Podcasts about gm csf

In this week's episode we'll discuss new insights on the role of GM-CSF in establishing immune memory. The authors propose that the coordination of opposing immune memory programs, driven by GM-CSF, may be essential to efficient, yet controlled, innate immune responses. After that: Interleukin-1 inhibition in TTP. Researchers explore the potential of recombinant IL-1 receptor antagonist, anakinra, in a murine model of thrombotic thrombocytopenic purpura—an uncommon but potentially fatal disorder with limited therapeutic options. Finally, we'll learn about CAR T-cell therapy outcomes by race and ethnicity in large B-cell lymphoma. Non-Hispanic Black patients had lower rates of response and progression-free survival in axi-cel clinical trials and real-world data, raising awareness and giving further insights into potential inequitable access to care.Featured Articles:GM-CSF receptor expression determines opposing innate memory phenotypes at different stages of myelopoiesis Mortality, cardiac and cerebral damage reduction by IL-1 inhibition in a murine model of TTP Real-World and Clinical Trial Outcomes in Large B-cell Lymphoma with Axicabtagene Ciloleucel Across Race and Ethnicity 

Dr. Diwakar Davar and Dr. Jason Luke discuss advances in the neoadjuvant immunotherapy space that were presented at the 2024 ASCO Annual Meeting, including promising outcomes in high-risk melanoma from the NADINA trial, as well as other new treatment options for patients with advanced cancers.    TRANSCRIPT Dr. Diwakar Davar: Hello and welcome to the ASCO Daily News Podcast. I'm your guest host, Dr. Diwakar Davar, and I am an associate professor of medicine and the clinical director of the Melanoma Skin Cancer Program at the University of Pittsburgh's Hillman Cancer Center. I am delighted to have my colleague and friend Dr. Jason Luke on the podcast today to discuss key late-breaking abstracts and advances in immunotherapy that were presented at the 2024 ASCO Annual Meeting. Dr. Luke is an associate professor of medicine, the associate director of clinical research, and the director of the Cancer Immunotherapeutic Center at the University of Pittsburgh Hillman Cancer Center.   You will find our full disclosures in the transcript of this episode.  Jason, it's always a pleasure to hear your insights on the key trials in these spaces and to have you back as a guest on this podcast that highlights some of the work, especially advances, that were just presented. Dr. Jason Luke: Well, thanks very much for the invitation. I always love joining the podcast. Dr. Diwakar Davar: We'll start very quickly by talking about some advances and really interesting things that happened both in the context of melanoma but also in immunotherapy in general. And we'll start with what I think was certainly one highlight for me, which was LBA2, the late-breaking abstract on the NADINA trial. It was featured in the Plenary Session, and in this abstract, Dr. Christian Blank and colleagues reported on the results of this phase 3 trial of neoadjuvant ipi-nivo. This is the flipped dose of ipi1/nivo3 versus adjuvant nivolumab in PD-1 naive, macroscopic, resectable, high-risk stage 3 melanoma.  By way of background, neoadjuvant immunotherapy for those listening is an area of increasing interest for drug developers and development for both approved and novel agents. Neoadjuvant immunotherapy has been studied with multiple approved agents, including PD-1 monotherapy, PD-1 LAG-3, PD-1 CTLA-4, T-VEC, as well as investigational agents and multiple randomized and non-randomized studies. The benchmark pathologic response rates with these agents range from 17% PCR with PD-1 monotherapy, 45% to 55% PCR with PD-1 CTLA-4 combination therapy, and slightly higher 57% PCR with PD-1 LAG-3 has recently reported by Dr. Rodabe Amaria from MD Anderson. However, as we embark on phase 3 comparisons for various neoadjuvant compared to adjuvant immunotherapy trials and combinations, we're increasingly moving towards event-free survival as the primary endpoint for neoadjuvant versus adjuvant studies. And this was most recently studied in the context of SWOG S1801, a study that was led by Dr. Sapna Patel.  So, Jason, before we start on NADINA, can you briefly summarize the SWOG S1801 trial and the event-free survival statistic reported by Dr. Patel and her colleagues? Dr. Jason Luke: Well, absolutely. And these data were reported at ESMO about two years ago and then in the New England Journal last year. The S1801 study answered a very simple question: What would happen if you took three of the doses of standard adjuvant therapy with pembrolizumab and moved them prior to surgery? And on a high level, the study is as simple as that. And many of us were somewhat skeptical of this trial design because we thought that just moving the doses earlier may not actually have a major impact.  In the study, you alluded to the event-free survival statistic, and that alludes to what was considered an event. And so, without reading all of it, there were several different aspects that were included in terms of time, based on the date of randomization until the first of a series of events, such as disease progression, toxicity from treatment, if the patient was unable to go to surgery or had surgical complications, or if they had delay in starting the adjuvant therapy due to toxicity, and obviously, recurrence of melanoma or death from any cause. In that context, merely moving the 3 doses of pembrolizumab to the neoadjuvant setting saw an improvement in this two-year event free survival to 72% for the neoadjuvant therapy compared to 49% for the adjuvant therapy. That was quite an outstanding change. And again, noting the power of neoadjuvant treatment, really dictating the impact of anti PD-1, again, just with 3 doses moving from adjuvant into the neoadjuvant setting, and I think all of us were somewhat surprised to see that magnitude of a benefit. But it set up the current study very well, where we now look at combination therapy. Dr. Diwakar Davar: So let's move on to the phase 3 NADINA trial. Do you want to perhaps discuss the study design, particularly focusing on the EFS primary endpoint and maybe also touching on the different schedules? So, SWOG S1801 was a neoadjuvant study of 3 cycles of pembrolizumab and how did that compare and contrast to the neoadjuvant combination that was studied in NADINA? Dr. Jason Luke: Well, as you alluded to, NADINA investigated the regimen of nivolumab plus ipilimumab and compared that against adjuvant therapy with nivolumab alone. So, in the study, as you alluded, the dose and schedule of the two drugs used was nivolumab at 3 milligrams per kilogram, and ipilimumab with 1 milligram per kilogram. That was based on a series of signal finding and safety studies that had been previously done by the same group of authors identifying that as the optimal treatment regimen. And it's worth noting that's slightly different than the labeled indication that's generally used for those same drugs for metastatic melanoma, albeit that the NCCN also endorses this schedule. So, in the trial, 423 patients were randomized, 1:1 to receive either neoadjuvant therapy with those 2 doses of nivolumab plus ipilimumab as compared with standard adjuvant therapy with nivolumab following surgery.   Now, one interesting tweak was that there was an adaptive nature to the study, meaning that patients had a fiducial placed at the index lymph node, and after the neoadjuvant therapy in that arm, that lymph node was removed. And if the patient had a major pathological response, they did not go on to receive the adjuvant portion of the treatment. So it was adaptive because those patients who did very well to the neoadjuvant did not require the adjuvant portion. And in those patients who did not achieve a major pathological response, they could go on to have the adjuvant therapy. And that also included the BRAF therapy for those whose tumors were BRAF mutants.  It's also worth pointing out that the definition of event free survival was slightly different than in the S1801 study that was alluded to just a second ago. And here, EFS was defined from the date of randomization until progression due to melanoma or due to treatment. So that's slightly different than the definition in the S1801 trial. So, a somewhat complicated study, but I really applaud the authors because I think this study does mirror what we would likely be doing in actual clinical practice.  Dr. Diwakar Davar: So, just to briefly summarize the efficacy, and then to get your comments on this, the path response, the PCR rate was 47%. The major pathologic response rate, which is the proportion of patients with between 0% to 1/10% of residual viable tumors, was about 12%. And for a major pathologic response rate of 0% to 10% of 59%. And then the rest of the patients had either pathologic partial response, which was 10% to 50%, or pathologic non response or 50% or greater residual viable tumor, all assessed using central pathology grades. The one year RFS was 95% in the FDR patient population versus 76% in the pathologic partial response patient population, 57% in the pathologic non response patient population. So how do you view these results? Can you context the FDR rates and the EFS rates from NADINA relative to nivo-rela and also potentially SWOG 1801? Dr. Jason Luke: Well, I think these are very exciting results. I think that for those of us that have been following the field closely, they're actually not especially surprising because they mirror several studies that have come before them. When we put them in context with other studies, we see that these rates of major pathological response are consistent with what we've seen in phase 2 studies. They're relatively similar. Or I should say that the results from nivolumab and relatlimab, which was also pursued in a phase 2 study of somewhat similar design, are somewhat similar to this. So, combination immunotherapy does look to deliver a higher major pathological response than pembrolizumab alone, as was known in S1801. Which of course, the caveat being is these are cross control comparisons that we need to be careful about. So I think all of these are active regimens, and I think adding a second agent does appear to enhance the major pathologic response rates. When we look at the event free survival, we see something similar, which is that numerically it looks to be that combination immunotherapy delivers a higher event free survival rate. And that looks to be rather meaningful given the difference in the hazard ratios that were observed between these various studies. And here in the NADINA study, we see that 0.3 hazard ratio for EFS is just extremely impressive.  So the abstract then, from ourselves, out of these specific studies, what does this mean more broadly in the real world, where patients exist and the rest of the landscape for clinical trials? I think we can't take enough time to stop for a second and just think about what a revolution we've come forward in with immune checkpoint blockade and melanoma. When I started my career, now, more than 15 years ago, melanoma was the cancer that made cancer bad. And now here we say, in the highest risk of perioperative patients, we can deliver 2 doses of nivolumab and ipilimumab, and essentially half of the patients then don't need to go on, and more than half the patients don't need to go on to have a full surgery and don't need adjuvant therapy. And from what we could tell of a very, very low risk of every heavy recurrence of melanoma. Of course, there's the other half of patients where we still need to do better, but these are just fantastic results and I think highly meaningful for patients.   In the context of ongoing clinical trials, another abstract that was presented during the meeting was the update to the individualized neoantigen therapy, or V940 with pembrolizumab or against pembrolizumab alone. That's the KEYNOTE-942 study. In that study, they presented updated data at two and a half years for relapse free survival, noting a 75% rate without relapse. So those results are also highly intriguing. And these are in a similar population of very high risk patients. And so I think most of us believe that neoadjuvant therapy with this study in NADINA is now confirmed as the priority approach for patients who present with high-risk stage 3 disease. So that would be bulky disease picked up on a scan or palpable in a clinic. I think essentially all of us now believe patients should get preoperative immunotherapy. We can debate which approach to take, and it may vary by an individual patient's ability to tolerate toxicity, because, of course, multi agent immunotherapy does have increased toxicity relative to anti PD-1 alone. But we'll have to wait now for the full phase 3 results from the V940 individualized neoantigen therapy. And if those come forward, that will be an extremely attractive approach to think about for patients who did not achieve a major pathological response to neoadjuvant therapy, as well as of course to the other populations of patients with melanoma where we otherwise currently give adjuvant therapy stage 2B all the way through stage 4 resected. It's an amazing time to think about perioperative therapy in melanoma. Dr. Diwakar Davar: So this is clearly outstanding data, outstanding news. Congratulations to the investigators for really doing what is an investigative initiated trial conducted across multiple continents with a huge sample size. So this clearly appears to be, at this point in time at least, a de facto standard. But is this going to be FDA-approved, guideline-approved, or is it possible in your mind? Dr. Jason Luke: Well, that's an interesting question. This study was not designed with the intent to necessarily try to register this treatment regimen with the FDA. One would have to take a step back and say, with how powerful these data appear, it sort of seemed like it would be too bad if that doesn't happen. But all the same, I think the community and those of us who participate in guideline recommendations are fully supportive of this. So, I think we will see this move into compendium listings that support insurance approval, I think, very, very quickly. So, whether or not this actually becomes formally FDA approved or is in the guidelines, I think this should become the standard approach that is considered for patients, again presenting with high-risk stage 3 disease.  Dr. Diwakar Davar: Fantastic. So now we're going to go in and talk about a slightly different drug, but also from the melanoma context, and that is the safety and efficacy of RP1 with nivolumab in the context of patients with melanoma who are PD-1 failures. So, this is Abstract 9517. And in this abstract, our academic colleagues essentially talked about these data, and we'll start by describing what RP1 is. RP1 essentially is a HSV-1 based oncolytic immunotherapy. And RP1 expresses GM-CSF as well as a fusogenic protein, GALV-GP-R-. And in this abstract, Dr. Michael Wong from MD Anderson and colleagues are reporting the results of IGNYTE, which is a phase I trial of intratumoral RP1 co-administered with systemic nivolumab in patients with advanced metastatic treatment refractory cutaneous melanoma. And the data presented in this abstract represents data from a registration directed, abbreviated as RD, registration directed cohort of RP1 plus nivolumab in PD-1 refractory melanoma. So, let's start with the description of the cohort.  Dr. Jason Luke: Right. So, in this study, there were a total of 156 patients who were presented, and that included an initial safety and dose finding group of 16, as well as the RD cohort, as you noted, of 140 patients. And it's important to point out that this was a cohort that was selected for a very strict definition of progression on anti PD-1, or a combination immunotherapy as their immediately prior treatment. So, all of the patients in the cohort had exposure to anti PD-1, and 46% of them had anti PD-1 plus anti CTLA4, nivolumab and ipilimumab as their immediately prior therapy. This was also a group of relatively high-risk patients when one considers stage. So, within the stage 4 population, the entry here included 51% who had stage M1B, C, and D melanoma. And that is worth pointing out because this is an injectable therapy. So, trials like this in the past have tended to be biased towards earlier stage, unresectable or metastatic melanoma, meaning stage 3B, 3C, 3D and then stage 4m1a. Again, to emphasize the point here, these were pretreated patients who had a strict definition of anti PD-1 resistance, and over half of them, in fact, had high-risk visceral metastatic disease.  In that context, it's very interesting to observe that the overall response rate was described in the total population, as 31%, and that included 12% who achieved complete response. And so, again, to make sure it's clear, we're talking about a treatment where the oncolytic virus is injected into one or multiple sites of recurrent disease, and then the patients administer nivolumab as per standard. And so, I think these data are quite intriguing. Again, such a high- risk population and their maturity now, with a follow-up of over a year, I think, makes this look to be a very interesting treatment option.  Dr. Diwakar Davar: I guess on that topic of mature follow-up, it probably would be important for us to inform our audience that the top line data for the primary analysis was actually just released, I think, earlier today, and wherein the central confirmed objective response rate was 34% by modified RECIST and 33% by RECIST, clearly indicating that these responses, as you noted, very treatment refractory patient population, these responses were clearly very durable. So, you mentioned that there were responses seen in uninjected visceral lesions, responses seen in both PD-1 and PD-1 CTLA-4 refractory patients. Can you talk a little bit about the response rate in these high-risk subgroups, the uninjected visceral lesions, the patients who had both combination checkpoint and epidural refractory response rate by primary PD-1 resistance.  Dr. Jason Luke: Sure. You know, I think, again, to emphasize this point in the study, we saw that there were responses in the non-injected lesions, and I think it's really important to emphasize that. Some have referred to this as a putative abscopal like effect, similar to what is described in radiation. But it implies that local treatment with the oncolytic virus is triggering a systemic immune response. In the higher risk patient population, we'll note that whereas the overall response rate in PD-1 refractory patients was 34%, in the combination of PD-1 and CTLA-4 refractory patients, the response rate was 26%. So, [this is] still very good. And when we looked at that split by stage, as I alluded to before, in the population of patients that had, what you might call earlier unresectable diseases, so 3B through 4A, the response rate was 38%, and in the stage 4 M1b through M1d, it was 25%. So slightly lower, but still very good. And that would be as expected, because, of course, the patients with visceral metastatic disease have more advanced disease, but those response rates look quite good. Again, looking at the combination refractory population as well as the more high-risk disease. Dr. Diwakar Davar: So, clearly, these are very promising data and exciting times for multiple investigators in the field and the company, Replimune, as well. So, what are the next steps? I believe that a registration trial is planned, essentially, looking at this with the goal of trying to get this combination registered. Can you tell us a little bit about IGNYTE-3, the trial design, the control arm, and what you foresee this trial doing over the next couple of years?  Dr. Jason Luke: So, as this agent has been maturing, it's worth pointing out that the company that makes this molecule, called RP1, but I guess now we'll have to get used to this name vusolimogene oderparepvec as the actual scientific term, they have been having ongoing discussions with the FDA, and there is the potential that this agent could come forward on an accelerated path prior to the results being released from a phase 3 trial. That being said, the phase 3 confirmatory study, which is called the IGNYTE-3 study, is in the process of being launched now. And that's a study investigating this molecule in combination with nivolumab, as was alluded to earlier, and a randomized phase 3 design, where that combination is compared with a physician's choice, essentially a chemotherapy-based option.   In that study, it will be 400 patients with stage 3B through stage 4; patients will have progressed on anti PD-1, either as a combination or in sequence, and then come on the study to be randomized to either vusolimogene oderparepvec plus nivolumab versus that physician's choice. And the physician's choice includes chemotherapy agents, but also nivolumab plus relatlimab as another option, or an anti PD-1 monotherapy, if that's deemed to be a reasonable option by the treating investigator. And the primary endpoint of that study is overall survival. And unfortunately, in this highly refractory patient population, that's something that may not take long to identify with key secondary endpoints of progression free survival, as well as overall response rate. I'm quite enthusiastic about this study, given these data, which have now been centrally confirmed as you alluded to before. I think this is a very exciting area of investigation and really crossing my fingers that this may be perhaps the first locally administered therapy which does appear to have a systemic impact that can hold up in phase 3. Dr. Diwakar Davar: Very, very, very exciting results. And I guess it's worthwhile pointing out that this company also has got, I think, multiple studies planned with both RP1 and cutaneous squamous cell carcinoma in a solid organ transplant patient population where single agent activity has already been reported by Dr. Migden at prior meetings, as well as a novel trial of potentially RP2 metastatic uveal melanoma. So we'll now pivot to Abstract 6014. So, 6014 is a drug by a company known as Merus. Essentially, it's a very novel agent. Merus essentially is a company that is specialized in making bicyclics and tricyclics. And these are not bicycles or tricycles, but rather drugs that essentially are bispecific antibodies. And Merus essentially has come up with petosemtamab. I think we're going to have to figure out better names for all of these drugs at some point. But petosemtamab, or MCLA-158, essentially is a bicyclic, targeting both EGFR as well as LGR-5. So EGR-5, of course, is a known oncogenic driver in multiple tumor types, squamous, including non small cell lung cancer, cutaneous squamous cell carcinoma, but also head and neck squamous cell carcinoma. And LGR-5 essentially is leucine-rich repeat-containing G-protein coupled receptor 5, but it's a receptor in cancer stem cells and certainly highly expressed in head neck squam. And MCLA-158, or petosemtamab is a IgG one bispecific with ADCC-activity because of IgG1 backbone co-targeting EGFR and LGR5. Merus had earlier results that evaluated petosemtamab monotherapy. They defined the RP2D and second- and third-line head and neck blastoma patients with a respectable response rate of 37% investigator-assessed ORR with six months median DoR, and this was published by Ezra Cohen about a year or so ago.  In this abstract, Dr. Fayette and colleagues report on the results of the MCLA-158-CL01 trial, which is a trial of pembrolizumab plus petosemtamab in one front line head and neck squamous cell population. So maybe let's start with the description of the cohort. And it is a small trial, but we'll be able, I think, to dig into a little bit about why this might be exciting. Dr. Jason Luke: Yes. So, as alluded to, it's not the biggest trial as yet, but there were 26 patients with anti PD-1 treatment naive head and neck squamous cell carcinoma. And all the patients in the study did receive, as you alluded to, pembrolizumab plus petosemtamab. Based on the label for pembrolizumab, all the patients in this study were PDL-1 positive. So that's one point that it's worth pointing out to make sure that that's understood. This is the population of patients who would be expected to benefit from pembrolizumab in the first place. Now, in the abstract, they reported out only 10 response evaluable patients, but they updated that in the actual slides of presentation at the meeting. So among 24 patients that were alluded to, 67% were described as having had a response, although some of those were yet to be confirmed responses. And when it was evaluated by PDL-1 status, there didn't seem to be a clear enrichment of response in the PD-1 positive more than 20% group, as compared to the 1-19% group. That isn't especially surprising because that was a trend that one would see, presumably with pembrolizumab alone. But overall, I think these data are pretty exciting in terms of a preliminary study. Dr. Diwakar Davar: You know, you mentioned that the objective response rate was high, almost 60-something%. The prognosis of these patients is generally poor. The OS is typically thought of as between 6-15 months. And based on KEYNOTE-048, which was led by Dr. Burtness and colleagues, the standard of care in the setting is pembrolizumab +/- platinum based chemotherapy regimens. Allowing for the fact that we only have 10 patients here, how do you think these results stack up against KEYNOTE-048? And you made a very important point earlier, which was, by definition, pembro is on label only for the CPS. So PDL-1 score, at least in head and neck squamous cell carcinoma CPS and not TPS. But in the CPS 1% or greater patient population, where pembro is on label, how do these results stack up against the KEYNOTE-048 results. Dr. Jason Luke: Right. KEYNOTE-048 is considered the seminal study that dictates frontline treatment in head and neck cancer. And before we dive into this too far, we do want to acknowledge that here we're comparing 26 patients versus a phase 3 trial. So, we're not trying to get too far ahead of ourselves, but this is just a preliminary comparison. But in KEYNOTE-048, as you alluded to, two regimens were superior to chemotherapy. One was the pembrolizumab monotherapy, as well as pembrolizumab plus chemotherapy. So again, the study overall survival, of course, was much higher, the PDL-1 positive subgroup, which is what dictated the unlabeled use of this. But response to pembro monotherapy in that population of patients is still modest. We're talking about upwards of 20-30%. So, if you compare that to, again, preliminary evidence here from this trial of only 24 patients, that response rate of 60% seems extremely high. And so even if that were to come down somewhat in a larger data series of patients, that still looks to be quite promising as a treatment regimen, that might eventually even be chemotherapy sparing for this population of patients. I think this raises a lot of eyebrows that perhaps this dual targeting approach, EGFR and LDR-5, may bring something really important to the field that evolves it. Dr. Diwakar Davar: So, what are the next steps for petosemtamab? You mentioned that the activity was interesting. Are we going to see a larger trial? Any thoughts on where things are going to go?  Dr. Jason Luke: Well, based on the phase 2 data of petosemtamab alone, even without pembrolizumab, the molecule had already been given fast track designation by FDA, which means allowing for greater communication between the drug sponsor in the FDA and designing a seminal study design. One would assume that this trial will be rapidly expanded quite greatly, perhaps to 100 or 200 patients, to try to flush out what the real response rate is in a more meaningful number of patients. But I think these data will probably also trigger the design and probably near-term evaluation or expedited acceleration of a phase III clinical trial design that would potentially validate this against the current standard of care. So, I'm pretty excited. I think we'll see a lot more about this agent in the relatively near future. Dr. Diwakar Davar: So, finally, we'll pivot to the last abstract that we're going to talk about, which is Abstract 2504. It's a relatively interesting target, CCR8 monoclonal antibody. But this is the efficacy and safety of LM-108, and LM-108 is an anti CCR8 monoclonal antibody that is being developed by LaNova Medicine. And the results that are described, actually a pool set of results of combinations of LM-108 with anti PD-1, two separate anti PD-1, in patients with gastric cancer, mostly done ex-U.S., which is interesting because of this patient population, and it's a pool result of several, 3 phase 1 and 2 studies.  LM-108 is an Fc-optimized anti CCR8 monoclonal antibody that selectively depletes tumor infiltrating Tregs. The abstract reported a pooled analysis of three phase 1, 2 trials with 3 different NCT numbers that all evaluated the efficacy of LM-108 and anti PD-1 in patients with gastric cancer. So, let's start with the description of the cohort. Maybe, Jason, you can tell us a little bit about before you start, as you describe the cohort, sort of what we know, editorially speaking, about the difficulty with which Tregs depletion has been tried and obviously failed up until now in the tumor microenvironment. Dr. Jason Luke: Right. I think that's a really interesting comment. And so, for decades, in fact, targeting regulatory T-cell to alleviate immune exclusion in the tumor microenvironment has been of interest in immuno-oncology. And in preclinical mouse models, it seems quite clear that such an approach can deliver therapeutic efficacy. However, by contrast, in human clinical trials, various different Treg depleting strategies have been attempted, and there's really little to no evidence that depleting Tregs from human tumors actually can deliver therapeutic responses. And by that we're referring to CD-25 antibodies. The drug ipilimumab, the CTLA-4 antibody, was punitively described as a Tregs depleter preclinically, but that doesn't seem to be the case in patients. And so, in that background, this is quite an eye raiser that an anti CCR8 antibody could be driving this effect. Now, before we talk about the results of this trial, I will point out, however, that given the Fc-optimization, it's entirely possible that the Tregs are being depleted by this mechanism, but that more could also be going on. Because Fc gamma RII binding by this antibody that could be nonspecific also has the potential to trigger immune responses in the tumor microenvironment, probably mediated by myeloid cells. So I think more to come on this. If this turns out to be the first meaningful Tregs depletor that leads to therapeutic efficacy, that would be very interesting. But it's also possible this drug could have multiple mechanisms.  So, having said all of that, in the clinical trial, which was a pooled analysis, like you mentioned, of LM-108 in combination with anti PD-1 of a couple different flavors, there were 48 patients treated either with LM-108, with pembrolizumab, or with toripalimab, which is another anti PD-1 antibody. On the drug combination was, generally speaking, pretty well tolerated, noting grade 3 treatment related adverse events in the range of 38%, which is somewhat expected given combination immunotherapy. We talked about nivolumab and ipilimumab before, which, of course, gives even higher rates of immune-related adverse events, with the most common toxicities being anemia, lipase elevations, rash, ALC decrease; albeit, quite manageable. Dr. Diwakar Davar: So, what about the objective response rate? Can you contextualize the efficacy? And as you do that, maybe we'll think about what you'd expect in the context of, say, gastric cancer, especially in patients who've never really had a prior checkpoint inhibitor before. What do you think about the ORR? What do you think about the relative efficacy of this combination? Dr. Jason Luke: Well, so, in the study, they described overall response rate in the 36 patients as 36% and described immediate progression for survival of about 6.5 months. And so that was among patients who were treatment naive. And in second-line patients, they actually described an even higher response rate, although it was only 11 patients, but they're at 64%. And so, I think those data look to be somewhat interesting. When I was actually scrutinizing the actual data presented, it was of some interest to note that the quality of responses seemed to be about as good on the lower dose of LM-108, so 3 milligrams per kilogram as compared to 10 milligrams per kilogram. I think there's definitely more to learn here to try to optimize the dose and to fully understand what the overall efficacy of this treatment combination would be.  I would emphasize that in this disease, I think novel treatment strategies are certainly warranted. While anti PD-1 with chemotherapy has moved the needle in terms of standard of care treatment, it's really only a minor subset of patients who derive durable long-term benefit like we normally associate with immune checkpoint blockade. I think these are preliminary data. They're very intriguing.   You alluded to earlier that this population of patients was an Asian data set, and it is well known that the efficacy of chemotherapy and immunotherapy does appear to be somewhat enhanced in Asian populations, and that goes to distributions of metastasis and tumor microenvironment effects, etc. Very difficult to try to tease any of that out in this abstract, other than to look at these data and suggest that this is pretty interesting, both from a novel therapeutic approach, we talked about the Tregs consideration, but also straight up on the efficacy because I think if these data could hold up in a larger number of patients, and particularly in a western population of patients, I think it would be very intriguing. Dr. Diwakar Davar: Certainly, ASCO 2024 had a lot of interesting data, including data from targeted agents, the LAURA trial, ADCs. But just focusing on the immune therapy subset, we certainly saw a lot of great advances in patients who were treated with neoadjuvant as well as relapse refractory disease in the context of RP1 and then a couple of newer agents such as this petosemtamab as well as LM-108. And of course, we cannot forget to highlight the extended DMFS data from the pembro vaccine study from KEYNOTE-942.  Jason, as always, thank you for taking a little bit of time out of your extremely busy schedule to come and give us insights as to how these agents are impacting the landscape. We really value your input and so thank you very much.  Dr. Jason Luke: Thank you for the opportunity. Dr. Diwakar Davar: And thank you to our listeners for your time today. You will find the links to all the abstracts that we discussed in the transcript of this episode. And finally, if you value the insights that you hear on this podcast, please take a moment to rate, review and subscribe wherever you get your podcasts. So, thank you.   Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Follow today's speakers:   Dr. Diwakar Davar   @diwakardavar   Dr. Jason Luke   @jasonlukemd      Follow ASCO on social media:    @ASCO on Twitter   ASCO on Facebook   ASCO on LinkedIn      Disclosures:       Dr. Diwakar Davar:     Honoraria: Merck, Tesaro, Array BioPharma, Immunocore, Instil Bio, Vedanta Biosciences    Consulting or Advisory Role: Instil Bio, Vedanta Biosciences    Consulting or Advisory Role (Immediate family member): Shionogi    Research Funding: Merck, Checkmate Pharmaceuticals, CellSight Technologies, GSK, Merck, Arvus Biosciences, Arcus Biosciences    Research Funding (Inst.): Zucero Therapeutics    Patents, Royalties, Other Intellectual Property: Application No.: 63/124,231 Title: COMPOSITIONS AND METHODS FOR TREATING CANCER Applicant: University of Pittsburgh–Of the Commonwealth System of Higher Education Inventors: Diwakar Davar Filing Date: December 11, 2020 Country: United States MCC Reference: 10504-059PV1 Your Reference: 05545; and Application No.: 63/208,719 Enteric Microbiotype Signatures of Immune-related Adverse Events and Response in Relation to Anti-PD-1 Immunotherapy       Dr. Jason Luke:    Stock and Other Ownership Interests: Actym Therapeutics, Mavu Pharmaceutical, Pyxis, Alphamab Oncology, Tempest Therapeutics, Kanaph Therapeutics, Onc.AI, Arch Oncology, Stipe, NeoTX    Consulting or Advisory Role: Bristol-Myers Squibb, Merck, EMD Serono, Novartis, 7 Hills Pharma, Janssen, Reflexion Medical, Tempest Therapeutics, Alphamab Oncology, Spring Bank, Abbvie, Astellas Pharma, Bayer, Incyte, Mersana, Partner Therapeutics, Synlogic, Eisai, Werewolf, Ribon Therapeutics, Checkmate Pharmaceuticals, CStone Pharmaceuticals, Nektar, Regeneron, Rubius, Tesaro, Xilio, Xencor, Alnylam, Crown Bioscience, Flame Biosciences, Genentech, Kadmon, KSQ Therapeutics, Immunocore, Inzen, Pfizer, Silicon Therapeutics, TRex Bio, Bright Peak, Onc.AI, STipe, Codiak Biosciences, Day One Therapeutics, Endeavor, Gilead Sciences, Hotspot Therapeutics, SERVIER, STINGthera, Synthekine    Research Funding (Inst.): Merck , Bristol-Myers Squibb, Incyte, Corvus Pharmaceuticals, Abbvie, Macrogenics, Xencor, Array BioPharma, Agios, Astellas Pharma , EMD Serono, Immatics, Kadmon, Moderna Therapeutics, Nektar, Spring bank, Trishula, KAHR Medical, Fstar, Genmab, Ikena Oncology, Numab, Replimmune, Rubius Therapeutics, Synlogic, Takeda, Tizona Therapeutics, Inc., BioNTech AG, Scholar Rock, Next Cure    Patents, Royalties, Other Intellectual Property: Serial #15/612,657 (Cancer Immunotherapy), and Serial #PCT/US18/36052 (Microbiome Biomarkers for Anti-PD-1/PD-L1 Responsiveness: Diagnostic, Prognostic and Therapeutic Uses Thereof)    Travel, Accommodations, Expenses: Bristol-Myers Squibb, Array BioPharma, EMD Serono, Janssen, Merck, Novartis, Reflexion Medical, Mersana, Pyxis, Xilio

Menopausal women should eat more blackcurrant to prevent bone loss University of Connecticut, December 11, 2022 Hormonal changes are one of the leading causes of bone loss or osteoporosis. Menopausal women, in particular, are more likely to experience bone loss because they are deficient in estrogen, a hormone in women that protects the bones. The amount of estrogen drops when women reach menopause. To lower the risk of bone loss, researchers at the University of Connecticut suggested menopausal women should eat more blackcurrant. The researchers conducted an animal study to look at the effect of blackcurrant on bone mass in an estrogen-deficient mouse model. Earlier studies have reported that the anthocyanins in blackcurrant have antioxidant and anti-inflammatory properties that could potentially improve bone mass.For their study, which was published in the Journal of Medicinal Food, the team removed the ovaries of the mice to mimic estrogen deficiency in menopausal women. Then, they gave the mice either a basal diet alone or a basal diet that contains anthocyanin-rich blackcurrant extract. They measured bone mineral density, trabecular bone volume, and serum bone markers. Ovariectomy resulted in a significant reduction in bone mineral density and trabecular bone volume. However, the treatment of blackcurrant reduced ovariectomy-induced bone loss. In addition, the treatment decreased osteoclast-like cell formation and bone resorption activity. These outcomes suggest that blackcurrant may mitigate postmenopausal bone loss. Adequate estrogen level is important for maintaining the rhythm of bone remodeling. Since estrogen levels decline after menopause, this causes an imbalance in bone production and breakdown. Osteoclasts are cells that break down bone and are responsible for bone remodeling. With the decline of estrogen levels, osteoclasts become more active and break down more bone than it can form. With these findings, the researchers concluded that blackcurrant may help prevent bone loss in postmenopausal women. Improving your gut microbiome is also a way to prevent and reduce your risk of age-related bone loss. A study published in the Journal of Internal Medicine suggested that taking probiotic supplements daily can cut age-related bone loss by half. Researchers at the University of Gothenburg in Sweden gave elderly women a probiotic supplement to be taken twice a day for one year. The supplementation resulted in lower bone loss compared to those who did not take the supplement. (NEXT) Long-term antacid use linked to vitamin B12 deficiency Kaiser Permanente in California, December 16, 2022 Antacids are commonly used to neutralize the acid in the stomach, helping many individuals who have acid reflux. But a new study suggests that using this medication consistently for 2 years or more is linked to a deficiency of vitamin B12, which can have adverse effects for the nervous system. The research, published in JAMA, is among the first to show associations between long-term exposure to antacids and vitamin B12 deficiencyin a large population-based study. The investigators say that antacids, including proton pump inhibitors (PPIs) and histamine 2 receptor antagonists (H2RAs), are some of the most commonly used pharmaceuticals in the US.However, because they suppress the creation of gastric acid, the team says antacids may lead to malabsorption of vitamin B12. This vitamin helps to keep the nervous system - consisting of the brain, nerves and spinal cord - healthy."Vitamin B12 deficiency is relatively common," say the researchers, "especially among older adults; it has potentially serious medical complications if undiagnosed." "Left untreated, vitamin B12 deficiency can lead to dementia, neurologic damage, anemia and other complications, which may be irreversible."The study found a link between 2 years' use of antacids or more and a deficiency of vitamin B12.Similarly, 4.2% of the vitamin-deficient patients had a 2-year or more supply of H2RAs, versus 3.2% in the control group.  (NEXT) Microbiome: Scientists highlight role of harmful gut bacteria in fever afflicting cancer patients University of Texas MD Anderson Cancer Center, December 16, 2022 An altered gut microbiome is an unexpected cause of fever afflicting many patients undergoing chemotherapy, according to scientists who've also discovered that poor appetite during cancer treatment may trigger the biological forces that can likewise adversely raise body temperature. The domino effect that leads to dangerous fevers in cancer patients is driven by a loss of infection-fighting white blood cells, a condition called neutropenia. Chemotherapy lowers blood neutrophils—white blood cells and key constituents of the immune system—resulting in fever in some, but not all, cancer patients. The new research shines a spotlight on the role of the gut microbiome and how it can promote neutropenic fever. An interdisciplinary group of researchers at the University of Texas MD Anderson Cancer Center in Houston has uncovered intriguing evidence demonstrating that an increase in a specific species of detrimental bacteria can overwhelm the gut among people receiving chemo. The research adds a tantalizing new dimension of understanding to the role of the gut microbiome among patients undergoing one of the most widely administered forms of cancer care. Concerns about neutropenia and fever are important because an estimated half of people with cancer who are receiving chemotherapy develop some degree of neutropenia. For patients undergoing treatment for leukemia, it's a common side effect, according to the American Cancer Society. Turning to an animal model in the laboratory, the team discovered that when they transferred the gut microbiota from 119 patients with cancer who developed neutropenic fever to irradiated mice, some of the animals inevitably developed a fever, too.What the team found when analyzing the gut microbiota of the mice was an excess of mucin-degrading Akkermansia bacteria, the same bacteria in the patients with neutropenic fever. The study of fecal samples confirmed that Akkermansia muciniphila replicates prolifically in the absence of sufficient neutrophils and is linked with subsequent fever. The bacteria are also noteworthy because they are mucin-degrading, which means they actively deplete the protective mucin layer of the intestines. A total of 63 patients—53%—developed a fever and their fecal microbiome displayed increased accumulation of Akkermansia muciniphila, the same species that grew excessively in the mice. (NEXT) Healthy diet may mean longer life for kidney patients University of Bari (Italy), December 9, 2022  A healthy diet may help people with kidney disease live longer, researchers report.They analyzed seven studies that included more than 15,000 people with chronic kidney disease, to assess the effects of a diet high in fruits, vegetables, fish, legumes, cereals, whole grains and fiber. In six of the studies, a healthy diet was consistently associated with a 20 percent to 30 percent lower rate of early death, and with 46 fewer deaths per 1,000 people over five years. But the study did not directly prove that a healthy diet would lengthen life. (NEXT) Study finds higher levels of common diet-associated microbe elevates heart failure risk Cleveland Clinic, December 16, 2022 New research at Cleveland Clinic expands the link between what we eat and how the gut microbiome impacts our susceptibility to develop different diseases—in this case, how a specific gut microbe-generated byproduct is linked to heart failure risk. Elevated levels of phenylacetylglutamine (PAG)—a byproduct created when microbes in the gut breakdown dietary protein—can be directly linked to both increased heart failure risk and severity, according to findings published in Circulation: Heart Failure.The new findings improve researchers' understanding of how the gut microbiome, through PAG levels, are linked to cardiac disease risks, and suggest potential approaches to modify PAG-associated risks through interventions such as diet and beta blocker use. Elevated PAG levels also were shown to correspond with types of heart failure. For example, elevated blood PAG was observed in subjects with heart failure with preserved ejection fraction, a condition where the heart muscle doesn't relax enough between beats and becomes too stiff, making it less able to fill and consequently pump blood.This new study dug deeper into other potential functions of PAG with focus on heart failure. The team of investigators found that PAG levels were linked to heart failure risks through patient data from thousands of patients in two independent study cohorts, one from Europe and another the U.S. In other studies, introducing PAG into cardiac cells in the lab allowed researchers to better understand the mechanism behind PAG's association with heart failure—and a foundation for countering its effects. (NEXT) Study: Running actually lowers inflammation in knee joints Running may also slow the process that leads to osteoarthritis Brigham Young University, December 12, 2022 We all know that running causes a bit of inflammation and soreness, and that's just the price you pay for cardiovascular health. You know; no pain, no gain. Well, maybe not. New research from BYU exercise science professors finds that pro-inflammatory molecules actually go down in the knee joint after running. In other words, it appears running can reduce joint inflammation. In a study recently published in the European Journal of Applied Physiology, Seeley and a group of BYU colleagues, as well as Dr. Eric Robinson from Intermountain Healthcare, measured inflammation markers in the knee joint fluid of several healthymen and women aged 18-35, both before and after running. The researchers found that the specific markers they were looking for in the extracted synovial fluid--two cytokines named GM-CSF and IL-15--decreased in concentration in the subjects after 30 minutes of running. When the same fluids were extracted before and after a non-running condition, the inflammation markers stayed at similar levels. Hyldahl said the study results indicate running is chondroprotective, which means exercise may help delay the onset of joint degenerative diseases such as osteoarthritis. This is potentially great news, since osteoarthritis--the painful disease where cartilage at the end of bones wears down and gradually worsens over time--affects about 27 million people in the United States.

Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2022.08.23.505001v1?rss=1 Authors: Sharma, S., Fallgren, C., Weil, M. M., Chatterjee, A., Nagpal, P. Abstract: Galactic cosmic rays (GCR) in space induce increase in cerebral amyloid-{beta} levels and elevated levels of microgliosis and astrocytosis, causing accelerated neurodegeneration from this increased neuroinflammation. Even exposure to low-levels of high-Z high-energy (HZE) radiation (50 cGy) has been shown to induce biochemical and immunohistochemical changes in short-term leading to degradation in cognition, motor skills, and development of space-induced neuropathy. There is lack of effective neuroinflammation countermeasures, and current experimental therapies require invasive intracerebral and intrathecal delivery due to difficulty associated with therapeutic crossover between blood-brain barrier. Here, we present a new countermeasure development approach for neurotherapeutics using high-throughput drug-discovery, target validation, and lead molecule identification with nucleic acid-based molecules. These NanoligomerTM molecules are rationally designed using a bioinformatics and AI-based ranking method and synthesized as a single-modality combining 6-different design elements to up- or down-regulate gene expression of target gene at will, resulting in elevated or diminished protein expression of intended target. This platform approach was used to perturb and identify most effective upstream regulators and canonical pathways for therapeutic intervention to reverse radiation-induced neuroinflammation. The lead NanoligomerTM and corresponding target granulocyte-macrophage colony-stimulating factor (GM-CSF) were identified using in vitro cell-based screening in human astrocytes and donor derived peripheral blood mononuclear cells (PBMCs) and further validated in vivo using a mouse model of radiation-induced neuroinflammation. GM-CSF transcriptional downregulator Nanoligomer 30D.443_CSF2 downregulated proinflammatory cytokine GM-CSF (or CSF2) using simple intraperitoneal injection of low-dose (3mg/kg) and completely reversed expression of CSF2 in cortex tissue, as well as other neuroinflammation markers. These results point to the broader applicability of this approach towards space countermeasure development, and potential for further investigation of lead neurotherapeutic molecule as a reversible gene therapy. Copy rights belong to original authors. Visit the link for more info Podcast created by PaperPlayer

In this 2nd episode, our co-hosts discuss the use of a macro-scale material to co-deliver GMCSF and CpG, both APC stimulating agents, as well as AML antigens to kill AML cells. GUEST: Alex Najibi is now a postdoctoral fellow at Harvard School of Engineering and Applied Sciences, studying bioengineering in David Mooney's lab. Original study => https://pubmed.ncbi.nlm.nih.gov/31937942/ Support the show

Guest host Dr. Nathan Pennell, of the Cleveland Clinic Taussig Cancer Institute, and Dr. Vamsi Velcheti, of the NYU Langone Perlmutter Cancer Center, discuss the ATLANTIS trial and other novel therapies in advanced SCLC, NSCLC, and malignant pleural mesothelioma featured at the 2022 ASCO Annual Meeting Poster Sessions.  Transcript   Dr. Nathan Pennell: Hello, I'm Dr. Nathan Pennell, your guest host for the ASCO Daily News Podcast, today. I'm the co-director of the Cleveland Clinic Lung Cancer Program and vice-chair of Clinical Research for the Taussig Cancer Institute.  My guest today is my friend Dr. Vamsidhar Velcheti, an associate professor and medical director of thoracic oncology at the Perlmutter Cancer Center at NYU Langone Health.  We'll be discussing key posters on lung cancer that will be featured at the 2022 ASCO Annual Meeting. Although the oral sessions tend to get the most press, we want to make sure you don't miss out on some high-impact abstracts that are presented in the poster session.  Our full disclosures are available in the show notes and disclosures of all guests on the podcast can be found on our transcripts at asco.orgpodcasts.  Vamsi, it's great to speak with you today.  Dr. Vamsidhar Velcheti: Thank you, Nate. It's a pleasure to discuss these 5 outstanding abstracts.  Dr. Nathan Pennell: Why don't we start with Abstract 9021, “Genomic correlates of acquired resistance to PD-(L)1 blockade in patients with advanced non—small cell lung cancer (NSCLC).” Vamsi, what were your key takeaways from this study?  Dr. Vamsidhar Velcheti: This is an important study in my opinion. This was a very large study of 1,700 patients from Dana Farber and the investigators looked at 45 specimens and matched pre- and post- immunotherapy treated patients. And they looked at the data mechanisms of resistance that were identified in 25 out of the 45 patients, that is 55% of the patients.  5 patients had acquired STK11 mutations. One patient had a KEAP1 alteration. There were several patients who had like KEAP1 SMARCA4 mutations. And interestingly, there were also some patients who developed KRAS-G12C mutation as well on the post-treatment specimens.  So, this is an interesting abstract. We typically don't do biopsies on patients progressing on immunotherapy. At this point, we don't have a standard clinical indication to do so. However, identifying these new novel mechanisms of genomic mechanisms of resistance is actually very important, because a lot of new therapy medications are being developed to target, for example, KEAP1, and could be approached to target microglobulin mutations. So, it's very important to kind of understand the mechanisms of resistance.  Dr. Nathan Pennell: Yeah, I completely agree. I mean, most of the benefits in second line in the refractory setting with targeted treatments came about through studies like this where there was broad sequencing of resistance and trying to understand and I think we're still kind of in the infancy of understanding resistance to immunotherapy, but it's a good start.  Abstract 9019 was another interesting study in non—small cell lung cancer. That was “A phase II study of AK112 (PD-1/VEGF bispecific) in combination with chemotherapy in patients with advanced non—small cell lung cancer.” Can you tell us a little bit about that study?  Dr. Vamsidhar Velcheti: Yeah, this is a multicenter phase-2 trial. This is an interesting agent. It's a PD-1/VEGF bispecific antibody developed by Akeso Bio. This is a single-arm study, and they did the study in 3 different cohorts.  One of the cohorts was patients with advanced non—small cell lung cancer who had wild-type EGFR/ALK, and they were treatment-naive. There was another cohort of patients where they enrolled patients with EGFR mutation who developed resistance to EGFR tyrosine kinase inhibitors (TKIs) and essentially progressed on osimertinib. And there was another cohort where patients were enrolled who were PD-1 refractory, they had prior PD-1or PD-1 chemo combination, and they had progressions. So, they enrolled a total of 133 patients, it was a decent-sized study, but a very early efficacy finding study.  In the cohort-1 which is the cohort that is enrolled with untreated patients with advanced non—small cell lung cancer. They had like 20 partial responses out of 26 patients that were evaluable and enrolled in the cohort, and there were 6 patients who had stable disease.  So, overall, the response rate was 76.9% and 100% disease control rate. So, this is a very small cohort and small data set. So, we have to interpret this with caution. But suddenly, a very interesting signal here for this VEGF/PD-1 bispecific antibody.  Dr. Nathan Pennell: The 40% response rate in the immunotherapy (IO) and chemo refractory patients, I thought was fairly interesting, although, as you said, very small numbers in these cohorts will have to be reproduced in larger trials.  Dr. Vamsidhar Velcheti: Right. I think there was a lot of excitement early on the IMpower150, right? With the combination of bevacizumab with chemo-theralizumab.  There seems to be some signal in terms of the addition of a VEGF inhibitor to immunotherapy. And we've seen that consistently in renal cells and other tumor types. So, I think this is a really intriguing signal. I think this definitely warrants further exploration.  So, the other interesting thing was cohort-2 where they enrolled patients who had progressed on EGFR TKIs. So, in that cohort, they had like 19 evaluable patients and 13 patients had a partial response and 5 had stable disease. So, a very respectable response rate of 68.4% and 94.7 disease control rate. So, again, very small numbers, but a nice signal here for the efficacy of the drug.  There was another cohort, which is the cohort-3 where they enrolled patients who progressed on PD-1 therapy, and they enrolled a total of 20 patients with 8 patients having a partial response, following progression on PD-1 therapy.  Dr. Nathan Pennell: Yeah, I look forward to seeing further follow-up on this. It definitely sounds interesting. Moving on to Abstract 8541. This was “Durvalumab (durva) after chemoradiotherapy (CRT) in unresectable, stage III, EGFR mutation-positive (EGFRm) NSCLC: A post hoc subgroup analysis from PACIFIC,' which of course was the study that led to the broad use of durvalumab, the anti-PD-L1 antibody after chemoradiotherapy for unresectable stage III non-small cell, but this was the post hoc subgroup analysis of the EGFR mutation-positive group. And this is a subgroup we've really been curious about whether there was a role for consolidation, immunotherapy, or not. And so, what are your thoughts on the study?  Dr. Vamsidhar Velcheti: I agree with you, Nate, that this is actually some data that I was really, really looking forward to. Before we actually talk about the abstract. What do you do for those patients? If you have an EGFR mutation patient who has stage IIIB, what do you do right now?  Dr. Nathan Pennell: It's a great question. I have a discussion with them about the potential pluses and minuses of doing consolidation durvalumab. But I actually don't always use durvalumab in this setting, because of concerns about if you're using durvalumab and they recur, perhaps there is a problem with toxicity with using osimertinib. Honestly, I go back and forth about what the right thing is to do in this subgroup.  Dr. Vamsidhar Velcheti: No, I think that's the right context. I think that's a good setup to kind of discuss the data from the trial. I'm really excited about this. And I'm glad that we have this data to look at.  So, as you pointed out, the Pacific trial, its U.S. Food and Drug Administration (FDA) approval for durvalumab in the consolidation setting for patients with stage III after chemoradiation. This has now been the standard of care for like a few years now. The problem with the study is that patients with EGFR/ALK were allowed to enroll in the study.  Typically, for most IO trials, we generally tend to see patients with EGFR/ALK being excluded. So, this trial was an exception. In this study, they actually presented a post-hoc exploratory analysis of efficacy and safety of patients who did consolidation with durvalumab, but there was a total of 35 patients of the 713 patients that were randomized in the trial. And out of the 35 patients with EGFR mutation, 24 received durvalumab and 11 received a placebo.  So, of course, you're going to interpret this data with a little bit of caution. This is a full stock analysis, not pre-planned in small numbers. In this dataset, essentially, the median progression-free survival (PFS) was not different among patients treated with durvalumab or placebo, and the median survival was also not statistically significant. Overall, there was not much benefit from adding durvalumab in this setting in patients who have EGFR mutation-positive stage III lung cancer.  Dr. Nathan Pennell: I think that tends to track along with what we who have been treating patients with EGFR mutations for years, and knowing the disappointing response rates, certainly in the advanced stage with immunotherapy, I think we were concerned that in this consolidation phase that it would also potentially be a relatively marginal benefit. I agree with you that 35 patients are too small to make any definitive conclusions, but it certainly isn't supportive of a large benefit.  Dr. Vamsidhar Velcheti: But I think I'm excited about the LAUREL study that's ongoing, hopefully, that'll give us a little bit more definitive answers as to what we should be doing for patients with EGFR mutation-positive disease. Suddenly this is a piece of information that's helpful for treating physicians to make some decisions on clinical management for these patients.  Dr. Nathan Pennell: I agree. Now moving beyond the non—small cell. Let's talk about “Final survival outcomes and immune biomarker analysis of a randomized, open-label, phase I/II study combining oncolytic adenovirus ONCOS-102 with pemetrexed/cisplatin (P/C) in patients with unresectable malignant pleural mesothelioma (MPM).” That's Abstract 8561. What were your takeaways here?  Dr. Vamsidhar Velcheti: Yeah, it's always good to see some new therapeutic options for patients with mesothelioma. This is somewhat of an orphan disease and we haven't seen a lot of advances. Granted, we have some new therapeutic options with immunotherapy now, like, there is now a standard of care in the frontline setting.  So, this particular approach with ONCOS-102 is an oncolytic adenovirus expressing GM-CSF. And this is intended to stimulate the local and systemic immune response and remodulate the tumor microenvironment.  This was a small phase 1 study where they had a CFT run-in of 6 patients and a total of 25 patients were randomly assigned to receive ONCOS-102 intratumorally with ultrasound guidance or CT guidance and they injected this oncolytic virus into the tumor directly.  They were also getting treatment with platinum pemetrexed which is the standard of care in the frontline setting. The control here was 6 cycles of platinum pemetrexed. So, they enrolled both the treatment-naive patients in the frontline setting and they also enrolled patients who will progress on a platinum doublet.  I should note that none of these patients were treated with immunotherapy. I think that's something that we'll kind of get back to and we'll discuss. Overall, from a safety standpoint, there were some expected toxicities like pyrexia and nausea which is seen in the experimental group. It's just kind of to be expected with an oncolytic virus. Overall, the 30-month survival rates were 34.3% and 18.2% in the control arm, and the median overall survival (OS) was 19.3 months and 18.3 in the controller.  So, for patients who were treated with the frontline chemotherapy, the survival rate was better with 30 months survival, it was 33.3 [months]. And in the experimental group, it was 0%.  So, overall, they also looked at tumor-infiltrating lymphocytes, they had CD4 around CD8 and granzyme B expressing CDA T-cells, and they had favorable PK from increased immune cell infiltration. So, this is very promising data but of course in a small study, and also in a population that hasn't had immunotherapy patients who are getting platinum doublet. In terms of safety, I think it looks promising. We need to see larger studies, especially with immunotherapy combinations.  Dr. Nathan Pennell: Yeah, I was impressed with the increased tumor infiltration of CD4 and CDA-positive T-cells, and the survival in the first line looked fairly impressive, although again, a very small subgroup of patients. But as you said, a standard of care these days is definitely going to involve immunotherapy. And so, I look forward to seeing combination trials in the future with this drug.  Shifting from mesothelioma over to small cell lung cancer, Abstract 8570 is “Stereotactic radiosurgery (SRS) versus whole brain radiation therapy (WBRT) in patients with small cell lung cancer (SCLC) and intracranial metastatic disease (IMD): A systematic review and meta-analysis.” Do you think that this would influence how we approach patients with brain metastases in the small cell?  Dr. Vamsidhar Velcheti: There are some in the community who kind of advocate for SRS in small cells if they have limited CNS disease. Certainly, I'm not one of them, but I think this is an interesting study in that light like we have never had any proper randomized trial. And we probably won't have randomized trials in that setting. So, at the end of the day, I think we all kind of customize our treatment approaches based on our patients and how much disease burden they have.  But having said that, the authors here have done a pretty large systemic analysis, and they looked at 3,700+ trials, they looked at random effects meta-analysis pooled hazard ratios for overall survival in patients who received SRS in the whole brain with or without SRS boost.  What they found was that overall survival following SRS was not inferior to whole brain RT. What do we really make out of this data? I think, given the heterogeneity, we have to see how the analysis was done and the kind of studies that went into the analysis. But however, I think the bigger question is, is there a population that we need to maybe—perhaps like, if somebody has an isolated brain met, you could potentially consider SRS with a whole brain RT for better local control.  So, the authors actually look at pooled data to look at local control versus intracranial distant control. So, this is a really interesting approach that asks the question, if patients had SRS and whole brain radiation, would it actually offer adequate intracranial distant control meaning like, do they develop new lesions?  So, it does look fairly decent. But again, it all depends on what kind of studies went into the analysis. And I don't think we should read too much into it. But at the same time, it kind of raises the question: is there a population of patients with small cell where it may be potentially appropriate to give SRS?  So, that's what I do in my day-to-day clinical practice. Sometimes there are situations where you kind of do the thing that we don't usually always do like in the small cell, we always think about whole brain radiation as something that we always have to offer, but I want to hear your perspectives too.  Dr. Nathan Pennell: No, I was always taught that you never did anything with whole brain radiation in the small cell even with a solitary metastasis. For a study like this, it's certainly interesting. You wonder how much selection bias there was towards people with fewer brain metastases and perhaps being in better health or better response to systemic disease that were referred for SRS, compared to whole brain radiation.  Part of the issue is the morbidity associated with whole brain radiation is significantly more than with SRS. And now that we are starting to, for the first time, see some patients with small cell [lung cancer] that are living substantially longer with immunotherapy, it might be worth exploring which patients might benefit from having that lower morbidity from whole brain radiation. But I agree with you that I'm not sure that we know who those patients are.  Dr. Vamsidhar Velcheti: Yeah, I think this is a difficult question to answer through a meta-analysis in my opinion. But having said that, your thought in terms of proving systemic therapies, then we kind of revisit the paradigm of offering SRS to some patients may be, especially with new BiTE T-cell engager studies that are ongoing, and hopefully, if you see some positive results, that might change what we do, but it's an important clinical question.  Dr. Nathan Pennell: And finally, in Abstract 8524, we have an interesting analysis of patients with relapsed small cell lung cancer, who received single-agent Lurbinectedin in the phase-3 Atlantis trial. What do you think about this poster, and why should this be on our radar?  Dr. Vamsidhar Velcheti: Yeah, I think this has been an interesting approval, of course, lurbinectedin FDA approved, as you know, like in June of 2020, based on data from a trial that uses 3.2 milligrams per meter square dosing every 21 days in second line setting post-chemotherapy.  What happened after that was there was a trial with the combination with doxorubicin in the second line setting comparative arm in that phase 3 trial topotecan or CAV.  In that trial, it was a negative trial, the primary endpoint was not met. The primary endpoint was overall survival, and it was a negative trial. And there were subgroup analyses done in the trial. The study that is presented now is actually a post-hoc analysis looking at patients who received treatment with this combination with doxorubicin that is like a lurbinectedin with doxorubicin, who had like a total of 10 cycles of the combination, and they switched to lurbinectedin monotherapy.  So, there were a total of 50 patients in that trial. They looked at the responses and the durability of responses in that population. It's a highly select population that made it to 10 cycles and they had stable disease or better and they switched to lurbinectedin monotherapy.  So, the highlight of the abstract is the median overall survival was 20.7 months. Of course, for small cell, that's really impressive. But I think we've got to be really careful in interpreting this data. This is like a small subgroup of highly selected patients who actually benefited from the trial. My question for you, Nate, is do you use lurbinectedin in the second line setting frequently or are you still treating them with topotecan?  Dr. Nathan Pannell: We still often use topotecan. I think lurbinectedin certainly seems to be an active drug, and it has some favorable schedule of administration pretty well tolerated from a tolerability standpoint, but from an efficacy standpoint, I still haven't really seen much that makes it stand out as significantly better than older options like topotecan or irinotecan.  That being said, it is intriguing that there is a subgroup of people who seem to have prolonged disease control with this. The problem, of course, is if you already select the people who make it 10 cycles without progression, then you're already picking the group of people who are doing extremely well. So, it's not surprising that they would continue to do extremely well.  Nonetheless, it's a sizable subgroup of people that seem to benefit and it would really be nice if there was, for example, a biomarker that might tell us which patients would truly benefit from this drug compared to our other options.  Dr. Vamsidhar Velcheti: Yeah, exactly. True. Right, I mean, like all of us have patients who have done exceedingly well on topotecan and I had a patient on paclitaxel for years. So, it's really important to kind of keep that in mind when we look at these sub-proof post hoc analyses.  Dr. Nathan Pennell: Well, thanks Vamsi for sharing these important advances in lung cancer that will be featured at the 2022 ASCO Annual Meeting.  Dr. Vamsidhar Velcheti: Thank you, Nate.  Dr. Nathan Pennell: And thank you to our listeners for joining us today. If you're enjoying the content on the ASCO Daily News podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts.    Disclosures:  Dr. Nathan Pennell:   Consulting or Advisory Role: AstraZeneca, Lilly, Cota Healthcare, Merck, Bristol-Myers Squibb, Genentech, Amgen, G1 Therapeutics, Pfizer, Boehringer Ingelheim, Viosera, Xencor, Mirati Therapeutics, Janssen Oncology, Sanofi/Regeneron  Research Funding (Inst): Genentech, AstraZeneca, Merck, Loxo, Altor BioScience, Spectrum Pharmaceuticals, Bristol-Myers Squibb, Jounce Therapeutics, Mirati Therapeutics, Heat Biologics, WindMIL, Sanofi  Dr. Vamsidhar Velcheti:  Honoraria: ITeos Therapeutics  Consulting or Advisory Role: Bristol-Myers Squibb, Merck, Foundation Medicine , AstraZeneca/MedImmune, Novartis, Lilly, EMD Serono, GSK, Amgen  Research Funding (Institution): Genentech, Trovagene, Eisai, OncoPlex Diagnostics, Alkermes, NantOmics, Genoptix, Altor BioScience, Merck, Bristol-Myers Squibb, Atreca, Heat Biologics, Leap Therapeutics, RSIP Vision, GlaxoSmithKline  Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.  Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   

Overview: This medical podcast will educate attendees on the drivers of COVID-19 in the community, and the factors that contribute to disease progression in the hospital. Dr. Deepa Gotur will discuss the role of GM-CSF in hyperinflammation in the severe COVID-19 patient. Guest: Deepa Gotur, MD & Patrick A. Taylor, MD

My guest today is Dr. Paul Peter Tak. Dr. Tak received his medical degree cum laude from the Free University in Amsterdam and was trained as an internist, rheumatologist, and immunologist at Leiden University Medical Center, where he also received his PhD. He has been a Clinical Associate Professor of Medicine at the University of California San Diego. Next, he served as Professor of Medicine and founding Chair of the Department of Clinical Immunology and Rheumatology at the Academic Medical Centre/University of Amsterdam (AMC). During this time, he founded Arthrogen b.v., a biotech company focused on gene therapy. He has published extensively in peer-reviewed journals (> 570 publications, H-index 130, >75,000 citations) and received numerous awards. He has been elected Fellow of the Academy of Medical Sciences (U.K.) At GlaxoSmithKline he served as Senior Vice President, Chief Immunology Officer, and Global Development Leader. He oversaw the creation of a portfolio of new medicines for immune-mediated inflammatory diseases, cancer, infectious disease and pain, including anti-OSM antibody, anti-LAG3 antibody, ESM-BET inhibitor, RIP1 kinase inhibitor, anti-GM-CSF antibody, anti-CCL17 antibody, Benlysta sc, gepotidacin, molibresib (BET inhibitor), belantamab mafodotin (anti-BCMA antibody-drug conjugate), and NY-ESO1 SPEAR T cell therapy. He was the Chair of the Scientific Review Board, the governing body accountable for the scientific assessment of GSK's R&D portfolio. During 2018-2020 Paul Peter served as Venture Partner at Flagship Pioneering and also as President and CEO of Kintai Therapeutics, a start-up focused on enteric signaling networks, where he oversaw the creation of a portfolio of proprietary small molecules called precision enteric medicines for the treatment of obesity, neurological disease, and cancer. In addition, he has served as President and CEO of Tempero Pharmaceuticals, Board Member of Galvani Bioelectronics, ViiV Healthcare, Sitryx Therapeutics (co-founder), Omega Therapeutics, Levicept, and Citryll.

- Founder, Black Horse Capital Advisors - Decades of biotechnology investment experience - HHMI Fellow, National Cancer Institute, Rosenberg Lab - Multiple publications in T-cell therapy, GM-CSF and immunology pathways

There are many approved or experimental therapies in development for a range of indications that, because of their mechanisms of action, have been pursued as potential therapies to treat patients with COVID-19. One of the most advanced candidates in this category is lenzilumab, an experimental monoclonal antibody that's in development for certain cancers and other conditions. The antibody has the potential to neutralize a cytokine known as GM-CSF, which can trigger a severe immune reaction and cause hyperinflammation as a result of a cytokine storm. It is this immune response that underlies the most serious cases of COVID-19 virus. We spoke to Cameron Durrant, chairman and CEO of Humanigen, about lenzilumab, how it was recognized as a potential treatment for COVID-19, and the path forward for the therapy.

Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2020.10.23.352872v1?rss=1 Authors: Kalinski, A. L., Yoon, C., Huffman, L. D., Duncker, P. C., Kohen, R., Passino, R., Hafner, H., Johnson, C., Kawaguchi, R., Carbajal, K. S., Jara, J. S., Hollis, E., Segal, B., Giger, R. J. Abstract: Sciatic nerve crush injury triggers sterile inflammation within the distal nerve and axotomized dorsal root ganglia (DRGs). Granulocytes and pro-inflammatory Ly6C high monocytes infiltrate the nerve first, and rapidly give way to Ly6C negative inflammation-resolving macrophages. In axotomized DRGs, few hematogenous leukocytes are detected and resident macrophages acquire a ramified morphology. Single-cell RNA-sequencing of injured sciatic nerve identifies five macrophage subpopulations, repair Schwann cells, and mesenchymal precursor cells. Macrophages at the nerve crush site are molecularly distinct from macrophages associated with Wallerian degeneration. In the injured nerve, macrophages "eat" apoptotic leukocytes, a process called efferocytosis, and thereby promote an anti-inflammatory milieu. Myeloid cells in the injured nerve, but not axotomized DRGs, strongly express receptors for the cytokine GM-CSF. In GM-CSF deficient (Csf2-/-) mice, inflammation resolution is delayed and conditioning-lesion induced regeneration of DRG neuron central axons is abolished. Thus, carefully orchestrated inflammation resolution in the nerve is required for conditioning-lesion induced neurorepair. Copy rights belong to original authors. Visit the link for more info

Dr. Cameron Durrant, Chairman and CEO, Humanigen explains the condition called cytokine storm and how their research into GMCSF, the master switch of the cytokine storm, has led to the development of the drug lenzilumab, LENZ, that neutralizes GMCSF. Adding LENZ to Remdesivir has shown promising results in early clinical trials and Humanigen recently announced they have signed an agreement with the National Institutes of Health to test LENZ in a larger trial in the search for a therapeutic for COVID-19. @humanigen #cytokinestorm #COVID19 #LENZ #Remdesivir #NIH Humanigen.com Listen to the podcast here.

Dr. Cameron Durrant, Chairman and CEO, Humanigen explains the condition called cytokine storm and how their research into GMCSF, the master switch of the cytokine storm, has led to the development of the drug lenzilumab, LENZ, that neutralizes GMCSF. Adding LENZ to Remdesivir has shown promising results in early clinical trials and Humanigen recently announced they have signed an agreement with the National Institutes of Health to test LENZ in a larger trial in the search for a therapeutic for COVID-19. @humanigen #cytokinestorm #COVID19 #LENZ #Remdesivir #NIH Humanigen.com Download the transcript here

Humanigen, Inc. (OTCQB: HGEN) is a biopharmaceutical company developing its portfolio of next-generation cell and gene therapies for the treatment of cancers via its novel, GM-CSF neutralization, and gene-knockout platforms. We welcome back Chairman & CEO of Humanigen, Cameron Durrant, MD, MBA, to explain the significance of “GM-CSF” pathway science for COVID-19 patients.

¡Gracias por escuchar! En este episodio hablaré del papel que juega la inflamación en la generación de dolor en pacientes con osteoartritis. La OA tiene una morbilidad asociada sustancial y constituye un creciente problema de salud pública derivado en gran medida del envejecimiento poblacional. Los síntomas de la OA pueden ser funcionales pero se manifiestan principalmente como dolor y el manejo de la enfermedad se centra principalmente en su control.Agradezco que escuchen este podcast y les recuerdo que se encuentra disponible en el catálogo de iTunes, en Google Play (siendo accesible a través del gestor de podcasts de su dispositivo móvil), así como en Spotify. Agradezco también su retroalimentación en estas plataformas y les pido amablemente que califiquen el podcast ya que esto es importante para su continuado desarrollo.A continuación se enlistan las referencias mencionadas en este episodio: Grace, P. M., Hutchinson, M. R., Maier, S. F. & Watkins, L. R. Pathological pain and the neuroimmune interface. Nat. Rev. Immunol. 14, 217–231(2014).Owens, C. & Conaghan, P. G. Improving joint pain and function in osteoarthritis. Practitioner 260, 17–20 (2016).O’Neil, C. K., Hanlon, J. T. & Marcum, Z. A. Adverse effects of analgesics commonly used by older adults with osteoarthritis: focus on non-opioid and opioid analgesics. Am. J. Geriatr. Pharmacother. 10, 331–342 (2012).Wang, Y., Teichtahl, A. J. & Cicuttini, F. M. Osteoarthritis year in review 2015: imaging. Osteoarthritis Cartilage 24, 49–57 (2016).Haringman, J. J., Smeets, T. J., Reinders-Blankert, P. & Tak, P. P. Chemokine and chemokine receptor expression in paired peripheral blood mononuclear cells and synovial tissue of patients with rheumatoid arthritis, osteoarthritis, and reactive arthritis. Ann. Rheum. Dis. 65, 294–300 (2006).de Lange-Brokaar, B. J. et al. Degree of synovitis on MRI by comprehensive whole knee semi-quantitative scoring method correlates with histologic and macroscopic features of synovial tissue inflammation in knee osteoarthritis. Osteoarthritis Cartilage 22, 1606–1613 (2014).Cook, A. D., Christensen, A. D., Tewari, D., McMahon, S. B. & Hamilton, J. A. Immune cytokines and their receptors in inflammatory pain. Trends Immunol. 39, 240–255 (2018).Malfait, A. M. & Schnitzer, T. J. Towards a mechanism-based approach to pain management in osteoarthritis. Nat. Rev. Rheumatol. 9, 654–664 (2013).Bellamy, N. et al. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst. Rev. 2, CD005328 (2006).McAlindon, T. E. et al. Effect of intra-articular triamcinolone versus saline on knee cartilage volume and pain in patients with knee osteoarthritis:a randomized clinical trial. JAMA 317, 1967–1975 (2017).Aitken, D. et al. A randomised double-blind placebo-controlled crossover trial of HUMira (adalimumab) for erosive hand OsteoaRthritis — the HUMOR trial. Osteoarthritis Cartilage 26, 880–887 (2018).Cohen, S. B. et al. A randomized, double-blind study of AMG 108 (a fully human monoclonal antibody to IL-1R1) in patients with osteoarthritis of the knee. Arthritis Res. Ther. 13, R125 (2011).Wang, S. X. et al. Safety, tolerability, and pharmacodynamics of an anti-interleukin-1alpha/beta dual variable domain immunoglobulin in patients with osteoarthritis of the knee: a randomized phase 1 study. Osteoarthritis Cartilage 25, 1952–1961 (2017).Eitner, A., Hofmann, G. O. & Schaible, H. G. Mechanisms of osteoarthritic pain. Studies in humans and experimental models. Front. Mol. Neurosci. 10, 349 (2017).Basbaum, A. I., Bautista, D. M., Scherrer, G. & Julius, D. Cellular and molecular mechanisms of pain. Cell 139, 267–284 (2009).Ji, R. R., Xu, Z. Z. & Gao, Y. J. Emerging targets in neuroinflammation-driven chronic pain. Nat. Rev. Drug Discov. 13, 533–548 (2014).McMahon, S. B., La Russa, F. & Bennett, D. L. Crosstalk between the nociceptive and immune systems in host defence and disease. Nat. Rev. Neurosci. 16, 389–402 (2015).Pinho-Ribeiro, F. A. et al. Blocking neuronal signaling to immune cells treats streptococcal invasive infection. Cell 173, 1083–1097 (2018).Shechter, R. et al. Infiltrating blood-derived macrophages are vital cells playing an anti-inflammatory role in recovery from spinal cord injury in mice. PLOS Med. 6, e1000113 (2009).Willemen, H. L. et al. Monocytes/macrophages control resolution of transient inflammatory pain. J. Pain 15, 496–506 (2014).Barthel, C. et al. Nerve growth factor and receptor expression in rheumatoid arthritis and spondyloarthritis. Arthritis Res. Ther. 11, R82 (2009).Skaper, S. D. Nerve growth factor: a neuroimmune crosstalk mediator for all seasons. Immunology 151, 1–15 (2017).Denk, F., Bennett, D. L. & McMahon, S. B. Nerve growth factor and pain mechanisms. Annu. Rev. Neurosci. 40, 307–325 (2017).Minnone, G., De Benedetti, F. & Bracci-Laudiero, L. NGF and its receptors in the regulation of inflammatory response. Int. J. Mol. Sci. 18, E1028 (2017).Bagal, S. K. et al. Discovery of potent, selective, and peripherally restricted Pan-Trk kinase inhibitors for the treatment of pain. J. Med. Chem. 61, 6779–6800 (2018).Pinho-Ribeiro, F. A., Verri, W. A. Jr & Chiu, I. M. Nociceptor sensory neuron-immune interactions in pain and inflammation. Trends Immunol. 38, 5–19 (2017).Robinson, W. H. et al. Low-grade inflammation as a key mediator of the pathogenesis of osteoarthritis. Nat. Rev. Rheumatol. 12, 580–592 (2016).de Lange-Brokaar, B. J. et al. Synovial inflammation, immune cells and their cytokines in osteoarthritis: a review. Osteoarthritis Cartilage 20, 1484–1499 (2012).Rahmati, M., Mobasheri, A. & Mozafari, M. Inflammatory mediators in osteoarthritis: a critical review of the state-of-the-art, current prospects, and future challenges. Bone 85, 81–90 (2016).Urban, H. & Little, C. B. The role of fat and inflammation in the pathogenesis and management of osteoarthritis.Rheumatology 57, iv10–iv21 (2018).Dawes, J. M., Kiesewetter, H., Perkins, J. R.,Bennett, D. L. & McMahon, S. B. Chemokine expression in peripheral tissues from the monosodium iodoacetate model of chronic joint pain. Mol. Pain 9, 57 (2013).Driscoll, C. et al. Nociceptive sensitizers are regulated in damaged joint tissues, including articular cartilage, when osteoarthritic mice display pain behavior. Arthritis Rheumatol. 68, 857–867 (2016).Sweitzer, S. M., Hickey, W. F., Rutkowski, M. D., Pahl, J. L. & DeLeo, J. A. Focal peripheral nerve injury induces leukocyte trafficking into the central nervous system: potential relationship to neuropathic pain. Pain 100, 163–170 (2002).Hu, P., Bembrick, A. L., Keay, K. A. & McLachlan, E. M. Immune cell involvement in dorsal root ganglia and spinal cord after chronic constriction or transectionof the rat sciatic nerve. Brain Behav. Immun. 21, 599–616 (2007).Lems, W. F. Bisphosphonates: a therapeutic option for knee osteoarthritis? Ann. Rheum. Dis. 77, 1247–1248 (2018).Wenham, C. Y. et al. A randomized, double-blind, placebo-controlled trial of low-dose oral prednisolone for treating painful hand osteoarthritis. Rheumatology 51, 2286–2294 (2012).Dorleijn, D. M. J. et al. Intramuscular glucocorticoid injection versus placebo injection in hip osteoarthritis: a 12-week blinded randomised controlled trial. Ann. Rheum. Dis. 77, 875–882 (2018).McCabe, P. S. et al. Synovial fluid white blood cell count in knee osteoarthritis: association with structural findings and treatment response. Arthritis Rheumatol. 69, 103–107 (2017).Leung, Y. Y. et al. Colchicine lack of effectiveness in symptom and inflammation modification in knee osteoarthritis (COLKOA): a randomized controlled trial. Osteoarthritis Cartilage 26, 631–640 (2018).Kingsbury, S. R. et al. Hydroxychloroquine effectiveness in reducing symptoms of hand osteoarthritis: a randomized trial. Ann. Intern. Med. 168, 385–395 (2018).Lee, W. et al. Efficacy of hydroxychloroquine in hand osteoarthritis: a randomized, double-blind, placebo-controlled trial. Arthritis Care Res. 70, 1320–1325 (2018).Wenham, C. Y. et al. Methotrexate for pain relief in knee osteoarthritis: an open-label study. Rheumatology 52, 888–892 (2013).Kingsbury, S. R. et al. Significant pain reduction with oral methotrexate in knee osteoarthritis; results from a randomised controlled phase III trial of treatment effectiveness [abstract 428]. Arthritis Rheumatol. 70 (Suppl. 9), 454–455 (2018).Ridker, P. M. et al. Antiinflammatory therapy with canakinumab for atherosclerotic disease. N. Engl. J. Med. 377, 1119–1131 (2017).Kashyap, M. P., Roberts, C., Waseem, M. & Tyagi, P. Drug targets in neurotrophin signaling in the central and peripheral nervous system. Mol. Neurobiol. 55, 6939–6955 (2018).Bannwarth, B. & Kostine, M. Nerve growth factor antagonists: is the future of monoclonal antibodies becoming clearer? Drugs 77, 1377–1387 (2017).Baamonde, A., Lastra, A., Juarez, L., Hidalgo, A. & Menendez, L. TRPV1 desensitisation and endogenous vanilloid involvement in the enhanced analgesia induced by capsaicin in inflamed tissues. Brain Res. Bull. 67, 476–481 (2005).Hamilton, J. A., Cook, A. D. & Tak, P. P. Anti-colony- stimulating factor therapies for inflammatory and autoimmune diseases. Nat. Rev. Drug Discov. 16, 53–70 (2017).Schett, G. et al. A phase IIA study of anti-GM-CSF antibody GSK3196165 in subjects with inflammatory hand osteoarthritis [abstract 1365]. Arthritis Rheumatol. 70 (Suppl. 9), 1494 (2018).Achuthan, A. et al. Granulocyte macrophage colony-stimulating factor induces CCL17 production via IRF4 to mediate inflammation. J. Clin. Invest. 126, 3453–3466 (2016).Wylde, V., Hewlett, S., Learmonth, I. D. & Dieppe, P. Persistent pain after joint replacement: prevalence, sensory qualities, and postoperative determinants. Pain 152, 566–572 (2011).Beswick, A. D., Wylde, V., Gooberman-Hill, R., Blom, A. & Dieppe, P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open 2, e000435 (2012).Li, H., Wang, R., Lu, Y., Xu, X. & Ni, J. Targeting G protein-coupled receptor for pain management. Brain Circ. 3, 109–113 (2017).

This JCO Podcast provides observations and commentary on the JCO article “Maintaining Outstanding Outcomes Using Response and Biology-Based Therapy for Intermediate-Risk Neuroblastoma: A Report From the Children's Oncology Group Study ANBL0531” by Twist et al. My name is Javed Khan, and I am Deputy Chief and Senior Investigator at the Genetics Branch and an Attending for the Pediatric Oncology Branch of the National Cancer Institutes of the NIH in Bethesda, Maryland. My oncologic specialty is Pediatric Hematology Oncology. Childhood cancer is a life-threatening disease where survival rates have increased exponentially to over 75% over the past three decades. However, this has come at a considerable cost with significant incidence of late effects including hearing loss, scoliosis, hypothyroidism, growth and development delay, infertility, psychological, emotional, cognitive and neurological sequelae, and secondary malignancies. Most of these late effects have been attributed therapy including chemotherapy, surgery and radiation. In the manuscript that accompanies this podcast, Twist et al report on the results of the Children’s Oncology Group study ANBL0531, whose primary aim was to reduce therapy for subsets of children aged =95% for the entire cohort. Neuroblastoma is an extracranial pediatric malignancy of neural crest origin that has often been described as an enigmatic cancer due to its significant clinical, molecular and biological heterogeneity. For example, some patients with widely metastatic disease are cured with minimal or no therapy whereas others have relentless progression to death despite intensive therapies.  There has been considerable progress in dissecting out the causes of this heterogeneity and developing prognostic biomarkers to stratify the risk based on several clinical, histological and molecular markers. At the time this clinical study was performed, and the manuscript written, the authors stratified patients using several clinical and biologic parameters including age, the International Neuroblastoma Staging System, MYCN amplification status, the International Neuroblastoma Pathology Classification of histopathology, and tumor DNA index. An additional marker utilized in this study was loss of heterozygosity determination of the tumors at chromosome bands 1p36 and 11q23. This stratification strategy has led to the identification of low and high-risk groups where therapy is more clearly defined and patients with low risk have excellent outcome for most patients with surgery alone and watchful waiting. For high-risk disease, significant strides have been made using a combination of surgery, aggressive chemotherapy, radiation followed by Chimeric Antibody 14.18 anti GD2 therapy, GM-CSF, IL-2 and Isotretinoin, however the five-year survival remains guarded at 40-50%. In the intermediate-risk group, the subject of this study, although the 5-year survival rates of 90-95% have been achieved, this group is significantly heterozygous raising the possibility of reducing therapy for subsets of patients within this group. This was the motivation for this study. Thus, the goal of this clinical protocol, ANBL0531, was to refine the minimal therapy needed to achieve excellent outcomes for patients with intermediate-risk neuroblastoma, with the aim to maintain an overall 3-year OS rate of > 95% for the entire cohort. Patients were stratified into Groups 2, 3, or 4, who were assigned to receive a minimum of 2, 4, or 8 cycles of chemotherapy, respectively. Chemotherapy was identical to that used on a previous study A3961. Reduction of therapy was planned to be achieved for patients with biologically favorable tumors (Groups 2 and 3) by using the achievement of Partial Response (PR) to chemotherapy +/- surgery to be the endpoint of therapy, rather than the achievement of Very Good Partial Response (VGPR) as was previously used on A3961. If the treatment endpoint was not achieved after completion of the scheduled chemotherapy courses, additional cycles of therapy could be administered, and patients re-evaluated following every 2 cycles to determine if the treatment endpoint has been achieved. VGPR, a more stringent response criteria, was used for Group 4 patients which includes those with age< 365 days, stage 4 disease, MYCN-not amplified, and either Unfavorable Histology (UH) or DNA Index or Ploidy (DI)=1. Patients within this subgroup received 8 cycles of chemotherapy on A3961, which was a reduction in therapy for these patients compared to prior studies. Group 4 patients also includes 2 subgroups who were previously stratified as high risk including those who had stage 3 disease, age 365- < 547days, stage 3, MYCN-NA, UH, any ploidy and also those with stage 4 disease, age 365 - < 547 days, MYCN-NA, FH, DI>1). These patients also received Isotretinoin (13-cis-retinoic acid, Accutane) for maintenance therapy, as they would have previously received this treatment on high-risk protocols. Thus, these patients would receive a significant reduction in therapy compared to prior studies.  These patients were closely monitored by interim stopping rules. Rescue therapy for this study for patients with an inadequate response to initial therapy and for patients with progressive, non-metastatic disease utilized standard cyclophosphamide and topotecan. Reduction of therapy was also planned and achieved on their study by reducing potential surgical morbidity for patients with stage 4S disease, who would no longer be required to undergo resection of their primary tumor. In the manuscript, the authors report that 404 evaluable patients were enrolled between 2007 and 2011, They found that compared to legacy COG studies, subsets of patients with locoregional disease, infants with stage 4 or 4S tumors, and toddlers with stage 3 or 4 disease had a reduction in treatment. The 3-year event-free survival (EFS) and OS were 83.2±1.9% and 94.9±1.1%, respectively. Infants with stage 4 favorable biology tumors (n=61) had superior 3-year EFS compared to patients with >= unfavorable biological feature (n=47; 86.9±4.4% versus 66.8±7.0%; p=0.02), with a trend towards OS advantage (95.0±2.8% and; 86.9±5.1% respectively p=0.08. For patients with localized disease OS was 100%. They conclude that comparable/excellent survival was achieved with this biology- and response-based algorithm, with reduction of therapy for subsets of intermediate-risk neuroblastoma patients. However, more effective treatment strategies are still needed for infants with unfavorable biology stage 4 disease. For the 32 infants with hyperdiploid, favorable histology (FH) stage 4 tumors with LOH at 1p36 or 11q23, or missing LOH data, intensification of treatment on ANBL0531 compared to A396110 did not reduce the risk of relapse previously reported for infants with tumors that harbor these genetic anomalies. Three-year EFS for this cohort was 68.6% (95% CI: 52.2-85.1%) versus 86.9% (95% CI: 78.3-95.4%) for stage 4 infants with favorable biology (p=0.04). Overall survival was not significantly different, indicating that many of the infants with 1p36/11q23 aberrations were successfully salvaged. Of the 20 patients who received CPM/TOPO due to an inadequate response to initial therapy, 9 achieved ≥VGPR. However, 6 of the 20 patients developed PD or relapsed, and 1 died, indicating that more effective treatment is needed for patients who do not meet the defined treatment endpoint after 8 cycles of chemotherapy. Take home messages: This is an important study with clinical implications for intermediate-risk neuroblastoma where the authors show that it is possible to reduce therapy based on a clinical Partial Response (PR) endpoint compared to Very Good Partial Response (VGPR). This most likely reflects the biology of the disease such that tumors that are responding to therapy will continue to involute. However, more effective therapy is needed for those patients who develop progressive disease (PD) or relapse or do not meet the defined treatment endpoint after 8 cycles of chemotherapy as these patients continue to have poor outcome. This will await the result of current biological and genomic studies and the development of novel therapies targeting ALK or RAS, or epigenetic targeting of MYC or MYCN activated tumors, or immunotherapeutic approaches such as adoptive cell therapies consisting of chimeric antigen receptor (CAR T cell) or, NK cells, or the use of immunocytokines such as hu14.18-IL2 or antibody drug conjugates. All these holds promise for future sub-stratification and new therapies for children with intermediate and high-risk neuroblastoma. This concludes this JCO Podcast. Thank you for listening.

Dr Carolyn Lam:                Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore.                                                 Our featured paper this week reports the five-year clinical outcomes and valve durability in the largest available cohort to date of consecutive high-risk patients undergoing transcatheter aortic valve replacement. You must listen up for this discussion, coming right up after these summaries.                                                 The first original paper describes a personalized risk assessment platform that promotes the implementation of precision medicine by helping us with the evaluation of a genomic variant of uncertain significance. A genomic variant of uncertain significance is a rare or novel variant for which disease pathogenicity has not been conclusively demonstrated or excluded and thus cannot be definitively annotated. These variants therefore pose critical challenges to the clinical interpretation and risk assessment. New methods are therefore urgently needed to better characterize their pathogenicity.                                                 Co-first authors, Dr Ma, Zhang, and Itzhaki, corresponding author Dr Wu from Stanford University School of Medicine and colleagues recruited a healthy, asymptomatic individual lacking cardiac disease clinical history and carrying hypertrophic cardiomyopathy associated genetic variant in the sarcomeric gene, MYL3, which has been reported by ClinVar database to be likely pathogenic.                                                 Human-induced pluripotent stem cells or IPSCs were derived from the heterozygous carrier, and their genome was edited using CRISPR/Cas9 genome editing to generate karyo-specific IPSCs. Extensive essays, including measurements of gene expression, sarcomere structure, cell size, contractility, action potentials, and calcium handling were performed on the isogenic IPSC-derived cardiomyocytes, and together, the platform was shown to elucidate both benign and pathogenic hypertrophic cardiomyopathy-functional phenotypes.                                                 Thus, this paper demonstrates for the first time the unique potential of combining IPSC-based disease modeling and CRISPR/Cas9 genome editing technology as a personalized risk assessment platform for determining the pathogenicity of a variant of unknown significance for hypertrophic cardiomyopathy in a patient-specific manner.                                                 Transcatheter aortic valve replacement is increasingly being used for the treatment of severe aortic valve stenosis in patients at intermediate risk for surgical aortic valve replacement. The next paper provides real world data comparing indications and clinical outcomes of patients at intermediate surgical risk undergoing isolated transcatheter vs. surgical aortic valve replacement.                                                 Co-first and corresponding others, Dr Werner and Zahn from Clinical Ludwigshafen in Germany compared clinical characteristics and outcomes of more than 7,600 patients with intermediate surgical risk who underwent isolated transcatheter or conventional surgical aortic valve replacement within the prospective all-comers, German aortic valve registry between 2012 and 2014.                                                 Multi-variable analyses reveal that factors that were associated with performing transcatheter instead of surgical aortic valve replacement included advanced age, coronary artery disease, New York Heart Association class three or four, pulmonary hypertension, prior cardiac decompensation, and elective procedure, arterial occlusive disease, no diabetes mellitus, and a smaller aortic valve area.                                                 Unadjusted in-hospital mortality rates were equal for transcatheter and surgical aortic valve replacement, whereas unadjusted one-year mortality was significantly higher in patients with transcatheter aortic valve replacement. After propensity score matching, the difference in one-year mortality was no longer significant. Thus, this large registry analysis suggests that both transcatheter and surgical aortic valve replacement are reasonable treatment options in a real world population with aortic stenosis and intermediate surgical risk.                                                 The next paper demonstrates a key role of vascular endothelial growth factor receptor 1 in hemorrhagic telangiectasia type 2. Now, this is an inherited genetic disorder where haplo-insufficiency of the activin receptor-like kinase 1 gene, ACVRL1, results in blood vessels that are prone to respond to angiogenic stimuli, leading to the development of telangiectatic lesions that can bleed.                                                 First author, Dr Thalgott, corresponding author, Dr Lebrin from Leiden University Medical Center and colleagues used ACVRL mutant mice and found that vascular endothelial growth factor, or VEGF receptor 1 levels were reduced, causing increased VEGF receptor 2 signaling that promoted sprouting angiogenesis, correcting the abnormal VEGF gradient, by expressing membranal-soluble VEGF receptor 1 in embryonic stem cells or blocking VEGF receptor 2 with antibodies in mutant mice, normalized the phenotype both in vitro and in vivo.                                                 Importantly, VEGF receptor 1 was reduced in the blood and skin blood vessels of patients with hemorrhagic telangiectasia type 2 compared with H match controls, demonstrating an important role of VEGF receptor 1 in these patients and explaining why their blood vessels might respond abnormally to angiogenic signals. These findings support the use of anti-VEGF therapy in hemorrhagic telangiectasia type 2.                                                 The next study suggests that hydroxychloroquine could be repurposed to reduce the risk of rheumatic heart disease following acute rheumatic fever. First author, Dr Kim, corresponding author, Dr Wicks from Walter and Eliza Hall Institute of Medical Research and University of Melbourne and their colleagues analyzed the immune response to group A streptococcus in peripheral blood mononuclear cells from an Australian Aboriginal acute rheumatic fever cohort by a combination of multiplex cytokine array, flow cytometric analysis, and global gene expression analysis by RNA sequencing.                                                 They then tested the widely used immunomodulatory drug, hydroxychloroquine for its effects on this response. They found that group A streptococcus activated persistent IL-1 beta production and selective expansion of a specific group of T helper 1 cells that produce GMCSF. Furthermore, hydroxychloroquine limited the expansion of these group A streptococcus-activated, GMCSF-producing T helper cells in vitro.                                                 Gene transcriptional profiling of peripheral blood mononuclear cells from patients with acute rheumatic fever showed dynamic changes at different stages of disease. Given the safety profile of hydroxychloroquine and its clinical pedigree in treating autoimmune diseases such as rheumatoid arthritis where GMCSF plays a pivotal role, the authors therefore proposed that hydroxychloroquine could be repurposed to reduce the risk of rheumatic heart fever following acute rheumatic fever.                                                 The next paper identifies a new anchoring B genetic variant in unrelated Han Chinese probands with ventricular tachycardia. In this paper from co-first authors, Dr Zhu, Wang and Hu, co-corresponding authors, Dr Hong from Second Affiliated Hospital of Nanjing University, Dr Mohler from Ohio State University Wexner Medical Center and colleagues, the authors identified the first anchoring B variant, Q1283H, localized to the ZU5C region in a proband with recurrent ventricular tachycardia.                                                 Knocking mice with this variant showed an increased susceptibility to arrhythmias associated with abnormal calcium dynamics. The variant was associated with loss of protein phosphatase 2A activity, increased phosphorylation of ryanodine receptor, exaggerated delayed after depolarization-mediated trigger activity, and arrhythmogenesis. Furthermore, the administration of metoprolol or flecainide decreased the incidence of stress-induced ventricular arrhythmias, representing potential therapies for anchoring B variant-associated arrhythmias.                                                 Does variability in metabolic parameters affect health outcomes? First author, Dr Kim, corresponding author, Dr Lee from Seoul Saint Mary's Hospital College of Medicine and Catholic University of Korea and their colleagues used nationally representative data from the Korean National Health Insurance system, consisting of more than 6.7 million people who are free of diabetes, hypertension, or dyslipidemia and who underwent three or more health examinations from 2005 to 2012 and were followed to the end of 2015.                                                 Variability and fasting blood glucose and total cholesterol, systolic blood pressure and body mass index was measured using the coefficient of variation, standard of deviation, variability independent of the mean, and average real variability. They found that a high variability in fasting glucose and cholesterol, systolic blood pressure and body mass index was associated with a higher risk for all-cause mortality, myocardial infarction, and stroke. Variabilities in several metabolic parameters had additive associations with the risk of mortality and cardiovascular outcomes in the general population.                                                 These findings suggest that treatment strategies to reduce fluctuations in metabolic parameters may be considered another goal to prevent adverse health outcomes.                                                 How much exercise over a lifetime is necessary to preserve efficient ventricular arterial coupling? First author Dr Hieda, corresponding author Dr Levine from Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center and colleagues studied 102 seniors and grouped them based on their 25 years of exercise training history. The dynamic Starling mechanism was estimated by transfer function gain between beat-by-beat changes in diastolic pulmonary artery pressure and stroke volume index.                                                 They found that there was a graded dose-dependent improvement in ventricular arterial coupling with increasing amounts of lifelong regular exercise in healthy older individuals. Their data suggested that the optimal does of lifelong endurance exercise to preserve ventricular arterial coupling with age appeared to be at least four to five sessions per week. The sufficient lifelong endurance exercise was effective for maintaining the normal dynamic Starling mechanism, left ventricular compliance, and arterial compliance with aging, all of which may lead to favorable effect on cardiovascular stiffness or function.                                                 And that brings us to the end of our summaries this week. Now, for our feature discussion.                                                 Transcatheter aortic valve replacement is taking over the interventional world. It's really rapidly growing, and we're increasingly using it for the treatment of aortic stenosis. It was initially used for inoperable and high-risk patients but now is indicated even in the treatment of intermediate-risk patient, and even low-risk patients are being enrolled into current trials.                                                 So, with TAVR being used for low- and intermediate-risk patients, the longer-term results of this treatment involved your abilities becoming more and more important. Well, gratefully, we have today's feature paper, and it describes the five-year clinical outcomes and valve durability of the FRANCE-2 Registry.                                                 I'm so pleased to have with us the corresponding author, Dr Martine Gilard from University Hospital of Brest in France, we have our editorialist, Dr Anita Asgar from Montreal Heart Institute, and we have our associate editor, Dr Dharam Kumbhani from UT Southwestern.                                                 Martine, congratulations on this largest cohort of high-risk patients and long-term outcomes. Could you please tell us what you found? Dr Martine Gilard:            Yes, and I'll just quote, actually, to have a follow-up of five years. We have 1,200 patients arrive at five years after rotation of TAVI. Each patient was a high-risk patient because it was at the beginning of each treatment, and in this time, it's only the high-risk patient was implanted with TAVI, and actually, we can follow this 1,200 patients, 50% of these patients of these patients have an echography because when we analyze these patients, we have an echography at five years, and the patients who have not echography at five years, the only difference is the age.                                                 It's very old patient. It's very difficult to make this echography on this patient to come back in our center, so it's why there is not all the patient who have an echography at five years.                                                 But our patients who have an echography, we can see that it's a very, very good result at five years. There is always the same area, just after before, of the valve. There is the same gradient. There is not a sign of deterioration.                                                 As you know, we have some guidelines published last year about how we asked to define deterioration of the valve, surgical or TAVI, and if we apply this new recommendation, we saw that in this largest cohort, at five years, there is only 13% of patient who have some sign of deterioration, and of these patients, we never need to make another valve in valve because the deterioration was not so important, and patient leave with this valve like that. There is no necessity to make a new valve in valve, so at five years of this very high-risk patient treated by TAVI, there is no necessity to implant a second valve because the valve deterioration. It's a very, very important message. Dr Carolyn Lam:                Thank you, Martine. Indeed, an important message. And Anita, you wrote a beautiful editorial about it. First, could I ask you to frame the issue? I mean, is there any reason we would expect the durability to be any different from a surgical replacement? Dr Anita Asgar:                  I think that's a great question, Carolyn, and I congratulate again Martine and her team for doing a fantastic job to add some very important results to the clinical literature on TAVI. Five years is relatively early to see structural valve deterioration, so in a sense, it's not surprising, and we would consider this sort of medium-term follow-up rather than really long-term durability, but very reassuring that in a high-risk population of patients, that TAVR performs very well in this population of patients and as mentioned, is very low to the dynamic structural valve deterioration.                                                 One question I have for Martine is, as you mentioned, there was only about 12% that had some evidence of structural valve deterioration hemodynamically, but this didn't result in another procedure, and I wonder if you could explain a little bit about that, whether it's the hemodynamic dynamic value, and yet there's a clinical indication for re-intervention. How do you incorporate the two? Dr Martine Gilard:            It's actually hemodynamic deterioration, there is some form of regurgitation. However, there is no need or clinical indication to make another intervention. So, if you compare this research to the bioprostheses surgical paths, the only one who have, at five years, no need to make a re-intervention appearing rotated, which is a valve, a surgical valve we have a longer bioprostheses surgical path.                                                 So, if we compare this best bioprostheses surgical valve, we have sustained results at five years. At five years, we have no need to make a re-intervention because the deterioration was not so important or as needed for clinical evidence as a need to make a new intervention. Dr Anita Asgar:                  So, there were some increased rates of heart failure in those patients with structural valve deterioration in your paper, and I know that in the paper you did mention that this is not an adjudicated outcome, and there wasn't a VARC definition for heart failure, but what's your interpretation of increasing heart failure events in these patients with structural valve deterioration? Dr Martine Gilard:            We have no real definition about that. We know that there is another registry. We say that there is an increasing of heart failure, and during the follow-up, and the result of this heart failure increase in mortality. There is an increasing of heart failure, but the number of these patients, there is more. So I don't know if this due to because patient is a high-risk patient, or it's because of the TAVI, but it's very difficult actually to have a real explanation about that. Dr Carolyn Lam:                Thanks, Anita and Martin. Dharam, could you share some of the thoughts and the discussions that were going on behind the scenes with the editors when we saw this paper? Dr Dharam Kumbhani:   Professor Gilard, this was a really excellent paper. We really appreciated you sending it to us, and I think for us, the fact that this was a very large cohort, the largest published cohort that has gotten to five years in a TAVR population, in a multicenter study, and having very good follow-up up to five years, with these patients is always this competing hazard that you want to know what the valve is doing at five years from an echocardiographic and hemodynamic perspective, but there's such a high competing hazard of death, just given the population that you're enrolling, and still, you had one of the largest echo follow-ups on these patients, so we want to congratulate you on the study and really a monumental endeavor, and so really great, great work there.                                                 And I think this is, exactly some of the questions that I think we had and I'm sure that the audience would have as well, I guess the one other question I have, and it's not really a question about your paper. So the median Euro score is 21 in this study, approximately 21, so that's obviously gonna, consistent with the patients that are being enrolled at that time between 2007 and 2012, which were predominantly high-risk and inoperable patients. Can you talk to us a little bit about the landscape of, how is TAVR practice in France as a society or from the regulatory standpoint, what are the benchmarks that you have achieve as you move towards low-risk now? Because intermediate-risk, I'm assuming is a [inaudible 00:20:16], so could you talk to us a little bit about the landscape there? Dr Martine Gilard:            Yes. In France, it's difficult because we have the authority to follow, not immediately, the ESC recommendations, so actually in France, we are allowed to implant only patients with high risk, patients with complication of surgery, and actually just since one year, patients with automatic risk, but we have no authorization to implant patient with low risk.                                                 However, the most important fact is the heart team, and if they write. Because we need to have something written, and if they write, if they explain that it's necessary to implant a patient at low risk because of some point while not including the risk score or it's very difficult to explain, for example, frailty or something, we can implant a patient with low risk.                                                 But normally actually, it is only for complication or high risk and for intermediate risk like the recommendation of the ESC.                                                 So the rate of implantation in France increased because we implant only 2,000 people per year, but actually, in 2017, we have implanted 10,200 patient, and this year, we think that we implant 12,800 patients, so as the number of patients increase, the number of patients who have a very high risk decrease because there is a futile indication, and we have a lot of futile indication, so we doesn't implant patient while too high-risk, and we select the most majority of patient implanted in France was high-risk but also intermediate-risk. Dr Dharam Kumbhani:   So, you think you're implanting more intermediate, like that is a bigger population that is getting TAVIs right now in France? Dr Martine Gilard:            Yes, exactly. Dr Carolyn Lam:                How about perspectives from Montreal? What do you think the implications of this findings from today's paper in relation to the types of patients that you might perform this in now? Dr Anita Asgar:                  For us, this is exceptionally reassuring, and as Martine has said, I mean, we have transitioned as well away from that very inoperable cohort C type of patient to more your higher-risk patient or intermediate, and to be honest, everyone over the age of 80 in Canada essentially is getting a TAVR. Dr Carolyn Lam:                Oh, wow. Dr Anita Asgar:                  Because regardless of their risk, and we've been very aggressive with that because trying to get patients back to an appropriate quality of life is very important, and to seeing this very reassuring data is telling us that, as she has already mentioned, we have reached the standard, at least in midterm follow-up as the gold standard of surgical valve replacement, and so structural valve deterioration is not as big a concern.                                                 I think we still however need longer-term data when we're looking at lower-risk patients, and lower-risk patients, let's remember, are not 60-year-olds. They're the 75-year-old, perhaps. But we're still gonna need some more data, but it's very reassuring, and patients are asking for it and are really advocating on their behalf to have a less invasive approach, and I think we can say now with more certainty that we know after five years, your chance of structural valve deterioration is actually quite low, and so I think that's very helpful from our point of view. Dr Carolyn Lam:                I love that, Anita, and it's so consistent with the title of your editorial, "Closing in on the Finish Line". Love it, love it, and recommend all listeners pick it up and have a good read. Dharam, I want to leave the last words to you. What do you think are the implications of this paper? Dr Dharam Kumbhani:   Well, I think that, as Anita said, this is very encouraging results that, in this kind of extreme and high-risk patient cohort, that there appear to be no medium- to long-term signals of structural valve degeneration, that the biggest hazard from this procedure is all upfront, and after that, it's pretty much, it's as we have seen with surgery, that after that, the actuarial rates come back to what you would expect.                                                 If they didn't have aortic stenosis and then they would die from whatever causes they had. Now obviously, that wasn't tested, but it seems like looking at the curves, that that seems like what's going on, so I think they've done a great service to our TAVR community in terms of showing us these results in very large, multicenter cohorts from France. Dr Carolyn Lam:                Thank you so much for joining us today. Thank you, listeners. You've been listening to Circulation on the Run. Don't forget to tune in again next week.                                                 This program is copyright American Heart Association, 2018.  

Dr. William Williams, BriaCell’s President & CEO, called in to SmallCapVoice.com, Inc. to discuss BriaCell Therapeutics Corp.’s history, management, advisory board, Bria-IMT™ (SV-BR-1-GM), the Company's lead product candidate as a targeted and safe approach to the management of cancer, and more. Recently, the Company announced the acceptance of a manuscript describing the novel mechanism of action of the Company’s lead product candidate, Bria-IMT™. The findings detailed in the paper provide a rationale for the encouraging clinical results observed with Bria-IMT™ in current and past clinical testing. The publication will appear in Frontiers in Immunology, the 5th most cited journal in Immunology worldwide. Bria-IMT™, also known as SV-BR-1-GM, has caused remarkable reduction of tumor size in some patients with advanced metastatic breast cancer. BriaCell is an immuno-oncology focused biotechnology company developing a targeted and safe approach to the management of cancer. Immunotherapy has come to the forefront in the fight against cancer, harnessing the body's own immune system in recognizing and selectively destroying cancer cells while sparing normal ones. Immunotherapy, in addition to generally being more targeted and less toxic than commonly used types of chemotherapy, is also thought to be a potent approach with the potential to prevent cancer recurrence. Bria-IMT™ (SV-BR-1-GM), the Company's lead product candidate, is derived from a specific breast cancer cell line. It is genetically engineered to release granulocyte-macrophage colony-stimulating factor (GM-CSF), a substance that activates the immune system. We believe that Bria-IMT™ helps the body to recognize and kill tumor cells by activating T cells that attack the tumor and B cells that produce anti-tumor antibodies. The results of two previous proof-of-concept clinical trials (one with the precursor cell line not genetically engineered to produce GM-CSF and one with Bria-IMT™) produced encouraging results in patients with advanced breast cancer. Most notably, one patient with metastatic breast cancer responded to Bria-IMT™ with substantial reduction in tumor burden including breast, lung, soft tissue and brain metastases. BriaCell is currently conducting a Phase I/IIa clinical trial for Bria-IMT™ in patients with advanced breast cancer. In this trial, Bria-IMT™ treatment appeared safe with similar instances of tumor reduction as those observed in the earlier proof-of-concept trials. This trial is listed in ClinicalTrials.gov as NCT03066947. The trial is being conducted along with the co-development of BriaDX™, the Company’s companion diagnostic test. Additionally, the FDA recently approved the roll-over combination study of Bria-IMT™ with pembrolizumab [Keytruda; manufactured by Merck & Co., Inc.] or ipilimumab [Yervoy; manufactured by Bristol-Myers Squibb Company] for patients previously treated with Bria-IMT™ in the Company’s ongoing Phase I/IIa clinical trial in advanced breast cancer. The roll-over trial is listed in ClinicalTrials.gov as NCT03328026. BriaCell is also developing Bria-OTS™, an off-the-shelf personalized Immunotherapy. Bria-OTS™ is a set of cell lines similar to Bria-IMT™ which are being engineered to express pre-manufactured HLA alleles. With a combined total of 15 different alleles Bria-OTS™ is expected to be able to match more than 90% of the US population. BriaCell’s BriaDX™ companion diagnostic reveals patient HLA types. One or two Bria-OTS™ cell lines carrying matching alleles are planned to be administered per patient. Bria-OTS™ eliminates the complex manufacturing logistics required for other personalized immunotherapies and is regarded as a personalized therapy without the need for personalized manufacturing. Yet another item in the BriaCell pipeline is a novel, selective protein kinase C delta (PKCδ) inhibitor. PKCδ inhibitors have shown activity in a number of pre-clinical models of RAS genes’ transformed cancers including bre...

Dr. Carolyn Lam:               Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal it's editors. I'm Dr. Carolyn Lam, associate editor from the National Heart Center, and Duke National University of Singapore. The new ACC/AHA hypertension guidelines are hotly discussed. So much so that we have invited perspectives of these new guidelines from around the world and authors will be discussing this right here on Circulation on the Run. Stay tuned, as it's coming right up after these summaries.                                                 The first original paper this week is a translation study suggesting that the parasympathetic system may be a novel therapeutic target in pulmonary arterial hypertension. Co-corresponding authors Dr. Handoko and de Man from University Medical Center Amsterdam used heart rate recovery after maximal cardiopulmonary exercise testing as a surrogate for parasympathetic activity, and assessed white ventricular ejection fraction in 112 patients with pulmonary arterial hypertension. They found that patients with a lower right ventricular ejection fraction had a significantly reduced heart rate recovery compared to patients with a higher right ventricular ejection fraction.                                                 Furthermore, they looked at tissues from the right ventricle of 11 patients undergoing heart-lung transplantation, and found that there was increased expression of nicotinic receptors with no difference in muscarinic receptor expression compared to controls.                                                 Finally, in a rat model of pulmonary hypertension, they showed that chronic pharmacologic sympathetic stimulation by pyridostigmine, which is an acetylcholinesterase inhibitor, improved surviving right ventricular function and reduced pulmonary vascular remodeling.                                                 In summary, the study shows that right ventricular dysfunction is associated with reduced systemic parasympathetic activity in patients with pulmonary arterial hypertension, with an inadequate adaptive response of the cholinergic system in the right ventricle. Furthermore, enhancing the parasympathetic activity in these patients may be a novel therapeutic strategy. Dr. Carolyn Lam:               The next study unveils a new mechanism by which pericardial adipose tissue coordinates immune cell activation and outcomes following a myocardial infarction. First author Dr. Horckmans, corresponding author Dr. Steffens, and colleagues from Institute of Cardiovascular Prevention in Munich identified larger B-cell clusters in epicardial adipose tissue of human patients with coronary artery disease compared to controls without coronary artery disease. Furthermore, they showed that infarcted mice had larger pericardial clusters, and a 3-fold up regulator numbers of GM-CSF producing B-cells within the pericardial adipose tissue, but not in the spleen or lymph nodes. This was associated with higher dendritic cell and T-cell counts in the pericardial adipose tissue.                                                 Further experiments show that activated dendritic cells migrated from infarcts into the pericardial adipose tissue. Cytokines and growth factors released locally within the pericardial adipose tissue as well as systemically promoted immune cell proliferation and emergency granulopoiesis after myocardial infarction.                                                 Finally, the enhanced fibrosis and worsened ejection fraction in mice was limited by removal of the pericardial adipose tissue.                                                 In summary, these pre-clinical data suggest that pericardial adipose tissue may be a central compartment for innate and adaptive immune responses, which regulate post-myocardial infarction healing. Dr. Carolyn Lam:               The next study reports for the first time in a large, comprehensive national cohort study, the incidence of atrial fibrillation in children and young adults with congenital heart disease. First and corresponding author Dr. Mandalenakis and colleagues from University of Gothenburg in Sweden used data from the Swedish Patient and Cause of Death registers to identify all patients with a diagnosis of congenital heart disease who were born between 1970 and 1993. Each patient with congenital heart disease was matched by birth year, sex, and county with ten controls from Sweden. Follow-up data were collected until 2011.                                                 The authors found that the risk of atrial fibrillation in children and young adults with congenital heart disease was 22 times higher than that in matched controls. Up to the age of 42 years, one in 12 patients with congenital heart disease had developed atrial fibrillation and one in 10 patients with congenital heart disease with atrial fibrillation had developed heart failure. In particular, patients with the most complex congenital malformations, conotruncal defects, had the highest risk to develop atrial fibrillation. These patients should be considered for targeted monitoring. Dr. Carolyn Lam:               The next study provides a novel and simple risk score for right-sided heart failure in adults undergoing Left Ventricular Assist Device implantation with the current mainstream devices. First and corresponding author Dr. Solomon and colleagues from University Medical Center Rotterdam studied almost 3000 adults who underwent continuous flow Left Ventricular Assist Device implantation in the largest EU registry of mechanical circulatory support devices. They derived and validated a right-sided heart failure prediction model that out-performed several published scores and well-known hemodynamic and echocardiographic individual markers of right-sided heart failure.                                                 This prediction model included the following risk factors: need for three or more inotropic agents, inter-agency registry from mechanically-assisted circulatory support class one through three, severe right ventricular dysfunction on semi-quantitative echo cardiography, ratio of right atrial to pulmonary capillary wedge pressure of more than 0.54, and a hemoglobin level of less than 10 grams per deciliter.                                                 These findings offer a step towards improving prediction of the risk of right-sided heart failure to target future optimal strategies aiming at early and intension right-sided heart failure management for the highest risk subgroups of patients undergoing Left Ventricular Assist Device implantation. Dr. Carolyn Lam:               Now, sharing a patient-level clinical trial data has been widely endorsed, but just how extensively have these data been used for cardio metabolic diseases? The final study this week attempts to answer this question. First and corresponding author Dr. Vaduganathan and colleagues from Brigima Women's Hospital extracted data from clinicalstudydatarequest.com, a large, multi-sponsored data sharing platform hosting individual patient-level data from completed studies sponsored by 13 pharmaceutical companies.                                                 They found that the median time from study completion to data availability was more than six years. Most data requesters of cardio metabolic clinical trial data were from academic centers in North America and Western Europe, and half the proposals were unfunded. Only 15% of these trials had been accessed by investigators thus far, and few findings have reached publication. Most requests for shared data access focused on new hypothesis generating questions rather than validation of the original study findings. These data may allow anticipation of barriers to effective system implementation and shared data consumption in cardiology.                                                 Well, that wraps it up for our summaries this week. Now for our feature discussion. Dr. Carolyn Lam:               We are having a truly global conversation today on a really global problem. That is hypertension. From Canada, we've got Dr. Ernesto Schiffrin from McGill University, from Europe we've got Dr. Giuseppe Mancia from university of Milano, from the United States we have Dr. Wonpen Vongpatanasin from UT Southwestern, our dear associate editor and regular voice on this podcast, and then of course from Asia, that's me. You know what we're talking about? It is the global impact of the 2017 ACC/AHA hypertension guidelines. So many novel aspects about these guidelines, including new definitions of hypertension and it's stages, new thresholds and goals of treatment, consideration of the global risks and treatment decisions, addition of classes of recommendations and levels of evidence. So much to talk about, and let's start right now.                                                 Wanpen, you were the brainchild of suggesting these global perspectives. Perhaps say a few words about the ACC/AHA new guidelines first. Dr. Wonpen Vongpatanasin:       Yeah, so I think that this is the guidelines that actually incorporating the more recent evidence and trials, particularly SPRINT, and applying this into the threshold and the blood pressure goal across the board. There's three comprehensive guidelines, and obviously ... The first time, the threshold was lower across the board, and that leads to a lot of discussion and concern and trying to see how we're implementing this or is it appropriate to all the population? Particularly not just in the US and around the world. I guess that leads to us reaching out to many hypertension leaders across the globe and really get very interesting and very insightful feedback from the global experts, two of which is on podcast today. I'm really thankful and excited to have some more in depth insight from them. Dr. Carolyn Lam:               Yeah, exactly. The buzz has really been worldwide, I can see that even from where I'm sitting here in Asia. But maybe Ernesto, I'm just gonna jump straight to the core questions. How are these guidelines different from the hypertension Canada guidelines, and frankly do you think that the ACC American guidelines are going to impact hypertension care in Canada? Dr. Ernesto Schiffrin:      Well, there are quite a few differences. The definition of hypertension remains the classical one in Canada. We have different thresholds and goals, and interestingly, the hypertension Canada guidelines have adopted a SPRINT-based recommendation for high cardiovascular risk patients in contrast to the AHA/ACC hypertension guideline. Although it has intensified the goals for treatment, it has lowered ... Has introduced as you mentioned a category of elevated blood pressure, a new definition of hypertension equal to or above 130 over 80 in contrast to ours equal to or above 140 over 90. It has not really introduced a SPRINT-based recommendation. As well, I think that one of the major questions remains the measurement of blood pressure. In Canada, we have adopted the AOBP, the Automated Office Blood Pressure measurement, at least for high risk, SPRINT like individuals. In the AHA/ACC hypertension guidelines, there is emphasis on standardized blood pressure measurement, but the SPRINT-like measurement of blood pressure has not been adopted. Dr. Carolyn Lam:               Very interesting. In Canada, with the AOBP, how do you translate that? I suppose you estimate it as lower than what would otherwise be labeled? Dr. Ernesto Schiffrin:      That is indeed a problem, because the evidence for the relationship between the AOBP carried out in the absence of a health care professional and the standardized oscillometric measurement, or the osculatory manual measurement, is unclear. The evidence is weak. So we have not really provided a guideline or recommendation with respect to these differences.                                                 In contrast, AHA/ACC provides at least a pragmatic expert-based recommendation on what the differences are between office blood pressure and out-of-office blood pressure measurement. But, as I mentioned, there is no recommendation regarding the SPRINT-like measurement of blood pressure, and that's important because there may be major differences in the order of ten or even 15 millimeters of [inaudible 00:13:32] systolic blood pressure. However, as I see it, the committee for the ACC/AHA hypertension guideline has adopted a prudent and pragmatic approach, and actually simplified thresholds and goals to 130 over 80, and in my view this is a prudent approach.                                                 Will it impact Canada? I think in Canada, most physicians follow the hypertension Canada guidelines, and they are recommended as best practice by governments across the country, provincial and federal. I think that physicians will be aware, but will still carry out their practice following the hypertension Canada guidelines. Dr. Carolyn Lam:               I like that. Aware but perhaps not so practice-changing in Canada. Let's shift to Europe though. Giuseppe, do you agree with that? How do you think these American guidelines may impact physicians in Europe? Dr. Giuseppe Mancia:    The American guidelines have been received with interest, lots of interest. But also there has been some criticism. For example, the question of the SPRINT [inaudible 00:14:55], you read the question of how blood pressure was measured as professor Schiffrin mentioned. It was measured at least in large number professions, why they were [inaudible 00:15:10], I'm not sure. This means that values have lower worth than those obtained by conventional office blood pressure measurement. How much room is still debated, but it could be 10, 15 millimeter mercury, which means that you could compare these SPRINT-like values to conventional office blood pressure values. Probably the SPRINT values are not much lower than 140 millimeters to the mercury systolic.                                                 Then there is the question that can SPRINT mutually [inaudible 00:15:50] at the start. Most of them with two hypertensive charts. So if it's difficult to decide the bounds of threshold to treatment, lower these pressures to the high-low of blood pressure range, less than 140 millimeters mercury systolic when you have patients already treated, because their original blood pressure was probably higher than 140 millimeters of mercury. This [inaudible 00:16:15], however there are other data suggesting that, at least in high-risk individuals, one might indeed start treatment when blood pressure is in the 140 millimeter of mercury. You'll see what the European guidelines will recommend ... They are going to be published in June ... But perhaps this fraction of the population will be a candidate for treatment.                                                 One last point, however, collecting the data from SPRINT is what you wish for in this regard, is that there should be a definite reduction in the threshold blood pressure for treatment in the elderly. In Europe, this was about 160 millimeters mercury based on randomized trials but probably in the future it will be about 140 millimeters mercury. So a large fraction of the elderly population will be involved in [inaudible 00:17:14]. Dr. Carolyn Lam:               You know a question I always get though, is what about the side effects? We talk about the benefits of lowering it further, but what about the side effects. I don't know, does anyone have any thoughts on that? Dr. Ernesto Schiffrin:      I would say that, when you look at SPRINT, although there were increased side effects in the intensive treatment group, actually side effects were relatively rare. Some of them were important, such as acute renal failure and hyperkinemia, and so on, and other electrolyte abnormalities and syncope. But they were rare, and when we are recommending intensified treatment for the elderly, for example, which is SPRINT based in the hypertension Canada guidelines, we do say that this approach should be a gentle and progressive one, very aware that particularly in the elderly orthostatic hypertension may occur. One has to be very careful about this intensification of treatment, but yet we believe that if using automated office blood pressure measurement unobserved, you are able to reach lower blood pressures and they are well tolerated around or below 120 systolic, this will benefit these patients as shown in the SPRINT trial. Dr. Carolyn Lam:               Yeah, indeed. That's very nicely put, and just brings up the gaps that we still need to answer, like the way blood pressure is measured, standardization. We may be accounting more about risk versus benefits, patient subgroups. Wanpen, have I missed out anything else? What is the other buzz that you've heard? Dr. Wonpen Vongpatanasin:       I think that we really need to do a better job in measuring blood pressure in basic clinical practice, particularly in the US where we allow only 20 minutes to see your follow-up patient. I don't think that it will be possible to do an AOBP in the US, but I think one thing that makes the issue a little bit murkier is the SPRINT group. I actually just had an abstract presentation at the last HA meeting, that said only half of that site measure in the intended way on AOBP.                                                 Actually, at UT Southwestern we also SPRINT site and we actually did not use AOBP, and when that stratified the treatment side by using AOBP versus non-AOBP, the outcomes was still the benefit of intensive blood pressure reduction for what it's worth. I think that the AOBP story is still controversial, but I think that I agree that we hardly have patient, sit down quietly, for five minutes before we do the measurement. I think that's first and foremost, we need to be able to do that, and do at least two measurements. We'd be lucky if we'd get one measurement after sitting down immediately, that's what we usually get in clinical practice. I definitely agree with Dr. Schifferin that when we ... Particularly the elderly, we have to be careful about orthostatic hypertension. Particular in the SPRINT trial, they actually exclude anyone who had standing systolic blood pressure less than 110. These people who are high risk of having [inaudible 00:20:35] never get into those trials to begin with. Dr. Carolyn Lam:               I can't thank you enough, everyone, for joining me in this chat around the world. It has been a learning conversation for me, as I'm sure it has been for our listeners as well.                                                 Listeners out there, you've been listening to Circulation on the Run. Thank you for joining us today.    

Editor's Summary by Howard Bauchner, MD, Editor in Chief of JAMA, the Journal of the American Medical Association, for the December 05, 2017 issue

Dr. C. Michael Gibson discusses the trial findings with Dr. Mary McDermott at AHA 2017.

Dr Harrington talks to ecancertv at EADO 2015 about the benefit and risk analysis from the phase III OPTiM trial of talimogene laherparepvec (T-VEC) vs granulocyte macrophage colony-stimulating factor (GM-CSF) in patients (pts) with stage IIIB-IV melanoma.

Hosts: Vincent Racaniello, Michele Swanson, and Michael Schmidt. Vincent, Michael, and Michele reveal how a fungal protease blunts the innate immune response and promotes pathogenicity. Subscribe to TWiM (free) on iTunes, Stitcher, RSS, or by email. You can also listen on your mobile device with the Microbeworld app. Links for this episode Michele on Flint Legionella outbreak (Detroit News) Fungal mimicry of a mammalian aminopeptidase (Cell Host Micr)   This episode is sponsored by ASM Agar Art Contest and ASM Microbe 2016 Send your microbiology questions and comments (email or mp3 file) to twim@twiv.tv, or call them in to 908-312-0760. You can also post articles that you would like us to discuss at microbeworld.org and tag them with twim.

Dr. James Gulley, National Cancer Institute, discusses immunotherapies for genitourinary cancers, including recent trial results. He also addresses early data which may indicate that using immunotherapy sooner may benefit patients.

Dr. James Gulley, National Cancer Institute, discusses immunotherapies for genitourinary cancers, including recent trial results. He also addresses early data which may indicate that using immunotherapy sooner may benefit patients.

Dr. James Gulley, National Cancer Institute, discusses immunotherapies for genitourinary cancers, including recent trial results. He also addresses early data which may indicate that using immunotherapy sooner may benefit patients.

Background The majority of cases with severe pulmonary alveolar proteinosis (PAP) are caused by auto-antibodies against GM-CSF. A multitude of genetic and exogenous causes are responsible for few other cases. Goal of this study was to determine the prevalence of GATA2 deficiency in children and adults with PAP and hematologic disorders. Methods Of 21 patients with GM-CSF-autoantibody negative PAP, 13 had no other organ involvement and 8 had some form of hematologic disorder. The latter were sequenced for GATA2. Results Age at start of PAP ranged from 0.3 to 64 years, 4 patients were children. In half of the subjects GATA2-sequence variations were found, two of which were considered disease causing. Those two patients had the typical phenotype of GATA2 deficiency, one of whom additionally showed a previously undescribed feature – a cholesterol pneumonia. Hematologic disorders included chronic myeloic leukemia, juvenile myelo-monocytic leukemia, lymphoblastic leukemia, sideroblastic anemia and two cases of myelodysplastic syndrome (MDS). A 4 year old child with MDS and DiGeorge Syndrome Type 2 was rescued with repetitive whole lung lavages and her PAP was cured with heterologous stem cell transplant. Conclusions In children and adults with severe GM-CSF negative PAP a close cooperation between pneumologists and hemato-oncologists is needed to diagnose the underlying diseases, some of which are caused by mutations of transcription factor GATA2. Treatment with whole lung lavages as well as stem cell transplant may be successful.

Background New therapeutic approaches with biologic agents such as anti-cytokine antibodies are currently on trial for the treatment of asthma, rhinosinusitis or allergic diseases necessitating patient selection by biomarkers. Allergic rhinitis (AR), affecting about 20 % of the Canadian population, is an inflammatory disease characterised by a disequilibrium of T-lymphocytes and tissue eosinophilia. Aim of the present study was to describe distinct cytokine patterns in nasal secretion between seasonal and perennial AR (SAR/PAR), and healthy controls by comparing cytokines regulating T-cells or stimulating inflammatory cells, and chemokines. Methods Nasal secretions of 44 participants suffering from SAR, 45 participants with PAR and 48 healthy controls were gained using the cotton wool method, and analysed for IL-1β, IL-4, IL-5, IL-6, IL-10, IL-12, IL-13, IL-17, GM-CSF, G-CSF, IFN-γ, MCP-1, MIP-1α, MIP-1β, eotaxin, and RANTES by Bio-Plex Cytokine Assay as well as for ECP and tryptase by UniCAP-FEIA. Results Participants with SAR or PAR presented elevated levels of tryptase, ECP, MCP-1, and MIP-1β, while values of GM-CSF, G-CSF, IL-1β, and IL-6 did not differ from the controls. Increased levels of IL-5, eotaxin, MIP-1α, and IL-17 and decreased levels of IFN-γ, IL-12 and IL-10 were found in SAR only. RANTES was elevated in SAR in comparison to PAR. Interestingly, we found reduced levels of IL-4 in PAR and of IL-13 in SAR. Conclusions Elevated levels of proinflammatory cytokines were seen in both disease entities. They were, however, more pronounced in SAR, indicating a higher degree of inflammation. This study suggests a downregulation of T H 1 and T reg -lymphocytes and an upregulation of T H 17 in SAR. Moreover, the results display a prominent role of eosinophils and mast cells in AR. The observed distinct cytokine profiles in nasal secretion may prove useful as a diagnostic tool helping to match patients to antibody therapies.

[intro music]   Host – Dan Keller Hello, and welcome to Episode Three of Multiple Sclerosis Discovery, the Podcast of the MS Discovery Forum. I’m your host, Dan Keller.   This week’s Podcast features an interview with investigators Daren Austin and Susan Van Meter of the pharmaceutical company GlaxoSmithKline, who will discuss results from the MIRROR trial of ofatumumab, a human monoclonal antibody already FDA approved for leukemia. But to begin, here’s a brief summary of some of the topics we’ve been covering on the MS Discovery Forum at msdiscovery.org.   First, a complementary approach to treating MS. A new study lends support to the prevailing theory that the immune system’s ancient complement system drives persistent axon damage between MS relapses. The complement system consists of proteins that can activate innate and adaptive immune responses, but have a poorly understood role in autoimmune diseases. The new results suggest that anticomplement therapies might help prevent damage to axons. Clinical trials are in the early planning phases, but one of the study’s authors cautions that even if this approach proves valuable, it would be used in addition to and not in place of therapies targeting inflammatory T-cells.   In a second article, we report on a study suggesting that inhibiting a common cytokine called granulocyte macrophage colony stimulating factor – GM-CSF – might be a new therapeutic target to treat MS. Studies have shown an association between the cytokine and MS flares. A newly described class of T helper cells produce GM-CSF, and inhibiting that production might be helpful in preventing flares.   Finally, we’d like to call your attention to our blog series called “MS Patient, Ph.D.” There are numerous blogs and other websites where people with MS talk with other people with MS. And there are also a few, including our own MS Discovery Forum, where MS researchers and clinicians talk with other researchers and clinicians. But we can’t think of any sites where people with MS who have a scientific bent communicate directly with researchers and clinicians. That’s what MS Patient, Ph.D. is all about. It’s a place where two articulate people struggling with MS, both of them Ph.D. biologists, present their points of view about their disease and about the state of MS research. You’ll find some of their opinions provocative and controversial, and we hope you’ll join the discussion. In our two most recent posts, Griselda Zuccarino-Catania discussed the snake oil treatments touted as MS cures and relates that to the recent testimony before the U.S. Senate Committee by Dr. Mehmet Oz. And Emily Willingham discusses conflicting evidence on whether exercise is good or bad for people with MS.   [transition music]   Now, onto the interview. Here at the 2014 annual meeting of the American Academy of Neurology, we caught up with Dr. Daren Austin of GSK in London. He’s presenting the MIRROR study, which is a randomized, placebo-controlled study doing dose-ranging on ofatumumab in subjects with relapsing-remitting multiple sclerosis.   Interviewer – MSDF What led you to implicate B-cells? We often think of T-cells as a target in multiple sclerosis.   Dr. Austin Well, there’d been previous work using other anti-CD20 therapies in immune inflammation diseases that have shown efficacy. Most notably the first was rituximab in rheumatoid arthritis and subsequently rheumatoid looking at multiple sclerosis, so the precedence for anti-CD20 modulation as a target for inflammatory diseases was known before we came to design this study. What wasn’t known before we designed the MIRROR study was how much modulation of B-cells would generate what level of clinical benefit. The primary objective of this study really was to look at how best we could administer ofatumumab, which is an anti-CD20 monoclonal antibody, to modulate B-cells and then modulate clinical disease.   MSDF How’d you go about it? Can you describe the study and also what you found?   Dr. Austin Well, the study was a randomized, double-blind, parallel group study looking at relapsing-remitting multiple sclerosis patients who had to have evidence of disease activity, i.e., they they would be requiring therapy. What we did was we took what we knew about the pharmacology of ofatumumab – and we’d previously conducted both an intravenous study in in multiple sclerosis patients, so we knew the drug could be efficacious in suppressing MRI lesions, and we took what we knew about the clinical pharmacology of ofatumumab; and, namely, that it is an extremely potent depleter of B-cells. We began by by hypothesizing that there was a link between the level of B-cell suppression and the level of MRI lesion suppression. From that we produced some some predictions. And our predictions led us to suggest that extremely low doses given relatively infrequently could be beneficial. We produced a transimulation before we conducted the trial, and we proposed a range of doses and dosing frequencies. So the first dose level was was placebo, the next level was a 3 mg dose that was given once every 12 weeks. The next dose level was 30 mg given once every 12 weeks. The next dose level was 60 mg given once every 12 weeks. And, finally, because we knew that a dose of 200 mg was efficacious over 12 weeks, we gave 60 mg every 4 weeks to give a cumulative dose of 180 mg. So we explored a dose range, a cumulative dose range, of 3 mg to 180 mg, with the primary endpoint being evaluation of MRI lesions at 12 weeks. Placebo patients were then given a 3 mg active dose. All patients were then followed for a further 12 weeks, and we now have the 24-week data. And, again, treatment then ceased and patients were followed-up to see repletion of B-cells.   And what we found in the study was, yes, that ofatumumab is is extremely potent at depleting B-cells. That single 3 mg dose was capable of knocking out about 75% of circulating B-cells, and the 60 mg dose given every 4 weeks depleted almost all patients right down to the undetectable levels, which is had been seen in the past. What we were able to do then is to look at the dose response to dosing of ofatumumab at the 12-week endpoint, and what we found is that at the cumulative dose of 180 mg, we see over 90% suppression of lesions. But we found that there was no incremental benefit in going above doses of about 60 mg, and in fact the dose that generated the half maximum effect from an analysis of the data was predicted to be less than 3 mg; a single 3 mg dose generated half of the maximum benefit.   Having shown that we have got clinical suppression of MRI lesions, we then decided to relay the pharmacology of ofatumumab, which is suppression of B-cells, to the clinical benefit, which is suppression of MRI lesions. And that was the purpose of this abstract, that the analysis that we presented showed quite clearly that there was a very strong relationship between how much you suppress B-cells and how much you suppress MRI lesions. But the surprising thing from this data is that you don’t have to fully deplete all patients to below the limit of quantification to derive benefit. We showed using a variety of analyses that patients that have circulating B-cells of less than 32 to 64 cells per microliter on average over the course of the dosing interval would still derive maximal benefit, i.e., suppression of lesions, to 90%. And that’s intriguing. And the reason it’s intriguing is that the doses that we gave are only acting on peripheral B-cells. There’s been speculation as to where the drug needs to get to give clinical benefit, and that the doses that we give – up to 60 mg doses – the drug can’t penetrate the blood-brain barrier. And, therefore, we know that by modulating peripheral circulating B-cells, we are deriving the maximal benefit in suppression of MRI lesions.   MSDF Is the drug acting on mature B-cells, or in B-cell development which may then migrate into the CNS during development?   Dr. Austin So ofatumumab only binds to the cells that express CD20, so there is some consideration as to where those cells exist. Now it is entirely possible that immature cells maybe sort of enter the periphery not expressing CD20, move to across the blood-brain barrier where they subsequently develop. That is a possibility. And if that is the case, our drug is not capable of reaching those B-cells. Only cells that express CD20 are depleted, so plasmablasts, for example, are not depleted because they do not express CD20. It is just that that population of of of B-cells that are expressing CD20. There’s a lot of hypotheses about how B-cells are working, how they may be producing pathogenic antibodies that may be detrimental. In MS it could be anti-myelin antibodies, for example. But we don’t absolutely know that that is the sole pathogenic mechanism in MS, as in other diseases. It may well be that B-cells are modulating other, say, T-cell activity, which we do not yet know. What we do know from our trial is that modulation of peripheral B-cells gives you benefit, and that’s the principal finding, and that the doses that we modulate at are much, much lower than the oncology doses that have previously been given.   MSDF So you don’t yet know whether you have a direct antibody effect on B-cells, or whether it’s acting possibly through antibody-dependent cellular cytotoxicity.   Dr. Austin We do know that the mechanism of B-cell depletion is through both ADCC and complement-dependent cytotoxicity. That is the primary pharmacology of ofatumumab on cells that express CD20. We do not and cannot say for certain what those B-cells were doing prior to being depleted and how they were driving the pathogenic process, but we have shown that by depleting them to levels of less than 32 cells per microliter, you see suppression of disease activity. One of the important things to say is that the regimens at the every 12-week dosing that we’d selected, there is some evidence that B-cells do start to grow back in at least half of patients, so dosing every 12 weeks pre-dose, there are some circulating B-cells. If we look at immature B-cells, there are lots of immature B-cells but they haven’t yet moved to the to express CD20. So what we see is that the regimens we’ve designed, there is some evidence of of repletion, i.e., that patients are seeing clinical benefit despite having circulating B-cells.   MSDF How does this fit in with the pathogenetic mechanisms of T-cells? Are there interactions in the pathologic process besides the regulatory effect of T-cells themselves?   Dr. Austin The truth is I don’t think we can say. All we can say is that modulation of B-cells circulating in the periphery gives clinical suppression of of MRI lesions, and by implication we believe at the clinical efficacy in multiple sclerosis, and possibly other diseases, although such low doses have not have yet to be tested in other diseases.   MSDF In terms of B-cell repletion, have you also followed new lesions after B-cells come back?   Dr. Austin We have the 24-week data and we have preliminary data out to 48 weeks, and that data won’t be reported yet because we’re still in the process of ana analyzing it. But in the trial we designed, we had individual follow-up to watch patients B-cell replete back up to the lower limit of normal or their baseline, and we are measuring their follow on MRI lesions.   MSDF Working along with Dr. Austin on this project is Dr. Susan Van Meter, the clinical physician involved in the project. Let me ask you, what sort of adverse effects did you see during the trial?   Dr. Van Meter The most common adverse effect that we saw was injection site reactions, and that can include things such as redness at the injection site, nausea, flu-like symptoms. That occurred in most of the patients receiving ofatumumab. It also, very interestingly, occurred in about 15% of patients who received placebo.   MSDF In terms of the more serious and chronic effects, did you see any opportunistic infections or especially progressive multifocal leukoencephalopathy?   Dr. Van Meter So you would certainly worry about infections, especially serious infections. We did not see any cases of PML or other opportunistic infections, and, in fact, no serious infections. As typical for patients with MS, patients did have a variety of infections – urinary tract infections, respiratory infections – but this was seen in all patients including placebo patients, and there was really no evidence of an increased rate of infection in patients receiving ofatumumab.   MSDF What do you see as the potential clinical significance of these findings?   Dr. Van Meter Well, I think it offers another therapy option for patients with MS. Obviously, we have to do further development and show that the benefits that we saw on MRI translate into clinical benefit on relapse rates and disability progression. But we’re offering a subcutaneous dose as opposed to an intravenous dose of medication, and potentially offering a medication that doesn’t completely wipe out one part of your immune system.   MSDF Is there a reason for selecting ofatumumab over rituximab?   Dr. Van Meter Well, I think that would be a clinician choice, to be honest. Rituximab has certainly been studied for multiple sclerosis even though it’s not indicated for multiple sclerosis. There’s another B-cell therapy that will be on the market when we launch, ocrelizumab, and I think it will come down to physician and patient choice.   MSDF Is there anything we’ve missed or that’s important to add?   Dr. Van Meter Well, I think at Glaxo we are very excited about this data; this is new science. Obviously, we need to understand more about it, replicate it. But for the first time, we’ve shown that you don’t need to completely destroy all the B-cells to have effect in multiple sclerosis.   MSDF Very good, I appreciate it. Thank you.   [transition music]   Thank you for listening to Episode Three of Multiple Sclerosis Discovery. This Podcast was produced by the MS Discovery Forum, MSDF, the premier source of independent news and information on MS research. MSDF’s executive editor is Robert Finn. Msdiscovery.org is part of the nonprofit Accelerated Cure Project for Multiple Sclerosis. Robert McBurney is our President and CEO, and Hollie Schmidt is Vice President of Scientific Operations.   Msdiscovery.org aims to focus attention on what is known and not yet known about the causes of MS and related conditions, their pathological mechanisms, and potential ways to intervene. By communicating this information in a way that builds bridges among different disciplines, we hope to open new routes toward significant clinical advances.   We’re interested in your opinions. Please join the discussion on one of our online forums or send comments, criticisms, and suggestions to editor@msdiscovery.org.   [outro music]

Prof Harrington talks to ecancertv at ASCO 2014 about a randomised phase III trial of talimogene laherparepvec (T-VEC) versus subcutaneous granulocyte-macrophage colony-stimulating factor (GM-CSF) for the treatment of unresected stage IIIB/C and IV melanoma.

Editor's Audio Summary by Mary McGrae McDermott, MD, Senior Editor, the Journal of the American Medical Association, for the December 25, 2013 issue

Background: Patients with nonallergic rhinitis with eosinophilia syndrome (NARES) show typical symptoms of persistent allergic rhinitis (PAR). The aim of the present study was to compare nasal cytokine patterns between NARES and PAR. Methods: Nasal secretions of 31 patients suffering from NARES, 20 patients with PAR to house dust mite and 21 healthy controls were collected using the cotton wool method and analyzed for interleukin (IL)-1 beta, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13, IL-17, granulocyte-macrophage colony-stimulating factor (GM-CSF), granulocyte colony-stimulating factor (G-CSF), interferon-gamma (IFN-gamma), tumor necrosis factor-alpha (TNF-alpha), monocyte chemoattractant protein-1 (MCP-1) and macrophage inflammatory protein-1 beta (MIP-1 beta) by Bio-Plex Cytokine Assay as well as eosinophil cationic protein (ECP) and tryptase by UniCAP-FEIA. Results: NARES and PAR presented elevated levels of tryptase, while ECP was markedly increased solely in NARES compared to both the controls and PAR. Elevated levels of IL-1 beta, IL-17, IFN-gamma, TNF-alpha and MCP-1 were found in NARES compared to the controls as well as PAR. MIP-1 beta was elevated in NARES and PAR, while IL-4, IL-6 and G-CSF showed increased levels in NARES, and IL-5 was elevated in PAR only. Conclusions: In patients with NARES and PAR, eosinophils and mast cells appear to be the pivotal cells of inflammation, reflected by high levels of tryptase and ECP as well as IL-5 and GM-CSF as factors for eosinophil migration and survival. The elevated levels of proinflammatory cytokines in NARES may indicate the chronic, self-perpetuating process of inflammation in NARES which seems to be more pronounced than in PAR. IL-17 might be a factor for neutrophilic infiltration or be responsible for remodeling processes in NARES. Copyright (C) 2012 S. Karger AG, Basel

In addition to forming the epithelial barrier against the outside environment keratinocytes are immunologically active cells. In the treatment of severely burned skin, cryoconserved keratinocyte allografts gain in importance. It has been proposed that these allografts accelerate wound healing also due to the expression of a favourable--keratinocyte-derived--cytokine and growth factor milieu. In this study the morphology and cytokine expression profile of keratinocytes from skin after acute burn injury was compared to non-burned skin. Skin samples were obtained from patients after severe burn injury and healthy controls. Cells were cultured and secretion of selected inflammatory mediators was quantified using Bioplex Immunoassays. Immunohistochemistry was performed to analyse further functional and morphologic parameters. Histology revealed increased terminal differentiation of keratinocytes (CK10, CK11) in allografts from non-burned skin compared to a higher portion of proliferative cells (CK5, vimentin) in acute burn injury. Increased levels of IL-1α, IL-2, IL-4, IL-10, IFN-γ and TNFα could be detected in culture media of burn injury skin cultures. Both culture groups contained large amounts of IL-1RA. IL-6 and GM-CSF were increased during the first 15 days of culture of burned skin compared to control skin. Levels of VEGF, FGF-basic, TGF-ß und G-CSF were high in both but not significantly different. Cryoconservation led to a diminished mediator synthesis except for higher levels of intracellular IL-1α and IL-1ß. Skin allografts from non-burned skin show a different secretion pattern of keratinocyte-derived cytokines and inflammatory mediators compared to keratinocytes after burn injury. As these secreted molecules exert auto- and paracrine effects and subsequently contribute to healing and barrier restoration after acute burn injury therapies affecting this specific cytokine/growth factor micromilieu could be beneficial in burned patients.

Sat, 30 Jul 2011 12:00:00 +0100 https://edoc.ub.uni-muenchen.de/13785/ https://edoc.ub.uni-muenchen.de/13785/1/Haas_Miriam_Sophia.pdf Haas, Miriam Sophia

Sat, 12 Feb 2011 12:00:00 +0100 https://edoc.ub.uni-muenchen.de/12978/ https://edoc.ub.uni-muenchen.de/12978/1/Hoeksma_Antje.pdf Hoeksma, Antje

Ambient air pollution can alter cytokine concentrations as shown in vitro and following short-term exposure to high air pollution levels in vivo. Exposure to pollution during late pregnancy has been shown to affect fetal lymphocytic immunophenotypes. However, effects of prenatal exposure to moderate levels of air pollutants on cytokine regulation in cord blood of healthy infants are unknown. In a birth cohort of 265 healthy term-born neonates, we assessed maternal exposure to particles with an aerodynamic diameter of 10 µm or less (PM₁₀), as well as to indoor air pollution during the last trimester, specifically the last 21, 14, 7, 3 and 1 days of pregnancy. As a proxy for traffic-related air pollution, we determined the distance of mothers' homes to major roads. We measured cytokine and chemokine levels (MCP-1, IL-6, IL-10, IL-1ß, TNF-α and GM-CSF) in cord blood serum using LUMINEX technology. Their association with pollution levels was assessed using regression analysis, adjusted for possible confounders. Mean (95%-CI) PM₁₀ exposure for the last 7 days of pregnancy was 18.3 (10.3-38.4 µg/m³). PM₁₀ exposure during the last 3 days of pregnancy was significantly associated with reduced IL-10 and during the last 3 months of pregnancy with increased IL-1ß levels in cord blood after adjustment for relevant confounders. Maternal smoking was associated with reduced IL-6 levels. For the other cytokines no association was found. Our results suggest that even naturally occurring prenatal exposure to moderate amounts of indoor and outdoor air pollution may lead to changes in cord blood cytokine levels in a population based cohort.

Background: Active-specific immunotherapy used as an adjuvant therapeutic strategy is rather unexplored for cancers with poorly characterized tumor antigens like gastric cancer. The aim of this study was to augment a therapeutic immune response to a low immunogenic tumor cell line derived from a spontaneous gastric tumor of a CEA424-SV40 large T antigen (CEA424-SV40 TAg) transgenic mouse. Methods: Mice were treated with a lymphodepleting dose of cyclophosphamide prior to reconstitution with syngeneic spleen cells and vaccination with a whole tumor cell vaccine combined with GM-CSF (a treatment strategy abbreviated as LRAST). Anti-tumor activity to subcutaneous tumor challenge was examined in a prophylactic as well as a therapeutic setting and compared to corresponding controls. Results: LRAST enhances tumor-specific T cell responses and efficiently inhibits growth of subsequent transplanted tumor cells. In addition, LRAST tended to slow down growth of established tumors. The improved anti-tumor immune response was accompanied by a transient decrease in the frequency and absolute number of CD4(+)CD25 (+)FoxP3(+) T cells (Tregs). Conclusions: Our data support the concept that whole tumor cell vaccination in a lymphodepleted and reconstituted host in combination with GM-CSF induces therapeutic tumor-specific T cells. However, the long-term efficacy of the treatment may be dampened by the recurrence of Tregs. Strategies to counteract suppressive immune mechanisms are required to further evaluate this therapeutic vaccination protocol.

Background: Clinical presentation, diagnosis, management and outcome of molecularly defined congenital pulmonary alveolar proteinosis (PAP) due to mutations in the GM-CSF receptor are not well known. Case presentation: A 2 1/2 years old girl was diagnosed as having alveolar proteinosis. Whole lung lavages were performed with a new catheter balloon technique, feasible in small sized airways. Because of some interstitial inflammation in the lung biopsy and to further improve the condition, empirical therapy with systemic steroids and azathioprin, and inhaled and subcutaneous GMCSF, were used. Based on clinical measures, total protein and lipid recovered by whole lung lavages, all these treatments were without benefit. Conversely, severe respiratory viral infections and an invasive aspergillosis with aspergilloma formation occurred. Recently the novel homozygous stop mutation p.Ser25X of the GMCSF receptor alpha chain was identified in the patient. This mutation leads to a lack of functional GMCSF receptor and a reduced response to GMCSF stimulation of CD11b expression of mononuclear cells of the patient. Subsequently a very intense treatment with monthly lavages was initiated, resulting for the first time in complete resolution of partial respiratory insufficiency and a significant improvement of the overall somato-psychosocial condition of the child. Conclusions: The long term management from early childhood into young adolescence of severe alveolar proteinosis due to GMCSF receptor deficiency requires a dedicated specialized team to perform technically demanding whole lung lavages and cope with complications.

Sat, 24 Jul 2010 12:00:00 +0100 https://edoc.ub.uni-muenchen.de/14771/ https://edoc.ub.uni-muenchen.de/14771/1/Walsch_Florian.pdf Walsch, Florian Markus

Immature dendritic cells (DC) represent potential clinical tools for tolerogenic cellular immunotherapy in both transplantation and autoimmunity. A major drawback in vivo is their potential to mature during infections or inflammation, which would convert their tolerogenicity into immunogenicity. The generation of immature DC from human bone marrow (BM) by low doses of GM-CSF (lowGM) in the absence of IL-4 under GMP conditions create DC resistant to maturation, detected by surface marker expression and primary stimulation by allogeneic T cells. This resistence could not be observed for BM-derived DC generated with high doses of GM-CSF plus IL-4 (highGM/4), although both DC types induced primary allogeneic T cell anergy in vitro. The estabishment of the anergic state requires two subsequent stimulations by immature DC. Anergy induction was more profound with lowGM-DC due to their maturation resistance. Together, we show the generation of immature, maturation-resistant lowGM-DC for potential clinical use in transplant rejection and propose a two-step-model of T cell anergy induction by immature DC.

Objective: Trauma-hemorrhage results in depressed immune responses of antigen-presenting cells (APCs) and T-cells. Recent studies suggest a key role of depressed T-cell derived interferon (IFN)-g in this complex immune cell interaction. The aim of this study was to elucidate further the underlying mechanisms responsible for dysfunctional T-cells and their interaction with APCs following trauma-hemorrhage. Design: Adult C3H/HeN male mice were subjected to trauma-hemorrhage (3-cm midline laparotomy) followed by hemorrhage (blood pressure of 35�5mmHg for 90 min and resuscitation) or sham operation. At 24 h thereafter, spleens were harvested and T-cells (by Microbeads) and APCs (via adherence) were Isolated. Co-cultures of T-cells and APCs were established for 48 h and stimulated with concanavalin A and lipopolysaccharide. T-Cell specific cytokines known to affect APC function (i.e. interleukin(IL)-2, IL-4 and granulocyte-macrophage colony-stimulating factor (GM-CSF)) were measured in culture supernatants by Multiplex assay. The expression of MHC class II as well as co-stimulatory surface molecules on T-cells and APCs was determined by flow cytometry. Results: The release of IL-4 and GM-CSF by T-cells was suppressed following trauma-hemorrhage, irrespective of whether sham or trauma-hemorrhage APCs were present. Antigen-presenting cells from animals subjected to trauma-hemorrhage did not affect T-cell derived cytokine release by sham T-cells. In contrast, T-cells from traumahemorrhage animals depressed MHC class II expression of CD11c(þ) cells, irrespective of whether APCs underwent sham or trauma-hemorrhage procedure. Surprisingly, co-stimulatory molecules on APCs (CD80, CD86) were not affected by trauma-hemorrhage. Conclusions: These results suggest that beside IFN-g other T-cell derived cytokines contribute to immunosuppression following trauma-hemorrhage causing diminished MHC II expression on APCs. Thus, T-cells appear to play an important role in this interaction at the time-point examined. Therapeutic approaches should aim at maintenance of T-cell function and their interaction with APCs to prevent extended immunosuppression following trauma-hemorrhage.

Background: Human Bronchial epithelial cells (hu-BEC) have been claimed to play a significant role in the pathogenesis of chronic inflammatory airway diseases like COPD. In this context IL-8 and GM-CSF have been shown to be key cytokines. Some antibiotics which are routinely used to treat lower respiratory tract infections have been shown to exert additional immunomodulatory or anti-inflammatory effects. We investigated whether these effects can also be detected in hu-BEC. Methods: Hu-BEC obtained from patients undergoing lung resections were transferred to air-liquid-interface (ALI) culture. These cultures were incubated with cefuroxime (CXM, 10-62.5 mg/l), azithromycin (AZM, 0.1-1.5 mg/l), levofloxacin (LVX, 1-8 mg/l) and moxifloxacin (MXF, 1-16 mg/l). The spontaneous and TNF-alpha (10 ng/ml) induced expression and release of IL-8 and GM-CSF were measured using PCR and ELISA in the absence or presence of these antibiotics. Results: The spontaneous IL-8 and GM-CSF release was significantly reduced with MXF (8 mg/l) by 37 +/- 20% and 45 +/- 31%, respectively (both p < 0.01). IL-8 release in TNF-alpha stimulated hu-BEC decreased by 16 +/- 8% (p < 0.05) with AZM (1.5 mg/l). With MXF a concentration dependent decrease of IL-8 release was noted up to 39 +/- 7% (p < 0.05). GM-CSF release from TNF-alpha stimulated hu-BEC was maximally decreased by 35 +/- 24% (p < 0.01) with MXF (4 mg/l). Conclusion: Using ALI cultures of hu-BEC we observed differential effects of antibiotics on spontaneous and TNF-a induced cytokine release. Our data suggest that MXF and AZM, beyond bactericidal effects, may attenuate the inflammatory process mediated by hu-BEC.

Der akute Myokardinfarkt ist eine der häufigsten Diagnosen in den industrialisierten Ländern. In der Regel kommt es zu einem thrombotischen Verschluss einer Koro-nararterie. Die rasche Revaskularisierung und die dadurch erhoffte Reduktion des in-farzierten Areals ist die wichtigste therapeutische Maßnahme zur Rettung des ischämischen Myokards und zur Senkung der Morbidität und Mortalität. Nach der plötzlichen Reperfusion des postischämischen Gewebes kommt es zu einem soge-nannten myokardialen Ischämie/Reperfusionsschaden, der sich als Endothel- und Myozytenschädigung ausbildet. Folge von rascher Reoxygenierung sind u. a. eine gesteigerte inflammatorische Re-aktion und in diesem Rahmen eine gesteigerte Einwanderung von Leukozyten in das ischämische Areal. Die Rolle der Thrombozyten für die postischämische Leukozyten-rekrutierung war bisher unklar. In unserer Studie wurden Wildtyp- (WT), P-Selektin- und ICAM-1/P-Selektin-defiziente Mäuse einer 20-minütigen LAD-Okklusion unterzogen, gefolgt von 15 Mi-nuten Reperfusion, um den Effekt der Interaktion zwischen Endothel, Leukozyten und Thrombozyten und den Einfluss auf den frühen Reperfusionsschaden zu unter-suchen. Anschließend wurden die Herzen ex vivo fluoreszenzmikroskopisch bzw. mittels LV-Druckmessung im isolierten Herzen analysiert. Zur Analyse der Zell-Zell-Interaktion wurden zu Beginn der Reperfusion zirkulierende Leukozyten mit Rhoda-min G6 gefärbt bzw. 2x108 BCECF-AM- oder Rhodamin G6-gefärbte homologe oder heterologe Thrombozyten systemisch infundiert. In P-Selektin-defizienten Tieren war die Verminderung der Leukozytenrekrutierung (Abb. 11) und die Bildung der Leukozyten/Thrombozyten-Co-Aggregate (Abb. 12 sowie die Reduktion des postischämischen linksventrikulären Funktionsverlustes (Tabelle 5) moderat. Dieser Effekt wurde durch die zusätzliche Abwesenheit von ICAM-1 verstärkt (Abb. 11, Abb. 12, Tabelle 5). Die Adhäsion von Plättchen war nicht beeinflusst (Abb. 13). Die Inhibition der Thrombozytenadhäsion mittels Tirofiban, ei-nem GPIIb/IIIa-Inhibitor (Abb. 14), reduzierte die Leukozytenadhäsion und die links-ventrikuläre Dysfunktion (Abb. 15, Tabelle 5). Während in ICAM-1/P-Selektin-defizienten Herzen die direkte Rekrutierung von Leukozyten stark eingeschränkt war, konnte diese durch die Infusion von Wildtyp-Plättchen nahezu vollständig wiederher-gestellt werden. Die Inhibition der Plättchenadhäsion durch die zusätzliche Gabe von Tirofiban konnte diesen Effekt wieder aufheben (Abb. 19). Unsere Experimente de-monstrieren erstmals die Rolle des thrombozytären P-Selektins und des ß3-Integrins GPIIb/IIIa als redundanten Rekrutierungsmechanismus für die thrombozyten-vermittelte postischämische Leukozytenrekrutierung in vivo. Über diesen redundanten Mechanismus tragen Thrombozyten indirekt zum Reperfu-sionsschaden bei, indem sie die postischämische Leukozytenadhäsion verstärken. Diese thrombozyten-vermittelte Leukozytenadhäsion benötigt P-Selektin-suffiziente Plättchen, nicht jedoch endotheliales P-Selektin. Die Antagonisierung von GPIIb/IIIa, die in Patienten effektiv ist für die Thrombolysehandlung31, PTCA177 und Stent-Implantation10, 149, 203, inhibiert sowohl die Plättchenadhäsion als auch thrombozyten-vermittelte Leukozytenrekrutierung. Im experimentellen Modell der akuten myokardialen Ischämie und Reperfusion zeigte die GPIIb/IIIa-Antagonisierung eine protektive Wirkung über die Plättchen-Inhibition hinaus, in dem sie den durch plättchen-vermittelte Leukozytenrekrutierung induzier-ten akuten Reperfusionsschaden reduzierte. In einem weiteren Schritt wurde ein chronisches Mausmodell der myokardialen Ischämie und Reperfusion etabliert, um die Auswirkungen einer reduzierten Leukozy-tenadhäsion auf den chronischen postischämischen Reperfusionsschaden zu unter-suchen und mit alternativen Behandlungsmethoden zu vergleichen. WT-Tiere und ICAM-1-defiziente Tiere wurden einer einstündigen LAD-Okklusion unterzogen, ge-folgt von 14 Tagen Reperfusion. Anschließend wurde die linksventrikuläre Funktion mittels invasiver Millar-Tip Kathetermessung analysiert. 24 Stunden nach Ischämie wurden 3*106 in vitro expandierte embryonale EPC (eEPC) systemisch in WT-Tiere oder ICAM-1-defiziente Tiere infundiert. In zwei weiteren WT-Gruppen wurden auto-loge Progenitorzellen und mononukleäre Zellen aus dem Knochenmark mobilisiert mittels Gabe von 0,5µg GM-CSF 7 Tage vor Ischämie bzw. direkt postischämisch. In den ICAM-1-defizienten Tieren war der postischämische Funktionsverlust im Ver-gleich zu den WT-Kontrollen etwa im gleichen Maß verringert wie bei den eEPC-behandelten Tieren (Abb. 22 Abb. 23, Abb. 24). Unter reduzierter Leukozytenredukti-on in den ICAM-1-defizienten Tieren zeigte sich ein zusätzlicher benefizieller Effekt durch die Behandlung mit eEPCs (Abb. 22 Abb. 23, Abb. 24). DiI-markierte eEPCs konnten histologisch im Infarkt-Areal in enger Nachbarschaft mit Blutgefäßen nach-gewiesen werden (Abb. 28). Die Adhäsion von Leukozyten und der damit verbundene leukozyten-assozierte Re-perfusionsschaden ist durch die Defizienz von ICAM-1 auch im chronischen Ischä-mie/Reperfusionsmodell vermindert. Embryonale EPCs sind in der Lage in ischämisches Areal einzuwandern, zu inkorpo-rieren und protektiv auf die postischämische Funktion zu wirken. Sie können so über einen längeren Zeitraum als Quelle für parakrine, angiogenese-fördernde, humorale Aktivatoren wie z. B. Thymosin-ß4 den Remodellingprozess unterstützen und führen somit zu einer verbesserten postischämischen Funktion. Die Adhäsion von embryonalen EPCs scheint dagegen unabhängig von ICAM-1 zu sein. Hier spielen Selektine211, 1-Integrine57, 141 und indirekt auch Thrombozyten118 eine wesentliche Rolle. Die präischämische Mobilisation von hämatopoetischen Progenitorzellen aus dem Knochenmark mittels GM-CSF hatte in unserem Modell eine vergleichbar protektive Wirkung wie die eEPC-Behandlung oder die Antagonisierung der Leukozytenadhäsi-on durch ICAM-1-Defizienz, während die postischämische Applikation den posti-schämischen Funktionsverlust nicht verbesserte (Abb. 25, Abb. 26, Abb. 27). Die Zytokin-Applikation zeigte bei rechtzeitiger Applikation vor Beginn der Ischämie eine protektive Wirkung. Dieses Protokoll ist allerdings nicht in der Klinik anwendbar. In weiteren Studien wird es notwendig sein, den optimalen Zeitpunkt und die optima-le Dosis zu evaluieren und mögliche Co-Applikation, z. B. Stromal-Cell-Derived-Factor-1, zur Verbesserung der Rekrutierung und zur Effizienzsteigerung zu untersu-chen, um knochenmark-stimulierende Zytokine als erfolgversprechende Behand-lungsalternativen im akuten Koronarsyndrom am Menschen einsetzen zu können.

Die adoptive T-Zelltherapie ist eine attraktive Alternative zu konventionellen Therapien zur Behandlung von malignen Erkrankungen. So konnten bereits Tumorremissionen bei Melanompatienten nach adoptivem T-Zelltransfer erreicht werden (Dudley et al, 2002b; Morgan et al, 2006). Während im autologen System jedoch oft nur unzureichende Antitumorantworten zu generieren sind, zeigt der Erfolg der allogenen Stammzelltransplantation, dass im allogenen System T-Zellen hoch effektiv Tumorzellen bekämpfen können. Die allogene Stammzelltransplantation konnte auch bei B-Zell-Non-Hodgkin-Lymphomen, wie beispielsweise der chronischen lymphatischen Leukämie (CLL), mit Hilfe eines Transplantat-gegen-Leukämie-Effektes (Graft-versus-Leukemia, GvL) lang andauerndes, krankheitsfreies Überleben bewirken. Sie birgt aber ein sehr hohes Morbiditäts- und Mortalitätsrisiko auf Grund der Transplantat-gegen-Wirts-Erkrankung (Graft-versus-Host-Disease, GvHD) in sich. Die im Transplantat enthaltenen T Zellen sind hierbei sowohl für den erwünschten GvL-Effekt verantwortlich, gleichzeitig aber auch für die unerwünschte GvHD (Horowitz et al, 1990; Kolb et al, 2004). Zur Minimierung des Risikos einer GvHD könnten T Zellen eingesetzt werden, die spezifisch und allorestringiert Peptide von tumorspezifischen Antigenen erkennen und somit bevorzugt Tumorzellen angreifen. Die Reaktivität der T Zellen kann durch einen T Zellrezeptor (TZR)-Transfer auf sekundäre Zellen übertragen werden. Diese transgenen Zellen können dann mittels adoptivem T Zelltransfer im Patienten zur selektiven Bekämpfung von Tumorzellen zum Einsatz kommen. In Vorarbeiten wurde FMNL1 (formin related protein in leukocytes 1) als hoch attraktives tumorassoziiertes Antigen identifiziert, das in der chronischen lymphatischen Leukämie (CLL) und in anderen Lymphomen, sowie in Zelllinien solider Tumoren stark überexprimiert wird, während es in gesunden Zellen fast ausschließlich in hämatopoetischen Zellen vorkommt. Ziel der vorliegenden Arbeit war es, allorestringierte FMNL1-peptidspezifische T-Zellen zu isolieren, zu charakterisieren und den T-Zellrezeptor dieser T-Zellen in sekundäre Zellen zu transduzieren. Hierzu wurden Peptide des tumorassoziierten Antigens FMNL1 mit Hilfe von Prädiktionsalgorithmen vorhergesagt und in T Zell-Stimulationsansätzen eingesetzt. Unter Einsatz von HLA-A2-positiven T2-Zellen als antigenpräsentierende Zellen, die mit dem prädizierten synthetischen Peptid FMNL1-PP2 beladen waren, ist es gelungen allorestringierte, FMNL1-PP2-spezifische T Zellen eines gesunden HLA-A2-negativen Spenders zu isolieren. Von 67 T-Zellklonen bzw. oligoklonalen T-Zellen konnte bei neun T-Zellklonen Allorestriktion und FMNL1-PP2-Peptidspezifität nachgewiesen werden. Der T-Zellklon SK22 war für diese neun T-Zellklone, die auf Sequenzebene einen identischen T-Zellrezeptor aufwiesen, repräsentativ. Der T-Zellklon SK22 zeigte in Reaktion auf peptidbeladene T2-Zellen eine hohe Peptidspezifität für FMNL1-PP2 im Kontext mit dem für SK22 allogenen HLA-A2. Nach Zielzellerkennung sezernierte der T-Zellklon Zytokine wie IFNγ, TNFα, GM-CSF und teilweise IL2. Der T Zellklon zeigte eine hohe Aktivität und mittlere Avidität gegen FMNL1 PP2-beladene T2-Zellen. Des Weiteren wurde die Reaktivität gegen unbeladene native Zellen getestet. Der T-Zellklon SK22 erkannte verschiedene Zellen, wenn sie HLA-A2-positiv waren und gleichzeitig FMNL1 exprimierten. Hierzu zählten zum einen maligne Zellen, darunter verschiedene Epstein-Barr-Virus (EBV)-positive und EBV-negative Lymphomzelllinien und die Nierenzellkarzinomzelllinie RCC26, die gut erkannt wurden sowie CD40-aktivierte CLL-Zellen, die schwächer erkannt wurden. Bei der Untersuchung von gesundem Gewebe wurden FMNL1-exprimierende HLA-A2-positive periphere Blutleukozyten (PBL) schwach und B-Zellen in mittlerer Stärke erkannt. HLA-A2-positive Zellen, die FMNL1 nicht exprimieren, wie beispielsweise Lungenfibroblasten, wurden vom T-Zellklon SK22 nicht erkannt. Der T Zellklon zeigte Kreuzreaktivität gegen neun verschiedene lymphoblastoide Zelllinien (LCL), die Allelvarianten von HLA-A2 exprimierten. Zusätzlich wurden 4 von 18 HLA-A2-negativen LCL-Zelllinien erkannt. Jeweils zwei dieser vom T Zellklon SK22 erkannten HLA-A2-negativen LCL-Zelllinien trugen ein gemeinsames MHC-Klasse-I-Molekül. Eines davon war HLA-A*3303, welches durch die Erkennung der HLA-A*3303-positiven Transfektante der C1R-Zelllinie bestätigt werden konnte. Das andere war HLA-A*6802, welches zur HLA-A2-Superfamilie gehört. Der T-Zellrezeptor des T-Zellklons SK22 wurde identifiziert, sequenziert und kloniert, sowie mit Hilfe von Retroviren in sekundäre Zellen eingebracht. Durch den Transfer des T Zellrezeptors von SK22 in sekundäre Zellen konnte nachgewiesen werden, dass dieser T Zellrezeptor für die spezifische Reaktivität des T-Zellklons SK22 verantwortlich war. Dies zeigte sich in der T-Zellrezeptor-Oberflächenexpression nach Transduktion in Jurkat76-CD8α-Zellen und in der Übertragung der Funktionalität des T-Zellklons in PBL. Der T Zellrezeptor von SK22 ist ein „schwacher“ Rezeptor, da er in der Konkurrenzsituation mit einem weiteren Rezeptor nur in geringem Grade an der Zelloberfläche von PBL exprimiert wurde. Durch einen Austausch der jeweiligen konstanten Regionen der T-Zellrezeptor-SK22-Sequenzen durch die konstanten Bereiche eines murinen T-Zellrezeptors konnten in der Summe verbesserte Expressionswerte in Jurkat76-Zellen und eine verbesserte Funktionalität in PBL erreicht werden. Der T-Zellklon SK22 zeigte Allorestriktion, FMNL1-PP2-Peptidspezifität und Zytotoxizität gegen FMNL1-exprimierende Zellen, insbesondere gegen Tumorzellen. Die beobachtete Kreuzreaktivität ist Fokus weiterführender Untersuchungen. Im Fall des T-Zellrezeptors von SK22 bedeutet es, dass Spender und Patienten sorgfältig nach Analyse des gesamten MHC-Klasse-I-Expressionsmuster ausgewählt werden müssen. Im Rahmen einer haploidentischen Stammzelltransplantation ist jedoch der klinische Einsatz dieses spezifischen T-Zellrezeptors zur Behandlung von B-Zell-Non-Hodgkin-Lymphomen und anderen FMNL1-überexprimierenden Tumorerkrankungen vielversprechend.

Trotz verbesserter Therapiemöglichkeiten ist die Prognose beim Fibrosarkom der Katze noch immer ungünstig. In der vorliegenden Arbeit sollte die Verträglichkeit eines neuen Therapieansatzes zur Behandlung des felinen Fibrosarkoms untersucht werden. Verwendet wurde ein nonviraler Gentransfer mittels Magnetofektion, um eine Transfektion mit dem felinen Zytokingen GM-CSF zu erreichen. Ziel der durchgeführten Phase-I-Studie war die Festlegung einer maximalen tolerierten Dosis. In die prospektive Dosis-Eskalations-Studie wurden Katzen, die definierte Einschlusskriterien erfüllten, aufgenommen. Die Steigerung der Dosis des Plasmids, das für feGM-CSF kodiert, erfolgte in vier festgelegten Schritten (50, 250, 750 und 1250 µg Plasmid). Jeweils vier Katzen wurden in eine Dosisgruppe aufgenommen. Die Plasmide wurden in wässriger Lösung in einem 1:1-Verhältnis mit magnetischen Nanopartikeln gemischt, die zur besseren Bindung an die DNA mit Polyethylenimin beschichtet waren. Die Plasmidlösung mit einem Volumen von 500 µl wurde intratumoral injiziert. Danach wurde durch Applikation eines Neodymium-Eisen-Bor-Magneten auf das Tumorgebiet ein Magnetfeld für die Dauer einer Stunde angelegt. Durch diese Magnetofektion wurde die Transfektion auf das Tumorgebiet beschränkt, sowie die Effektivität des Gentransfers verbessert. Das Behandlungsprotokoll umfasste zwei intratumorale Injektionen an den Tagen -14 und -7 sowie die großräumige en-bloc-Resektion des Fibrosarkoms an Tag 1. Eine Kontrollgruppe bestehend aus vier Katzen wurde ohne Zusatztherapie einer Operation unterzogen. Aus ethischen Gründen wurde dabei auf eine Verzögerung der chirurgischen Entfernung durch Placebo-Applikationen im Zeitraum von 14 Tagen verzichtet. Eine Untersuchung auf mögliche auftretende Toxizitäten erfolgte an den Tagen -7, 0, 14, 45, 90 und 180. Zwei weitere Untersuchungen an den Tagen 270 und 360 dienten zur Kontrolle auf Rezidiv- und Metastasenbildung. Aufgetretene klinische oder hämatologische Toxizitäten wurden anhand eines speziellen Nebenwirkungskatalogs (VCOG-CTCAE-Tabelle) erfasst und in Korrelation zur durchgeführten Therapie gestellt, um über eine Zuordnung als Nebenwirkung entscheiden zu können. Ein statistischer Vergleich erfolgte für die Parameter Körpergewicht, Leukozytenzahl und das Differentialblutbild zwischen Kontrollkatzen, behandelten Katzen und den Katzen der verschiedenen Dosisgruppen. Sieben weitere Katzen wurden mit derselben Gentherapie mit humanem GM-CSF behandelt, bei denen der Expressionsachweis von huGM-CSF mittels ELISA in den Zellkulturüberständen der angezüchteten Tumore gelang. In den ersten drei Dosisgruppen traten keine schwerwiegenden Nebenwirkungen auf. Da bei drei der vier Katzen der höchsten Dosis leichte Nebenwirkungen beobachtet wurden, wurden zwei weitere Katzen mit der höchsten Dosis behandelt. Dabei traten jedoch keine Toxizitäten auf, so dass die Dosis von 1250 µg für feGM-CSF kodierendes Plasmid als sichere, gut verträgliche Dosis für nachfolgende Phase-II-Studien festgelegt werden konnte. Auch die beobachteten Ergebnisse bezüglich Rezidivrate sind als sehr viel versprechend einzustufen.

The prognosis for cats with fibrosarcoma is still poor as the treatment options existing to date do not lead to satisfying results. After sole surgical removal of the tumor, up to 70 % of the cats develop local recurrences. Even with adjuvant radiation and/or chemotherapy, the recurrence rate can just be reduced to at most 40 %. In the present work an alternative treatment method in terms of neoadjuvant immunostimulatory gene therapy should be established. Via plasmids, three feline cytokine genes were transferred into the tumor. The plasmids coded for feIL-2, feIFN-γ and feGM-CSF. Using magnetofection, gene transfer should be optimized. The aim of this clinical dose escalation study was to define a well tolerated dose, which can be tested for its efficacy in a subsequent phase-II trial. Therefore the cats were examined at defined time points for treatment-related toxicity up to 180 days after surgery. Two more check-ups on day 270 and 360 after surgery were performed to elongate the observation period for local recurrences. Prerequisite for a cat’s admission to the study was the localization of the fibrosarcoma (primary tumor or recurrence) on the trunk. The tumor had to be excised in one setting without limb amputation. Affected cats were neither allowed to be pretreated with chemo-, radiation- or gene therapy nor with corticosteroids within the past six weeks. Further exclusion criteria were hints for metastases or other severe illnesses which reduce life expectancy to less than one year. Due to the potential teratogenic effect of the expressed cytokines, pregnancy had to be ruled out. Only cats with histopathologically confirmed fibrosarcoma continued the study after surgery. As this was a scientific study with a drug not registered yet, written informed consent from the owners was a prerequisite for the participation of each cat. Four treatment groups with defined dose escalation were prospectively fixed. The dose of the feline cytokines was 15, 50, 150 and 450 µg per plasmid in group I, II, III and IV. The initial dose (3 x 15 µg) was oriented to the total dose for small oral melanomas in dogs (400 µg) established by DOW et al. and is 1/10 of it. Plasmids as non-viral vectors were chosen for several reasons. Their handling is not liable to such strict regulations as the potentially more dangerous viral vectors. Their production is simple and affordable. They induce fewer side effects than viral vectors. Therefore plasmids are more suitable for application in veterinary clinical practice. Equal amounts of the plasmids were brought into 0.9 % saline. The positively charged magnetic nanoparticles were brought into solution with aqua for injections and were mixed with the plasmid formulation in a 1:1 ratio. This formulation had a total volume of 500 µl and was injected twice intratumorally in weekly intervals. Transfection was enhanced and targeted to the tumor area by the application of a neodymium-iron-boron magnet for the duration of 60 minutes. One week after the second application, wide en-bloc resection of the tumor was performed. Four cats were assigned to each treatment group. As questionable toxicity occured in group IV, four more cats were added to this group. A control group also consisting of four cats received surgery without neoadjuvant therapy. For ethical reasons, the application of empty plasmids was avoided so that in this group surgery could be performed without delay. Medical care of all the cats was carried out by the same team of internists, anesthetists and surgeons. Clinical and laboratory parameters were evaluated according to the VCOG-CTCAE system. All adverse events were registered, classified with severity grades and correlated to treatment. Plasma samples of all cats up to 14 days after surgery were examined for the existence of feGM-CSF and feIFN-γ with commercially available ELISA kits. Statistical analyses were performed comparing the treatment groups themselves as well as treatment groups and the control group regarding body weight, white blood cells and differential blood counts. Only one cat out of group IV showed adverse events during the neoadjuvant treatment period, which were classified as grade 3 and which were probably correlated to treatment (correlation grade 4). For this reason four more cats were treated with the highest dose. None of these cats showed side effects that could be correlate to treatment. The occurrence of early recurrences in four cats of group IV was outstanding, but of course, the expressiveness of this statement is low regarding the small group sizes. However it is known that biological drugs, especially IL-2, often do not have a linear dose-response profile. Therefore the optimal effective dose lies within a strictly defined area and is probably lower than the maximal tolerated dose. The highest applied dose which is 450 µg per plasmid was defined as a well tolerated dose. It can be safely tested for its efficacy in a subsequent phase-II trial. Because of the reflections mentioned above it would undoubtedly be convenient to test the third dose (150 µg per plasmid) in parallel for its effectiveness.

Background: For optimal T cell activation it is desirable that dendritic cells (DCs) display peptides within MHC molecules as signal 1, costimulatory molecules as signal 2 and, in addition, produce IL-12p70 as signal 3. IL-12p70 polarizes T cell responses towards CD4(+) T helper 1 cells, which then support the development of CD8(+) cytotoxic T lymphocytes. We therefore developed new maturation cocktails allowing DCs to produce biologically active IL-12p70 for large-scale cancer vaccine development. Methods: After elutriation of leukapheresis products in a closed bag system, enriched monocytes were cultured with GM-CSF and IL-4 for six days to generate immature DCs that were then matured with cocktails, containing cytokines, interferon-gamma, prostaglandin E2, and a ligand for Toll-like receptor 8, with or without poly (I: C). Results: Mature DCs expressed appropriate maturation markers and the lymph node homing chemokine receptor, CCR7. They retained full maturity after culture for two days without maturation cocktails and following cryopreservation. TLR ligand stimulation induced DCs capable of secreting IL-12p70 in primary cultures and after one day of coculture with CD40L-expressing fibroblasts, mimicking an encounter with T cells. DCs matured with our new cocktails containing TLR8 ligand, with or without poly (I: C), induced alloresponses and stimulated virus-specific T cells after peptide-pulsing. DCs matured in cocktails containing TLR8 ligand without poly (I: C) could also be loaded with RNA as a source of antigen, whereas DCs matured in cocktails containing poly (I: C) were unable to express proteins following RNA transfer by electroporation. Conclusion: Our new maturation cocktails allowed easy DC harvesting, stable maturation and substantial recoveries of mature DCs after cryopreservation. Our procedure for generating DCs is easily adaptable for GMP-compliance and yields IL-12p70-secreting DCs suitable for development of cancer vaccines using peptides or RNA as sources of immunizing antigens.

Background: Given the considerable toxicity and modest benefit of adjuvant chemotherapy for non-small cell lung cancer (NSCLC), there is clearly a need for new treatment modalities in the adjuvant setting. Active specific immunotherapy may represent such an option. However, clinical responses have been rare so far. Manipulating the host by inducing lymphopenia before vaccination resulted in a magnification of the immune response in the preclinical setting. To evaluate feasibility and safety of an irradiated, autologous tumor cell vaccine given following induction of lymphopenia by chemotherapy and reinfusion of autologous peripheral blood mononuclear cells (PBMC), we are currently conducting a pilot-phase I clinical trial in patients with NSCLC following surgical resection. This paper reports on the first clinical experience and evidence of an immune response in patients suffering from NSCLC. Methods: NSCLC patients stages I-IIIA are recruited. Vaccines are generated from their resected lung specimens. Patients undergo leukapheresis to harvest their PBMC prior to or following the surgical procedure. Furthermore, patients receive preparative chemotherapy ( cyclophosphamide 350 mg/m(2) and fludarabine 20 mg/m(2) on 3 consecutive days) for induction of lymphopenia followed by reconstitution with their autologous PBMC. Vaccines are administered intradermally on day 1 following reconstitution and every two weeks for a total of up to five vaccinations. Granulocytemacrophagecolony- stimulating-factor (GM-CSF) is given continuously ( at a rate of 50 mu g/24 h) at the site of vaccination via minipump for six consecutive days after each vaccination. Results: To date, vaccines were successfully manufactured for 4 of 4 patients. The most common toxicities were local injection-site reactions and mild constitutional symptoms. Immune responses to chemotherapy, reconstitution and vaccination are measured by vaccine site and delayed type hypersensitivity (DTH) skin reactions. One patient developed positive DTH skin tests so far. Immunohistochemical assessment of punch biopsies taken at the local vaccine site reaction revealed a dense lymphocyte infiltrate. Further immunohistochemical differentiation showed that CD1a+ cells had been attracted to the vaccine site as well as predominantly CD4+ lymphocytes. The 3-day combination chemotherapy consisting of cyclophosphamide and fludarabine induced a profound lymphopenia in all patients. Sequential FACS analysis revealed that different T cell subsets (CD4, CD8, CD4CD25) as well as granulocytes, B cells and NK cells were significantly reduced. Here, we report on clinical safety and feasibility of this vaccination approach during lymphoid recovery and demonstrate a patient example. Conclusion: Thus far, all vaccines were well tolerated. The overall trial design seems safe and feasible. Vaccine site reactions associated with infusion of GM-CSF via mini-pump are consistent with the postulated mechanism of action. More detailed immune-monitoring is required to evaluate a potential systemic immune response. Further studies to exploit homeostasis-driven T cell proliferation for the induction of a specific anti-tumor immune response in this clinical setting are warranted.

Infections of the bovine mammary gland are, in addition to the affliction of the animals, a great economic burden in the dairy industry. A better understanding of the innate immune response of the host could lead to a better selection of mastitis resistant cows or to better prophylactic and therapeutical treatments. The objective of the present study was to investigate the involvement of the epithelial cells into the outcome of mastitis induced by different pathogens. Primary epithelial cell cultures isolated from milk of Brown swiss cows and coloured german goats, and tissue of cows were used to test the immune response. Because the cells of the cows showed different responses to isolated bacterial endotoxins (lipopolysaccharide, lipoteichoic acid, and peptidoglycans) compared to whole bacteria, they were treated with heat inactivated (10 MOI) gram-negative Escherichia coli (E.coli), a very common pathogen causing acute and severe intra-mammary infections, with Staphylococcus aureus (S.aureus) and coagulase-negative Staphylococcus (CNS), both prevalent cause of chronic and subclinical, and, Streptococcus uberis (Str.uberis) an inducer of acute and chronic mastitis. Goat cells were treated with 10 MOI heat inactivated S.aureus causing in opposite to cows an acute, clinical mastitis and LPS. In cows E.coli induced an increased mRNA expression of interleukin-(IL) 8, IL-6, tumor necrosis factor alpha (TNF) and granulozytes, macrophage-stimulating factor (GM-CSF) within a 30 min treatment. IL-8, IL-6 and TNF mRNA levels were still elevated after 60 min, 90 min, 6 h and 24 h. After 6 h S.aureus induced an increase in mRNA expression of IL-6, IL-8, TNF and SAA. After a 24 h treatment the expression of these immunomodulators was still elevated. Interestingly, Str.uberis in the same concentration did only induce the mRNA expression of GM-CSF after 60 min and the IL-8 after a 6 h treatment but had no influence on other immunomodulator mRNA expression. CNS treated cells needed a MOI of 50 for any reaction. This MOI induced a reaction on mRNA levels of IL-6 and IL-8 but not on TNF after 6 h. In goats S.aureus induced an increase in mRNA expression of IL-8 and TNF after 1 and 6 h. After a 24 h treatment just the mRNA level of TNF was elevated. In conclusion mammary gland epithelial cells are involved in the different immune response to various mastitis pathogens. In cows, E.coli always induced an earlier immune response compared to S.aureus. This pathogen induced a later and probably for the immne system weaker reaction, not strong enough to cause an acute intramammary infection. Str.uberis in the same concentration induced only an increased GM-CSF and IL-8 mRNA expression after a 60 min or a 6 h treatment, respectively. This bacterium probably stimulates different immune relevant gene expressions not measured here or does not stimulate the mammary gland epithelial cells. The cells needed a 5-fold higher dose of KNS to respond with induced mRNA levels of IL-6 and TNF but not IL-8. KNS maybe does not stimulate the immune system enough to induce an acute mastitis and is like by the epithelial cells just recognized in very high dosis. IL-8 plays an important role as a chemotactic stimulus that is missing here. Goat mammary gland epithelial cells showed a early increase of IL-8 and TNF, that could be high enough, combined with the response of the immune cells in the milk, to induce an acute and severe intra-mammary infection.

Leukämische Blasten bei AML können ex vivo in DC umgewandelt werden, wodurch Anti-gen-präsentierende Zellen entstehen, welche leukämische Antigene präsentieren. Im kleineren Rahmen sollten zunächst Daten zu methodischen Vorversuchen ausgewertet werden, um bei AML und MDS unter serumfreien Bedingungen DC zu generieren. Diese me-thodischen Vorversuche an 50 AML-, 24 MDS-Patienten und 23 gesunden Probanden erga-ben, dass adhärente Zellfraktionen die DC-Ausbeute im Vergleich zu totalen MNC-Fraktionen nicht verbessern, dass bei MACS-depletierten `MNC(-)`- und aufgetauten MNC-Fraktionen niedrigere DC-Zahlen erreicht werden, und dass die DC-Ernte bei AML- und MDS-Patienten nach 10-14tägiger Kulturzeit, bei gesunden Probanden jedoch nach 7tägiger Kulturzeit höher ist. Außerdem zeigte sich, dass die Zugabe von FL die DC-Ernte erhöht, der Einsatz von autologem Plasma dagegen in vielen Fällen einen inhibitorischen Effekt auf die DC-Generierung hat. Die Kulturmedien CellGro und Xvivo erzielten vergleichbare DC-Ausbeuten. Nach Ermittlung der optimalen Zellfraktion, Kulturdauer und –zusätze, wurden serumfreie DC von 100 AML-, 55 MDS- und 38 gesunden Proben in einem 10-14-tägigem serumfreien Xvivo-Kultursystem mit GM-CSF, IL-4, FL und TNFα angezüchtet und charak-terisiert. Bei der DC-Generierung unter standardisierten Bedingungen betrug die Ausbeute der MNC-Fraktionen durchschnittlich 20% bei MDS, 34% bei AML und 25% bei gesunden Probanden. Zwischen 53-58% der DC waren reife CD83+DC. Die DC-Ernten waren in den monozytären FAB-Klassen (AML-M4/5, MDS-CMML) am höchsten, dagegen unabhängig von den zyto-genetischen Risikogruppen. Das Oberflächenmarkerprofil der DC von den AML- und MDS-Proben (einschließlich 1 MDS- und 3 AML-Zelllinien) war mit dem der gesunden DC ver-gleichbar. In parallelen Kulturansätzen konnte außerdem gezeigt werden, dass in einem `MCM-Mimic`-Medium mit PGE2 der Anteil reifer, CCR7+DC besonders hoch war. Der leu-kämische Ursprung der AML- und MDS-DC wurde bei 5 AML- und 4 MDS-Fällen mittels FISH durch die Persistenz klonaler, zytogenetischer Aberrationen in den DC oder in übrigen Fällen durch die Coexpression leukämischer Antigene auf den DC bewiesen. Durch eine kombinierte FISH/Immunophänotyp-Analyse (FISH-IPA) konnte zudem nachgewiesen wer-den, dass obige klonale, numerische Aberrationen konstant in Kombination mit DC-Markern detektierbar, jedoch nicht alle klonalen Zellen zu leukämischen DC umwandelbar waren (durchschnittlich 53% der AML- und MDS-Blasten). Umgekehrt trugen auch nicht alle gene-rierten DC die klonale Aberration (im Durchschnitt 51% der DC). In 41 AML-Fällen mit ei-ner Leukämie-spezifischen bzw. aberranten Antigenexpression oder in AML-Fällen mit ei-nem CD33+ Blastenphänotyp und gleichzeitig

s Karyotypic evolution is a well-known phenomenon in patients with malignant hernatological disorders during disease progression. We describe a 50-year-old male patient who had originally presented with pancytopenia in October 1992. The diagnosis of a myelodysplastic syndrome (MDS) FAB subtype RAEB-t was established in April 1993 by histological bone marrow (BM) examination, and therapy with low-dose cytosine arabinoside was initiated. In a phase of partial hernatological remission, cytogenetic assessment in August 1993 revealed a ring chromosome 1 in 13 of 21 metaphases beside BM cells with normal karyotypes {[}46,XY,r(1)(p35q31)/46,XY]. One month later, the patient progressed to an acute myeloid leukemia (AML), subtype M4 with 40% BM blasts and cytogenetic examination showed clonal evolution by the appearance of additional numerical aberrations in addition to the ring chromosome{[}46,XY,r(1),+8,-21/45,XY,r(1),+8,-21,-22/46, XY]. Intensive chemotherapy and radiotherapy was applied to induce remission in preparation for allogeneic bone marrow transplantation (BMT) from the patient's HLA-compatible son. After BMT, complete remission was clinically, hematologically and cytogenetically (normal male karyotype) confirmed. A complete hematopoietic chimerism was demonstrated. A relapse in January 1997 was successfully treated using donor lymphocyte infusion and donor peripheral blood stem cells (PB-SC) in combination with GM-CSF as immunostimulating agent in April 1997, and the patient's clinical condition remained stable as of January 2005. This is an interesting case of a patient with AML secondary to MDS. With the ring chromosome 1 we also describe a rare cytogenetic abnormality that predicted the poor prognosis of the patient, but the patient could be cured by adoptive immunotherapy and the application of donor's PB-SC. This case confirms the value of cytogenetic analysis in characterizing the malignant clone in hernatological neoplasias, the importance of controlling the quality of an induced remission and of the detection of a progress of the disease. Copyright (c) 2006 S. Karger AG, Basel.

The feline fibrosarcoma is a spontaneous malignant soft tissue sarcoma. Due to the high recurrence rate of approximatelly 70 % even after radical surgical excision the prognosis is very poor. There have been carried out different gene-therapy protocolls adjuvant to tumour excision, yet. In the following study a local, nonviral gene-transfer with the feline cytokine-genes Interleukin 2, Granulocyte-macrophage colony-stimulating factor and Interferon γ is conducted. As local gene delivery system serves a collagen-sponge loaded with a plasmid-DNA-PEI-PEG-formulation. The immunomodulating cytokines are expected to improve the antigen presentation, to activate immune effector cells and to generate memory cells against specific tumour antigens. The goal is to enhance tumour cell killing and anti cancer immune response to extend the tumour free survival time or even to decrease the recurrence rate in fibrosarcoma bearing cats. First a phase I dose escalation study is carried out using these vector-loaded collagen sponge. The adjuvant immunotherapy is combined with the surgical standard treatment of the feline fibrosarcoma. Blood was collected from healthy cats. Feline peripheral mononuclear blood cells were separated, cultured and stimulated in vitro by Concanavalin A. mRNA was isolated and reverse transcribed in cDNA. The cDNA served as template for the PCR amplification. Specific primers are based on already published sequences and introduced restriction endonuclease sequences in the amplified product. PCR products and expression vector were cut with these restriction enzymes. After ligation of PCR products and expression vector p55pCMV_ivs_luc+ transformation in DH 10 B bacteria was performed. Further analysed inserts were sequenced. Before therapeutic use the cytokines had to show biological activity. Recombinant proteins are expressed in the mammalian cell line COS-7. The feIL-2 and feGM-CSF bioactivity is demonstrated in proliferation assays, using the IL-2 and GM-CSF dependent cell lines CTLL-2 and TF-1. The biological acitivty of feIFNγ is measured by FACS analysis. A MHC I and II induction assay was performed on feline fibrosarcoma cells. After plasmid DNA preparation with polykation polyethylenimine and protective copolymers (polyethylene glycol) the collagen sponge is loaded with these gene vectors under sterile conditions. The vector loaded sponge is stored at 4 °C till implanted in the tumour bed of fibrosarcoma bearing cats.

Die Zahl der Patienten mit arteriellen Gefäßverschlüssen nimmt stetig zu. Eine Alternative zu invasiven Techniken stellt die Förderung des körpereigenen Kollateralwachstums (Arteriogenese) dar. Arteriogenese beschreibt die Entwicklung von großlumigen Kollateralarterien aus präexistenten arteriellen oder arteriolären Anastomosen, während Angiogenese die Neuentwicklung von kapillären Netzwerken beschreibt. Aufgrund des Hagen-Poiseuillschen Gesetzes bedarf es für den Ersatz von Arterien größerer Gefäße, die nicht durch Angiogenese entstehen können. Experimentell lässt sich das Wachstum von Kollateralarterien durch Granulozyten-Makrophagen-Kolonie Stimulierender Faktor (GM-CSF) fördern. Die Wirkung von GM-CSF auf die Arteriogenese in größeren Organismen ist jedoch noch unbekannt und soll in einem Schweinehinterlaufmodell überprüft werden. Material und Methoden: Die rechte Femoralarterie von 24 Schweinen Deutscher Landrasse (n=8/Gruppe) wurde ligiert, kanüliert und an eine implantierte Pumpe angeschlossen. Die erste Gruppe erhielt 0,9%Natriumchloridlösung, in der zweiten Gruppe wurden die Tiere kontinuierlich mit GM-CSF 5 µg/kg/d behandelt, die Tiere der dritten Gruppe erhielten die selbe Tagesdosis in einem intermittierenden Applikationsmodus (1h Infusion, 7h Pause, 3Zyklen/d). Nach einwöchigem Behandlungszeitraum wurde die kollaterale Konduktanz bestimmt unter maximaler Vasodilatation sowie weitere klinische Parameter (ABI, Fluss unter Hyperämie, Angiographien) bestimmt. Ergebnisse: Angiographisch und durch Bestimmung des ABI ließen sich keine signifikanten Unterschiede feststellen. Funktionelle Untersuchungen zeigten jedoch, dass sowohl die kontinuierliche als auch die intermittierende Applikation von GM-CSF zu einer signifikanten Steigerung der reaktiven Hyperämie und der kollateralen Konduktanz im Vergleich zur Kontrollgruppe führte ([ml/min/mmHg] NaCl:37,73±5,42; GM-CSF kont.:69,16±12,46; GM-CSF interm.:71,50±11,08). Schlussfolgerung: Die vorliegenden Ergebnisse bestätigen die Wirksamkeit von GM-CSF als pro-arteriogene Substanz im Großtierorganismus. Die intermittierende Anwendung von GM-CSF führte zu keiner signifikanten Wirkungssteigerung im Vergleich zur kontinuierlichen Infusion. Eine tachyphylaktische Rezeptorregulation unter GM-CSF-Therapie in der Arteriogenese erscheint somit unwahrscheinlich. Der Einsatz von programmierbaren Infusionspumpen stellt eine mögliche Lösung für die intravasale Anwendung bei Menschen mit peripherer arterieller Verschlusskrankheit dar

Das feline Fibrosarkom hat mit einer Rezidivneigung von bis zu 70 % nach alleiniger chirurgischer Entfernung eine ungünstige Heilungsprognose. Auch adjuvante Chemo- oder Strahlentherapien führen nur in 42 % der Patienten zu einer rezidivfreien Zeit von über einem Jahr. In der vorliegenden Arbeit soll ein nonvirales Gentransfersystem etabliert werden, bei dem erstmalig eine Kombination aus drei felinen Zytokin-Genen zur adjuvanten Immunstimulation nach Tumorexstirpation beim Fibrosarkom der Katze eingesetzt wird. Ziel dieser Studie ist die Festlegung einer maximal tolerierten Dosis. Mit Hilfe eines Nebenwirkungskataloges, der auf der Common-Toxicity-Criteria-Tabelle des National Cancer Instiute basiert, werden klinische wie auch labordiagnostische Parameter objektiv erfasst und in Relation zur Therapie gestellt. Nach definierten Aufnahmekriterien werden Katzen mit Fibrosarkomen von prak-tischen Tierärzten an die Medizinische Kleintierklinik überwiesen. Es werden nur Tiere in die Studie aufgenommen, deren Tumoren (Primärtumor oder Rezidiv) am Rumpf lokalisiert sind. Die Tumorexstirpation muss in einer Sitzung möglich sein und darf dabei weder zu einer Gliedmaßenamputation noch zur Eröffnung einer Körperhöhle führen. Katzen, bei denen Hinweise auf Metastasen oder eine andere schwere Krankheit vorliegen, sowie Tiere, die bereits zuvor mit einer Chemo-, Strahlen- oder Gentherapie behandelt wurden, können nicht in die Studie aufge-nommen werden. Nach Tumorexstirpation wird den Tieren ein Kollagenschwamm in das Tumorbett implantiert. Dieser Kollagenschwamm trägt Plasmide, die jeweils für feIL-2, feIFNγ und feGM-CSF kodieren. Die Plasmid-DNA ist zusätzlich an Polyethylenimin (PEI) assoziiert und mit einem Hüllpolymer (P6YE5C) ummantelt. Insgesamt werden 15 Tiere in vier verschiedenen Dosisgruppen therapiert. Gruppe I (n=3) mit 75 μg je Plasmid, Gruppe II (n=3) mit 150 μg je Plasmid, Gruppe III (n=6) mit 300 μg je Plasmid und in Dosisgruppe IV (n=3) mit 600 μg je Plasmid. Als Ver-gleichsgruppe gelten vier Katzen, die unter gleichen Bedingungen nur mit einer en bloc Resektion behandelt werden. In die Studie werden 15 Katzen (mk=9, wk=6) im Alter zwischen drei und 15 Jahren aufgenommen. Die Fibrosarkome sind häufiger im Interscapularbereich lokalisiert. Bei keinem Patienten kommt es zu therapiebedingten Beeinträchtigungen des Allgemeinbefindens. Drei Katzen entwickeln postoperativ ein Serom, das ohne thera-peutisches Eingreifen resorbiert wird. Systemische Veränderungen, die auf die Therapie zurückgeführt werden, manifestieren sich erst in Dosisgruppe IV mit einem Abfall der Lymphozytenpopulation. Dabei fallen in einem Zeitraum bis 45 Tage nach Implantation des Kollagenschwammes die Lymphozyten bis zu 70 % des Ausgangs-wertes ab. Bei dieser Phase I-Studie handelt es sich um eine Dosisfindungsstudie. Diese wird durch das Auftreten erster Nebenwirkungen, die auf das Transgen oder auf dessen Expressionsprodukt zurückgeführt werden können, beendet. Die maximal tolerierte Dosis wird somit in vorliegender Studie auf 600 μg je Zytokin-Plasmid festgesetzt.

Durch den Transfer tumorspezifischer T-Zellen können solide Tumore nicht nur in Tieren, sondern auch im Menschen erfolgreich behandelt werden. Dudley et al. konnten kürzlich nach dem autologen Transfer stimulierter tumorinfiltrierender Lymphozyten (TIL) nach vorheriger non-myeloablativer Konditionierung in zwei von zwölf Patienten mit Melanomen eine Tumorregression erreichen (Dudley et al. 2002). Änliche Erfolge konnten Chang et al. bei der Behandlung von fortgeschrittenen Nierenkarzinomzellen erzielen (Chang et al. 2003). Sie vakzinierten Patienten mit Calmette-Guérin Bacillus versetzten Tumorzellen und ernteten anschließend die T-Zellen aus den angrenzenden Lymphknoten der Vakzinierungsregion. Nach autologem Transfer der vorwiegend CD8+ T-Zellen, welche in vitro mit anti-CD3 stimuliert wurden, sprach die Therapie bei neun von 34 Patienten an. Die Mechanismen der T-zellvermittelten Tumorregression sind aber bis heute noch unklar. Gegenstand dieser Arbeit war es daher Faktoren zu untersuchen, welche eine Rolle bei der Regression von D5-Melanomlungenmetastasen durch den adoptiven Transfer CD4+/CD8+ T-Zellen aus Tumorvakzin drainierenden Lymphknoten (TVDLN) nach Vakzinierung mit D5G6 (einem GM-CSF transduzieren D5-Subklon) spielen. Hierzu wurden D5-Zellen in vitro mit Zytokinen, welche von Effektor T-Zellen (TE) produziert werden, stimuliert. Wir konnten zeigen, dass D5-Tumorzellen die als proapoptotisch geltenden Rezeptoren TNF-R I sowie Fas nach IFN-g-Stimulation exprimieren. Die Inkubation mit den Liganden dieser Rezeptoren TNF-a, LT-a und FasAb bewirkt keine Apoptoseinduktion. Gleichzeitige Inkubation dieser Liganden führt nur zu einer Apoptoserate von 25% in D5. Mögliche Gründe der relativen Apoptoseresistenz von D5 könnten die intrazellulären Apoptoseinhibitionsproteine c-IAP I, c-IAP II und Survivin sein, welche wir in D5 nachweisen konnten. Da nach adoptivem Transfer tumorspezifischer TE Makrophagen die pulmonalen Tumormetastasen infiltrieren, untersuchten wir, ob TE Chemokine exprimieren. Unsere Untersuchungen ergaben, dass TE die Chemokine MIP-1a, MIP-1b und RANTES tumorspezifisch exprimieren. Nach Stimulation von D5-Tumorzellen mit den Zytokinen TNF-a und IFN-g, welche von TE tumorspezifisch exprimiert werden, wird die Chemokin-mRNA von KC, MCP-1, IP-10 und Mig in D5 exprimiert. Auch die Koinkubation von D5 mit TE induziert die Expression der mRNA von KC, MCP-1, IP-10 und Mig. Deutlich erhöhte KC und MCP-1 Proteinkonzentrationen wurden im Überstand von D5-Tumorzellen mittels ELISA nach TNF-a Stimulation gegenüber unstimulierten und IFN-g stimulierten D5-Zellen festgestellt. Um zu prüfen, ob die von D5 gebildeten Substanzen auch tatsächlich chemotaktisch auf Makrophagen wirken, führten wir einen chemotaktischen Assay durch. Wir konnten zeigen, dass es zu einer signifikanten Steigerung der Anzahl migrierter Makrophagen in Richtung D5- Tumorzellen nach deren Stimulation mit IFN-g und TNF-a kommt. Da wir in TE die Expression von TNF-a-mRNA und die Sekretion von IFN-g tumorspezifisch nachweisen konnten, besteht Grund zur Annahme, dass in vivo TE in der Lage sind Tumorzellen zur Chemokinbildung anzuregen, was zu einer Invasion von Makrophagen in die Tumorregionen führt. Dass Makrophagen möglicherweise eine entscheidende Rolle bei der Tumorregression spielen, deckt sich auch mit der Beobachtung von Feinmesser et. al., welche mit einer peritumorösen Injektion von Multikinen (Zytokin-/Chemokinmischung) Kopf und Halstumore behandelten (Feinmesser et al. 2003). Nach dieser Therapie zeigte sich in den Tumorregionen der erfolgreich behandelten Patienten im Gegensatz zu Non-Respondern eine hohe Anzahl migrierter und aktivierter Makrophagen. Wir fanden mit den Ergebnissen unserer Studie erstmals Hinweise darauf, dass im murinen Melanommodell B16BL6-D5 nicht ausschließlich die direkte T-zellabhängige Zytotoxizität zur Tumorregression führt, sondern dabei weitere Zellarten wie Makrophagen/Monozyten involviert sind, welche mittels tumorspezifischer Chemokine rekrutiert werden. Die vorliegende Arbeit liefert einen Beitrag zur Erforschung der Mechanismen T-zellvermittelter Tumorregression. Die Kenntnisse dieser Mechanismen haben entscheidende Bedeutung bei der Entwicklung neuer, effektiver Behandlungskonzepte gegen solide Tumore.

Background The inflammation in acne vulgaris is widely thought to be induced by an immunological reaction to Propionibacterium acnes. Objectives In the present study we examined the local host response mechanism of keratinocytes 3 and 6 h after stimulation with viable and heat- killed P. acnes. Methods The quantitative expression of cytokines was measured at the mRNA level by real time RT-PCR. Results The co-incubation of keratinocytes with active, but not heat- killed, P. acnes modulated an adequate cytokine response for IL-1beta, GM-CSF, and IL-8. High-performance liquid chromatography analysis of the in vivo porphyrin pattern secreted by P. acnes revealed a predominance of coproporphyrin III in inflammatory acne lesions. This same porphyrin fraction also modestly induced IL-8 expression by keratinocytes. Conclusions This cytokine pattern may favor a chemotactic response and implicates P. acnes and coproporphyrin III in the recruitment of leukocytes to the site of infection and in the development of inflammatory lesions.

Neue Therapieansätze zur Krebsbehandlung aus dem Bereich der Gen- und Immuntherapie haben als Ergänzung zu den konventionellen Behandlungsmethoden besondere Bedeutung erlangt. Zu ihnen zählen u.a. die Suizidgentherapie und die Verwendung Zytokin-Gen-modifizierter Tumorzellvakzine. Beide Strategien wurden in der vorliegenden Arbeit herangezogen, um eine Immunantwort gegen das murine B-Zell-Lymphom A20 zu erzeugen. 1. Versuche mit HSV-tk-Gen-transduzierten Lymphomzellen. Das Prinzip der Suizidgentherapie mit dem HSV-tk/GCV-System beruht auf der Transduktion des HSV-tk-Gens in Tumorzellen, die dadurch gezielt durch GCV abgetötet werden können. Dabei werden auch nicht-transduzierte, angrenzende Zellen miterfasst („Bystander“-Effekt). Ganciclovirsensible, HSV-tk-Gen-transduzierte A20-Zellen (A20-TK) zeigten in vitro einen eingeschränkten „Bystander“-Effekt. In vivo konnten A20-TK-Zellen nur bei jeder dritten Maus vollständig durch GCV eliminiert werden, wobei sich jedoch bei der Hälfte der überlebenden Tiere eine dauerhafte, systemische Antitumorantwort induzieren ließ. 2. Versuche mit HSV-tk-Gen-transduzierten Triomzellen. Die Triomzelle BiV, hervorgegangen aus der Fusion des Lymphoms A20 mit der Hybridomzellinie 2.4G2, dirigiert Tumorantigene über die Expression eines anti-Fc-Rezeptor-Antikörpers an APC und führt auf diese Weise zur Tumorabstoßung. Trotz Xenogenität sind BiV-Zellen jedoch bis zu 11 Wochen nach Immunisierung in vivo nachweisbar. Auch HSV-tk-Gen-transduzierte BiV-Zellen (BiV-TK) konnten trotz GCV-Verabreichung vier Wochen post iniectionem in den Milzen immunisierter Mäuse nachgewiesen werden, allerdings in niedriger Frequenz. Obwohl nicht alle BiV-TK-Zellen durch GCV in vivo eliminiert werden, hatte eine frühzeitige Rückholung der Zellen einen verminderten Antitumoreffekt zur Folge. Im Gegensatz dazu beeinflusste eine späte GCV-Gabe die Tumorabstoßung nicht. Dies deutet darauf hin, dass für einen potenten Tumorschutz die langdauernde Verfügbarkeit von Vakzinezellen im Sinne einer persistierenden Antigenquelle erforderlich sein könnte. 3. Versuche mit GM-CSF-Gen-transfizierten Triomzellen. GM-CSF-Gen-transfizierte Triomzellen (BiV-BNG) schützten in Präimmunisierungsversuchen effektiver vor Tumorwachstum als Wildtyp-BiV-Zellen, bei therapeutischer Applikation wurde der Antitumoreffekt jedoch überaschenderweise aufgehoben. Durch Blockierung der Triomzell-vermittelten Tumorantigen-Heranführung an APC durch BiVneg-BNG bzw. den Antikörper 2.4G2 konnte die ursprüngliche Antitumorantwort vollständig bzw. teilweise wiederhergestellt werden. Eine mögliche Erklärung hierfür wäre eine hemmende Interaktion zwischen intaktem BiV-Protein und GM-CSF, resultierend in einer Hemmung der APC. Offenbar beschränkt sich die Hemmung nur auf die betroffene APC, denn BiV-BNG hob den Therapieeffekt von A20-BNG bzw. BiV bei simultaner Applikation nicht auf. Die Applikationsroute als mögliche Ursache der Wirkungslosigkeit von BiV-BNG im Therapieansatz wurde durch Änderung des Präimmunisierungsprotokolls ausgeschlossen. Da IL-4-defiziente Mäuse bei therapeutischer BiV-BNG-Gabe eine bessere Überlebensrate erreichten als Wildtypmäuse, könnte der aufgehobene Therapieeffekt von BiV-BNG mit einer Verschiebung des Th1/Th2-Verhältnisses zu Gunsten einer Th2-Antwort zusammenhängen.

Die Immuntherapie von niedrig malignen Tumoren stellt eine vielversprechende alternative Behandlungsmethode dar. Epstein Barr-Virus (EBV) etabliert eine latente Infektion in der Zielzelle, in der das EBV-Genom extrachromosomal aufrecht erhalten wird. EBV eignet sich mit diesen Eigenschaften hervorragend als Genvektor. Meine Aufgabenstellung war es, neue EBV-abgeleitete Genvektoren zu entwickeln, die das therapeutische Zytokin GM-CSF in Tumorzellen von B-CLL-Patienten (Chronische lymphatische Leukämie) exprimieren. Dabei entscheidend ist die Eigenschaft von EBV naive, wie auch reife und maligne B-Lymphozyten über den CD21-Rezeptor spezifisch zu infizieren. Als Grundlage diente das Maxi-EBV-System, mit dem das EBV-Genom für genetische Veränderungen zugänglich ist. Im Rahmen dieser Arbeit wurde ein sicherer EBV-Basis-Vektor etabliert, der replikations-defizient ist und dem zusätzlich die immortalisierenden Eigenschaften von EBV fehlen. Im selben Zuge wurden verschiedene Expressionskassetten für das Transgen GM-CSF in den EBV-Basis-Vektor eingebracht. Es konnten fünf unterschiedliche GM-CSF-Vektoren etabliert werden, die das Transgen an verschiedenen Genorten innerhalb des Maxi-EBV-Genoms tragen. Zwei dieser GM-CSF-Vektoren erzielten besonders hohe Transduktionseffizienzen und Expressionsraten in der Modellzelllinie Raji (Burkitt-Lymphom-B-Zelllinie). Auch B-CLL-Zellen konnten mit guter Effizienz transduziert werden, die Expression des GM-CSF war aber deutlich schwächer. Das immunstimulatorische Zytokin GM-CSF führt in vivo zu einer verbesserten Immunantwort gegen Tumore. Es konnte in dieser Arbeit gezeigt werden, dass GM-CSF-haltige Überstände von Vektor-transduzierten Raji-Zellen eine Reifung von dendritischen Zellen (DC) bewirken, die als wichtige Effektoren bei einer Anti-Tumorantwort gelten. Die Funktion von GM-CSF konnte auch anhand eines Proliferationsversuchs mit einer Zytokin-abhängigen Zelllinie gezeigt werden. Darüber hinaus waren DC nach exogener Antigenbeladung in der Lage, spezifischen CD4-positiven T-Zell-Klonen effizienter ein antigenes Peptid zu präsentieren, wenn die DC in Gegenwart von GM-CSF gereift waren. Damit zeigt das nach Gentransfer sezernierte GM-CSF einen immunstimulatorischen Effekt ähnlich dem von rekombinantem GM-CSF und kann eine effizientere Antigenpräsentation von Tumorantigenen hervorrufen. Prinzipiell eignen sich B-CLL-Zellen daher als Produzenten von EBV-Genvektor-transduziertem GM-CSF, das zur immunologischen Demaskierung von B-CLL-spezifischen, tumor-assoziierten Antigenen auch in vivo führen sollte.

Die vorliegende Arbeit beschäftigt sich mit neuen Ansätzen zur Immuntherapie von B-Zell-Lymphomen. Als Mausmodell wurden das Lymphom A20 und der eher leukämisch wachsende BCL1-Tumor verwendet. Alle Zellen eines B-Zell-Lymphoms produzieren einen identischen Antikörper, den sogenannten Idiotyp, der als tumorspezifisches Antigen benutzt werden kann: Die antigenbindenden variablen Regionen von schwerer und leichter Kette sind für die Tumorzellen jedes Patienten spezifisch. Die variablen Regionen lassen sich mit einem flexiblen Linker-Peptid zu single-chain Fragmenten (scFv) fusionieren. Die Antigenbindung und die Struktur als Tumorantigen bleiben dabei erhalten. Die BCL1-Sequenz war bereits bekannt, sie ließ sich mit Hilfe familienspezischer Primer mit PCR amplifizieren und klonieren. Bei der stark hypermutierten Sequenz des A20-Idiotyps versagte das Standardverfahren der Konsensus-Primer, erst eine 5'-RACE-PCR war erfolgreich. Der optimale Effektormechanismus (humoral, CD4 oder CD8 vermittelt) zur Immuntherapie von Lymphomen ist nicht bekannt. Bei DNA-Vakzinen lässt sich die Immunantwort besonders effektiv modulieren. Hier wurde ein System entwickelt, um rasch die Wirksamkeit verschiedener Kombinationen in vivo untersuchen zu können: Der scFv-Idiotyp wurde mit einem Zytokin (IL1beta, IL4, IL12, GM-CSF oder Flt3 ligand) und/oder einem Adjuvans (Tetanus Toxin Fragment C oder HBsAg) gekoppelt. In vitro wurde die Expression, die Faltung des scFv und die biologische Aktivität bestätigt. Neben der spezifischen Zytokinwirkung stabilisieren die Fusionspartner die scFv-Proteine deutlich. Zunächst wurde mit dem Modellantigen HBsAg die Immunisierungstechnik optimiert: Intradermale Plasmid-Injektion in die Ohr Pinna ergab konsistent hohe Antikörper-Titer. Bereits ohne in vitro-Restimulation konnte eine starke zelluläre Antwort nachgewiesen werden. Weiterhin wurde für die beiden Tumormodelle A20 und BCL1 die Wachstumskinetik invivo bestimmt und ein Pilotversuch (32 Tiere) mit drei ausgewählten Konstrukten durchgeführt: Von sechs splenektomierten Mäusen zeigte nur eine nach zwei Immunisierungen eine spezifische zelluläre Antwort gegen A20. In keiner Versuchsgruppe zeigte sich eine signifikante Lebensverlängerung nach Lymphomchallenge. Zusammenfassend ist erstmalig ein System entwickelt worden, das es auf einfache Weise ermöglicht, die Wirksamkeit von verschiedenen Zytokinen und Adjuvantien zur Idiotyp-Vakzinierung zu untersuchen. Dieses System bietet viel Raum für Optimierungen.

Bei der akuten myeloischen Leukämie (AML) stellen die unkontrollierte Proliferation und Reifungsblockade myeloider Vorläuferzellen, Expansion dieser Zellen in das periphere Blut, extramedulläre Manifestationen und verminderte Elimination der Leukämiezellen durch das Immunsystem grundlegende Pathomechanismen dar. Diese Vorgänge werden über ein komplexes Zusammenspiel von Zytokinen und Adhäsionsmolekülen reguliert. In dieser Arbeit wurde daher mittels Durchflußzytometrie die Expression von Zytokinrezeptoren, Adhäsions- und kostimulatorischen Molekülen in Knochenmarks(KM-) Proben von 103 AML-Patienten bei Diagnosestellung und acht gesunden Probanden untersucht. Zytokinrezeptoren weisen bei der normalen Hämopoese ein reifegradabhängiges und linienspezifisches Expressionsmuster auf. Es wurden daher zum einen Zytokinrezeptoren ausgewählt, die schon in der frühen Hämopoese exprimiert werden, wie der SCF-R (CD117), FL-R (CD135), IL-3-R (CD123) und zum andern Zytokinrezeptoren, die erst in späteren Differenzierungsstadien der monozytären Zelllinie (v.a. GM-CSF-R; CD116) und der granulozytären Zelllinie (v.a. G-CSF-R, CD114) exprimiert werden. Die gp130-Subunit (CD130) stellt die signaltransduzierende Untereinheit von IL-6, IL-11, LIF etc. dar und wirkt synergistisch auf allen Stufen der Hämopoese mit. Die untersuchten Adhäsionsmoleküle wurden in drei Gruppen unterteilt: a) Adhäsionsmoleküle, die den Kontakt zur KM-Matrix oder zu sich selbst beeinflussen: VLA-2 (CD49b), VLA-3 (CD49c) und die erst kürzlich auf hämopoetischen Zellen gefundenen Adhäsionsmoleküle PRR-1 und PRR-2. b) Adhäsionsmoleküle, die den Kontakt zum Endothel fördern: LFA-1 (CD11a), Mac-1 (CD11b), L-Selektin (CD62L) und UPA-R (CD87) c) kostimulatorische Moleküle, die eine Rolle bei der Interaktion der Leukämiezellen mit immunkompetenten Zellen spielen: ICAM-1 (CD54), LFA-3 (CD58), B7-1 (CD80), B7-2 (CD87) und NCAM (CD58). Eine KM-Probe wurde als positiv gewertet, wenn mehr als 20% der Blasten im Auswertefenster den entsprechenden Marker exprimierten. Ergebnisse: Der durchschnittliche Anteil Zytokinrezeptoren exprimierender Zellen war in KM-Proben von AML-Patienten deutlich höher als in KM-Proben von gesunden Probanden. Einzige Ausnahme bildete die gp130-Subunit, die nur auf durchschnittlich 4% der AML-Blasten exprimiert wurde, während durchschnittlich 23% der Zellen in gesunden KM-Proben die gp130-Subunit exprimierten. Bei den Adhäsionsmolekülen zeigte sich im Vergleich zu den gesunden KM-Proben bei der AML ein höherer Anteil von Zellen, die kostimulatorische und Endothel-Kontakt-fördernde Moleküle exprimierten, während der Anteil von Zellen, die das Stroma-Kontakt-fördernde ß1-Integrin VLA-2 exprimierten, vermindert war. VLA-3 konnte dagegen in keinem der untersuchten AML-Fälle und der gesunden KM-Proben als positiv gewertet werden. Innerhalb der AML-Subtypen konnte ein reifegrad– und linienabhängiges (monozytäres, granulozytäres) Verteilungsmuster der Zytokinrezeptoren festgestellt werden: Blasten unreifer Leukämien (M0; M1) exprimierten bevorzugt SCF-R und FL-R. Blasten von AML-Subtypen, die der granulozytären Differenzierungslinie zugeordnet werden (M2, M3), exprimierten v.a. G-CSF-R. Blasten monozytärer Leukämien (M4, M5) exprimierten v.a. GM-CSF-R und FL-R. Der IL-3-R wurde in fast allen AML-KM-Proben auf einem Großteil der Blasten exprimiert. Den größten Anteil positiver Zellen für Adhäsions- und kostimulatorische Moleküle (Integrine, B7-2, NCAM, UPA-R) wiesen die monozytären Leukämien auf. B7-1 wurde v.a. auf Blasten des FAB-Typs M3 exprimiert. L-Selektin, ICAM-1 und PRR-1/PRR-2 zeigten eine variable Expression innerhalb aller FAB-Typen. In der Gruppe der sekundären Leukämien waren signifikant mehr Fälle Mac-1-positiv als in der Gruppe der primären Leukämien (p = 0.074, Qui2-Test). Ansonsten zeigten sich zwischen primären und sekundären Leukämien keine signifikanten Unterschiede. Wichtig für die Entscheidung über Art und Intensität der Therapie bei der AML ist das Abschätzen der Prognose eines Patienten bei Diagnosestellung. Bislang werden Patienten v.a. anhand zytogenetischer Untersuchungen von Karyotypanomalien in Prognosegruppen eingeteilt. Da aber nur ca. 50-60% der AML-Patienten chromosomale Veränderungen aufweisen, besteht ein Bedarf an Karyotyp-unabhängigen Prognosekriterien. Zytogenetische Analysen wurden bei allen AML-KM-Proben durchgeführt und die Expression der Marker sowohl mit den zytogenetischen Risikogruppen als auch mit dem tatsächlichen klinischen Verlauf der Patienten korreliert. In die klinische Auswertung wurden nur Patienten (n = 55) eingeschlossen, die nach dem Therapieprotokoll der German AML-Cooperative-Group behandelt worden waren. In der zytogenetisch günstigen Prognosegruppe zeigten sich im Vergleich zur zytogenetisch ungünstigen Prognosegruppe signifikant mehr G-CSF-R-positive Zellen (p = 0.027, T-Test), signifikant weniger L-Selektin-positive Fälle (p = 0.037, Qui2-Test) und signifikant mehr Mac-1- und PRR-1-positive Fälle (p = 0.005; p = 0.009; Qui2-Test). Diese Marker zeigten aber keine signifikanten Unterschiede bezüglich Remissionrate und progressfreier Überlebenswahrscheinlichkeit der Patienten. Dies läßt sich auf die zum Teil geringe Fallzahl und die kurze Beobachtungsdauer von im Mittel 11 Monaten nach Remission erklären. Andere Marker zeigten dagegen keine Korrelation mit den zytogenetischen Risikogruppen, dagegen aber mit dem tatsächlichen klinischen Verlauf der Patienten: VLA-2-, NCAM-, UPA-R-positive Leukämien zeigten eine signifikant niedrigere Remissionsrate (p = 0.049, p = 0.03, p = 0.03, Qui2-Test). Patienten, in deren KM-Proben >85% der Blasten den FL-R oder >45,5% den SCF-R exprimierten, wiesen eine signifikant niedrigere Wahrscheinlichkeit für progressfreies Überleben auf, ebenso wie Patienten, in deren KM-Proben >60,5% der Blasten ICAM-1-, >15% B7-1-, >65% B7-2- und >8% NCAM-positiv waren. NCAM korrelierte als einziger Marker negativ sowohl mit der Remissionsrate, als auch mit der progressfreien Überlebenswahrscheinlichkeit, allerdings nicht mit der Einteilung in zytogenetische Risikogruppen. Auch für die übrigen Marker konnten Cut-off-Werte für den Anteil Marker-positiver Blasten ermittelt werden, bei denen aus dem Vergleich der entstandenen Gruppen ein deutlicher Unterschied in der Dauer der progressfreien Überlebenszeit hervorging. Diese Unterschiede waren allerdings aufgrund der geringen Fallzahl nicht signifikant, so dass sich eine eindeutige prognostische Aussagen nicht treffen ließ. Dabei wiesen Patienten mit einem höheren Anteil von G-CSF-R-, GM-CSF-R- und einem niedrigeren Anteil von IL-3-R-exprimierenden Blasten eine längere progressfreie Überlebenszeit auf. Patienten mit sehr hohem Anteil PRR-2- oder mit geringem Anteil PRR-1-positiver Blasten tendierten zu einer eher kürzeren progressfreien Überlebenszeit. Umgekehrt wies eine niedrige Expression von Endothel-Kontakt fördernden Oberflächenmolekülen, wie z.B. L-Selektin, Mac-1 und UPA-R auf eine schlechte Prognose hinsichtlich der Dauer des progressfreien Überlebens hin. Therapeutische Konsequenzen: Die in dieser Arbeit aufgezeigten Zusammenhänge zwischen der Expression bestimmter Oberflächenmarker und dem klinischen Verlauf der Patienten helfen, die Prognoseeinschätzung von Patienten - über die Zytogenetik hinaus - weiter zu spezifizieren: So stellt die NCAM-positive Leukämie eine eigene Entität mit prognostisch schlechtem Verlauf unabhängig vom Karyotyp dar. Bei UPA-R- und/oder VLA-2-positiven AML-Fällen sollten aufgrund der verminderten Remissionswahrscheinlichkeit intensivere therapeutische Induktionstherapien eingeleitet werden. Für die Remissionsdauer ist sowohl die hohe Expression kostimulatorischer Moleküle, als auch die hohe Expression von Zytokinrezeptoren, die v.a. auf Stammzellebene wirksam sind und die die Expression von diesen kostimulatorischen Molekülen fördern, prognostisch ungünstig. Diese Patienten sollten bei intensiver Konsolidierungstherapie engmaschig kontrolliert werden und die Indikation zur Knochenmarkstransplantation sollte frühzeitig gestellt weren. In der Zytokintherapie werden G-CSF und GM-CSF regelmäßig in der Klinik zur Verkürzung der Neutropeniephase nach Chemotherapie eingesetzt. Dagegen konnte mit dem Einsatz von G-CSF und GM-CSF als Priming-Medikamente bisher noch kein eindeutiger klinischer Benefit für die Patienten erzielt werden. Die in dieser Arbeit vorgestellten Ergebnisse einer linienspezifischen und reifegradabhängigen Expression der Zytokinrezeptoren legen nahe, dass G-CSF als Primingmedikament v.a. bei granulozytär-differenzierten AML-Subtypen und GM-CSF eher bei monozytär-differenzierten AML-Subtypen eingesetzt werden sollte. In der Supportivtherapie, bei der die Stimulation von AML-Blasten nicht mehr gewünscht ist, sollten G- und GM-CSF genau umgekehrt eingesetzt werden. Da eine hohe Expression von FL-R und SCF-R mit einer schlechten Prognose für die Dauer des progressfreien Überlebens korrelierte, kann sich eine Stimulation dieser Rezeptoren durch die Gabe von SCF und FL in der Supportivtherapie eher ungünstig auswirken, ebenso wie beim Priming, da auch gesunde Stammzellen stimuliert und damit sensibler gegen Zytostatika werden. Darüber hinaus geben diese Ergebnisse auch Hinweise auf mögliche pathobiologische Bedeutungen und damit verbundener neuer therapeutischer Strategien bei der AML: So kann die erhöhte FL-R-Expression - wie bei der Tandemduplikation des FL-R auch - zu einer erhöhten, prognostisch ungünstigen Phophorylierung von Tyrosinkinasen führen. Auch der SCF-R aktiviert intrazellulär Tyrosinkinasen. Neue Medikamente, wie z.B. Tyrosinkinase-Inhibitoren, oder Dexamethason, das die FL-R-Expression auf den AML-Blasten herunterreguliert, könnten bei diesen AML-Patienten neue benefit-bringende therapeutische Möglichkeiten darstellen. Ebenso scheint die Immunantwort bei AML-Patienten trotz, oder vielleicht sogar gerade bei Expression von kostimulatorischen Molekülen vermindert zu sein, was die Gabe von immunstimulierenden Medikamenten, wie rIL-2 oder CTLA-4-Inhibitoren im Bereich der Immuntherapie sinnvoll erscheinen lässt. So leistet diese Arbeit nicht nur einen Beitrag zur Diagnostik, Prognose und Biologie der AML, sondern entwickelt in Zusammenschau mit bereits publizierten Daten neue, therapeutische Möglichkeiten für die Behandlung der AML.

Epithelzellen spielen im Immunsystem eine wichtige Rolle als Vermittler zwischen äußerem Milieu und darunterliegender Mukosa. Epithelzellen treten als Erste mit potentiellen Pathogenen in Kontakt: durch die Sekretion von Zytokinen als Warnsignale an umliegende Zellen können sie eine Entzündungsreaktion einleiten. Yersinia enterocolitica ist ein enteropathogener, vorwiegend extrazellulär lokalisierter Erreger, der eine akute Enterokolitis, Sepsis und immunologische Folgeerkrankungen verursacht. Die Rolle der intestinalen Epithelzellen bei der Infektion mit Y. enterocolitica ist bisher nicht ausreichend erörtert. Ziel dieser Arbeit war zum einen die Untersuchung des von Epithelzellen initiierten Zytokin-Netzwerks während der frühen Phase der Y. enterocolitica- Infektion. Hierzu wurden HeLa-Zell-Monolayer mit verschiedenen Y. enterocolitica- Stämmen infiziert und mittels Reverser Transkriptions (RT)-PCR zunächst wichtige Zytokine identifiziert. Die Kinetik der Zytokin-Produktion wurde durch semiquantitative RT-PCR analysiert sowie die intra- oder extrazelluläre Lokalisation der Zytokine mittels ELISA quantitativ erfasst. Die Stimulation von epithelialen Zellen mit rekombinanten humanen Zytokinen lieferte weitere Informationen über die Funktion der einzelnen Zytokine. Zum anderen wurden die Mechanismen der Wirt-Pathogen- Interaktion analysiert, die das Zytokin-Netzwerk während der initialen Phase der Y. enterocolitica-Infektion auslösen. Die Auswirkungen der Hemmung der bakteriellen Invasion (durch PI3-Kinase-Inhibitoren) sowie der bakteriellen Proteinsynthese (mittels Antibiotika) wurden untersucht. Durch die Infektion von Epithelzellen mit verschiedenen bakteriellen Mutantenstämmen gelang es, die Bedeutung des chromosomal kodierten Oberflächenproteins Yersinia Invasin zu charakterisieren. Folgende Ergebnisse wurden im Rahmen dieser Arbeit erzielt: 1. Y. enterocolitica pYV– induziert eine Stunde nach Infektion von HeLa-Zellen die de novo-Synthese von IL-8-, IL-1a-, MCP-1-, IL-1b-, GM-CSF- und TNF-a- mRNA. Y. enterocolitica pVY+ hemmt durch bestimmte Yersinia outer proteins die de novo-Synthese aller untersuchten Zytokine in HeLa-Zellen. 2. Die Zytokin-mRNA-Produktion in HeLa-Zellen nach Y. enterocolitica pYV–-Infektion erreicht nach 3 h ihr Maximum, um 5–6 h nach Infektion wieder auf Normalwerte abzufallen. IL-8 wird hierbei als Erstes und in den größten Mengen produziert. Diese pro-inflammatorische Zytokin-Antwort ist wahrscheinlich verantwortlich für den histopathologisch beobachteten massiven Einstrom von Immunzellen in infizierte Peyer’sche Plaques, was deren Zerstörung zur Folge hat. 3. Nur IL-8, MCP-1 und GM-CSF werden von HeLa-Zellen sekretiert, IL-1a und IL-1b verbleiben intrazellulär. IL-1a stimuliert bei HeLa-Zellen eine proinflammatorische Zytokin-Antwort, nicht jedoch IL-8, MCP-1 oder GM-CSF. Dies spricht für eine spezielle Rolle von IL-1: es könnte als ‚Verstärker-Zytokin’ dienen, das erst im späteren Verlauf der Infektion, nach Lyse der infizierten Zellen, freigesetzt wird und eine erneute Zytokin-Produktion verursacht. 4. Die Zytokin-Induktion nach Y. enterocolitica-Infektion von HeLa-Zellen ist wahrscheinlich nicht LPS-vermittelt. 5. Auch nach Hemmung der bakteriellen Invasion durch Wortmannin, einem PI3- Kinase-Inhibitor, beobachtet man die gleichen Zytokin-Antwort: schon die Adhäsion der Bakterien an die Wirtszelle genügt, um eine inflammatorische Zytokin- Reaktion auszulösen. 6. Wir zeigten, dass die Zytokin-Induktion durch die Bindung von Yersinia Invasin an b1-Integrine der Wirtszelle vermittelt wird: Eine Invasin-defiziente Y. enterocolitica- Mutante löst (ebenso wie ein nicht-invasiver E. coli-Stamm) keine Zytokin- Reaktion in HeLa-Zellen aus. Der Transfer des Invasin-Gens in E. coli hingegen vermittelt diesem die Fähigkeit, eine inflammatorische Zytokin-Antwort auszulösen. 7. Die Invasin-induzierte Zytokin-Antwort nach Y. enterocolitica pYV– ist unabhängig von bakterieller Proteinbiosynthese oder einem intakten Typ III-Sekretionssystem: auch Gentamicin- oder Hitze-getötete Yersinien induzieren eine inflammatorische Zytokin-Antwort wie metabolisch aktive Yersinien. Diese Ergebnisse verdeutlichen zum einen die wichtige Rolle von Epithelzellen bei der Generierung von Signalen zur Initiation der Abwehrreaktion des Immunsystems gegen Y. enterocolitica. Zum anderen wurde Yersinia Invasin als Pathogenitätsfaktor charakterisiert, der gezielt eine zelluläre Entzündungsreaktion der Darmmukosa auf eine Y. enterocolitica-Infektion initiiert.

We have already shown that cytokine cocktails (IL-1 beta, IL-3, IL-6, SCF, GM-CSF) and/or lymphokine-activated killer (LAK) cells can reduce the amounts of clonal, CD34-positive mononuclear bone marrow cells (BM-MNC) in acute myeloid leukemia (AML). In addition, the influence of those cocktails and/or LAK cells on the clonogenic potential of AML BM-MNC was investigated. BM colonies cultured in agar during different stages of the disease were immunophenotyped in situ: 17 patients at diagnosis, 14 patients in complete remission, 8 patients at relapse, 8 healthy donors. A significant reduction in leukemic cells and colonies positive for CD34 after in vitro culture of BM-MNC with cytokine cocktails was achieved with all samples obtained at diagnosis (n = 8, p < 0.01), in 6 of 8 cases in complete remission but only in 2 of 6 cases at relapse. Cytokine cocktails stimulated granulopoiesis as well as B and T lymphopoiesis. Colonies with leukemic phenotype could never be detected in healthy BM. A significant reduction in leukemic colonies was achieved by coculture of BM-MNC (uncultured or cytokine precultured) with autologous LAK cells in all 4 cases at diagnosis and in 1 case at relapse. An additive effect of in vitro cytokine preincubation of BM samples on the leukemia-reducing effect of LAK cells could be demonstrated in all samples studied (p