Immunotherapy of non-Hodgkin's lymphoma with hLL2 (epratuzumab, an anti-CD22 monoclonal antibody) and Hu1D10 (apolizumab)

Lipid Nanoparticles─From Liposomes to mRNA Vaccine Delivery, a Landscape of Research Diversity and Advancement

Lipid nanoparticles (LNPs) have emerged across the pharmaceutical industry as promising vehicles to deliver a variety of therapeutics. Currently in the spotlight as vital components of the COVID-19 mRNA vaccines, LNPs play a key role in effectively protecting and transporting mRNA to cells. Liposomes, an early version of LNPs, are a versatile nanomedicine delivery platform. A number of liposomal drugs have been approved and applied to medical practice. Subsequent generations of lipid nanocarriers, such as solid lipid nanoparticles, nanostructured lipid carriers, and cationic lipid-nucleic acid complexes, exhibit more complex architectures and enhanced physical stabilities. With their ability to encapsulate and deliver therapeutics to specific locations within the body and to release their contents at a desired time, LNPs provide a valuable platform for treatment of a variety of diseases. Here, we present a landscape of LNP-related scientific publications, including patents and journal articles, based on analysis of the CAS Content Collection, the largest human-curated collection of published scientific knowledge. Rising trends are identified, such as nanostructured lipid carriers and solid lipid nanoparticles becoming the preferred platforms for numerous formulations. Recent advancements in LNP formulations as drug delivery platforms, such as antitumor and nucleic acid therapeutics and vaccine delivery systems, are discussed. Challenges and growth opportunities are also evaluated in other areas, such as medical imaging, cosmetics, nutrition, and agrochemicals. This report is intended to serve as a useful resource for those interested in LNP nanotechnologies, their applications, and the global research effort for their development.

Anti-CD22 CAR-T Cell Therapy as a Salvage Treatment in B Cell Malignancies Refractory or Relapsed After Anti-CD19 CAR-T therapy

Background

To observe efficacy of the anti-CD22 chimeric antigen receptor modified (anti-CD22-CAR) T cell salvage therapy in relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL) and B cell acute lymphoid leukemia (B-ALL) patients whose disease did not reach CR or progressed again after anti-CD19-CAR T cell therapy.

Methods

In our study, seven R/R DLBCL patients reached stable disease (SD) or progression of disease (PD) after their anti-CD19-CAR T cell therapy. Only three in all the six R/R B-ALL patients obtained complete response (CR)/CR with incomplete count recovery (Cri) in their anti-CD19-CAR T cell therapy, but they relapsed again in the following three, six and one months. Then, all these thirteen R/R DLBCL and B-ALL patients received anti-CD22 CAR-T cell salvage therapy because their disease did not reach CR or progressed again.

Results

Four R/R DLBCL patients obtained CR, while two R/R DLBCL patients achieved PR and one patient achieved SD. But only two R/R B-ALL patients obtained Cri in their anti-CD22 CAR-T cell salvage therapy. The overall survival (OS) of R/R DLBCL patients after the anti-CD22 CAR-T cell therapy was 6.142±3.395 months until August 31, 2020. There was no different of the median expansion peaks of the two kinds of CAR T cells (P=0.920). The time of anti-CD22-CAR T cell proportion peak days was later than that of the time of anti-CD19-CAR T cell peak days post infusion (P=0.022). Their cytokine release syndrome (CRS) was graded 2-4 in their anti-CD19-CAR T cell therapy, while the notable CRS was graded 1-2 in their anti-CD22-CAR T cell therapy. But there was no difference in the CRS and the immune effect or cell associated neurotoxic syndrome (ICANS) grades in the two kinds of therapies. And there was no difference in the hematological toxicity grades in the two kinds of therapies.

Conclusion

The anti-CD22-CAR T cell salvage therapy is highly effective in R/R DLBCL patients than in R/R B-ALL patients who failed in anti-CD19-CAR T cell therapy before. We need to expand the number of R/R DLBCL or B-ALL patients and continue to observe.

Trial Registration

ChiCTR-ONN-16009862 and ChiCTR1800019298.

Exploring the role of immunotherapeutic drugs in autoimmune diseases: A comprehensive review

Autoimmune diseases are group of disorders where an immune response is mounted against the self. The prevalence and burden of this well established and recognised entity is on the rise. Irrespective of being a systemic or organ specific autoimmune disorder, the common underlying mechanism of action, is the imbalance in immune system resulting in loss of tolerance to self-antigens. The oral cavity is no alien to these disorders or to their influences. Pemphigus group of lesions, systemic lupus erythematosus, psoriasis and even Sjogren's syndrome are some of the established autoimmune disorders with prominent oral manifestations. Though these diseases are well documented and enumerated, however addressing them is where the dilemma lies. Science, research and discoveries are a crucial part of medical discipline which help in looking beyond the horizon. With the introduction of selective targeted immunotherapies for autoimmune diseases as a treatment modality either in solitary or in combination with the conventional immunosuppressive treatments, are emerging as a promising elixir for patients enduring them. However, being unique, exploration of these biologics from its inception, to its mechanism of action, recognition of its application and evaluation of its safety norms are equally vital. Therefore, this review aims to provide a comprehensive particular on the novel biologics, the immunotherapies in autoimmune disorders targeting the different cells, their receptors or cytokines of the immune system.

Anti-CD22 epratuzumab for systemic lupus erythematosus: A systematic review and meta-analysis of randomized controlled trials

Systemic lupus erythematosus (SLE) is a remarkable and challenging autoimmune disorder that is characterized by a broad range of clinical manifestations, such as flares and remissions. Recently, the humanized anti-CD22 antibody epratuzumab for SLE has been extensively studied. The aim of the present study was to perform a meta-analysis on the findings of associated randomized controlled trials in order to evaluate the effects of epratuzumab on SLE. Data from publications in PubMed, EMBASE and the Cochrane Library were collected up to March 2017. To calculate the risk ratio or standardized mean differences (SMDs) with 95% confidence intervals (CIs), a random effect model was applied when heterogeneity was significant and a fixed effect model was used when heterogeneity was negligible. All statistical tests were performed using Review Manager 5.3 software. A total of 1,921 participants in 4 studies (5 trials) that met the selection criteria were analyzed in this meta-analysis. Analyses of the BILAG-based Combined Lupus Assessment (BICLA) response and SLE Disease Activity Index 2000 (SLEDA-2K) score revealed that epratuzumab (720-3,600 mg) significantly improved the BICLA response (RR=1.09; 95% CI, 1.04 to 1.14) and decreased the SLEDA-2K score (SMD=-0.31; 95% CI, -0.67 to 0.06; P=0.10). While the British Isles Lupus Assessment Group index score was not significantly altered between the epratuzumab and control groups. For safety analyses, no statistically significant differences were identified between the two groups, which were proved by the pooled results (all P-values >0.05). These findings suggested that epratuzumab may be relatively safe and may have better therapeutic effectiveness than placebo control conditions in patients with SLE.

Targeting CD22 in B-cell malignancies: current status and clinical outlook

CD22 is a B-cell-specific transmembrane glycoprotein found on the surface of most B cells; it modulates B-cell function, survival and apoptosis. CD22 has emerged as an ideal target for monoclonal antibody (mAb)-based therapy of B-cell malignancies including most lymphomas and many leukemias. Epratuzumab, an anti-CD22 mAb, has been developed in various forms, including as an unlabeled (naked) mAb, as a radioimmunotherapeutic, as an antibody drug conjugate (ADC), and as a vehicle for CD22-targeted nanoparticles. While clinical trials with unlabeled epratuzumab have demonstrated modest results, its combination with rituximab in phase II studies has been more encouraging. Based on the potential for CD22 to become internalized, CD22-targeted constructs carrying radioisotopes or toxins have generated promising results. Radioimmunotherapy, utilizing ⁹⁰Y-labeled epratuzumab, was shown to be highly effective in patients with follicular lymphoma, generating a complete response (CR) rate of 92 % and progression-free survival of more than 2 years. ADC therapy is a promising therapeutic approach to B-cell malignancies which includes the direct conjugation of mAbs with cytotoxic agents. Phase II studies of inotuzumab ozogamicin, an ADC which combines anti-CD22 mAb with calicheamicin, an enediyne antibiotic which mediates apoptosis, in patients with acute lymphoblastic leukemia have produced an overall response rate (ORR) of greater than 50 % in treatment-refractory patients. Phase I trials of moxetumomab pasudotox, an ADC which combines anti-CD22 with PE38, a fragment of Pseudomonas exotoxin A, have been completed in hairy cell leukemia with a ORR of 86 %. Finally, a review of CD22-targeted nanoparticles, that include a doxorubicin-containing lipid complex that uses synthetic high-affinity CD22 ligand mimetics as well as anti-CD22 mAb-coated pegylated liposomas doxorubin (PLD), has demonstrated promising results in pre-clinical models of human lymphoma. Moreover, novel anti-CD22 mAb that block CD22 ligand binding as well as second generation ADC that utilize biodegradable linkers and more potent toxins hold great hope for the future of CD22-targeted therapeutics that may translate into better outcomes for patients with CD22-positive malignancies.

Cancer dormancy: lessons from a B cell lymphoma and adenocarcinoma of the prostate

Cancer dormancy delineates a situation in which residual tumor cells persist in a patient with no apparent clinical symptoms. Although the precise mechanisms underlying cancer dormancy have not been explained, experimental models have provided some insights into the factors that might be involved in the induction and maintenance of a tumor dormant state. The authors of the present chapter studied a murine B cell lymphoma that can be made dormant when interacting with antibodies directed against the idiotype on its immunoglobulin Ig receptor. This experimental model of antibody-induced dormancy enabled the isolation and characterization of dormant lymphoma cells. The results indicated that anti-Ig antibodies activate growth-inhibiting signals that induced cycle arrest and apoptosis. This process appeared to be balanced by the growth of the tumor cells such that the tumor did not expand. In contrast, antibodies against HER-2expressed on prostate adenocarcinoma (PAC) cells were not growth inhibitory. However, an immunotoxin (IT) prepared by conjugating HER-2 to the A-chain of ricin (RTA) was internalized by PAC cells, followed by induction of cycle arrest and apoptotic death. Infusion of HER-2-specific IT into PAC-bearing immunodeficient mice did not eradicate the tumor but retained it dormant over an extended period of time. Hence, certain aspects of signaling receptors expressed on cancer can be manipulated by antibodies to induce and maintain a tumor dormant state.

Treatment of non-Hodgkin's lymphoma xenografts with the HB22.7 anti-CD22 monoclonal antibody and phosphatase inhibitors improves efficacy

PURPOSE

To examine the role of phosphatase inhibition on anti-CD22, HB22.7-mediated lymphomacidal effects.

EXPERIMENTAL DESIGN

CD22 is a cell-surface molecule expressed on most B cell lymphomas (NHL). HB22.7 is an anti-CD22 monoclonal antibody that binds a unique CD22-epitope, blocks ligand binding, initiates signaling, and has demonstrated lymphomacidal activity. The SHP-1 tyrosine phosphatase is associated with the cytoplasmic domain of CD22. Sodium orthovanadate (NaV) is a phosphatase inhibitor. The SHP-1-CD22 interaction presents an opportunity to manipulate CD22-mediated signaling effects. In vitro cell culture assays and in vivo human NHL xenograft studies were used to assess the effects of phosphatase inhibition.

RESULTS

NaV caused dose dependent killing of NHL cells in vitro; when HB22.7 was given with NaV, antibody-mediated cell death was augmented. Flow cytometry showed that NaV-pretreatment resulted in less CD22 internalization after ligation with HB22.7 than did control cells. Studies in mice bearing Raji NHL xenografts showed that the combination of NaV and HB22.7 shrank NHL tumors more rapidly, had a higher complete response rate (80%), and produced the best survival compared to controls; no toxicity was detected. Studies using Raji cells stably transfected with SHP-1DN confirmed that these observations were due to SHP-1 inhibition.

CONCLUSION

The relatively specific association of SHP-1 with CD22 suggests that CD22-specific signal augmentation by phosphatase inhibitors can improve the clinical outcome of anti-CD22 based immunotherapy.

Siglecs as targets for therapy in immune-cell-mediated disease

The sialic-acid-binding immunoglobulin-like lectins (siglecs) comprise a family of receptors that are differentially expressed on leukocytes and other immune cells. The restricted expression of several siglecs to one or a few cell types makes them attractive targets for cell-directed therapies. The anti-CD33 (also known as Siglec-3) antibody gemtuzumab (Mylotarg) is approved for the treatment of acute myeloid leukemia, and antibodies targeting CD22 (Siglec-2) are currently in clinical trials for treatment of B cell non-Hodgkins lymphomas and autoimmune diseases. Because siglecs are endocytic receptors, they are well suited for a 'Trojan horse' strategy, whereby therapeutic agents conjugated to an antibody, or multimeric glycan ligand, bind to the siglec and are efficiently carried into the cell. Although the rapid internalization of unmodified siglec antibodies reduces their utility for induction of antibody-dependent cellular cytotoxicity or complement-mediated cytotoxicity, antibody binding of Siglec-8, Siglec-9 and CD22 has been demonstrated to induce apoptosis of eosinophils, neutrophils and depletion of B cells, respectively. Here, we review the properties of siglecs that make them attractive for cell-targeted therapies.

Monoclonal antibodies for cancer immunotherapy

Monoclonal antibodies are effective treatments for many malignant diseases. However, the ability of antibodies to initiate tumour-antigen-specific immune responses has received less attention than have other mechanisms of antibody action. We describe the rationale and evidence for the development of antibodies that can stimulate host tumour-antigen-specific immune responses. Such responses can be induced through the induction of antibody-dependent cellular cytotoxicity, promotion of antibody-targeted cross-presentation of tumour antigens, or by triggering of the idiotypic network. Future treatment modifications or combinations might be able to prolong, amplify, and shape these immune responses to increase the clinical benefits of antibody therapy for human cancer.

Engineering therapeutic monoclonal antibodies

During last two decades, the chimerization and humanization of monoclonal antibodies (mAbs) have led to the approval of several for the treatment of cancer, autoimmune diseases, and transplant rejection. Additional approaches have been used to further improve their in vivo activity. These include combining them with other modalities such as chemotherapy and redesigning them for improved pharmacokinetics, effector function, and signaling activity. The latter has taken advantage of new insights emerging from an increased understanding of the cellular and molecular mechanisms that are involved in the interaction of immunoglobulin G with Fc receptors and complement as well as the negative signaling resulting from the hypercrosslinking of their target antigens. Hence, mAbs have been redesigned to include mutations in their Fc portions, thereby endowing them with enhanced or decreased effector functions and more desirable pharmacokinetic properties. Their valency has been increased to decrease their dissociation rate from cells and enhance their ability to induce apoptosis and cell cycle arrest. In this review we discuss these redesigned mAbs and current data concerning their evaluation both in vitro and in vivo.

Targeting CD70 for human therapeutic use

Expression of CD70, a member of the tumor necrosis factor superfamily, is restricted to activated T-and B-lymphocytes and mature dendritic cells. Binding of CD70 to its receptor, CD27, is important in priming, effector functions, differentiation and memory formation of T-cells as well as plasma and memory B-cell generation. Antibody blockade of CD70-CD27 interaction inhibits the onset of experimental autoimmune encephalomyelits and cardiac allograft rejection in mice. CD70 has been also detected on hematological tumors and on carcinomas. The highly restricted expression pattern of CD70 in normal tissues and its widespread expression in various malignancies as well as its potential role in autoimmune and inflammatory conditions makes it an attractive target for antibody-based therapeutics. This chapter provides an overview of the physiological role of CD70-CD27 interactions and discusses various approaches to target this pathway for therapeutic use in cancers and autoimmunity.

CD70 as a therapeutic target in human malignancies

BACKGROUND

Expression of CD70, a member of the tumor necrosis factor superfamily, is restricted to activated T and B lymphocytes and mature dendritic cells. CD70 has also been detected on hematological tumors and on carcinomas. The restricted expression pattern of CD70 in normal tissues and its widespread expression in various malignancies makes it an attractive target for antibody-based therapeutics. Investigations to exploit CD70 as a cancer target have lead to the identification of potential antibody-based clinical candidates. Anti-CD70 antibodies for therapeutic use have been developed and used to validate CD70 as a target for cancers. Antibodies are also used as a vehicle to deliver potent cytotoxic drugs to target CD70+ malignant cells. Both unconjugated antibodies and antibody-drug conjugates targeting CD70 have been tested in animal models of human cancers.

OBJECTIVE

To describe the expression of CD70 in cancer cells and the development of antibody-based therapies against CD70.

METHODS

A review of the available literature.

RESULTS/CONCLUSIONS

Humanized anti-CD70 antibodies have shown significant antitumor activity in preclinical xenograft models of cancer. Additionally, anti-CD70 antibody-drug conjugates exhibit potent antitumor activity in solid tumor xenograft models, confirming increased therapeutic efficacy through cytotoxic drug delivery. Thus, preclinical animal models have provided strong evidence that targeting CD70 either with unconjugated antibodies or with antibody-drug conjugates represents a promising approach to treat human malignancies.

Lym-1-induced apoptosis of non-Hodgkin's lymphomas produces regression of transplanted tumors

Lym-1 was one of the first antibodies to be used successfully for the radioimmunotherapy of the human malignant lymphomas. This antibody, which recognizes the HLA-DR10 antigen preferentially expressed in B-cell lymphomas, was recently shown to induce apoptosis upon binding to lymphoma cells. In this study, Lym-1-induced apoptosis was studied to identify the potential molecular pathways of programmed cell death and to demonstrate the clinical potential of this antibody in the treatment of the human malignant lymphomas. Immunofluorescence microscopy revealed that Lym-1 stained focal areas of the cell surface, consistent with the fact that the HLA-DR10 antigen is associated with lipid rafts, a known prerequisite for apoptosis signaling. Likewise, Annexin V/propidium iodide staining and TUNEL assays demonstrated that both murine Lym-1 and chimeric Lym-1 induced both early and late apoptosis, respectively, unlike anti-CD20 rituximab. Furthermore, Lym-1 was found to produce a rapid loss of mitochondrial membrane potential and mitochondrial release of cytochrome C 14 hours post-Lym-1 treatment. Although it was found to activate caspase-3, inhibitors of caspase pathways showed that the Lym-1-induced apoptosis in lymphoma cell lines is independent of caspase induction. Finally, treatment studies in vivo demonstrated that, compared with murine anti-CD20 (2B8), Lym-1 was more effective in inducing the regression of human lymphoma xenografts. Based upon these results, chimeric Lym-1 should be especially effective in treating lymphoma patients, as, in addition to being able to elicit immune effector functions such as chimeric anti-CD20, it can also induce apoptosis directly upon cell binding.

Selective High-Affinity Ligand Antibody Mimics for Cancer Diagnosis and Therapy: Initial Application to Lymphoma/Leukemia

PURPOSE

More than two decades of research and clinical trials have shown radioimmunotherapy to be a promising approach for treating various forms of cancer. Lym-1 antibody, which binds selectively to HLA-DR10 on malignant B-cell lymphocytes, has proved to be effective in delivering radionuclides to non-Hodgkin's lymphoma and leukemia. Using a new approach to create small synthetic molecules that mimic the targeting properties of the Lym-1 antibody, a prototype, selective high-affinity ligand (SHAL), has been developed to bind to a unique region located within the Lym-1 epitope on HLA-DR10.

EXPERIMENTAL DESIGN

Computer docking methods were used to predict two sets of small molecules that bind to neighboring cavities on the beta subunit of HLA-DR10 surrounding a critical amino acid in the epitope, and the ligands were confirmed to bind to the protein by nuclear magnetic resonance spectroscopy. Pairs of these molecules were then chemically linked together to produce a series of bidentate and bisbidentate SHALs.

RESULTS

These SHALs bind with nanomolar to picomolar K(d)'s only to cell lines expressing HLA-DR10. Analyses of biopsy sections obtained from patients also confirmed that SHAL bound to both small and large cell non-Hodgkin's lymphomas mimicking the selectivity of Lym-1.

CONCLUSIONS

These results show that synthetic molecules less than 1/50th the mass of an antibody can be designed to exhibit strong binding to subtle structural features on cell surface proteins similar to those recognized by antibodies. This approach offers great potential for developing small molecule therapeutics that target other types of cancer and disease.

Induction of adaptive Anti-HER2/neu immune responses in a Phase 1B/2 trial of 2B1 bispecific murine monoclonal antibody in metastatic breast cancer (E3194): a trial coordinated by the Eastern Cooperative Oncology Group

2B1 is a bispecific murine monoclonal antibody that binds to the extracellular domains of HER2/neu and FcgammaRIII. 2B1 efficiently promotes the lysis of tumor cells overexpressing HER2/neu by natural killer cells and mononuclear phagocytes that express the FcgammaRIII A isoform. Here, we report the results of E3194, a phase 1B/2 trial conducted by the Eastern Cooperative Oncology Group that employed 2B1 therapy in 20 women with metastatic breast cancer. The median age was 51 years. All but 1 patient had received prior chemotherapy. After the first dose, 3 of the initial 8 patients experienced dose-limiting toxicities that required dose-reduction. The nature of these dose-limiting toxicities resulted in a reduced dose from 2.5 mg/m/d to 1 mg/m/d in the remaining 12 patients. Objective antitumor responses were not seen. However, 2B1 therapy induced adaptive immune responses to both intracellular and extracellular domains of HER2/neu. Even though 2B1 antibody therapy did not show activity in metastatic breast cancer at the current administered doses, the ability of this antibody to induce detectable immune responses against an important tumor antigen has implications for understanding the mechanisms by which antibodies that mediate antibody-directed cellular cytotoxicity may exert their clinical antitumor effects.

B lymphocytes as therapeutic targets in systemic lupus erythematosus

In recent years, experimental evidence supporting a major role of B cells in the pathogenesis of autoimmune diseases has grown. This includes the discovery of novel mechanisms of autoantibody pathogenicity and the potential of B cells to mediate inflammation and tissue injury. In some instances, engagement of the B cell receptor and other surface receptors is sufficient to stimulate B cells to produce antibody. As a result, B cells have become targets for immunointervention. In lupus, targeting B cell activation factor (BAFF, BLys) indicates that specific blockade of this longevity factor might be sufficient to suppress systemic autoimmunity. Targeting CD20 represents another promising avenue for the treatment of refractory lupus in both adults and children. Although the clinical data add weight to the importance of B cells in the pathogenesis of lupus, new targets for B cell depletion therapy are being investigated. In experimental models, combining CD19 and CD20 antibodies was more effective than either treatment alone.

Cure of incurable lymphoma

The most potent method for augmenting the cytocidal power of monoclonal antibody (MAb) treatment is to conjugate radionuclides to the MAb to deliver systemic radiotherapy (radioimmunotherapy; RIT). The antigen, MAb, and its epitope can make a difference in the performance of the drug. Additionally, the radionuclide, radiochemistry, chelator for radiometals and the linker between the MAb and chelator can have a major influence on the performance of drugs (radiopharmaceuticals) for RIT. Smaller radionuclide carriers, such as antibody fragments and mimics, and those used for pretargeting strategies, have been described and evaluated. All of these changes in the drugs and strategies for RIT have documented potential for improved performance and patient outcomes. RIT is a promising new therapy that should be incorporated into the management of patients with B-cell non-Hodgkin's lymphoma (NHL) soon after these patients have proven incurable. Predictable improvements using better drugs, strategies, and combinations with other drugs seem certain to make RIT integral to the management of patients with NHL, and likely lead to cure of currently incurable NHL.

T-cell activation and B-cell depletion in chimpanzees treated with a bispecific anti-CD19/anti-CD3 single-chain antibody construct

BscCD19xCD3 is a bispecific single-chain antibody construct with exceptional cytotoxic potency in vitro and in vivo. Here, we have investigated the biological activity of bscCD19xCD3 in chimpanzee, the only animal species identified in which bscCD19xCD3 showed bispecific binding, redirected B-cell lysis and cytokine production comparable to human cells. Pharmacokinetic analysis following 2-h intravenous infusion of 0.06, 0.1 or 0.12 mug/kg of bscCD19xCD3 as part of a dose escalation study in a single female chimpanzee revealed a half-life of approximately 2 h and elimination of the bispecific antibody from circulation within approximately 8 h after the end of infusion. This short exposure to bscCD19xCD3 elicited a transient increase in serum levels of IFNgamma, IL-6, IL-2, soluble CD25, and transiently upregulated expression of CD69 and MHC class II on CD8-positive cells. Cytokine release and upregulation of T-cell activation markers were not observed with vehicle controls. A multiple-dose study using 5 weekly doses of 0.1 mug/kg in two animals also showed transient cytokine release and an activation of peripheral T cells with a first-dose effect, accompanied by a transient lymphopenia. While oscillations of T-cell counts were relatively even during repeated treatments, the amplitudes of peripheral B cells declined with every infusion, which was not observed in a vehicle control animal. Our data show that bscCD19xCD3 can be safely administered to chimpanzees at dose levels that cause fully reversible T-cell activation and, despite a very short exposure time, cumulative loss of peripheral B lymphocytes. A clinical trial testing prolonged administration of bscCD19xCD3 (MT103) for improving efficacy is currently ongoing.

Concurrent administration of granulocyte colony-stimulating factor or granulocyte-monocyte colony-stimulating factor enhances the biological activity of rituximab in a severe combined immunodeficiency mouse lymphoma model

A predominant percentage of the in vivo antitumor activity of rituximab occurs through antibody-dependent cellular cytotoxicity (ADCC) via FcgammaRIII receptors. Co-expression of CD11b/CD18 (MAC-1), an adhesion molecule present in activated neutrophils, plays an important role in the induction of ADCC. The effects of granulocyte-monocyte colony-stimulating factor (GM-CSF) and granulocyte colony-stimulating factor (G-CSF) on the biological activity of rituximab were studied in a non-Hodgkin's lymphoma (NHL)-bearing severe combined immunodeficiency (SCID) mouse model. Natural killer (NK) cell-depleted SCID mice were inoculated intravenously with Raji cells. Animals were divided into 6 cohorts: group A: placebo (saline injection); group B: murine (m)-G-CSF; group C: m-GM-CSF; group D: rituximab alone; group E: concurrent m-G-CSF and rituximab; and group F: concurrent m-GM-CSF and rituximab. Treatment with G-CSF or GM-CSF led to a 1.5- to 2-fold increase of CD11b/CD18 expression in neutrophils. Treatment with G-CSF led to the highest expression of CD11b/CD18 on neutrophils. No antitumor activity was observed among mice treated with G-CSF or GM-CSF alone. After 3 months, survival rates were highest in animals treated with rituximab and G-CSF (53.3%) compared to rituximab alone (13.3%) or in combination with peg-GM-CSF (26.7%). Increasing neutrophil counts via cytokine stimulation may play an important role in augmenting rituximab-associated antitumor activity.

Monoclonal antibody therapy of cancer

The most significant recent advances in the application of monoclonal antibodies (mAbs) to oncology have been the introduction and approval of bevacizumab (Avastin), an anti-vascular endothelial growth factor antibody, and of cetuximab (Erbitux), an anti-epidermal growth factor antibody. In combination with standard chemotherapy regimens, bevacizumab significantly prolongs the survival of patients with metastatic cancers of the colorectum, breast and lung. Cetuximab, used alone or with salvage chemotherapy, produces clinically meaningful anti-tumor responses in patients with chemotherapy-refractory cancers of the colon and rectum. In addition, the anti-HER2/neu antibody trastuzumab (Herceptin), in combination with standard adjuvant chemotherapy, has been shown to reduce relapses and prolong disease-free and overall survival in high-risk patients after definitive local therapy for breast cancer. These exciting recent results provide optimism for the development of mAbs that bind novel targets, exploit novel mechanisms of action or possess improved tumor targeting. Progress in the clinical use of radioimmunoconjugates remains hindered by complexity of administration, toxicity concerns and insufficiently selective tumor targeting.

Direct Antilymphoma Effects on Human Lymphoma Cells of Monotherapy and Combination Therapy with CD20 and HLA-DR Antibodies and 90Y-Labeled HLA-DR Antibodies

PURPOSE

Monoclonal antibodies (mAb) in combination and mAbs combined with a radionuclide (radioimmunotherapy) have both been more effective in patients than mAb monotherapy.

EXPERIMENTAL DESIGN

Using assays of cell growth and viability, the dose response and temporal characteristics of CD20 (rituximab) and HLA-DR (Lym-1) mAbs, singly and in combination, and of 90Y-conjugated Lym-1 mAb have been characterized in five human lymphoma cell lines (B35M, Raji, SU-DHL-4, SU-DHL-6, and Ramos) spanning Burkitt's to diffuse large cell lymphoma. Although Ramos had a lower HLA-DR density, these cell lines were otherwise selected because of high cell surface CD20 and HLA-DR abundance. Assays of cell growth and death were done using microscopy and trypan blue dye.

RESULTS

Lym-1 and rituximab, used singly, showed direct antilymphoma effects; those of Lym-1 were often more potent than those of rituximab. Combinations of these mAbs were more effective, sometimes synergistic, than either mAb singly, even in more resistant SU-DHL-4 cells. Conjugation of 90Y to Lym-1 also augmented potency in all cell lines and overcame resistance to both Lym-1 and rituximab in Ramos cells.

CONCLUSIONS

Lym-1 exhibited substantially greater direct antilymphoma effects than rituximab in lymphoma cells in culture. Combination of Lym-1 with rituximab or 90Y increased potency and overcame treatment resistance in lymphoma cells. Greater use of combination therapies of this type to increase potency and range of effectiveness seems likely to improve patient outcome.

Treatment of Non-Hodgkin’s Lymphoma (NHL) With Radiolabeled Antibodies (mAbs)

Most patients with non-Hodgkin's lymphoma (NHL) achieve remission but, despite newer drugs, the natural history of this disease has not improved during the last 20 years. Less than one half of patients with aggressive NHL are cured, and few of those with low-grade NHL are curable. Furthermore, NHL becomes progressively more chemoresistant while remaining responsive to external beam radiation therapy. Radioimmunotherapy (RIT) is a logical strategy for the treatment of NHL because this disease is multifocal and radiosensitive. Because of their remarkable effectiveness for RIT, 2 anti-CD20 monoclonal antibodies (mAbs), one labeled with (111)In for imaging or (90)Y for therapy and a second labeled with (131)I for imaging and therapy, have been approved for use in patients with NHL. These drugs have proven remarkably effective and safe. Evidence for the importance of the radionuclide is manifested by the data in the randomized pivotal phase III trial of (90)Y-ibritumomab that revealed response rates were several times greater in the (90)Y-ibritumomab arm than in the rituximab arm. A second drug for RIT, (131)I-tositumomab, was compared in a pivotal trial with the efficacy of the last chemotherapy received by each patient. Once again, response rates were much higher for RIT. Both (90)Y-ibritumomab and (131)I-tositumomab require preinfusion of several hundred milligrams of unlabeled anti-CD20 mAb to obtain "favorable" biodistribution, that is, targeting of NHL. Response rates for other mAbs and radionuclides in NHL also have been high but these drugs have not reached the approval stage. These drugs can be used safely by physicians who have suitable training and judgment. Unlike chemotherapy, RIT is not associated with mucositis, hair loss, or persistent nausea or vomiting. Although hematologic toxicity is dose limiting, hospitalization for febrile neutropenia is uncommon. Randomized trials of RIT in different formulations have not been conducted, but there is evidence to suggest that the mAb, antigen, radionuclide, chelator, linker, and dosing strategy may make a difference in the outcome.

CD22: A Multifunctional Receptor That Regulates B Lymphocyte Survival and Signal Transduction

Recent advances in the study of CD22 indicate a complex role for this transmembrane glycoprotein member of the immunoglobulin superfamily in the regulation of B lymphocyte survival and proliferation. CD22 has been previously recognized as a potential lectin-like adhesion molecule that binds alpha2,6-linked sialic acid-bearing ligands and as an important regulator of B-cell antigen receptor (BCR) signaling. However, genetic studies in mice reveal that some CD22 functions are regulated by ligand binding, whereas other functions are ligand-independent and may only require expression of an intact CD22 cytoplasmic domain at the B-cell surface. Until recently, most of the functional activity of CD22 has been widely attributed to CD22's ability to recruit potent intracellular phosphatases and limit the intensity of BCR-generated signals. However, a more complex role for CD22 has recently emerged, including a central role in a novel regulatory loop controlling the CD19/CD21-Src-family protein tyrosine kinase (PTK) amplification pathway that regulates basal signaling thresholds and intensifies Src-family kinase activation after BCR ligation. CD22 is also central to the regulation of peripheral B-cell homeostasis and survival, the promotion of BCR-induced cell cycle progression, and is a potent regulator of CD40 signaling. Herein we discuss our current understanding of how CD22 governs these complex and overlapping processes, how alterations in these tightly controlled regulatory activities may influence autoimmune disease, and the current and future applications of CD22-directed therapies in oncology and autoimmunity.

Characterization of a new humanized anti-CD20 monoclonal antibody, IMMU-106, and Its use in combination with the humanized anti-CD22 antibody, epratuzumab, for the therapy of non-Hodgkin's lymphoma

PURPOSE

A new humanized anti-CD20 monoclonal antibody (MAb), IMMU-106, was evaluated to elucidate its action as an antilymphoma therapeutic, as a single agent, and in combination with the anti-CD22 MAb, epratuzumab.

EXPERIMENTAL DESIGN

Antiproliferative effects, apoptotic effects, and the ability of IMMU-106 to mediate complement-mediated cytotoxicity and antibody-dependent cellular cytotoxicity on a panel of non-Hodgkin's lymphoma (NHL) cell lines were compared with the chimeric anti-CD20 MAb, rituximab, and evaluated in light of the various levels of antigen expression by the cell lines. In vivo therapy studies were performed in SCID mice bearing disseminated Raji lymphoma.

RESULTS

The mechanisms of cytotoxicity of IMMU-106 were found to be similar to rituximab, and include direct apoptosis, antibody-dependent cellular cytotoxicity, and complement-mediated cytotoxicity. IMMU-106 was also found to be very similar to rituximab in terms of antigen-binding specificity, binding avidity, and dissociation constant. Treatment of Raji-bearing SCID mice with IMMU-106 yielded median survival increases of up to 4.2-fold compared with control mice. Survival in mice treated with IMMU-106 plus epratuzumab was compared with IMMU-106 treatment alone. Although the combined treatment did not improve median survival, an increased proportion of long-term survivors was observed. An enhanced antiproliferative effect was also observed in vitro in SU-DHL-6 cells when IMMU-106 was combined with epratuzumab. These findings are consistent with the up-regulation of CD22 expression observed after pretreatment of NHL cells in vitro with CD20 MAb (IMMU-106).

CONCLUSIONS

It is expected that in humans IMMU-106 should be at least as effective as rituximab and, due to its human framework construction, it may exhibit different pharmacokinetic, toxicity, and therapy profiles. In addition, it may be possible to enhance efficacy by combination therapy comprised of anti-CD20 and other B-cell lineage targeting MAbs, such as epratuzumab. The current results emphasize that in vitro as well as in vivo studies with many of the NHL cell lines were generally predictive of the known activity of anti-CD20 MAbs in NHL patients, as well as the enhanced efficacy of epratuzumab combined with rituximab observed in early clinical trials.

Bispecific Minibodies Targeting HER2/neu and CD16 Exhibit Improved Tumor Lysis When Placed in a Divalent Tumor Antigen Binding Format

Unconjugated monoclonal antibodies have emerged as important therapeutic agents for selected malignancies. One mechanism by which antibodies can exert cytotoxic effects is antibody-dependent cellular cytotoxicity (ADCC). In an effort to increase the efficiency of ADCC at tumor sites, we have focused on the construction of bispecific antibodies specific for the tumor antigen HER2/neu and the Fc gamma RIII-activating receptor (CD16) found on NK cells, mononuclear phagocytes, and neutrophils. Here, we describe the production of bispecific minibodies in two distinct binding formats. The parent minibody was constructed such that the IgG1 C(H)3 constant domain serves as the oligomerization domain and is attached to an anti-CD16 and an anti-HER2/ neu single-chain Fv via 19- and 29-amino acid linkers, respectively. This molecule can be expressed in mammalian cells from a dicistronic vector and has been purified using sequential affinity purification techniques. Analysis by surface plasmon resonance shows that the bispecific minibody can bind to HER2/neu and CD16, both individually and simultaneously. Furthermore, cytotoxicity studies show that the minibody can induce significant tumor cell lysis at a concentration as low as 20 nm. A trimeric, bispecific minibody (TriBi) that binds dimerically to HER2/neu and monomerically to CD16 induces equivalent cytotoxicity at lower antibody concentrations than either the parent minibody or the corresponding single-chain dimer. Both minibody constructs are stable in mouse and human serum for up to 72 h at 37 degrees C. These minibodies have the potential to target solid tumors and promote tumor lysis by natural killer cells and mononuclear phagocytes.

Antibody-targeted therapy: a paradigm of innovative treatment strategies in indolent and aggressive B-cell non-Hodgkin lymphoma

PURPOSE OF REVIEW

This review outlines the principles of treatment of indolent and aggressive B-cell lymphoma based on current knowledge on the classification of hematologic malignancies and the rationale to implement new antibody-targeted immunotherapeutic approaches.

RECENT FINDINGS

An update is provided on the use of antibody-targeted therapies in clinical trials, with emphasis on new, emerging strategies of immunotherapy in B-cell non-Hodgkin lymphoma.

SUMMARY

The success of immune-mediated therapies has encouraged studies on antibody-targeted therapy in B-cell non-Hodgkin lymphoma. Promising new approaches combine classical dose-intense chemotherapy with "tumor-specific" antibody targeting during several phases of the disease. The safety and efficacy of anti-CD20 in the treatment of indolent and aggressive B-cell non-Hodgkin lymphoma at any stage of disease, either as a single agent or as part of multimodality regimes, as an unconjugated antibody or as radioimmunoconjugate have changed dramatically our treatment strategies. Increasing insights into basic molecular biology and immunology of B-cell non-Hodgkin lymphoma may identify subgroups of patients categorized in current classification systems who may benefit from tailored approaches with new modality antibody-targeted therapy in near future.

Novel therapies for chronic lymphocytic leukemia

New therapies for chronic lymphocytic leukemia (CLL) are moving away from non-specific cytotoxic to more targeted approaches. The monoclonal antibody alemtuzumab induces responses in 33% to 43% of patients with relapsed or refractory disease, with 2-5% CR. Side effects include infusional reactions as well as immunosuppressive effects. Rituximab has limited activity in relapsed refractory patients, but response rates are comparable to follicular non-Hodgkin's lymphoma in untreated patients. Other antibodies in early phases of development include anti-CD23 [IDEC-152], anti-CD22 [epratuzumab], Hu1D10 [apolizumab], and anti-CD80 [anti-B7, IDEC-114]. Other agents that are being studied include denileukin diftitox fusion protein (Ontak), and bcl-2 antisense [G3139, Genasense]. The mechanism of action of the new drugs and their role in CLL, as well as the emergence of new prognostic markers are discussed.

Antibody-targeted chemotherapy with CMC-544: a CD22-targeted immunoconjugate of calicheamicin for the treatment of B-lymphoid malignancies

Antibody-targeted chemotherapy with gemtuzumab ozogamicin (CMA-676, a CD33-targeted immunoconjugate of N-acetyl-γ-calicheamicin dimethyl hydrazide [CalichDMH], a potent DNA-binding cytotoxic antitumor antibiotic) is a clinically validated therapeutic option for patients with acute myeloid leukemia (AML). Here, we describe the preclinical profile of another immunoconjugate of CalichDMH, CMC-544, targeted to CD22 expressed by B-lymphoid malignancies. CMC-544 comprises a humanized IgG4 anti-CD22 monoclonal antibody (mAb), G5/44, covalently linked to CalichDMH via an acid-labile 4-(4′-acetylphenoxy) butanoic acid (AcBut) linker. Both CMC-544 and unconjugated G5/44 bound human CD22 with subnanomolar affinity. CMC-544, but not unconjugated G5/44, exerted potent cytotoxicity against CD22+ B-cell lymphoma (BCL) cell lines (inhibitory concentration of 50%: 6-600 pM CalichDMH). CMC-544 caused a potent inhibition of growth of small but established BCL xenografts leading to cures (therapeutic index > 10). CMC-544 prevented the establishment of BCL xenografts and also caused regression of large BCLs (> 1.5 g tumor mass). In contrast, unconjugated CalichDMH, unconjugated G5/44, and an isotype-matched control conjugate, CMA-676, were ineffective against these BCL xenografts. Thus, CD22-targeted delivery of CalichDMH is a potent and effective preclinical therapeutic strategy for BCLs. The strong antitumor profile of CMC-544 supports its clinical evaluation as a treatment option for B-lymphoid malignancies.

Emerging antibody-targeted therapy in leukemia and lymphoma: current concepts and clinical implications

The success of immune-mediated therapies has encouraged studies on passive and active immunotherapy in leukemia and lymphoma. This review outlines the impact of increasing insights from basic immunology studies on the potentiation of effective immune responses and the identification of new antigens as targets for antibody (Ab)-targeted therapies. The principles of treatment in leukemia and lymphoma based on current knowledge on the classification of hematologic malignancies are reviewed, and discussed in the context of a rationale to implement new Ab-targeted immunotherapeutic approaches. An update is provided on the use of Ab-targeted therapies in clinical trials with emphasis on new emerging strategies to further expand the successful field of immunotherapy in leukemia and lymphoma.

Biotechnology and drug discovery: from bench to bedside

New biotechnology and drug discovery technologies are facilitating the rapid expansion of the clinical drug chest, empowering clinicians with a better understanding of disease as well as novel modalities for treating patients. Important research tools and themes include genomics, proteomics, ligand-receptor interaction, signal transduction, rational drug design, biochips, and microarrays. Emerging drug classes include monoclonal antibodies, cancer vaccines, gene therapy, antisense strands, enzymes, and proteins. In this article, we review these topics and illustrate their potential impact by presenting an overview of promising drugs in the pipeline. Clinicians who use these novel treatments must become familiar with these trends.

Rituximab (monoclonal anti-CD20 antibody): mechanisms of action and resistance

Rituximab, a chimeric monoclonal antibody targeted against the pan-B-cell marker CD20, was the first monoclonal antibody to be approved for therapeutic use. Treatment with rituximab at standard weekly dosing is effective in more than 50% of patients with relapsed or refractory CD20-positive follicular non-Hodgkin's lymphoma, but is not curative. It is less effective in other subtypes of CD20-positive lymphoma and for retreatment, even with CD20 still expressed. Thus, binding of rituximab to CD20 is not sufficient to kill many lymphoma cells, indicating that there are mechanisms of resistance. Mechanisms of cell destruction that have been demonstrated to be activated by rituximab binding to CD20 include direct signaling of apoptosis, complement activation and cell-mediated cytotoxicity. The relative importance of each of these mechanisms in determining clinical response to rituximab treatment remains a matter of conjecture. Thus, the role of various resistance pathways, some documented in experimental systems and others still hypothetical, remains uncertain. Resistance could potentially be mediated by alterations in CD20 expression or signaling, elevated apoptotic threshold, modulation of complement activity or diminished cellular cytotoxicity. As the first of an expanding class of anticancer agents, lessons learned regarding the mechanism of rituximab action and resistance will be of increasing importance.

Activated peripheral T lymphocytes undergo apoptosis when cultured with monocytes activated by HLA class II ligation

We treated PBMC with anti-MHC class II mAb known to inhibit T lymphocyte proliferation. Adherent cells from mAb-treated PBMC showed increased metabolic activity by the MTS assay that was not due to cell proliferation. PBMC cultured with solid-phase anti-class II mAb in chamber inserts inhibited, across a membrane, the proliferation of PBMC cultured with soluble anti-CD3 mAb. PBMC treated with both soluble mAb underwent apoptosis as shown by nucleosomal DNA fragmentation. The monocytes formed multinucleated giant cells as shown by fluorescent microscopy, and contained apoptotic bodies as shown by the TUNEL method and by electron microscopy. The apoptotic cells were identified as T cells by double-staining with anti-CD4/CD8-PE and annexin-V-FITC. Thus, MHC class II ligation stimulates monocytes to increase their metabolic activity, induce apoptosis of activated T lymphocytes, and phagocytize the apoptotic cells. TCR-mediated ligation of MHC class II may play a role in the downregulation of immune responses.

Immunotherapy of lymphoma: update and review of the literature

PURPOSE

The therapeutic options for treating patients with lymphoma have dramatically expanded with the advent of immune-based treatments. While monoclonal antibodies have quickly become incorporated into the therapeutic armamentarium in the treatment of lymphoma, others have struggled to find a niche. This review will summarize the state of the art of this burgeoning therapy.

RECENT FINDINGS

The optimal use and timing of existing immunotherapies such as rituximab and radioimmunoconjugates has generated much data in the past few years. Other research has concentrated on the development of newer generation antibodies with alternate binding sites, such as epratuzumab and HU1D10, and bispecific antibodies that can directly interact with cellular immunity. Furthermore, the role of therapeutic vaccines continued to be an important ongoing research question.

SUMMARY

This review will enumerate the available and most promising developments in immunotherapy as well as provide a working framework to incorporate them into the treatment paradigm for patients with lymphoma.

Monoclonal antibody therapy for cancer

Monoclonal antibody therapy has emerged as an important therapeutic modality for cancer. Unconjugated antibodies show significant efficacy in the treatment of breast cancer, non-Hodgkin's lymphoma, and chronic lymphocytic leukemia. Promising new targets for unconjugated antibody therapy include cellular growth factor receptors, receptors or mediators of tumor-driven angiogenesis, and B cell surface antigens other than CD20. Immunoconjugates composed of antibodies conjugated to radionuclides or toxins show efficacy in non-Hodgkin's lymphoma. One immunoconjugate containing an antibody and a chemotherapy agent exhibits clinically meaningful antitumor activity in acute myeloid leukemia. Numerous efforts to exploit the ability of antibodies to focus the activities of toxic payloads at tumor sites are under way and show early promise. The ability to create essentially human antibody structures has reduced the likelihood of host-protective immune responses that otherwise limit the duration of therapy. Antibody structures now can be readily manipulated to facilitate selective interaction with host immune effectors. Other structural manipulations that improve the selective targeting properties and rapid systemic clearance of immunoconjugates should lead to the design of effective new treatments, particularly for solid tumors.

Immunotherapy for lymphomas

A growing list of immunotherapeutic strategies is now being employed to combat lymphoid malignancies. These efforts are warranted given that B-cell lymphomas, particularly those of the common follicular subtype, are among the most "immune-responsive" of all human cancers. Although systemic cytokine therapies for B-cell malignancies have been largely disappointing to date, monoclonal antibody therapies, principally the anti-CD20 antibody rituximab, have already made enormous impact on the treatment algorithm for many B-cell lymphomas. Therapeutic vaccines targeting the tumor-specific immunoglobulin idiotype have demonstrated promising results against lymphomas in phase I/II studies and are currently being evaluated in phase III randomized trials. Additional vaccine therapies being developed include those based on dendritic cells, recombinant idiotype proteins, DNA, heat shock proteins, and gene-modified tumor cells. It is hoped that immunotherapeutic agents, used in tandem or in combination, may someday allow effective treatment of lymphoid malignancies and delay or even replace the need for conventional cytotoxic therapies.

Expression of serotherapy target antigens in Waldenstrom's macroglobulinemia: therapeutic applications and considerations

Monoclonal antibody (mAb) therapy (serotherapy) has been successfully used in the treatment of many B-cell malignancies, among them lymphoplasmacytic lymphoma, an uncommon disorder that includes patients with the clinicopathological diagnosis of Waldenstrom's macroglobulinemia (WM). Rituximab, a mAb directed at CD20, was recently demonstrated by us and others to induce remissions and facilitate hematological recovery in patients with WM. The expression of CD20, along with targets of other mAbs which are commercially available, currently in clinical trials, or in preclinical development, have not been extensively studied or well documented in lymphoplasmacytic lymphoma. As such, we examined by flow cytometric analysis tumor cells from a large series of patients with the histopathlogical diagnosis of lymphoplasmacytic lymphoma and the clinicopathological diagnosis of WM for expression of the serotherapy target antigens CD20, CD22, CD40, CD52, IgM, MUC1 core protein, and 1D10. These studies demonstrated antigen expression on >or=50% of bone marrow tumor cells (CD19(+), kappa/lambda light chain-restricted), respectively, from patients as follows: CD20 (98.3%), CD22 (88.3%), CD40 (83.3%), CD52 (77.4%), IgM (83.3%), MUC1 core protein (57.8%), and 1D10 (50%). Both interpatient and intrapatient tumor clone antigen expression was heterogeneous. Combined mAb therapy might be a useful approach to cope with this variation, and could be tailored to target all members of the tumor clone for an individual patient.

Monoclonal antibodies combined to chemotherapy for the treatment of patients with lymphoma

Humanized monoclonal antibodies have transformed the treatment of patients with lymphomas. The first application of these new drugs appeared less than 10 years ago but currently one patient will certainly receive them once or several time during the evolution of his disease. This review will cover the use of these monoclonal antibodies alone or in combination with chemotherapy. Rituximab, an unconjugated anti-CD20 chimeric antibody, is certainly the most widely used but other unconjugated or radiolabeled monoclonal antibodies catch up quickly. If there are randomized studies demonstrating the benefit of adding these drugs to the treatment of patients with lymphoma, very few studies have compared the activity of the different monoclonal antibodies. A lot of questions needs to be answered before the best setting of these drugs will be known.

Immunobiological treatments of hairy-cell leukaemia

Hairy cell leukaemia (HCL) is extremely responsive to purine analogue theropy developed during the early 1990s, but some patients have emerged with resistance to purine analogues. For these patients, as well as for those with primarily refractory HCL, new treatments are necessary. Several new therapeutic options have been developed for the salvage treatment of HCL. These include recombinant immunotoxins and unlabelled monoclonal antibodies (mAbs). Recombinant immunotoxins are chimeric proteins in which the Fv portion of a mAb is fused to a 38 kDa fragment of Pseudomonas exotoxin A. Two recombinant immunotoxins, BL22 and LMB-2, targeting CD22 and CD25, respectively, have demonstrated efficacy in patients with HCL resistant to purine analogues. BL22 was reported to induce complete remissions (CRs) in the majority of patients with cladribine-resistant HCL; its clinical efficacy and safety profile are currently being further defined. The unlabelled mAb rituximab has also been reported to induce responses in the majority of HCL patients treated, and several CRs have been observed.

New agents in the treatment of acute lymphocytic leukaemia

The overall prognosis of adult patients with acute lymphocytic leukaemia (ALL) has improved significantly over the past few decades. Combined modality strategies (e.g. chemotherapy used with targeted therapies such as monoclonal antibodies or tyrosine kinase inhibitors) may improve long-term disease-free survival. Still, most patients succumb to complications of disease progression, with current long-term disease-free survival rates of 30-45% overall. Thus, either new strategies or refinements of old ones are needed to improve the long-term prognosis. An increasing number of unique active new chemotherapeutic and biological agents are available for study. This chapter reviews new agents with the potential to be incorporated into therapeutic strategies for the treatment of ALL.

Ligand-targeted therapeutics in anticancer therapy

Cytotoxic chemotherapy or radiotherapy of cancer is limited by serious, sometimes life-threatening, side effects that arise from toxicities to sensitive normal cells because the therapies are not selective for malignant cells. So how can selectivity be improved? One strategy is to couple the therapeutics to antibodies or other ligands that recognize tumour-associated antigens. This increases the exposure of the malignant cells, and reduces the exposure of normal cells, to the ligand-targeted therapeutics.

Radioimmunotherapy in non-Hodgkin lymphoma

Targeted therapy using monoclonal antibodies against a tumor-specific antigen is now an established mode of therapy in the management of malignant lymphomas. Radioimmunotherapy, a novel way of delivering systemic radiotherapy concurrently with immunotherapy, has finally appeared on the horizon, with promising results. Recent clinical trials have demonstrated the safety and efficacy of radioimmunoconjugates. Durable antitumor responses have been achieved, even in heavily pretreated patients. The optimal position that these novel agents should take in the algorithm of lymphoma therapy remains to be defined.