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Leveraging Natural Killer Cell Innate Immunity against Hematologic Malignancies: From Stem Cell Transplant to Adoptive Transfer and Beyond. Int J Mol Sci 2022; 24:ijms24010204. [PMID: 36613644 PMCID: PMC9820370 DOI: 10.3390/ijms24010204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Numerous recent advancements in T-cell based immunotherapies have revolutionized the treatment of hematologic malignancies. In the race towards the first approved allogeneic cellular therapy product, there is growing interest in utilizing natural killer (NK) cells as a platform for off-the-shelf cellular therapies due to their scalable manufacturing potential, potent anti-tumor efficacy, and superior safety profile. Allogeneic NK cell therapies are now being actively explored in the setting of hematopoietic stem cell transplantation and adoptive transfer. Increasingly sophisticated gene editing techniques have permitted the engineering of chimeric antigen receptors, ectopic cytokine expression, and tumor recognition signals to improve the overall cytotoxicity of NK cell therapies. Furthermore, the enhancement of antibody-dependent cellular cytotoxicity has been achieved through the use of NK cell engagers and combination regimens with monoclonal antibodies that act synergistically with CD16-expressing NK cells. Finally, a greater understanding of NK cell biology and the mechanisms of resistance have allowed the preclinical development of NK checkpoint blockade and methods to modulate the tumor microenvironment, which have been evaluated in early phase trials. This review will discuss the recent clinical advancements in NK cell therapies in hematologic malignancies as well as promising avenues of future research.
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Valent P, Sadovnik I, Eisenwort G, Bauer K, Herrmann H, Gleixner KV, Schulenburg A, Rabitsch W, Sperr WR, Wolf D. Immunotherapy-Based Targeting and Elimination of Leukemic Stem Cells in AML and CML. Int J Mol Sci 2019; 20:E4233. [PMID: 31470642 PMCID: PMC6747233 DOI: 10.3390/ijms20174233] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/25/2019] [Accepted: 08/27/2019] [Indexed: 12/30/2022] Open
Abstract
The concept of leukemic stem cells (LSC) has been developed with the idea to explain the clonal hierarchies and architectures in leukemia, and the more or less curative anti-neoplastic effects of various targeted drugs. It is now widely accepted that curative therapies must have the potential to eliminate or completely suppress LSC, as only these cells can restore and propagate the malignancy for unlimited time periods. Since LSC represent a minor cell fraction in the leukemic clone, little is known about their properties and target expression profiles. Over the past few years, several cell-specific immunotherapy concepts have been developed, including new generations of cell-targeting antibodies, antibody-toxin conjugates, bispecific antibodies, and CAR-T cell-based strategies. Whereas such concepts have been translated and may improve outcomes of therapy in certain lymphoid neoplasms and a few other malignancies, only little is known about immunological targets that are clinically relevant and can be employed to establish such therapies in myeloid neoplasms. In the current article, we provide an overview of the immunologically relevant molecular targets expressed on LSC in patients with acute myeloid leukemia (AML) and chronic myeloid leukemia (CML). In addition, we discuss the current status of antibody-based therapies in these malignancies, their mode of action, and successful examples from the field.
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MESH Headings
- Acute Disease
- B7-H1 Antigen/antagonists & inhibitors
- B7-H1 Antigen/immunology
- B7-H1 Antigen/metabolism
- CTLA-4 Antigen/antagonists & inhibitors
- CTLA-4 Antigen/immunology
- CTLA-4 Antigen/metabolism
- Humans
- Immunologic Factors/therapeutic use
- Immunotherapy/methods
- Immunotherapy/trends
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/immunology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/metabolism
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Leukemia, Myeloid/immunology
- Leukemia, Myeloid/metabolism
- Leukemia, Myeloid/therapy
- Molecular Targeted Therapy/methods
- Molecular Targeted Therapy/trends
- Neoplastic Stem Cells/drug effects
- Neoplastic Stem Cells/immunology
- Neoplastic Stem Cells/metabolism
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Affiliation(s)
- Peter Valent
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, 1090 Vienna, Austria.
- Ludwig Boltzmann Institute for Hematology & Oncology, Medical University of Vienna, 1090 Vienna, Austria.
| | - Irina Sadovnik
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Hematology & Oncology, Medical University of Vienna, 1090 Vienna, Austria
| | - Gregor Eisenwort
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Hematology & Oncology, Medical University of Vienna, 1090 Vienna, Austria
| | - Karin Bauer
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Hematology & Oncology, Medical University of Vienna, 1090 Vienna, Austria
| | - Harald Herrmann
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Hematology & Oncology, Medical University of Vienna, 1090 Vienna, Austria
- Department of Radiotherapy, Medical University of Vienna, 1090 Vienna, Austria
| | - Karoline V Gleixner
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Hematology & Oncology, Medical University of Vienna, 1090 Vienna, Austria
| | - Axel Schulenburg
- Ludwig Boltzmann Institute for Hematology & Oncology, Medical University of Vienna, 1090 Vienna, Austria
- Division of Blood and Bone Marrow Transplantation, Department of Internal Medicine I, Medical University of Vienna, 1090 Vienna, Austria
| | - Werner Rabitsch
- Ludwig Boltzmann Institute for Hematology & Oncology, Medical University of Vienna, 1090 Vienna, Austria
- Division of Blood and Bone Marrow Transplantation, Department of Internal Medicine I, Medical University of Vienna, 1090 Vienna, Austria
| | - Wolfgang R Sperr
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, 1090 Vienna, Austria
- Ludwig Boltzmann Institute for Hematology & Oncology, Medical University of Vienna, 1090 Vienna, Austria
| | - Dominik Wolf
- Department of Internal Medicine V (Hematology & Oncology), Medical University of Innsbruck, 1090 Innsbruck, Austria
- Medical Clinic 3, Oncology, Hematology, Immunoncology & Rheumatology, University Clinic Bonn (UKB), 53127 Bonn, Germany
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3
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Mehta RS, Rezvani K. Chimeric Antigen Receptor Expressing Natural Killer Cells for the Immunotherapy of Cancer. Front Immunol 2018; 9:283. [PMID: 29497427 PMCID: PMC5818392 DOI: 10.3389/fimmu.2018.00283] [Citation(s) in RCA: 191] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 01/31/2018] [Indexed: 12/12/2022] Open
Abstract
Adoptive cell therapy has emerged as a powerful treatment for advanced cancers resistant to conventional agents. Most notable are the remarkable responses seen in patients receiving autologous CD19-redirected chimeric antigen receptor (CAR) T cells for the treatment of B lymphoid malignancies; however, the generation of autologous products for each patient is logistically cumbersome and has restricted widespread clinical use. A banked allogeneic product has the potential to overcome these limitations, yet allogeneic T-cells (even if human leukocyte antigen-matched) carry a major risk of graft-versus-host disease (GVHD). Natural killer (NK) cells are bone marrow-derived innate lymphocytes that can eliminate tumors directly, with their activity governed by the integration of signals from activating and inhibitory receptors and from cytokines including IL-15, IL-12, and IL-18. NK cells do not cause GVHD or other alloimmune or autoimmune toxicities and thus, can provide a potential source of allogeneic “off-the-shelf” cellular therapy, mediating major anti-tumor effects without inducing potentially lethal alloreactivity such as GVHD. Given the multiple unique advantages of NK cells, researchers are now exploring the use of CAR-engineered NK cells for the treatment of various hematological and non-hematological malignancies. Herein, we review preclinical data on the development of CAR-NK cells, advantages, disadvantages, and current obstacles to their clinical use.
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4
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Cuapio A, Post M, Cerny-Reiterer S, Gleixner KV, Stefanzl G, Basilio J, Herndlhofer S, Sperr WR, Brons NHC, Casanova E, Zimmer J, Valent P, Hofer E. Maintenance therapy with histamine plus IL-2 induces a striking expansion of two CD56bright NK cell subpopulations in patients with acute myeloid leukemia and supports their activation. Oncotarget 2018; 7:46466-46481. [PMID: 27341131 PMCID: PMC5216810 DOI: 10.18632/oncotarget.10191] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 05/28/2016] [Indexed: 11/25/2022] Open
Abstract
Histamine dihydrochloride (HDC) plus IL-2 has been proposed as a novel maintenance-immunotherapy in acute myeloid leukemia (AML). We analyzed the immunophenotype and function of natural killer (NK) cells in blood of AML patients treated after chemotherapy with HDC plus IL-2. The treatment caused a striking expansion of CD56brightCD16neg and CD56brightCD16low NK cell subpopulations. A reduced NK cell fraction recovered and high proportions of cells expressed the activating receptors NKG2D, NKp30, and NKp46. Concomitantly, KIR-expressing NK cells were reduced and NK cells with inhibitory NKG2A/CD94 receptors increased beyond normal levels. In addition, the immunotherapy-induced NK cells exhibited high capacity to produce IFN-γ and to degranulate. Furthermore, we provide evidence from subsequent in vitro studies that this is caused in part by direct effects of IL-2 on the CD56bright cells. IL-2 specifically induced proliferation of both CD56bright subpopulations, but not of CD56dim cells. It further preserved the expression of activating receptors and the capacity to produce IFN-γ and to degranulate. These data suggest that therapy with HDC plus IL-2 supports the reconstitution of a deficient NK cell fraction through the specific amplification of CD56bright NK cells giving rise to a functional NK cell compartment with high potential to combat leukemic disease.
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Affiliation(s)
- Angélica Cuapio
- Department of Vascular Biology and Thrombosis Research, Medical University of Vienna, Vienna, Austria
| | - Mirte Post
- Department of Vascular Biology and Thrombosis Research, Medical University of Vienna, Vienna, Austria
| | - Sabine Cerny-Reiterer
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Vienna, Austria
| | - Karoline V Gleixner
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Vienna, Austria
| | - Gabriele Stefanzl
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Jose Basilio
- Department of Vascular Biology and Thrombosis Research, Medical University of Vienna, Vienna, Austria
| | - Susanne Herndlhofer
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Vienna, Austria
| | - Wolfgang R Sperr
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Vienna, Austria
| | - Nicolaas H C Brons
- National Core Facility Cytometry, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
| | - Emilio Casanova
- Ludwig Boltzmann Institute of Cancer Research, Vienna, Austria.,Institute of Pharmacology, Center of Physiology and Pharmacology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Jacques Zimmer
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Luxembourg
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Vienna, Austria
| | - Erhard Hofer
- Department of Vascular Biology and Thrombosis Research, Medical University of Vienna, Vienna, Austria
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5
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Mehta RS, Randolph B, Daher M, Rezvani K. NK cell therapy for hematologic malignancies. Int J Hematol 2018; 107:262-270. [PMID: 29383623 DOI: 10.1007/s12185-018-2407-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/22/2018] [Indexed: 12/17/2022]
Abstract
Natural killer (NK) cells are part of the innate immune system and represent the first line of defense against infections and tumors. In contrast to T cells, NK cells do not require prior antigen sensitization to induce cytotoxicity and do not cause graft-versus-host disease. These, along with other advantages, make NK cells an attractive candidate for adoptive cellular therapy. Herein, we describe the mechanisms of NK cell cytotoxicity, which is governed by an intricate balance between various activating and inhibitory receptors, including the killer cell immunoglobulin-like receptors (KIRs). We illustrate the advantages of NK alloreactivity as demonstrated in various types of hematopoietic stem cell transplants (HSCT), such as haploidentical, human leukocyte antigen-matched related or unrelated donor and umbilical cord blood transplant. We elaborate on different models used to predict NK cell alloreactivity in these studies, which are either based on the absence of the ligands for inhibitory KIRs, presence of activating NK cell receptors and KIR genes content in donors, or a combination of these. We will review clinical studies demonstrating anti-tumor efficacy of NK cells used either as a stand-alone immunotherapy or as an adjunct to HSCT and novel genetic engineering strategies to improve the anti-tumor activity of NK cells.
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Affiliation(s)
- Rohtesh S Mehta
- Department of Stem Cell Transplant and Cellular Therapy, University of Texas M. D. Anderson Cancer Center, Unit 0423, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
| | - Brion Randolph
- Department of Stem Cell Transplant and Cellular Therapy, University of Texas M. D. Anderson Cancer Center, Unit 0423, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - May Daher
- Department of Stem Cell Transplant and Cellular Therapy, University of Texas M. D. Anderson Cancer Center, Unit 0423, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Katayoun Rezvani
- Department of Stem Cell Transplant and Cellular Therapy, University of Texas M. D. Anderson Cancer Center, Unit 0423, 1515 Holcombe Blvd., Houston, TX, 77030, USA
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6
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Mehta RS, Rezvani K. Can we make a better match or mismatch with KIR genotyping? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:106-118. [PMID: 27913469 PMCID: PMC6142490 DOI: 10.1182/asheducation-2016.1.106] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Natural killer (NK) cell function is regulated by a fine balance between numerous activating and inhibitory receptors, of which killer-cell immunoglobulin-like receptors (KIRs) are among the most polymorphic and comprehensively studied. KIRs allow NK cells to recognize downregulation or the absence of HLA class I molecules on target cells (known as missing-self), a phenomenon that is commonly observed in virally infected cells or cancer cells. Because KIR and HLA genes are located on different chromosomes, in an allogeneic environment such as after hematopoietic stem cell transplantation, donor NK cells that express an inhibitory KIR for an HLA class I molecule that is absent on recipient targets (KIR/KIR-ligand mismatch), can recognize and react to this missing self and mediate cytotoxicity. Accumulating data indicate that epistatic interactions between KIR and HLA influence outcomes in several clinical conditions. Herein, we discuss the genetic and functional features of KIR/KIR-ligand interactions in hematopoietic stem cell transplantation and how these data can guide donor selection. We will also review clinical studies of adoptive NK cell therapy in leukemia and emerging data on the use of genetically modified NK cells that could broaden the scope of cancer immunotherapy.
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Affiliation(s)
- Rohtesh S Mehta
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Katayoun Rezvani
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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7
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Vasold J, Wagner M, Drolle H, Deniffel C, Kütt A, Oostendorp R, Sironi S, Rieger C, Fiegl M. The bone marrow microenvironment is a critical player in the NK cell response against acute myeloid leukaemia in vitro. Leuk Res 2015; 39:257-62. [DOI: 10.1016/j.leukres.2014.12.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 11/29/2014] [Accepted: 12/01/2014] [Indexed: 12/29/2022]
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8
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Individual patient data meta-analysis of randomized trials evaluating IL-2 monotherapy as remission maintenance therapy in acute myeloid leukemia. Blood 2011; 117:7007-13. [PMID: 21518931 DOI: 10.1182/blood-2011-02-337725] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
IL-2 is a natural, T cell-derived cytokine that stimulates the cytotoxic functions of T and natural killer cells. IL-2 monotherapy has been evaluated in several randomized clinical trials (RCTs) for remission maintenance in patients with acute myeloid leukemia (AML) in first complete remission (CR1), and none demonstrated a significant benefit of IL-2 monotherapy. The objective of this meta-analysis was to reliably determine IL-2 efficacy by combining all available individual patient data (IPD) from 5 RCTs (N = 905) and summary data from a sixth RCT (N = 550). Hazard ratios (HRs) were estimated using Cox regression models stratified by trial, with HR < 1 indicating treatment benefit. Combined IPD showed no benefit of IL-2 over no treatment in terms of leukemia-free survival (HR = 0.97; P = .74) or overall survival (HR = 1.08; P = .39). Analyses including the sixth RCT yielded qualitatively identical results (leukemia-free survival HR = 0.96, P = .52; overall survival HR = 1.06; P = .46). No significant heterogeneity was found between the trials. Prespecified subset analyses showed no interaction between the lack of IL-2 effect and any factor, including age, sex, baseline performance status, karyotype, AML subtype, and time from achievement of CR1 to initiation of maintenance therapy. We conclude that IL-2 alone is not an effective remission maintenance therapy for AML patients in CR1.
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9
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Thorén FB, Romero AI, Brune M, Hellstrand K. Histamine dihydrochloride and low-dose interleukin-2 as post-consolidation immunotherapy in acute myeloid leukemia. Expert Opin Biol Ther 2009; 9:1217-23. [PMID: 19653866 DOI: 10.1517/14712590903130566] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Acute myeloid leukemia (AML) is the most common acute leukemia in adults. Although most patients achieve complete remission (CR) after chemotherapy, the majority suffer from subsequent leukemic relapse, which is associated with poor long-term survival. Thus, new therapies to maintain CR are highly warranted. After the completion of chemotherapy, AML patients have a minimal burden of leukemic cells, which are reportedly susceptible to cytotoxic lymphocytes such as NK cells and T cells. A therapy that boosts the function of these effector cells therefore has the potential to eradicate the malignant clone in AML and prevent relapse, Here, we briefly review the literature on the role of the immune system in AML and introduce the rationale for the use of histamine dihydrochloride (HDC) in conjuction with low-dose IL-2 as relapse-preventive immunotherapy for this disease.
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Affiliation(s)
- Fredrik B Thorén
- The Sahlgrenska Academy at University of Gothenburg, Department of Hematology, Göteborg, Sweden
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10
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Romero AI, Thorén FB, Aurelius J, Askarieh G, Brune M, Hellstrand K. Post-consolidation immunotherapy with histamine dihydrochloride and interleukin-2 in AML. Scand J Immunol 2009; 70:194-205. [PMID: 19703009 DOI: 10.1111/j.1365-3083.2009.02303.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The initial chemotherapy in acute myeloid leukaemia (AML) comprises a first phase of induction and a second phase of consolidation. In the majority of patients, the induction treatment leads to complete remission (CR), defined as microscopic disappearance of leukaemic disease along with the return of normal haematopoiesis. However, despite the introduction of more efficacious consolidation regimens, a worryingly large proportion of AML patients in CR will subsequently experience relapses with poor prospects of long-term survival. A relapse is assumed to be the result of expansion of residual leukaemic cells that have escaped the initial chemotherapy. The anti-leukaemic functions of T cells and natural killer (NK) cells has formed the background to the use of interleukin-2 (IL-2), a T- and NK cell-activating cytokine, with the aim to eliminate residual leukaemia and hence reduce the relapse rate in AML, but the clinical trials using IL-2 monotherapy have yielded disappointment. A recent phase III study has demonstrated that post-consolidation treatment with the combination of histamine dihydrochloride (HDC) and IL-2 significantly prevents relapse in AML patients. Here we account for the preclinical background to the use of HDC/IL-2 in AML along with a review of clinical results.
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Affiliation(s)
- A I Romero
- Department of Infectious Diseases, University of Gothenburg, S-41346 Gothenburg, Sweden
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11
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Abstract
The applications of chemotherapy for the treatment of AML have been unchanged over the past three decades, with only 30% of patients demonstrating disease-free survival (DFS) [118]. Despite achieving CR following induction chemotherapy, the majority of patients relapse and succumb to their disease [6]. In view of the limitations encountered by cytarabine/anthracycline based regimes, attention has shifted to immunotherapy as a means to treat AML and provide significant long-term DFS. This chapter will discuss the role of the immune system and recent advances in immunotherapy for the treatment of AML, focusing on cellular and non-cellular approaches.
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12
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Stone RM, DeAngelo DJ, Janosova A, Galinsky I, Canning C, Ritz J, Soiffer RJ. Low dose interleukin-2 following intensification therapy with high dose cytarabine for acute myelogenous leukemia in first complete remission. Am J Hematol 2008; 83:771-7. [PMID: 18756547 DOI: 10.1002/ajh.21253] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The most important problem in the therapy of patients with acute myeloid leukemia (AML) is relapse after intensive therapy. We sought to determine if interleukin-2 (low-dose with intermittent boluses) administration could be feasibly administered after standard therapy to potentiate anti-tumor immunity in a fashion analogous to the post-allogeneic stem cell transplant "graft-vs-leukemic" effect. Adults with de novo AML received daunorubicin and cytosine arabinoside induction therapy. Patients achieving complete remission received high dose ara-C (HIDAC) for three courses followed by low dose rIL-2 (Amgen), administered by continuous infusion (450,000 U/m(2)/day) for 10 weeks with intermittent boluses (500,000/U/m(2) over 2 hr) given in weekly intervals starting on Week 4. Of the 32 enrolled patients, 27 achieved CR; 8/11 who received rIL-2 completed therapy. 6/11 are long term survivors (median follow-up, 139 months). rIL-2 was well tolerated and associated with a 5-fold increase in circulating NK-lymphocytes and a 3-fold increase in circulating T-cells. Mononuclear cells from patients receiving rIL-2 exhibited enhanced cytolytic activity in vitro against cryopreserved autologous leukemia cells. This study supports further investigation of immunotherapy in the post-intensive chemotherapy setting in the management of patients with AML.
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Affiliation(s)
- Richard M Stone
- Department of Medical Oncology, Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts 02115, USA.
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13
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Alyea EP. Modulating graft-versus-host disease to enhance the graft-versus-leukemia effect. Best Pract Res Clin Haematol 2008; 21:239-50. [DOI: 10.1016/j.beha.2008.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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14
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Mato AR, Luger SM. Autologous stem cell transplant in ALL: who should we be transplanting in first remission? Bone Marrow Transplant 2006; 37:989-95. [PMID: 16633362 DOI: 10.1038/sj.bmt.1705370] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Long-term disease-free survival (DFS) has been reported after autologous stem cell transplantation for acute lymphoblastic leukemia. Phase II studies have evaluated its role in first and subsequent complete remission (CR) with DFS rates of up to 50%. It has been under-utilized in 1st CR in part, due to a concern that patients who relapse after autologous stem cell transplantation (ASCT) have fewer options for salvage treatment of relapsed disease. Unfortunately, survival rates of <5% are reported in patients who relapse, regardless of initial therapy. Few prospective, randomized trials have analyzed large enough numbers of patients to allow us to determine the appropriate patient population for autologous transplantation. Although variability in the available studies makes it difficult to draw a definite conclusion, and many issues remain unresolved, available data suggests that there may be a group of patients for whom ASCT in first remission is a reasonable and perhaps superior treatment choice. Factors such as risk features at diagnosis, and minimal residual disease following induction therapy greatly affect outcome following ASCT. The available data as well as the questions that remain to be answered will be discussed and reviewed.
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Affiliation(s)
- A R Mato
- Hematologic Malignancies Program, Division of Hematology and Oncology, Department of Internal Medicine, University of Pennsylvania Medical Center, Philadelphia, PA, USA
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15
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Abstract
Myeloid growth factors, such as granulocyte colony-stimulating factor and granulocyte-macrophage colony-stimulating factor, have been used to decrease the duration of chemotherapy-induced neutropenia and thereby reduce the incidence and severity of infections in various regimens used to treat acute myeloid leukemia and acute lymphoblastic leukemia. These growth factors have also been used to recruit dormant myeloid leukemia cells into the S phase of cell cycle in order to increase their susceptibility to the antileukemic effects of agents such as cytarabine. Multiple prospective randomized trials have examined the benefit and safety of the addition of growth factors before, during, and after chemotherapy. A reduction in the duration of neutropenia has been the most consistent finding; this has not been associated with stimulation of leukemia cells, the main concern of using this strategy. Unfortunately, few studies have reported a benefit in prolonging the duration of disease-free survival or overall survival. Other cytokines, including interleukins and thrombopoietin, have also been evaluated for their theoretical ability to recruit immune mechanisms to eradicate residual leukemia burden after chemotherapy, and to stimulate platelet production. In this review, we summarize the clinical experience with these growth factors in treating acute leukemias.
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Affiliation(s)
- F Ravandi
- Department of Leukemia, University of Texas - MD Anderson Cancer Center, Houston, TX 77030, USA.
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16
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Dhédin N, Dombret H, Thomas X, Lhéritier V, Boiron JM, Rigal-Huguet F, Vey N, Kuentz M, Reman O, Witz F, Delannoy A, Kovacsovics T, Bradstock K, Charrin C, Boucheix C, Gabert J, Blaise D, Fière D, Vernant JP. Autologous stem cell transplantation in adults with acute lymphoblastic leukemia in first complete remission: analysis of the LALA-85, -87 and -94 trials. Leukemia 2005; 20:336-44. [PMID: 16357838 DOI: 10.1038/sj.leu.2404065] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
To evaluate the results of autologous stem cell transplantation (ASCT) in a large population of adults with acute lymphoblastic leukemia (ALL) in first complete remission (CR), we performed an individual data-based overview of the last three trials from the LALA group. Overall, 349 patients with ALL prospectively randomized in the consecutive LALA-85, -87, and -94 trials to receive either ASCT or chemotherapy as post-CR treatment were analyzed. Eligibility criteria were 15-50-year-old patients without sibling donors in both LALA-85/87 trials and 15-55-year-old patients with high-risk ALL and no sibling donors in the LALA-94 trial. Intent-to-treat analysis, which compared 175 patients from the ASCT arm to 174 patients from the chemotherapy arm, showed that ASCT was associated with a lower cumulative incidence of relapse (66 vs 78% at 10 years; P=0.05), without significant gain in disease-free or overall survival. Despite a possible lack of statistical power, a nested case-control analysis performed in 85 patient pairs adjusted for time to transplant and prognostic covariates confirmed these intent-to-treat results in patients actually transplanted. Of interest, the reduced relapse risk after ASCT translated in better disease-free survival in the 300 rapid responders who reached CR after the first induction course.
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Affiliation(s)
- N Dhédin
- Department of Hematology, Hôpital Pitié-Salpétrière, Paris, France
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17
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Majumder D, Bandyopadhyay D, Chandra S, Mukhopadhayay A, Mukherjee N, Bandyopadhyay SK, Banerjee S. Analysis of HLA class Ia transcripts in human leukaemias. Immunogenetics 2005; 57:579-89. [PMID: 16133450 DOI: 10.1007/s00251-005-0018-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2005] [Accepted: 06/22/2005] [Indexed: 10/25/2022]
Abstract
Several leukaemia-specific antigens have been discovered in the recent past, which raised the possibility for T-cell-based immunotherapy for leukaemia. However, failure of such approaches involving interleukin-2 and/or T-cell-based immunotherapy indicated the importance of investigation of the human leucocyte antigen (HLA) status of the haematopoietic malignant cells. Considerable number of reports indicate that both HLA class I and class II are down-regulated in different cases of leukaemias, enabling them to evade immuno-surveillance. However, locus-specific down-regulation in leukaemia has not been widely investigated, although majority of cytotoxic T lymphocyte (CTL) responses are modulated by HLA-A and HLA-B, whereas expression of only HLA-C is unable to block natural killer (NK)-cell-mediated cytotolysis. Therefore, using RT-PCR, we have investigated the HLA class I transcriptional expression in a locus-specific manner, along with HLA-associated accessory molecules beta2-microglobulin and transporter-associated antigen processing molecule (TAP1). Our data suggest that in several newly diagnosed untreated leukaemic patients, HLA-C and beta2-microglobulin are expressed, but not the locus HLA-A or -B. Moreover, TAP1 and beta2-microglobulin were observed to be down-regulated in a number of cases of leukaemia. Our flow cytometric analysis of HLA-ABC also indicates a decrease in mean fluorescent intensity but no complete loss in surface expression of HLA class Ia on the leukaemic cells. Therefore, the observed low surface expression of HLA-ABC may be due to the down-regulation of transcription of HLA-A or -B itself and/or transcriptional suppression of the accessory molecules.
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Affiliation(s)
- Durjoy Majumder
- Biophysics Division, Structural Genomics Section, Saha Institute of Nuclear Physics, Calcutta, India
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18
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Ravandi F, Kebriaei P. Cytokines in the treatment of acute leukemias. Cancer Treat Res 2005; 126:313-31. [PMID: 16209072 DOI: 10.1007/0-387-24361-5_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- Farhad Ravandi
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Vey N, Bouabdallah R, Stoppa A, Faucher C, Lafage M, Chabannon C, Sainty D, Gastaut J, Maraninchi D, Blaise D. Autologous stem cell transplantation for acute myelogenous leukemia in first complete remission: a 6-year follow-up study of 101 patients from a single institution. Bone Marrow Transplant 2003; 33:177-82. [PMID: 14647259 DOI: 10.1038/sj.bmt.1704326] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The objective of the study was to assess the long-term outcome and impact of stem cell source in patients with acute myelogenous leukemia (AML) who received ASCT in first complete remission (CR). A total of 101 patients (median age 46 years) were included in the study. Cytogenetic categories distribution was: favorable: 18%, intermediate: 42%, and unfavorable: 7%. More than one induction course was needed for CR in 21% of patients. In all, 78% of patients had received at least one course of high-dose ara-C before autologous stem cell transplantation (ASCT). Bone marrow (n=58) or peripheral blood stem cells (PBSC) (n=43) transplantation was performed at a median of 3.5 months from CR. Hematologic recovery and hospitalization duration were significantly reduced in the PBSC group. No toxic death was recorded in this group. The median follow-up of survivors is 67 months (range: 15-183). The 6-year survival, disease-free survival (DFS), and relapse probabilities are 44%, 38%, and 54%, respectively. The presence of a favorable karyotype and the use of PBSC are independently associated to better survival, and DFS by multivariate analysis. Our results confirm that long-term DFS can be achieved with high-dose chemotherapy and ASCT in patients with AML. They show that use of PBSC is associated to very low mortality rate and acceptable morbidity and contributes to an improvement of autotransplant results.
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Affiliation(s)
- N Vey
- Department of Hematology, Institut Paoli-Calmettes, 232 Boulevard de Sainte Marguerite, 13273 Marseille cedex 9, France.
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20
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Burns LJ, Weisdorf DJ, DeFor TE, Vesole DH, Repka TL, Blazar BR, Burger SR, Panoskaltsis-Mortari A, Keever-Taylor CA, Zhang MJ, Miller JS. IL-2-based immunotherapy after autologous transplantation for lymphoma and breast cancer induces immune activation and cytokine release: a phase I/II trial. Bone Marrow Transplant 2003; 32:177-86. [PMID: 12838283 DOI: 10.1038/sj.bmt.1704086] [Citation(s) in RCA: 183] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We determined the safety, immune activating effects, and potential efficacy of i.v. infusion of ex vivo interleukin-2 (IL-2) activated natural killer (NK) cells (part I) or IL-2 boluses (part II) during daily s.c. IL-2 administration following hematopoietic recovery from autologous transplantation. In all, 57 patients with relapsed lymphoma (n=29) or metastatic breast cancer (n=28) were enrolled. In part I of the study, 34 patients were enrolled at three dose levels of ex vivo IL-2-activated NK cells. Lymphaphereses were performed on days 28 and 42 of s.c. IL-2 administration. Following overnight ex vivo IL-2 activation of the pheresis product, the cells were reinfused the following day. In part II, 23 patients were enrolled at three dose levels of supplemental i.v. IL-2 bolus infusions, given on days 28 and 35 during s.c. IL-2 administration. Toxicities were generally mild, and no patient required hospitalization. Lytic function was markedly enhanced for fresh peripheral blood mononuclear cells (PBMNCs) obtained 1 day postinfusion of either IL-2-activated cells or IL-2 boluses. IL-2 boluses transiently increased the levels of IL-6, IFN-gamma, TNF-alpha and IL1-beta, with increases in IL-6 and IFN-gamma being dose dependent. A total of 37 patients (19 patients with lymphoma, 18 with breast cancer) treated with an optimum dose of post-transplant immunotherapy (defined as having received 1.75 x 10(6) IU/m(2)/day of s.c. IL-2 plus at least one of the planned ex vivo IL-2-activated cell infusions/IL-2 boluses) could be matched with controls from the Autologous Blood and Marrow Transplant Registry database. The matched-pairs analysis demonstrated no improvement in disease outcomes of survival and relapse. We conclude that IL-2-activated cells/IL-2 boluses can be safely administered, generate PBMNCs with enhanced cytotoxicity against NK-resistant targets, and increase cytokine levels. With this dose and schedule of administration of IL-2, no improvement in patient disease outcomes was noted. Alternative strategies will be needed to exploit the immunotherapeutic potential of IL-2-activated NK cells.
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Affiliation(s)
- L J Burns
- Blood and Marrow Transplant Program and Cancer Center, University of Minnesota, Mayo Mail Code 286, Minneapolis, MN 55455, USA
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Abstract
Although the outcome for Philadelphia positive (Ph+) acute lymphoblastic leukemia (ALL) with conventional chemotherapy is poor, the outcome after a sibling-matched allogeneic bone marrow transplantation (BMT) seems to be significantly better. The surprising success of allogeneic BMT may be because of disease response to high-dose chemotherapy combined with a graft-versus-leukemia effect. However, less than 30% of patients have a matched related donor available, and some of them will be too old/not fit for conventional BMT. While young patients who do not have a matched related donor should be considered for matched unrelated donor (MUD) transplant, older patients may be treated with autologous stem cell transplantation (ASCT) or rarely considered for a low-intensity MUD transplant. The efficacy of autologous BMT compared with chemotherapy is still debatable, although the new tyrosine kinase inhibitor Imatinib may be used for pretransplant purging/post-transplant therapy, aiming to improve autologous and allogeneic BMT results. The advantage of low-intensity sib/MUD allograft compared with chemotherapy is not proven either and is currently under investigation. However, if shown to be curative, low-intensity allograft may significantly improve the outcome of older Ph+ ALL patients, who are not eligible for conventional allograft.
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Affiliation(s)
- I Avivi
- University College of London Hospitals, London, UK
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22
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Stein AS, O'Donnell MR, Slovak ML, Snyder DS, Nademanee AP, Parker P, Molina A, Somlo G, Fung HC, Krishnan A, Rodriguez R, Spielberger RT, Wang S, Dagis A, Vora N, Arber DA, Niland JC, Forman SJ. Interleukin-2 after autologous stem-cell transplantation for adult patients with acute myeloid leukemia in first complete remission. J Clin Oncol 2003; 21:615-23. [PMID: 12586797 DOI: 10.1200/jco.2003.12.125] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine the disease-free survival (DFS) and toxicity of administering interleukin-2 (IL-2) immunotherapy early after autologous stem-cell transplantation (ASCT) to simulate a graft versus leukemia effect observed in allogeneic transplantation. PATIENTS AND METHODS Fifty-six patients with acute myeloid leukemia in first remission received a single consolidation of high-dose cytarabine-idarubicin at a median of 1.1 month postremission with the intent to proceed to ASCT and IL-2 9 x 10(6) U/m(2)/24 h for 4 days, followed by 10 days of IL-2 1.6 x 10(6) U/m(2)/24 h on hematologic recovery. RESULTS Eighty-four percent of patients received the intended ASCT, and 68% of patients received IL-2 treatment. With a median follow-up of 39.4 months (range, 1.2 to 76.3 months), the 2-year cumulative probability of DFS for all 56 patients is 68% (95% confidence interval [CI], 55% to 80%) and 74% (95% CI, 57% to 85%) for the 39 patients undergoing IL-2 treatment after ASCT. The 2-year cumulative probability of DFS for favorable, intermediate, and unfavorable cytogenetics is 88% (95% CI, 59% to 97%), 48% (95% CI, 26% to 67%), and 70% (95% CI, 23% to 93%), respectively. Toxicities from IL-2 were mainly thrombocytopenia, leukopenia, fever, and fluid retention. Two septic deaths occurred during neutropenia, which includes one during consolidation and one during transplant, for an overall 4% mortality rate. CONCLUSION These results suggest that a moderate dose of IL-2 after high-dose cytarabine-idarubicin-mobilized ASCT is associated with a low regimen-related toxicity and may improve DFS. A phase III study of IL-2 is now warranted.
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Affiliation(s)
- Anthony S Stein
- Division of Hematology and Bone Marrow Transplantation, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA.
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23
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Abstract
Despite successful chemotherapeutic remission induction, most patients with acute myeloid leukemia still are destined to die from recurrent and refractory disease. Strategies to prolong remission and improve survival include high-dose chemotherapy, autologous or allogeneic stem cell transplantation, and other immunotherapeutic approaches. The focus on interleukin-2 (IL-2) has arisen from in vitro demonstration of enhancement of tumor-specific cytotoxic T-lymphocyte and natural killer-cell activity after cytokine activation. The local secretion of inhibitory substances and oxidative stress by monocyte/macrophage populations may inhibit the cytotoxic capacity of these effector cells. Recently, agents capable of modulating cytotoxic effector function have been identified, including histamine dihydrochloride, which has been shown to act as an inhibitor of cellular-mediated free-radical production. In the presence of histamine, cytotoxic effector function may be restored. The addition of histamine to IL-2-based cytokine therapies has resulted in enhanced in vitro cytotoxic T-cell and natural killer-cell function and has allowed for the development of lower, and thus, less toxic, IL-2 regimens. Preliminary studies of this combination in patients with acute myeloid leukemia in remission suggest improved survival with tolerable toxicity. The strategy for implementation of IL-2-based immunotherapy in patients with acute myeloid leukemia is reviewed.
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Affiliation(s)
- Edward A Stadtmauer
- Hematologic Malignancies Program, University of Pennsylvania Cancer Center, Philadelphia, PA 19014, USA
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24
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Martin TG, Linker CA. Autologous stem cell transplantation for acute lymphocytic leukemia in adults. Hematol Oncol Clin North Am 2001; 15:121-43. [PMID: 11253604 DOI: 10.1016/s0889-8588(05)70202-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Autologous bone marrow transplantation remains an investigational treatment for adult ALL. Despite many anecdotal studies showing efficacy, the rarity of ALL has prevented the large randomized trials necessary to confirm effectiveness. Candidates for autoBMT include adult patients in first CR with adverse risk factors and all patients who have experienced disease relapse. It remains debatable which preparative regimen is optimal, whether purging is necessary, or if chemotherapy or immunotherapy administered after transplantation can decrease disease relapse. Overall, every effort should be made to enter ALL patients on well-designed randomized multi-institutional trials. These trials should compare autologous transplantation to newer more intensive chemotherapy regimens and should take into account the heterogeneity of ALL. A quality of life analysis should be performed as one high-dose treatment may be less toxic and better tolerated than multiple cycles of consolidation chemotherapy. Strategies aimed at enhancing an autologous graft-versus-leukemia effect after transplantation may enhance long-term survival. Many more studies are needed to further define the optimal role of autoBMT in adult ALL.
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Affiliation(s)
- T G Martin
- Department of Blood and Marrow Transplantation, University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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25
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Goldberg SL, Pecora AL, Rosenbluth RJ, Jennis AA, Preti RA. Treatment of leukemic relapse following unrelated umbilical cord blood transplantation with interleukin-2: potential for augmenting graft-versus-leukemia and graft-versus-host effects with cytokines. Bone Marrow Transplant 2000; 26:353-5. [PMID: 10967580 DOI: 10.1038/sj.bmt.1702520] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In comparison to bone marrow, umbilical cord blood has decreased intrinsic immune responsiveness allowing transplantation across HLA barriers with lower rates of graft-versus-host disease. However, laboratory models have also suggested that cord blood may be extremely sensitive to stimulation by cytokines. We report an adult recipient of an ex vivo expanded, HLA-mismatched, unrelated cord blood transplant who experienced a late extramedullary relapse while still in hematologic remission. Despite demonstrating immune tolerance on minimal immunosuppressive agents, a brief course of intravenous interleukin-2 resulted in rapid, aggressive graft-versus-host and graft-versus-leukemia reactions. This case highlights the potential of cytokine immunomodulation following cord blood transplantation, but also suggests caution in stimulating these cells.
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Affiliation(s)
- S L Goldberg
- Adult Blood and Marrow Transplant Program, Hackensack University Medical Center, NJ, USA
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26
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Thomas DA, Kantarjian H, Smith TL, Koller C, Cortes J, O'Brien S, Giles FJ, Gajewski J, Pierce S, Keating MJ. Primary refractory and relapsed adult acute lymphoblastic leukemia: characteristics, treatment results, and prognosis with salvage therapy. Cancer 1999; 86:1216-30. [PMID: 10506707 DOI: 10.1002/(sici)1097-0142(19991001)86:7<1216::aid-cncr17>3.0.co;2-o] [Citation(s) in RCA: 148] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Relapses continue to be problematic for adults with acute lymphoblastic leukemia (ALL). New therapies generally are first tested in the salvage setting prior to incorporation into frontline regimens. Defining the prognosis at relapse (or at failure of induction) and subsequently predicting outcome would be useful to select the population in whom to test new strategies, rather than attempting traditional reinduction therapy. METHODS Between March 1980 and March 1997, 314 eligible adults with primary refractory (24%) or primary relapsed (76%) ALL were treated with various chemotherapy or stem cell transplantation (SCT) regimens. The Cox proportional hazards model was used to assess biologic factors and disease history in relation to survival. RESULTS A complete remission (CR) was achieved in 97 patients (31%), 21% died prior to a response, and 49% were refractory to salvage therapy. Of the 76 patients refractory to induction therapy for their de novo ALL, 26 patients (34%) achieved a CR with salvage therapy. The median overall CR duration was 6 months. The median overall survival was 5 months; 24% of the patients were alive at 1 year, and the projected survival at 5 years was 3%. Nineteen patients were alive at the time of last follow-up, 10 with 6 weeks to 10 years of continuous CR from the time of their first salvage therapy. SCT consolidation in second CR was performed in 25% of patients; 28% of those who received allogeneic SCT remain in continuous CR at 4 months, 2(1/2) years, 3(1/2) years, and 10 years, whereas all 8 who received autologous SCT have relapsed. Favorable factors for longer survival by multivariate analysis were age <40 years, absence of circulating blasts, and first CR duration longer than 1 year. Patients were stratified into 4 risk groups: Group 1, with no unfavorable features or only short initial CR duration; Group 2, with only increased age or peripheral blasts; Group 3, with any 2 unfavorable features; and Group 4, with all 3 unfavorable features. The median survival times for each group were 11, 6, 4, and 2 months, respectively; 1-year survival rates were 44%, 25%, 12%, and 9%, respectively (P < 0.01). The resulting model was also predictive for CR rates; the corresponding CR rates were 47%, 35%, 14%, and 9%, respectively (P < 0.01). CONCLUSIONS Salvage therapy for adult ALL patients continues to yield poor results, but it is an area of research where it may be possible to discover new agents or strategies to be incorporated into frontline therapy. The prognostic model derived will be utilized prospectively to select patients for new therapeutic strategies involving such novel agents as liposomal compounds, purine nucleoside phosphorylase inhibitors, and monoclonal antibodies.
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Affiliation(s)
- D A Thomas
- Department of Leukemia, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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27
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Abstract
Autologous bone marrow transplantation can induce long-term LFS in 20% to 40% of patients with relapsed acute leukemia and should be considered as salvage therapy for patients who lack an HLA-matched donor and for patients over 45. Adult ALL patients and children with ALL in extramedullary relapse beyond second CR should receive alloBMT if at all possible. The role of ABMT in acute leukemia patients in first CR remains unclear despite randomized trials (Table 2). Because protocol deviations, early relapse, and inappropriately high treatment-related mortality unequally affected the ABMT cohort, and because recent randomized trials have used old purging methodologies, it is not possible to conclude that ABMT is not beneficial. More recent studies show that most patients are able to proceed with the intended ABMT and that modern purging may be associated with a treatment-related mortality rate of less then 5%. Immunomodulation and graft engineering uniquely suited to autologous progenitor cells indicate that ABMT should continue to be studied in the management of acute leukemia.
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Affiliation(s)
- B Spellberg
- Department of Medicine, Harbor-University of California Los Angeles Medical Center, USA
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28
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Cortes JE, Kantarjian HM, O'Brien S, Giles F, Keating MJ, Freireich EJ, Estey EH. A pilot study of interleukin-2 for adult patients with acute myelogenous leukemia in first complete remission. Cancer 1999. [DOI: 10.1002/(sici)1097-0142(19990401)85:7<1506::aid-cncr11>3.0.co;2-o] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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29
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Affiliation(s)
- D Blaise
- Cellular Therapy and Hematology Unit, Institut Paoli Calmettes, Marseille, France
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30
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Maraninchi D, Vey N, Viens P, Stoppa AM, Archimbaud E, Attal M, Baume D, Bouabdallah R, Demeoq F, Fleury J, Michallet M, Olive D, Reiffers J, Sainty D, Tabilio A, Tiberghien P, Brandely M, Hercend T, Blaise D. A phase II study of interleukin-2 in 49 patients with relapsed or refractory acute leukemia. Leuk Lymphoma 1998; 31:343-9. [PMID: 9869198 DOI: 10.3109/10428199809059227] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In this report we present the results of a multicenter phase II study of high-dose recombinant Interleukin-2 (rIL-2) in patients with refractory or relapsed acute leukemia. Forty-nine patients with acute myeloid leukemia (AML: 30 patients) or acute lymphoblastic leukemia (ALL: 19 patients) were included. Median age was 30 years (range: 4-71). Four patients were treated for primary refractory disease and 45 for relapsed disease (16 patients > 2nd relapse). Twenty-four patients (49%) had previously received bone marrow transplantation (allogeneic: 5, autologous: 19). Patients were scheduled to receive three 5-day cycles of rIL-2 given every other week. rIL-2 was administered as bolus I.V. infusion of 8 x 10(6) UI/m2 every 8 hours during cycle I and every 12 hours during cycles 2 and 3. Patients received a mean of 76% of rIL-2 planned dose. Main toxicity was hematologic (grade IV thrombopenia: 84%). Hemodynamic and metabolic toxicities lead to treatment discontinuation in 10 patients (20%). Strong immune activation was achieved including a significant increase in activated T-cells and Lymphokine-Activating-Killer cell (LAK) activity. Twenty-seven out of 30 AML patients could be evaluated for response: 2(7%) achieved complete remission (CR) which lasted 3 and 4 months. No response was observed in the 18 assessable ALL patients, most of whom (77 %) presented absolute drug resistance. These results show that this high dose rIL-2 regimen induces significant biological effects and provides some anti-leukemic activity in patients with advanced leukemia. Considering the severe toxicity observed and the limited remission rate achieved here, rIL-2 does not appear to be a valuable therapeutic option for such patients. However, the undoubted anti-leukemic activity of this cytokine invites further investigation especially in the minimal residual disease situation.
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Affiliation(s)
- D Maraninchi
- Institut Paoli-Calmettes and INSERM Unit 119, Marseille, France
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31
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Immune Reconstitution and Immunotherapy After Autologous Hematopoietic Stem Cell Transplantation. Blood 1998. [DOI: 10.1182/blood.v92.5.1471] [Citation(s) in RCA: 233] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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