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Ma P, Jiang Y, Zhao G, Wang W, Xing S, Tang Q, Miao H, Fang H, Sun C, Fang Y, Jiang N, Huang H, Wang S, Xie X, Li N. Toward a comprehensive solution for treating solid tumors using T-cell receptor therapy: A review. Eur J Cancer 2024; 209:114224. [PMID: 39067370 DOI: 10.1016/j.ejca.2024.114224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/27/2024] [Accepted: 07/03/2024] [Indexed: 07/30/2024]
Abstract
T-cell receptor therapy (TCR-T) has demonstrated efficacy, durability, and safety advantages in certain solid tumors (such as human papillomavirus-related tumors, synovial sarcoma, and melanoma). This study aimed to provide careful considerations for developing TCR-T for solid tumors. Therefore, in this review, we have summarized the current clinical application, advantage of TCR-T modalities and explored efficacy/safety-related parameters, particularly avidity, pharmacokinetics/pharmacodynamics, and indications, for solid tumors. Furthermore, we have investigated critical factors related to avidity, including antigen selection, T-cell receptor acquisition, optimization, and co-receptor engagement. Moreover, we have re-examined the expression of tumor antigens for a potentially higher coverage rate of solid tumors based on the current RNA-seq datasets. Finally, we have discussed the current limitations and future directions of TCR-Ts.
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Affiliation(s)
- Peiwen Ma
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yale Jiang
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Guo Zhao
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Wenbo Wang
- Department of Oncology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Shujun Xing
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Qiyu Tang
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Huilei Miao
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hong Fang
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Chao Sun
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yuan Fang
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Ning Jiang
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Huiyao Huang
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Shuhang Wang
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
| | - Xingwang Xie
- Building 1, Bohui innovation building, yard 9, Sheng Life Garden Road, Changping District, Beijing, China.
| | - Ning Li
- Clinical Trial Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
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2
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Ye J, Li D, Jie Y, Luo H, Zhang W, Qiu C. Exosome-based nanoparticles and cancer immunotherapy. Biomed Pharmacother 2024; 179:117296. [PMID: 39167842 DOI: 10.1016/j.biopha.2024.117296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 08/06/2024] [Accepted: 08/09/2024] [Indexed: 08/23/2024] Open
Abstract
Over the past decades, cancer immunotherapy has encountered challenges such as immunogenicity, inefficiency, and cytotoxicity. Consequently, exosome-based cancer immunotherapy has gained rapid traction as a promising alternative. Exosomes, a type of extracellular vesicles (EVs) ranging from 50 to 150 nm, are self-originating and exhibit fewer side effects compared to traditional therapies. Exosome-based immunotherapy encompasses three significant areas: cancer vaccination, co-inhibitory checkpoints, and adoptive T-cell therapy. Each of these fields leverages the inherent advantages of exosomes, demonstrating substantial potential for individualized tumor therapy and precision medicine. This review aims to elucidate the reasons behind the promise of exosome-based nanoparticles as cancer therapies by examining their characteristics and summarizing the latest research advancements in cancer immunotherapy.
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Affiliation(s)
- Jiarong Ye
- Department of General Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang University, Jiangxi Province, 330000 China.
| | - Danni Li
- Second Clinical Medical School, Nanchang University, Jiangxi Province 330000, China
| | - Yiting Jie
- Second Clinical Medical School, Nanchang University, Jiangxi Province 330000, China
| | - Hongliang Luo
- Gastrointestinal Surgery, The Second Affiliated Hospital of Nanchang University, Jiangxi Province 330000, China
| | - Wenjun Zhang
- Gastrointestinal Surgery, The Second Affiliated Hospital of Nanchang University, Jiangxi Province 330000, China
| | - Cheng Qiu
- Gastrointestinal Surgery, Pingxiang People's Hospital, Jiangxi Province 330000, China.
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3
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De Castro V, Galaine J, Loyon R, Godet Y. CRISPR-Cas gene knockouts to optimize engineered T cells for cancer immunotherapy. Cancer Gene Ther 2024; 31:1124-1134. [PMID: 38609574 DOI: 10.1038/s41417-024-00771-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024]
Abstract
While CAR-T and tgTCR-T therapies have exhibited noteworthy and promising outcomes in hematologic and solid tumors respectively, a set of distinct challenges remains. Consequently, the quest for novel strategies has become imperative to safeguard and more effectively release the full functions of engineered T cells. These factors are intricately linked to the success of adoptive cell therapy. Recently, CRISPR-based technologies have emerged as a major breakthrough for maintaining T cell functions. These technologies have allowed the discovery of T cells' negative regulators such as specific cell-surface receptors, cell-signaling proteins, and transcription factors that are involved in the development or maintenance of T cell dysfunction. By employing a CRISPR-genic invalidation approach to target these negative regulators, it has become possible to prevent the emergence of hypofunctional T cells. This review revisits the establishment of the dysfunctional profile of T cells before delving into a comprehensive summary of recent CRISPR-gene invalidations, with each invalidation contributing to the enhancement of engineered T cells' antitumor capacities. The narrative unfolds as we explore how these advancements were discovered and identified, marking a significant advancement in the pursuit of superior adoptive cell therapy.
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Affiliation(s)
- Valentine De Castro
- Université de Franche-Comté, EFS, INSERM, UMR RIGHT, F-25000, Besançon, France
| | - Jeanne Galaine
- Université de Franche-Comté, EFS, INSERM, UMR RIGHT, F-25000, Besançon, France
| | - Romain Loyon
- Université de Franche-Comté, EFS, INSERM, UMR RIGHT, F-25000, Besançon, France
| | - Yann Godet
- Université de Franche-Comté, EFS, INSERM, UMR RIGHT, F-25000, Besançon, France.
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4
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Han J, Son H, Jung D, Kim KY, Jin C, Hwang H, Kang SS, Mitalipov S, An HJ, Lee Y, Kang E. Comparison of Natural Killer Cells Differentiated from Various Pluripotent Stem Cells. Int J Mol Sci 2024; 25:8209. [PMID: 39125777 PMCID: PMC11311719 DOI: 10.3390/ijms25158209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/03/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024] Open
Abstract
Allogeneic natural killer (NK) cell therapy has been effective in treating cancer. Many studies have tested NK cell therapy using human pluripotent stem cells (hPSCs). However, the impacts of the origin of PSC-NK cells on competence are unclear. In this study, several types of hPSCs, including human-induced PSCs (hiPSCs) generated from CD34+, CD3-CD56+, and CD56- cells in umbilical cord blood (UCB), three lines of human embryonic stem cells (hESCs, ES-1. ES-2 and ES-3) and MHC I knockout (B2M-KO)-ESCs were used to differentiate into NK cells and their capacities were analyzed. All PSC types could differentiate into NK cells. Among the iPSC-derived NK cells (iPSC-NKs) and ESC-derived NK cells (ES-NKs), 34+ iPSCs and ES-3 had a higher growth rate and cytotoxicity, respectively, ES-3 also showed better efficacy than 34+ iPSCs. B2M-KO was similar to the wild type. These results suggest that the screening for differentiation of PSCs into NK cells prior to selecting the PSC lines for the development of NK cell immunotherapy is an essential process for universal allotransplantation, including the chimeric antigen receptor (CAR).
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Affiliation(s)
- Jongsuk Han
- Department of Biomedical Science, College of Life Science, CHA University, Seongnam-si 13488, Gyeonggi-do, Republic of Korea; (J.H.); (H.S.); (C.J.); (H.H.)
| | - Hyeongbin Son
- Department of Biomedical Science, College of Life Science, CHA University, Seongnam-si 13488, Gyeonggi-do, Republic of Korea; (J.H.); (H.S.); (C.J.); (H.H.)
| | - Daun Jung
- Department of Pathology, CHA Bundang Medical Center, CHA University, Sungnam-si 13496, Gyeonggi-do, Republic of Korea; (D.J.); (K.-Y.K.); (H.-J.A.)
| | - Ki-Yeon Kim
- Department of Pathology, CHA Bundang Medical Center, CHA University, Sungnam-si 13496, Gyeonggi-do, Republic of Korea; (D.J.); (K.-Y.K.); (H.-J.A.)
| | - Chaeyeon Jin
- Department of Biomedical Science, College of Life Science, CHA University, Seongnam-si 13488, Gyeonggi-do, Republic of Korea; (J.H.); (H.S.); (C.J.); (H.H.)
| | - Hyeonwook Hwang
- Department of Biomedical Science, College of Life Science, CHA University, Seongnam-si 13488, Gyeonggi-do, Republic of Korea; (J.H.); (H.S.); (C.J.); (H.H.)
| | - Soon-Suk Kang
- Cell Therapy 3 Center, CHA Advanced Research Institute, CHA Bundang Medical Center, Sungnam-si 13488, Gyeonggi-do, Republic of Korea;
| | - Shoukhrat Mitalipov
- Center for Embryonic Cell and Gene Therapy, Oregon Health and Science University, Portland, OR 97239, USA;
| | - Hee-Jung An
- Department of Pathology, CHA Bundang Medical Center, CHA University, Sungnam-si 13496, Gyeonggi-do, Republic of Korea; (D.J.); (K.-Y.K.); (H.-J.A.)
| | - Yeonmi Lee
- Department of Biomedical Science, College of Life Science, CHA University, Seongnam-si 13488, Gyeonggi-do, Republic of Korea; (J.H.); (H.S.); (C.J.); (H.H.)
- Cell Therapy 3 Center, CHA Advanced Research Institute, CHA Bundang Medical Center, Sungnam-si 13488, Gyeonggi-do, Republic of Korea;
| | - Eunju Kang
- Department of Biomedical Science, College of Life Science, CHA University, Seongnam-si 13488, Gyeonggi-do, Republic of Korea; (J.H.); (H.S.); (C.J.); (H.H.)
- Cell Therapy 3 Center, CHA Advanced Research Institute, CHA Bundang Medical Center, Sungnam-si 13488, Gyeonggi-do, Republic of Korea;
- Department of Biochemistry, School of Medicine, CHA University, Seongnam-si 13488, Gyeonggi-do, Republic of Korea
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5
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Blud D, Rubio-Reyes P, Perret R, Weinkove R. Tuning CAR T-cell therapies for efficacy and reduced toxicity. Semin Hematol 2024:S0037-1963(24)00082-9. [PMID: 39095226 DOI: 10.1053/j.seminhematol.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/24/2024] [Accepted: 07/03/2024] [Indexed: 08/04/2024]
Abstract
Chimeric antigen receptor (CAR) T-cell therapies are a standard of care for certain relapsed or refractory B-cell cancers. However, many patients do not respond to CAR T-cell therapy or relapse later, short- and long-term toxicities are common, and current CAR T-cell therapies have limited efficacy for solid cancers. The gene engineering inherent in CAR T-cell manufacture offers an unprecedented opportunity to control cellular characteristics and design products that may overcome these limitations. This review summarises available methods to "tune" CAR T-cells for optimal efficacy and safety. The components of a typical CAR, and the modifications that can influence CAR T-cell function are discussed. Methods of engineering passive, inducible or autonomous control mechanisms into CAR T-cells, allowing selective limitation or enhancement of CAR T-cell activity are reviewed. The impact of manufacturing processes on CAR T-cell function are considered, including methods of limiting CAR T-cell terminal differentiation and exhaustion, and the use of specific T-cell subsets as the CAR T starting material. We discuss the use of multicistronic transgenes and multiplexed gene editing. Finally, we highlight the need for innovative clinical trial designs if we are to make the most of the opportunities offered by CAR T-cell therapies.
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Affiliation(s)
- Danielle Blud
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
| | - Patricia Rubio-Reyes
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
| | - Rachel Perret
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
| | - Robert Weinkove
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand; Wellington Blood & Cancer Centre, Te Whatu Ora Health New Zealand Capital Coast & Hutt Valley, Wellington, New Zealand; Department of Pathology and Molecular Medicine, University of Otago Wellington, Wellington, New Zealand; Maurice Wilkins Centre for Molecular Biodiscovery, Auckland, New Zealand.
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6
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Bexte T, Botezatu L, Miskey C, Gierschek F, Moter A, Wendel P, Reindl LM, Campe J, Villena-Ossa JF, Gebel V, Stein K, Cathomen T, Cremer A, Wels WS, Hudecek M, Ivics Z, Ullrich E. Engineering of potent CAR NK cells using non-viral Sleeping Beauty transposition from minimalistic DNA vectors. Mol Ther 2024; 32:2357-2372. [PMID: 38751112 PMCID: PMC11287004 DOI: 10.1016/j.ymthe.2024.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/25/2024] [Accepted: 05/09/2024] [Indexed: 06/06/2024] Open
Abstract
Natural killer (NK) cells have high intrinsic cytotoxic capacity, and clinical trials have demonstrated their safety and efficacy for adoptive cancer therapy. Expression of chimeric antigen receptors (CARs) enhances NK cell target specificity, with these cells applicable as off-the-shelf products generated from allogeneic donors. Here, we present for the first time an innovative approach for CAR NK cell engineering employing a non-viral Sleeping Beauty (SB) transposon/transposase-based system and minimized DNA vectors termed minicircles. SB-modified peripheral blood-derived primary NK cells displayed high and stable CAR expression and more frequent vector integration into genomic safe harbors than lentiviral vectors. Importantly, SB-generated CAR NK cells demonstrated enhanced cytotoxicity compared with non-transfected NK cells. A strong antileukemic potential was confirmed using established acute lymphocytic leukemia cells and patient-derived primary acute B cell leukemia and lymphoma samples as targets in vitro and in vivo in a xenograft leukemia mouse model. Our data suggest that the SB-transposon system is an efficient, safe, and cost-effective approach to non-viral engineering of highly functional CAR NK cells, which may be suitable for cancer immunotherapy of leukemia as well as many other malignancies.
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Affiliation(s)
- Tobias Bexte
- Goethe University, Department of Pediatrics, Experimental Immunology and Cell Therapy, Frankfurt am Main, Germany; Frankfurt Cancer Institute (FCI), Goethe University, Frankfurt am Main, Germany; University Cancer Center (UCT) Frankfurt, Frankfurt, Germany; Mildred Scheel Career Center (MSNZ), Hospital of the Goethe University Frankfurt, Frankfurt, Germany; Institute for Transfusion Medicine and Immunohematology, German Red Cross Blood Service Baden-Württemberg - Hesse, Frankfurt, Germany
| | - Lacramioara Botezatu
- Research Centre, Division of Hematology, Gene and Cell Therapy, Paul-Ehrlich-Institut, Langen, Germany; German Cancer Consortium (DKTK), partner site Heidelberg, Heidelberg, Germany
| | - Csaba Miskey
- Research Centre, Division of Hematology, Gene and Cell Therapy, Paul-Ehrlich-Institut, Langen, Germany
| | - Fenja Gierschek
- Goethe University, Department of Pediatrics, Experimental Immunology and Cell Therapy, Frankfurt am Main, Germany; Frankfurt Cancer Institute (FCI), Goethe University, Frankfurt am Main, Germany
| | - Alina Moter
- Goethe University, Department of Pediatrics, Experimental Immunology and Cell Therapy, Frankfurt am Main, Germany; Frankfurt Cancer Institute (FCI), Goethe University, Frankfurt am Main, Germany
| | - Philipp Wendel
- Goethe University, Department of Pediatrics, Experimental Immunology and Cell Therapy, Frankfurt am Main, Germany; Frankfurt Cancer Institute (FCI), Goethe University, Frankfurt am Main, Germany; German Cancer Consortium (DKTK), partner site Frankfurt/Mainz and German Cancer Research Center (DKFZ), Heidelberg, Germany; Institute for Organic Chemistry and Biochemistry, Technical University of Darmstadt, Darmstadt, Germany
| | - Lisa Marie Reindl
- Goethe University, Department of Pediatrics, Experimental Immunology and Cell Therapy, Frankfurt am Main, Germany; Frankfurt Cancer Institute (FCI), Goethe University, Frankfurt am Main, Germany
| | - Julia Campe
- Goethe University, Department of Pediatrics, Experimental Immunology and Cell Therapy, Frankfurt am Main, Germany; Frankfurt Cancer Institute (FCI), Goethe University, Frankfurt am Main, Germany
| | - Jose Francisco Villena-Ossa
- Institute for Transfusion Medicine and Gene Therapy, Medical Center - University of Freiburg, Freiburg, Germany; Center for Chronic Immunodeficiency, Medical Center - University of Freiburg, Freiburg, Germany
| | - Veronika Gebel
- Goethe University, Department of Pediatrics, Experimental Immunology and Cell Therapy, Frankfurt am Main, Germany; Frankfurt Cancer Institute (FCI), Goethe University, Frankfurt am Main, Germany; University Cancer Center (UCT) Frankfurt, Frankfurt, Germany; Mildred Scheel Career Center (MSNZ), Hospital of the Goethe University Frankfurt, Frankfurt, Germany
| | - Katja Stein
- Goethe University, Department of Pediatrics, Experimental Immunology and Cell Therapy, Frankfurt am Main, Germany; Frankfurt Cancer Institute (FCI), Goethe University, Frankfurt am Main, Germany; University Cancer Center (UCT) Frankfurt, Frankfurt, Germany
| | - Toni Cathomen
- Institute for Transfusion Medicine and Gene Therapy, Medical Center - University of Freiburg, Freiburg, Germany; Center for Chronic Immunodeficiency, Medical Center - University of Freiburg, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK), partner site Freiburg, Freiburg, Germany
| | - Anjali Cremer
- Frankfurt Cancer Institute (FCI), Goethe University, Frankfurt am Main, Germany; University Cancer Center (UCT) Frankfurt, Frankfurt, Germany; Mildred Scheel Career Center (MSNZ), Hospital of the Goethe University Frankfurt, Frankfurt, Germany; German Cancer Consortium (DKTK), partner site Frankfurt/Mainz and German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Hematology/Oncology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Winfried S Wels
- Frankfurt Cancer Institute (FCI), Goethe University, Frankfurt am Main, Germany; German Cancer Consortium (DKTK), partner site Frankfurt/Mainz and German Cancer Research Center (DKFZ), Heidelberg, Germany; Georg-Speyer-Haus, Institute for Tumor Biology and Experimental Therapy, Frankfurt am Main, Germany
| | - Michael Hudecek
- Department of Medicine II, Chaire in Cellular Immunotherapy, University Hospital Würzburg, Würzburg, Germany; Fraunhofer Institute for Cell Therapy and Immunology, Cellular Immunotherapy Branch Site Würzburg, Würzburg, Germany
| | - Zoltán Ivics
- Research Centre, Division of Hematology, Gene and Cell Therapy, Paul-Ehrlich-Institut, Langen, Germany; German Cancer Consortium (DKTK), partner site Heidelberg, Heidelberg, Germany
| | - Evelyn Ullrich
- Goethe University, Department of Pediatrics, Experimental Immunology and Cell Therapy, Frankfurt am Main, Germany; Frankfurt Cancer Institute (FCI), Goethe University, Frankfurt am Main, Germany; University Cancer Center (UCT) Frankfurt, Frankfurt, Germany; Mildred Scheel Career Center (MSNZ), Hospital of the Goethe University Frankfurt, Frankfurt, Germany; German Cancer Consortium (DKTK), partner site Frankfurt/Mainz and German Cancer Research Center (DKFZ), Heidelberg, Germany.
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7
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Shrestha N, Dee MJ, Chaturvedi P, Leclerc GM, Mathyer M, Dufour C, Arthur L, Becker-Hapak M, Foster M, McClain E, Pena NV, Kage K, Zhu X, George V, Liu B, Egan J, Echeverri C, Wang M, You L, Kong L, Li L, Berrien-Elliott MM, Cooper ML, Fehniger TA, Rhode PR, Wong HC. A "Prime and Expand" strategy using the multifunctional fusion proteins to generate memory-like NK cells for cell therapy. Cancer Immunol Immunother 2024; 73:179. [PMID: 38960949 PMCID: PMC11222348 DOI: 10.1007/s00262-024-03765-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 06/19/2024] [Indexed: 07/05/2024]
Abstract
Adoptive cellular therapy (ACT) using memory-like (ML) natural killer (NK) cells, generated through overnight ex vivo activation with IL-12, IL-15, and IL-18, has shown promise for treating hematologic malignancies. We recently reported that a multifunctional fusion molecule, HCW9201, comprising IL-12, IL-15, and IL-18 domains could replace individual cytokines for priming human ML NK cell programming ("Prime" step). However, this approach does not include ex vivo expansion, thereby limiting the ability to test different doses and schedules. Here, we report the design and generation of a multifunctional fusion molecule, HCW9206, consisting of human IL-7, IL-15, and IL-21 cytokines. We observed > 300-fold expansion for HCW9201-primed human NK cells cultured for 14 days with HCW9206 and HCW9101, an IgG1 antibody, recognizing the scaffold domain of HCW9206 ("Expand" step). This expansion was dependent on both HCW9206 cytokines and interactions of the IgG1 mAb with CD16 receptors on NK cells. The resulting "Prime and Expand" ML NK cells exhibited elevated metabolic capacity, stable epigenetic IFNG promoter demethylation, enhanced antitumor activity in vitro and in vivo, and superior persistence in NSG mice. Thus, the "Prime and Expand" strategy represents a simple feeder cell-free approach to streamline manufacturing of clinical-grade ML NK cells to support multidose and off-the-shelf ACT.
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Affiliation(s)
- Niraj Shrestha
- HCW Biologics Inc., 2929 N. Commerce Parkway, Miramar, FL, 33025, USA
| | - Michael J Dee
- HCW Biologics Inc., 2929 N. Commerce Parkway, Miramar, FL, 33025, USA
| | | | - Gilles M Leclerc
- HCW Biologics Inc., 2929 N. Commerce Parkway, Miramar, FL, 33025, USA
| | | | | | | | - Michelle Becker-Hapak
- Division of Oncology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, 63110, USA
| | - Mark Foster
- Division of Oncology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, 63110, USA
| | - Ethan McClain
- Division of Oncology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, 63110, USA
| | | | - Karen Kage
- HCW Biologics Inc., 2929 N. Commerce Parkway, Miramar, FL, 33025, USA
| | - Xiaoyun Zhu
- HCW Biologics Inc., 2929 N. Commerce Parkway, Miramar, FL, 33025, USA
| | - Varghese George
- HCW Biologics Inc., 2929 N. Commerce Parkway, Miramar, FL, 33025, USA
| | - Bai Liu
- HCW Biologics Inc., 2929 N. Commerce Parkway, Miramar, FL, 33025, USA
| | - Jack Egan
- HCW Biologics Inc., 2929 N. Commerce Parkway, Miramar, FL, 33025, USA
| | | | - Meng Wang
- HCW Biologics Inc., 2929 N. Commerce Parkway, Miramar, FL, 33025, USA
| | - Lijing You
- HCW Biologics Inc., 2929 N. Commerce Parkway, Miramar, FL, 33025, USA
| | - Lin Kong
- HCW Biologics Inc., 2929 N. Commerce Parkway, Miramar, FL, 33025, USA
| | - Liying Li
- HCW Biologics Inc., 2929 N. Commerce Parkway, Miramar, FL, 33025, USA
| | - Melissa M Berrien-Elliott
- Division of Oncology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, 63110, USA
| | | | - Todd A Fehniger
- Division of Oncology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, 63110, USA
| | - Peter R Rhode
- HCW Biologics Inc., 2929 N. Commerce Parkway, Miramar, FL, 33025, USA
| | - Hing C Wong
- HCW Biologics Inc., 2929 N. Commerce Parkway, Miramar, FL, 33025, USA.
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8
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Hammer Q, Perica K, Mbofung RM, van Ooijen H, Martin KE, Momayyezi P, Varady E, Pan Y, Jelcic M, Groff B, Abujarour R, Krokeide SZ, Lee T, Williams A, Goodridge JP, Valamehr B, Önfelt B, Sadelain M, Malmberg KJ. Genetic ablation of adhesion ligands mitigates rejection of allogeneic cellular immunotherapies. Cell Stem Cell 2024:S1934-5909(24)00219-4. [PMID: 38981470 DOI: 10.1016/j.stem.2024.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 04/10/2024] [Accepted: 06/14/2024] [Indexed: 07/11/2024]
Abstract
Allogeneic cellular immunotherapies hold promise for broad clinical implementation but face limitations due to potential rejection of donor cells by the host immune system. Silencing of beta-2 microglobulin (B2M) expression is commonly employed to evade T cell-mediated rejection by the host, although the absence of B2M is expected to trigger missing-self responses by host natural killer (NK) cells. Here, we demonstrate that genetic deletion of the adhesion ligands CD54 and CD58 in B2M-deficient chimeric antigen receptor (CAR) T cells and multi-edited induced pluripotent stem cell (iPSC)-derived CAR NK cells reduces their susceptibility to rejection by host NK cells in vitro and in vivo. The absence of adhesion ligands limits rejection in a unidirectional manner in B2M-deficient and B2M-sufficient settings without affecting the antitumor functionality of the engineered donor cells. Thus, these data suggest that genetic ablation of adhesion ligands effectively alleviates rejection by host immune cells, facilitating the implementation of universal immunotherapy.
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Affiliation(s)
- Quirin Hammer
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.
| | - Karlo Perica
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA; Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Cell Therapy Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Hanna van Ooijen
- Department of Applied Physics, Science for Life Laboratory, KTH Royal Institute of Technology, Solna, Sweden
| | - Karen E Martin
- Precision Immunotherapy Alliance, Institute for Cancer Research, University of Oslo, Oslo, Norway; Department of Cancer Immunology, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
| | - Pouria Momayyezi
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | | | - Yijia Pan
- Fate Therapeutics, Inc., San Diego, CA, USA
| | | | | | | | - Silje Z Krokeide
- Precision Immunotherapy Alliance, Institute for Cancer Research, University of Oslo, Oslo, Norway; Department of Cancer Immunology, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
| | - Tom Lee
- Fate Therapeutics, Inc., San Diego, CA, USA
| | | | | | | | - Björn Önfelt
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden; Department of Applied Physics, Science for Life Laboratory, KTH Royal Institute of Technology, Solna, Sweden
| | - Michel Sadelain
- Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Karl-Johan Malmberg
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden; Precision Immunotherapy Alliance, Institute for Cancer Research, University of Oslo, Oslo, Norway; Department of Cancer Immunology, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway.
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9
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Ochi T, Konishi T, Takenaka K. Bispecific antibodies for multiple myeloma: past, present and future. Int J Hematol 2024; 120:23-33. [PMID: 38613724 DOI: 10.1007/s12185-024-03766-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/15/2024]
Abstract
Despite the development of various therapeutic agents, multiple myeloma remains incurable. Recently, T-cell redirected immunotherapy has become a promising strategy for the treatment of refractory myeloma. Clinical trials using chimeric antigen receptor (CAR)-T cells and bispecific antibodies have demonstrated successful anti-myeloma responses in triple-class-refractory patients. However, unique and unwanted immune effects associated with on-target/off-target reactivity of activated immune cells need to be considered and properly managed. This review summarizes recent advances in bispecific antibodies for the treatment of refractory myeloma. It outlines the history of their development, along with a discussion of their mechanisms of action and their current and potential future role in myeloma therapy. As more evidence emerges to inform the timing of CAR-T-cell therapy, the results of clinical trials and off-the-shelf nature of bispecifics also suggest the timing of their treatment. These findings will promote further development and application of bispecifics for refractory myeloma in combination with other appropriate agents.
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Affiliation(s)
- Toshiki Ochi
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan.
- Division of Immune Regulation, Proteo-Science Center, Ehime University, Toon, Ehime, 791-0295, Japan.
| | - Tatsuya Konishi
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan
| | - Katsuto Takenaka
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan
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10
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Schlegel LS, Werbrouck C, Boettcher M, Schlegel P. Universal CAR 2.0 to overcome current limitations in CAR therapy. Front Immunol 2024; 15:1383894. [PMID: 38962014 PMCID: PMC11219820 DOI: 10.3389/fimmu.2024.1383894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 06/03/2024] [Indexed: 07/05/2024] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapy has effectively complemented the treatment of advanced relapsed and refractory hematological cancers. The remarkable achievements of CD19- and BCMA-CAR T therapies have raised high expectations within the fields of hematology and oncology. These groundbreaking successes are propelling a collective aspiration to extend the reach of CAR therapies beyond B-lineage malignancies. Advanced CAR technologies have created a momentum to surmount the limitations of conventional CAR concepts. Most importantly, innovations that enable combinatorial targeting to address target antigen heterogeneity, using versatile adapter CAR concepts in conjunction with recent transformative next-generation CAR design, offer the promise to overcome both the bottleneck associated with CAR manufacturing and patient-individualized treatment regimens. In this comprehensive review, we delineate the fundamental prerequisites, navigate through pivotal challenges, and elucidate strategic approaches, all aimed at paving the way for the future establishment of multitargeted immunotherapies using universal CAR technologies.
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Affiliation(s)
- Lara Sophie Schlegel
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Coralie Werbrouck
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Patrick Schlegel
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Department of Pediatric Hematology and Oncology, Westmead Children’s Hospital, Sydney, NSW, Australia
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11
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Zhang Y, Shi Q, Wang P, Huang C, Tang S, Zhou M, Hu Q, Wu L, Liang D. iPSC-derived NK cells with site-specific integration of CAR19 and IL24 at the multi-copy rDNA locus enhanced antitumor activity and proliferation. MedComm (Beijing) 2024; 5:e553. [PMID: 38737469 PMCID: PMC11082533 DOI: 10.1002/mco2.553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 02/22/2024] [Accepted: 04/01/2024] [Indexed: 05/14/2024] Open
Abstract
The generation of chimeric antigen receptor-modified natural killer (CAR-NK) cells using induced pluripotent stem cells (iPSCs) has emerged as one of the paradigms for manufacturing off-the-shelf universal immunotherapy. However, there are still some challenges in enhancing the potency, safety, and multiple actions of CAR-NK cells. Here, iPSCs were site-specifically integrated at the ribosomal DNA (rDNA) locus with interleukin 24 (IL24) and CD19-specific chimeric antigen receptor (CAR19), and successfully differentiated into iPSC-derived NK (iNK) cells, followed by expansion using magnetic beads in vitro. Compared with the CAR19-iNK cells, IL24 armored CAR19-iNK (CAR19-IL24-iNK) cells showed higher cytotoxic capacity and amplification ability in vitro and inhibited tumor progression more effectively with better survival in a B-cell acute lymphoblastic leukaemia (B-ALL) (Nalm-6 (Luc1))-bearing mouse model. Interestingly, RNA-sequencing analysis showed that IL24 may enhance iNK cell function through nuclear factor kappa B (NFκB) pathway-related genes while exerting a direct effect on tumor cells. This study proved the feasibility and potential of combining IL24 with CAR-iNK cell therapy, suggesting a novel and promising off-the-shelf immunotherapy strategy.
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Affiliation(s)
- Yuxuan Zhang
- Center for Medical Genetics & Hunan Key Laboratory of Medical GeneticsSchool of Life SciencesCentral South UniversityChangshaChina
| | - Qingxin Shi
- Center for Medical Genetics & Hunan Key Laboratory of Medical GeneticsSchool of Life SciencesCentral South UniversityChangshaChina
| | - Peiyun Wang
- Center for Medical Genetics & Hunan Key Laboratory of Medical GeneticsSchool of Life SciencesCentral South UniversityChangshaChina
| | - Chujun Huang
- Center for Medical Genetics & Hunan Key Laboratory of Medical GeneticsSchool of Life SciencesCentral South UniversityChangshaChina
| | - Shuqing Tang
- Center for Medical Genetics & Hunan Key Laboratory of Medical GeneticsSchool of Life SciencesCentral South UniversityChangshaChina
| | - Miaojin Zhou
- Center for Medical Genetics & Hunan Key Laboratory of Medical GeneticsSchool of Life SciencesCentral South UniversityChangshaChina
| | - Qian Hu
- Center for Medical Genetics & Hunan Key Laboratory of Medical GeneticsSchool of Life SciencesCentral South UniversityChangshaChina
| | - Lingqian Wu
- Center for Medical Genetics & Hunan Key Laboratory of Medical GeneticsSchool of Life SciencesCentral South UniversityChangshaChina
| | - Desheng Liang
- Center for Medical Genetics & Hunan Key Laboratory of Medical GeneticsSchool of Life SciencesCentral South UniversityChangshaChina
- Hunan Key Laboratory of Animal Models for Human DiseasesSchool of Life SciencesCentral South UniversityChangshaChina
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12
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Kong JC, Sa’ad MA, Vijayan HM, Ravichandran M, Balakrishnan V, Tham SK, Tye GJ. Chimeric antigen receptor-natural killer cell therapy: current advancements and strategies to overcome challenges. Front Immunol 2024; 15:1384039. [PMID: 38726000 PMCID: PMC11079817 DOI: 10.3389/fimmu.2024.1384039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/15/2024] [Indexed: 05/12/2024] Open
Abstract
Chimeric antigen receptor-natural killer (CAR-NK) cell therapy is a novel immunotherapy targeting cancer cells via the generation of chimeric antigen receptors on NK cells which recognize specific cancer antigens. CAR-NK cell therapy is gaining attention nowadays owing to the ability of CAR-NK cells to release potent cytotoxicity against cancer cells without side effects such as cytokine release syndrome (CRS), neurotoxicity and graft-versus-host disease (GvHD). CAR-NK cells do not require antigen priming, thus enabling them to be used as "off-the-shelf" therapy. Nonetheless, CAR-NK cell therapy still possesses several challenges in eliminating cancer cells which reside in hypoxic and immunosuppressive tumor microenvironment. Therefore, this review is envisioned to explore the current advancements and limitations of CAR-NK cell therapy as well as discuss strategies to overcome the challenges faced by CAR-NK cell therapy. This review also aims to dissect the current status of clinical trials on CAR-NK cells and future recommendations for improving the effectiveness and safety of CAR-NK cell therapy.
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Affiliation(s)
- Jun Chang Kong
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia, Minden, Penang, Malaysia
| | - Mohammad Auwal Sa’ad
- Celestialab Sdn Bhd, Kuala Lumpur, Malaysia
- Department of Biotechnology, Faculty of Applied Sciences, AIMST University, Bedong, Kedah, Malaysia
| | | | - Manickam Ravichandran
- Department of Biotechnology, Faculty of Applied Sciences, AIMST University, Bedong, Kedah, Malaysia
- MyGenome, ALPS Global Holding, Kuala Lumpur, Malaysia
| | - Venugopal Balakrishnan
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia, Minden, Penang, Malaysia
| | - Seng Kong Tham
- ALPS Medical Centre, ALPS Global Holding, Kuala Lumpur, Malaysia
| | - Gee Jun Tye
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia, Minden, Penang, Malaysia
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13
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Zhang T, Qian C, Song M, Tang Y, Zhou Y, Dong G, Shen Q, Chen W, Wang A, Shen S, Zhao Y, Lu Y. Application Prospect of Induced Pluripotent Stem Cells in Organoids and Cell Therapy. Int J Mol Sci 2024; 25:2680. [PMID: 38473926 DOI: 10.3390/ijms25052680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/13/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
Since its inception, induced pluripotent stem cell (iPSC) technology has been hailed as a powerful tool for comprehending disease etiology and advancing drug screening across various domains. While earlier iPSC-based disease modeling and drug assessment primarily operated at the cellular level, recent years have witnessed a significant shift towards organoid-based investigations. Organoids derived from iPSCs offer distinct advantages, particularly in enabling the observation of disease progression and drug metabolism in an in vivo-like environment, surpassing the capabilities of iPSC-derived cells. Furthermore, iPSC-based cell therapy has emerged as a focal point of clinical interest. In this review, we provide an extensive overview of non-integrative reprogramming methods that have evolved since the inception of iPSC technology. We also deliver a comprehensive examination of iPSC-derived organoids, spanning the realms of the nervous system, cardiovascular system, and oncology, as well as systematically elucidate recent advancements in iPSC-related cell therapies.
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Affiliation(s)
- Teng Zhang
- Jiangsu Joint International Research Laboratory of Chinese Medicine and Regenerative Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing 210023, China
| | - Cheng Qian
- Jiangsu Joint International Research Laboratory of Chinese Medicine and Regenerative Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing 210023, China
| | - Mengyao Song
- Jiangsu Joint International Research Laboratory of Chinese Medicine and Regenerative Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing 210023, China
| | - Yu Tang
- Jiangsu Joint International Research Laboratory of Chinese Medicine and Regenerative Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing 210023, China
| | - Yueke Zhou
- Jiangsu Joint International Research Laboratory of Chinese Medicine and Regenerative Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing 210023, China
| | - Guanglu Dong
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Department of Biochemistry and Molecular Biology, School of Medicine & Holistic Integrative Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, China
| | - Qiuhong Shen
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Department of Biochemistry and Molecular Biology, School of Medicine & Holistic Integrative Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, China
| | - Wenxing Chen
- Jiangsu Joint International Research Laboratory of Chinese Medicine and Regenerative Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing 210023, China
| | - Aiyun Wang
- Jiangsu Joint International Research Laboratory of Chinese Medicine and Regenerative Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing 210023, China
| | - Sanbing Shen
- Regenerative Medicine Institute, School of Medicine, University of Galway, H91 W2TY Galway, Ireland
| | - Yang Zhao
- Jiangsu Joint International Research Laboratory of Chinese Medicine and Regenerative Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Department of Biochemistry and Molecular Biology, School of Medicine & Holistic Integrative Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, China
| | - Yin Lu
- Jiangsu Joint International Research Laboratory of Chinese Medicine and Regenerative Medicine, Nanjing University of Chinese Medicine, Nanjing 210023, China
- Jiangsu Key Laboratory for Pharmacology and Safety Evaluation of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing 210023, China
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14
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Kim S, Chung H, Kwak JE, Kim YR, Park CH, Kim Y, Cheong JW, Wu J, Shin EC, Cho H, Kim JS. Clearing soluble MIC reverses the impaired function of natural killer cells from patients with multiple myeloma. J Immunother Cancer 2024; 12:e007886. [PMID: 38191242 PMCID: PMC10806558 DOI: 10.1136/jitc-2023-007886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Major histocompatibility complex (MHC) class I chain-related protein (MIC) is a stress-induced ligand released from multiple myeloma (MM) cells during progression, and soluble MIC impairs natural killer group 2D (NKG2D) activating receptor-mediated recognition and function of natural killer (NK) cells. However, whether clearing soluble MIC with a monoclonal antibody (mAb) can restore NK cell activity of MM patients remains undetermined. METHODS We analyzed The Cancer Genome Atlas (TCGA) Multiple Myeloma Research Foundation (MMRF) CoMMpass data set to examine the prognostic significance of MIC expression in MM. We examined the level of soluble MIC in paired peripheral blood (PB) and bone marrow (BM) plasma of patients with MM at diagnosis by ELISA. We evaluated the correlation between the level of soluble MIC and immunophenotype of NK cells from MM patients by multicolor flow cytometry. We also generated MIC-overexpressing MM cell line and characterized the cytotoxic function of patient NK cells in the presence of soluble MIC, and examined the impact of clearing soluble MIC with a humanized mAb (huB10G5). RESULTS We characterize the importance of MICA in MM by revealing the significantly better overall survival of patients with high MICA expression from TCGA MMRF CoMMpass data set. The level of soluble MICA is more highly elevated in MM than in precursor stages, and the concentration of soluble MICA is higher in BM plasma than in PB. The concentration of soluble MICA in BM was correlated with myeloma burden, while it was negatively correlated with the frequency of NKG2D+ NK cells in diagnostic BM aspirates of MM patients. Soluble MICA downregulated NKG2D expression and decreased cytotoxicity of MM patient NK cells ex vivo, which were reversed by a humanized soluble MIC-clearing mAb (huB10G5) with enhanced degranulation of NK cells. CONCLUSIONS Our findings indicate targeting soluble MIC with huB10G5 might be a viable therapeutic approach to promote NKG2D-dependent cellular immunotherapy outcome in MM.
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Affiliation(s)
- Sojeong Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Haerim Chung
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Jeong-Eun Kwak
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Yu Ri Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Chung Hyun Park
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Yeonhee Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - June-Won Cheong
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Jennifer Wu
- Department of Urology and Department of Microbiology and Immunology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Eui-Cheol Shin
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Korea (the Republic of)
| | - Hyunsoo Cho
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
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15
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Snyder KM, Dixon KJ, Davis Z, Hosking M, Hart G, Khaw M, Matson A, Bjordahl R, Hancock B, Shirinbak S, Miller JS, Valamehr B, Wu J, Walcheck B. iPSC-derived natural killer cells expressing the FcγR fusion CD64/16A can be armed with antibodies for multitumor antigen targeting. J Immunother Cancer 2023; 11:e007280. [PMID: 38056893 PMCID: PMC10711901 DOI: 10.1136/jitc-2023-007280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Antibody therapies can direct natural killer (NK) cells to tumor cells, tumor-associated cells, and suppressive immune cells to mediate antibody-dependent cell-mediated cytotoxicity (ADCC). This antigen-specific effector function of human NK cells is mediated by the IgG Fc receptor CD16A (FcγRIIIA). Preclinical and clinical studies indicate that increasing the binding affinity and avidity of CD16A for antibodies improves the therapeutic potential of ADCC. CD64 (FcγRI), expressed by myeloid cells but not NK cells, is the only high affinity IgG Fc receptor and is uniquely capable of stably binding to free monomeric IgG as a physiological function. We have reported on the generation of the FcγR fusion CD64/16A, consisting of the extracellular region of CD64 and the transmembrane and cytoplasmic regions from CD16A, retaining its signaling and cellular activity. Here, we generated induced pluripotent stem cell (iPSC)-derived NK (iNK) cells expressing CD64/16A as a potential adoptive NK cell therapy for increased ADCC potency. METHODS iPSCs were engineered to express CD64/16A as well as an interleukin (IL)-15/IL-15Rα fusion (IL-15RF) protein and differentiated into iNK cells. iNK cells and peripheral blood NK cells were expanded using irradiated K562-mbIL21-41BBL feeder cells and examined. NK cells, ovarian tumor cell lines, and therapeutic monoclonal antibodies were used to assess ADCC in vitro, performed by a DELFIA EuTDA assay or in real-time by IncuCyte assays, and in vivo. For the latter, we developed a xenograft mouse model with high circulating levels of human IgG for more physiological relevance. RESULTS We demonstrate that (1) iNK-CD64/16A cells after expansion or thaw from cryopreservation can be coupled to therapeutic antibodies, creating armed iNK cells; (2) antibody-armed iNK-CD64/16A cells can be redirected by added antibodies to target new tumor antigens, highlighting additional potential of these cells; (3) cytokine-autonomous activity by iNK-CD64/16A cells engineered to express IL-15RF; and that (4) antibody-armed iNK-CD64/16A cells thawed from cryopreservation are capable of sustained and robust ADCC in vitro and in vivo, as determined by using a modified tumor xenograft model with high levels of competing human IgG. CONCLUSIONS iNK cells expressing CD64/16A provide an off-the-shelf multiantigen targeting platform to address tumor heterogeneity and mitigate antigen escape.
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Affiliation(s)
- Kristin M Snyder
- Department of Veterinary and Biomedical Sciences, University of Minnesota, Saint Paul, Minnesota, USA
| | - Kate J Dixon
- Department of Veterinary and Biomedical Sciences, University of Minnesota, Saint Paul, Minnesota, USA
| | - Zachary Davis
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Geoffrey Hart
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Melissa Khaw
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anders Matson
- Department of Veterinary and Biomedical Sciences, University of Minnesota, Saint Paul, Minnesota, USA
| | | | | | | | - Jeffrey S Miller
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Jianming Wu
- Department of Veterinary and Biomedical Sciences, University of Minnesota, Saint Paul, Minnesota, USA
| | - Bruce Walcheck
- Department of Veterinary and Biomedical Sciences, University of Minnesota, Saint Paul, Minnesota, USA
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Nersesian S, Carter EB, Lee SN, Westhaver LP, Boudreau JE. Killer instincts: natural killer cells as multifactorial cancer immunotherapy. Front Immunol 2023; 14:1269614. [PMID: 38090565 PMCID: PMC10715270 DOI: 10.3389/fimmu.2023.1269614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 10/30/2023] [Indexed: 12/18/2023] Open
Abstract
Natural killer (NK) cells integrate heterogeneous signals for activation and inhibition using germline-encoded receptors. These receptors are stochastically co-expressed, and their concurrent engagement and signaling can adjust the sensitivity of individual cells to putative targets. Against cancers, which mutate and evolve under therapeutic and immunologic pressure, the diversity for recognition provided by NK cells may be key to comprehensive cancer control. NK cells are already being trialled as adoptive cell therapy and targets for immunotherapeutic agents. However, strategies to leverage their naturally occurring diversity and agility have not yet been developed. In this review, we discuss the receptors and signaling pathways through which signals for activation or inhibition are generated in NK cells, focusing on their roles in cancer and potential as targets for immunotherapies. Finally, we consider the impacts of receptor co-expression and the potential to engage multiple pathways of NK cell reactivity to maximize the scope and strength of antitumor activities.
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Affiliation(s)
- Sarah Nersesian
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
- Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
| | - Emily B. Carter
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
- Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
| | - Stacey N. Lee
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
- Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
| | | | - Jeanette E. Boudreau
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
- Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
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17
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Li Y, Rezvani K, Rafei H. Next-generation chimeric antigen receptors for T- and natural killer-cell therapies against cancer. Immunol Rev 2023; 320:217-235. [PMID: 37548050 PMCID: PMC10841677 DOI: 10.1111/imr.13255] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/12/2023] [Indexed: 08/08/2023]
Abstract
Adoptive cellular therapy using chimeric antigen receptor (CAR) T cells has led to a paradigm shift in the treatment of various hematologic malignancies. However, the broad application of this approach for myeloid malignancies and solid cancers has been limited by the paucity and heterogeneity of target antigen expression, and lack of bona fide tumor-specific antigens that can be targeted without cross-reactivity against normal tissues. This may lead to unwanted on-target off-tumor toxicities that could undermine the desired antitumor effect. Recent advances in synthetic biology and genetic engineering have enabled reprogramming of immune effector cells to enhance their selectivity toward tumors, thus mitigating on-target off-tumor adverse effects. In this review, we outline the current strategies being explored to improve CAR selectivity toward tumor cells with a focus on natural killer (NK) cells, and the progress made in translating these strategies to the clinic.
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Affiliation(s)
- Ye Li
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Katayoun Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hind Rafei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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18
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Moy AB, Kamath A, Ternes S, Kamath J. The Challenges to Advancing Induced Pluripotent Stem Cell-Dependent Cell Replacement Therapy. MEDICAL RESEARCH ARCHIVES 2023; 11:4784. [PMID: 38188933 PMCID: PMC10768945 DOI: 10.18103/mra.v11i11.4784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Induced pluripotent stem cells (iPSC) represent a potentially exciting regenerative-medicine cell therapy for several chronic conditions such as macular degeneration, soft tissue and orthopedic conditions, cardiopulmonary disease, cancer, neurodegenerative disorders and metabolic disorders. The field of iPSC therapeutics currently exists at an early stage of development. There are several important stakeholders that include academia, industry, regulatory agencies, financial institutions and patients who are committed to advance the field. Yet, unlike more established therapeutic modalities like small and large molecules, iPSC therapies pose significant unique challenges with respect to safety, potency, genetic stability, immunogenicity, tumorgenicity, cell reproducibility, scalability and engraftment. The aim of this review article is to highlight the unique technical challenges that need to be addressed before iPSC technology can be fully realized as a cell replacement therapy. Additionally, this manuscript offers some potential solutions and identifies areas of focus that should be considered in order for the iPSC field to achieve its promise. The scope of this article covers the following areas: (1) the impact of different iPSC reprogramming methods on immunogenicity and tumorigenicity; (2) the effect of genetic instability on cell reproducibility and differentiation; (3) the role of growth factors and post-translational modification on differentiation and cell scalability; (4) the potential use of gene editing in improving iPSC differentiation; (5) the advantages and disadvantages between autologous and allogeneic cell therapy; (6) the regulatory considerations in developing a viable and reproducible cell product; and (7) the impact of local tissue inflammation on cell engraftment and cell viability.
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Affiliation(s)
- Alan B. Moy
- Cellular Engineering Technologies, Inc. Coralville, IA, 52241
- John Paul II Medical Research Institute, Coralville, IA 52241
| | - Anant Kamath
- Cellular Engineering Technologies, Inc. Coralville, IA, 52241
| | - Sara Ternes
- Cellular Engineering Technologies, Inc. Coralville, IA, 52241
| | - Jay Kamath
- John Paul II Medical Research Institute, Coralville, IA 52241
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19
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Wong P, Foltz JA, Chang L, Neal CC, Yao T, Cubitt CC, Tran J, Kersting-Schadek S, Palakurty S, Jaeger N, Russler-Germain DA, Marin ND, Gang M, Wagner JA, Zhou AY, Jacobs MT, Foster M, Schappe T, Marsala L, McClain E, Pence P, Becker-Hapak M, Fisk B, Petti AA, Griffith OL, Griffith M, Berrien-Elliott MM, Fehniger TA. T-BET and EOMES sustain mature human NK cell identity and antitumor function. J Clin Invest 2023; 133:e162530. [PMID: 37279078 PMCID: PMC10313375 DOI: 10.1172/jci162530] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 05/19/2023] [Indexed: 06/07/2023] Open
Abstract
Since the T-box transcription factors (TFs) T-BET and EOMES are necessary for initiation of NK cell development, their ongoing requirement for mature NK cell homeostasis, function, and molecular programming remains unclear. To address this, T-BET and EOMES were deleted in unexpanded primary human NK cells using CRISPR/Cas9. Deleting these TFs compromised in vivo antitumor response of human NK cells. Mechanistically, T-BET and EOMES were required for normal NK cell proliferation and persistence in vivo. NK cells lacking T-BET and EOMES also exhibited defective responses to cytokine stimulation. Single-cell RNA-Seq revealed a specific T-box transcriptional program in human NK cells, which was rapidly lost following T-BET and EOMES deletion. Further, T-BET- and EOMES-deleted CD56bright NK cells acquired an innate lymphoid cell precursor-like (ILCP-like) profile with increased expression of the ILC-3-associated TFs RORC and AHR, revealing a role for T-box TFs in maintaining mature NK cell phenotypes and an unexpected role of suppressing alternative ILC lineages. Our study reveals the critical importance of sustained EOMES and T-BET expression to orchestrate mature NK cell function and identity.
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Affiliation(s)
- Pamela Wong
- Department of Medicine, Division of Oncology
| | | | - Lily Chang
- Department of Medicine, Division of Oncology
| | | | - Tony Yao
- Department of Medicine, Division of Oncology
| | | | | | | | | | | | | | | | | | | | | | | | - Mark Foster
- Department of Medicine, Division of Oncology
| | | | | | | | | | | | - Bryan Fisk
- Department of Medicine, Division of Oncology
| | | | | | | | | | - Todd A. Fehniger
- Department of Medicine, Division of Oncology
- Siteman Cancer Center, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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20
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Capelli C, Cuofano C, Pavoni C, Frigerio S, Lisini D, Nava S, Quaroni M, Colombo V, Galli F, Bezukladova S, Panina-Bordignon P, Gaipa G, Comoli P, Cossu G, Martino G, Biondi A, Introna M, Golay J. Potency assays and biomarkers for cell-based advanced therapy medicinal products. Front Immunol 2023; 14:1186224. [PMID: 37359560 PMCID: PMC10288881 DOI: 10.3389/fimmu.2023.1186224] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/24/2023] [Indexed: 06/28/2023] Open
Abstract
Advanced Therapy Medicinal Products (ATMPs) based on somatic cells expanded in vitro, with or without genetic modification, is a rapidly growing area of drug development, even more so following the marketing approval of several such products. ATMPs are produced according to Good Manufacturing Practice (GMP) in authorized laboratories. Potency assays are a fundamental aspect of the quality control of the end cell products and ideally could become useful biomarkers of efficacy in vivo. Here we summarize the state of the art with regard to potency assays used for the assessment of the quality of the major ATMPs used clinic settings. We also review the data available on biomarkers that may substitute more complex functional potency tests and predict the efficacy in vivo of these cell-based drugs.
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Affiliation(s)
- Chiara Capelli
- Center of Cellular Therapy "G. Lanzani", ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Carolina Cuofano
- Center of Cellular Therapy "G. Lanzani", ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Chiara Pavoni
- Center of Cellular Therapy "G. Lanzani", ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Simona Frigerio
- Cell Therapy Production Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Daniela Lisini
- Cell Therapy Production Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Sara Nava
- Cell Therapy Production Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Michele Quaroni
- Laboratory of Cell and Gene Therapy Stefano Verri, ASST Monza Ospedale San Gerardo, Monza, Italy
| | - Valentina Colombo
- Laboratory of Cell and Gene Therapy Stefano Verri, ASST Monza Ospedale San Gerardo, Monza, Italy
| | - Francesco Galli
- Division of Cell Matrix Biology & Regenerative Medicine, Faculty of Biology, Medicine and Health (FBMH), University of Manchester, Manchester, United Kingdom
| | - Svetlana Bezukladova
- Università Vita-Salute San Raffaele, Milan, Italy
- IRCCS San Raffaele Hospital, Neuroimmunology Unit, Division of Neuroscience, Milan, Italy
| | - Paola Panina-Bordignon
- Università Vita-Salute San Raffaele, Milan, Italy
- IRCCS San Raffaele Hospital, Neuroimmunology Unit, Division of Neuroscience, Milan, Italy
| | - Giuseppe Gaipa
- Laboratory of Cell and Gene Therapy Stefano Verri, ASST Monza Ospedale San Gerardo, Monza, Italy
| | - Patrizia Comoli
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giulio Cossu
- Division of Cell Matrix Biology & Regenerative Medicine, Faculty of Biology, Medicine and Health (FBMH), University of Manchester, Manchester, United Kingdom
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Gianvito Martino
- IRCCS San Raffaele Hospital, Neuroimmunology Unit, Division of Neuroscience, Milan, Italy
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Biondi
- Department of Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Martino Introna
- Center of Cellular Therapy "G. Lanzani", ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Josée Golay
- Center of Cellular Therapy "G. Lanzani", ASST Papa Giovanni XXIII, Bergamo, Italy
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21
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Berrien-Elliott MM, Jacobs MT, Fehniger TA. Allogeneic natural killer cell therapy. Blood 2023; 141:856-868. [PMID: 36416736 PMCID: PMC10023727 DOI: 10.1182/blood.2022016200] [Citation(s) in RCA: 58] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 11/24/2022] Open
Abstract
Interest in adoptive cell therapy for treating cancer is exploding owing to early clinical successes of autologous chimeric antigen receptor (CAR) T lymphocyte therapy. However, limitations using T cells and autologous cell products are apparent as they (1) take weeks to generate, (2) utilize a 1:1 donor-to-patient model, (3) are expensive, and (4) are prone to heterogeneity and manufacturing failures. CAR T cells are also associated with significant toxicities, including cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, and prolonged cytopenias. To overcome these issues, natural killer (NK) cells are being explored as an alternative cell source for allogeneic cell therapies. NK cells have an inherent ability to recognize cancers, mediate immune functions of killing and communication, and do not induce graft-versus-host disease, cytokine release syndrome, or immune effector cell-associated neurotoxicity syndrome. NK cells can be obtained from blood or cord blood or be derived from hematopoietic stem and progenitor cells or induced pluripotent stem cells, and can be expanded and cryopreserved for off-the-shelf availability. The first wave of point-of-care NK cell therapies led to the current allogeneic NK cell products being investigated in clinical trials with promising preliminary results. Basic advances in NK cell biology and cellular engineering have led to new translational strategies to block inhibition, enhance and broaden target cell recognition, optimize functional persistence, and provide stealth from patients' immunity. This review details NK cell biology, as well as NK cell product manufacturing, engineering, and combination therapies explored in the clinic leading to the next generation of potent, off-the-shelf cellular therapies for blood cancers.
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Affiliation(s)
| | - Miriam T. Jacobs
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Todd A. Fehniger
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
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