Immunobiology and immunotherapy of leukemia

白血病的免疫生物学和免疫治疗

• 批准号: 8939873
• 负责人: Austin John Barrett
• 金额: $ 135.38万
• 依托单位: NATIONAL HEART, LUNG, AND BLOOD INSTITUTE
• 依托单位国家: 美国
• 资助国家: 美国
• 起止时间: 至
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/8939873
• 关键词: Acute Myelocytic Leukemia; Acute leukemia; Address; Adverse effects; Agranulocytosis; Allogenic; Anemia; Antibodies; Area; Autologous; Biological; Blast Cell; CD34 gene; CD8B1 gene; CDW52 gene; Cell Therapy; Cell physiology; Cells; Chemotherapy-Oncologic Procedure; Chronic Myeloid Leukemia; Chronic Phase; Clinical; Clinical Trials; Clofarabine; Collaborations; Cytotoxic T-Lymphocytes; Development; Diagnosis; Disease; Disease Progression; Disease remission; Donor person; Dose; Dysmyelopoietic Syndromes; Effector Cell; Enrollment; Erythropoiesis; Failure; Genetic; Growth Factor; Hematopoiesis; Hematopoietic; Hematopoietic stem cells; Imatinib; Immune; Immune response; Immune system; Immunobiology; Immunologic Surveillance; Immunosuppression; Immunosuppressive Agents; Immunotherapeutic agent; Immunotherapy; Incubated; Investigation; Large granular lymphocyte; Late Effects; Leukemia in Remission; Leukemic Cell; Life; Light; Link; Lymphocyte; Lymphoproliferative Disorders; Maintenance; Malignant - descriptor; Mediating; Memory; Monoclonal Antibodies; Multivariate Analysis; Myelogenous; Myelopoiesis; Myeloproliferative disease; National Heart, Lung, and Blood Institute; Natural Increases; Natural Killer Cells; Neutropenia; Normal Cell; Outcome; Outcome Study; Pancytopenia; Pathway interactions; Patients; Peptide Library; Peptides; Phase; Plasma; Population; Prognostic Factor; Proteins; Recovery; Recurrence; Regulatory T-Lymphocyte; Relapse; Remission Induction; Reporting; Research; Research Personnel; Residual Tumors; Resistance; Sampling; Siblings; Stem cell transplant; Stem cells; Study models; Supportive care; Suppressor-Effector T-Lymphocytes; T cell response; T cell therapy; T memory cell; T-Lymphocyte; T-Lymphocyte and Natural Killer Cell; Testing; Time; Transcript; Transplantation; Tyrosine Kinase Inhibitor; University Hospitals; Vaccines; advanced disease; alemtuzumab; base; bcr-abl Fusion Proteins; burden of illness; cancer cell; chemotherapy; cohort; combinatorial; cytokine; cytotoxic; design; exhaustion; follow-up; graft vs leukemia effect; healthy volunteer; high risk; immune function; killer inhibitory receptor; lenalidomide; leukemia; leukemic stem cell; outcome forecast; prevent; progenitor; prospective; receptor; response

1) CML: The advent of TkI has transformed CML treatment, but while targeted treatment is highly effective at reducing disease burden to minimal levels, it is not a reliable curative approach. Continuing investigations explore potential of using leukemia vaccines to eradicate residual disease and eliminate the need for continued TkI treatment. Resistance of CML stem cells to the GVL effect: Late relapse occurring in the second decade after SCT is a particular problem for patients with CML. Recurrence after a long period of disease quiescence suggests that in CML disease is never eradicated but is mostly effectively suppressed by a continuing long-lived GVL effect. To better define clinical and biological parameters determining post-relapse outcome, we studied 59 patients with CML relapsing after HLA-identical sibling allo-SCT between 1993 and 2008. Eighteen (30.5%) were transplanted in advanced phase and 41(69.5%) in chronic phase. At a median follow up from relapse of 7.9 years, 5-year post-relapse survival (PRS) was 62%. Multivariate analysis found disease status at transplant, time to diagnosis of relapse from transplant, and pre- transplant TKI use as significant factors associated with PRS. Analysis of BCR-ABL transcript expression in the hematopoietic progenitor compartment was performed in 36 patients (22 relapsed, 8 non-relapsed, and 6 TKI alone controls). Patients with BCR-ABL expression in their early hematopoietic stem cell compartment (HSC: Lineage-CD34+CD38-CD90+) had worse survival irrespective of the disease status. These findings demonstrate that disease status remains the strongest clinical prognostic factor for PRS in CML following allo-SCT. The persistence of BCR-ABL expression in the progenitor cell compartment in some patients after SCT emphasizes the need to develop new immune strategies to target CML-leukemia stem cells. 2) Acute Myeloblastic Leukemia: Both NK cells and T lymphocytes are cytotoxic to AML cells. Clinical evidence for immune control of AML comes from the observation of a strong GVL effect of allogeneic SCT, and several observations linking rapid lymphocyte recovery after chemotherapy-induced remission with relapse free survival. The inability of chemotherapy to maintain remission, once achieved, has stimulated investigators to apply immunotherapeutic approaches to patients in remission. Many immunotherapeutic strategies are currently being explored, including antileukemic antibodies, leukemia specific vaccines, growth factors, cell therapy with NK cells and immunomodulatory agents such as lenalidomide, and 5-AZA. However many questions need need to be answered before rational immunotherapy can be applied to AML. NK cells in myeloid malignancies: Dr Kate Stringaris has completed studies of natural killer (NK) cell immune function in acute myelogenous leukemia: In 32 AML patients undergoing remission induction chemotherapy patients were found to have reduced NK activatory receptors, increased NK inhibitory receptors, and reduced cytotoxic function towards leukaemia, compared to healthy donors. These abnormalities corresponded with failure to achieve remission and could be induced in normal NK incubated with AML blasts. These results indicate that KIR genetics have a limited influence on AML development and outcome but that AML can impair NK function, reducing the chance of achieving remission. These findings have implications for NK based immunotherapy for AML. Immune profiling in AML: To explore T cell function in AML we established A collaboration with Dr Stephen Strickland, (Vanderbilt University Hospital, Nashville TN) to study immune profile of patients with AML at presentation, after remission induction, and at relapse. We hypothesize that immune function is compromised by the leukemia through one or more mechanisms that suppress T cell responses. We have analyzed 30 patients. We found an increase in T reg cells at presentation and remission and the occurrence of AML blasts with myeloid-derived suppressor cell function suggesting that immune responses to AML may be blunted by a negative immune milieu. Levels of IL-27 are strongly elevated in AML and patients failing to enter remission had the highest and most persistent elevations in IL-27. These findings suggest that AML blunts the T cell response by an IL27 mediated induction of regulatory T cells and a concomittent exhaustion of effector T cells. We also analyzed the potential of patients with AML in remission to generate LAA specific T cells. In comparison with their HLA identical stem cell transplant donors patients possess a comparable but different repertoire of cytotoxic T cells recognizing a panel of LAA. These findings support the development of LAA-specific T cell in the autologous setting to maintain remission in AML patients. Ultimately these studies should identify protective immune mechanisms in AML that inform rational immunotherapy with cytokine treatment or adoptive NK or T cell therapy. 3) MDS: The interaction of T cells with MDS cells remains a model for studying the immune response to a myeloid malignancy. We have shown in prior reports that patients with low grade MDS can respond to immunosuppressive treatment with monoclonal anti T cell antibodies. We have now addressed the problem of MDS patients with more advanced disease in transformation to AML who do not respond to immunosuppression. These patients have a poor prognosis. A clinical trial (12-H-0146) Clofarabine Followed by Lenalidomide for Treatment of High Risk Myelodysplastic Syndromes and Acute Myeloid Leukemia is ongoing and has accrued five patients. 4) Large granular lymphoproliferative disease (LGL): is a bone marrow failure disorder caused by an expanded large granular lymphocyte CD8 T cell clone or clones. Patients may have erythrocytopenia, granulocytopenia or both. Initial clinical trials at NHLBI showed that patients with LGL can recover from neutropenia or anemia using treatment with CSA. We showed that the LGL clone was distributed across central memory, effector-memory and a CD57+ effector cell suggesting that the true progenitor is a central memory T cell. To explore whether more intensive immunosuppression would be more effective at restoring hematopoiesis, we initiated a phase II non-randomized trial of the immunosuppressive monoclonal antibody alemtuzemab (anti CD52) in LGL (www.clinicaltrials.gov - NCT00345345). Twenty consecutive subjects with T-LGL were enrolled. After a 1 mg test dose, alemtuzumab was administered at 10 mg/dose/day intravenously for 10 days. At 3 months 11/20 subjects had a hematological response. Treatment with alemtuzumab produced sustained reduction of both CD57+ and CD57- T-cytotoxic lymphocytes, but the abnormal clone persisted in responders. When compared with healthy volunteers T-LGL subjects had a distinct plasma cytokine signature as well as JAK-STAT pathway activation prior to treatment but neither was correlated to clinical responses to alemtuzumab, likely due to the diversity of prior treatments. This is the largest and only prospective cohort of T-LGL subjects treated with alemtuzumab reported. Treatment was well tolerated with minimal side effects. The 55% overall response rate (73% in typical T-LGL) represents an effective and safe treatment for this condition. Clonal LGL samples are being screened against a combinatorial peptide library to identify the cognate peptides and attempt to identify the target protein of the LGL clone (collaboration with Dr M Wooldridge, Cardiff, UK). Understanding how the LGL T cell suppresses myelopoiesis and erythropoiesis may shed light on the mechanism of suppression of both normal and leukemic cells by cytotoxic T cell populations.

1) CML：TkI 的出现改变了 CML 的治疗方法，但虽然靶向治疗在将疾病负担降至最低水平方面非常有效，但它并不是一种可靠的治疗方法。持续的研究探索使用白血病疫苗消除残留疾病并消除持续 TkI 治疗的需要的潜力。 CML 干细胞对 GVL 效应的抵抗：SCT 后第二个十年发生的晚期复发对于 CML 患者来说是一个特殊的问题。疾病长期静止后的复发表明，CML 疾病从未被根除，但大多被持续的长期 GVL 效应有效抑制。为了更好地定义决定复发后结果的临床和生物学参数，我们研究了 1993 年至 2008 年间 59 例 HLA 相合同胞同种异体 SCT 后复发的 CML 患者。其中 18 例 (30.5%) 进行了晚期移植，41 例 (69.5%) 进行了晚期移植。慢性期。复发后的中位随访时间为 7.9 年，复发后 5 年生存率 (PRS) 为 62%。多变量分析发现移植时的疾病状态、诊断移植复发的时间以及移植前 TKI 的使用是与 PRS 相关的重要因素。对 36 名患者（22 名复发患者、8 名非复发患者和 6 名单独 TKI 对照）的造血祖细胞区室中的 BCR-ABL 转录物表达进行了分析。无论疾病状态如何，早期造血干细胞区室（HSC：谱系-CD34+CD38-CD90+）中表达 BCR-ABL 的患者的生存率较差。这些发现表明，疾病状态仍然是异基因 SCT 后 CML 中 PRS 的最强临床预后因素。 SCT 后一些患者的祖细胞区室中 BCR-ABL 的持续表达强调需要开发新的免疫策略来靶向 CML 白血病干细胞。 2）急性髓细胞白血病：NK细胞和T淋巴细胞对AML细胞都有细胞毒性。 AML 免疫控制的临床证据来自对同种异体 SCT 强烈 GVL 效应的观察，以及将化疗诱导缓解后淋巴细胞快速恢复与无复发生存联系起来的一些观察结果。一旦达到缓解，化疗无法维持缓解，这促使研究人员将免疫治疗方法应用于缓解患者。目前正在探索许多免疫治疗策略，包括抗白血病抗体、白血病特异性疫苗、生长因子、NK 细胞的细胞治疗以及来那度胺和 5-AZA 等免疫调节剂。然而，在将合理的免疫疗法应用于 AML 之前，还需要回答许多问题。 骨髓恶性肿瘤中的 NK 细胞：Kate Stringaris 博士完成了急性髓性白血病中自然杀伤 (NK) 细胞免疫功能的研究：在 32 名接受缓解诱导化疗的 AML 患者中，发现患者 NK 激活性受体减少，NK 抑制性受体增加，并且与健康捐赠者相比，对白血病的细胞毒性功能降低。这些异常与未能达到缓解相对应，并且可以在与 AML 母细胞一起孵育的正常 NK 中诱导。这些结果表明，KIR 遗传学对 AML 的发展和结果影响有限，但 AML 会损害 NK 功能，降低实现缓解的机会。这些发现对基于 NK 的 AML 免疫疗法具有重要意义。 AML 中的免疫特征分析：为了探索 AML 中的 T 细胞功能，我们与 Stephen Strickland 博士（田纳西州纳什维尔范德比尔特大学医院）建立了合作关系，研究 AML 患者就诊时、诱导缓解后和复发时的免疫特征。我们假设白血病通过一种或多种抑制 T 细胞反应的机制损害免疫功能。我们分析了 30 名患者。我们发现，在出现和缓解时，T reg 细胞有所增加，并且具有骨髓源性抑制细胞功能的 AML 母细胞的出现，表明对 AML 的免疫反应可能会因负面免疫环境而减弱。 AML 中 IL-27 水平大幅升高，未能进入缓解期的患者 IL-27 升高最高且最持久。这些发现表明，AML 通过 IL27 介导的调节性 T 细胞诱导和效应 T 细胞的伴随耗尽来减弱 T 细胞反应。我们还分析了缓解期 AML 患者产生 LAA 特异性 T 细胞的潜力。与 HLA 相同的干细胞移植供体相比，患者拥有可识别一组 LAA 的可比较但不同的细胞毒性 T 细胞库。这些发现支持在自体环境中开发 LAA 特异性 T 细胞以维持 AML 患者的缓解。最终，这些研究应该确定 AML 中的保护性免疫机制，为细胞因子治疗或过继性 NK 或 T 细胞治疗的合理免疫治疗提供信息。 3) MDS：T 细胞与 MDS 细胞的相互作用仍然是研究骨髓恶性肿瘤免疫反应的模型。 我们在之前的报告中已经表明，低度 MDS 患者可以对单克隆抗 T 细胞抗体的免疫抑制治疗产生反应。我们现在已经解决了患有更晚期疾病并转化为 AML 且对免疫抑制无反应的 MDS 患者的问题。这些患者的预后较差。一项临床试验 (12-H-0146) 氯法拉滨继以来那度胺治疗高危骨髓增生异常综合征和急性髓系白血病正在进行中，并已招募了 5 名患者。 4）大颗粒淋巴细胞增殖性疾病（LGL）：是由扩张的大颗粒淋巴细胞CD8 T细胞克隆引起的骨髓衰竭疾病。患者可能患有红细胞减少症、粒细胞减少症或两者兼而有之。 NHLBI 的初步临床试验表明，LGL 患者可以通过 CSA 治疗从中性粒细胞减少症或贫血中恢复。我们发现 LGL 克隆分布在中央记忆、效应记忆和 CD57+ 效应细胞中，表明真正的祖细胞是中央记忆 T 细胞。为了探讨更强的免疫抑制是否会更有效地恢复造血功能，我们在 LGL 中启动了免疫抑制单克隆抗体阿仑单抗（抗 CD52）的 II 期非随机试验（www.clinicaltrials.gov - NCT00345345）。连续二十名患有 T-LGL 的受试者被纳入。 1 mg 测试剂量后，阿仑单抗以 10 mg/剂/天静脉注射，持续 10 天。 3 个月时，11/20 受试者出现血液学反应。阿仑单抗治疗导致 CD57+ 和 CD57- T 细胞毒性淋巴细胞持续减少，但异常克隆在应答者中持续存在。与健康志愿者相比，T-LGL 受试者在治疗前具有独特的血浆细胞因子特征以及 JAK-STAT 通路激活，但两者均与阿仑单抗的临床反应无关，可能是由于先前治疗的多样性。这是报道的最大且唯一的接受阿仑单抗治疗的 T-LGL 受试者前瞻性队列。治疗耐受性良好，副作用最小。 55% 的总体缓解率（典型 T-LGL 为 73%）代表了针对这种情况的有效且安全的治疗方法。 克隆 LGL 样品正在针对组合肽库进行筛选，以鉴定同源肽并尝试鉴定 LGL 克隆的靶蛋白（与英国卡迪夫的 M Wooldridge 博士合作）。了解 LGL T 细胞如何抑制骨髓生成和红细胞生成可能有助于阐明细胞毒性 T 细胞群抑制正常细胞和白血病细胞的机制。