1
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Wen B, Chen J, Ding T, Mao Z, Jin R, Wang Y, Shi M, Zhao L, Yang A, Qin X, Chen X. Development and experimental validation of hypoxia-related gene signatures for osteosarcoma diagnosis and prognosis based on WGCNA and machine learning. Sci Rep 2024; 14:18734. [PMID: 39134603 PMCID: PMC11319349 DOI: 10.1038/s41598-024-69638-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 08/07/2024] [Indexed: 08/15/2024] Open
Abstract
Osteosarcoma (OS) is the most common primary malignant tumour of the bone with high mortality. Here, we comprehensively analysed the hypoxia signalling in OS and further constructed novel hypoxia-related gene signatures for OS prediction and prognosis. This study employed Gene Set Enrichment Analysis (GSEA), Weighted correlation network analysis (WGCNA) and Least absolute shrinkage and selection operator (LASSO) analyses to identify Stanniocalcin 2 (STC2) and Transmembrane Protein 45A (TMEM45A) as the diagnostic biomarkers, which further assessed by Receiver Operating Characteristic (ROC), decision curve analysis (DCA), and calibration curves in training and test dataset. Univariate and multivariate Cox regression analyses were used to construct the prognostic model. STC2 and metastasis were devised to forge the OS risk model. The nomogram, risk score, Kaplan Meier plot, ROC, DCA, and calibration curves results certified the excellent performance of the prognostic model. The expression level of STC2 and TMEM45A was validated in external datasets and cell lines. In immune cell infiltration analysis, cancer-associated fibroblasts (CAFs) were significantly higher in the low-risk group. And the immune infiltration of CAFs was negatively associated with the expression of STC2 (P < 0.05). Pan-cancer analysis revealed that the expression level of STC2 was significantly higher in Esophageal carcinoma (ESCA), Head and Neck squamous cell carcinoma (HNSC), Kidney renal clear cell carcinoma (KIRC), Lung squamous cell carcinoma (LUSC), and Stomach adenocarcinoma (STAD). Additionally, the higher expression of STC2 was associated with the poor outcome in those cancers. In summary, this study identified STC2 and TMEM45A as novel markers for the diagnosis and prognosis of osteosarcoma, and STC2 was shown to correlate with immune infiltration of CAFs negatively.
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Affiliation(s)
- Bo Wen
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, 300050, China
- Department of Orthopedics, No. 945 Hospital of the PLA Joint Logistics Support Force, Yaan, 625000, Sichuan, China
| | - Jian Chen
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, 300050, China
| | - Tianqi Ding
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, 300050, China
| | - Zhiyou Mao
- Department of Orthopedics, No. 945 Hospital of the PLA Joint Logistics Support Force, Yaan, 625000, Sichuan, China
| | - Rong Jin
- Department of Orthopedics, No. 945 Hospital of the PLA Joint Logistics Support Force, Yaan, 625000, Sichuan, China
| | - Yirui Wang
- Department of Cardiology, No. 945 Hospital of the PLA Joint Logistics Support Force, Yaan, 625000, Sichuan, China
| | - Meiqin Shi
- Department of Orthopedics, No. 945 Hospital of the PLA Joint Logistics Support Force, Yaan, 625000, Sichuan, China
| | - Lixun Zhao
- Department of Orthopedics, No. 945 Hospital of the PLA Joint Logistics Support Force, Yaan, 625000, Sichuan, China
| | - Asang Yang
- Department of Orthopedics, No. 945 Hospital of the PLA Joint Logistics Support Force, Yaan, 625000, Sichuan, China
| | - Xianyun Qin
- Department of Orthopedics, No. 945 Hospital of the PLA Joint Logistics Support Force, Yaan, 625000, Sichuan, China.
| | - Xuewei Chen
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, 300050, China.
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2
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Zappa E, Vitali A, Anders K, Molenaar JJ, Wienke J, Künkele A. Adoptive cell therapy in paediatric extracranial solid tumours: current approaches and future challenges. Eur J Cancer 2023; 194:113347. [PMID: 37832507 PMCID: PMC10695178 DOI: 10.1016/j.ejca.2023.113347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/03/2023] [Accepted: 09/09/2023] [Indexed: 10/15/2023]
Abstract
Immunotherapy has ignited hope to cure paediatric solid tumours that resist traditional therapies. Among the most promising methods is adoptive cell therapy (ACT). Particularly, ACT using T cells equipped with chimeric antigen receptors (CARs) has moved into the spotlight in clinical studies. However, the efficacy of ACT is challenged by ACT-intrinsic factors, like lack of activation or T cell exhaustion, as well as immune evasion strategies of paediatric solid tumours, such as their highly immunosuppressive microenvironment. Novel strategies, including ACT using innate-like lymphocytes, innovative cell engineering techniques, and ACT combination therapies, are being developed and will be crucial to overcome these challenges. Here, we discuss the main classes of ACT for the treatment of paediatric extracranial solid tumours, reflect on the available preclinical and clinical evidence supporting promising strategies, and address the challenges that ACT is still facing. Ultimately, we highlight state-of-the-art developments and opportunities for new therapeutic options, which hold great potential for improving outcomes in this challenging patient population.
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Affiliation(s)
- Elisa Zappa
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Alice Vitali
- Department of Pediatric Oncology and Hematology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.
| | - Kathleen Anders
- Department of Pediatric Oncology and Hematology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany; German Cancer Consortium (DKTK), Partner Site Berlin, Berlin, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jan J Molenaar
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Judith Wienke
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Annette Künkele
- Department of Pediatric Oncology and Hematology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany; German Cancer Consortium (DKTK), Partner Site Berlin, Berlin, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
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3
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Kurioka A, Klenerman P. Aging unconventionally: γδ T cells, iNKT cells, and MAIT cells in aging. Semin Immunol 2023; 69:101816. [PMID: 37536148 PMCID: PMC10804939 DOI: 10.1016/j.smim.2023.101816] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 08/05/2023]
Abstract
Unconventional T cells include γδ T cells, invariant Natural Killer T cells (iNKT) cells and Mucosal Associated Invariant T (MAIT) cells, which are distinguished from conventional T cells by their recognition of non-peptide ligands presented by non-polymorphic antigen presenting molecules and rapid effector functions that are pre-programmed during their development. Here we review current knowledge of the effect of age on unconventional T cells, from early life to old age, in both mice and humans. We then discuss the role of unconventional T cells in age-associated diseases and infections, highlighting the similarities between members of the unconventional T cell family in the context of aging.
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Affiliation(s)
- Ayako Kurioka
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Paul Klenerman
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; Translational Gastroenterology Unit, University of Oxford, Oxford, UK
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4
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Fetahu IS, Esser-Skala W, Dnyansagar R, Sindelar S, Rifatbegovic F, Bileck A, Skos L, Bozsaky E, Lazic D, Shaw L, Tötzl M, Tarlungeanu D, Bernkopf M, Rados M, Weninger W, Tomazou EM, Bock C, Gerner C, Ladenstein R, Farlik M, Fortelny N, Taschner-Mandl S. Single-cell transcriptomics and epigenomics unravel the role of monocytes in neuroblastoma bone marrow metastasis. Nat Commun 2023; 14:3620. [PMID: 37365178 DOI: 10.1038/s41467-023-39210-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 05/29/2023] [Indexed: 06/28/2023] Open
Abstract
Metastasis is the major cause of cancer-related deaths. Neuroblastoma (NB), a childhood tumor has been molecularly defined at the primary cancer site, however, the bone marrow (BM) as the metastatic niche of NB is poorly characterized. Here we perform single-cell transcriptomic and epigenomic profiling of BM aspirates from 11 subjects spanning three major NB subtypes and compare these to five age-matched and metastasis-free BM, followed by in-depth single cell analyses of tissue diversity and cell-cell interactions, as well as functional validation. We show that cellular plasticity of NB tumor cells is conserved upon metastasis and tumor cell type composition is NB subtype-dependent. NB cells signal to the BM microenvironment, rewiring via macrophage mgration inhibitory factor and midkine signaling specifically monocytes, which exhibit M1 and M2 features, are marked by activation of pro- and anti-inflammatory programs, and express tumor-promoting factors, reminiscent of tumor-associated macrophages. The interactions and pathways characterized in our study provide the basis for therapeutic approaches that target tumor-to-microenvironment interactions.
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Affiliation(s)
- Irfete S Fetahu
- St. Anna Children's Cancer Research Institute, Vienna, Austria.
| | - Wolfgang Esser-Skala
- Department of Biosciences and Medical Biology, University of Salzburg, Salzburg, Austria
| | - Rohit Dnyansagar
- Department of Biosciences and Medical Biology, University of Salzburg, Salzburg, Austria
| | - Samuel Sindelar
- Department of Biosciences and Medical Biology, University of Salzburg, Salzburg, Austria
| | | | - Andrea Bileck
- University of Vienna, Department of Analytical Chemistry, Faculty of Chemistry, Vienna, Austria
- Joint Metabolomics Facility, University of Vienna and Medical University of Vienna, Vienna, Austria
| | - Lukas Skos
- University of Vienna, Department of Analytical Chemistry, Faculty of Chemistry, Vienna, Austria
| | - Eva Bozsaky
- St. Anna Children's Cancer Research Institute, Vienna, Austria
| | - Daria Lazic
- St. Anna Children's Cancer Research Institute, Vienna, Austria
| | - Lisa Shaw
- Medical University of Vienna, Department of Dermatology, Vienna, Austria
| | - Marcus Tötzl
- St. Anna Children's Cancer Research Institute, Vienna, Austria
| | | | - Marie Bernkopf
- St. Anna Children's Cancer Research Institute, Vienna, Austria
| | - Magdalena Rados
- St. Anna Children's Cancer Research Institute, Vienna, Austria
| | - Wolfgang Weninger
- Medical University of Vienna, Department of Dermatology, Vienna, Austria
| | - Eleni M Tomazou
- St. Anna Children's Cancer Research Institute, Vienna, Austria
| | - Christoph Bock
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
- Medical University of Vienna, Institute of Artificial Intelligence, Center for Medical Data Science, Vienna, Austria
| | - Christopher Gerner
- University of Vienna, Department of Analytical Chemistry, Faculty of Chemistry, Vienna, Austria
- Joint Metabolomics Facility, University of Vienna and Medical University of Vienna, Vienna, Austria
| | - Ruth Ladenstein
- St. Anna Children's Hospital and St. Anna Children's Cancer Research Institute, Department of Studies and Statistics for Integrated Research and Projects, Vienna, Austria
- Medical University of Vienna, Department of Pediatrics, Vienna, Austria
| | - Matthias Farlik
- Medical University of Vienna, Department of Dermatology, Vienna, Austria
| | - Nikolaus Fortelny
- Department of Biosciences and Medical Biology, University of Salzburg, Salzburg, Austria.
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5
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Role of NKT cells in cancer immunotherapy-from bench to bed. MEDICAL ONCOLOGY (NORTHWOOD, LONDON, ENGLAND) 2022; 40:29. [PMID: 36460881 DOI: 10.1007/s12032-022-01888-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/08/2022] [Indexed: 12/04/2022]
Abstract
Natural killer T (NKT) cells are a specific T cell subset known to express the αβ-T cell receptor (TCR) for antigens identification and express typical NK cell specifications, such as surface expression of CD56 and CD16 markers as well as production of granzyme. Human NKT cells are divided into two subgroups based on their cytokine receptor and TCR repertoire. Both of them are CD1-restricted and recognize lipid antigens presented by CD1d molecules. Studies have demonstrated that these cells are essential in defense against malignancies. These cells secret proinflammatory and regulatory cytokines that stimulate or suppress immune system responses. In several murine tumor models, activation of type I NKT cells induces tumor rejection and inhibits metastasis's spread. However, type II NKT cells are associated with an inhibitory and regulatory function during tumor immune responses. Variant NKT cells may suppress tumor immunity via different mechanisms that require cross-talk with other immune-regulatory cells. NKT-like cells display high tumor-killing abilities against many tumor cells. In the recent decade, different studies have been performed based on the application of NKT-based immunotherapy for cancer therapy. Moreover, manipulation of NKT cells through administering autologous dendritic cell (DC) loaded with α-galactosylceramide (α-GalCer) and direct α-GalCer injection has also been tested. In this review, we described different subtypes of NKT cells, their function in the anti-tumor immune responses, and the application of NKT cells in cancer immunotherapy from bench to bed.
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6
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Du H, Cai W. Opsoclonus-myoclonus syndrome associated with neuroblastoma: Insights into antitumor immunity. Pediatr Blood Cancer 2022; 69:e29949. [PMID: 36094353 DOI: 10.1002/pbc.29949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 07/08/2022] [Accepted: 08/04/2022] [Indexed: 11/08/2022]
Abstract
Opsoclonus-myoclonus syndrome (OMS) is a rare neurological disorder. Half of these cases occur in children with neuroblastoma. Neuroblastoma patients with OMS usually have better oncological outcomes than those without OMS even after stratification by tumor stage and age, indicating that factors mediating OMS may also inhibit tumor cell proliferation. Although the mechanisms underlying OMS remain undefined, the cytokines and lymphocytes alterations in the cerebrospinal fluid support the concept that it is a pattern of neuroinflammation due to an autoimmune effect. The presence of lymphoid follicles consisting of follicular dendritic cells, CD20+ B lymphocytes, CD3+ T lymphocytes, and CD68+ macrophages in the tumor microenvironment in OMS-associated neuroblastoma support the autoimmune nature of this disorder. This review focuses on the clinical and genetic features of OMS-associated neuroblastoma, and we update readers on immune features of neuroblastoma with or without OMS to gain insights into antitumor immunity as it relates to tumor biology and prognosis.
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Affiliation(s)
- Hongmei Du
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Weisong Cai
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
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7
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Schoutrop E, Moyano-Galceran L, Lheureux S, Mattsson J, Lehti K, Dahlstrand H, Magalhaes I. Molecular, cellular and systemic aspects of epithelial ovarian cancer and its tumor microenvironment. Semin Cancer Biol 2022; 86:207-223. [PMID: 35395389 DOI: 10.1016/j.semcancer.2022.03.027] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/11/2022] [Accepted: 03/30/2022] [Indexed: 02/07/2023]
Abstract
Ovarian cancer encompasses a heterogeneous group of malignancies that involve the ovaries, fallopian tubes and the peritoneal cavity. Despite major advances made within the field of cancer, the majority of patients with ovarian cancer are still being diagnosed at an advanced stage of the disease due to lack of effective screening tools. The overall survival of these patients has, therefore, not substantially improved over the past decades. Most patients undergo debulking surgery and treatment with chemotherapy, but often micrometastases remain and acquire resistance to the therapy, eventually leading to disease recurrence. Here, we summarize the current knowledge in epithelial ovarian cancer development and metastatic progression. For the most common subtypes, we focus further on the properties and functions of the immunosuppressive tumor microenvironment, including the extracellular matrix. Current and future treatment modalities are discussed and finally we provide an overview of the different experimental models used to develop novel therapies.
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Affiliation(s)
- Esther Schoutrop
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Lidia Moyano-Galceran
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Stephanie Lheureux
- University of Toronto, Toronto, Ontario, Canada; Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jonas Mattsson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden; University of Toronto, Toronto, Ontario, Canada; Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Gloria and Seymour Epstein Chair in Cell Therapy and Transplantation, Toronto, Ontario, Canada
| | - Kaisa Lehti
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden; Department of Biomedical Laboratory Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hanna Dahlstrand
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden; Medical unit Pelvic Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden.
| | - Isabelle Magalhaes
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden; Department of Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden.
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8
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Gomez RL, Ibragimova S, Ramachandran R, Philpott A, Ali FR. Tumoral heterogeneity in neuroblastoma. Biochim Biophys Acta Rev Cancer 2022; 1877:188805. [PMID: 36162542 DOI: 10.1016/j.bbcan.2022.188805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 08/28/2022] [Accepted: 09/17/2022] [Indexed: 10/31/2022]
Abstract
Neuroblastoma is a solid, neuroendocrine tumor with divergent clinical behavior ranging from asymptomatic to fatal. The diverse clinical presentations of neuroblastoma are directly linked to the high intra- and inter-tumoral heterogeneity it presents. This heterogeneity is strongly associated with therapeutic resistance and continuous relapses, often leading to fatal outcomes. The development of successful risk assessment and tailored treatment strategies lies in evaluating the extent of heterogeneity via the accurate genetic and epigenetic profiling of distinct cell subpopulations present in the tumor. Recent studies have focused on understanding the molecular mechanisms that drive tumoral heterogeneity in pursuing better therapeutic and diagnostic approaches. This review describes the cellular, genetic, and epigenetic aspects of neuroblastoma heterogeneity. In addition, we summarize the recent findings on three crucial factors that can lead to heterogeneity in solid tumors: the inherent diversity of the progenitor cells, the presence of cancer stem cells, and the influence of the tumor microenvironment.
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Affiliation(s)
- Roshna Lawrence Gomez
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai Healthcare City, Dubai, United Arab Emirates
| | - Shakhzada Ibragimova
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai Healthcare City, Dubai, United Arab Emirates
| | - Revathy Ramachandran
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai Healthcare City, Dubai, United Arab Emirates
| | - Anna Philpott
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom; Wellcome-MRC Cambridge Stem Cell Institute, Jeffrey Cheah Biomedical Center, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Fahad R Ali
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai Healthcare City, Dubai, United Arab Emirates.
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9
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Kacher J, Manches O, Aspord C, Sartelet H, Chaperot L. Impaired Antitumor Immune Response in MYCN-amplified Neuroblastoma Is Associated with Lack of CCL2 Secretion and Poor Dendritic Cell Recruitment. CANCER RESEARCH COMMUNICATIONS 2022; 2:577-589. [PMID: 36923280 PMCID: PMC10010397 DOI: 10.1158/2767-9764.crc-21-0134] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 03/28/2022] [Accepted: 06/09/2022] [Indexed: 11/16/2022]
Abstract
In neuroblastoma, MYCN amplification is associated with sparse immune infiltrate and poor prognosis. Dendritic cells (DC) are crucial immune sentinels but their involvement in neuroblastoma pathogenesis is poorly understood. We observed that the migration of monocytes, myeloid and plasmacytoid DC induced by MYCN-nonamplified neuroblastoma supernatants was abrogated by the addition of anti-CCL2 antibodies, demonstrating the involvement of the CCR2/CCL2 axis in their recruitment by these tumors. Using public RNA sequencing and microarray datasets, we describe lower level of expression of CCL2 in MYCN-amplified neuroblastoma tumors, and we propose a working model for T-cell recruitment in neuroblastoma tumors in which CCL2 produced by neuroblastoma cells initiates the recruitment of monocytes, myeloid and plasmacytoid DCs. Among these cells, the CD1c+ subset may recruit T cells by means of CCL19/CCL22 secretion. In vitro, supernatants from DCs cocultured with neuroblastoma cell lines and activated contain CCL22 and CCL19, and are chemotactic for both CD4+ and CD8+ T cells. We also looked at immunomodulation induced by neuroblastoma cell lines, and found MYCN-nonamplified neuroblastoma cell lines were able to create a microenvironment where DC activation is enhanced. Overall, our findings highlight a major role for CCL2/CCR2 axis in monocytes, myeloid and plasmacytoid cells recruitment toward MYCN-nonamplified neuroblastoma, allowing further immune cell recruitment, and show that these tumors present a microenvironment that can favor DC responses. Significance In MYCN-nonamplified neuroblastoma, CCL2 produced by neuroblastoma cells induces the recruitment of antigen-presenting cells (DCs and monocytes/macrophages), allowing infiltration by T cells, in link with CCL19 and CCL22 production, hence favoring immune responses.
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Affiliation(s)
- Jamila Kacher
- Institute for Advanced Biosciences, Inserm U1209, CNRS UMR5309, Université Grenoble Alpes, Grenoble, France.,Etablissement Français du Sang Auvergne-Rhône-Alpes, Grenoble, France
| | - Olivier Manches
- Institute for Advanced Biosciences, Inserm U1209, CNRS UMR5309, Université Grenoble Alpes, Grenoble, France.,Etablissement Français du Sang Auvergne-Rhône-Alpes, Grenoble, France
| | - Caroline Aspord
- Institute for Advanced Biosciences, Inserm U1209, CNRS UMR5309, Université Grenoble Alpes, Grenoble, France.,Etablissement Français du Sang Auvergne-Rhône-Alpes, Grenoble, France
| | - Hervé Sartelet
- Laboratoire de Biopathologie, CHRU de Nancy, Nancy, France.,Inserm U1256, Université de Lorraine, Nancy, France
| | - Laurence Chaperot
- Institute for Advanced Biosciences, Inserm U1209, CNRS UMR5309, Université Grenoble Alpes, Grenoble, France.,Etablissement Français du Sang Auvergne-Rhône-Alpes, Grenoble, France
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10
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Verhoeven BM, Mei S, Olsen TK, Gustafsson K, Valind A, Lindström A, Gisselsson D, Fard SS, Hagerling C, Kharchenko PV, Kogner P, Johnsen JI, Baryawno N. The immune cell atlas of human neuroblastoma. Cell Rep Med 2022; 3:100657. [PMID: 35688160 PMCID: PMC9245004 DOI: 10.1016/j.xcrm.2022.100657] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/26/2022] [Accepted: 05/17/2022] [Indexed: 12/03/2022]
Abstract
Understanding the complete immune cell composition of human neuroblastoma (NB) is crucial for the development of immunotherapeutics. Here, we perform single-cell RNA sequencing (scRNA-seq) on 19 human NB samples coupled with multiplex immunohistochemistry, survival analysis, and comparison with normal fetal adrenal gland data. We provide a comprehensive immune cell landscape and characterize cell-state changes from normal tissue to NB. Our analysis reveals 27 immune cell subtypes, including distinct subpopulations of myeloid, NK, B, and T cells. Several different cell types demonstrate a survival benefit. In contrast to adult cancers and previous NB studies, we show an increase in inflammatory monocyte cell state when contrasting normal and tumor tissue, while no differences in cytotoxicity and exhaustion score for T cells, nor in Treg activity, are observed. Our receptor-ligand interaction analysis reveals a highly complex interactive network of the NB microenvironment from which we highlight several interactions that we suggest for future therapeutic studies. 27 different immune subtypes form a complex neuroblastoma microenvironment Inflammatory monocytes correlate with neuroblastoma disease progression Active NK cells correlate with improved survival in human neuroblastoma T cell exhaustion and Treg activity demonstrate no difference between risk groups
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Affiliation(s)
- Bronte Manouk Verhoeven
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Shenglin Mei
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA 02115, USA
| | - Thale Kristin Olsen
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Karin Gustafsson
- Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Anders Valind
- Department of Laboratory Medicine, Division of Clinical Genetics, Lund University, 221 85 Lund, Sweden; Department of Pediatrics, Skåne University Hospital, Lund, Sweden
| | - Axel Lindström
- Department of Laboratory Medicine, Division of Clinical Genetics, Lund University, 221 85 Lund, Sweden
| | - David Gisselsson
- Department of Laboratory Medicine, Division of Clinical Genetics, Lund University, 221 85 Lund, Sweden
| | - Shahrzad Shirazi Fard
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Catharina Hagerling
- Department of Laboratory Medicine, Division of Clinical Genetics, Lund University, 221 85 Lund, Sweden
| | - Peter V Kharchenko
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA 02115, USA
| | - Per Kogner
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - John Inge Johnsen
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Ninib Baryawno
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, 171 77 Stockholm, Sweden.
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11
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Delfanti G, Dellabona P, Casorati G, Fedeli M. Adoptive Immunotherapy With Engineered iNKT Cells to Target Cancer Cells and the Suppressive Microenvironment. Front Med (Lausanne) 2022; 9:897750. [PMID: 35615083 PMCID: PMC9125179 DOI: 10.3389/fmed.2022.897750] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 04/14/2022] [Indexed: 12/12/2022] Open
Abstract
Invariant Natural Killer T (iNKT) cells are T lymphocytes expressing a conserved semi-invariant TCR specific for lipid antigens (Ags) restricted for the monomorphic MHC class I-related molecule CD1d. iNKT cells infiltrate mouse and human tumors and play an important role in the immune surveillance against solid and hematological malignancies. Because of unique functional features, they are attractive platforms for adoptive cells immunotherapy of cancer compared to conventional T cells. iNKT cells can directly kill CD1d-expressing cancer cells, but also restrict immunosuppressive myelomonocytic populations in the tumor microenvironment (TME) via CD1d-cognate recognition, promoting anti-tumor responses irrespective of the CD1d expression by cancer cells. Moreover, iNKT cells can be adoptively transferred across MHC barriers without risk of alloreaction because CD1d molecules are identical in all individuals, in addition to their ability to suppress graft vs. host disease (GvHD) without impairing the anti-tumor responses. Within this functional framework, iNKT cells are successfully engineered to acquire a second antigen-specificity by expressing recombinant TCRs or Chimeric Antigen Receptor (CAR) specific for tumor-associated antigens, enabling the direct targeting of antigen-expressing cancer cells, while maintaining their CD1d-dependent functions. These new evidences support the exploitation of iNKT cells for donor unrestricted, and possibly off the shelf, adoptive cell therapies enabling the concurrent targeting of cancer cells and suppressive microenvironment.
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Affiliation(s)
- Gloria Delfanti
- Experimental Immunology Unit, Division of Immunology, Transplantation, and Infectious Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
- *Correspondence: Gloria Delfanti
| | - Paolo Dellabona
- Experimental Immunology Unit, Division of Immunology, Transplantation, and Infectious Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Casorati
- Experimental Immunology Unit, Division of Immunology, Transplantation, and Infectious Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
- Giulia Casorati
| | - Maya Fedeli
- Experimental Immunology Unit, Division of Immunology, Transplantation, and Infectious Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Maya Fedeli
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12
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Liu Z, Chen X, Roberts R, Huang R, Mikailov M, Tong W. Unraveling Gene Fusions for Drug Repositioning in High-Risk Neuroblastoma. Front Pharmacol 2021; 12:608778. [PMID: 33967751 PMCID: PMC8105087 DOI: 10.3389/fphar.2021.608778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 03/23/2021] [Indexed: 11/13/2022] Open
Abstract
High-risk neuroblastoma (NB) remains a significant therapeutic challenge facing current pediatric oncology patients. Structural variants such as gene fusions have shown an initial promise in enhancing mechanistic understanding of NB and improving survival rates. In this study, we performed a comprehensive in silico investigation on the translational ability of gene fusions for patient stratification and treatment development for high-risk NB patients. Specifically, three state-of-the-art gene fusion detection algorithms, including ChimeraScan, SOAPfuse, and TopHat-Fusion, were employed to identify the fusion transcripts in a RNA-seq data set of 498 neuroblastoma patients. Then, the 176 high-risk patients were further stratified into four different subgroups based on gene fusion profiles. Furthermore, Kaplan-Meier survival analysis was performed, and differentially expressed genes (DEGs) for the redefined high-risk group were extracted and functionally analyzed. Finally, repositioning candidates were enriched in each patient subgroup with drug transcriptomic profiles from the LINCS L1000 Connectivity Map. We found the number of identified gene fusions was increased from clinical the low-risk stage to the high-risk stage. Although the technical concordance of fusion detection algorithms was suboptimal, they have a similar biological relevance concerning perturbed pathways and regulated DEGs. The gene fusion profiles could be utilized to redefine high-risk patient subgroups with significant onset age of NB, which yielded the improved survival curves (Log-rank p value ≤ 0.05). Out of 48 enriched repositioning candidates, 45 (93.8%) have antitumor potency, and 24 (50%) were confirmed with either on-going clinical trials or literature reports. The gene fusion profiles have a discrimination power for redefining patient subgroups in high-risk NB and facilitate precision medicine-based drug repositioning implementation.
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Affiliation(s)
- Zhichao Liu
- Division of Bioinformatics and Biostatistics, National Center for Toxicological Research, US Food and Drug Administration, Jefferson, AR, United States
| | - Xi Chen
- Division of Bioinformatics and Biostatistics, National Center for Toxicological Research, US Food and Drug Administration, Jefferson, AR, United States
| | - Ruth Roberts
- ApconiX, BioHub at Alderley Park, Alderley Edge, United Kingdom.,University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Ruili Huang
- National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, MD, United States
| | - Mike Mikailov
- Office of Science and Engineering Labs, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD, United States
| | - Weida Tong
- Division of Bioinformatics and Biostatistics, National Center for Toxicological Research, US Food and Drug Administration, Jefferson, AR, United States
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13
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Liao YM, Hung TH, Tung JK, Yu J, Hsu YL, Hung JT, Yu AL. Low Expression of IL-15 and NKT in Tumor Microenvironment Predicts Poor Outcome of MYCN-Non-Amplified Neuroblastoma. J Pers Med 2021; 11:jpm11020122. [PMID: 33668573 PMCID: PMC7918138 DOI: 10.3390/jpm11020122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 12/11/2022] Open
Abstract
Immune tumor microenvironment (TME) in neuroblastoma (NBL) contributes to tumor behavior and treatment response. T cells and natural killer (NK) cells have been shown to play important roles in the neuroblastoma TME. However, few reports address the clinical relevance of natural killer T cells (NKTs) and interleukin-15 (IL-15), one of the crucial cytokines controlling the activation and expansion of NK/NKT cells, in NBL. In this study, we examined NKT immunoscores and IL-15 expression in both MYCN-amplified and MYCN-non-amplified NBL to correlate with clinical outcomes such as event-free survival (EFS) and overall survival (OS). From Gene Expression Omnibus (GEO) datasets GSE45480 (n = 643) and GSE49711 (n = 493), we found that NKT immunoscore and IL-15 expression were both significantly lower in MYCN-amplified NBL, and similar results were observed using our clinical NBL samples (n = 53). Moreover, NBL patients (GEO dataset GSE49711 and our clinical samples) with both lower NKT immunoscore and IL-15 expression exhibited decreased EFS and OS regardless of MYCN gene amplification status. Multivariate analysis further showed that the combination of low NKT immunoscore and low IL-15 expression level was an independent prognostic factor for poor EFS and OS in our NBL patients. These findings provide the rationale for the development of strategy to incorporate IL-15 and NKT cell therapy into the treatment regimen for neuroblastoma.
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Affiliation(s)
- Yu-Mei Liao
- Institute of Stem Cell and Translational Cancer Research, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan; (Y.-M.L.); (T.-H.H.); (J.K.T.); (J.Y.)
- Program in Translational Medicine, Kaohsiung Medical University, Kaohsiung, and Academia Sinica, Taipei 115, Taiwan
- Division of Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
| | - Tsai-Hsien Hung
- Institute of Stem Cell and Translational Cancer Research, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan; (Y.-M.L.); (T.-H.H.); (J.K.T.); (J.Y.)
| | - John K. Tung
- Institute of Stem Cell and Translational Cancer Research, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan; (Y.-M.L.); (T.-H.H.); (J.K.T.); (J.Y.)
| | - John Yu
- Institute of Stem Cell and Translational Cancer Research, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan; (Y.-M.L.); (T.-H.H.); (J.K.T.); (J.Y.)
- Institute of Cellular and Organismic Biology, Academia Sinica, Taipei 115, Taiwan
| | - Ya-Ling Hsu
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
| | - Jung-Tung Hung
- Institute of Stem Cell and Translational Cancer Research, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan; (Y.-M.L.); (T.-H.H.); (J.K.T.); (J.Y.)
- Correspondence: (J.-T.H.); (A.L.Y.); Tel.: +886-3328-1200 (ext. 7813) (J.-T.H.); +886-3328-1200 (ext. 7805) (A.L.Y.); Fax: +886-3328-1200 (A.L.Y. & J.-T.H.)
| | - Alice L. Yu
- Institute of Stem Cell and Translational Cancer Research, Chang Gung Memorial Hospital at Linkou, Taoyuan 333, Taiwan; (Y.-M.L.); (T.-H.H.); (J.K.T.); (J.Y.)
- Department of Pediatrics, University of California in San Diego, San Diego, CA 92103, USA
- Genomics Research Center, Academia Sinica, Taipei 115, Taiwan
- Correspondence: (J.-T.H.); (A.L.Y.); Tel.: +886-3328-1200 (ext. 7813) (J.-T.H.); +886-3328-1200 (ext. 7805) (A.L.Y.); Fax: +886-3328-1200 (A.L.Y. & J.-T.H.)
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14
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Wienke J, Dierselhuis MP, Tytgat GAM, Künkele A, Nierkens S, Molenaar JJ. The immune landscape of neuroblastoma: Challenges and opportunities for novel therapeutic strategies in pediatric oncology. Eur J Cancer 2020; 144:123-150. [PMID: 33341446 DOI: 10.1016/j.ejca.2020.11.014] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 11/03/2020] [Indexed: 12/12/2022]
Abstract
Immunotherapy holds great promise for the treatment of pediatric cancers. In neuroblastoma, the recent implementation of anti-GD2 antibody Dinutuximab into the standard of care has improved patient outcomes substantially. However, 5-year survival rates are still below 50% in patients with high-risk neuroblastoma, which has sparked investigations into novel immunotherapeutic approaches. T cell-engaging therapies such as immune checkpoint blockade, antibody-mediated therapy and adoptive T cell therapy have proven remarkably successful in a range of adult cancers but still meet challenges in pediatric oncology. In neuroblastoma, their limited success may be due to several factors. Neuroblastoma displays low immunogenicity due to its low mutational load and lack of MHC-I expression. Tumour infiltration by T and NK cells is especially low in high-risk neuroblastoma and is prognostic for survival. Only a small fraction of tumour-infiltrating lymphocytes shows tumour reactivity. Moreover, neuroblastoma tumours employ a variety of immune evasion strategies, including expression of immune checkpoint molecules, induction of immunosuppressive myeloid and stromal cells, as well as secretion of immunoregulatory mediators, which reduce infiltration and reactivity of immune cells. Overcoming these challenges will be key to the successful implementation of novel immunotherapeutic interventions. Combining different immunotherapies, as well as personalised strategies, may be promising approaches. We will discuss the composition, function and prognostic value of tumour-infiltrating lymphocytes (TIL) in neuroblastoma, reflect on challenges for immunotherapy, including a lack of TIL reactivity and tumour immune evasion strategies, and highlight opportunities for immunotherapy and future perspectives with regard to state-of-the-art developments in the tumour immunology space.
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Affiliation(s)
- Judith Wienke
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.
| | | | | | - Annette Künkele
- Department of Pediatric Oncology and Hematology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt - Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Stefan Nierkens
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Jan J Molenaar
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
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15
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Lehmann N, Paret C, El Malki K, Russo A, Neu MA, Wingerter A, Seidmann L, Foersch S, Ziegler N, Roth L, Backes N, Sandhoff R, Faber J. Tumor Lipids of Pediatric Papillary Renal Cell Carcinoma Stimulate Unconventional T Cells. Front Immunol 2020; 11:1819. [PMID: 32973759 PMCID: PMC7468390 DOI: 10.3389/fimmu.2020.01819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/07/2020] [Indexed: 01/25/2023] Open
Abstract
Papillary renal cell carcinoma (PRCC) is a rare entity in children with no established therapy protocols for advanced diseases. Immunotherapy is emerging as an important therapeutic tool for childhood cancer. Tumor cells can be recognized and killed by conventional and unconventional T cells. Unconventional T cells are able to recognize lipid antigens presented via CD1 molecules independently from major histocompatibility complex, which offers new alternatives for cancer immunotherapies. The nature of those lipids is largely unknown and α-galactosylceramide is currently used as a synthetic model antigen. In this work, we analyzed infiltrating lymphocytes of two pediatric PRCCs using flow cytometry, immunohistochemistry and qRT-PCR. Moreover, we analyzed the CD1d expression within both tumors. Tumor lipids of PRCC samples and three normal kidney samples were fractionated and the recognition of tumor own lipid fractions by unconventional T cells was analyzed in an in vitro assay. We identified infiltrating lymphocytes including γδ T cells and iNKT cells, as well as CD1d expression in both samples. One lipid fraction, containing ceramides and monoacylglycerides amongst others, was able to induce the proliferation of iNKT cells isolated from peripheral blood mononuclear cells (PBMCs) of healthy donors and of one matched PRCC patient. Furthermore, CD1d tetramer stainings revealed that a subset of iNKT cells is able to bind lipids being present in fraction 2 via CD1d. We conclude that PRCCs are infiltrated by conventional and unconventional T cells and express CD1d. Moreover, certain lipids, present in pediatric PRCC, are able to stimulate unconventional T cells. Manipulating these lipids and T cells may open new strategies for therapy of pediatric PRCCs.
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Affiliation(s)
- Nadine Lehmann
- Department of Pediatric Hematology/Oncology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,University Cancer Center (UCT), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Claudia Paret
- Department of Pediatric Hematology/Oncology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,University Cancer Center (UCT), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Khalifa El Malki
- Department of Pediatric Hematology/Oncology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,University Cancer Center (UCT), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Alexandra Russo
- Department of Pediatric Hematology/Oncology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,University Cancer Center (UCT), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Marie Astrid Neu
- Department of Pediatric Hematology/Oncology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,University Cancer Center (UCT), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Arthur Wingerter
- Department of Pediatric Hematology/Oncology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,University Cancer Center (UCT), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Larissa Seidmann
- Institute of Pathology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Sebastian Foersch
- Institute of Pathology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Nicole Ziegler
- Department of Pediatric Hematology/Oncology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,University Cancer Center (UCT), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Lea Roth
- Department of Pediatric Hematology/Oncology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,University Cancer Center (UCT), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Nora Backes
- Department of Pediatric Hematology/Oncology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,University Cancer Center (UCT), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Roger Sandhoff
- Lipid Pathobiochemistry, German Cancer Research Center, Heidelberg, Germany
| | - Joerg Faber
- Department of Pediatric Hematology/Oncology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,University Cancer Center (UCT), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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16
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McNerney KO, Karageorgos SA, Hogarty MD, Bassiri H. Enhancing Neuroblastoma Immunotherapies by Engaging iNKT and NK Cells. Front Immunol 2020; 11:873. [PMID: 32457760 PMCID: PMC7225357 DOI: 10.3389/fimmu.2020.00873] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/16/2020] [Indexed: 12/13/2022] Open
Abstract
Neuroblastoma (NB) is the most common extracranial solid tumor in children and, in the high-risk group, has a 5-year mortality rate of ~50%. The high mortality rate and significant treatment-related morbidities associated with current standard of care therapies belie the critical need for more tolerable and effective treatments for this disease. While the monoclonal antibody dinutuximab has demonstrated the potential for immunotherapy to improve overall NB outcomes, the 5-year overall survival of high-risk patients has not yet substantially changed. The frequency and type of invariant natural killer T cells (iNKTs) and natural killer cells (NKs) has been associated with improved outcomes in several solid and liquid malignancies, including NB. Indeed, iNKTs and NKs inhibit tumor associated macrophages (TAMs) and myeloid derived suppressor cells (MDSCs), kill cancer stem cells (CSCs) and neuroblasts, and robustly secrete cytokines to recruit additional immune effectors. These capabilities, and promising pre-clinical and early clinical data suggest that iNKT- and NK-based therapies may hold promise as both stand-alone and combination treatments for NB. In this review we will summarize the biologic features of iNKTs and NKs that confer advantages for NB immunotherapy, discuss the barriers imposed by the NB tumor microenvironment, and examine the current state of such therapies in pre-clinical models and clinical trials.
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Affiliation(s)
- Kevin O McNerney
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Spyridon A Karageorgos
- School of Medicine, European University Cyprus, Nicosia, Cyprus.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Michael D Hogarty
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Hamid Bassiri
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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17
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Ascui G, Gálvez-Jirón F, Kramm K, Schäfer C, Siña J, Pola V, Cristi F, Hernández C, Garrido-Tapia M, Pesce B, Bustamante M, Fluxá P, Molina MC, Ribeiro CH. Decreased invariant natural killer T-cell-mediated antitumor immune response in patients with gastric cancer. Immunol Cell Biol 2020; 98:500-513. [PMID: 32189398 DOI: 10.1111/imcb.12331] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 03/16/2020] [Accepted: 03/16/2020] [Indexed: 12/24/2022]
Abstract
Gastric cancer (GC) is the third most common cause of cancer-related death worldwide. Invariant natural killer T (iNKT) cells are innate-like cytotoxic T lymphocytes involved in tumor immune surveillance. They can be activated either through CD1d-presented glycolipid antigens recognized by their invariant T-cell receptor, cytokines or by sensing tumor-associated stress-induced ligands through the natural killer group 2, member D (NKG2D) receptor. Although the number and functionality of iNKT cells may be decreased in several types of cancer, here we show that GC patients presented a mild increase in iNKT cell frequencies and numbers in the blood compared with healthy donors. In GC patients, iNKT cells, expanded in vitro with α-galactosyl ceramide and stimulated with phorbol 12-myristate 13-acetate and ionomycin, produced higher levels of interleukin-2 and transforming growth factor-beta, while their capacity to degranulate remained preserved. Because tumor-derived epithelial cell adhesion molecule-positive epithelial cells did not display surface CD1d, and NKG2D ligands (NKG2DLs) were detected in the gastric tumor milieu, we envisioned a role for NKG2D in iNKT cell functions. Peripheral iNKT cells from GC patients and controls presented similar levels of NKG2D; nevertheless, the percentages of interferon-γ-producing and CD107a-positive iNKT cells from patients were reduced upon challenge with CD1d-negative, NKG2DL-positive K562 cells, suggesting a compromised response by iNKT cells in GC patients, which may not result from impaired NKG2D/NKG2DL signaling. The decreased response of iNKT cells may explain the fact that higher frequencies of circulating iNKT cells did not confer a survival benefit for GC patients. Therefore, functional impairment of iNKT cells in GC may contribute to tumor immune escape and favor disease progression.
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Affiliation(s)
- Gabriel Ascui
- Laboratory of Cancer Immunoediting, Immunology Program, Biomedical Sciences Institute (ICBM), School of Medicine of University of Chile, Santiago de Chile, Chile
| | - Felipe Gálvez-Jirón
- Laboratory of Cancer Immunoediting, Immunology Program, Biomedical Sciences Institute (ICBM), School of Medicine of University of Chile, Santiago de Chile, Chile
| | - Karina Kramm
- Laboratory of Cancer Immunoediting, Immunology Program, Biomedical Sciences Institute (ICBM), School of Medicine of University of Chile, Santiago de Chile, Chile
| | - Carolina Schäfer
- Laboratory of Cancer Immunoediting, Immunology Program, Biomedical Sciences Institute (ICBM), School of Medicine of University of Chile, Santiago de Chile, Chile
| | - Josefina Siña
- Laboratory of Cancer Immunoediting, Immunology Program, Biomedical Sciences Institute (ICBM), School of Medicine of University of Chile, Santiago de Chile, Chile
| | - Víctor Pola
- Laboratory of Cancer Immunoediting, Immunology Program, Biomedical Sciences Institute (ICBM), School of Medicine of University of Chile, Santiago de Chile, Chile
| | - Francisca Cristi
- Laboratory of Cancer Immunoediting, Immunology Program, Biomedical Sciences Institute (ICBM), School of Medicine of University of Chile, Santiago de Chile, Chile
| | - Carolina Hernández
- Laboratory of Immune Surveillance and Immune Evasion, Immunology Program, Biomedical Sciences Institute (ICBM), School of Medicine of University of Chile, Santiago de Chile, Chile
| | - Macarena Garrido-Tapia
- Laboratory of Immune Surveillance and Immune Evasion, Immunology Program, Biomedical Sciences Institute (ICBM), School of Medicine of University of Chile, Santiago de Chile, Chile
| | - Bárbara Pesce
- MED.UCHILE-FACS Laboratory, Biomedical Sciences Institute (ICBM), School of Medicine of University of Chile, Santiago de Chile, Chile
| | - Marco Bustamante
- Department of Surgery (Oriente), Hospital del Salvador, University of Chile, Santiago de Chile, Chile
| | - Paula Fluxá
- Department of Surgery (Oriente), Hospital del Salvador, University of Chile, Santiago de Chile, Chile
| | - María C Molina
- Laboratory of Immune Surveillance and Immune Evasion, Immunology Program, Biomedical Sciences Institute (ICBM), School of Medicine of University of Chile, Santiago de Chile, Chile.,Centro de InmunoBiotecnología, Immunology Program, Biomedical Sciences Institute (ICBM), School of Medicine of University of Chile, Santiago de Chile, Chile
| | - Carolina H Ribeiro
- Laboratory of Cancer Immunoediting, Immunology Program, Biomedical Sciences Institute (ICBM), School of Medicine of University of Chile, Santiago de Chile, Chile
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18
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Zhong X, Zhang Y, Wang L, Zhang H, Liu H, Liu Y. Cellular components in tumor microenvironment of neuroblastoma and the prognostic value. PeerJ 2019; 7:e8017. [PMID: 31844563 PMCID: PMC6910112 DOI: 10.7717/peerj.8017] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 10/09/2019] [Indexed: 01/14/2023] Open
Abstract
Background Tumor microenvironment (TME) contributes to tumor development, progression, and treatment response. In this study, we detailed the cell composition of the TME in neuroblastoma (NB) and constructed a cell risk score model to predict the prognosis of NB. Methods xCell score was calculated through transcriptomic data from the datasets GSE49711 and GSE45480 based on the xCell algorithm. The random forest method was employed to select important features and the coefficient was obtained via multivariate cox regression analysis to construct a prognostic model, and the performance was validated in another two independent datasets, GSE16476 and TARGET-NBL. Results We found that both immune and non-immune cells varies significantly in different prognostic groups, and were correlated with survival time. The proposed prognostic cell risk score (pCRS) model we constructed can be an independent prognostic indicator for overall survival (OS) and event-free survival (EFS) (training: OS, HR 1.579, EFS, HR 1.563; validation: OS, HR 1.665, 3.848, EFS, HR 2.203, all p-values < 0.01) and only independent prognostic factor in International Neuroblastoma Risk Group high risk patients (HR 1.339, 3.631; p-value 1.76e–2, 3.71e–5), rather than MYCN amplification. Besides, pCRS model showed good performance in grouping, in discriminating MYCN status, the area under the curve (AUC) was 0.889, 0.933, and 0.861 in GSE49711, GSE45480, and GSE16476, respectively. In separating high risk groups, the AUC was 0.904 in GSE49711. Conclusion This study details the cellular components in the TME of NB through gene expression data, the proposed pCRS model might provide a basis for treatment selection of high risk patients or targeting cellular components of TME in NB.
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Affiliation(s)
- Xiaodan Zhong
- College of Computer Science and Technology, Jilin University, Changchun, Jilin, China.,Department of Pediatric Oncology, The First Hospital of Jilin University, Changchun, Jilin, China.,Key Laboratory of Symbolic Computation and Knowledge Engineering, Ministry of Education, Jilin University, Changchun, Jilin, China
| | - Yutong Zhang
- Department of Pediatric Oncology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Linyu Wang
- College of Computer Science and Technology, Jilin University, Changchun, Jilin, China.,Key Laboratory of Symbolic Computation and Knowledge Engineering, Ministry of Education, Jilin University, Changchun, Jilin, China
| | - Hao Zhang
- College of Computer Science and Technology, Jilin University, Changchun, Jilin, China.,Key Laboratory of Symbolic Computation and Knowledge Engineering, Ministry of Education, Jilin University, Changchun, Jilin, China
| | - Haiming Liu
- College of Computer Science and Technology, Jilin University, Changchun, Jilin, China.,Key Laboratory of Symbolic Computation and Knowledge Engineering, Ministry of Education, Jilin University, Changchun, Jilin, China
| | - Yuanning Liu
- College of Computer Science and Technology, Jilin University, Changchun, Jilin, China.,Key Laboratory of Symbolic Computation and Knowledge Engineering, Ministry of Education, Jilin University, Changchun, Jilin, China
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19
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Wang Z, Wang Z, Li B, Wang S, Chen T, Ye Z. Innate Immune Cells: A Potential and Promising Cell Population for Treating Osteosarcoma. Front Immunol 2019; 10:1114. [PMID: 31156651 PMCID: PMC6531991 DOI: 10.3389/fimmu.2019.01114] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 05/01/2019] [Indexed: 12/13/2022] Open
Abstract
Advanced, recurrent, or metastasized osteosarcomas remain challenging to cure or even alleviate. Therefore, the development of novel therapeutic strategies is urgently needed. Cancer immunotherapy has greatly improved in recent years, with options including adoptive cellular therapy, vaccination, and checkpoint inhibitors. As such, immunotherapy is becoming a potential strategy for the treatment of osteosarcoma. Innate immunocytes, the first line of defense in the immune system and the bridge to adaptive immunity, are one of the vital effector cell subpopulations in cancer immunotherapy. Innate immune cell-based therapy has shown potent antitumor activity against hematologic malignancies and some solid tumors, including osteosarcoma. Importantly, some immune checkpoints are expressed on both innate and adaptive immune cells, modulating their functions in tumor immunity. Therefore, blocking or activating immune checkpoint-mediated downstream signaling pathways can improve the therapeutic effects of innate immune cell-based therapy. In this review, we summarize the current status and future prospects of innate immune cell-based therapy for the treatment of osteosarcoma, with a focus on the potential synergistic effects of combination therapy involving innate immunotherapy and immune checkpoint inhibitors/oncolytic viruses.
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Affiliation(s)
- Zenan Wang
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Orthopedic Research, Zhejiang University, Hangzhou, China
| | - Zhan Wang
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Orthopedic Research, Zhejiang University, Hangzhou, China
| | - Binghao Li
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Orthopedic Research, Zhejiang University, Hangzhou, China
| | - Shengdong Wang
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Orthopedic Research, Zhejiang University, Hangzhou, China
| | - Tao Chen
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Orthopedic Research, Zhejiang University, Hangzhou, China
| | - Zhaoming Ye
- Department of Orthopedics, Musculoskeletal Tumor Center, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Orthopedic Research, Zhejiang University, Hangzhou, China
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20
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Godfrey DI, Le Nours J, Andrews DM, Uldrich AP, Rossjohn J. Unconventional T Cell Targets for Cancer Immunotherapy. Immunity 2018; 48:453-473. [PMID: 29562195 DOI: 10.1016/j.immuni.2018.03.009] [Citation(s) in RCA: 214] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 03/01/2018] [Accepted: 03/02/2018] [Indexed: 02/07/2023]
Abstract
Most studies on the immunotherapeutic potential of T cells have focused on CD8 and CD4 T cells that recognize peptide antigens (Ag) presented by polymorphic major histocompatibility complex (MHC) class I and MHC class II molecules, respectively. However, unconventional T cells, which interact with MHC class Ib and MHC-I like molecules, are also implicated in tumor immunity, although their role therein is unclear. These include unconventional T cells targeting MHC class Ib molecules such as HLA-E and its murine ortholog Qa-1b, natural killer T (NKT) cells, mucosal associated invariant T (MAIT) cells, and γδ T cells. Here, we review the current understanding of the roles of these unconventional T cells in tumor immunity and discuss why further studies into the immunotherapeutic potential of these cells is warranted.
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Affiliation(s)
- Dale I Godfrey
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, Victoria 3010, Australia; ARC Centre of Excellence in Advanced Molecular Imaging, University of Melbourne, Parkville, Victoria 3010, Australia.
| | - Jérôme Le Nours
- Infection and Immunity Program and The Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, Victoria 3800, Australia; ARC Centre of Excellence in Advanced Molecular Imaging, Monash University, Clayton, Victoria 3800, Australia
| | - Daniel M Andrews
- Department of Immunology and Pathology, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Adam P Uldrich
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, Victoria 3010, Australia; ARC Centre of Excellence in Advanced Molecular Imaging, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Jamie Rossjohn
- Infection and Immunity Program and The Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, Victoria 3800, Australia; ARC Centre of Excellence in Advanced Molecular Imaging, Monash University, Clayton, Victoria 3800, Australia; Institute of Infection and Immunity, Cardiff University, School of Medicine, Heath Park, Cardiff CF14 4XN, UK.
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21
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Twist CJ, Naranjo A, Schmidt ML, Tenney SC, Cohn SL, Meany HJ, Mattei P, Adkins ES, Shimada H, London WB, Park JR, Matthay KK, Maris JM. Defining Risk Factors for Chemotherapeutic Intervention in Infants With Stage 4S Neuroblastoma: A Report From Children's Oncology Group Study ANBL0531. J Clin Oncol 2018; 37:115-124. [PMID: 30444686 DOI: 10.1200/jco.18.00419] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE Infants with stage 4S neuroblastoma usually have favorable outcomes with observation or minimal chemotherapy. However, young infants with symptoms secondary to massive hepatomegaly or with unfavorable tumor biology are at high risk of death. Our aim was to improve outcomes for patients with symptomatic and/or unfavorable biology 4S neuroblastoma with a uniform treatment approach using a biology- and response-based algorithm. PATIENTS AND METHODS The subset of patients with 4S disease with MYCN-not amplified tumors with impaired or impending organ dysfunction, or with unfavorable histology and/or diploid DNA index, were eligible. Patients were assigned to receive two, four, or eight cycles of chemotherapy on the basis of histology, diploid DNA index, chromosome arm 1p or 11q loss of heterozygosity (LOH) status, and symptoms. RESULTS Forty-nine eligible patients were enrolled: 41 were symptomatic and 28 had unfavorable biology. Seventeen patients (symptomatic, favorable biology) were assigned two cycles, 21 patients (any unfavorable biologic feature without 1p or 11q LOH) were assigned four cycles, and 11 patients (unfavorable biology including 1p and/or 11q LOH [n = 7] or symptomatic with unknown biology [n = 4]), were assigned eight cycles. The 3-year overall survival was 81.4% ± 5.8%. Eight of nine deaths were in patients younger than 2 months of age at diagnosis (median, 9 days [range, 1 to 68 days]): five acute deaths were a result of hepatomegaly and associated toxicities; two were a result of late relapse in patients with unfavorable biology; and two were a result of treatment complications. No deaths occurred after protocol-mandated pre-emptive treatment of infants younger than 2 months with hepatomegaly, regardless of symptoms. A new scoring algorithm for emergent chemotherapy in patients with 4S disease was developed on the basis of this experience. CONCLUSION The outcome for 4S neuroblastoma can be improved with pre-emptive chemotherapy for evolving hepatomegaly or other baseline comorbidities in infants younger than 2 months of age.
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Affiliation(s)
| | | | - Mary Lou Schmidt
- 3 University of Illinois at Chicago College of Medicine, Chicago, IL
| | | | | | - Holly J Meany
- 5 Children's National Medical Center, Washington, DC
| | - Peter Mattei
- 6 Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | - Wendy B London
- 9 Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA
| | | | - Katherine K Matthay
- 11 University of California San Francisco School of Medicine and UCSF Benioff Children's Hospital, San Francisco, CA
| | - John M Maris
- 6 Children's Hospital of Philadelphia, Philadelphia, PA.,12 Perelman School of Medicine, Philadelphia, PA
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22
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Consonni M, Dellabona P, Casorati G. Potential advantages of CD1-restricted T cell immunotherapy in cancer. Mol Immunol 2018; 103:200-208. [PMID: 30308433 DOI: 10.1016/j.molimm.2018.09.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/01/2018] [Accepted: 09/29/2018] [Indexed: 12/11/2022]
Abstract
Adoptive cell therapy (ACT) using tumor-specific "conventional" MHC-restricted T cells obtained from tumor-infiltrating lymphocytes, or derived ex vivo by either antigen-specific expansion or genetic engineering of polyclonal T cell populations, shows great promise for cancer treatment. However, the wide applicability of this therapy finds limits in the high polymorphism of MHC molecules that restricts the use in the autologous context. CD1 antigen presenting molecules are nonpolymorphic and specialized for lipid antigen presentation to T cells. They are often expressed on malignant cells and, therefore, may represent an attractive target for ACT. We provide a brief overview of the CD1-resticted T cell response in tumor immunity and we discuss the pros and cons of ACT approaches based on unconventional CD1-restricted T cells.
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Affiliation(s)
- Michela Consonni
- Experimental Immunology Unit, Division of Immunology, Transplantation and Infectious Diseases, San Raffaele Scientific Institute, Milano, Italy.
| | - Paolo Dellabona
- Experimental Immunology Unit, Division of Immunology, Transplantation and Infectious Diseases, San Raffaele Scientific Institute, Milano, Italy
| | - Giulia Casorati
- Experimental Immunology Unit, Division of Immunology, Transplantation and Infectious Diseases, San Raffaele Scientific Institute, Milano, Italy
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23
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Krijgsman D, Hokland M, Kuppen PJK. The Role of Natural Killer T Cells in Cancer-A Phenotypical and Functional Approach. Front Immunol 2018. [PMID: 29535734 PMCID: PMC5835336 DOI: 10.3389/fimmu.2018.00367] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Natural killer T (NKT) cells are a subset of CD1d-restricted T cells at the interface between the innate and adaptive immune system. NKT cells can be subdivided into functional subsets that respond rapidly to a wide variety of glycolipids and stress-related proteins using T- or natural killer (NK) cell-like effector mechanisms. Because of their major modulating effects on immune responses via secretion of cytokines, NKT cells are also considered important players in tumor immunosurveillance. During early tumor development, T helper (TH)1-like NKT cell subsets have the potential to rapidly stimulate tumor-specific T cells and effector NK cells that can eliminate tumor cells. In case of tumor progression, NKT cells may become overstimulated and anergic leading to deletion of a part of the NKT cell population in patients via activation-induced cell death. In addition, the remaining NKT cells become hyporesponsive, or switch to immunosuppressive TH2-/T regulatory-like NKT cell subsets, thereby facilitating tumor progression and immune escape. In this review, we discuss this important role of NKT cells in tumor development and we conclude that there should be three important focuses of future research in cancer patients in relation with NKT cells: (1) expansion of the NKT cell population, (2) prevention and breaking of NKT cell anergy, and (3) skewing of NKT cells toward TH1-like subsets with antitumor activity.
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Affiliation(s)
- Daniëlle Krijgsman
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands.,Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | | | - Peter J K Kuppen
- Department of Surgery, Leiden University Medical Center, Leiden, Netherlands
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