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Lin Y, Han Q, Chen L, Wang Y, Ren P, Liu G, Lan L, Lei X, Chen J, Han F. Obinutuzumab in Refractory Membranous Nephropathy: A Case Series. Kidney Med 2024; 6:100853. [PMID: 39100869 PMCID: PMC11295861 DOI: 10.1016/j.xkme.2024.100853] [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] [Indexed: 08/06/2024] Open
Abstract
Rationale & Objective Membranous nephropathy (MN), recognized as an autoimmune kidney disease, responds well to anti-CD20 monoclonal antibodies. Obinutuzumab, a type Ⅱ humanized anti-CD20 and immunoglobulin G1 Fc-optimized monoclonal antibody, when compared with rituximab, has demonstrated superior efficacy in B-cell leukemia and lymphoma, especially in rituximab-resistant cases. However, the efficacy and safety of obinutuzumab in MN remain unclear. Study Design A case series study. Setting & Participants A total of 18 patients were diagnosed with MN and had received obinutuzumab at our center without secondary MN, undergoing dialysis, having a history of kidney transplantation, or infections requiring treatment. Exposure Obinutuzumab treatment. Outcomes Primary outcomes included remission rate, time to first remission, and first relapse-free survival time during the follow-up period. Analytical Approach Survival analysis was performed with Cox proportional hazards models, log-rank test, and Kaplan-Meier survival analysis. Results Patients with MN (median age of 52.5 years, 83.3% males) received an average dose of 2.1 ± 0.8 g of obinutuzumab during a median follow-up period of 13.6 months. During the follow-up, 17 patients (94.4%) achieved remission, with 12 patients (66.7%) achieving partial remission, and 5 patients (27.8%) achieving complete remission. The median time to first remission and first relapse-free survival time was 2.7 (1.0-6.1) months and 9.8 (2.6-11.2) months, respectively. Of 12 patients with previous rituximab treatment, all achieved remission successfully, with 8 (66.7%) achieving partial remission and 4 (33.3%) achieving complete remission. Adverse events were mostly mild, and no severe treatment-related adverse events were observed. Limitations Limited or missing data; risks of selection bias; or recall bias; underestimated first relapse-free survival time because of a limited follow-up period; unmonitored counts of CD19+ B-cells and other lymphocyte subsets. Conclusions Obinutuzumab demonstrated promising efficacy and safety in inducing remission in MN, particularly in patients with an unsatisfactory response to rituximab.
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Affiliation(s)
| | | | - Liangliang Chen
- Kidney Disease Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Institute of Nephrology, Zhejiang University, Hangzhou, China; National Key Clinical Department of Kidney Diseases, Hangzhou, China; Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Yaomin Wang
- Kidney Disease Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Institute of Nephrology, Zhejiang University, Hangzhou, China; National Key Clinical Department of Kidney Diseases, Hangzhou, China; Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Pingping Ren
- Kidney Disease Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Institute of Nephrology, Zhejiang University, Hangzhou, China; National Key Clinical Department of Kidney Diseases, Hangzhou, China; Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Guangjun Liu
- Kidney Disease Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Institute of Nephrology, Zhejiang University, Hangzhou, China; National Key Clinical Department of Kidney Diseases, Hangzhou, China; Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Lan Lan
- Kidney Disease Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Institute of Nephrology, Zhejiang University, Hangzhou, China; National Key Clinical Department of Kidney Diseases, Hangzhou, China; Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Xin Lei
- Kidney Disease Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Institute of Nephrology, Zhejiang University, Hangzhou, China; National Key Clinical Department of Kidney Diseases, Hangzhou, China; Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Institute of Nephrology, Zhejiang University, Hangzhou, China; National Key Clinical Department of Kidney Diseases, Hangzhou, China; Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Fei Han
- Kidney Disease Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Institute of Nephrology, Zhejiang University, Hangzhou, China; National Key Clinical Department of Kidney Diseases, Hangzhou, China; Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
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2
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Moquist PN, Zhang X, Leiske CI, Eng-Duncan NML, Zeng W, Bindman NA, Wo SW, Wong A, Henderson CM, Crowder K, Lyon R, Doronina SO, Senter PD, Neff-LaFord HD, Sussman D, Gardai SJ, Levengood MR. Reversible Chemical Modification of Antibody Effector Function Mitigates Unwanted Systemic Immune Activation. Bioconjug Chem 2024; 35:855-866. [PMID: 38789102 PMCID: PMC11191404 DOI: 10.1021/acs.bioconjchem.4c00212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 05/13/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024]
Abstract
Antibody effector functions including antibody-dependent cellular cytotoxicity (ADCC) and phagocytosis (ADCP) are mediated through the interaction of the antibody Fc region with Fcγ receptors present on immune cells. Several approaches have been used to modulate antibody Fc-Fcγ interactions with the goal of driving an effective antitumor immune response, including Fc point mutations and glycan modifications. However, robust antibody-Fcγ engagement and immune cell binding of Fc-enhanced antibodies in the periphery can lead to the unwanted induction of systemic cytokine release and other dose-limiting infusion-related reactions. Creating a balance between effective engagement of Fcγ receptors that can induce antitumor activity without incurring systemic immune activation is an ongoing challenge in the field of antibody and immuno-oncology therapeutics. Herein, we describe a method for the reversible chemical modulation of antibody-Fcγ interactions using simple poly(ethylene glycol) (PEG) linkers conjugated to antibody interchain disulfides with maleimide attachments. This method enables dosing of a therapeutic with muted Fcγ engagement that is restored in vivo in a time-dependent manner. The technology was applied to an effector function enhanced agonist CD40 antibody, SEA-CD40, and experiments demonstrate significant reductions in Fc-induced immune activation in vitro and in mice and nonhuman primates despite showing retained efficacy and improved pharmacokinetics compared to the parent antibody. We foresee that this simple, modular system can be rapidly applied to antibodies that suffer from systemic immune activation due to peripheral FcγR binding immediately upon infusion.
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Affiliation(s)
- Philip N. Moquist
- ADC
Chemistry, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United states
| | - Xinqun Zhang
- ADC
Antibody Engineering, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Chris I. Leiske
- ADC
Antibody Engineering, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | | | - Weiping Zeng
- ADC
In Vivo Pharmacology, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Noah A. Bindman
- ADC
Antibody Engineering, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Serena W. Wo
- ADC
Antibody Engineering, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Abbie Wong
- ADC
Translational Sciences, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Clark M. Henderson
- ADC
Translational Sciences, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Karalyne Crowder
- Non-Clinical
Sciences, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Robert Lyon
- ADC
Antibody Engineering, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Svetlana O. Doronina
- ADC
Chemistry, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United states
| | - Peter D. Senter
- ADC
Chemistry, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United states
| | - Haley D. Neff-LaFord
- Non-Clinical
Sciences, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Django Sussman
- ADC
Antibody Engineering, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
| | - Shyra J. Gardai
- Immunology, Pfizer,
Inc., 21823 30th Dr.
SE, Bothell, Washington 98021, United States
| | - Matthew R. Levengood
- ADC
Antibody Engineering, Pfizer, Inc., 21823 30th Dr. SE, Bothell, Washington 98021, United States
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3
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Dabkowska A, Domka K, Firczuk M. Advancements in cancer immunotherapies targeting CD20: from pioneering monoclonal antibodies to chimeric antigen receptor-modified T cells. Front Immunol 2024; 15:1363102. [PMID: 38638442 PMCID: PMC11024268 DOI: 10.3389/fimmu.2024.1363102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 03/25/2024] [Indexed: 04/20/2024] Open
Abstract
CD20 located predominantly on the B cells plays a crucial role in their development, differentiation, and activation, and serves as a key therapeutic target for the treatment of B-cell malignancies. The breakthrough of monoclonal antibodies directed against CD20, notably exemplified by rituximab, revolutionized the prognosis of B-cell malignancies. Rituximab, approved across various hematological malignancies, marked a paradigm shift in cancer treatment. In the current landscape, immunotherapies targeting CD20 continue to evolve rapidly. Beyond traditional mAbs, advancements include antibody-drug conjugates (ADCs), bispecific antibodies (BsAbs), and chimeric antigen receptor-modified (CAR) T cells. ADCs combine the precision of antibodies with the cytotoxic potential of drugs, presenting a promising avenue for enhanced therapeutic efficacy. BsAbs, particularly CD20xCD3 constructs, redirect cytotoxic T cells to eliminate cancer cells, thereby enhancing both precision and potency in their therapeutic action. CAR-T cells stand as a promising strategy for combatting hematological malignancies, representing one of the truly personalized therapeutic interventions. Many new therapies are currently being evaluated in clinical trials. This review serves as a comprehensive summary of CD20-targeted therapies, highlighting the progress and challenges that persist. Despite significant advancements, adverse events associated with these therapies and the development of resistance remain critical issues. Understanding and mitigating these challenges is paramount for the continued success of CD20-targeted immunotherapies.
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Affiliation(s)
- Agnieszka Dabkowska
- Laboratory of Immunology, Mossakowski Medical Research Institute Polish Academy of Sciences, Warsaw, Poland
- Department of Immunology, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Domka
- Laboratory of Immunology, Mossakowski Medical Research Institute Polish Academy of Sciences, Warsaw, Poland
- Department of Immunology, Medical University of Warsaw, Warsaw, Poland
| | - Malgorzata Firczuk
- Laboratory of Immunology, Mossakowski Medical Research Institute Polish Academy of Sciences, Warsaw, Poland
- Department of Immunology, Medical University of Warsaw, Warsaw, Poland
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4
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B cells in autoimmune hepatitis: bystanders or central players? Semin Immunopathol 2022; 44:411-427. [PMID: 35488094 PMCID: PMC9256567 DOI: 10.1007/s00281-022-00937-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/07/2022] [Indexed: 02/07/2023]
Abstract
B cells are central for the adaptive immune system to mount successful immune responses not only as antibody producers but also as regulators of cellular immunity. These multifaceted features are also reflected in autoimmunity where autoreactive B cells can fuel disease by production of cytotoxic autoantibodies, presentation of autoantigens to autoreactive T cells, and secretion of cytokines and chemokines that either promote detrimental immune activation or impair regulatory T and B cells. The role of B cells and autoantibodies in autoimmune hepatitis (AIH) have been controversially discussed, with typical autoantibodies and hypergammaglobulinemia indicating a key role, while strong HLA class II association suggests T cells as key players. In this review, we summarize current knowledge on B cells in AIH and how different B cell subpopulations may drive AIH progression beyond autoantibodies. We also discuss recent findings of B cell-directed therapies in AIH.
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Del Vecchio L, Allinovi M, Rocco P, Brando B. Rituximab Therapy for Adults with Nephrotic Syndromes: Standard Schedules or B Cell-Targeted Therapy? J Clin Med 2021; 10:5847. [PMID: 34945143 PMCID: PMC8709396 DOI: 10.3390/jcm10245847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 12/12/2022] Open
Abstract
Rituximab is a chimeric anti-CD20 monoclonal antibody. It acts mainly through complement-dependent cytotoxicity on B cells expressing the CD20 marker. In this review, we analyse the efficacy and possible pitfalls of rituximab to treat nephrotic syndromes by taking into account pharmacological considerations and CD19 marker testing utility. Despite the fact that the drug has been in use for years, efficacy and treatment schedules in adults with nephrotic syndrome are still a matter of debate. Clinical trials have proven the efficacy and safety of rituximab in idiopathic membranous nephropathy. Data from observational studies also showed the efficacy of rituximab in minimal change disease and focal segmental glomerulosclerosis. Rituximab use is now widely recommended by new Kidney Disease Improved Outcome (KDIGO) guidelines in membranous nephropathy and in frequent-relapsing, steroid-dependent minimal change disease or focal segmental glomerulosclerosis. However, rituximab response has a large interindividual variability. One reason could be that rituximab is lost in the urine at a higher extent in patients with nonselective nephrotic proteinuria, exposing patients to different rituximab plasma levels. Moreover, the association between CD19+ levels and clinical response or relapses is not always present, making the use of this marker in clinical practice complex. High resolution flow cytometry has increased the capability of detecting residual CD19+ B cells. Moreover, it can identify specific B-cell subsets (including IgG-switched memory B cells), which can repopulate at different rates. Its wider use could become a useful tool for better understanding reasons of rituximab failure or avoiding unnecessary retreatments.
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Affiliation(s)
- Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant’Anna Hospital, ASST Lariana, 22042 Como, Italy
| | - Marco Allinovi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, 50134 Florence, Italy;
| | - Paolo Rocco
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Via G. Colombo, 71-20133 Milan, Italy;
| | - Bruno Brando
- Haematology Laboratory and Transfusion Centre, Legnano General Hospital (Milan), 20025 Milan, Italy;
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6
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Rampotas A, Sangha G, Collins GP. Integration of cell therapies and bispecific antibodies into the treatment pathway of relapsed diffuse large B-cell lymphoma. Ther Adv Hematol 2021; 12:20406207211053120. [PMID: 34733463 PMCID: PMC8558790 DOI: 10.1177/20406207211053120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Gina Sangha
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Graham P Collins
- Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK
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7
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Bewarder M, Stilgenbauer S, Thurner L, Kaddu-Mulindwa D. Current Treatment Options in CLL. Cancers (Basel) 2021; 13:2468. [PMID: 34069354 PMCID: PMC8158749 DOI: 10.3390/cancers13102468] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 02/07/2023] Open
Abstract
After impressive developments in recent years with the rise of new targeted agents, chemoimmunotherapy (CIT) only plays a minor role in the treatment of patients with chronic lymphocytic leukemia (CLL). Inhibitors of the Bruton tyrosine kinase (BTK), such as ibrutinib or more recently acalabrutinib, are highly effective, even in poor-risk or chemo-refractory patients. Venetoclax, an inhibitor of the anti-apoptotic BCL2 protein and, to a lesser extent, phosphoinositide-3 kinase (PI3K) delta inhibitors, add to the armamentarium of targeted agents for the treatment of CLL. Furthermore, anti-CD20 monoclonal antibodies are used very successfully either alone or in combination with BTK, BCL2 or PI3K inhibitors. Despite these advances, there is still an ongoing pursuit for new therapeutic approaches in the treatment of CLL. An even bigger challenge poses the determination of the optimal combination and sequence of those drugs. Here, we give an overview of current treatment options in CLL, weighing the advantages and disadvantages of each approach in the light of different clinical settings.
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Affiliation(s)
| | | | | | - Dominic Kaddu-Mulindwa
- Department of Hematology, Oncology, Clinical Immunology, Rheumatology, Medical School, University of Saarland, 66424 Homburg, Germany; (M.B.); (S.S.); (L.T.)
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8
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Dieudonné Y, Guffroy A, Poindron V, Sprauel PS, Martin T, Korganow AS, Gies V. B cells in primary antiphospholipid syndrome: Review and remaining challenges. Autoimmun Rev 2021; 20:102798. [PMID: 33722752 DOI: 10.1016/j.autrev.2021.102798] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 01/03/2021] [Indexed: 02/03/2023]
Abstract
It is now widely accepted that antiphospholipid antibodies (aPL) have direct pathogenic effects and that B cells, notably through aPL production, play a key role in the development of antiphospholipid syndrome (APS). Recent findings strengthened the implication of B cells with the description of specific B cell phenotype abnormalities and inborn errors of immunity involving B cell signaling in APS patients. In addition, it has been shown in preclinical models that cross-reactivity between APS autoantigens and mimotopes expressed by human gut commensals can lead to B cell tolerance breakdown and are sufficient for APS development. However, B cell targeting therapies are surprisingly not as effective as expected in APS compared to other autoimmune diseases. Elucidation of the B cell tolerance breakdown mechanisms in APS patients may help to develop and guide the use of novel therapeutic agents that target B cells or specific immune pathway.
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Affiliation(s)
- Yannick Dieudonné
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Medicine, F-67000 Strasbourg, France.
| | - Aurélien Guffroy
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Medicine, F-67000 Strasbourg, France
| | - Vincent Poindron
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Medicine, F-67000 Strasbourg, France
| | - Pauline Soulas Sprauel
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Pharmacy, F-67400 Illkirch, France
| | - Thierry Martin
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Medicine, F-67000 Strasbourg, France
| | - Anne-Sophie Korganow
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Medicine, F-67000 Strasbourg, France
| | - Vincent Gies
- Université de Strasbourg, INSERM UMR - S1109, F-67000 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, Department of Clinical Immunology and Internal Medicine, National Reference Center for Systemic Autoimmune Diseases (CNR RESO), Tertiary Center for Primary Immunodeficiencies, F-67000 Strasbourg, France; Université de Strasbourg, Faculty of Pharmacy, F-67400 Illkirch, France
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9
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Obinutuzumab in Kidney Transplantation: Effect on B-cell Counts and Crossmatch Tests. Transplantation 2021; 106:369-372. [PMID: 33577249 DOI: 10.1097/tp.0000000000003686] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Resistance to the action of rituximab (RTX) has been documented in several diseases. More recently, obinutuzumab (OBZ) has shown promise where RTX has failed in oncology and lupus nephritis. Unlike RTX, OBZ is a weak activator of complement, which may avoid the false-positive complement-dependent cytotoxicity (CDC) crossmatch tests after RTX infusions. METHODS The aim of this study was to explore the effect of OBZ on B-cell depletion in kidney-transplant candidates and its impact on crossmatch test results. We included 12 patients: who were either highly sensitized kidney-transplant candidates or kidney-transplant recipients presenting with antibody-mediated rejection. Six received OBZ and 6 received RTX. CD-19 counts, flow cytometry and CDC crossmatch tests were run immediately before and at 2 weeks after drug infusion. RESULTS OBZ reduced CD-19 counts: median reduction was 98%. B-cell CDC crossmatch test results became positive following RTX infusion but were not affected by OBZ infusion. CONCLUSIONS OBZ effectively depleted B-cell counts in sensitized kidney-transplant candidates and, unlike RTX, had no effect on CDC crossmatch results.
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Luo C, Wu G, Huang X, Ma Y, Zhang Y, Song Q, Xie M, Sun Y, Huang Y, Huang Z, Hou Y, Xu S, Chen J, Li X. Efficacy and safety of new anti-CD20 monoclonal antibodies versus rituximab for induction therapy of CD20 + B-cell non-Hodgkin lymphomas: a systematic review and meta-analysis. Sci Rep 2021; 11:3255. [PMID: 33547368 PMCID: PMC7864901 DOI: 10.1038/s41598-021-82841-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 01/20/2021] [Indexed: 12/25/2022] Open
Abstract
Rituximab combined with chemotherapy is the first-line induction therapy of CD20 positive B-cell non-Hodgkin lymphomas (CD20+ B-NHL). Recently new anti-CD20 monoclonal antibodies (mAbs) have been developed, but their efficacy and safety compared with rituximab are still controversial. We searched MEDLINE, Embase, and Cochrane Library for eligible randomized controlled trials (RCTs) that compared new anti-CD20 mAbs with rituximab in induction therapy of B-NHL. The primary outcomes are progression-free survival (PFS) and overall survival (OS), additional outcomes include event-free survival (EFS), disease-free survival (DFS), overall response rate (ORR), complete response rate (CRR) and incidences of adverse events (AEs). Time-to-event data were pooled as hazard ratios (HRs) using the generic inverse-variance method and dichotomous outcomes were pooled as odds ratios (ORs) using the Mantel-Haenszel method with their respective 95% confidence interval (CI). Eleven RCTs comprising 5261 patients with CD20+ B-NHL were included. Compared with rituximab, obinutuzumab significantly prolonged PFS (HR 0.84, 95% CI 0.73-0.96, P = 0.01), had no improvement on OS, ORR, and CRR, but increased the incidences of serious AEs (OR 1.29, 95% CI 1.13-1.48, P < 0.001). Ofatumumab was inferior to rituximab in consideration of ORR (OR 0.73, 95% CI 0.55-0.96, P = 0.02), and had no significant differences with rituximab in regard to PFS, OS and CRR. 131I-tositumomab yielded similar PFS, OS, ORR and CRR with rituximab. 90Y-ibritumomab tiuxetan increased ORR (OR 3.07, 95% CI 1.47-6.43, P = 0.003), but did not improve PFS, DFS, OS and CRR compared with rituximab. In conclusion, compared with rituximab in induction therapy of CD20+ B-NHL, obinutuzumab significantly improves PFS but with higher incidence of AEs, ofatumumab decreases ORR, 90Y-ibritumomab tiuxetan increases ORR.
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Affiliation(s)
- Chengxin Luo
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Key Laboratory of Cancer Immunotherapy of Chongqing, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Guixian Wu
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Key Laboratory of Cancer Immunotherapy of Chongqing, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Xiangtao Huang
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Key Laboratory of Cancer Immunotherapy of Chongqing, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Yanni Ma
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Key Laboratory of Cancer Immunotherapy of Chongqing, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Yali Zhang
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Key Laboratory of Cancer Immunotherapy of Chongqing, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Qiuyue Song
- Department of Health Statistics, Third Military Medical University, Chongqing, China
| | - Mingling Xie
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Key Laboratory of Cancer Immunotherapy of Chongqing, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Yanni Sun
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Key Laboratory of Cancer Immunotherapy of Chongqing, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Yarui Huang
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Key Laboratory of Cancer Immunotherapy of Chongqing, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Zhen Huang
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Key Laboratory of Cancer Immunotherapy of Chongqing, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Yu Hou
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China
- Key Laboratory of Cancer Immunotherapy of Chongqing, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Shuangnian Xu
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China.
- Key Laboratory of Cancer Immunotherapy of Chongqing, Southwest Hospital, Third Military Medical University, Chongqing, China.
| | - Jieping Chen
- Center for Hematology, Southwest Hospital, Third Military Medical University, Chongqing, China.
- Key Laboratory of Cancer Immunotherapy of Chongqing, Southwest Hospital, Third Military Medical University, Chongqing, China.
| | - Xi Li
- Institute of Infectious Disease, Southwest Hospital, Third Military Medical University, Chongqing, China.
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11
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Mihăilă RG. Monoclonal Antibodies, Bispecific Antibodies and Antibody-Drug Conjugates in Oncohematology. Recent Pat Anticancer Drug Discov 2020; 15:272-292. [DOI: 10.2174/1574892815666200925120717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/22/2020] [Accepted: 08/12/2020] [Indexed: 12/15/2022]
Abstract
Background:
The therapeutic outcomes and the prognosis of patients with various hematologic
malignancies are not always ideal with the current standard of care.
Objective:
The aim of this study is to analyze the results of the use of monoclonal antibodies, bispecific
antibodies and antibody-drug conjugates for the therapy of malignant hemopathies.
Methods:
A mini-review was achieved using the articles published in Web of Science and PubMed
between January 2017 and January 2020 and the new patents were made in this field.
Results:
Naked monoclonal antibodies have improved the therapeutic results obtained with standard
of care, but they also have side effects and the use of some of them can lead to the loss of the
target antigen through trogocytosis, which explains the resistance that occurs during therapy. The
results obtained with naked monoclonal antibodies have been improved by a better monoclonal
antibody preparation, the use of bispecific antibodies (against two antigens on the target cell surface
or by binding both surface antigen on target cells and T-cell receptor complex, followed by cytotoxic
T-lymphocytes activation and subsequent cytolysis of the target cell), the use of monoclonal
or bispecific constructs in frontline regimens, combining immunotherapy with chemotherapy, including
through the use of antibody-drug conjugates (which provides a targeted release of a chemotherapeutic
agent).
Conclusion:
Immunotherapy and immuno-chemotherapy have improved the outcome of the patients
with malignant hemopathies through a targeted, personalized therapy, with reduced systemic
toxicity, which in some cases can even induce deep complete remissions, including minimal residual
disease negativity.
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Affiliation(s)
- Romeo G. Mihăilă
- Faculty of Medicine, Lucian Blaga University of Sibiu, Hematology Department, Emergency County Clinical Hospital Sibiu, Sibiu 550169, Romania
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12
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van der Horst HJ, Nijhof IS, Mutis T, Chamuleau MED. Fc-Engineered Antibodies with Enhanced Fc-Effector Function for the Treatment of B-Cell Malignancies. Cancers (Basel) 2020; 12:E3041. [PMID: 33086644 PMCID: PMC7603375 DOI: 10.3390/cancers12103041] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 11/17/2022] Open
Abstract
Monoclonal antibody (mAb) therapy has rapidly changed the field of cancer therapy. In 1997, the CD20-targeting mAb rituximab was the first mAb to be approved by the U.S. Food and Drug Administration (FDA) for treatment of cancer. Within two decades, dozens of mAbs entered the clinic for treatment of several hematological cancers and solid tumors, and numerous more are under clinical investigation. The success of mAbs as cancer therapeutics lies in their ability to induce various cytotoxic machineries against specific targets. These cytotoxic machineries include antibody-dependent cellular cytotoxicity (ADCC), antibody-dependent cellular phagocytosis (ADCP), and complement-dependent cytotoxicity (CDC), which are all mediated via the fragment crystallizable (Fc) domain of mAbs. In this review article, we will outline the novel approaches of engineering these Fc domains of mAbs to enhance their Fc-effector function and thereby their anti-tumor potency, with specific focus to summarize their (pre-) clinical status for the treatment of B-cell malignancies, including chronic lymphocytic leukemia (CLL), B-cell non-Hodgkin lymphoma (B-NHL), and multiple myeloma (MM).
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Affiliation(s)
- Hilma J. van der Horst
- Department of Hematology, Cancer Center Amsterdam, Amsterdam UMC, VU Medical Center, 1081 HV Amsterdam, The Netherlands; (I.S.N.); (T.M.); (M.E.D.C.)
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13
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Kumar A, Planchais C, Fronzes R, Mouquet H, Reyes N. Binding mechanisms of therapeutic antibodies to human CD20. Science 2020; 369:793-799. [DOI: 10.1126/science.abb8008] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/22/2020] [Indexed: 12/25/2022]
Abstract
Monoclonal antibodies (mAbs) targeting human antigen CD20 (cluster of
differentiation 20) constitute important immunotherapies for the treatment
of B cell malignancies and autoimmune diseases. Type I and II therapeutic
mAbs differ in B cell binding properties and cytotoxic effects, reflecting
differential interaction mechanisms with CD20. Here we present 3.7- to
4.7-angstrom cryo–electron microscopy structures of full-length CD20 in
complexes with prototypical type I rituximab and ofatumumab and type II
obinutuzumab. The structures and binding thermodynamics demonstrate that
upon binding to CD20, type II mAbs form terminal complexes that preclude
recruitment of additional mAbs and complement components, whereas type I
complexes act as molecular seeds to increase mAb local concentration for
efficient complement activation. Among type I mAbs, ofatumumab complexes
display optimal geometry for complement recruitment. The uncovered
mechanisms should aid rational design of next-generation immunotherapies
targeting CD20.
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Affiliation(s)
- Anand Kumar
- Membrane Protein Mechanisms Unit, Institut Pasteur, 75015 Paris, France
- Membrane Protein Mechanisms Group, European Institute of Chemistry and Biology, University of Bordeaux, 33607 Pessac, France
- CNRS UMR 5234 Fundamental Microbiology and Pathogenicity, Bordeaux, France
| | - Cyril Planchais
- Laboratory of Humoral Immunology, Department of Immunology, Institut Pasteur, Paris, France
- INSERM U1222, Paris, France
| | - Rémi Fronzes
- CNRS UMR 5234 Fundamental Microbiology and Pathogenicity, Bordeaux, France
- Structure and Function of Bacterial Nanomachines Group, European Institute of Chemistry and Biology, University of Bordeaux, 33607 Pessac, France
| | - Hugo Mouquet
- Laboratory of Humoral Immunology, Department of Immunology, Institut Pasteur, Paris, France
- INSERM U1222, Paris, France
| | - Nicolas Reyes
- Membrane Protein Mechanisms Unit, Institut Pasteur, 75015 Paris, France
- Membrane Protein Mechanisms Group, European Institute of Chemistry and Biology, University of Bordeaux, 33607 Pessac, France
- CNRS UMR 5234 Fundamental Microbiology and Pathogenicity, Bordeaux, France
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14
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Baleydier F, Bernard F, Ansari M. The Possibilities of Immunotherapy for Children with Primary Immunodeficiencies Associated with Cancers. Biomolecules 2020; 10:biom10081112. [PMID: 32731356 PMCID: PMC7464796 DOI: 10.3390/biom10081112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/12/2020] [Accepted: 07/24/2020] [Indexed: 12/13/2022] Open
Abstract
Many primary immunodeficiencies (PIDs) are recognised as being associated with malignancies, particularly lymphoid malignancies, which represent the highest proportion of cancers occurring in conjunction with this underlying condition. When patients present with genetic errors of immunity, clinicians must often reflect on whether to manage antitumoral treatment conventionally or to take a more personalised approach, considering possible existing comorbidities and the underlying status of immunodeficiency. Recent advances in antitumoral immunotherapies, such as monoclonal antibodies, antigen-specific adoptive cell therapies or compounds with targeted effects, potentially offer significant opportunities for optimising treatment for those patients, especially with lymphoid malignancies. In cases involving PIDs, variable oncogenic mechanisms exist, and opportunities for antitumoral immunotherapies can be considered accordingly. In cases involving a DNA repair defect or genetic instability, monoclonal antibodies can be proposed instead of chemotherapy to avoid severe toxicity. Malignancies secondary to uncontrolled virus-driven proliferation or the loss of antitumoral immunosurveillance may benefit from antivirus cell therapies or allogeneic stem cell transplantation in order to restore the immune antitumoral caretaker function. A subset of PIDs is caused by gene defects affecting targetable signalling pathways directly involved in the oncogenic process, such as the constitutive activation of phosphoinositol 3-kinase/protein kinase B (PI3K/AKT) in activated phosphoinositide 3-kinase delta syndrome (APDS), which can be settled with PI3K/AKT inhibitors. Therefore, immunotherapy provides clinicians with interesting antitumoral therapeutic weapons to treat malignancies when there is an underlying PID.
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Affiliation(s)
- Frederic Baleydier
- Department for Women, Children and Adolescents, Paediatric Haemato-Oncology unit, Geneva University Hospital, CH-1211 Geneva, Switzerland; (F.B.); (M.A.)
- CANSEARCH research laboratory, Medical Faculty, Geneva University, 1205 Geneva, Switzerland
- Correspondence: ; Tel.: +41-79-55-34-221; Fax: +41-22-37-24-720
| | - Fanette Bernard
- Department for Women, Children and Adolescents, Paediatric Haemato-Oncology unit, Geneva University Hospital, CH-1211 Geneva, Switzerland; (F.B.); (M.A.)
- CANSEARCH research laboratory, Medical Faculty, Geneva University, 1205 Geneva, Switzerland
| | - Marc Ansari
- Department for Women, Children and Adolescents, Paediatric Haemato-Oncology unit, Geneva University Hospital, CH-1211 Geneva, Switzerland; (F.B.); (M.A.)
- CANSEARCH research laboratory, Medical Faculty, Geneva University, 1205 Geneva, Switzerland
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15
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Improving Immunotherapy Against B-Cell Malignancies Using γδ T-Cell-specific Stimulation and Therapeutic Monoclonal Antibodies. J Immunother 2020; 42:331-344. [PMID: 31318724 DOI: 10.1097/cji.0000000000000289] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Tumor antigen-targeting monoclonal antibodies (mAbs) are an important element of current cancer therapies. Some of these therapeutic mAbs enable antibody-dependent cell mediated cytotoxicity (ADCC) against tumor cells. However, cancer-related functional impairment of immune effector cells may limit the clinical efficacy of antibody treatments. We reckoned that combining mAbs with cell-based immunotherapies would provide a clinically relevant synergism and benefit for cancer patients. Here, we focus on γδ T cells, as earlier studies demonstrated that γδ T-cell-based therapies are safe and promising for several types of malignancies. Similar to natural killer cells, their antitumor effects can be enhanced using antibodies, and they could, therefore, become a versatile effector cell platform for use with a variety of licensed therapeutic mAbs against cancer. In this study, we explore the potential of a combination therapy of activated γδ T cells with rituximab and the more recently developed mAbs (obinutuzumab and daratumumab) in different B-cell malignancies in vitro. Obinutuzumab outperformed the other mAbs with regard to direct target cell lysis and ADCC by γδ T cells in several CD20 cell lines and primary lymphoma specimens. We demonstrate that comparatively few CD16 γδ T cells are sufficient to mediate a strong ADCC. Using Fc-receptor-positive B-cell lymphomas as target cells, ADCC cannot be blocked by high concentrations of immunoglobulins or anti-CD16 antibodies, but both substances can promote cell mediated target cell lysis. This study expands on earlier reports on the therapeutic potential of distinctive tumor antigen-targeting mAbs and facilitates the understanding of the mechanism and potential of ADCC by γδ T-cell subsets.
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16
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Gatti A, Buccisano F, Scupoli MT, Brando B. The ISCCA flow protocol for the monitoring of anti-CD20 therapies in autoimmune disorders. CYTOMETRY PART B-CLINICAL CYTOMETRY 2020; 100:194-205. [PMID: 32598578 DOI: 10.1002/cyto.b.21930] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/15/2020] [Accepted: 05/20/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Anti-CD20 monoclonals (MoAbs) are used in a variety of autoimmune disorders. The aim is to eliminate memory B cells sustaining the tissue damage and the production of pathogenic autoantibodies, while preserving naïve cells. The disappearance of memory B cells and the repopulation by naïve cells correlate with good clinical response, while the reappearance of memory B cells and plasmablasts correlates with relapse or resistance to therapy. Anti-CD20 induce extremely low B cell levels, requiring high-resolution techniques. The immune monitoring protocol developed by ISCCA is described and validated, to provide a standardized method for the clinical decision-making process during anti-CD20 therapies in autoimmune diseases. METHODS A 10-marker, 8-color staining panel (CD20-V450, CD45-V500c, CD4-FITC + sIgM-FITC, CD38-PE, CD3-PerCP Cy5.5, CD19-PE-Cy7, CD27-APC, CD8-APC H7 + sIgG-APC-H7) is used to identify B cells, plasma cells/blasts, naïve and memory B cells, sIgM+ and sIgG-switched memory B cells, T and NK cells, with high-sensitivity analysis (>106 CD45+ cells). RESULTS After an anti-CD20 dose, the B cell level is about zero in most patients. If B cells remain virtually absent (<0.1/μl), subsetting is not reliable nor meaningful. If B cells raise >0.3-0.5/μl, subsetting is possible and informative, acquiring >1.0-1.5 × 106 CD45+ events. Further testings can follow the quality of B cell repopulation. If B cells become detectable (>1/μl), the prevalence of memory B cells indicates non-responsiveness or a possible relapse. CONCLUSIONS The ISCCA Protocol is proposed for a standardized prospective monitoring of patients with autoimmune disorders, to assist the safe and rational usage of anti-CD20 therapies.
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Affiliation(s)
- Arianna Gatti
- Hematology Laboratory and Transfusion Center, Western Milan Area Hospital Consortium, Legnano, Milan, Italy
| | - Francesco Buccisano
- Department of Biomedicine and Prevention, Hematology, Tor Vergata University of Rome, Rome, Italy
| | - Maria T Scupoli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy.,Research Center LURM (Interdepartmental Laboratory of Medical Research), University of Verona, Verona, Italy
| | - Bruno Brando
- Hematology Laboratory and Transfusion Center, Western Milan Area Hospital Consortium, Legnano, Milan, Italy
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17
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Natural Killer Cell Responses in Hepatocellular Carcinoma: Implications for Novel Immunotherapeutic Approaches. Cancers (Basel) 2020; 12:cancers12040926. [PMID: 32283827 PMCID: PMC7226319 DOI: 10.3390/cancers12040926] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/03/2020] [Accepted: 04/07/2020] [Indexed: 12/11/2022] Open
Abstract
Hepatocellular carcinoma (HCC) still represents a significant complication of chronic liver disease, particularly when cirrhosis ensues. Current treatment options include surgery, loco-regional procedures and chemotherapy, according to specific clinical practice guidelines. Immunotherapy with check-point inhibitors, aimed at rescuing T-cells from exhaustion, has been applied as second-line therapy with limited and variable success. Natural killer (NK) cells are an essential component of innate immunity against cancer and changes in phenotype and function have been described in patients with HCC, who also show perturbations of NK activating receptor/ligand axes. Here we discuss the current status of NK cell treatment of HCC on the basis of existing evidence and ongoing clinical trials on adoptive transfer of autologous or allogeneic NK cells ex vivo or after activation with cytokines such as IL-15 and use of antibodies to target cell-expressed molecules to promote antibody-dependent cellular cytotoxicity (ADCC). To this end, bi-, tri- and tetra-specific killer cell engagers are being devised to improve NK cell recognition of tumor cells, circumventing tumor immune escape and efficiently targeting NK cells to tumors. Moreover, the exciting technique of chimeric antigen receptor (CAR)-engineered NK cells offers unique opportunities to create CAR-NK with multiple specificities along the experience gained with CAR-T cells with potentially less adverse effects.
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18
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Pharmacokinetic/pharmacodynamic relationship of therapeutic monoclonal antibodies used in oncology: Part 1, monoclonal antibodies, antibody-drug conjugates and bispecific T-cell engagers. Eur J Cancer 2020; 128:107-118. [DOI: 10.1016/j.ejca.2020.01.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 01/02/2020] [Accepted: 01/07/2020] [Indexed: 01/31/2023]
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19
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Scheffold A, Stilgenbauer S. Revolution of Chronic Lymphocytic Leukemia Therapy: the Chemo-Free Treatment Paradigm. Curr Oncol Rep 2020; 22:16. [PMID: 32025827 PMCID: PMC7002327 DOI: 10.1007/s11912-020-0881-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose of Review Over the last years, targeted anticancer therapy with small molecule inhibitors and antibodies has much replaced chemoimmunotherapy, which has been the gold standard of care for patients with chronic lymphocytic leukemia (CLL). Here we give an overview of novel targeted agents used in therapy of chronic lymphocytic leukemia, as well as efforts to overcome resistance development, focusing on approved drugs since they gained high relevance in clinical practice. Recent Findings Novel agents moved to the forefront as a treatment strategy of CLL due to their outstanding efficacy, almost irrespectively of the underlying genetic features. Inhibition of Bruton’s tyrosine kinase (BTK), a key molecule in the B cell receptor pathway, achieved dramatic efficacy even in poor-risk and chemo-refractory patients. Further success was accomplished with venetoclax, which specifically inhibits anti-apoptotic BCL2 and induces apoptosis of CLL cells. Summary Inhibition of BTK or BCL2 is very effective and induces prolongation of progression-free and overall survival. Approved combination treatments such as venetoclax or ibrutinib with obinutuzumab show high responses rates and long remission durations. However, evolution and selection of subclones with continuous treatment leads to resistance towards these novel drugs and disease relapse. Hence, comparison of sequential treatment with combinations and discontinuation of therapy are important aspects which need to be investigated.
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Affiliation(s)
- Annika Scheffold
- Department of Internal Medicine III, Universitätsklinikum Ulm, Albert-Einstein Allee 23, D-89081, Ulm, Germany
| | - Stephan Stilgenbauer
- Department of Internal Medicine III, Universitätsklinikum Ulm, Albert-Einstein Allee 23, D-89081, Ulm, Germany. .,Department of Internal Medicine I, Saarland University, D-66421, Homburg, Germany.
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20
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Villalba M, Alexia C, Bellin-Robert A, Fayd'herbe de Maudave A, Gitenay D. Non-Genetically Improving the Natural Cytotoxicity of Natural Killer (NK) Cells. Front Immunol 2020; 10:3026. [PMID: 31998309 PMCID: PMC6970430 DOI: 10.3389/fimmu.2019.03026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 12/10/2019] [Indexed: 12/19/2022] Open
Abstract
The innate lymphocyte lineage natural killer (NK) is now the target of multiple clinical applications, although none has received an agreement from any regulatory agency yet. Transplant of naïve NK cells has not proven efficient enough in the vast majority of clinical trials. Hence, new protocols wish to improve their medical use by producing them from stem cells and/or modifying them by genetic engineering. These techniques have given interesting results but these improvements often hide that natural killers are mainly that: natural. We discuss here different ways to take advantage of NK physiology to improve their clinical activity without the need of additional modifications except for in vitro activation and expansion and allograft in patients. Some of these tactics include combination with monoclonal antibodies (mAb), drugs that change metabolism and engraftment of specific NK subsets with particular activity. Finally, we propose to use specific NK cell subsets found in certain patients that show increase activity against a specific disease, including the use of NK cells derived from patients.
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Affiliation(s)
- Martin Villalba
- IRMB, Univ Montpellier, INSERM, CHU Montpellier, CNRS, Montpellier, France.,IRMB, CHU Montpellier, Montpellier, France
| | - Catherine Alexia
- IRMB, Univ Montpellier, INSERM, CHU Montpellier, Montpellier, France
| | | | | | - Delphine Gitenay
- IRMB, Univ Montpellier, INSERM, CHU Montpellier, Montpellier, France
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21
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Cahill KE, Leukam MJ, Riedell PA. Refining patient selection for CAR T-cell therapy in aggressive large B-cell lymphoma. Leuk Lymphoma 2019; 61:799-807. [DOI: 10.1080/10428194.2019.1691201] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Kirk E. Cahill
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Michael J. Leukam
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Peter A. Riedell
- Hematopoietic Cellular Therapy Program, Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
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22
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Robertz J, Andres M, Mansouri Taleghani B, Koneth I, Binet I, Kremer Hovinga JA. Obinutuzumab in two patients suffering from immune-mediated thrombotic thrombocytopenic purpura intolerant to rituximab. Am J Hematol 2019; 94:E259-E261. [PMID: 31321811 DOI: 10.1002/ajh.25583] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/06/2019] [Accepted: 07/13/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Judith Robertz
- Department of Hematology and Central Hematology LaboratoryInselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Martin Andres
- Department of Hematology and Central Hematology LaboratoryInselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Behrouz Mansouri Taleghani
- Department of Hematology and Central Hematology LaboratoryInselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Irene Koneth
- Nephrology and Transplantation MedicineKantonsspital St. Gallen Sankt Gallen Switzerland
| | - Isabelle Binet
- Nephrology and Transplantation MedicineKantonsspital St. Gallen Sankt Gallen Switzerland
| | - Johanna A. Kremer Hovinga
- Department of Hematology and Central Hematology LaboratoryInselspital, Bern University Hospital, University of Bern Bern Switzerland
- Department for Biomedical ResearchUniversity of Bern Bern Switzerland
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23
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Majzner RG, Mackall CL. Clinical lessons learned from the first leg of the CAR T cell journey. Nat Med 2019; 25:1341-1355. [DOI: 10.1038/s41591-019-0564-6] [Citation(s) in RCA: 252] [Impact Index Per Article: 50.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 07/29/2019] [Indexed: 01/03/2023]
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24
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Chu Y, Gardenswartz A, Termuhlen AM, Cairo MS. Advances in cellular and humoral immunotherapy - implications for the treatment of poor risk childhood, adolescent, and young adult B-cell non-Hodgkin lymphoma. Br J Haematol 2019; 185:1055-1070. [PMID: 30613939 PMCID: PMC6555680 DOI: 10.1111/bjh.15753] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Patients with relapsed, refractory or advanced stage B non-Hodgkin lymphoma (NHL) continue to have a dismal prognosis. This review summarises current and novel cellular and immunotherapy for these high-risk populations, including haematopoietic stem cell transplant, bispecific antibodies, viral-derived cytotoxic T cells, chimeric antigen receptor (CAR) T cells, and natural killer (NK) cell therapy, as discussed at the 6th International Symposium on Childhood, Adolescent and Young Adult Non-Hodgkin Lymphoma on September 26th-29th 2018 in Rotterdam, the Netherlands, and explores the future of NK/CAR NK therapies.
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Affiliation(s)
- Yaya Chu
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | | | - Amanda M. Termuhlen
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Mitchell S. Cairo
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
- Department of Medicine, New York Medical College, Valhalla, NY, USA
- Department of Pathology, New York Medical College, Valhalla, NY, USA
- Department of Microbiology & Immunology, New York Medical College, Valhalla, NY, USA
- Department of Cell Biology & Anatomy, New York Medical College, Valhalla, NY, USA
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25
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Li LR, Wang L, He YZ, Young KH. Current perspectives on the treatment of double hit lymphoma. Expert Rev Hematol 2019; 12:507-514. [PMID: 31117849 DOI: 10.1080/17474086.2019.1623020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: Double hit lymphoma (DHL) represents a new diagnostic category with genetic, immunohistochemical and clinical characteristics intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma. Patients with DHL usually experience poor survival after frontline R-CHOP treatment and require alternative therapies. However, the ideal therapeutic options remain undefined. Areas covered: Traditional therapies for the treatment of DHL are discussed, including intensive induction, hematopoietic stem cell transplantation (HSCT), methotrexate CNS-directed prophylaxis, and radiation therapy. The authors further introduce small-molecule inhibitors targeting myc or bcl-2 signaling pathways, chimeric antigen receptor T-cell therapy, programmed death-1 monoclonal antibody and immunomodulatory drugs as novel approaches. Expert opinion: No standard treatment exists for DHL. At present, DA-EPOCH-R exhibits an upfront induction option. Central nervous system prophylaxis with methotrexate is recommended as part of the induction therapy. For those who do not obtain complete remission, HSCT or clinical trials should be considered. Targeted approaches, especially chimeric antigen receptor T-cell therapies and small-molecule inhibitors targeting myc or bcl-2, exhibit the potential of improving outcomes for patients with DHL. High-throughput sequencing is a promising technique both at diagnosis and relapse, in order to predict outcomes and potential novel therapies.
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Affiliation(s)
- Lin-Rong Li
- a Second Clinical Medical College , Southern Medical University , Guangzhou , China
| | - Liang Wang
- b Department of Hematology , Zhujiang Hospital of Southern Medical University , Guangzhou , China
| | - Ying-Zhi He
- b Department of Hematology , Zhujiang Hospital of Southern Medical University , Guangzhou , China
| | - Ken H Young
- c Department of Hematopathology , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
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26
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Chavez JC, Bachmeier C, Kharfan-Dabaja MA. CAR T-cell therapy for B-cell lymphomas: clinical trial results of available products. Ther Adv Hematol 2019; 10:2040620719841581. [PMID: 31019670 PMCID: PMC6466472 DOI: 10.1177/2040620719841581] [Citation(s) in RCA: 149] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 03/07/2019] [Indexed: 12/17/2022] Open
Abstract
Adoptive cellular immunotherapy with chimeric antigen receptor (CAR) T cell has changed the treatment landscape of B-cell non-Hodgkin's lymphoma (NHL), especially for aggressive B-cell lymphomas. Single-center and multicenter clinical trials with anti-CD19 CAR T-cell therapy have shown great activity and long-term remissions in poor-risk diffuse large B-cell lymphoma (DLBCL) when no other effective treatment options are available. Two CAR T-cell products [axicabtagene ciloleucel (axi-cel) and tisagenlecleucel] have obtained US Food and Drug Administration approval for the treatment of refractory DLBCL after two lines of therapy. A third product, liso-cel, is currently being evaluated in clinical trials and preliminary results appear very promising. CAR T-cell-related toxicity with cytokine-release syndrome and neurotoxicity remain important potential complications of this therapy. Here, we review the s biology, structure, clinical trial results and toxicity of two commercially approved CAR T-cell products and others currently being studied in multicenter clinical trials in B-cell NHLs.
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Affiliation(s)
- Julio C Chavez
- Department of Malignant Hematology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Christina Bachmeier
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
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André P, Denis C, Soulas C, Bourbon-Caillet C, Lopez J, Arnoux T, Bléry M, Bonnafous C, Gauthier L, Morel A, Rossi B, Remark R, Breso V, Bonnet E, Habif G, Guia S, Lalanne AI, Hoffmann C, Lantz O, Fayette J, Boyer-Chammard A, Zerbib R, Dodion P, Ghadially H, Jure-Kunkel M, Morel Y, Herbst R, Narni-Mancinelli E, Cohen RB, Vivier E. Anti-NKG2A mAb Is a Checkpoint Inhibitor that Promotes Anti-tumor Immunity by Unleashing Both T and NK Cells. Cell 2018; 175:1731-1743.e13. [PMID: 30503213 PMCID: PMC6292840 DOI: 10.1016/j.cell.2018.10.014] [Citation(s) in RCA: 756] [Impact Index Per Article: 126.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/03/2018] [Accepted: 10/02/2018] [Indexed: 02/08/2023]
Abstract
Checkpoint inhibitors have revolutionized cancer treatment. However, only a minority of patients respond to these immunotherapies. Here, we report that blocking the inhibitory NKG2A receptor enhances tumor immunity by promoting both natural killer (NK) and CD8+ T cell effector functions in mice and humans. Monalizumab, a humanized anti-NKG2A antibody, enhanced NK cell activity against various tumor cells and rescued CD8+ T cell function in combination with PD-x axis blockade. Monalizumab also stimulated NK cell activity against antibody-coated target cells. Interim results of a phase II trial of monalizumab plus cetuximab in previously treated squamous cell carcinoma of the head and neck showed a 31% objective response rate. Most common adverse events were fatigue (17%), pyrexia (13%), and headache (10%). NKG2A targeting with monalizumab is thus a novel checkpoint inhibitory mechanism promoting anti-tumor immunity by enhancing the activity of both T and NK cells, which may complement first-generation immunotherapies against cancer. Blocking NKG2A unleashes both T and NK cell effector functions Combined blocking of the NKG2A and the PD-1 axis promotes anti-tumor immunity Blocking NKG2A and triggering CD16 illustrates the efficacy of dual checkpoint therapy
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Affiliation(s)
- Pascale André
- Innate Pharma, 117 Avenue de Luminy, 13009 Marseille, France.
| | - Caroline Denis
- Innate Pharma, 117 Avenue de Luminy, 13009 Marseille, France
| | - Caroline Soulas
- Innate Pharma, 117 Avenue de Luminy, 13009 Marseille, France
| | | | - Julie Lopez
- Innate Pharma, 117 Avenue de Luminy, 13009 Marseille, France
| | - Thomas Arnoux
- Innate Pharma, 117 Avenue de Luminy, 13009 Marseille, France
| | - Mathieu Bléry
- Innate Pharma, 117 Avenue de Luminy, 13009 Marseille, France
| | | | | | - Ariane Morel
- Innate Pharma, 117 Avenue de Luminy, 13009 Marseille, France
| | - Benjamin Rossi
- Innate Pharma, 117 Avenue de Luminy, 13009 Marseille, France
| | - Romain Remark
- Innate Pharma, 117 Avenue de Luminy, 13009 Marseille, France
| | - Violette Breso
- Innate Pharma, 117 Avenue de Luminy, 13009 Marseille, France
| | - Elodie Bonnet
- Innate Pharma, 117 Avenue de Luminy, 13009 Marseille, France
| | - Guillaume Habif
- Innate Pharma, 117 Avenue de Luminy, 13009 Marseille, France
| | - Sophie Guia
- Aix Marseille Université, INSERM, CNRS, Centre d'Immunologie de Marseille-Luminy, 13009 Marseille, France
| | - Ana Ines Lalanne
- Unité INSERM U932, Immunité et Cancer, Institut Curie, 75248 Paris Cedex 5, France
| | - Caroline Hoffmann
- Unité INSERM U932, Immunité et Cancer, Institut Curie, 75248 Paris Cedex 5, France; Service ORL et Chirurgie cervico-faciale, Institut Curie, 75248 Paris Cedex 5, France
| | - Olivier Lantz
- Unité INSERM U932, Immunité et Cancer, Institut Curie, 75248 Paris Cedex 5, France
| | | | | | - Robert Zerbib
- Innate Pharma, 117 Avenue de Luminy, 13009 Marseille, France
| | - Pierre Dodion
- Innate Pharma, 117 Avenue de Luminy, 13009 Marseille, France
| | - Hormas Ghadially
- MedImmune, Ltd., Aaron Klug Building, Granta Park, Cambridge, CB21 6GH, UK
| | | | - Yannis Morel
- Innate Pharma, 117 Avenue de Luminy, 13009 Marseille, France
| | - Ronald Herbst
- MedImmune, LLC, One MedImmune Way, Gaithersburg, MD 20878, USA
| | - Emilie Narni-Mancinelli
- Aix Marseille Université, INSERM, CNRS, Centre d'Immunologie de Marseille-Luminy, 13009 Marseille, France
| | - Roger B Cohen
- Abramson Cancer Center, 3400 Civic Center Boulevard West Pavilion, Philadelphia, PA, USA
| | - Eric Vivier
- Innate Pharma, 117 Avenue de Luminy, 13009 Marseille, France; Aix Marseille Université, INSERM, CNRS, Centre d'Immunologie de Marseille-Luminy, 13009 Marseille, France; Service d'Immunologie, Marseille Immunopole, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13005 Marseille, France.
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Kanesvaran R, Cordoba R, Maggiore R. Immunotherapy in Older Adults With Advanced Cancers: Implications for Clinical Decision-Making and Future Research. Am Soc Clin Oncol Educ Book 2018; 38:400-414. [PMID: 30231397 DOI: 10.1200/edbk_201435] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Immunotherapy has expanded the therapeutic landscape for advanced cancers, including solid tumors and lymphomas. For many patients with cancer, these agents have been shown to have substantial efficacy and favorable toxicity compared with cytotoxic agents, particularly in the second-line setting. With the advent of anti-PD-1 and anti-PD-L1 checkpoint inhibitors, combination immunotherapy- and chemoimmunotherapy-based strategies have emerged as promising novel regimens to improve cancer-related outcomes. Older adults age 65 or older represent the growing majority of patients diagnosed with cancer. However, older adults are under-represented in clinical trials in general, as well as in the landmark studies that led to approval of these immunotherapy agents. Because of increasing age and attendant multimorbidity and impaired functional status, many of these patients seen in the community-based oncology practices would not have been considered eligible for such studies. Thus, the results of these studies are difficult to generalize to a broader patient population with these competing risks. Furthermore, robust evaluation of toxicities, effect on quality of life and functional status, and aging-related (i.e., immunosenescence) and immunotherapy-related changes affecting the immune system remain underexplored research areas for older adults. This review examines the role of immunotherapy and its unique issues, specifically in older adults with lung cancer, bladder cancer, and lymphomas.
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Affiliation(s)
- Ravindran Kanesvaran
- From the National Cancer Centre Singapore, Singapore; Hospital Universitario Fundacion Jimenez Diaz, Madrid, Spain; University of Rochester, Rochester, NY
| | - Raul Cordoba
- From the National Cancer Centre Singapore, Singapore; Hospital Universitario Fundacion Jimenez Diaz, Madrid, Spain; University of Rochester, Rochester, NY
| | - Ronald Maggiore
- From the National Cancer Centre Singapore, Singapore; Hospital Universitario Fundacion Jimenez Diaz, Madrid, Spain; University of Rochester, Rochester, NY
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Macor P, Capolla S, Tedesco F. Complement as a Biological Tool to Control Tumor Growth. Front Immunol 2018; 9:2203. [PMID: 30319647 PMCID: PMC6167450 DOI: 10.3389/fimmu.2018.02203] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 09/05/2018] [Indexed: 01/21/2023] Open
Abstract
Deposits of complement components have been documented in several human tumors suggesting a potential involvement of the complement system in tumor immune surveillance. In vitro and in vivo studies have revealed a double role played by this system in tumor progression. Complement activation in the cancer microenvironment has been shown to promote cancer growth through the release of the chemotactic peptide C5a recruiting myeloid suppressor cells. There is also evidence that tumor progression can be controlled by complement activated on the surface of cancer cells through one of the three pathways of complement activation. The aim of this review is to discuss the protective role of complement in cancer with special focus on the beneficial effect of complement-fixing antibodies that are efficient activators of the classical pathway and contribute to inhibit tumor expansion as a result of MAC-mediated cancer cell killing and complement-mediated inflammatory process. Cancer cells are heterogeneous in their susceptibility to complement-induced killing that generally depends on stable and relatively high expression of the antigen and the ability of therapeutic antibodies to activate complement. A new generation of monoclonal antibodies are being developed with structural modification leading to hexamer formation and enhanced complement activation. An important progress in cancer immunotherapy has been made with the generation of bispecific antibodies targeting tumor antigens and able to neutralize complement regulators overexpressed on cancer cells. A great effort is being devoted to implementing combined therapy of traditional approaches based on surgery, chemotherapy and radiotherapy and complement-fixing therapeutic antibodies. An effective control of tumor growth by complement is likely to be obtained on residual cancer cells following conventional therapy to reduce the tumor mass, prevent recurrences and avoid disabilities.
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Affiliation(s)
- Paolo Macor
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Sara Capolla
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - Francesco Tedesco
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, IRCCS, Milan, Italy
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31
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Watier H. Rituximab mechanisms of action in B-CLL: a new piece of the puzzle. Oncotarget 2018; 9:32732-32733. [PMID: 30214679 PMCID: PMC6132346 DOI: 10.18632/oncotarget.26016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 08/16/2018] [Indexed: 11/25/2022] Open
Affiliation(s)
- Hervé Watier
- Hervé Watier: Université de Tours, Tours, France
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32
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Evers M, Jak M, Leusen JHW. The latest developments with anti-CD20 monoclonal antibodies in chronic lymphocytic leukemia. Expert Opin Biol Ther 2018; 18:973-982. [DOI: 10.1080/14712598.2018.1508444] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Mitchell Evers
- Laboratory of Translational Immunology, UMC Utrecht, Utrecht, the Netherlands
| | - Margot Jak
- Department of Hematology, UMC Utrecht, Utrecht, the Netherlands
| | - J. H. W. Leusen
- Laboratory of Translational Immunology, UMC Utrecht, Utrecht, the Netherlands
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33
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Quintás-Cardama A. CD19 directed CAR T cell therapy in diffuse large B-cell lymphoma. Oncotarget 2018; 9:29843-29844. [PMID: 30042816 PMCID: PMC6057459 DOI: 10.18632/oncotarget.25688] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 06/17/2018] [Indexed: 12/02/2022] Open
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Watkins MP, Bartlett NL. CD19-targeted immunotherapies for treatment of patients with non-Hodgkin B-cell lymphomas. Expert Opin Investig Drugs 2018; 27:601-611. [PMID: 29940805 DOI: 10.1080/13543784.2018.1492549] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Ubiquitous expression of CD19 on B cell non-Hodgkin lymphoma identified it as a potential target for immune-based therapies. AREAS COVERED This article reviews the current literature on anti-CD19 therapies currently in clinical trials including monoclonal antibodies (mAb), antibody targeted cytotoxic drug conjugates (ADC), bispecific antibodies, and chimeric antigen receptor (CAR) modified T cells. EXPERT OPINION Naked anti-CD19 mAbs have shown little clinical benefit in B cell lymphomas. Despite unusual toxicity profiles with many anti-CD19 ADCs slowing development, durable remissions in a substantial minority of patients with refractory aggressive lymphomas should encourage continued efforts in this area. Blinatumomab, an anti-CD19 bispecific T cell engager, has shown impressive responses in relapse/refractory diffuse large B cell lymphoma (DLBCL), but is plagued by neurotoxicity issues and the need for continuous infusion. CD19 targeting CAR-T cell therapies are the most promising, with the potential for curing a third of refractory DLBCL patients. There is still much work to be done to address potentially life-threatening cytokine release syndrome and neurotoxicity, an extended production time precluding patients with rapidly progressive disease, and treatment expense. However, if the promise of CAR-T cell technology is confirmed, this will likely change the approach and prognosis for relapse/refractory aggressive lymphoma.
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35
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Sanchez-Martinez D, Allende-Vega N, Orecchioni S, Talarico G, Cornillon A, Vo DN, Rene C, Lu ZY, Krzywinska E, Anel A, Galvez EM, Pardo J, Robert B, Martineau P, Hicheri Y, Bertolini F, Cartron G, Villalba M. Expansion of allogeneic NK cells with efficient antibody-dependent cell cytotoxicity against multiple tumors. Theranostics 2018; 8:3856-3869. [PMID: 30083264 PMCID: PMC6071536 DOI: 10.7150/thno.25149] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 04/26/2018] [Indexed: 01/09/2023] Open
Abstract
Monoclonal antibodies (mAbs) have significantly improved the treatment of certain cancers. However, in general mAbs alone have limited therapeutic activity. One of their main mechanisms of action is to induce antibody-dependent cell-mediated cytotoxicity (ADCC), which is mediated by natural killer (NK) cells. Unfortunately, most cancer patients have severe immune dysfunctions affecting NK activity. This can be circumvented by the injection of allogeneic, expanded NK cells, which is safe. Nevertheless, despite their strong cytolytic potential against different tumors, clinical results have been poor. Methods: We combined allogeneic NK cells and mAbs to improve cancer treatment. We generated expanded NK cells (e-NK) with strong in vitro and in vivo ADCC responses against different tumors and using different therapeutic mAbs, namely rituximab, obinutuzumab, daratumumab, cetuximab and trastuzumab. Results: Remarkably, e-NK cells can be stored frozen and, after thawing, armed with mAbs. They mediate ADCC through degranulation-dependent and -independent mechanisms. Furthermore, they overcome certain anti-apoptotic mechanisms found in leukemic cells. Conclusion: We have established a new protocol for activation/expansion of NK cells with high ADCC activity. The use of mAbs in combination with e-NK cells could potentially improve cancer treatment.
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36
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Rigo A, Ferrarini I, Bonalumi A, Tecchio C, Montresor A, Laudanna C, Vinante F. Efficient lysis of B-chronic lymphocytic leukemia cells by the plant-derived sesquiterpene alcohol α-bisabolol, a dual proapoptotic and antiautophagic agent. Oncotarget 2018; 9:25877-25890. [PMID: 29899828 PMCID: PMC5995246 DOI: 10.18632/oncotarget.25398] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/28/2018] [Indexed: 12/14/2022] Open
Abstract
The sesquiterpene α-bisabolol (α-BSB) is a cytotoxic agent against acute leukemia and chronic myeloid leukemia cells. Here the profile of α-BSB citotoxicity was evaluated ex vivo in primary mononuclear blood cells isolated from 45 untreated B-chronic lymphocytic leukemia (B-CLL) patients. We studied the effects of α-BSB by flow cytometric and western blotting techniques with the following findings: (1) α-BSB was an effective proapoptotic agent against B-CLL cells (IC50 42 ± 15 μM). It was also active, but to a lesser extent, on normal residual B cells and monocytes (IC50 68 ± 34 and 74 ± 28 μM, respectively; p < 0.01), while T-cells, though not achieving IC50, were nevertheless decreased. (2) Lipid raft content positively correlated with α-BSB cell sensitivity, while neither the phenotype of B-CLL cells nor the disease clinical stage did affect the sensitivity to α-BSB. (3) Flow cytometry analysis evidenced the induction of pores in mitochondrial and lysosomal membrane after 3- to 5-hour exposure of B-CLL cells to α-BSB, leading to apoptosis; in contrast, western blotting analysis showed inhibition of the autophagic flux. Therefore, according to cellular selectivity, α-BSB is a cytotoxic agent preferentially active against leukemic cells, while its lower activity on normal B cells, monocytes and T cells may account for an additive anti-inflammatory effect targeting the leukemia-associated pro-inflammatory microenvironment. Consistent with the observed effects on intracellular processes, α-BSB should be regarded as a dual agent, both activating mitochondrial-based apoptosis and inhibiting autophagy by disrupting lysosomes.
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Affiliation(s)
- Antonella Rigo
- Section of Hematology, Department of Medicine, University of Verona, Verona, Italy
- Cancer Research and Cell Biology Laboratory, Department of Medicine, University of Verona, Verona, Italy
| | - Isacco Ferrarini
- Section of Hematology, Department of Medicine, University of Verona, Verona, Italy
- Cancer Research and Cell Biology Laboratory, Department of Medicine, University of Verona, Verona, Italy
| | - Angela Bonalumi
- Section of Hematology, Department of Medicine, University of Verona, Verona, Italy
| | - Cristina Tecchio
- Section of Hematology, Department of Medicine, University of Verona, Verona, Italy
| | - Alessio Montresor
- Section of General Pathology, Department of Medicine, University of Verona, Verona, Italy
| | - Carlo Laudanna
- Section of General Pathology, Department of Medicine, University of Verona, Verona, Italy
| | - Fabrizio Vinante
- Section of Hematology, Department of Medicine, University of Verona, Verona, Italy
- Cancer Research and Cell Biology Laboratory, Department of Medicine, University of Verona, Verona, Italy
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37
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38
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Neelapu SS, Tummala S, Kebriaei P, Wierda W, Locke FL, Lin Y, Jain N, Daver N, Gulbis AM, Adkins S, Rezvani K, Hwu P, Shpall EJ. Toxicity management after chimeric antigen receptor T cell therapy: one size does not fit 'ALL'. Nat Rev Clin Oncol 2018; 15:218. [PMID: 29434334 DOI: 10.1038/nrclinonc.2018.20] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Sattva S Neelapu
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center
| | - Sudhakar Tummala
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center
| | - William Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Frederick L Locke
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alison M Gulbis
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center
| | - Sherry Adkins
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center
| | - Katayoun Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center
| | - Patrick Hwu
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center
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39
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Elias S, Kahlon S, Kotzur R, Kaynan N, Mandelboim O. Obinutuzumab activates FcγRI more potently than other anti-CD20 antibodies in chronic lymphocytic leukemia (CLL). Oncoimmunology 2018; 7:e1428158. [PMID: 29872553 PMCID: PMC5980409 DOI: 10.1080/2162402x.2018.1428158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/07/2018] [Accepted: 01/09/2018] [Indexed: 11/03/2022] Open
Abstract
Treatment with monoclonal antibodies has revolutionized clinical medicine, especially in the fields of cancer and immunology. One of the oldest antibodies, which is widely used for the treatment of lymphomas and autoimmune diseases, is the anti-CD20 antibody rituximab. In recent years, new antibodies against CD20 have been developed including ofatumumab and obinutuzumab. An important mechanism of action of therapeutic monoclonal antibodies is activation of immune cells via Fc receptors (FcγRs). However, surprisingly, little is known about triggering of FcγRs by different therapeutic antibodies in general and anti-CD20 antibodies in particular. Here we establish a reporter assay to assess whether a particular antibody activates a certain Fc receptor. Using this assay we corroborated previous reports demonstrating obinutuzumab's ability to highly activate FcγRIIIa (CD16a). Importantly, we discovered that obinutuzumab also activates FcγRI (CD64) significantly more than rituximab and ofatumumab in response to chronic lymphocytic leukemia (CLL) cells obtained from patients. Mechanistically we show that this is due to the lack of FcγRIIb-mediated internalization of obinutuzumab following binding to CD20. Moreover, we show that obinutuzumab induces increased phagocytosis by primary macrophages in an FcγRI-dependent manner. Beyond the discovery of a new mechanism of obinutuzumab activity, the reporter assay can be applied to other therapeutic antibodies and may assist in developing antibodies with improved immunological properties.
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Affiliation(s)
- Shlomo Elias
- Department of Hematology, Hadassah - Hebrew University Medical Center, Jerusalem, Israel.,The Lautenberg Center for General and Tumor Immunology, Department of Immunology and Cancer Research, Institute for Medical Research Israel Canada (IMRIC), Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Shira Kahlon
- The Lautenberg Center for General and Tumor Immunology, Department of Immunology and Cancer Research, Institute for Medical Research Israel Canada (IMRIC), Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Rebecca Kotzur
- Department of Transfusion Medicine, Institute of Immunogenetics, Hannover Medical School, Hannover, Germany
| | - Noah Kaynan
- The Lautenberg Center for General and Tumor Immunology, Department of Immunology and Cancer Research, Institute for Medical Research Israel Canada (IMRIC), Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Ofer Mandelboim
- The Lautenberg Center for General and Tumor Immunology, Department of Immunology and Cancer Research, Institute for Medical Research Israel Canada (IMRIC), Hebrew University-Hadassah Medical School, Jerusalem, Israel
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40
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Wang Z, Han W. Biomarkers of cytokine release syndrome and neurotoxicity related to CAR-T cell therapy. Biomark Res 2018; 6:4. [PMID: 29387417 PMCID: PMC5778792 DOI: 10.1186/s40364-018-0116-0] [Citation(s) in RCA: 177] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/02/2018] [Indexed: 12/22/2022] Open
Abstract
Severe cytokine release syndrome (CRS) and neurotoxicity following chimeric antigen receptor T cell (CAR-T) therapy can be life-threatening in some cases, and management of those toxicities is still a great challenge for physicians. Researchers hope to understand the pathophysiology of CRS and neurotoxicity, and identify predictive biomarkers that can forecast those toxicities in advance. Some risk factors for severe CRS and/or neurotoxicity including patient and treatment characteristics have been identified in multiple clinical trials of CAR-T cell therapy. Moreover, several groups have identified some predictive biomarkers that are able to determine beforehand which patients may suffer severe CRS and/or neurotoxicity during CAR-T cell therapy, facilitating testing of early intervention strategies for those toxicities. However, further studies are needed to better understand the biology and related risk factors for CRS and/or neurotoxicity, and determine if those identified predictors can be extrapolated to other series. Herein, we review the pathophysiology of CRS and neurotoxicity, and summarize the progress of predictive biomarkers to improve CAR-T cell therapy in cancer.
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Affiliation(s)
- Zhenguang Wang
- Molecular & Immunological Department, Bio-therapeutic Department, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853 China
| | - Weidong Han
- Molecular & Immunological Department, Bio-therapeutic Department, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853 China
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41
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Vo DN, Alexia C, Allende-Vega N, Morschhauser F, Houot R, Menard C, Tarte K, Cartron G, Villalba M. NK cell activation and recovery of NK cell subsets in lymphoma patients after obinutuzumab and lenalidomide treatment. Oncoimmunology 2017; 7:e1409322. [PMID: 29632722 DOI: 10.1080/2162402x.2017.1409322] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/20/2017] [Accepted: 11/20/2017] [Indexed: 01/08/2023] Open
Abstract
Obinutuzumab (OBZ) shows stronger antibody-dependent cell cytotoxicity (ADCC) compared to rituximab and improved clinical activity for treating certain CD20+ neoplasia. However, the efficacy of monoclonal antibody (mAb) as a monotherapy is limited. Natural Killer (NK) cells are mediators of ADCC. Hematological cancer patients possess antitumor NK cells that are unable to control disease, possibly because they are dysfunctional. The immunomodulatory drug lenalidomide (LEN) could be a treatment to restore exhausted NK cell cytotoxic functions. The clinical trial GALEN is a Phase Ib/II study of OBZ combined with LEN for the treatment of relapsed/refractory follicular and aggressive (DLBCL and MCL) B-cell Lymphoma. During treatment, we analyzed specific aspects of NK cell biology. Treatment reversed the immature NK phenotype of patients and increased expression of NK activating receptors. Inhibitory receptors were either unchanged or decreased. There was a strong NK response at the end of the 1st cycle: NK number and intracellular granzyme B (GrzB) expression decreased, degranulation increased and NK responded better to allogeneic target challenge. Moreover, the interaction of NK cells with B cell targets, measured by trogocytosis, decreased during treatment. At the end of treatment, when target cells had been wiped out, the proportion of reactive NK cells (CD69+, CD45RARO+, CD107a+, CD19+) strongly decreased. Because all patients received LEN and OBZ, it was uncertain which drug was responsible of our observations, or even if a combination of both products was necessary for the described effects on this lymphocyte lineage.
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Affiliation(s)
- Dang-Nghiem Vo
- INSERM U1183, Université de Montpellier 1, UFR Médecine, Montpellier, France.,Institute for Regenerative Medicine and Biotherapy (IRMB), CHU Montpellier, Montpellier, France
| | - Catherine Alexia
- INSERM U1183, Université de Montpellier 1, UFR Médecine, Montpellier, France
| | - Nerea Allende-Vega
- INSERM U1183, Université de Montpellier 1, UFR Médecine, Montpellier, France.,Institute for Regenerative Medicine and Biotherapy (IRMB), CHU Montpellier, Montpellier, France
| | - Franck Morschhauser
- Univ. Lille, CHU Lille, EA 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille, France
| | - Roch Houot
- Department of Clinical Hematology, University Hospital Rennes, Rennes, France.,UMR U1236, INSERM Université Rennes 1, Etablissement Français du Sang, Rennes, France
| | - Cedric Menard
- UMR U1236, INSERM Université Rennes 1, Etablissement Français du Sang, Rennes, France.,SITI, Pôle de Biologie, CHU de Rennes, Rennes, France
| | - Karin Tarte
- UMR U1236, INSERM Université Rennes 1, Etablissement Français du Sang, Rennes, France.,SITI, Pôle de Biologie, CHU de Rennes, Rennes, France
| | - Guillaume Cartron
- Département d'Hématologie Clinique, CHU Montpellier, Université Montpellier I, 80 avenue Augustin Fliche, Montpellier, France.,CNRS UMR5235, Université de Montpellier, Montpellier, France
| | - Martin Villalba
- INSERM U1183, Université de Montpellier 1, UFR Médecine, Montpellier, France.,Institute for Regenerative Medicine and Biotherapy (IRMB), CHU Montpellier, Montpellier, France
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Said R, Tsimberidou AM. Obinutuzumab for the treatment of chronic lymphocytic leukemia and other B-cell lymphoproliferative disorders. Expert Opin Biol Ther 2017; 17:1463-1470. [PMID: 28893099 PMCID: PMC6166403 DOI: 10.1080/14712598.2017.1377178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Chemoimmunotherapeutic regimens using the anti-CD20 antibody rituximab improved significantly the survival rates in various B-cell lymphoproliferative disorders (LPDs), including chronic lymphocytic leukemia (CLL). The next-generation CD20 antibody obinutuzumab represents an addition to the drug armamentarium used for the therapeutic management of patients with LPDs. Areas covered: Herein, the authors discuss the biochemical and conformational engineering of obinutuzumab to increase antibody-dependent cell-mediated cytotoxicity and direct cell death. They also describe the available preclinical data on obinutuzumab's role in B-cell LPDs. Furthermore, the authors summarize the Phase I and II clinical trials of obinutuzumab, focusing on the main pharmacokinetic/pharmacodynamic characteristics, the most common clinically significant adverse events, dose optimization, and clinical outcomes of patients with CLL and other B-cell LPDs treated with obinutuzumab as monotherapy or in combination with other agents. To put these data in perspective, the use of obinutuzumab is compared with that of rituximab in CLL and other B-cell LPDs. Expert opinion: Clinical trials have demonstrated that obinutuzumab is well tolerated. The novel mechanism of action of obinutuzumab is associated with significant efficacy in CLL and other B-cell LPDs. Ongoing clinical trials are expected to determine the optimal use of obinutuzumab in these diseases.
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MESH Headings
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/immunology
- Antibodies, Monoclonal, Humanized/pharmacokinetics
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antigens, CD20/immunology
- Antineoplastic Agents, Alkylating/therapeutic use
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/pharmacokinetics
- Antineoplastic Agents, Immunological/therapeutic use
- Clinical Trials as Topic
- Drug Therapy, Combination
- Half-Life
- Humans
- Leukemia, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Neutropenia/etiology
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Affiliation(s)
- Rabih Said
- a Department of Oncology , University of Balamand, St. George Hospital University Medical Center , Beirut , Lebanon
- b Department of Investigational Cancer Therapeutics , MD Anderson Cancer Center , Houston , TX , USA
| | - Apostolia M Tsimberidou
- b Department of Investigational Cancer Therapeutics , MD Anderson Cancer Center , Houston , TX , USA
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Sarraf Yazdy M, Cheson BD. Impact of obinutuzumab alone and in combination for follicular lymphoma. BLOOD AND LYMPHATIC CANCER-TARGETS AND THERAPY 2017; 7:73-83. [PMID: 31360086 PMCID: PMC6467363 DOI: 10.2147/blctt.s114173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Although rituximab-based chemoimmunotherapy prolongs the survival of patients with follicular lymphoma (FL), this disease is considered incurable in most patients. Thus, new therapies are needed not only for those in the relapsed/refractory setting, but also for initial treatment. Obinutuzumab (G, GA101) is a third-generation, fully humanized type II glycoengineered, anti-CD20 monoclonal antibody that results in increased direct cell death and antibody-dependent, cell-mediated cytotoxicity/phagocytosis compared to rituximab. Obinutuzumab has significant antitumor activity when used alone or in combinations in untreated or relapsed refractory FL patients. Studies have demonstrated its ability to prolong progression-free survival and, in some cases, overall survival, and to eliminate minimal residual disease. Several ongoing trials are investigating combinations with chemotherapy, immunomodulators, targeted drugs, and immunotherapy agents. G is generally well tolerated, with associated adverse effects including infusion-related reactions, neutropenia, thrombocytopenia, and reactivation of hepatitis B virus. Future studies with this antibody should focus on identifying predictive markers and developing chemotherapy-free combinations that will improve the outcome of patients with FL.
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Affiliation(s)
- Maryam Sarraf Yazdy
- Division of Hematology-Oncology, Georgetown University Hospital, Lombardi Comprehensive Cancer Center, Washington, DC, USA,
| | - Bruce D Cheson
- Division of Hematology-Oncology, Georgetown University Hospital, Lombardi Comprehensive Cancer Center, Washington, DC, USA,
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Goy A. Succeeding in Breaking the R-CHOP Ceiling in DLBCL: Learning From Negative Trials. J Clin Oncol 2017; 35:3519-3522. [PMID: 28926287 DOI: 10.1200/jco.2017.74.7360] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Andre Goy
- Andre Goy, Hackensack University Medical Center, Hackensack, NJ
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