunology Research Centre, McMaster University, Hamilton, ON Canada
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Strategies and Advancements in Harnessing the Immune System for Gastric Cancer Immunotherapy. J Immunol Res 2015; 2015:308574. [PMID: 26579545 PMCID: PMC4633567 DOI: 10.1155/2015/308574] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 10/05/2015] [Indexed: 12/12/2022] Open
Abstract
In cancer biology, cells and molecules that form the fundamental components of the tumor microenvironment play a major role in tumor initiation, and progression as well as responses to therapy. Therapeutic approaches that would enable and harness the immune system to target tumor cells mark the future of anticancer therapy as it could induce an immunological memory specific to the tumor type and further enhance tumor regression and relapse-free survival in cancer patients. Gastric cancer is one of the leading causes of cancer-related mortalities that has a modest survival benefit from existing treatment options. The advent of immunotherapy presents us with new approaches in gastric cancer treatment where adaptive cell therapies, cancer vaccines, and antibody therapies have all been used with promising outcomes. In this paper, we review the current advances and prospects in the gastric cancer immunotherapy. Special focus is laid on new strategies and clinical trials that attempt to enhance the efficacy of various immunotherapeutic modalities in gastric cancer.
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Regan D, Guth A, Coy J, Dow S. Cancer immunotherapy in veterinary medicine: Current options and new developments. Vet J 2015; 207:20-28. [PMID: 26545847 DOI: 10.1016/j.tvjl.2015.10.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 09/24/2015] [Accepted: 10/04/2015] [Indexed: 12/12/2022]
Abstract
Excitement in the field of tumor immunotherapy is being driven by several remarkable breakthroughs in recent years. This review will cover recent advances in cancer immunotherapy, including the use of T cell checkpoint inhibitors, engineered T cells, cancer vaccines, and anti-B cell and T cell antibodies. Inhibition of T cell checkpoint molecules such as PD-1 and CTLA-4 using monoclonal antibodies has achieved notable success against advanced tumors in humans, including melanoma, renal cell carcinoma, and non-small cell lung cancer. Therapy with engineered T cells has also demonstrated remarkable tumor control and regression in human trials. Autologous cancer vaccines have recently demonstrated impressive prolongation of disease-free intervals and survival times in dogs with lymphoma. In addition, caninized monoclonal antibodies targeting CD20 and CD52 just recently received either full (CD20) or conditional (CD52) licensing by the United States Department of Agriculture for clinical use in the treatment of canine B-cell and T-cell lymphomas, respectively. Thus, immunotherapy for cancer is rapidly moving to the forefront of cancer treatment options in veterinary medicine as well as human medicine.
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Affiliation(s)
- Daniel Regan
- Animal Cancer Center, Department of Clinical Sciences, Colorado State University, Ft. Collins, CO 80523, USA
| | - Amanda Guth
- Animal Cancer Center, Department of Clinical Sciences, Colorado State University, Ft. Collins, CO 80523, USA
| | - Jonathan Coy
- Animal Cancer Center, Department of Clinical Sciences, Colorado State University, Ft. Collins, CO 80523, USA
| | - Steven Dow
- Animal Cancer Center, Department of Clinical Sciences, Colorado State University, Ft. Collins, CO 80523, USA.
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Targeted Therapy in Oropharyngeal Squamous Cell Carcinoma: The Implications of HPV for Therapy. ACTA ACUST UNITED AC 2015; 3:89-117. [PMID: 27182480 PMCID: PMC4837939 DOI: 10.1007/s40487-015-0008-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Indexed: 12/13/2022]
Abstract
Oropharyngeal cancers caused by human papillomaviruses (HPV) have a different epidemiology, prognosis, genetic mutational landscape, response to treatment, and outcome when compared to HPV-negative cancers. In this review, a summary of our current understanding of HPV in head and neck cancer and the important advances that have shown HPV to be an etiological agent are discussed. HPV-positive and HPV-negative tumors are compared discussing clinicopathological factors, prognosis, outcome following treatment, and the molecular and genetic differences. Currently, the standard of care for oropharyngeal cancer is both surgery and post-operative radiotherapy with or without cisplatin or concurrent chemo-radiotherapy. The latter is used more often, especially in cancers of tonsil and base of tongue. However, there is increased interest in trying to de-intensify treatment and in the development of new treatments to target the underlying different molecular pathways of HPV-positive cancers. The current clinical trials involving surgery, chemotherapy, and radiation therapy are discussed. The new targeted treatments are also summarized. Although there is currently is no evidence from prospective studies to support a change in the treatment algorithm, the treatment options for patients with HPV-positive disease are likely to change in the future.
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Transgene integration into the human AAVS1 locus enhances myosin II-dependent contractile force by reducing expression of myosin binding subunit 85. Biochem Biophys Res Commun 2015; 465:270-4. [PMID: 26260320 DOI: 10.1016/j.bbrc.2015.08.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 08/04/2015] [Indexed: 12/12/2022]
Abstract
The adeno-associated virus site 1 (AAVS1) locus in the human genome is a strong candidate for gene therapy by insertion of an exogenous gene into the locus. The AAVS1 locus includes the coding region for myosin binding subunit 85 (MBS85). Although the function of MBS85 is not well understood, myosin II-dependent contractile force may be affected by altered expression of MBS85. The effect of altered expression of MBS85 on cellular contractile force should be examined prior to the application of gene therapy. In this study, we show that transgene integration into AAVS1 and consequent reduction of MBS85 expression changes myosin II-dependent cellular contractile force. We established a human fibroblast cell line with exogenous DNA knocked-in to AAVS1 (KI cells) using the CRISPR/Cas9 genome editing system. Western blotting analysis showed that KI cells had significantly reduced MBS85 expression. KI cells also showed greater cellular contractile force than control cells. The increased contractile force was associated with phosphorylation of the myosin II regulatory light chain (MRLC). Transfection of KI cells with an MBS85 expression plasmid restored cellular contractile force and phosphorylation of MRLC to the levels in control cells. These data suggest that transgene integration into the human AAVS1 locus induces an increase in cellular contractile force and thus should be considered as a gene therapy to effect changes in cellular contractile force.
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Abstract
The potential to harness the power of the immune system and effectively treat patients with metastatic melanoma is finally being realized with the advent of immune checkpoint inhibitors. These new therapies herald a new era in the treatment of melanoma with the potential to produce very durable responses and possible cure for a subset of patients, though bring with them challenges including novel toxicities and nonconventional response patterns. This article reviews the currently available immune checkpoint inhibitors, potential biomarkers to predict response and promising investigational approaches including combination therapies.
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Affiliation(s)
- Adam J Cooper
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, NSW, Australia
- School of Medicine, The University of Sydney, Sydney, NSW, Australia
- Melanoma Institute Australia, Sydney, NSW, Australia
| | - Matteo S Carlino
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, NSW, Australia
- School of Medicine, The University of Sydney, Sydney, NSW, Australia
- Melanoma Institute Australia, Sydney, NSW, Australia
- Westmead Institute for Cancer Research, University of Sydney at the Westmead Millennium Institute, Westmead, NSW, Australia
| | - Richard F Kefford
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, NSW, Australia
- School of Medicine, The University of Sydney, Sydney, NSW, Australia
- Melanoma Institute Australia, Sydney, NSW, Australia
- Westmead Institute for Cancer Research, University of Sydney at the Westmead Millennium Institute, Westmead, NSW, Australia
- Department of Clinical Medicine, Macquarie University, Sydney, NSW, Australia
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Generation of MANAbodies specific to HLA-restricted epitopes encoded by somatically mutated genes. Proc Natl Acad Sci U S A 2015. [PMID: 26216968 DOI: 10.1073/pnas.1511996112] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Mutant epitopes encoded by cancer genes are virtually always located in the interior of cells, making them invisible to conventional antibodies. We here describe an approach to identify single-chain variable fragments (scFvs) specific for mutant peptides presented on the cell surface by HLA molecules. We demonstrate that these scFvs can be successfully converted to full-length antibodies, termed MANAbodies, targeting "Mutation-Associated Neo-Antigens" bound to HLA. A phage display library representing a highly diverse array of single-chain variable fragment sequences was first designed and constructed. A competitive selection protocol was then used to identify clones specific for mutant peptides bound to predefined HLA types. In this way, we obtained two scFvs, one specific for a peptide encoded by a common KRAS mutant and the other by a common epidermal growth factor receptor (EGFR) mutant. The scFvs bound to these peptides only when the peptides were complexed with HLA-A2 (KRAS peptide) or HLA-A3 (EGFR peptide). We converted one scFv to a full-length antibody (MANAbody) and demonstrate that the MANAbody specifically reacts with mutant peptide-HLA complex even when the peptide differs by only one amino acid from the normal, WT form.
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Andrijauskaite K, Suriano S, Cloud CA, Li M, Kesarwani P, Stefanik LS, Moxley KM, Salem ML, Garrett-Mayer E, Paulos CM, Mehrotra S, Kochenderfer JN, Cole DJ, Rubinstein MP. IL-12 conditioning improves retrovirally mediated transduction efficiency of CD8+ T cells. Cancer Gene Ther 2015; 22:360-7. [PMID: 26182912 PMCID: PMC4807400 DOI: 10.1038/cgt.2015.28] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 01/10/2015] [Accepted: 05/20/2015] [Indexed: 02/07/2023]
Abstract
The ability to genetically modify T cells is a critical component to many immunotherapeutic strategies and research studies. However, the success of these approaches is often limited by transduction efficiency. As retroviral vectors require cell division for integration, transduction efficiency is dependent on the appropriate activation and culture conditions for T cells. Naive CD8(+) T cells, which are quiescent, must be first activated to induce cell division to allow genetic modification. To optimize this process, we activated mouse T cells with a panel of different cytokines, including interleukin-2 (IL-2), IL-4, IL-6, IL-7, IL-12, IL-15 and IL-23, known to act on T cells. After activation, cytokines were removed, and activated T cells were retrovirally transduced. We found that IL-12 preconditioning of mouse T cells greatly enhanced transduction efficiency, while preserving function and expansion potential. We also observed a similar transduction-enhancing effect of IL-12 preconditioning on human T cells. These findings provide a simple method to improve the transduction efficiencies of CD8(+) T cells.
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Affiliation(s)
| | - Samantha Suriano
- Department of Surgery, Medical University of South Carolina, Charleston SC 29425
| | - Colleen A. Cloud
- Department of Surgery, Medical University of South Carolina, Charleston SC 29425
| | - Mingli Li
- Department of Surgery, Medical University of South Carolina, Charleston SC 29425
| | - Pravin Kesarwani
- Department of Surgery, Medical University of South Carolina, Charleston SC 29425
| | - Leah S. Stefanik
- Department of Microbiology & Immunology, Medical University of South Carolina, Charleston SC 29425
| | | | - Mohamed L Salem
- Immunology & Biotechnology Division, Tanta University, Egypt
| | | | - Chrystal M. Paulos
- Department of Surgery, Medical University of South Carolina, Charleston SC 29425
- Department of Microbiology & Immunology, Medical University of South Carolina, Charleston SC 29425
| | - Shikhar Mehrotra
- Department of Surgery, Medical University of South Carolina, Charleston SC 29425
- Department of Microbiology & Immunology, Medical University of South Carolina, Charleston SC 29425
| | - James N. Kochenderfer
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892
| | - David J. Cole
- Department of Surgery, Medical University of South Carolina, Charleston SC 29425
- Department of Microbiology & Immunology, Medical University of South Carolina, Charleston SC 29425
| | - Mark P. Rubinstein
- Department of Surgery, Medical University of South Carolina, Charleston SC 29425
- Department of Microbiology & Immunology, Medical University of South Carolina, Charleston SC 29425
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Klausen MS, Anderson MV, Jespersen MC, Nielsen M, Marcatili P. LYRA, a webserver for lymphocyte receptor structural modeling. Nucleic Acids Res 2015; 43:W349-55. [PMID: 26007650 PMCID: PMC4489227 DOI: 10.1093/nar/gkv535] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 05/09/2015] [Indexed: 01/22/2023] Open
Abstract
The accurate structural modeling of B- and T-cell receptors is fundamental to gain a detailed insight in the mechanisms underlying immunity and in developing new drugs and therapies. The LYRA (LYmphocyte Receptor Automated modeling) web server (http://www.cbs.dtu.dk/services/LYRA/) implements a complete and automated method for building of B- and T-cell receptor structural models starting from their amino acid sequence alone. The webserver is freely available and easy to use for non-specialists. Upon submission, LYRA automatically generates alignments using ad hoc profiles, predicts the structural class of each hypervariable loop, selects the best templates in an automatic fashion, and provides within minutes a complete 3D model that can be downloaded or inspected online. Experienced users can manually select or exclude template structures according to case specific information. LYRA is based on the canonical structure method, that in the last 30 years has been successfully used to generate antibody models of high accuracy, and in our benchmarks this approach proves to achieve similarly good results on TCR modeling, with a benchmarked average RMSD accuracy of 1.29 and 1.48 Å for B- and T-cell receptors, respectively. To the best of our knowledge, LYRA is the first automated server for the prediction of TCR structure.
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Affiliation(s)
- Michael Schantz Klausen
- Center for Biological Sequence Analysis, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Mads Valdemar Anderson
- Center for Biological Sequence Analysis, Technical University of Denmark, Kgs. Lyngby, Denmark
| | | | - Morten Nielsen
- Center for Biological Sequence Analysis, Technical University of Denmark, Kgs. Lyngby, Denmark Instituto de Investigaciones Biotecnológicas, Universidad Nacional de San Martín, Buenos Aires, Argentina
| | - Paolo Marcatili
- Center for Biological Sequence Analysis, Technical University of Denmark, Kgs. Lyngby, Denmark
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Petrioli R, Francini E, Fiaschi AI, Laera L, Roviello G. Targeted Therapies for Prostate Cancer. Cancer Invest 2015; 33:276-85. [DOI: 10.3109/07357907.2015.1033105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Aranda F, Buqué A, Bloy N, Castoldi F, Eggermont A, Cremer I, Fridman WH, Fucikova J, Galon J, Spisek R, Tartour E, Zitvogel L, Kroemer G, Galluzzi L. Trial Watch: Adoptive cell transfer for oncological indications. Oncoimmunology 2015; 4:e1046673. [PMID: 26451319 DOI: 10.1080/2162402x.2015.1046673] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 04/25/2015] [Indexed: 12/15/2022] Open
Abstract
One particular paradigm of anticancer immunotherapy relies on the administration of (potentially) tumor-reactive immune effector cells. Generally, these cells are obtained from autologous peripheral blood lymphocytes (PBLs) ex vivo (in the context of appropriate expansion, activation and targeting protocols), and re-infused into lymphodepleted patients along with immunostimulatory agents. In spite of the consistent progress achieved throughout the past two decades in this field, no adoptive cell transfer (ACT)-based immunotherapeutic regimen is currently approved by regulatory agencies for use in cancer patients. Nonetheless, the interest of oncologists in ACT-based immunotherapy continues to increase. Accumulating clinical evidence indicates indeed that specific paradigms of ACT, such as the infusion of chimeric antigen receptor (CAR)-expressing autologous T cells, are associated with elevated rates of durable responses in patients affected by various neoplasms. In line with this notion, clinical trials investigating the safety and therapeutic activity of ACT in cancer patients are being initiated at an ever increasing pace. Here, we review recent preclinical and clinical advances in the development of ACT-based immunotherapy for oncological indications.
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Affiliation(s)
- Fernando Aranda
- Group of Immune Receptors of the Innate and Adaptive System; Institut d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS) ; Barcelona, Spain
| | - Aitziber Buqué
- Gustave Roussy Cancer Campus ; Villejuif, France ; INSERM; U1138 ; Paris, France ; Equipe 11 labellisée par la Ligue Nationale contre le Cancer; Centre de Recherche des Cordeliers ; Paris, France
| | - Norma Bloy
- Gustave Roussy Cancer Campus ; Villejuif, France ; INSERM; U1138 ; Paris, France ; Equipe 11 labellisée par la Ligue Nationale contre le Cancer; Centre de Recherche des Cordeliers ; Paris, France
| | - Francesca Castoldi
- INSERM; U1138 ; Paris, France ; Equipe 11 labellisée par la Ligue Nationale contre le Cancer; Centre de Recherche des Cordeliers ; Paris, France ; Faculté de Medicine; Université Paris Sud/Paris XI ; Le Kremlin-Bicêtre, France ; Sotio a.c. ; Prague, Czech Republic
| | | | - Isabelle Cremer
- INSERM; U1138 ; Paris, France ; Equipe 13; Centre de Recherche des Cordeliers ; Paris, France ; Université Pierre et Marie Curie/Paris VI ; Paris, France
| | - Wolf Hervé Fridman
- INSERM; U1138 ; Paris, France ; Equipe 13; Centre de Recherche des Cordeliers ; Paris, France ; Université Pierre et Marie Curie/Paris VI ; Paris, France
| | - Jitka Fucikova
- Sotio a.c. ; Prague, Czech Republic ; Dept. of Immunology; 2nd Faculty of Medicine and University Hospital Motol; Charles University ; Prague, Czech Republic
| | - Jérôme Galon
- INSERM; U1138 ; Paris, France ; Université Pierre et Marie Curie/Paris VI ; Paris, France ; Laboratory of Integrative Cancer Immunology; Centre de Recherche des Cordeliers ; Paris, France ; Université Paris Descartes/Paris V , Sorbonne Paris Cité , Paris, France
| | - Radek Spisek
- Sotio a.c. ; Prague, Czech Republic ; Dept. of Immunology; 2nd Faculty of Medicine and University Hospital Motol; Charles University ; Prague, Czech Republic
| | - Eric Tartour
- Université Paris Descartes/Paris V , Sorbonne Paris Cité , Paris, France ; INSERM; U970 ; Paris, France ; Paris-Cardiovascular Research Center (PARCC) ; Paris, France ; Service d'Immunologie Biologique; Hôpital Européen Georges Pompidou (HEGP); AP-HP ; Paris, France
| | - Laurence Zitvogel
- Gustave Roussy Cancer Campus ; Villejuif, France ; INSERM; U1015; CICBT507 ; Villejuif, France
| | - Guido Kroemer
- INSERM; U1138 ; Paris, France ; Equipe 11 labellisée par la Ligue Nationale contre le Cancer; Centre de Recherche des Cordeliers ; Paris, France ; Université Pierre et Marie Curie/Paris VI ; Paris, France ; Université Paris Descartes/Paris V , Sorbonne Paris Cité , Paris, France ; Pôle de Biologie; Hôpital Européen Georges Pompidou; AP-HP ; Paris, France ; Metabolomics and Cell Biology Platforms; Gustave Roussy Cancer Campus ; Villejuif, France
| | - Lorenzo Galluzzi
- Gustave Roussy Cancer Campus ; Villejuif, France ; INSERM; U1138 ; Paris, France ; Equipe 11 labellisée par la Ligue Nationale contre le Cancer; Centre de Recherche des Cordeliers ; Paris, France ; Université Pierre et Marie Curie/Paris VI ; Paris, France ; Université Paris Descartes/Paris V , Sorbonne Paris Cité , Paris, France
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Greco R, Oliveira G, Stanghellini MTL, Vago L, Bondanza A, Peccatori J, Cieri N, Marktel S, Mastaglio S, Bordignon C, Bonini C, Ciceri F. Improving the safety of cell therapy with the TK-suicide gene. Front Pharmacol 2015; 6:95. [PMID: 25999859 PMCID: PMC4419602 DOI: 10.3389/fphar.2015.00095] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 04/17/2015] [Indexed: 01/07/2023] Open
Abstract
While opening new frontiers for the cure of malignant and non-malignant diseases, the increasing use of cell therapy poses also several new challenges related to the safety of a living drug. The most effective and consolidated cell therapy approach is allogeneic hematopoietic stem cell transplantation (HSCT), the only cure for several patients with high-risk hematological malignancies. The potential of allogeneic HSCT is strictly dependent on the donor immune system, particularly on alloreactive T lymphocytes, that promote the beneficial graft-versus-tumor effect (GvT), but may also trigger the detrimental graft-versus-host-disease (GvHD). Gene transfer technologies allow to manipulate donor T-cells to enforce GvT and foster immune reconstitution, while avoiding or controlling GvHD. The suicide gene approach is based on the transfer of a suicide gene into donor lymphocytes, for a safe infusion of a wide T-cell repertoire, that might be selectively controlled in vivo in case of GvHD. The herpes simplex virus thymidine kinase (HSV-TK) is the suicide gene most extensively tested in humans. Expression of HSV-TK in donor lymphocytes confers lethal sensitivity to the anti-herpes drug, ganciclovir. Progressive improvements in suicide genes, vector technology and transduction protocols have allowed to overcome the toxicity of GvHD while preserving the antitumor efficacy of allogeneic HSCT. Several phase I-II clinical trials in the last 20 years document the safety and the efficacy of HSV-TK approach, able to maintain its clear value over the last decades, in the rapidly progressing horizon of cancer cellular therapy.
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Affiliation(s)
- Raffaella Greco
- Unit of Hematology and Bone Marrow Transplantation, Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan Italy
| | - Giacomo Oliveira
- Experimental Hematology Unit, Division of Immunology, Transplantation and Infectious Diseases, Program in Immunology and Bio-immunotherapy of Cancer, IRCCS San Raffaele Scientific Institute, Milan Italy
| | - Maria Teresa Lupo Stanghellini
- Unit of Hematology and Bone Marrow Transplantation, Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan Italy
| | - Luca Vago
- Unit of Hematology and Bone Marrow Transplantation, Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan Italy ; Unit of Molecular and Functional Immunogenetics, Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan Italy
| | - Attilio Bondanza
- Leukemia Immunotherapy Unit, Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan Italy
| | - Jacopo Peccatori
- Unit of Hematology and Bone Marrow Transplantation, Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan Italy
| | - Nicoletta Cieri
- Experimental Hematology Unit, Division of Immunology, Transplantation and Infectious Diseases, Program in Immunology and Bio-immunotherapy of Cancer, IRCCS San Raffaele Scientific Institute, Milan Italy
| | - Sarah Marktel
- Unit of Hematology and Bone Marrow Transplantation, Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan Italy
| | - Sara Mastaglio
- Experimental Hematology Unit, Division of Immunology, Transplantation and Infectious Diseases, Program in Immunology and Bio-immunotherapy of Cancer, IRCCS San Raffaele Scientific Institute, Milan Italy
| | | | - Chiara Bonini
- Experimental Hematology Unit, Division of Immunology, Transplantation and Infectious Diseases, Program in Immunology and Bio-immunotherapy of Cancer, IRCCS San Raffaele Scientific Institute, Milan Italy
| | - Fabio Ciceri
- Unit of Hematology and Bone Marrow Transplantation, Division of Regenerative Medicine, Stem Cells and Gene Therapy, IRCCS San Raffaele Scientific Institute, Milan Italy
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Gilham DE, Anderson J, Bridgeman JS, Hawkins RE, Exley MA, Stauss H, Maher J, Pule M, Sewell AK, Bendle G, Lee S, Qasim W, Thrasher A, Morris E. Adoptive T-cell therapy for cancer in the United kingdom: a review of activity for the British Society of Gene and Cell Therapy annual meeting 2015. Hum Gene Ther 2015; 26:276-85. [PMID: 25860661 PMCID: PMC4442586 DOI: 10.1089/hum.2015.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 03/31/2015] [Indexed: 12/25/2022] Open
Abstract
Adoptive T-cell therapy is delivering objective clinical responses across a number of cancer indications in the early phase clinical setting. Much of this clinical activity is taking place at major clinical academic centers across the United States. This review focuses upon cancer-focused cell therapy activity within the United Kingdom as a contribution to the 2015 British Society of Gene and Cell Therapy annual general meeting. This overview reflects the diversity and expansion of clinical and preclinical studies within the United Kingdom while considering the background context of this work against new infrastructural developments and the requirements of nationalized healthcare delivery within the UK National Health Service.
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Affiliation(s)
- David Edward Gilham
- Clinical and Experimental Immunotherapy Group, Institute of Cancer Sciences, The University of Manchester, Manchester M20 4BX, United Kingdom
| | - John Anderson
- UCL Institute of Child Health, London WC1N 1EH, United Kingdom
| | | | - Robert Edward Hawkins
- Clinical and Experimental Immunotherapy Group, Institute of Cancer Sciences, The University of Manchester, Manchester M20 4BX, United Kingdom
- Cellular Therapeutics Ltd., UMIC Bio-incubator, Manchester M13 9XX, United Kingdom
| | - Mark Adrian Exley
- MCCIR, Faculty of Medicine, The University of Manchester, Manchester M13 9NT, United Kingdom
| | - Hans Stauss
- Department of Immunology, University College London, Royal Free Hospital, London NW3 2PF, United Kingdom
| | - John Maher
- Department of Research Oncology, Bermondsey Wing, Guy's Hospital, London SE1 9RT, United Kingdom
| | - Martin Pule
- Research Department of Haematology, UCL Cancer Institute, London WC1E 6DD, United Kingdom
| | - Andrew Kelvin Sewell
- Division of Infection and Immunity, Cardiff University School of Medicine, University Hospital, Cardiff CF14 4XN, United Kingdom
| | - Gavin Bendle
- School of Cancer Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Steven Lee
- School of Cancer Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Waseem Qasim
- Molecular and Cellular Immunology Institute, Institute of Child Health, London WC1N 1EH, United Kingdom
| | - Adrian Thrasher
- Molecular and Cellular Immunology Institute, Institute of Child Health, London WC1N 1EH, United Kingdom
| | - Emma Morris
- Department of Immunology, University College London, Royal Free Hospital, London NW3 2PF, United Kingdom
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Künkele A, Johnson AJ, Rolczynski LS, Chang CA, Hoglund V, Kelly-Spratt KS, Jensen MC. Functional Tuning of CARs Reveals Signaling Threshold above Which CD8+ CTL Antitumor Potency Is Attenuated due to Cell Fas-FasL-Dependent AICD. Cancer Immunol Res 2015; 3:368-79. [PMID: 25576337 DOI: 10.1158/2326-6066.cir-14-0200] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 12/22/2014] [Indexed: 11/16/2022]
Abstract
Chimeric antigen receptor (CAR) development is biased toward selecting constructs that elicit the highest magnitude of T-cell functional outputs. Here, we show that components of CAR extracellular spacer and cytoplasmic signaling domain modulate, in a cooperative manner, the magnitude of CD8(+)CTL activation for tumor-cell cytolysis and cytokine secretion. Unexpectedly, CAR constructs that generate the highest in vitro activity, either by extracellular spacer length tuning or by the addition of cytoplasmic signaling modules, exhibit attenuated antitumor potency in vivo, whereas CARs tuned for moderate signaling outputs mediate tumor eradication. Recursive CAR triggering renders CTLs expressing hyperactive CARs highly susceptible to activation-induced cell death (AICD) as a result of augmented FasL expression. CAR tuning using combinations of extracellular spacers and cytoplasmic signaling modules, which limit AICD of CD8(+)CTLs, may be a critical parameter for achieving clinical activity against solid tumors.
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Affiliation(s)
- Annette Künkele
- BTCCCR, Seattle Children's Research Institute, Seattle, Washington
| | - Adam J Johnson
- BTCCCR, Seattle Children's Research Institute, Seattle, Washington
| | | | - Cindy A Chang
- BTCCCR, Seattle Children's Research Institute, Seattle, Washington
| | - Virginia Hoglund
- BTCCCR, Seattle Children's Research Institute, Seattle, Washington
| | | | - Michael C Jensen
- BTCCCR, Seattle Children's Research Institute, Seattle, Washington. Department of Pediatrics, University of Washington, Seattle, Washington. Department of Bioengineering, University of Washington, Seattle, Washington.
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80
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Abstract
Using the immune system to control cancer has been investigated for over a century. Yet it is only over the last several years that therapeutic agents acting directly on the immune system have demonstrated improved overall survival for cancer patients in phase III clinical trials. Furthermore, it appears that some patients treated with such agents have been cured of metastatic cancer. This has led to increased interest and acceleration in the rate of progress in cancer immunotherapy. Most of the current immunotherapeutic success in cancer treatment is based on the use of immune-modulating antibodies targeting critical checkpoints (CTLA-4 and PD-1/PD-L1). Several other immune-modulating molecules targeting inhibitory or stimulatory pathways are being developed. The combined use of these medicines is the subject of intense investigation and holds important promise. Combination regimens include those that incorporate targeted therapies that act on growth signaling pathways, as well as standard chemotherapy and radiation therapy. In fact, these standard therapies have intrinsic immune-modulating properties that can support antitumor immunity. In the years ahead, adoptive T-cell therapy will also be an important part of treatment for some cancer patients. Other areas which are regaining interest are the use of oncolytic viruses that immunize patients against their own tumors and the use of vaccines against tumor antigens. Immunotherapy has demonstrated unprecedented durability in controlling multiple types of cancer and we expect its use to continue expanding rapidly.
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81
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Shalabi H, Angiolillo A, Fry TJ. Beyond CD19: Opportunities for Future Development of Targeted Immunotherapy in Pediatric Relapsed-Refractory Acute Leukemia. Front Pediatr 2015; 3:80. [PMID: 26484338 PMCID: PMC4589648 DOI: 10.3389/fped.2015.00080] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/18/2015] [Indexed: 12/30/2022] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapy has been used as a targeted approach in cancer therapy. Relapsed and refractory acute leukemia in pediatrics has been difficult to treat with conventional therapy due to dose-limiting toxicities. With the recent success of CD 19 CAR in pediatric patients with B cell acute lymphoblastic leukemia (ALL), this mode of therapy has become a very attractive option for these patients with high-risk disease. In this review, we will discuss current treatment paradigms of pediatric acute leukemia and potential therapeutic targets for additional high-risk populations, including T cell ALL, AML, and infant ALL.
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Affiliation(s)
- Haneen Shalabi
- Center for Cancer and Blood Disorders, Children's National Medical Center , Washington, DC , USA
| | - Anne Angiolillo
- Center for Cancer and Blood Disorders, Children's National Medical Center , Washington, DC , USA
| | - Terry J Fry
- Hematologic Malignancies Section, Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health , Bethesda, MD , USA
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82
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Makkouk A, Weiner GJ. Cancer immunotherapy and breaking immune tolerance: new approaches to an old challenge. Cancer Res 2014; 75:5-10. [PMID: 25524899 DOI: 10.1158/0008-5472.can-14-2538] [Citation(s) in RCA: 209] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cancer immunotherapy has proven to be challenging as it depends on overcoming multiple mechanisms that mediate immune tolerance to self-antigens. A growing understanding of immune tolerance has been the foundation for new approaches to cancer immunotherapy. Adoptive transfer of immune effectors such as antitumor mAb and chimeric antigen receptor T cells bypasses many of the mechanisms involved in immune tolerance by allowing for expansion of tumor-specific effectors ex vivo. Vaccination with whole tumor cells, protein, peptide, or dendritic cells has proven challenging, yet may be more useful when combined with other cancer immunotherapeutic strategies. Immunomodulatory approaches to cancer immunotherapy include treatment with agents that enhance and maintain T-cell activation. Recent advances in the use of checkpoint blockade to block negative signals and to maintain the antitumor response are particularly exciting. With our growing knowledge of immune tolerance and ways to overcome it, combination treatments are being developed, tested, and have particular promise. One example is in situ immunization that is designed to break tolerance within the tumor microenvironment. Progress in all these areas is continuing based on clear evidence that cancer immunotherapy designed to overcome immune tolerance can be useful for a growing number of patients with cancer.
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Affiliation(s)
- Amani Makkouk
- Interdisciplinary Graduate Program in Immunology, University of Iowa, Iowa City, Iowa
| | - George J Weiner
- Interdisciplinary Graduate Program in Immunology, University of Iowa, Iowa City, Iowa. Holden Comprehensive Cancer Center and Department of Internal Medicine, University of Iowa, Iowa City, Iowa.
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