Biology:Adoptive cell transfer

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Adoptive cell transfer (ACT) is the transfer of cells into a patient.[1] The cells may have originated from the patient or from another individual. The cells are most commonly derived from the immune system with the goal of improving immune functionality and characteristics. In autologous cancer immunotherapy, T cells are extracted from the patient, genetically modified and cultured in vitro and returned to the same patient. Comparatively, allogeneic therapies involve cells isolated and expanded from a donor separate from the patient receiving the cells.[2]

History

In the 1960s, lymphocytes were discovered to be the mediators of allograft rejection in animals. Attempts to use T cells to treat transplanted murine tumors required cultivating and manipulating T cells in culture. Syngeneic lymphocytes were transferred from rodents heavily immunized against the tumor to inhibit growth of small established tumors, becoming the first example of ACT.[3]

Description of T cell growth factor interleukin-2 (IL-2) in 1976 allowed T lymphocytes to be grown in vitro, often without loss of effector functions. High doses of IL-2 could inhibit tumor growth in mice. 1982, studies demonstrated that intravenous immune lymphocytes could treat bulky subcutaneous FBL3 lymphomas. Administration of IL-2 after cell transfer enhanced therapeutic potential.[3]

In 1985 IL-2 administration produced durable tumor regressions in some patients with metastatic melanoma. Lymphocytes infiltrating the stroma of growing, transplantable tumors provided a concentrated source of tumor-infiltrating lymphocytes (TIL) and could stimulate regression of established lung and liver tumors. In 1986, human TILs from resected melanomas were found to contain cells that could recognize autologous tumors. In 1988 autologous TILs were shown to reduce metastatic melanoma tumors.[3] Tumor-derived TILs are generally mixtures of CD8+ and CD4+ T cells with few major contaminating cells.[3]

In 1989 Zelig Eshhar published the first study in which a T cell's targeting receptor was replaced, and noted that this could be used to direct T cells to attack any kind of cell; this is the essential biotechnology underlying CAR-T therapy.[4]

Responses were often of short duration and faded days after administration. In 2002, lymphodepletion using a nonmyeloablative chemotherapy regimen administered immediately before TIL transfer increased cancer regression, as well as the persistent oligoclonal repopulation of the host with the transferred lymphocytes. In some patients, the administered antitumor cells represented up to 80% of the CD8+ T cells months after the infusion.[3]

Initially, melanoma was the only cancer that reproducibly yielded useful TIL cultures. In 2006 administration of normal circulating lymphocytes transduced with a retrovirus encoding a T-cell receptor (TCR) that recognized the MART-1 melanoma-melanocyte antigen, mediated tumor regression. In 2010 administration of lymphocytes genetically engineered to express a chimeric antibody receptor (CAR) against B cell antigen CD19 was shown to mediate regression of an advanced B cell lymphoma.[3]

By 2010, doctors had begun experimental treatments for leukemia patients using CD19-targeted T cells with added DNA to stimulate cell division. As of 2015 trials had treated about 350 leukemia and lymphoma patients. Antigen CD19 appears only on B cells, which go awry in lymphoma and leukemia. Loss of B cells can be countered with immunoglobulin.[4]

Startups including Juno Therapeutics exploit the combination of aggressive tumors and FDA willingness to approve potential therapies for such ailments to accelerate approvals for new therapies.[4]

In checkpoint therapy, antibodies bind to molecules involved in T-cell regulation to remove inhibitory pathways that block T-cell responses, known as immune checkpoint therapy.[4]

As of 2015 the technique had expanded to treat cervical cancer, lymphoma, leukemia, bile duct cancer and neuroblastoma[3] and in 2016, lung cancer, breast cancer, sarcoma and melanoma.[5] In 2016, CD19-specific chimeric antigen receptor (CAR)-modified T cells were used to treat patients with relapsed and refractory CD19+ B cell malignancies, including B cell acute lymphoblastic leukemia (B-ALL) harboring rearrangement of the mixed lineage leukemia (MLL) gene with CD19 CAR-T cells.[6]

In 2016, researchers developed a technique that used cancer cells' RNA to produce T cells and an immune response. They encased the RNA in a negatively charged fatty membrane. In vivo, this electrical charge guided the particles towards the patient's dendritic immune cells that specify immune system targets.[7]

In 2017, researchers announced the first use of donor cells (rather than the patients' own cells) to defeat leukemia in two infants for whom other treatments had failed. The cells had four genetic modifications. Two were made using TALENs. One changed the cells so that they did not attack all the cells of another person. Another modification made tumor cells their target.[8]

Process

In melanoma, a resected melanoma specimen is digested into a single-cell suspension or divided into multiple tumor fragments. The result is individually grown in IL-2. Lymphocytes overgrow. They destroy the tumors in the sample within 2 to 3 weeks. They then produce pure cultures of lymphocytes that can be tested for reactivity against other tumors, in coculture assays. Individual cultures are then expanded in the presence of IL-2 and excess irradiated anti-CD3 antibodies. The latter targets the epsilon subunit within the human CD3 complex of the TCR. 5–6 weeks after resecting the tumor, up to 1011 lymphocytes can be obtained.[3]

Prior to infusion, a lymphodepleting preparative regimen is undergone, typically 60 mg/kg cyclophosphamide for 2 days and 25 mg/m2 fludarabine administered for 5 days. This substantially increases infused cell persistence and the incidence and duration of clinical responses. Then cells and IL-2 at 720,000 IU/kg to tolerance are infused.[3]

Interleukin-21 may play an important role in enhancing the efficacy of T cell based in vitro therapies.

In early trials, preparing engineered T cells cost $75,000 to manufacture cells for each patient.[4]

Interleukin-2 is normally added to the extracted T cells to boost their effectiveness, but in high doses it can have a toxic effect. The reduced number of injected T cells is accompanied by reduced IL-2, thereby reducing side effects. In vitro tests on melanoma and kidney cancer models met expectations.[9]

In 2016 Strep-tag II sequences were introduced into synthetic CAR or natural T-cell receptors to serve as a marker for identification, rapid purification, tailoring spacer length for optimal function and selective, antibody-coated, microbead-driven, large-scale expansion. This facilitates cGMP manufacturing of pure populations of engineered T cells and enables in vivo tracking and retrieval of transferred cells for downstream research applications.[10]

Genetic engineering

Antitumor receptors genetically engineered into normal T cells can be used for therapy. T cells can be redirected by the integration of genes encoding either conventional alpha-beta TCRs or CARs. CARs (Chimeric Antibody Receptors) were pioneered in the late 1980s and can be constructed by linking the variable regions of the antibody heavy and light chains to intracellular signaling chains such as CD3-zeta, potentially including costimulatory domains encoding CD28 or CD137. CARs can provide recognition of cell surface components not restricted to major histocompatibility complexes (MHC). They can be introduced into T cells with high efficiency using viral vectors.[3][11]

Correlations between T cell differentiation status, cellular persistence, and treatment outcomes

Improved antitumor responses have been seen in mouse and monkey models using T cells in early differentiation stages (such as naïve or central memory cells). CD8+ T cells follow a progressive pathway of differentiation from naïve T cells into stem cell memory, central memory, effector memory, and ultimately terminally differentiated effector T cell populations.[12] CD8+ T cells paradoxically lose antitumor power as they acquire the ability to lyse target cells and to produce the cytokine interferon-γ, qualities otherwise thought to be important for antitumor efficacy.[13][14] Differentiation state is inversely related to proliferation and persistence. Age is negatively correlated with clinical effectiveness. CD8+ T cells can exist in a stem cell–like state, capable of clonal proliferation. Human T memory stem cells express a gene program that enables them to proliferate extensively and differentiate into other T cell populations.[3]

CD4+ T cells can also promote tumor rejection. CD4+ T cells enhance CD8+ T cell function and can directly destroy tumor cells. Evidence suggests that T helper 17 cells can promote sustained antitumor immunity.[3][15][16]

Intrinsic (Intracellular) checkpoint blockade

Other modes of enhancing immuno-therapy include targeting so-called intrinsic immune checkpoint blockades. Many of these intrinsic regulators include molecules with ubiquitin ligase activity, including CBLB. More recently, CISH, another molecule with ubiquitin ligase activity, was found to be induced by T cell receptor ligation (TCR) and negatively regulate it by targeting the critical signaling intermediate PLC-gamma-1 for degradation.[17] The deletion of CISH in effector T cells has been shown to dramatically augment TCR signaling and subsequent effector cytokine release, proliferation and survival. The adoptive transfer of tumor-specific effector T cells knocked out or knocked down for CISH resulted in a significant increase in functional avidity and long-term tumor immunity. Surprisingly there was no changes in activity of Cish's purported target, STAT5. Thus Cish represents a new class of T-cell intrinsic immunologic checkpoints with the potential to enhance adoptive immunotherapies for cancer.[18][19][20]

Context

Neither tumor bulk nor metastasis site affect the likelihood of achieving a complete cancer regression. Of 34 complete responders in two trials, one recurred. Only one patient with complete regression received more than one treatment. Prior treatment with targeted therapy using Braf inhibitor vemurafenib (Zelboraf) did not affect the likelihood that melanoma patients would experience an objective response. Prior failed immunotherapies did not reduce the odds of objective response.[citation needed]

Stem cells

An emerging treatment modality for various diseases is the transfer of stem cells.[21] Clinically, this approach has been exploited to transfer either immune-promoting or tolerogenic cells (often lymphocytes) to either enhance immunity against viruses and cancer[22][23][24] or to promote tolerance in the setting of autoimmune disease,[25] such as Type I diabetes or rheumatoid arthritis. Cells used in adoptive therapy may be genetically modified using recombinant DNA technology. One example of this in the case of T cell adoptive therapy is the addition of CARs to redirect the specificity of cytotoxic and helper T cells.[citation needed]

Applications

Cancer

The adoptive transfer of autologous tumor infiltrating lymphocytes (TIL)[26][27][28] or genetically re-directed peripheral blood mononuclear cells[29][30] has been used experimentally to treat patients with advanced solid tumors, including melanoma and colorectal carcinoma, as well as patients with CD19-expressing hematologic malignancies,[31] cervical cancer, lymphoma, leukemia, bile duct cancer and neuroblastoma,[3] lung cancer, breast cancer, sarcoma, melanoma,[5] relapsed and refractory CD19+ B cell malignancies, including B cell acute lymphoblastic leukemia (B-ALL) harboring rearrangement of the mixed lineage leukemia (MLL).[6]

Autoimmune disease

The transfer of regulatory T cells has been used to treat Type 1 diabetes and others.[25]

Trial results

Trials began in the 1990s and accelerated beginning in 2010.[3]

Cells Year Cancer histology Molecular target Patients Number of ORs Comments
Tumor-infiltrating lymphocytes* 1998 Melanoma 20 55% Original use TIL ACT
1994 Melanoma 86 34%
2002 Melanoma 13 46% Lymphodepletion before cell transfer
2011 Melanoma 93 56% 20% CR beyond 5 years
2012 Melanoma 31 48%
2012 Melanoma 13 38% Intention to treat: 26% OR rate
2013 Melanoma 57 40% Intention to treat: 29% OR rate
2014 Cervical cancer 9 22% Probably targeting HPV antigens
2014 Bile duct Mutated ERB2 1 – Selected to target a somatic mutation
In vitro sensitization 2008 Melanoma NY-ESO-1 9 33% Clones reactive against cancer-testes antigens
2014 Leukemia WT-1 11 – Many treated at high risk for relapse
Genetically engineered with CARs 2010 Lymphoma CD19 1 100% First use of anti-CD19 CAR
2011 CLL CD19 3 100% Lentivirus used for transduction
2013 ALL CD19 5 100% Four of five then underwent allo-HSCT
2014 ALL CD19 30 90% CR in 90%
2014 Lymphoma 15 80% Four of seven CR in DLBCL
2014 ALL CD19 16 88% Many moved to allo-HSCT
2014 ALL CD19 21 67% Dose-escalation study
2011 Neuroblastoma GD2 11 27% CR2 CARs into EBV-reactive cells
2016 ALL CD19 30 93% J Clin Invest. 2016;126(6):2123–2138.
Genetically engineered with TCRs 2011 Synovial sarcoma NY-ESO-1 6 67% First report targeting nonmelanoma solid tumor
2006 Melanoma MART-1 11 45%

Solid tumors

Several ongoing clinical trials of adoptive cell therapies are ongoing in solid tumors, but challenges in the development of such therapies for this type of malignancy include the lack of surface antigens that are not found on essential normal tissues,[11] difficult-to-penetrate tumor stroma, and factors in the tumor microenvironment that impede the activity of the immune system.[32]

Safety

Toxicity

Targeting normal, nonmutated antigenic targets that are expressed on normal tissues, but overexpressed on tumors has led to severe on-target, off-tumor toxicity. Toxicity was encountered in patients who received high-avidity TCRs that recognized either the MART-1 or gp100 melanoma-melanocyte antigens, in mice when targeting melanocyte antigens, in patients with renal cancer using a CAR targeting carbonic anhydrase 9 and in patients with metastatic colorectal cancer.[3]

Toxicities can also result when previously unknown cross-reactivities are seen that target normal self-proteins expressed in vital organs. Cancer-testes antigen MAGE-A3 is not known to be expressed in any normal tissues. However, targeting an HLA-A*0201–restricted peptide in MAGE-A3 caused severe damage to gray matter in the brain, because this TCR also recognized a different but related epitope that is expressed at low levels in the brain. That CARs are potentially toxic to self-antigens was observed after infusion of CAR T cells specific for ERBB2. Two patients died when treated with an HLA-A1–restricted MAGE-A3–specific TCR whose affinity was enhanced by a site-specific mutagenesis.[3]

Cancer-testis antigens are a family of intracellular proteins that are expressed during fetal development, but with little expression in normal adult tissues. More than 100 such molecules are epigenetically up-regulated in from 10 to 80% of cancer types. However, they lack high levels of protein expression. Approximately 10% of common cancers appear to express enough protein to be of interest for antitumor T cells. Low levels of some cancer-testes antigens are expressed in normal tissues, with associated toxicities. The NYESO-1 cancer-testes antigen has been targeted via a human TCR transduced into autologous cells. ORs were seen in 5 of 11 patients with metastatic melanoma and 4 of 6 patients with highly refractory synovial cell sarcoma.[3]

"Suicide switches" let doctors kill engineered T cells in emergencies which threaten patient survival.[4]

Cytokine release syndrome

Cytokine release syndrome is another side effect and can be a function of therapeutic effectiveness. As the tumor is destroyed, it releases large quantities of cell signaling protein molecules. This effect killed at least seven patients.[4]

B cells

Molecules shared among tumors and nonessential normal organs represent potential ACT targets, despite the related toxicity. For example, the CD19 molecule is expressed on more than 90% of B cell malignancies and on non-plasma B cells at all differentiation stages and has been successfully used to treat patients with follicular lymphoma, large-cell lymphomas, chronic lymphocytic leukemia and acute lymphoblastic leukemia. Toxicity against CD19 results in B cell loss in circulation and in bone marrow that can be overcome by periodic immunoglobulin infusions.[3]

Multiple other B cell antigens are being studied as targets, including CD22, CD23, ROR-1 and the immunoglobulin light-chain idiotype expressed by the individual cancer. CARs targeting either CD33 or CD123 have been studied as a therapy for patients with acute myeloid leukemia, though the expression of these molecules on normal precursors can lead to prolonged myeloablation. BCMA is a tumor necrosis factor receptor family protein expressed on mature B cells and plasma cells and can be targeted on multiple myeloma.[3]

References

  1. ↑ "Minimally cultured tumor-infiltrating lymphocytes display optimal characteristics for adoptive cell therapy". Journal of Immunotherapy 31 (8): 742–51. October 2008. doi:10.1097/CJI.0b013e31818403d5. PMID 18779745. 
  2. ↑ "Allogeneic adoptive cell transfer therapy as a potent universal treatment for cancer". Oncotarget 2 (7): 525–6. 2011. doi:10.18632/oncotarget.300. PMID 21719916. 
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 "Adoptive cell transfer as personalized immunotherapy for human cancer". Science 348 (6230): 62–8. April 2015. doi:10.1126/science.aaa4967. PMID 25838374. Bibcode: 2015Sci...348...62R. 
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Regalado, Antonio (June 18, 2015). "Biotech's Coming Cancer Cure". Technology Review. http://www.technologyreview.com/featuredstory/538441/biotechs-coming-cancer-cure. 
  5. ↑ 5.0 5.1 "Dramatic remissions in blood cancer in immunotherapy treatment trial". March 10, 2016. http://www.kurzweilai.net/dramatic-remissions-in-blood-cancer-in-immunotherapy-treatment-trial. [unreliable medical source?]
  6. ↑ 6.0 6.1 "Acquisition of a CD19-negative myeloid phenotype allows immune escape of MLL-rearranged B-ALL from CD19 CAR-T-cell therapy". Blood 127 (20): 2406–10. May 2016. doi:10.1182/blood-2015-08-665547. PMID 26907630. 
  7. ↑ "Systemic RNA delivery to dendritic cells exploits antiviral defence for cancer immunotherapy". Nature 534 (7607): 396–401. June 2016. doi:10.1038/nature18300. PMID 27281205. Bibcode: 2016Natur.534..396K. 
  8. ↑ Regalado, Antonio. "Two infants treated with universal immune cells have their cancer vanish" (in en). MIT Technology Review. https://www.technologyreview.com/s/603502/two-infants-treated-with-universal-immune-cells-have-their-cancer-vanish/. 
  9. ↑ "Chitosan thermogels for local expansion and delivery of tumor-specific T lymphocytes towards enhanced cancer immunotherapies". Biomaterials 75: 237–249. January 2016. doi:10.1016/j.biomaterials.2015.10.021. PMID 26513416. http://espace2.etsmtl.ca/id/eprint/11779/1/Lerouge%20S.%202016%2011779%20Chitosan%20thermogels%20for%20local%20expansion.pdf. 
  10. ↑ "Inclusion of Strep-tag II in design of antigen receptors for T-cell immunotherapy". Nature Biotechnology 34 (4): 430–4. April 2016. doi:10.1038/nbt.3461. PMID 26900664. 
  11. ↑ 11.0 11.1 "Prospects for gene-engineered T cell immunotherapy for solid cancers". Nature Medicine 22 (1): 26–36. January 2016. doi:10.1038/nm.4015. PMID 26735408. PMC 6295670. https://zenodo.org/record/1233455. 
  12. ↑ "Lineage relationship of CD8(+) T cell subsets is revealed by progressive changes in the epigenetic landscape". Cellular & Molecular Immunology 13 (4): 502–13. July 2016. doi:10.1038/cmi.2015.32. PMID 25914936. 
  13. ↑ "A human memory T cell subset with stem cell-like properties". Nature Medicine 17 (10): 1290–7. September 2011. doi:10.1038/nm.2446. PMID 21926977. 
  14. ↑ "Acquisition of full effector function in vitro paradoxically impairs the in vivo antitumor efficacy of adoptively transferred CD8+ T cells". The Journal of Clinical Investigation 115 (6): 1616–26. June 2005. doi:10.1172/JCI24480. PMID 15931392. 
  15. ↑ "Th17 cells are long lived and retain a stem cell-like molecular signature". Immunity 35 (6): 972–85. December 2011. doi:10.1016/j.immuni.2011.09.019. PMID 22177921. 
  16. ↑ "Tumor-specific Th17-polarized cells eradicate large established melanoma". Blood 112 (2): 362–73. July 2008. doi:10.1182/blood-2007-11-120998. PMID 18354038. 
  17. ↑ "Cish actively silences TCR signaling in CD8+ T cells to maintain tumor tolerance". The Journal of Experimental Medicine 212 (12): 2095–113. November 2015. doi:10.1084/jem.20150304. PMID 26527801. 
  18. ↑ "The Cish SH2 domain is essential for PLC-γ1 regulation in TCR stimulated CD8+ T cells". Scientific Reports 8 (1): 5336. March 2018. doi:10.1038/s41598-018-23549-2. PMID 29593227. Bibcode: 2018NatSR...8.5336G. 
  19. ↑ "Cish actively silences TCR signaling in CD8+ T cells to maintain tumor tolerance". The Journal of Experimental Medicine 212 (12): 2095–113. November 2015. doi:10.1084/jem.20150304. PMID 26527801. 
  20. ↑ Palmer DC, Webber BR, Patel Y, Johnson MJ, Kariya CM, Lahr WS, Parkhurst MR, Gartner JJ, Prickett TD, Lowery FJ, Kishton RJ (2020-09-25). "Internal checkpoint regulates T cell neoantigen reactivity and susceptibility to PD1 blockade". bioRxiv 10.1101/2020.09.24.306571.
  21. ↑ "Paths to stemness: building the ultimate antitumour T cell". Nature Reviews. Cancer 12 (10): 671–84. October 2012. doi:10.1038/nrc3322. PMID 22996603. 
  22. ↑ "Adoptive immunotherapy for cancer: building on success". Nature Reviews. Immunology 6 (5): 383–93. May 2006. doi:10.1038/nri1842. PMID 16622476. 
  23. ↑ "Adoptive T cell therapy for cancer in the clinic". The Journal of Clinical Investigation 117 (6): 1466–76. June 2007. doi:10.1172/JCI32446. PMID 17549249. 
  24. ↑ "T cell receptor gene therapy for cancer". Human Gene Therapy 20 (11): 1240–8. November 2009. doi:10.1089/hum.2009.146. PMID 19702439. 
  25. ↑ 25.0 25.1 "Human T regulatory cell therapy: take a billion or so and call me in the morning". Immunity 30 (5): 656–65. May 2009. doi:10.1016/j.immuni.2009.04.006. PMID 19464988. 
  26. ↑ "Clinical responses in a phase II study using adoptive transfer of short-term cultured tumor infiltration lymphocytes in metastatic melanoma patients". Clinical Cancer Research 16 (9): 2646–55. May 2010. doi:10.1158/1078-0432.CCR-10-0041. PMID 20406835. 
  27. ↑ "Cancer regression and autoimmunity in patients after clonal repopulation with antitumor lymphocytes". Science 298 (5594): 850–4. October 2002. doi:10.1126/science.1076514. PMID 12242449. Bibcode: 2002Sci...298..850D. 
  28. ↑ "Adoptive cell transfer therapy following non-myeloablative but lymphodepleting chemotherapy for the treatment of patients with refractory metastatic melanoma". Journal of Clinical Oncology 23 (10): 2346–57. April 2005. doi:10.1200/JCO.2005.00.240. PMID 15800326. 
  29. ↑ "Gene therapy with human and mouse T-cell receptors mediates cancer regression and targets normal tissues expressing cognate antigen". Blood 114 (3): 535–46. July 2009. doi:10.1182/blood-2009-03-211714. PMID 19451549. 
  30. ↑ "Cancer regression in patients after transfer of genetically engineered lymphocytes". Science 314 (5796): 126–9. October 2006. doi:10.1126/science.1129003. PMID 16946036. Bibcode: 2006Sci...314..126M. 
  31. ↑ "T cells with chimeric antigen receptors have potent antitumor effects and can establish memory in patients with advanced leukemia". Science Translational Medicine 3 (95): 95ra73. August 2011. doi:10.1126/scitranslmed.3002842. PMID 21832238. 
  32. ↑ "CAR T cells for solid tumors: armed and ready to go?". Cancer Journal 20 (2): 151–5. 2014-01-01. doi:10.1097/PPO.0000000000000032. PMID 24667962. 

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