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Ward GA, Zhang Z, Jueliger S, Potapov IS, Davis MP, Boxall AR, Taylor J, Keer H, Biondo A, Lyons JF, Sims M, Smyth T. Epigenetic Priming by Hypomethylation Enhances the Immunogenic Potential of Tolinapant in T-cell Lymphoma. CANCER RESEARCH COMMUNICATIONS 2024; 4:1441-1453. [PMID: 38727208 PMCID: PMC11155518 DOI: 10.1158/2767-9764.crc-23-0415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 03/02/2024] [Accepted: 05/08/2024] [Indexed: 06/07/2024]
Abstract
Programmed cell death mechanisms are important for the regulation of tumor development and progression. Evasion of and resistance to apoptosis are significant factors in tumorigenesis and drug resistance. Bypassing apoptotic pathways and eliciting another form of regulated cell death, namely necroptosis, an immunogenic cell death (ICD), may override apoptotic resistance. Here, we present the mechanistic rationale for combining tolinapant, an antagonist of the inhibitor of apoptosis proteins (IAP), with decitabine, a hypomethylating agent (HMA), in T-cell lymphoma (TCL). Tolinapant treatment alone of TCL cells in vitro and in syngeneic in vivo models demonstrated that ICD markers can be upregulated, and we have shown that epigenetic priming with decitabine further enhances this effect. The clinical relevance of ICD markers was confirmed by the direct measurement of plasma proteins from patients with peripheral TCL treated with tolinapant. We showed increased levels of necroptosis in TCL lines, along with the expression of cancer-specific antigens (such as cancer testis antigens) and increases in genes involved in IFN signaling induced by HMA treatment, together deliver a strong adaptive immune response to the tumor. These results highlight the potential of a decitabine and tolinapant combination for TCL and could lead to clinical evaluation. SIGNIFICANCE The IAP antagonist tolinapant can induce necroptosis, a key immune-activating event, in TCL. Combination with DNA hypomethylation enhances tolinapant sensitivity and primes resistant cells by re-expressing necrosome proteins. In addition, this combination leads to increases in genes involved in IFN signaling and neoantigen expression, providing further molecular rationale for this novel therapeutic option.
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Affiliation(s)
| | | | | | | | | | | | - Jason Taylor
- Astex Pharmaceuticals, Inc., Pleasanton, California
| | - Harold Keer
- Astex Pharmaceuticals, Inc., Pleasanton, California
| | | | | | - Martin Sims
- Astex Pharmaceuticals, Cambridge, United Kingdom
| | - Tomoko Smyth
- Astex Pharmaceuticals, Cambridge, United Kingdom
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2
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Noronha N, Durette C, Cahuzac M, E Silva B, Courtois J, Humeau J, Sauvat A, Hardy MP, Vincent K, Laverdure JP, Lanoix J, Baron F, Thibault P, Perreault C, Ehx G. Autophagy degrades immunogenic endogenous retroelements induced by 5-azacytidine in acute myeloid leukemia. Leukemia 2024; 38:1019-1031. [PMID: 38627586 DOI: 10.1038/s41375-024-02250-6] [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: 12/22/2022] [Revised: 04/02/2024] [Accepted: 04/08/2024] [Indexed: 05/08/2024]
Abstract
The hypomethylating agent 5-azacytidine (AZA) is the first-line treatment for AML patients unfit for intensive chemotherapy. The effect of AZA results in part from T-cell cytotoxic responses against MHC-I-associated peptides (MAPs) deriving from hypermethylated genomic regions such as cancer-testis antigens (CTAs), or endogenous retroelements (EREs). However, evidence supporting higher ERE MAPs presentation after AZA treatment is lacking. Therefore, using proteogenomics, we examined the impact of AZA on the repertoire of MAPs and their source transcripts. AZA-treated AML upregulated both CTA and ERE transcripts, but only CTA MAPs were presented at greater levels. Upregulated ERE transcripts triggered innate immune responses against double-stranded RNAs but were degraded by autophagy, and not processed into MAPs. Autophagy resulted from the formation of protein aggregates caused by AZA-dependent inhibition of DNMT2. Autophagy inhibition had an additive effect with AZA on AML cell proliferation and survival, increased ERE levels, increased pro-inflammatory responses, and generated immunogenic tumor-specific ERE-derived MAPs. Finally, autophagy was associated with a lower abundance of CD8+ T-cell markers in AML patients expressing high levels of EREs. This work demonstrates that AZA-induced EREs are degraded by autophagy and shows that inhibiting autophagy can improve the immune recognition of AML blasts in treated patients.
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MESH Headings
- Humans
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/immunology
- Leukemia, Myeloid, Acute/pathology
- Azacitidine/pharmacology
- Autophagy/drug effects
- Antimetabolites, Antineoplastic/pharmacology
- Antimetabolites, Antineoplastic/therapeutic use
- DNA Methylation/drug effects
- Cell Proliferation
- Antigens, Neoplasm/genetics
- Antigens, Neoplasm/immunology
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Affiliation(s)
| | | | | | - Bianca E Silva
- GIGA Institute, Laboratory of Hematology, University of Liege, Liege, Belgium
| | - Justine Courtois
- GIGA Institute, Laboratory of Hematology, University of Liege, Liege, Belgium
| | | | - Allan Sauvat
- Equipe labellisée par la Ligue contre le Cancer, Université de Paris, Sorbonne Université, Inserm U1138, Institut Universitaire de France, Paris, France
| | | | | | | | - Joël Lanoix
- IRIC, Université de Montréal, Montreal, QC, Canada
| | - Frédéric Baron
- GIGA Institute, Laboratory of Hematology, University of Liege, Liege, Belgium
| | | | | | - Gregory Ehx
- IRIC, Université de Montréal, Montreal, QC, Canada.
- GIGA Institute, Laboratory of Hematology, University of Liege, Liege, Belgium.
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3
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Garcia JS, Flamand Y, Penter L, Keng M, Tomlinson BK, Mendez LM, Koller P, Cullen N, Arihara Y, Pfaff K, Wolff JO, Brunner AM, Galinsky I, Bashey A, Antin JH, Cutler C, Ho V, Jonas BA, Luskin MR, Wadleigh M, Winer ES, Savell A, Leonard R, Robertson T, Davids MS, Streicher H, Rodig SJ, Ritz J, Wu CJ, DeAngelo DJ, Neuberg D, Stone RM, Soiffer RJ. Ipilimumab plus decitabine for patients with MDS or AML in posttransplant or transplant-naïve settings. Blood 2023; 141:1884-1888. [PMID: 36332187 PMCID: PMC10122101 DOI: 10.1182/blood.2022017686] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/20/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
Two articles in this week’s issue focus on the use of ipilimumab and decitabine for patients with myelodysplasia (MDS) and acute myeloid leukemia (AML) before and after hematopoietic stem cell transplantation (HSCT) for high-risk disease. In the first article, Garcia et al report on the results of a phase 1 trial of the combination in 54 patients, demonstrating overall response rate of 52% in patients who are HSCT-naïve and 20% in patients post-HSCT; responses are usually short-lived. In the second article, Penter and colleagues characterize gene expression responses to therapy and conclude that decitabine acts directly to clear leukemic cells while ipilimumab acts on infiltrating lymphocytes in marrow and extramedullary sites. Responses are determined by leukemic cell burden and by the frequency and phenotype of infiltrating lymphocytes. Increasing bone marrow regulatory T cells is identified as a potential contributor to checkpoint inhibitor escape.
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Affiliation(s)
| | - Yael Flamand
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Livius Penter
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Michael Keng
- Division of Hematology/Oncology, University of Virginia, Charlottesville, VA
| | | | - Lourdes M. Mendez
- Department of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Paul Koller
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Nicole Cullen
- Center for Immuno-Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Yohei Arihara
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Kathleen Pfaff
- Center for Immuno-Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Andrew M. Brunner
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Ilene Galinsky
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Asad Bashey
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA
| | - Joseph H. Antin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Corey Cutler
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Vincent Ho
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Brian A. Jonas
- Division of Cellular Therapy, BMT and Malignant Hematology, University of California, Davis, Sacramento, CA
| | - Marlise R. Luskin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Martha Wadleigh
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Eric S. Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Alexandra Savell
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Rebecca Leonard
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Taylor Robertson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Matthew S. Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Howard Streicher
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, MD
| | - Scott J. Rodig
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA
| | - Jerome Ritz
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Catherine J. Wu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Daniel J. DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Donna Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Richard M. Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Robert J. Soiffer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
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Almutairi MH, Alrubie TM, Almutairi BO, Alamri AM, Alrefaei AF, Arafah MM, Alanazi M, Semlali A. The Expression Patterns of Human Cancer-Testis Genes Are Induced through Epigenetic Drugs in Colon Cancer Cells. Pharmaceuticals (Basel) 2022; 15:1319. [PMID: 36355490 PMCID: PMC9692864 DOI: 10.3390/ph15111319] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 09/28/2022] [Accepted: 10/21/2022] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND The expression of human germline genes is restricted to the germ cells of the gonads, which produce sperm and eggs. The germline genes involved in testis development and potentially activated in cancer cells are known as cancer-testis (CT) genes. These genes are potential therapeutic targets and biomarkers, as well as drivers of the oncogenic process. CT genes can be reactivated by treatment with drugs that demethylate DNA. The majority of the existing literature on CT gene activation focuses on X-chromosome-produced CT genes. We tested the hypothesis that epigenetic landscape changes, such as DNA methylation, can alter several CT gene expression profiles in cancer and germ cells. METHODS Colon cancer (CC) cell lines were treated with the DNA methyltransferase inhibitor (DNMTi) 5-aza-2'-deoxycytidine, or with the histone deacetylase inhibitor (HDACi) trichostatin A (TSA). The effects of these epigenetic treatments on the transcriptional activation of previously published CT genes (CTAG1A, SCP2D1, TKTL2, LYZL6, TEX33, and ACTRT1) and testis-specific genes (NUTM1, ASB17, ZSWIM2, ADAM2, and C10orf82) were investigated. RESULTS We found that treatment of CC cell lines with 5-aza-2'-deoxycytidine or TSA correlated with activation of X-encoded CT genes and non-X-encoded CT genes in somatic (non-germline) cells. CONCLUSION These findings confirm that a subset of CT genes can be regulated by hypomethylating drugs and subsequently provide a potential therapeutic target for cancer.
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Affiliation(s)
- Mikhlid H. Almutairi
- Zoology Department, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
| | - Turki M. Alrubie
- Zoology Department, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
| | - Bader O. Almutairi
- Zoology Department, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
| | - Abdullah M. Alamri
- Genome Research Chair, Department of Biochemistry, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
| | - Abdulwahed F. Alrefaei
- Zoology Department, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
| | - Maha M. Arafah
- Pathology Department, College of Medicine, King Saud University, Riyadh 11451, Saudi Arabia
| | - Mohammad Alanazi
- Genome Research Chair, Department of Biochemistry, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
| | - Abdelhabib Semlali
- Groupe de Recherche en Écologie Buccale, Faculté de Médecine Dentaire, Université Laval, 2420 Rue de la Terrasse, Local 1758, Québec, QC G1V 0A6, Canada
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5
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Kang S, Wang L, Xu L, Wang R, Kang Q, Gao X, Yu L. Decitabine enhances targeting of AML cells by NY-ESO-1-specific TCR-T cells and promotes the maintenance of effector function and the memory phenotype. Oncogene 2022; 41:4696-4708. [PMID: 36097193 PMCID: PMC9568428 DOI: 10.1038/s41388-022-02455-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 08/19/2022] [Accepted: 08/25/2022] [Indexed: 12/03/2022]
Abstract
NY-ESO-1 is a well-known cancer-testis antigen (CTA) with re-expression in numerous cancer types, but its expression is suppressed in myeloid leukemia cells. Patients with acute myeloid leukemia (AML) receiving decitabine (DAC) exhibit induced expression of NY-ESO-1 in blasts; thus, we investigated the effects of NY-ESO-1-specific TCR-engineered T (TCR-T) cells combined with DAC against AML. NY-ESO-1-specific TCR-T cells could efficiently eliminate AML cell lines (including U937, HL60, and Kasumi-1cells) and primary AML blasts in vitro by targeting the DAC-induced NY-ESO-1 expression. Moreover, the incubation of T cells with DAC during TCR transduction (designated as dTCR-T cells) could further enhance the anti-leukemia efficacy of TCR-T cells and increase the generation of memory-like phenotype. The combination of DAC with NY-ESO-1-specific dTCR-T cells showed a superior anti-tumor efficacy in vivo and prolonged the survival of an AML xenograft mouse model, with three out of five mice showing complete elimination of AML cells over 90 days. This outcome was correlated with enhanced expressions of IFN-γ and TNF-α, and an increased proportion of central memory T cells (CD45RO+CD62L+ and CD45RO+CCR7+). Taken together, these data provide preclinical evidence for the combined use of DAC and NY-ESO-1-specific dTCR-T cells for the treatment of AML.
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Affiliation(s)
- Synat Kang
- Department of Hematology and Oncology, International Cancer Center, Shenzhen Key Laboratory of Precision Medicine for Hematological Malignancies, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen University Health Science Center, Shenzhen, 518000, Guangdong, China
| | - Lixin Wang
- Department of Hematology and Oncology, International Cancer Center, Shenzhen Key Laboratory of Precision Medicine for Hematological Malignancies, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen University Health Science Center, Shenzhen, 518000, Guangdong, China
| | - Lu Xu
- Department of Hematology and Oncology, International Cancer Center, Shenzhen Key Laboratory of Precision Medicine for Hematological Malignancies, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen University Health Science Center, Shenzhen, 518000, Guangdong, China
| | - Ruiqi Wang
- School of Medicine, Nankai University, Tianjin, 300071, China
| | - Qingzheng Kang
- Department of Hematology and Oncology, International Cancer Center, Shenzhen Key Laboratory of Precision Medicine for Hematological Malignancies, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen University Health Science Center, Shenzhen, 518000, Guangdong, China
| | - Xuefeng Gao
- Department of Hematology and Oncology, International Cancer Center, Shenzhen Key Laboratory of Precision Medicine for Hematological Malignancies, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen University Health Science Center, Shenzhen, 518000, Guangdong, China. .,Central Laboratory, Shenzhen Key Laboratory of Precision Medicine for Hematological Malignancies, Shenzhen University General Hospital, Shenzhen, 518000, Guangdong, China.
| | - Li Yu
- Department of Hematology and Oncology, International Cancer Center, Shenzhen Key Laboratory of Precision Medicine for Hematological Malignancies, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen University Health Science Center, Shenzhen, 518000, Guangdong, China.
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Symeonidou V, Metzner M, Usukhbayar B, Jackson AE, Fox S, Craddock CF, Vyas P. Heterogeneous genetic and non-genetic mechanisms contribute to response and resistance to azacitidine monotherapy. EJHAEM 2022; 3:794-803. [PMID: 36051087 PMCID: PMC9421974 DOI: 10.1002/jha2.527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/19/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022]
Abstract
Acute myeloid leukaemia is prevalent in older patients that are often ineligible for intensive chemotherapy and treatment options remain limited with azacitidine being at the forefront. Azacitidine has been used in the clinic for decades, however, we still lack a complete understanding of the mechanisms by which the drug exerts its anti-tumour effect. To gain insight into the mechanism of action, we defined the mutational profile of sequential samples of patients treated with azacitidine. We did not identify any mutations that could predict response and observed lack of a uniform pattern of clonal evolution. Focusing on responders, at remission, we observed three types of response: (1) an almost complete elimination of mutations (33%), (2) no change (17%), and (3) change with no discernible pattern (50%). Heterogeneous patterns were also observed at relapse, with no clonal evolution between remission and relapse in some patients. Lack of clonal evolution suggests that non-genetic mechanisms might be involved. Towards understanding such mechanisms, we investigated the immune microenvironment in a number of patients and we observed lack of a uniform response following therapy. We identified a higher frequency of cytotoxic T cells in responders and higher frequency of naïve helper T cells in non-responders.
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Affiliation(s)
- Vasiliki Symeonidou
- MRC Molecular Haematology Unit, Oxford Biomedical Research Centre Haematology Theme, Oxford Centre for Haematology, Weatherall Institute of Molecular Medicine, Radcliffe Department of MedicineUniversity of OxfordOxfordUK
| | - Marlen Metzner
- MRC Molecular Haematology Unit, Oxford Biomedical Research Centre Haematology Theme, Oxford Centre for Haematology, Weatherall Institute of Molecular Medicine, Radcliffe Department of MedicineUniversity of OxfordOxfordUK
| | - Batchimeg Usukhbayar
- MRC Molecular Haematology Unit, Oxford Biomedical Research Centre Haematology Theme, Oxford Centre for Haematology, Weatherall Institute of Molecular Medicine, Radcliffe Department of MedicineUniversity of OxfordOxfordUK
| | - Aimee E. Jackson
- Cancer Research UK Clinical Trials UnitUniversity of BirminghamBirminghamUK
| | - Sonia Fox
- Centre for Clinical HaematologyQueen Elizabeth HospitalBirminghamUK
| | | | - Paresh Vyas
- MRC Molecular Haematology Unit, Oxford Biomedical Research Centre Haematology Theme, Oxford Centre for Haematology, Weatherall Institute of Molecular Medicine, Radcliffe Department of MedicineUniversity of OxfordOxfordUK
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DiMarco AV, Maddalo D. In Vivo Modeling of Tumor Heterogeneity for Immuno-Oncology Studies: Failures, Improvements, and Hopes. Curr Protoc 2022; 2:e377. [PMID: 35255200 DOI: 10.1002/cpz1.377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Murine tumor modeling is fundamental for the preclinical development of anti-cancer therapies. Use of immunocompetent mouse models is becoming increasingly relevant as we gain more knowledge of how cancer cells interact with the immune system in the tumor microenvironment and how we can harness the immune system to fight tumors. However, there are few intrinsically immunogenic preclinical tumor models, and the vast majority either do not respond to therapy or do not faithfully predict the responses of the therapy when applied in the clinic. Here, we discuss the limitations of commonly used murine tumor models in immuno-oncology and strategies to improve their immunogenicity and mutational burden to more accurately reflect the heterogeneity of patient tumors. © 2022 Wiley Periodicals LLC.
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Affiliation(s)
- Ashley V DiMarco
- Department of Translational Oncology, Genentech, Inc., South San Francisco, California
| | - Danilo Maddalo
- Department of Translational Oncology, Genentech, Inc., South San Francisco, California
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8
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Ciotti G, Marconi G, Martinelli G. Hypomethylating Agent-Based Combination Therapies to Treat Post-Hematopoietic Stem Cell Transplant Relapse of Acute Myeloid Leukemia. Front Oncol 2022; 11:810387. [PMID: 35071015 PMCID: PMC8770807 DOI: 10.3389/fonc.2021.810387] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/10/2021] [Indexed: 12/23/2022] Open
Abstract
Allogeneic stem cell transplantation still represents the best curative option for most patients with acute myeloid leukemia, but relapse is still dramatically high. Due to their immunologic activity and safety profile, hypomethylating agents (HMAs) represent an interesting backbone for combination therapies. This review reports mechanism of action, safety, and efficacy data on combination strategies based on HMAs in the setting of post-allogeneic stem cell transplant relapse. Several studies highlighted how HMAs and donor lymphocyte infusion (DLI) combination may be advantageous. The combination strategy of HMA with venetoclax, possibly in association with DLI, is showing excellent results in terms of response rate, including molecular responses. Lenalidomide, despite its well-known high rates of severe graft-versus-host disease in post-transplant settings, is showing an acceptable safety profile in association with HMAs with a competitive response rate. Regarding FLT3 internal tandem duplication (ITD) mutant AML, tyrosine kinase inhibitors and particularly sorafenib have promising results as monotherapy and in combination with HMAs. Conversely, combination strategies with gemtuzumab ozogamicin or immune checkpoint inhibitors did not show competitive response rates and seem to be currently less attractive strategies. Associations with histone deacetylase inhibitors and isocitrate dehydrogenase 1 and 2 (IDH1/2) inhibitors represent new possible strategies that need to be better investigated.
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Affiliation(s)
- Giulia Ciotti
- Ematologia, Dipartimento di Medicina Traslazionale e di Precisione, Università La Sapienza, Azienda Ospedaliera Policlinico Umberto I, Rome, Italy
| | - Giovanni Marconi
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Giovanni Martinelli
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
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9
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Goswami M, Gui G, Dillon LW, Lindblad KE, Thompson J, Valdez J, Kim DY, Ghannam JY, Oetjen KA, Destefano CB, Smith DM, Tekleab H, Li Y, Dagur P, Hughes T, Marté JL, Del Rivero J, Klubo-Gwiezdzinksa J, Gulley JL, Calvo KR, Lai C, Hourigan CS. Pembrolizumab and decitabine for refractory or relapsed acute myeloid leukemia. J Immunother Cancer 2022; 10:jitc-2021-003392. [PMID: 35017151 PMCID: PMC8753450 DOI: 10.1136/jitc-2021-003392] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2021] [Indexed: 12/11/2022] Open
Abstract
Background The powerful ‘graft versus leukemia’ effect thought partly responsible for the therapeutic effect of allogeneic hematopoietic cell transplantation in acute myeloid leukemia (AML) provides rationale for investigation of immune-based therapies in this high-risk blood cancer. There is considerable preclinical evidence for potential synergy between PD-1 immune checkpoint blockade and the hypomethylating agents already commonly used for this disease. Methods We report here the results of 17 H-0026 (PD-AML, NCT02996474), an investigator sponsored, single-institution, single-arm open-label 10-subject pilot study to test the feasibility of the first-in-human combination of pembrolizumab and decitabine in adult patients with refractory or relapsed AML (R-AML). Results In this cohort of previously treated patients, this novel combination of anti-PD-1 and hypomethylating therapy was feasible and associated with a best response of stable disease or better in 6 of 10 patients. Considerable immunological changes were identified using T cell receptor β sequencing as well as single-cell immunophenotypic and RNA expression analyses on sorted CD3+ T cells in patients who developed immune-related adverse events (irAEs) during treatment. Clonal T cell expansions occurred at irAE onset; single-cell sequencing demonstrated that these expanded clones were predominately CD8+ effector memory T cells with high cell surface PD-1 expression and transcriptional profiles indicative of activation and cytotoxicity. In contrast, no such distinctive immune changes were detectable in those experiencing a measurable antileukemic response during treatment. Conclusion Addition of pembrolizumab to 10-day decitabine therapy was clinically feasible in patients with R-AML, with immunological changes from PD-1 blockade observed in patients experiencing irAEs.
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Affiliation(s)
- Meghali Goswami
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA.,National Cancer Institute, Bethesda, Maryland, USA
| | - Gege Gui
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Laura W Dillon
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | | | - Julie Thompson
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Janet Valdez
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Dong-Yun Kim
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Jack Y Ghannam
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Karolyn A Oetjen
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | | | - Dana M Smith
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Hanna Tekleab
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Yeusheng Li
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Pradeep Dagur
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Thomas Hughes
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | | | | | | | | | - Katherine R Calvo
- National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Catherine Lai
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Christopher S Hourigan
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA .,Trans-NIH Center for Human Immunology, National Institutes of Health, Bethesda, Maryland, USA
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10
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Holtzman NG, Lebowitz MS, Koka R, Baer MR, Malhotra K, Shahlaee A, Ghanbari HA, Bentzen SM, Emadi A. Aspartate β-Hydroxylase (ASPH) Expression in Acute Myeloid Leukemia: A Potential Novel Therapeutic Target. Front Oncol 2022; 11:783744. [PMID: 35004304 PMCID: PMC8727599 DOI: 10.3389/fonc.2021.783744] [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: 09/26/2021] [Accepted: 12/01/2021] [Indexed: 11/23/2022] Open
Abstract
Background Aspartate β-hydroxylase (ASPH) is an embryonic transmembrane protein aberrantly upregulated in cancer cells, associated with malignant transformation and, in some reports, with poor clinical prognosis. Objective To report the expression patterns of ASPH in acute myeloid leukemia (AML). Methods Cell surface expression of ASPH was measured via 8-color multiparameter flow cytometry in 41 AML patient samples (31 bone marrow, 10 blood) using fluorescein isothiocyanate (FITC)-conjugated anti-ASPH antibody, SNS-622. A mean fluorescent intensity (MFI) of 10 was used as a cutoff for ASPH surface expression positivity. Data regarding patient and disease characteristics were collected. Results ASPH surface expression was found on AML blasts in 16 samples (39%). Higher ASPH expression was seen in myeloblasts of African American patients (p=0.02), but no correlation was found between ASPH expression and other patient or disease characteristics. No association was found between ASPH status and CR rate (p=0.53), EFS (p=0.87), or OS (p=0.17). Conclusions ASPH is expressed on blasts in approximately 40% of AML cases, and may serve as a new therapeutically targetable leukemia-associated antigen.
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Affiliation(s)
- Noa G Holtzman
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, United States.,Immune Deficiency Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | | | - Rima Koka
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Maria R Baer
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, United States.,Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Kanam Malhotra
- Sensei Biotherapeutics Inc., Gaithersburg, MD, United States
| | - Amir Shahlaee
- Sensei Biotherapeutics Inc., Gaithersburg, MD, United States
| | | | - Søren M Bentzen
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, United States.,Department of Epidemiology and Biostatistics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Ashkan Emadi
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, United States.,Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States.,Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD, United States
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11
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Checkpoint Inhibitors and Other Immune-Based Therapies in Acute Myeloid Leukemia. Cancer J 2022; 28:43-50. [DOI: 10.1097/ppo.0000000000000573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Fujii SI, Yamasaki S, Hanada K, Ueda S, Kawamura M, Shimizu K. Cancer immunotherapy using artificial adjuvant vector cells to deliver NY-ESO-1 antigen to dendritic cells in situ. Cancer Sci 2021; 113:864-874. [PMID: 34971473 PMCID: PMC8898705 DOI: 10.1111/cas.15259] [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: 09/07/2021] [Revised: 12/19/2021] [Accepted: 12/22/2021] [Indexed: 11/26/2022] Open
Abstract
NY‐ESO‐1 is a cancer/testis antigen expressed in various cancer types. However, the induction of NY‐ESO‐1‐specific CTLs through vaccines is somewhat difficult. Thus, we developed a new type of artificial adjuvant vector cell (aAVC‐NY‐ESO‐1) expressing a CD1d‐NKT cell ligand complex and a tumor‐associated antigen, NY‐ESO‐1. First, we determined the activation of invariant natural killer T (iNKT) and natural killer (NK) cell responses by aAVC‐NY‐ESO‐1. We then showed that the NY‐ESO‐1‐specific CTL response was successfully elicited through aAVC‐NY‐ESO‐1 therapy. After injection of aAVC‐NY‐ESO‐1, we found that dendritic cells (DCs) in situ expressed high levels of costimulatory molecules and produced interleukn‐12 (IL‐12), indicating that DCs undergo maturation in vivo. Furthermore, the NY‐ESO‐1 antigen from aAVC‐NY‐ESO‐1 was delivered to the DCs in vivo, and it was presented on MHC class I molecules. The cross‐presentation of the NY‐ESO‐1 antigen was absent in conventional DC‐deficient mice, suggesting a host DC‐mediated CTL response. Thus, this strategy helps generate sufficient CD8+ NY‐ESO‐1‐specific CTLs along with iNKT and NK cell activation, resulting in a strong antitumor effect. Furthermore, we established a human DC‐transferred NOD/Shi‐scid/IL‐2γcnull immunodeficient mouse model and showed that the NY‐ESO‐1 antigen from aAVC‐NY‐ESO‐1 was cross‐presented to antigen‐specific CTLs through human DCs. Taken together, these data suggest that aAVC‐NY‐ESO‐1 has potential for harnessing innate and adaptive immunity against NY‐ESO‐1‐expressing malignancies.
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Affiliation(s)
- Shin-Ichiro Fujii
- Laboratory for Immunotherapy, RIKEN Research Center for Integrative Medicine (IMS), Yokohama, Japan.,RIKEN Program for drug discovery and medical technology platforms, Yokohama, Japan
| | - Satoru Yamasaki
- Laboratory for Immunotherapy, RIKEN Research Center for Integrative Medicine (IMS), Yokohama, Japan
| | - Kenichi Hanada
- Surgery Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Shogo Ueda
- Laboratory for Immunotherapy, RIKEN Research Center for Integrative Medicine (IMS), Yokohama, Japan
| | - Masami Kawamura
- Laboratory for Immunotherapy, RIKEN Research Center for Integrative Medicine (IMS), Yokohama, Japan
| | - Kanako Shimizu
- Laboratory for Immunotherapy, RIKEN Research Center for Integrative Medicine (IMS), Yokohama, Japan
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13
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Linder K, Lulla P. Myelodysplastic syndrome and immunotherapy novel to next in-line treatments. Hum Vaccin Immunother 2021; 17:2602-2616. [PMID: 33941042 PMCID: PMC8475606 DOI: 10.1080/21645515.2021.1898307] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/09/2021] [Accepted: 02/27/2021] [Indexed: 01/28/2023] Open
Abstract
Patients with Myelodysplastic syndromes (MDS) have few therapy options for sustainable responses in the frontline setting, and even less after hypomethylating agent (HMA) failure in relapsed and refractory setting. The only potential cure is an allogeneic hematopoietic stem cell transplant which is an unrealistic option for the majority of MDS patients. Immunotherapy with checkpoint inhibition, CAR-T cells, and vaccine therapy few have shown promise in a variety cancer and have now been tested in patients with MDS. Most trials have focused on AML patients and included small numbers of MDS patients. Until now, a dedicated review of immunotherapy outcomes in MDS patients has been lacking. Thus, herein we review outcomes of MDS patients after immunotherapies on a variety of clinical trials reported to date.
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Affiliation(s)
- Katherine Linder
- Baylor College of Medicine, Section of Hematology & Oncology, Houston, TX, USA
| | - Premal Lulla
- Baylor College of Medicine, Center for Cell and Gene Therapy, Hematology-Oncology, Houston, TX, USA
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14
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Holmberg-Thydén S, Dufva IH, Gang AO, Breinholt MF, Schejbel L, Andersen MK, Kadivar M, Svane IM, Grønbæk K, Hadrup SR, El Fassi D. Epigenetic therapy in combination with a multi-epitope cancer vaccine targeting shared tumor antigens for high-risk myelodysplastic syndrome - a phase I clinical trial. Cancer Immunol Immunother 2021; 71:433-444. [PMID: 34218294 DOI: 10.1007/s00262-021-02993-6] [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: 12/05/2020] [Accepted: 06/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Standard care for patients with high-risk myelodysplastic syndrome (MDS) is hypomethylating agents such as azacitidine (AZA), which can induce expression of methylated tumor-associated antigens and therefore potentiate immunotherapeutic targeting. METHOD In this phase 1 trial, we combined AZA with a therapeutic peptide vaccine targeting antigens encoded from NY-ESO-1, MAGE-A3, PRAME, and WT-1, which have previously been demonstrated to be upregulated by AZA treatment. RESULT Five patients who had responded to AZA monotherapy were included in the study and treated with the vaccine. The combination therapy showed only few adverse events during the study period, whereof none classified as serious. However, no specific immune responses could be detected using intracellular cytokine staining or ELISpot assays. Minor changes in the phenotypic composition of immune cells and their expression of stimulatory and inhibitory markers were detected. All patients progressed to AML with a mean time to progression from inclusion (TTP) of 5.2 months (range 2.8 to 7.6). Mean survival was 18.1 months (range 10.9 to 30.6) from MDS diagnosis and 11.3 months (range 4.3 to 22.2) from inclusion. Sequencing of bone marrow showed clonal expansion of malignant cells, as well as appearance of novel mutations. CONCLUSION The patients progressed to AML with an average time of only five months after initiating the combination therapy. This may be unrelated to the experimental treatment, but the trial was terminated early as there was no sign of clinical benefit or immunological response. Why the manuscript is especially interesting This study is the first to exploit the potential synergistic effects of combining a multi-peptide cancer vaccine with epigenetic therapy in MDS. Although our results are negative, they emphasize challenges to induce immune reactivity in patients with high-risk MDS.
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Affiliation(s)
- Staffan Holmberg-Thydén
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark.,Experimental & Translational Immunology (XTI), Health Technology, T-Cells and Cancer, Technical University of Denmark, Lyngby, Denmark
| | - Inge Høgh Dufva
- Department of Oncology and Palliative Care, Copenhagen University Hospital, Hillerød, Denmark
| | - Anne Ortved Gang
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Lone Schejbel
- Department of Pathology, Copenhagen University Hospital, Herlev, Denmark
| | | | - Mohammad Kadivar
- Experimental & Translational Immunology (XTI), Health Technology, T-Cells and Cancer, Technical University of Denmark, Lyngby, Denmark
| | - Inge Marie Svane
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,National Center for Cancer Immune Therapy, Copenhagen University Hospital, Herlev, Denmark.,Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Kirsten Grønbæk
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Biotech Research and Innovation Centre, BRIC, University of Copenhagen, Copenhagen, Denmark
| | - Sine Reker Hadrup
- Experimental & Translational Immunology (XTI), Health Technology, T-Cells and Cancer, Technical University of Denmark, Lyngby, Denmark.
| | - Daniel El Fassi
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark. .,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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15
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Clinical effects of administering leukemia-specific donor T cells to patients with AML/MDS after allogeneic transplant. Blood 2021; 137:2585-2597. [PMID: 33270816 DOI: 10.1182/blood.2020009471] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/20/2020] [Indexed: 01/11/2023] Open
Abstract
Relapse after allogeneic hematopoietic stem cell transplantation (HCT) is the leading cause of death in patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS). Infusion of unselected donor lymphocytes (DLIs) enhances the graft-versus-leukemia (GVL) effect. However, because the infused lymphocytes are not selected for leukemia specificity, the GVL effect is often accompanied by life-threatening graft-versus-host disease (GVHD), related to the concurrent transfer of alloreactive lymphocytes. Thus, to minimize GVHD and maximize GVL, we selectively activated and expanded stem cell donor-derived T cells reactive to multiple antigens expressed by AML/MDS cells (PRAME, WT1, Survivin, and NY-ESO-1). Products that demonstrated leukemia antigen specificity were generated from 29 HCT donors. In contrast to DLIs, leukemia-specific T cells (mLSTs) selectively recognized and killed leukemia antigen-pulsed cells, with no activity against recipient's normal cells in vitro. We administered escalating doses of mLSTs (0.5 to 10 × 107 cells per square meter) to 25 trial enrollees, 17 with high risk of relapse and 8 with relapsed disease. Infusions were well tolerated with no grade >2 acute or extensive chronic GVHD seen. We observed antileukemia effects in vivo that translated into not-yet-reached median leukemia-free and overall survival at 1.9 years of follow-up and objective responses in the active disease cohort (1 complete response and 1 partial response). In summary, mLSTs are safe and promising for the prevention and treatment of AML/MDS after HCT. This trial is registered at www.clinicaltrials.com as #NCT02494167.
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16
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Wu M, Wang S, Chen JY, Zhou LJ, Guo ZW, Li YH. Therapeutic cancer vaccine therapy for acute myeloid leukemia. Immunotherapy 2021; 13:863-877. [PMID: 33955237 DOI: 10.2217/imt-2020-0277] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Antitumor function of the immune system has been harnessed to eradicate tumor cells as cancer therapy. Therapeutic cancer vaccines aim to help immune cells recognize tumor cells, which are difficult to target owing to immune escape. Many attempts at vaccine designs have been conducted throughout the last decades. In addition, as the advanced understanding of immunosuppressive mechanisms mediated by tumor cells, combining cancer vaccines with other immune therapies seems to be more efficient for cancer treatment. Acute myeloid leukemia (AML) is the most common acute leukemia in adults with poor prognosis. Evidence has shown T-cell-mediated immune responses in AML, which encourages the utility of immune therapies in AML. This review discusses cancer vaccines in AML from vaccine design as well as recent progress in vaccination combination with other immune therapies.
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Affiliation(s)
- Ming Wu
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China.,Department of Hematology, Zhongshan People's Hospital, Zhongshan 528400, China
| | - Sheng Wang
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Jian-Yu Chen
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Li-Juan Zhou
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Zi-Wen Guo
- Department of Hematology, Zhongshan People's Hospital, Zhongshan 528400, China
| | - Yu-Hua Li
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
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17
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Wong KK, Hassan R, Yaacob NS. Hypomethylating Agents and Immunotherapy: Therapeutic Synergism in Acute Myeloid Leukemia and Myelodysplastic Syndromes. Front Oncol 2021; 11:624742. [PMID: 33718188 PMCID: PMC7947882 DOI: 10.3389/fonc.2021.624742] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/06/2021] [Indexed: 02/06/2023] Open
Abstract
Decitabine and guadecitabine are hypomethylating agents (HMAs) that exert inhibitory effects against cancer cells. This includes stimulation of anti-tumor immunity in acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) patients. Treatment of AML and MDS patients with the HMAs confers upregulation of cancer/testis antigens (CTAs) expression including the highly immunogenic CTA NY-ESO-1. This leads to activation of CD4+ and CD8+ T cells for elimination of cancer cells, and it establishes the feasibility to combine cancer vaccine with HMAs to enhance vaccine immunogenicity. Moreover, decitabine and guadecitabine induce the expression of immune checkpoint molecules in AML cells. In this review, the accumulating knowledge on the immunopotentiating properties of decitabine and guadecitabine in AML and MDS patients are presented and discussed. In summary, combination of decitabine or guadecitabine with NY-ESO-1 vaccine enhances vaccine immunogenicity in AML patients. T cells from AML patients stimulated with dendritic cell (DC)/AML fusion vaccine and guadecitabine display increased capacity to lyse AML cells. Moreover, decitabine enhances NK cell-mediated cytotoxicity or CD123-specific chimeric antigen receptor-engineered T cells antileukemic activities against AML. Furthermore, combination of either HMAs with immune checkpoint blockade (ICB) therapy may circumvent their resistance. Finally, clinical trials of either HMAs combined with cancer vaccines, NK cell infusion or ICB therapy in relapsed/refractory AML and high-risk MDS patients are currently underway, highlighting the promising efficacy of HMAs and immunotherapy synergy against these malignancies.
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Affiliation(s)
- Kah Keng Wong
- Department of Immunology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Rosline Hassan
- Department of Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Nik Soriani Yaacob
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
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18
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Loo Yau H, Bell E, Ettayebi I, de Almeida FC, Boukhaled GM, Shen SY, Allard D, Morancho B, Marhon SA, Ishak CA, Gonzaga IM, da Silva Medina T, Singhania R, Chakravarthy A, Chen R, Mehdipour P, Pommey S, Klein C, Amarante-Mendes GP, Roulois D, Arribas J, Stagg J, Brooks DG, De Carvalho DD. DNA hypomethylating agents increase activation and cytolytic activity of CD8 + T cells. Mol Cell 2021; 81:1469-1483.e8. [PMID: 33609448 DOI: 10.1016/j.molcel.2021.01.038] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 12/16/2020] [Accepted: 01/27/2021] [Indexed: 12/15/2022]
Abstract
We demonstrate that DNA hypomethylating agent (HMA) treatment can directly modulate the anti-tumor response and effector function of CD8+ T cells. In vivo HMA treatment promotes CD8+ T cell tumor infiltration and suppresses tumor growth via CD8+ T cell-dependent activity. Ex vivo, HMAs enhance primary human CD8+ T cell activation markers, effector cytokine production, and anti-tumor cytolytic activity. Epigenomic and transcriptomic profiling shows that HMAs vastly regulate T cell activation-related transcriptional networks, culminating with over-activation of NFATc1 short isoforms. Mechanistically, demethylation of an intragenic CpG island immediately downstream to the 3' UTR of the short isoform was associated with antisense transcription and alternative polyadenylation of NFATc1 short isoforms. High-dimensional single-cell mass cytometry analyses reveal a selective effect of HMAs on a subset of human CD8+ T cell subpopulations, increasing both the number and abundance of a granzyme Bhigh, perforinhigh effector subpopulation. Overall, our findings support the use of HMAs as a therapeutic strategy to boost anti-tumor immune response.
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Affiliation(s)
- Helen Loo Yau
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7, Canada
| | - Emma Bell
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada
| | - Ilias Ettayebi
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7, Canada
| | - Felipe Campos de Almeida
- Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo 05508-000, Brazil; Instituto de Investigação em Imunologia, Institutos Nacionais de Ciência e Tecnologia (INCT-iii), São Paulo 05403-900, Brazil
| | - Giselle M Boukhaled
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada; Department of Immunology, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Shu Yi Shen
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada
| | - David Allard
- Centre de recherche du Centre Hospitalier de l'Université de Montréal et Institut du Cancer de Montréal, Montréal, QC H2X 0A9, Canada; Faculté de Pharmacie, Université de Montréal, Montréal, QC H3T 1J4, Canada
| | - Beatriz Morancho
- Preclinical Research Program, Vall d'Hebron Institute of Oncology (VHIO) and CIBERONC, 08035 Barcelona, Spain
| | - Sajid A Marhon
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada
| | - Charles A Ishak
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada
| | - Isabela M Gonzaga
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada
| | - Tiago da Silva Medina
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada; Translational Immuno-oncology Laboratory, A.C. Camargo Cancer Center, São Paulo 01509-001, Brazil
| | - Rajat Singhania
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada
| | - Ankur Chakravarthy
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada
| | - Raymond Chen
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7, Canada
| | - Parinaz Mehdipour
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada
| | - Sandra Pommey
- Centre de recherche du Centre Hospitalier de l'Université de Montréal et Institut du Cancer de Montréal, Montréal, QC H2X 0A9, Canada
| | - Christian Klein
- Roche Pharma Research and Early Development, Roche Innovation Center Zurich, Wagistrasse 10, 8952 Schlieren, Switzerland
| | - Gustavo P Amarante-Mendes
- Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo 05508-000, Brazil; Instituto de Investigação em Imunologia, Institutos Nacionais de Ciência e Tecnologia (INCT-iii), São Paulo 05403-900, Brazil
| | - David Roulois
- UMR U1236, INSERM, Université de Rennes 1, EFS, 35000 Rennes, France
| | - Joaquín Arribas
- Preclinical Research Program, Vall d'Hebron Institute of Oncology (VHIO) and CIBERONC, 08035 Barcelona, Spain; Institució Catalana de Recerca i Estudis Avançats (ICREA), 08010 Barcelona, Spain; Cancer Research Program, IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
| | - John Stagg
- Centre de recherche du Centre Hospitalier de l'Université de Montréal et Institut du Cancer de Montréal, Montréal, QC H2X 0A9, Canada; Faculté de Pharmacie, Université de Montréal, Montréal, QC H3T 1J4, Canada
| | - David G Brooks
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada; Department of Immunology, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Daniel D De Carvalho
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2C1, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7, Canada.
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19
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Zhang R, Mou N, Pu YD, Li Q, Jiang YY, Yuan T, Deng Q. [Overexpression of NKG2D-CD3ζ in NY-ESO-1 TCR-T cells enhanced cytotoxicity to acute myeloid leukemia cells in vitro]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 41:946-950. [PMID: 33333701 PMCID: PMC7767805 DOI: 10.3760/cma.j.issn.0253-2727.2020.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- R Zhang
- Department of Hematology, Tianjin First Central Hospital, Tianjin 300192, China
| | - N Mou
- Shanghai Genbase Biotechnology Co., Ltd. Shanghai 201206, China
| | - Y D Pu
- Department of Hematology, Tianjin First Central Hospital, Tianjin 300192, China
| | - Q Li
- Department of Hematology, Tianjin First Central Hospital, Tianjin 300192, China
| | - Y Y Jiang
- Department of Hematology, Tianjin First Central Hospital, Tianjin 300192, China
| | - T Yuan
- Department of Hematology, Tianjin First Central Hospital, Tianjin 300192, China
| | - Q Deng
- Department of Hematology, Tianjin First Central Hospital, Tianjin 300192, China
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20
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Jones HF, Molvi Z, Klatt MG, Dao T, Scheinberg DA. Empirical and Rational Design of T Cell Receptor-Based Immunotherapies. Front Immunol 2021; 11:585385. [PMID: 33569049 PMCID: PMC7868419 DOI: 10.3389/fimmu.2020.585385] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/04/2020] [Indexed: 01/04/2023] Open
Abstract
The use of T cells reactive with intracellular tumor-associated or tumor-specific antigens has been a promising strategy for cancer immunotherapies in the past three decades, but the approach has been constrained by a limited understanding of the T cell receptor’s (TCR) complex functions and specificities. Newer TCR and T cell-based approaches are in development, including engineered adoptive T cells with enhanced TCR affinities, TCR mimic antibodies, and T cell-redirecting bispecific agents. These new therapeutic modalities are exciting opportunities by which TCR recognition can be further exploited for therapeutic benefit. In this review we summarize the development of TCR-based therapeutic strategies and focus on balancing efficacy and potency versus specificity, and hence, possible toxicity, of these powerful therapeutic modalities.
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Affiliation(s)
- Heather F Jones
- Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, NY, United States.,Weill Cornell Medicine, New York, NY, United States
| | - Zaki Molvi
- Weill Cornell Medicine, New York, NY, United States.,Immunology Program, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Martin G Klatt
- Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Tao Dao
- Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - David A Scheinberg
- Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, NY, United States.,Weill Cornell Medicine, New York, NY, United States
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21
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Bewersdorf JP, Carraway H, Prebet T. Emerging treatment options for patients with high-risk myelodysplastic syndrome. Ther Adv Hematol 2020; 11:2040620720955006. [PMID: 33240476 PMCID: PMC7675905 DOI: 10.1177/2040620720955006] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/31/2020] [Indexed: 12/20/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are clonal hematopoietic stem cell disorders
characterized by ineffective hematopoiesis with peripheral blood cytopenias,
dysplastic cell morphology, and a variable risk of progression to acute myeloid
leukemia (AML). The hypomethylating agents (HMA) azacitidine and decitabine have
been used for over a decade in MDS treatment and lead to a modest survival
benefit. However, response rates are only around 40% and responses are mostly
transient. For HMA-refractory patients the prognosis is poor and there are no
therapies approved by the United States Food and Drug Administration. Combinations of HMAs, especially along with immune checkpoint inhibitors, have
shown promising signals in both the frontline and HMA-refractory setting.
Several other novel agents including orally available and longer acting HMAs,
the BCL-2 inhibitor venetoclax, oral agents targeting driver mutations
(IDH1/2, FLT3), immunotherapies, and new options for
intensive chemotherapy have been studied with variable success and will be
reviewed herein. Except for the minority of patients with targetable driver
mutations, HMAs – likely as part of combination therapies – will remain the
backbone of frontline MDS treatment. However, the wider use of genetic testing
may enable a more targeted and individualized therapy of MDS patients.
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Affiliation(s)
- Jan Philipp Bewersdorf
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
| | - Hetty Carraway
- Leukemia Program, Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Thomas Prebet
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, 37 College Street, Room 101, New Haven, CT 06511, USA
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22
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Blecua P, Martinez‐Verbo L, Esteller M. The DNA methylation landscape of hematological malignancies: an update. Mol Oncol 2020; 14:1616-1639. [PMID: 32526054 PMCID: PMC7400809 DOI: 10.1002/1878-0261.12744] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 06/04/2020] [Indexed: 12/17/2022] Open
Abstract
The rapid advances in high-throughput sequencing technologies have made it more evident that epigenetic modifications orchestrate a plethora of complex biological processes. During the last decade, we have gained significant knowledge about a wide range of epigenetic changes that crucially contribute to some of the most aggressive forms of leukemia, lymphoma, and myelodysplastic syndromes. DNA methylation is a key epigenetic player in the abnormal initiation, development, and progression of these malignancies, often acting in synergy with other epigenetic alterations. It also contributes to the acquisition of drug resistance. In this review, we summarize the role of DNA methylation in hematological malignancies described in the current literature. We discuss in detail the dual role of DNA methylation in normal and aberrant hematopoiesis, as well as the involvement of this type of epigenetic change in other aspects of the disease. Finally, we present a comprehensive overview of the main clinical implications, including a discussion of the therapeutic strategies that regulate or reverse aberrant DNA methylation patterns in hematological malignancies, including their combination with (chemo)immunotherapy.
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Affiliation(s)
- Pedro Blecua
- Cancer Epigenetics GroupJosep Carreras Leukaemia Research Institute (IJC)BarcelonaSpain
| | - Laura Martinez‐Verbo
- Cancer Epigenetics GroupJosep Carreras Leukaemia Research Institute (IJC)BarcelonaSpain
| | - Manel Esteller
- Cancer Epigenetics GroupJosep Carreras Leukaemia Research Institute (IJC)BarcelonaSpain
- Centro de Investigación Biomedica en Red Cancer (CIBERONC)MadridSpain
- Institució Catalana de Recerca i Estudis Avançats (ICREA)BarcelonaSpain
- Physiological Sciences DepartmentSchool of Medicine and Health SciencesUniversity of BarcelonaSpain
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23
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Abstract
Myeloproliferative diseases, including myeloproliferative neoplasms (MPN) and myelodysplastic syndromes (MDS), are driven by genetic abnormalities and increased inflammatory signaling and are at high risk to transform into acute myeloid leukemia (AML). Myeloid-derived suppressor cells were reported to enhance leukemia immune escape by suppressing an effective anti-tumor immune response. MPNs are a potentially immunogenic disease as shown by their response to interferon-α treatment and allogeneic hematopoietic stem-cell transplantation (allo-HSCT). Novel immunotherapeutic approaches such as immune checkpoint inhibition, tumor vaccination, or cellular therapies using target-specific lymphocytes have so far not shown strong therapeutic efficacy. Potential reasons could be the pro-inflammatory and immunosuppressive microenvironment in the bone marrow of patients with MPN, driving tumor immune escape. In this review, we discuss the biology of MPNs with respect to the pro-inflammatory milieu in the bone marrow (BM) and potential immunotherapeutic approaches.
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24
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Mardiana S, Gill S. CAR T Cells for Acute Myeloid Leukemia: State of the Art and Future Directions. Front Oncol 2020; 10:697. [PMID: 32435621 PMCID: PMC7218049 DOI: 10.3389/fonc.2020.00697] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 04/14/2020] [Indexed: 12/27/2022] Open
Abstract
Relapse after conventional chemotherapy remains a major problem in patients with myeloid malignancies such as acute myeloid leukemia (AML), and the major cause of death after diagnosis of AML is from relapsed disease. The only potentially curative treatment option currently available is allogeneic hematopoietic stem cell transplantation (allo-HSCT), which through its graft-vs.-leukemia effects has the ability to eliminate residual leukemia cells. Despite its long history of success however, relapse following allo-HSCT is still a major challenge and is associated with poor prognosis. In the field of adoptive therapy, CD19-targeted chimeric antigen receptor (CAR) T cells have yielded remarkable clinical success in certain types of B-cell malignancies, and substantial efforts aimed at translating this success to myeloid malignancies are currently underway. While complete ablation of CD19-expressing B cells, both cancerous and healthy, is clinically tolerated, the primary challenge limiting the use of CAR T cells in myeloid malignancies is the absence of a dispensable antigen, as myeloid antigens are often co-expressed on normal hematopoietic stem/progenitor cells (HSPCs), depletion of which would lead to intolerable myeloablation. This review provides a discussion on the current state of CAR T cell therapy in myeloid malignancies, limitations for clinical translation, as well as the most recent approaches to overcome these barriers, through various genetic modification and combinatorial strategies in an attempt to make CAR T cell therapy a safe and viable option for patients with myeloid malignancies.
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Affiliation(s)
- Sherly Mardiana
- Center for Cellular Immunotherapies, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
- Division of Hematology-Oncology and Center for Cellular Immunotherapies, University of Pennsylvania, PA, United States
| | - Saar Gill
- Center for Cellular Immunotherapies, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
- Division of Hematology-Oncology and Center for Cellular Immunotherapies, University of Pennsylvania, PA, United States
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25
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Bansal R, Reshef R. Revving the CAR - Combination strategies to enhance CAR T cell effectiveness. Blood Rev 2020; 45:100695. [PMID: 32402724 DOI: 10.1016/j.blre.2020.100695] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/22/2020] [Accepted: 04/11/2020] [Indexed: 12/14/2022]
Abstract
Chimeric antigen receptor (CAR) T cell therapy is currently approved for treatment of refractory B-cell malignancies. Response rates in these diseases are impressive by historical standards, but most patients do not have a durable response and there remains room for improvement. To date, CAR T cell activity has been even more limited in solid malignancies. These limitations are thought to be due to several pathways of resistance to CAR T cells, including cell-intrinsic mechanisms and the immunosuppressive tumor microenvironment. In this review, we discuss current experimental strategies that combine small molecules and monoclonal antibodies with CAR T cells to overcome these resistance mechanisms. We describe the biological rationale, pre-clinical data and clinical trials in progress that test the efficacy and safety of these combinations.
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Affiliation(s)
- Rajat Bansal
- Division of Hematology/Oncology, Columbia University Irving Medical Center, 177 Ft. Washington Ave, Floor: 6GN-435, New York, NY 10032, USA.
| | - Ran Reshef
- Division of Hematology/Oncology, Columbia University Irving Medical Center, 630 W. 168(th) Street Mailbox 127, New York, NY 10032, USA.
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26
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Thummalapalli R, Knaus HA, Gojo I, Zeidner JF. Immune Checkpoint Inhibitors in AML-A New Frontier. Curr Cancer Drug Targets 2020; 20:545-557. [PMID: 32316893 DOI: 10.2174/1568009620666200421081455] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/19/2020] [Accepted: 03/29/2020] [Indexed: 12/15/2022]
Abstract
Despite recent therapeutic advancements, acute myeloid leukemia (AML) remains a challenging clinical entity with overall poor outcomes. Given the evident role of T cell-mediated immunity in response to allogeneic stem cell transplantation and donor lymphocyte infusions, strategies that enhance immune activation and mitigate immune dysfunction represent attractive therapeutic platforms to improve clinical outcomes in AML. Pre-clinical data suggest that immune dysfunction is a major contributor to AML progression and relapse. Increased expression of immune checkpoints such as programmed death 1 (PD-1) contributes to AML immune evasion and is associated with disease progression. Immune checkpoint inhibition is being explored in AML with early evidence of clinical activity, particularly in combination with cytotoxic chemotherapy and hypomethylating agents. In this review, we explore the scientific rationale behind the use of immune checkpoint inhibition either as single agents or in combination with hypomethylating agents or cytotoxic chemotherapy and provide a clinical update of both completed and ongoing trials in AML.
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Affiliation(s)
- Rohit Thummalapalli
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Hanna A Knaus
- Medical University of Vienna, Department of Medicine, Division of Bone Marrow Transplantation and Cellular Therapies, Vienna, Austria
| | - Ivana Gojo
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States
| | - Joshua F Zeidner
- University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC, United States
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27
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Lichtenegger FS, Schnorfeil FM, Rothe M, Deiser K, Altmann T, Bücklein VL, Köhnke T, Augsberger C, Konstandin NP, Spiekermann K, Moosmann A, Boehm S, Boxberg M, Heemskerk MH, Goerlich D, Wittmann G, Wagner B, Hiddemann W, Schendel DJ, Kvalheim G, Bigalke I, Subklewe M. Toll-like receptor 7/8-matured RNA-transduced dendritic cells as post-remission therapy in acute myeloid leukaemia: results of a phase I trial. Clin Transl Immunology 2020; 9:e1117. [PMID: 32153780 PMCID: PMC7053229 DOI: 10.1002/cti2.1117] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/10/2020] [Accepted: 02/10/2020] [Indexed: 12/19/2022] Open
Abstract
Objectives Innovative post‐remission therapies are needed to eliminate residual AML cells. DC vaccination is a promising strategy to induce anti‐leukaemic immune responses. Methods We conducted a first‐in‐human phase I study using TLR7/8‐matured DCs transfected with RNA encoding the two AML‐associated antigens WT1 and PRAME as well as CMVpp65. AML patients in CR at high risk of relapse were vaccinated 10× over 26 weeks. Results Despite heavy pretreatment, DCs of sufficient number and quality were generated from a single leukapheresis in 11/12 cases, and 10 patients were vaccinated. Administration was safe and resulted in local inflammatory responses with dense T‐cell infiltration. In peripheral blood, increased antigen‐specific CD8+ T cells were seen for WT1 (2/10), PRAME (4/10) and CMVpp65 (9/10). For CMVpp65, increased CD4+ T cells were detected in 4/7 patients, and an antibody response was induced in 3/7 initially seronegative patients. Median OS was not reached after 1057 days; median RFS was 1084 days. A positive correlation was observed between clinical benefit and younger age as well as mounting of antigen‐specific immune responses. Conclusions Administration of TLR7/8‐matured DCs to AML patients in CR at high risk of relapse was feasible and safe and resulted in induction of antigen‐specific immune responses. Clinical benefit appeared to occur more likely in patients <65 and in patients mounting an immune response. Our observations need to be validated in a larger patient cohort. We hypothesise that TLR7/8 DC vaccination strategies should be combined with hypomethylating agents or checkpoint inhibition to augment immune responses. Trial registration The study was registered at https://clinicaltrials.gov on 17 October 2012 (NCT01734304) and at https://www.clinicaltrialsregister.eu (EudraCT‐Number 2010‐022446‐24) on 10 October 2013.
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Affiliation(s)
- Felix S Lichtenegger
- Department of Medicine III University Hospital, LMU Munich Munich Germany.,Laboratory for Translational Cancer Immunology Gene Center LMU Munich Munich Germany.,Present address: Roche Innovation Center Munich Penzberg Germany
| | - Frauke M Schnorfeil
- Department of Medicine III University Hospital, LMU Munich Munich Germany.,Laboratory for Translational Cancer Immunology Gene Center LMU Munich Munich Germany.,German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) Heidelberg Germany.,Present address: Medigene AG Planegg Germany
| | - Maurine Rothe
- Department of Medicine III University Hospital, LMU Munich Munich Germany.,Laboratory for Translational Cancer Immunology Gene Center LMU Munich Munich Germany
| | - Katrin Deiser
- Department of Medicine III University Hospital, LMU Munich Munich Germany.,Laboratory for Translational Cancer Immunology Gene Center LMU Munich Munich Germany
| | - Torben Altmann
- Department of Medicine III University Hospital, LMU Munich Munich Germany.,Laboratory for Translational Cancer Immunology Gene Center LMU Munich Munich Germany
| | - Veit L Bücklein
- Department of Medicine III University Hospital, LMU Munich Munich Germany.,Laboratory for Translational Cancer Immunology Gene Center LMU Munich Munich Germany
| | - Thomas Köhnke
- Department of Medicine III University Hospital, LMU Munich Munich Germany.,Laboratory for Translational Cancer Immunology Gene Center LMU Munich Munich Germany
| | - Christian Augsberger
- Department of Medicine III University Hospital, LMU Munich Munich Germany.,Laboratory for Translational Cancer Immunology Gene Center LMU Munich Munich Germany
| | | | | | - Andreas Moosmann
- DZIF Research Group "Host Control of Viral Latency and Reactivation" (HOCOVLAR) Helmholtz Zentrum München Munich Germany
| | - Stephan Boehm
- Max von Pettenkofer Institute LMU Munich Munich Germany
| | - Melanie Boxberg
- Institute of Pathology Technical University of Munich Munich Germany
| | - Mirjam Hm Heemskerk
- Department of Hematology Leiden University Medical Center Leiden The Netherlands
| | - Dennis Goerlich
- Institute of Biostatistics and Clinical Research University of Muenster Muenster Germany
| | - Georg Wittmann
- Department of Transfusion Medicine, Cellular Therapeutics and Hemostaseology University Hospital LMU Munich Munich Germany
| | - Beate Wagner
- Department of Transfusion Medicine, Cellular Therapeutics and Hemostaseology University Hospital LMU Munich Munich Germany
| | - Wolfgang Hiddemann
- Department of Medicine III University Hospital, LMU Munich Munich Germany.,German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) Heidelberg Germany
| | | | - Gunnar Kvalheim
- Department of Cellular Therapy The Norwegian Radium Hospital Oslo University Hospital Oslo Norway
| | - Iris Bigalke
- Department of Cellular Therapy The Norwegian Radium Hospital Oslo University Hospital Oslo Norway.,Present address: BioNTech IMFS Idar-Oberstein Germany
| | - Marion Subklewe
- Department of Medicine III University Hospital, LMU Munich Munich Germany.,Laboratory for Translational Cancer Immunology Gene Center LMU Munich Munich Germany.,German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ) Heidelberg Germany
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28
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Knorr DA, Goldberg AD, Stein EM, Tallman MS. Immunotherapy for acute myeloid leukemia: from allogeneic stem cell transplant to novel therapeutics. Leuk Lymphoma 2019; 60:3350-3362. [PMID: 31335250 PMCID: PMC6928392 DOI: 10.1080/10428194.2019.1639167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 06/20/2019] [Accepted: 06/23/2019] [Indexed: 12/18/2022]
Abstract
Immunotherapy in the form of allogeneic stem cell transplantation (SCT) plays an instrumental role in the treatment of acute myeloid leukemia (AML), with non-transplant modalities of immunotherapy including checkpoint blockade now being actively explored. Here, we provide an overview of the graft versus leukemia (GVL) effect in AML as a window into understanding the prospects of AML immunotherapy. We explore the roles of various cell types in orchestrating anti-leukemic immunity, as well as those contributing to the unique immune suppressive state of myeloid diseases. We discuss specific approaches to engage the immune system, while noting the challenges of the AML antigen landscape and the barriers to immune modulation. We review the potential for immunomodulatory agents in combination with cellular therapies, donor lymphocyte infusion, and following SCT. Finally, to address the challenge of minimal residual disease (MRD) following chemotherapy, we propose combination epigenetic and immunotherapy for the eradication of MRD.
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Affiliation(s)
- David A. Knorr
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Laboratory of Molecular Genetics and Immunology, Rockefeller University, New York, NY, USA
| | - Aaron D. Goldberg
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eytan M. Stein
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin S. Tallman
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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29
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Barrett AJ. Acute myeloid leukaemia and the immune system: implications for immunotherapy. Br J Haematol 2019; 188:147-158. [DOI: 10.1111/bjh.16310] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- A. John Barrett
- GW Cancer Center George Washington University Hospital Washington DC USA
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30
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Conditioning Regimen of 5-Day Decitabine Administration for Allogeneic Stem Cell Transplantation in Patients with Myelodysplastic Syndrome and Myeloproliferative Neoplasms. Biol Blood Marrow Transplant 2019; 26:285-291. [PMID: 31494229 DOI: 10.1016/j.bbmt.2019.09.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 08/31/2019] [Accepted: 09/03/2019] [Indexed: 01/09/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a potentially curative treatment for patients with myelodysplastic syndromes (MDS) and myelodysplastic/myeloproliferative neoplasms (MDS/MPN). However, post-HSCT relapse remains a major cause of treatment failure. Here we assessed the efficacy of a new conditioning regimen comprising decitabine (Dec), busulfan (Bu), cyclophosphamide (Cy), fludarabine (Flu), and cytarabine (Ara-c) for allo-HSCT in patients with MDS and MDS/MPN. A total of 48 patients were enrolled, including 44 with MDS and 4 with chronic myelomonocytic leukemia (CMML). Patients received Dec 20 mg/m2/day on days -9 to -5, combined with a Bu/Cy/Flu/Ara-c-modified preparative regimen. At a median follow-up of 522 days (range, 15 to 1313 days), the overall survival (OS) was 86%, relapse incidence was 12%, and nonrelapse mortality was 12%. The incidence of severe acute (grade III-IV) graft-versus-host disease (GVHD) was 23% and that of chronic GVHD was 15%. At 2 years, OS was 74% and 86%, respectively for high-risk and very-high-risk patients with MDS. Survival was promising in patients with poor-risk gene mutations, such as TP53 and ASXL1 (88%), and in those with ≥3 gene mutations (79%). Results of immunomonitoring studies revealed that proper natural killer cells made essential contributions to these favorable clinical outcomes. Overall, this new regimen was associated with a low relapse rate, low incidence and severity of GVHD, and satisfactory survival in allo-HSCT recipients with MDS and MDS/MPN.
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31
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Xue L, Hu Y, Wang J, Liu X, Wang X. T cells targeting multiple tumor-associated antigens as a postremission treatment to prevent or delay relapse in acute myeloid leukemia. Cancer Manag Res 2019; 11:6467-6476. [PMID: 31406473 PMCID: PMC6642655 DOI: 10.2147/cmar.s205296] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/12/2019] [Indexed: 01/31/2023] Open
Abstract
Background Relapse is a major problem in acute myeloid leukemia (AML) and adversely affects survival. Tumor-associated antigen-specific cytotoxic T lymphocyte (TAA-CTLs)-based therapy was introduced and increasingly used clinically to kill tumor cells via tumor antigen activation. Method In this study, we expanded autologous lymphocytes reactive to five TAA (NY-ESO-1, MAGE-A3, WT1, Survivin, and PRAME) and evaluated its safety and efficacy in 9 patients with AML at high risk of relapse. Results Before first TAA-CTL infusion, 5 patients were minimal residual disease (MRD) positive, whereas 4 were MRD negative. Patients received TAA-CTL infusion for 1–3 times. None of them had obvious adverse reactions during or post the infusion. Of the 4 MRD-negative patients who were infused with TAA-CTLs, one developed relapsed disease. Among 5 MRD+ patients, there was a demonstrable antileukemic effect of the TAA-CTLs alone without any concomitant chemotherapy in 2 patients, as demonstrated by the negative of MRD in bone marrow after TAA-CTL infusion. Conclusions In summary, we have observed preliminary indications of activity and safety after administration of autologous TAA-CTLs in patients with AML. The ultimate question of clinical efficacy, however, will need to be addressed in a larger trial with larger homogeneous patient population.
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Affiliation(s)
- Lei Xue
- Department of Hematology, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Sciences and Technology of China, Hefei, Anhui 230001, People's Republic of China
| | - Yan Hu
- Department of Hematology, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Sciences and Technology of China, Hefei, Anhui 230001, People's Republic of China
| | - Jian Wang
- Department of Hematology, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Sciences and Technology of China, Hefei, Anhui 230001, People's Republic of China
| | - Xin Liu
- Department of Hematology, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Sciences and Technology of China, Hefei, Anhui 230001, People's Republic of China
| | - Xingbing Wang
- Department of Hematology, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Sciences and Technology of China, Hefei, Anhui 230001, People's Republic of China.,Department of Hematology, Anhui Provincial Hospital, Anhui Medical University, Hefei, Anhui, People's Republic of China
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32
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EWSR1-FLI1 Activation of the Cancer/Testis Antigen FATE1 Promotes Ewing Sarcoma Survival. Mol Cell Biol 2019; 39:MCB.00138-19. [PMID: 31036566 DOI: 10.1128/mcb.00138-19] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 04/25/2019] [Indexed: 01/07/2023] Open
Abstract
Ewing sarcoma is characterized by a pathognomonic chromosomal translocation that generates the EWSR1-FLI1 chimeric transcription factor. The transcriptional targets of EWSR1-FLI1 that are essential for tumorigenicity are incompletely defined. Here, we found that EWSR1-FLI1 modulates the expression of cancer/testis (CT) antigen genes, whose expression is biased to the testes but is also activated in cancer. Among these CT antigens, fetal and adult testis expressed 1 (FATE1) is most robustly induced. EWSR1-FLI1 associates with the GGAA repeats in the proximal promoter of FATE1, which exhibits accessible chromatin exclusively in mesenchymal progenitor cells (MPCs) and Ewing sarcoma cells. Expression of EWSR1-FLI1 in non-Ewing sarcoma cells and in MPCs enhances FATE1 mRNA and protein expression. Conversely, depletion of EWSR1-FLI1 in Ewing sarcoma cells leads to a loss of FATE1 expression. Importantly, we found that FATE1 is required for survival and anchorage-independent growth in Ewing sarcoma cells via attenuating the accumulation of BNIP3L, a BH3-only protein that is toxic when stabilized. This action appears to be mediated by the E3 ligase RNF183. We propose that engaging FATE1 function can permit the bypass of cell death mechanisms that would otherwise inhibit tumor progression.
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33
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Stahl M, Goldberg AD. Immune Checkpoint Inhibitors in Acute Myeloid Leukemia: Novel Combinations and Therapeutic Targets. Curr Oncol Rep 2019; 21:37. [PMID: 30904967 DOI: 10.1007/s11912-019-0781-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Immune checkpoint therapy has dramatically changed the therapeutic landscape of solid malignancies. Here, we review the scientific rationale and current data evaluating immune checkpoint inhibitors in acute myeloid leukemia (AML). RECENT FINDINGS Immune checkpoint inhibitor monotherapy has shown limited clinical activity in AML. Initial results from early-phase clinical trials suggest that rational combinations of immune checkpoint inhibition with hypomethylating agents (HMAs) are safe and potentially more promising. There are currently no data directly comparing immune checkpoint inhibition to standard therapies. Emerging immune targets more specific for leukemia cells including LILRB4 may improve future therapeutic efficacy. The success of immune checkpoint inhibition in AML has been modest to date. However, an improved understanding of the biology and the use of rational combinations has potential to improve rates of durable responses. Multiple clinical trials in AML are currently evaluating the use of immune checkpoints alone and in combination.
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Affiliation(s)
- Maximilian Stahl
- Department of Medicine, Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Aaron D Goldberg
- Department of Medicine, Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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34
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Bewersdorf JP, Shallis R, Stahl M, Zeidan AM. Epigenetic therapy combinations in acute myeloid leukemia: what are the options? Ther Adv Hematol 2019; 10:2040620718816698. [PMID: 30719265 PMCID: PMC6348528 DOI: 10.1177/2040620718816698] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 11/08/2018] [Indexed: 01/01/2023] Open
Abstract
Epigenetics refers to the regulation of gene expression mainly by changes in DNA methylation and modifications of histone proteins without altering the actual DNA sequence. While epigenetic modifications are essential for normal cell differentiation, several driver mutations in leukemic pathogenesis have been identified in genes that affect epigenetic processes, such as DNA methylation and histone acetylation. Several therapeutic options to target epigenetic alterations in acute myeloid leukemia (AML) have been successfully tested in preclinical studies and various drugs have already been approved for use in clinical practice. Among these already approved therapeutics are hypomethylating agents (azacitidine and decitabine) and isocitrate dehydrogenase inhibitors (ivosidenib, enasidenib). Other agents such as bromodomain-containing epigenetic reader proteins and histone methylation (e.g. DOT1L) inhibitors are currently in advanced clinical testing. As several epigenetic therapies have only limited efficacy when used as single agents, combination therapies that target AML pathogenesis at different levels and exploit synergistic mechanisms are also in clinical trials. Combinations of either epigenetic therapies with conventional chemotherapy, different forms of epigenetic therapies, or epigenetic therapies with immunotherapy are showing promising early results. In this review we summarize the underlying pathophysiology and rationale for epigenetically-based combination therapies, review current preclinical and clinical data and discuss the future directions of epigenetic therapy combinations in AML.
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Affiliation(s)
- Jan Philipp Bewersdorf
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
| | - Rory Shallis
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
| | - Maximilian Stahl
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, 333 Cedar Street, PO Box 208028, New Haven, CT 06520-8055, USA
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35
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Loo Yau H, Ettayebi I, De Carvalho DD. The Cancer Epigenome: Exploiting Its Vulnerabilities for Immunotherapy. Trends Cell Biol 2019; 29:31-43. [DOI: 10.1016/j.tcb.2018.07.006] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 07/27/2018] [Accepted: 07/31/2018] [Indexed: 01/06/2023]
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36
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Combination treatment of acute myeloid leukemia cells with DNMT and HDAC inhibitors: predominant synergistic gene downregulation associated with gene body demethylation. Leukemia 2018; 33:945-956. [PMID: 30470836 DOI: 10.1038/s41375-018-0293-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 06/21/2018] [Accepted: 09/06/2018] [Indexed: 12/20/2022]
Abstract
DNA methyltransferase inhibitors (DNMTi) approved for older AML patients are clinically tested in combination with histone deacetylase inhibitors (HDACi). The mechanism of action of these drugs is still under debate. In colon cancer cells, 5-aza-2'-deoxycytidine (DAC) can downregulate oncogenes and metabolic genes by reversing gene body DNA methylation, thus implicating gene body methylation as a novel drug target. We asked whether DAC-induced gene body demethylation in AML cells is also associated with gene repression, and whether the latter is enhanced by HDACi.Transcriptome analyses revealed that a combined treatment with DAC and the HDACi panobinostat or valproic acid affected significantly more transcripts than the sum of the genes regulated by either treatment alone, demonstrating a quantitative synergistic effect on genome-wide expression in U937 cells. This effect was particularly striking for downregulated genes. Integrative methylome and transcriptome analyses showed that a massive downregulation of genes, including oncogenes (e.g., MYC) and epigenetic modifiers (e.g., KDM2B, SUV39H1) often overexpressed in cancer, was associated predominantly with gene body DNA demethylation and changes in acH3K9/27. These findings have implications for the mechanism of action of combined epigenetic treatments, and for a better understanding of responses in trials where this approach is clinically tested.
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Immunomodulatory Effects of Drugs for Effective Cancer Immunotherapy. JOURNAL OF ONCOLOGY 2018; 2018:8653489. [PMID: 30498512 PMCID: PMC6222238 DOI: 10.1155/2018/8653489] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 10/10/2018] [Indexed: 12/12/2022]
Abstract
Recent advances in cancer immunotherapy, including immune checkpoint inhibitors or adoptive T cell therapies, have contributed to better outcomes in cancer patients. However, there are still many cancers with no cure. Therefore, combinations of several treatment strategies are being explored, and enhancing anticancer immunity will play an important role to combat the disease. There have been several reports on the immune-modulatory effects of commonly used drugs, namely, statin, metformin, and angiotensin receptor blockers (ARBs), which suggest that these drugs could enhance immunity against cancer cells. Other anticancer drugs, such as anthracyclines, thalidomides, lenalidomides, and hypomethylating drugs, could also strengthen the immune system to attack cancer cells at a relatively low dose. Hence, these drugs might contribute to better outcomes in cancer patients.
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Klausen U, Holmberg S, Holmström MO, Jørgensen NGD, Grauslund JH, Svane IM, Andersen MH. Novel Strategies for Peptide-Based Vaccines in Hematological Malignancies. Front Immunol 2018; 9:2264. [PMID: 30327655 PMCID: PMC6174926 DOI: 10.3389/fimmu.2018.02264] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 09/11/2018] [Indexed: 12/12/2022] Open
Abstract
Peptides vaccination is an interesting approach to activate T-cells toward desired antigens in hematological malignancies. In addition to classical tumor associated antigens, such as cancer testis antigens, new potential targets for peptide vaccination comprise neo-antigens including JAK2 and CALR mutations, and antigens from immune regulatory proteins in the tumor microenvironment such as programmed death 1 ligands (PD-L1 and PD-L2). Immunosuppressive defenses of tumors are an important challenge to overcome and the T cell suppressive ligands PD-L1 and PD-L2 are often present in tumor microenvironments. Thus, PD-L1 and PD-L2 are interesting targets for peptide vaccines in diseases where the tumor microenvironment is known to play an essential role such as multiple myeloma and follicular lymphoma. In myelodysplastic syndromes the drug azacitidine re-exposes tumor associated antigens, why vaccination with related peptides would be an interesting addition. In myeloproliferative neoplasms the JAK2 and CALR mutations has proven to be immunogenic neo-antigens and thus possible targets for peptide vaccination. In this mini review we summarize the basis for these novel approaches, which has led to the initiation of clinical trials with various peptide vaccines in myelodysplastic syndromes, myeloproliferative neoplasms, multiple myeloma, and follicular lymphoma.
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Affiliation(s)
- Uffe Klausen
- Center for Cancer Immune Therapy, Herlev Hospital, Department of Hematology and Oncology, Herlev, Denmark
| | - Staffan Holmberg
- Department of Hematology, Herlev Hospital, Herlev, Denmark
- Division of Immunology - T cells & Cancer, DTU Nanotech, Technical University of Denmark, Lyngby, Denmark
| | - Morten Orebo Holmström
- Center for Cancer Immune Therapy, Herlev Hospital, Department of Hematology and Oncology, Herlev, Denmark
- Department of Hematology, Zealand University Hospital, Roskilde, Denmark
| | | | - Jacob Handlos Grauslund
- Center for Cancer Immune Therapy, Herlev Hospital, Department of Hematology and Oncology, Herlev, Denmark
- Department of Hematology, Zealand University Hospital, Roskilde, Denmark
| | - Inge Marie Svane
- Center for Cancer Immune Therapy, Herlev Hospital, Department of Hematology and Oncology, Herlev, Denmark
- Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mads Hald Andersen
- Center for Cancer Immune Therapy, Herlev Hospital, Department of Hematology and Oncology, Herlev, Denmark
- Institute for Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
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Sommer S, Cruijsen M, Claus R, Bertz H, Wäsch R, Marks R, Zeiser R, Bogatyreva L, Blijlevens NM, May A, Duyster J, Huls G, van der Velden WJ, Finke J, Lübbert M. Decitabine in combination with donor lymphocyte infusions can induce remissions in relapsed myeloid malignancies with higher leukemic burden after allogeneic hematopoietic cell transplantation. Leuk Res 2018; 72:20-26. [DOI: 10.1016/j.leukres.2018.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/26/2018] [Accepted: 07/07/2018] [Indexed: 12/19/2022]
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Holmström MO, Hasselbalch HC. Cancer immune therapy for myeloid malignancies: present and future. Semin Immunopathol 2018; 41:97-109. [PMID: 29987478 DOI: 10.1007/s00281-018-0693-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 06/12/2018] [Indexed: 02/07/2023]
Abstract
The myelodysplastic syndromes, the chronic myeloproliferative neoplasms, and the acute myeloid leukemia are malignancies of the myeloid hematopoietic stem cells of the bone marrow. The diseases are characterized by a dysregulation of the immune system as both the cytokine milieu, immune phenotype, immune regulation, and expression of genes related to immune cell functions are deregulated. Several treatment strategies try to circumvent this deregulation, and several clinical and preclinical trials have shown promising results, albeit not in the same scale as chimeric antigen receptor T cells have had in the treatment of refractory lymphoid malignancies. The use of immune checkpoint blocking antibodies especially in combination with hypomethylating agents has had some success-a success that will likely be enhanced by therapeutic cancer vaccination with tumor-specific antigens. In the chronic myeloproliferative neoplasms, the recent identification of immune responses against the Januskinase-2 and calreticulin exon 9 driver mutations could also be used in the vaccination setting to enhance the anti-tumor immune response. This immune response could probably be enhanced by the concurrent use of immune checkpoint inhibitors or by vaccination with epitopes from immune regulatory proteins such as arginase-1 and programmed death ligand-1. Herein, we provide an overview of current cancer immune therapeutic treatment strategies as well as potential future cancer immune therapeutic treatment options for the myeloid malignancies.
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Affiliation(s)
- Morten Orebo Holmström
- Department of Hematology, Zealand University Hospital, Sygehusvej 10, 4000, Roskilde, Denmark. .,Center for Cancer Immune Therapy, Department of Hematology, Herlev Hospital, Herlev, Denmark.
| | - Hans Carl Hasselbalch
- Department of Hematology, Zealand University Hospital, Sygehusvej 10, 4000, Roskilde, Denmark
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Efficacy of azacitidine is independent of molecular and clinical characteristics - an analysis of 128 patients with myelodysplastic syndromes or acute myeloid leukemia and a review of the literature. Oncotarget 2018; 9:27882-27894. [PMID: 29963245 PMCID: PMC6021252 DOI: 10.18632/oncotarget.25328] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/24/2018] [Indexed: 12/16/2022] Open
Abstract
Azacitidine is the first drug to demonstrate a survival benefit for patients with MDS. However, only half of patients respond and almost all patients eventually relapse. Limited and conflicting data are available on predictive factors influencing response. We analyzed 128 patients from two institutions with MDS or AML treated with azacitidine to identify prognostic indicators. Genetic mutations in ASXL1, RUNX1, DNMT3A, IDH1, IDH2, TET2, TP53, NRAS, KRAS, FLT3, KMT2A-PTD, EZH2, SF3B1, and SRSF2 were assessed by next-generation sequencing. With a median follow up of 5.6 years median survival was 1.3 years with a response rate of 49%. The only variable with significant influence on response was del(20q). All 6 patients responded (p = 0.012) but survival was not improved. No other clinical, cytogenetic or molecular marker for response or survival was identified. Interestingly, patients from poor-risk groups as high-risk cytogenetics (55%), t-MDS/AML (54%), TP53 mutated (48%) or relapsed after chemotherapy (60%) showed a high response rate. Factors associated with shorter survival were low platelets, AML vs. MDS, therapy-related disease, TP53 and KMT2A-PTD. In multivariate analysis anemia, platelets, FLT3-ITD, and therapy-related disease remained in the model. Poor-risk factors such as del(7q)/-7, complex karyotype, ASXL1, RUNX1, EZH2, and TP53 did not show an independent impact. Thus, no clear biomarker for response and survival can be identified. Although a number of publications on predictive markers for response to AZA exist, results are inconsistent and improved response rates did not translate to improved survival. Here, we provide a comprehensive overview comparing the studies published to date.
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Abstract
Acute myeloid leukemia (AML) is one of the best studied malignancies, and significant progress has been made in understanding the clinical implications of its disease biology. Unfortunately, drug development has not kept pace, as the '7+3' induction regimen remains the standard of care for patients fit for intensive therapy 40 years after its first use. Temporal improvements in overall survival were mostly confined to younger patients and driven by improvements in supportive care and use of hematopoietic stem cell transplantation. Multiple forms of novel therapy are currently in clinical trials and are attempting to bring bench discoveries to the bedside to benefit patients. These novel therapies include improved chemotherapeutic agents, targeted molecular inhibitors, cell cycle regulators, pro-apoptotic agents, epigenetic modifiers, and metabolic therapies. Immunotherapies in the form of vaccines; naked, conjugated and bispecific monoclonal antibodies; cell-based therapy; and immune checkpoint inhibitors are also being evaluated in an effort to replicate the success seen in other malignancies. Herein, we review the scientific basis of these novel therapeutic approaches, summarize the currently available evidence, and look into the future of AML therapy by highlighting key clinical studies and the challenges the field continues to face.
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Efficacy and safety of decitabine in treatment of elderly patients with acute myeloid leukemia: A systematic review and meta-analysis. Oncotarget 2018; 8:41498-41507. [PMID: 28489568 PMCID: PMC5522197 DOI: 10.18632/oncotarget.17241] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/11/2017] [Indexed: 11/25/2022] Open
Abstract
Elderly patients with acute myeloid leukemia (AML) have limited treatment options concerned about their overall fitness and potential treatment related mortality. Although a number of clinical trials demonstrated benefits of decitabine treatment in elderly AML patients, the results remains controversial. A meta-analysis was performed to evaluate efficacy and safety of decitabine in treatment of elderly AML patients. Eligible studies were identified from PubMed, Web of Science, Embase and Cochrane Library. Nine published studies were included in the meta-analysis, enrolling 718 elderly AML patients. The efficacy outcomes were complete remission (CR), overall response rate (ORR) and overall survival (OS). Safety was evaluated based on treatment related grades 3–4 adverse events (AEs) and early death (ED) rate. Pooled estimates with 95% confidence interval (CI) for CR, ORR and OS were 27% (95% CI 19%–36%), 37% (95% CI 28%–47%) and 8.09 months (95% CI 5.77–10.41), respectively. The estimated treatment related early death (ED) incidences were within 30-days 7% (95% CI 2%–11%) and 60-days 17% (95% CI 11%–22%), respectively. Thrombocytopenia was the most common grades 3–4 AEs. Subgroup analyses of age, cytogenetics risk, AML type and bone marrow blast percentage showed no significant differences of treatment response to decitabine. In conclusion, decitabine is an effective and well-tolerated therapeutic alternative with acceptable side effects in elderly AML patients.
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Daifuku R, Grimes S, Stackhouse M. NUC041, a Prodrug of the DNA Methytransferase Inhibitor 5-aza-2',2'-Difluorodeoxycytidine (NUC013), Leads to Tumor Regression in a Model of Non-Small Cell Lung Cancer. Pharmaceuticals (Basel) 2018; 11:ph11020036. [PMID: 29690576 PMCID: PMC6027359 DOI: 10.3390/ph11020036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/17/2018] [Accepted: 04/18/2018] [Indexed: 01/10/2023] Open
Abstract
5-aza-2′,2′-difluorodeoxycytidine (NUC013) has been shown to be significantly safer and more effective than decitabine in xenograft models of human leukemia and colon cancer. However, it suffers from a similar short half-life as other DNA methyltransferase inhibitors with a 5-azacytosine base, which is problematic for nucleosides that primarily target tumor cells in S phase. Because of the relative instability of 5-azanucleosides, a prodrug approach was developed to improve the pharmacology of NUC013. NUC013 was conjugated with trimethylsilanol (TMS) at the 3′ and 5′ position of the sugar, rendering the molecule hydrophobic and producing 3′,5′-di-trimethylsilyl-2′,2′-difluoro-5-azadeoxycytidine (NUC041). NUC041 was designed to be formulated in a hydrophobic vehicle, protecting it from deamination and hydrolysis. In contact with blood, the TMS moieties are readily hydrolyzed to release NUC013. The half-life of NUC013 administered intravenously in mice is 20.1 min, while that of NUC013 derived from intramuscular NUC041 formulated in a pegylated-phospholipid depot is 3.4 h. In a NCI-H460 xenograft of non-small cell lung cancer, NUC013 was shown to significantly inhibit tumor growth and improve survival. Treatment with NUC041 also led to significant tumor growth inhibition. However, NUC041-treated mice had significantly more tumors ulcerate than either NUC013 treated mice or saline control mice, and such ulceration occurred at significantly lower tumor volumes. In these nude mice, tumor regression was likely mediated by the derepression of the tumor suppressor gene p53 and resultant activation of natural killer (NK) cells.
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Affiliation(s)
- Richard Daifuku
- Epigenetics Pharma, 9270 SE 36th Pl, Mercer Island, WA 98040, USA.
| | - Sheila Grimes
- Southern Research, 2000 9th Avenue South, Birmingham, AL 35205, USA.
| | - Murray Stackhouse
- Southern Research, 2000 9th Avenue South, Birmingham, AL 35205, USA.
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45
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Involvement of X-chromosome Reactivation in Augmenting Cancer Testis Antigens Expression: A Hypothesis. Curr Med Sci 2018; 38:19-25. [DOI: 10.1007/s11596-018-1842-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 01/08/2018] [Indexed: 12/28/2022]
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46
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Matei D, Ghamande S, Roman L, Alvarez Secord A, Nemunaitis J, Markham MJ, Nephew KP, Jueliger S, Oganesian A, Naim S, Su XY, Keer H, Azab M, Fleming GF. A Phase I Clinical Trial of Guadecitabine and Carboplatin in Platinum-Resistant, Recurrent Ovarian Cancer: Clinical, Pharmacokinetic, and Pharmacodynamic Analyses. Clin Cancer Res 2018; 24:2285-2293. [PMID: 29500276 DOI: 10.1158/1078-0432.ccr-17-3055] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/11/2018] [Accepted: 02/27/2018] [Indexed: 12/19/2022]
Abstract
Purpose: Epigenetic changes are implicated in acquired resistance to platinum. Guadecitabine is a next-generation hypomethylating agent (HMA). Here, we report the clinical results, along with pharmacokinetic (PK) and pharmacodynamic analyses of the phase I study of guadecitabine and carboplatin in patients with recurrent, platinum-resistant high-grade serous ovarian cancer, primary peritoneal carcinoma (PPC), or fallopian tube cancer (FTC).Experimental Design: Guadecitabine was administered once daily on days 1 to 5 followed by carboplatin i.v. on day 8 of a 28-day cycle. Patients had either measurable or detectable disease. Safety assessments used CTCAE v4.Results: Twenty patients were enrolled and treated. Median age was 56 years (38-72 years). The median number of prior regimens was 7 (1-14). In the first cohort (N = 6), the starting doses were guadecitabine 45 mg/m2 and carboplatin AUC5. Four patients experienced dose-limiting toxicity (DLT; neutropenia and thrombocytopenia), leading to dose deescalation of guadecitabine to 30 mg/m2 and of carboplatin to AUC4. No DLTs were observed in the subsequent 14 patients. Grade ≥3 adverse events ≥10% were neutropenia, leukopenia, anemia, nausea, vomiting, ascites, constipation, hypokalemia, pulmonary embolism, small-intestinal obstruction, and thrombocytopenia. Three patients had a partial response (PR), and 6 patients had stable disease (SD) >3 months, for an overall response rate (ORR) and clinical benefit rate of 15% and 45%, respectively. LINE-1 demethylation in PBMCs and promoter demethylation/gene reexpression in paired tumor biopsies/ascites were recorded.Conclusions: Guadecitabine and carboplatin were tolerated and induced clinical responses in a heavily pretreated platinum-resistant ovarian cancer population, supporting a subsequent randomized phase II trial. Clin Cancer Res; 24(10); 2285-93. ©2018 AACR.
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Affiliation(s)
- Daniela Matei
- Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Sharad Ghamande
- Georgia Cancer Center at Augusta University, Augusta, Georgia
| | - Lynda Roman
- USC Norris Comprehensive Cancer Center, Los Angeles, California
| | - Angeles Alvarez Secord
- Department of Obstetrics and Gynecology, Duke Cancer Institute, Division of Gynecologic Oncology, Durham, North Carolina
| | - John Nemunaitis
- University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | | | | | | | | | - Sue Naim
- Astex Pharmaceuticals Inc., Pleasanton, California
| | - Xiang Yao Su
- Astex Pharmaceuticals Inc., Pleasanton, California
| | - Harold Keer
- Astex Pharmaceuticals Inc., Pleasanton, California
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47
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Fuchs EJ. Immunotherapy of Myelodysplastic Syndrome: You Can Run, but You Can't Hide. Clin Cancer Res 2018; 24:991-993. [PMID: 29284705 DOI: 10.1158/1078-0432.ccr-17-2960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 12/15/2017] [Accepted: 12/21/2017] [Indexed: 11/16/2022]
Abstract
The hypomethylating agent decitabine induces expression of the cancer/testis antigen NY-ESO-1 in the myeloid cells of patients with myelodysplastic syndrome (MDS). Patients with MDS treated with decitabine and an NY-ESO-1 vaccine developed NY-ESO-1-specific T-cell responses directed against their abnormal myeloid cells, raising hopes for combinatorial immunotherapy of this disease. Clin Cancer Res; 24(5); 991-3. ©2017 AACRSee related article by Griffiths et al., p. 1019.
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Affiliation(s)
- Ephraim Joseph Fuchs
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland.
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48
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Hypomethylating agents in combination with immune checkpoint inhibitors in acute myeloid leukemia and myelodysplastic syndromes. Leukemia 2018; 32:1094-1105. [PMID: 29487386 DOI: 10.1038/s41375-018-0070-8] [Citation(s) in RCA: 139] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/15/2018] [Accepted: 01/26/2018] [Indexed: 12/31/2022]
Abstract
Immune checkpoint inhibitors, as single-agent therapy, have shown modest clinical efficacy in the treatment of acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS). As has been successfully shown in other less immunogenic hematologic malignancies, rationally designed combination approaches may be more effective than single-agent checkpoint inhibitors, and may be the approach to pursue in AML/MDS. Hypomethylating agents (HMAs) such as azacitidine, while enhancing anti-tumor immune response, concurrently dampen immune response by upregulating inhibitory immune checkpoint molecule expression. Immune checkpoint molecule upregulation may be an important mechanism of azacitidine resistance. These findings have resulted in multiple clinical trials combining HMAs with immune checkpoint blockade. Clinical trial data have shown encouraging response rates and durable responses without resorting to stem cell transplant. In this review, we discuss preclinical data supporting the use of these agents in combination, and focus on clinical and correlative data emerging from numerous clinical trials investigating HMA-immune checkpoint inhibitor combinations in AML/MDS.
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49
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Hobo W, Hutten TJA, Schaap NPM, Dolstra H. Immune checkpoint molecules in acute myeloid leukaemia: managing the double-edged sword. Br J Haematol 2018; 181:38-53. [PMID: 29318591 DOI: 10.1111/bjh.15078] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
New immunotherapeutic interventions have revolutionized cancer treatment. The immune responsiveness of acute myeloid leukaemia (AML) was first demonstrated by allogeneic stem cell transplantation. In addition, milder immunotherapeutic approaches are exploited. However, the long-term efficacy of these therapies is hampered by various immune resistance and editing mechanisms. In this regard, co-inhibitory signalling pathways have been shown to play a crucial role. Via up-regulation of inhibitory checkpoints, tumour-reactive T cell and Natural Killer cell responses can be strongly impeded. Accordingly, the introduction of checkpoint inhibitors targeting CTLA-4 (CTLA4) and PD-1 (PDCD1, CD279)/PD-L1 (CD274, PDCD1LG1) accomplished a breakthrough in cancer treatment, with impressive clinical responses. Numerous new co-inhibitory players and novel combination therapies are currently investigated for their potential to boost anti-tumour immunity and improve survival of cancer patients. Although the challenge here remains to avoid severe systemic toxicity. This review addresses the involvement of co-inhibitory signalling in AML immune evasion and discusses the opportunities for checkpoint blockers in AML treatment.
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Affiliation(s)
- Willemijn Hobo
- Department of Laboratory Medicine - Laboratory of Haematology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Tim J A Hutten
- Department of Laboratory Medicine - Laboratory of Haematology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Nicolaas P M Schaap
- Department of Haematology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Harry Dolstra
- Department of Laboratory Medicine - Laboratory of Haematology, Radboud University Medical Centre, Nijmegen, the Netherlands
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50
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Griffiths EA, Srivastava P, Matsuzaki J, Brumberger Z, Wang ES, Kocent J, Miller A, Roloff GW, Wong HY, Paluch BE, Lutgen-Dunckley LG, Martens BL, Odunsi K, Karpf AR, Hourigan CS, Nemeth MJ. NY-ESO-1 Vaccination in Combination with Decitabine Induces Antigen-Specific T-lymphocyte Responses in Patients with Myelodysplastic Syndrome. Clin Cancer Res 2017; 24:1019-1029. [PMID: 28947565 DOI: 10.1158/1078-0432.ccr-17-1792] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 08/24/2017] [Accepted: 09/18/2017] [Indexed: 01/12/2023]
Abstract
Purpose: Treatment options are limited for patients with high-risk myelodysplastic syndrome (MDS). The azanucleosides, azacitidine and decitabine, are first-line therapy for MDS that induce promoter demethylation and gene expression of the highly immunogenic tumor antigen NY-ESO-1. We demonstrated that patients with acute myeloid leukemia (AML) receiving decitabine exhibit induction of NY-ESO-1 expression in circulating blasts. We hypothesized that vaccinating against NY-ESO-1 in patients with MDS receiving decitabine would capitalize upon induced NY-ESO-1 expression in malignant myeloid cells to provoke an NY-ESO-1-specific MDS-directed cytotoxic T-cell immune response.Experimental Design: In a phase I study, 9 patients with MDS received an HLA-unrestricted NY-ESO-1 vaccine (CDX-1401 + poly-ICLC) in a nonoverlapping schedule every four weeks with standard-dose decitabine.Results: Analysis of samples serially obtained from the 7 patients who reached the end of the study demonstrated induction of NY-ESO-1 expression in 7 of 7 patients and NY-ESO-1-specific CD4+ and CD8+ T-lymphocyte responses in 6 of 7 and 4 of 7 of the vaccinated patients, respectively. Myeloid cells expressing NY-ESO-1, isolated from a patient at different time points during decitabine therapy, were capable of activating a cytotoxic response from autologous NY-ESO-1-specific T lymphocytes. Vaccine responses were associated with a detectable population of CD141Hi conventional dendritic cells, which are critical for the uptake of NY-ESO-1 vaccine and have a recognized role in antitumor immune responses.Conclusions: These data indicate that vaccination against induced NY-ESO-1 expression can produce an antigen-specific immune response in a relatively nonimmunogenic myeloid cancer and highlight the potential for induced antigen-directed immunotherapy in a group of patients with limited options. Clin Cancer Res; 24(5); 1019-29. ©2017 AACRSee related commentary by Fuchs, p. 991.
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Affiliation(s)
- Elizabeth A Griffiths
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York. .,Department of Immunology, Roswell Park Cancer Institute, Buffalo, New York.,Department of Pharmacology and Therapeutics, Roswell Park Cancer Institute, Buffalo, New York
| | - Pragya Srivastava
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Junko Matsuzaki
- Center for Immunotherapy, Roswell Park Cancer Institute, Buffalo, New York
| | - Zachary Brumberger
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Eunice S Wang
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Justin Kocent
- Clinical Research Services, Roswell Park Cancer Institute, Buffalo, New York
| | - Austin Miller
- Department of Biostatistics and Bioinformatics, Roswell Park Cancer Institute, Buffalo, New York
| | - Gregory W Roloff
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Hong Yuen Wong
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Benjamin E Paluch
- Department of Pharmacology and Therapeutics, Roswell Park Cancer Institute, Buffalo, New York
| | | | - Brandon L Martens
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Kunle Odunsi
- Department of Immunology, Roswell Park Cancer Institute, Buffalo, New York.,Center for Immunotherapy, Roswell Park Cancer Institute, Buffalo, New York.,Department of Gynecologic Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Adam R Karpf
- Eppley Institute for Cancer Research, The Fred & Pamela Buffett Cancer Center, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, Nebraska
| | - Christopher S Hourigan
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Michael J Nemeth
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York. .,Department of Immunology, Roswell Park Cancer Institute, Buffalo, New York
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