The generation of LMP2a-specific cytotoxic T lymphocytes for the treatment of patients with Epstein-Barr virus-positive Hodgkin disease

The Function and Therapeutic Potential of Epstein-Barr Virus-Encoded MicroRNAs in Cancer

Epstein-Barr virus (EBV) is a ubiquitous human γ-herpesvirus that infects over 90% of the global population. EBV is considered a contributory factor in a variety of malignancies including nasopharyngeal carcinoma, gastric carcinoma, Burkitt lymphoma, and Hodgkin’s lymphoma. Notably, EBV was the first virus found to encode microRNAs (miRNAs). Increasing evidence indicates that EBV-encoded miRNAs contribute to the carcinogenesis and development of EBV-associated malignancies. EBV miRNAs have been shown to inhibit the expression of genes involved in cell proliferation, apoptosis, invasion, and immune signaling pathways. Therefore, EBV miRNAs perform a significant function in the complex host-virus interaction and EBV-driven carcinogenesis. However, the integrated mechanisms underlying the roles of EBV miRNAs in carcinogenesis remain to be further explored. In this review, we describe recent advances regarding the involvement of EBV miRNAs in the pathogenesis of EBV-associated malignancies and discuss their potential utility as cancer biomarkers. An in-depth investigation into the pro-carcinogenic role of EBV miRNAs will expand our knowledge of the biological processes associated with virus-driven tumors and contribute to the development of novel therapeutic strategies for the treatment of EBV-associated malignancies.

Epstein-Barr virus-encoded microRNAs as regulators in host immune responses

Epstein-Barr virus (EBV) is an oncogenic virus that infects over 90% of the world's adult population. EBV can establish life-long latent infection in host due to the balance between EBV and host immune system. EBV latency is associated with various malignancies such as nasopharyngeal carcinoma, gastric carcinoma and Burkitt's lymphoma. EBV is the first human virus that has the capability to encode microRNAs (miRNAs). Remarkably, EBV-encoded miRNAs are abundantly expressed in latently-infected cells and serve important function in viral infection and pathogenesis. Increasing evidence indicates that EBV miRNAs target the host mRNAs involved in cell proliferation, apoptosis and transformation. EBV miRNAs also inhibit the expression of viral antigens, thereby enabling infected cells to escape immune recognition. Intriguingly, EBV miRNAs directly suppress host antiviral immunity by interfering with antigen presentation and immune cell activation. This review will update the current knowledge about EBV miRNAs implicated in host immune responses. An in-depth understanding of the functions of EBV miRNAs in host antiviral immunity will shed light on the EBV-host interactions and provide potential therapeutic targets for the treatment of EBV-associated malignancies.

Fighting Viral Infections and Virus-Driven Tumors with Cytotoxic CD4+ T Cells

CD4+ T cells have been and are still largely regarded as the orchestrators of immune responses, being able to differentiate into distinct T helper cell populations based on differentiation signals, transcription factor expression, cytokine secretion, and specific functions. Nonetheless, a growing body of evidence indicates that CD4+ T cells can also exert a direct effector activity, which depends on intrinsic cytotoxic properties acquired and carried out along with the evolution of several pathogenic infections. The relevant role of CD4+ T cell lytic features in the control of such infectious conditions also leads to their exploitation as a new immunotherapeutic approach. This review aims at summarizing currently available data about functional and therapeutic relevance of cytotoxic CD4+ T cells in the context of viral infections and virus-driven tumors.

Herpesviruses placating the unwilling host: manipulation of the MHC class II antigen presentation pathway

Lifelong persistent infection by herpesviruses depends on the balance between host immune responses and viral immune evasion. CD4 T cells responding to antigens presented on major histocompatibility complex class II (MHC-II) molecules are known to play an important role in controlling herpesvirus infections. Here we review, with emphasis on human herpesvirus infections, the strategies evolved to evade CD4 T cell immunity. These viruses target multiple points on the MHC class II antigen presentation pathway. The mechanisms include: suppression of CIITA to inhibit the synthesis of MHC class II molecules, diversion or degradation of HLA-DR molecules during membrane transport, and direct targeting of the invariant chain chaperone of HLA-DR.

Destruction of lymphoid organ architecture and hepatitis caused by CD4+ T cells

Immune responses have the important function of host defense and protection against pathogens. However, the immune response also causes inflammation and host tissue injury, termed immunopathology. For example, hepatitis B and C virus infection in humans cause immunopathological sequel with destruction of liver cells by the host's own immune response. Similarly, after infection with lymphocytic choriomeningitis virus (LCMV) in mice, the adaptive immune response causes liver cell damage, choriomeningitis and destruction of lymphoid organ architecture. The immunopathological sequel during LCMV infection has been attributed to cytotoxic CD8(+) T cells. However, we now show that during LCMV infection CD4(+) T cells selectively induced the destruction of splenic marginal zone and caused liver cell damage with elevated serum alanin-transferase (ALT) levels. The destruction of the splenic marginal zone by CD4(+) T cells included the reduction of marginal zone B cells, marginal zone macrophages and marginal zone metallophilic macrophages. Functionally, this resulted in an impaired production of neutralizing antibodies against LCMV. Furthermore, CD4(+) T cells reduced B cells with an IgM(high)IgD(low) phenotype (transitional stage 1 and 2, marginal zone B cells), whereas other B cell subtypes such as follicular type 1 and 2 and germinal center/memory B cells were not affected. Adoptive transfer of CD4(+) T cells lacking different important effector cytokines and cytolytic pathways such as IFNγ, TNFα, perforin and Fas-FasL interaction did reveal that these cytolytic pathways are redundant in the induction of immunopathological sequel in spleen. In conclusion, our results define an important role of CD4(+) T cells in the induction of immunopathology in liver and spleen. This includes the CD4(+) T cell mediated destruction of the splenic marginal zone with consecutively impaired protective neutralizing antibody responses.

Role of CD4+ cytotoxic T lymphocytes in the control of viral diseases and cancer

Our knowledge on the physiological role of CD4(+) T lymphocytes has improved in the last decade: available data convincingly demonstrate that, besides the 'helper' activity, CD4(+) T cells may be also endowed with lytic properties. The cytotoxic function of these effector cells has a relevant role in the control of pathogenic infections and in mediating antitumor immune responses. On these bases, several immunotherapeutic approaches exploiting the cytotoxic properties of CD4(+) T cells are under investigation. This review summarizes available data supporting the functional and therapeutic relevance of cytotoxic CD4(+) T cells, with a particular focus on Epstein-Barr virus (EBV)-related disorders.

Treatment of lymphoma with adoptively transferred T cells

BACKGROUND

Chemotherapy-resistant lymphomas can be cured with allogeneic hematopoietic cell transplantation, demonstrating the susceptibility of these tumors to T cell mediated immune responses. However, high rates of transplant-related morbidity and mortality limit this approach. Efforts have, therefore, been made to develop alternative T cell based therapies, and there is growing evidence that adoptive therapy with T cells targeted to lymphoma-associated antigens may be a safe and effective new method for treating this group of diseases.

OBJECTIVE/METHODS

We review publications on adoptive therapy with ex vivo expanded T cells targeting viral antigens, as well as genetically modified autologous T cells, as strategies for the treatment of lymphoma, with the goal of providing an overview of these approaches.

RESULTS/CONCLUSIONS

Epstein-Barr virus specific T cell therapy is an effective and safe method of treating Epstein-Barr virus associated lymphomas; however, most lymphoma subtypes do not express EBV antigens. For these diseases, adoptive immunotherapy with genetically modified T cells expressing chimeric T cell receptors targeting lymphoma-associated antigens such as CD19 and CD20 appears to be a promising alternative. Recent innovations including enhanced co-stimulation, exogenous cytokine administration and use of memory T cells promise to overcome many of the limitations and pitfalls initially encountered with this approach.

Adoptive Immunotherapy for EBV-associated Malignancies

Latent Epstein-Barr virus (EBV) infection is associated with a diverse group of malignancies including Burkitt's lymphoma, Hodgkin's disease, nasopharyngeal carcinoma (NPC), and lymphoproliferative disease (LPD). EBV proteins expressed in these malignancies provide targets for the adoptive immunotherapy with antigen-specific cytotoxic T cells (CTL) and EBV-specific CTL have been used successfully for the prophylaxis and treatment of EBV-LPD post hematopoietic stem cell transplantation (HSCT). The clinical experience with EBV-specific CTL for other EBV-associated malignancies such as Hodgkin's disease and NPC is limited and the results obtained so far indicate that EBV-specific CTL are less effective than for EBV-LPD post HSCT. Decreased CTL efficacy most likely reflect immune evasion strategies by tumor cells such as down regulation of immunodominant EBV proteins and secretion of inhibitory cytokines. To overcome these immune evasion strategies a number of approaches have been developed including targeting CTL to subdominant EBV antigens and genetically modifying CTL to increase their potency.

Optimization of LMP-specific CTL expansion for potential adoptive immunotherapy in NPC patients

Nasopharyngeal carcinoma (NPC) is Epstein-Barr virus (EBV) positive in all undifferentiated cases, expressing the latency II phenotype of latent membrane proteins (LMPs) 1 and 2, in addition to EBV nuclear antigen (EBNA) 1. Several studies have attempted to treat NPC with EBV-specific cytotoxic T lymphocyte (CTL) with a partial response. To improve this therapy, there is a need to expand CTL targeted to the latency II antigens of EBV, rather than the immunodominant EBV nuclear antigens 3-6 peptides typically expanded by lymphoblastoid cells. In order to maximize the expansion of LMP-specific CTL in vitro for use in adoptive immunotherapy of nasopharyngeal carcinoma patients, we used lymphoblastoid cell lines coated with synthetic peptides corresponding to CTL determinants from the LMP proteins. We investigated several issues pertaining to the expansion of an immunologically weak CTL response, including peptide and interleukin-2 concentration, and screening assays for selecting the optimal peptide for use in expansion of LMP-specific CTL. Although screening of ex vivo peripheral blood mononuclear cells did not prove to be useful in the selection of an LMP peptide for use in CTL cultures, the peptide and interleukin-2 concentrations were critical for the maximum expansion of CTL. Therefore, it is imperative that stimulation protocols are optimized for the expansion of LMP-specific CTL.

CD4 T cells mediate killing during persistent gammaherpesvirus 68 infection

CD4 T cells are critical for the control of gammaherpesvirus persistence, but their direct effector mechanisms of virus control in vivo are still poorly understood. In this study, we use murine gammaherpesvirus 68 (gammaHV68) in in vitro and in vivo cytotoxicity assays to show CD4-dependent killing of gammaHV68-loaded cells in mice persistently infected with gammaHV68. Our results underscore the cytotoxic capacity of CD4 T cells during gammaHV68 persistence.

Differentiation of human embryonic stem cells into immunostimulatory dendritic cells under feeder-free culture conditions

PURPOSE

The objective of this study was to develop a scalable and broadly applicable active immunotherapy approach against cancer, circumventing the limitations typically encountered with autologous vaccination strategies. We hypothesized that human embryonic stem cells (hESC) can serve as a virtually unlimited source for generating dendritic cells (DC) with potent antigen-presenting function. Here, we investigated the developmental processes and requirements for generating large numbers of mature, antigen-presenting DC from pluripotent hESC.

EXPERIMENTAL DESIGN

A feeder cell-free culture system was developed to differentiate hESC into mature DC sequentially through hematopoietic and myeloid precursor stages.

RESULTS

Using this method, we were able to yield large numbers of mature immunostimulatory DC from hESC to enable clinical investigation. Upon activation, the hESC-derived DC secreted interleukin-12p70, migrated in response to MIP-3beta, and exhibited allostimulatory capacity. Most importantly, antigen-loaded, hESC-derived DC were capable of stimulating potent antigen-specific CD8(+) T-cell responses in an HLA class I-matched semiallogeneic assay system. Moreover, HLA class II-mismatched hESC-derived DC induced a potent Th1-type cytokine response without expanding FOXP3(+) regulatory T cells in vitro.

CONCLUSIONS

These data suggest the development of a novel active immunotherapy platform to stimulate potent T-cell immunity in patients with intractable diseases, such as cancer or viral infection.

Immunotherapy targeting EBV-expressing lymphoproliferative diseases

Epstein-Barr virus (EBV) is associated with non-Hodgkin's lymphoma (NHL), occurring in immunocompetent individuals as well as those with immunodeficiency. In patients with immunodeficiency, the nature of EBV infection in the malignant cell determines the pattern of antigen expression and the associated presence of targets for cellular immunotherapy. EBV-expressing lymphoma cells in the setting of immunodeficiency express type III latency, characterized by expression of all nine latent-cycle EBV antigens, and strategies to restore EBV-specific immune responses have resulted in effective anti-tumour activity. In contrast, EBV-associated NHL in immunocompetent individuals is characterized by type II latency, where a more restricted array of EBV-associated antigens is expressed. In this setting, T-cell therapies are limited by inadequate persistence of transferred T cells and by tumour-evasion strategies. A number of strategies to genetically modify the infused T cells and modulate the host environment are under evaluation.

Immunotherapies for Hodgkin's lymphoma

Multiple immune evasion strategies characterize the pathobiology of Hodgkin's lymphoma. These must be considered when developing and testing immunotherapeutic approaches for this disease. The clinical experience with adoptive immunotherapy of Epstein-Barr virus positive tumors, and with monoclonal antibodies directed against CD30, CD20, and other antigens, is herein reviewed.

Contribution of the Epstein Barr virus to the molecular pathogenesis of Hodgkin lymphoma

Although the morphology of the pathognomonic Reed-Sternberg cells of Hodgkin lymphoma (HL) was described over a century ago, it was not until recently that their origin from B lymphocytes was recognised. The demonstration that a proportion of cases of HL harbour the Epstein-Barr virus (EBV) and that its genome is monoclonal in these tumours suggests that the virus contributes to the development of HL in some cases. This review summarises current knowledge of the pathogenesis of HL with particular emphasis on the association with EBV.

Relapsed and Refractory Hodgkin's Lymphoma: New Avenues?

Relapse or progression following therapy for Hodgkin's lymphoma occurs in 10% to 60% of patients depending on initial clinical stage. Patterns of failure in advanced disease determine prognosis of salvage therapy. Progression or early relapse after less than 12 months requires intensive salvage therapy. Only late, isolated, asymptomatic relapse, which occurs in less than 25% of those relapsing from systemic therapy, can be treated with conventional-dose chemotherapy with or without radiation. Overall about 40% to 50% of relapses from advanced disease can be salvaged with higher percentages for patients relapsing from early stage disease.

Interferon-gamma expressing EBV LMP2A-specific T cells for cellular immunotherapy

To generate therapeutic T cells for adoptive immunotherapy, T cells specific to Epstein-Barr virus LMP2A were enriched on the basis of antigen-specific production of interferon-gamma (IFNgamma). The enriched T cells, contained over 60% LMP2A-specific effectors, were polyclonal and targeted multiple LMP2A epitopes. A high proportion of the enriched T cells produced the Th1 cytokines interleukin (IL)-2 and granulocyte monocyte colony stimulating factor, while few cells expressed the Th2 cytokines IL4 and IL10. The enriched T cells specifically lysed LMP2A-expressing target cells, with concomitant production of IFNgamma and surface expression of CD107, suggesting the involvement of the granule exocytosis-mediated cytolytic pathway. In addition, the enriched T cells expressed CD45RO, CD28 and CD27, but not CD45RA, consistent with a differentiation stage capable of self-renewal for long-term persistence. LMP2A-specific T cells enriched based on IFNgamma-production may provide improved efficacy for the treatment of Epstein-Barr virus related malignancy.

Anti-tumor immunity against nasopharyngeal carcinoma by means of LMP2A-specific cytotoxic T lymphocytes induced by dendritic cells

OBJECTIVE

Adoptive immunotherapy with specific cytotoxicity T lymphocytes (CTLs) induced by dendritic cells (DCs) pulsed with tumor antigens plays a crucial role in the immunity against tumor. The purpose of this study was to assess the feasibility and efficacy of latent membrane protein 2A (LMP2A)-specific CTLs immunity against nasopharyngeal carcinoma (NPC) in vitro and in vivo.

METHODS

DCs were generated by culturing the monocytes purified from human peripheral blood mononuclear cells (PBMCs) in cytokine cocktail containing granulocyte/macrophage colony-stimulating factor (GM-CSF), interleukin-4 (IL-4), and tumor necrosis factor-alpha (TNF-alpha). The phenotype of mature DCs was analyzed by fluorescence activated cell sorter (FACS). Mature DCs transfected with EBV-LMP2A recombinant adenovirus were co-cultured with autologous PBMCs to induce LMP2A-specific CTLs. The expression of the surface antigens such as CD3, CD4, CD8 and CD56 on CTLs were detected by FACS. The specific cytotoxicity of CTLs on target CNE cells expressing EBV-LMP2A was confirmed using cytotoxicity assay. The anti-tumor effect of LMP2A-specific CTLs in vivo was assessed in the mice tumor models implanted with CNE cells expressing EBV-LMP2A.

RESULTS

Mature DCs expressed typically morphologic characteristics and high level of surface markers (CD1a, CD83, CD86, CD80 and HLA-DR). LMP2A-transfected DCs could induce LMP2A-specific CTLs consisting of a majority of CD4+ and CD8+ T cells. Cytotoxicity assay confirmed that the LMP2A-specific CTLs displayed significant cytotoxicity on target CNE cells compared with the controls. The study in vivo demonstrated that the treatment using these specific CTLs retarded the growth of established tumor in the treated mice.

CONCLUSION

These findings suggest that DCs transfected with EBV-LMP2A recombinant adenovirus can elicit LMP2A-specific CTLs that have a specific killing effect on NPC in vitro and in vivo. The results provide experimental basis for the further immunotherapy of NPC in clinical trails.

Virus-specific CD4+ T cells: ready for direct attack

CD4⁺ T cells are classically thought to orchestrate adaptive immune responses. But recent studies demonstrate that they can also kill infected cells directly. A new paper shows that highly efficient processing of Epstein Barr virus (EBV) glycoproteins for presentation on MHC class II makes virus-transformed B cells susceptible to lysis by CD4⁺ T cells. Thus, antiviral vaccines should aim to stimulate both helper and cytolytic CD4⁺ T cells.

Induction of the Epstein-Barr virus latent membrane protein 2 antigen-specific cytotoxic T lymphocytes using human leukocyte antigen tetramer-based artificial antigen-presenting cells

Cytotoxic T lymphocytes (CTLs) specific for the Epstein-Barr virus (EBV) latent membrane protein 2 (LMP2) antigen are important reagents for the treatment of some EBV-associated malignancies, such as EBV-positive Hodgkin's disease and nasopharyngeal carcinoma. However, the therapeutic amount of CTLs is often hampered by the limited supply of antigen-presenting cells. To address this issue, an artificial antigen-presenting cell (aAPC) was made by coating a human leukocyte antigen (HLA)-pLMP2 tetrameric complex, anti-CD28 antibody and CD54 molecule to a cell-sized latex bead, which provided the dual signals required for T cell activation. By co-culture of the HLA-A2-LMP2 bearing aAPC and peripheral blood mononuclear cells from HLA-A2 positive healthy donors, LMP2 antigen-specific CTLs were induced and expanded in vitro. The specificity of the aAPC-induced CTLs was demonstrated by both HLA-A2-LMP2 tetramer staining and cytotoxicity against HLA-A2-LMP2 bearing T2 cell, the cytotoxicity was inhibited by the anti-HLA class I antibody (W6/32). These results showed that LMP2 antigen-specific CTLs could be induced and expanded in vitro by the HLA-A2-LMP2-bearing aAPC. Thus, aAPCs coated with an HLA-pLMP2 complex, anti-CD28 and CD54 might be promising tools for the enrichment of LMP2-specific CTLs for adoptive immunotherapy.

Messenger RNA-based vaccines

RNA is the only molecule known to recapitulate all biochemical functions of life: definition, control and transmission of genetic information, creation of defined three-dimensional structures, enzymatic activities and storage of energy. Because of its versatility and thanks to several recent scientific breakthroughs, RNA became the focus of intense research in molecular medicine at the beginning of the millennium. In particular, mRNA can be seen as a safe and efficient alternative to protein-, recombinant virus- or DNA-based therapies in the field of vaccination. This review summarises the most remarkable advances in this area and presents the advantages and limits of the five different mRNA-based vaccination methods. The paper will present the official, industrial and financial aspects of mRNA-based vaccination that are paving the way for therapeutic and prophylactic drugs with mRNA as the active component.

Cancer immunotherapy with mRNA-transfected dendritic cells

Bone marrow-derived dendritic cells (DCs) are the most potent antigen-presenting cells capable of activating naïve T cells. Loading DCs ex vivo with tumor antigens can stimulate potent antitumor immunity in tumor-bearing mice. This review describes the use of mRNA-encoded tumor antigens as a form of antigen loaded onto DCs, including our early experience from clinical trials in urological cancers. Transfection of DCs with mRNA is simple and effective. Comparative studies suggest that mRNA transfection is superior to other antigen-loading techniques in generating immunopotent DCs. The ability to amplify RNA from microscopic amounts of tumor tissue extends the use of DC vaccination to virtually every cancer patient. The striking observation from two phase I clinical trials, in patients with prostate cancer immunized with prostate-specific antigen mRNA-transfected DCs and patients with renal cancer immunized with autologous tumor RNA-transfected DCs, was that the majority of patients exhibited a vaccine-induced T-cell response. Suggestive evidence of clinically related responses was seen in both the trials. Immunization with mRNA-transfected DCs is a promising strategy to stimulate potent antitumor immunity and could serve as a foundation for developing effective treatments for cancer.

Treatment options for post-transplant lymphoproliferative disorder and other Epstein-Barr virus-associated malignancies

Epstein-Barr virus (EBV) is associated with a range of malignancies that largely arise from a defect in EBV-specific cytotoxic T lymphocyte (CTL) immunity and function. Much work has focused on the reconstitution of CTL immunity to EBV in transplant patients, in whom immunosuppression modalities render them susceptible to post-transplant lymphoproliferative disease (PTLD). Adoptive transfer of autologous CTLs is effective at both preventing and curing PTLD in solid organ transplant recipients and can produce a long-term memory response and protection against recurring disease. In this review, the benefits and restrictions of administering EBV-specific CTLs for the treatment of PTLD are discussed and compared with emerging therapies including the generation of allogeneic human leukocyte antigen-matched CTL banks and the anti-CD20 monoclonal antibody therapy, MabThera. Furthermore, studies involving other EBV-associated disorders have described the potential benefit of adoptive transfer of EBV-specific CTLs for Hodgkin's disease, nasopharyngeal carcinoma, chronic active EBV infection, and Burkitt's lymphoma. The challenges of tailor-making therapies for individual diseases and EBV antigen expression latencies are highlighted, in addition to considering vaccination strategies for optimal treatment.

Epstein–Barr virus-specific cytotoxic T-lymphocytes for adoptive immunotherapy of post-transplant lymphoproliferative disease

Post-transplant lymphoproliferative disease (PTLD) refers to a collection of clinically and pathologically diverse tumours associated with iatrogenic immunosuppression following transplantation. In most cases, tumourigenesis results from a deficit in Epstein-Barr virus (EBV)-specific cytotoxic T-lymphocyte (CTL) activity that leads to uncontrolled EBV-driven outgrowth of latently infected B-lymphocytes. Conventional treatment for PTLD typically involves a reduction in immunosuppression, but this approach is frequently unsuccessful and mortality remains high. An alternative, adoptive immunotherapy, involving the administration of EBV-specific CTLs cultured in vitro has been developed with the aim of selectively reconstituting EBV-directed immunity and effecting targeted tumour destruction. This approach has been the subject of several clinical studies, and these provide encouraging evidence of its clinical efficacy. This review presents an overview of the pathogenesis of PTLD and examines current progress in the use of adoptive immunotherapy for its treatment.

T cell-based therapies for EBV-associated malignancies

Epstein-Barr virus (EBV) is associated with a number of human malignancies. The cells of these tumours express a range of EBV latent cycle gene products that have the potential to be exploited as targets for T cell-mediated immunological therapies. Considerable progress has been made in developing adoptive T cell transfer for EBV-associated post-transplant lymphoproliferative disease (PTLD) and clinical experience clearly demonstrates that EBV-specific T cell responses can be used to treat this EBV-associated malignancy. Adoptive T cell therapies for other EBV-associated malignancies are less advanced, although encouraging data are starting to emerge. Adoptive T cell transfer, however, does require significant levels of specialist laboratory support. Large-scale treatment of patients in geographical areas with a high prevalence of EBV-associated malignancy is likely to require the development of therapeutic vaccination strategies, a number of which are in development at present. Although it remains to be seen whether long-lasting sterilising immunity to EBV could be achieved, an alternative vaccine-based approach would be to develop a prophylactic vaccine to protect against primary EBV infection.

Adoptive immunotherapy with allogeneic Epstein-Barr virus (EBV)-specific cytotoxic T-lymphocytes for recurrent, EBV-positive Hodgkin disease

BACKGROUND

It has been shown that adoptive immunotherapy with Epstein-Barr virus (EBV)-specific cytotoxic T-lymphocytes (CTL) is effective for the treatment of EBV-induced lymphoproliferative disease in stem cell transplantation recipients and organ transplantation recipients. The role of EBV CTL in other tumors for which this virus has been implicated in pathogenesis, such as EBV-positive Hodgkin disease (HD), has not been demonstrated clearly.

METHODS

To investigate the antitumor effects and toxicity of allogeneic EBV CTL in EBV-positive HD, the authors initiated a pilot trial in which EBV CTL were cultured from allogeneic, partially human leukocyte antigen-matched donors and were infused into patients who had therapy-refractory disease. The first cohort of 3 patients (Cohort I) received 3 separate infusions of EBV CTL (5.0 x 10(6) EBV CTL/kg per dose), and the second cohort (Cohort II) received 30 mg/m(2) per day of fludarabine for 3 days followed by a single CTL infusion (1.5 x 10(7) EBV CTL/kg).

RESULTS

All three patients in Cohort I had decreases in measurable disease after EBV CTL infusions, and one of those patients was without evidence of disease 22 months after infusion. Two of 3 patients in Cohort II had decreases in measurable disease, although it was not determined whether those decreases were related to fludarabine or to CTL, and 1 patient in Cohort II had 7 months without disease progression. Unlike the patients in Cohort I, fludarabine recipients did not have increases in antidonor CTL responses. Donor cells could not be detected in any of the CTL recipients.

CONCLUSIONS

Adoptive immunotherapy with allogeneic EBV CTL was safe for patients with recurrent, refractory, EBV-positive HD; and clinical responses may be observed without the establishment of detectable donor lymphoid chimerism.

Novel approaches to treat asymptomatic, hormone-naive patients with rising prostate-specific antigen after primary treatment for prostate cancer

Biochemical-only recurrent prostate cancer presents the ideal setting for assessing novel agents or approaches for prostate cancer treatment. There is no clear evidence that delay in initiation of more definitive androgen-deprivation therapy is harmful, and a simple blood test--the prostate-specific antigen (PSA) level--is readily available to screen for potential antineoplastic activity. Current novel approaches include vaccines, cyclooxygenase-2 (COX-2) inhibitors, selective apoptotic antineoplastic drugs, endothelin-A receptor antagonists, chemotherapy, vitamin D, and peroxisome proliferator-activated receptor-gamma agonists. In this screening process, certain therapies have emerged as delaying PSA progression or decelerating PSA velocity. These therapies, such as the COX-2 inhibitors, will need to proceed to phase 3 trials to answer the more important question of whether this change in PSA dynamics translates into improved survival. Patients enrolling in these trials need to be clearly informed of the limited expectations of these novel exploratory approaches.

Induction of cytotoxic T-cell responses against the oncofetal antigen-immature laminin receptor for the treatment of hematologic malignancies

The oncofetal antigen immature laminin receptor protein (OFA-iLRP) is a highly conserved protein that is preferentially expressed in fetal tissues and in many types of cancer, including hematopoietic malignancies, whereas OFA-iLRP is not detectable on healthy differentiated adult cells. To investigate whether OFA-iLRP-specific cytotoxic T lymphocytes (CTLs) are capable of killing OFA-iLRP-expressing hematologic targets, CTLs were generated from healthy HLA-A*0201-positive volunteers by incubating T cells with autologous dendritic cells (DCs) transfected with OFA-iLRP RNA. OFA-iLRP-specific CTLs lysed HLA-A2+ OFA-iLRP+ tumor cells, including several lymphoma and leukemia cell lines, as well as fresh leukemic targets from patients with acute myeloid leukemia (AML) and chronic lymphatic leukemia (CLL), indicating that OFA-iLRP-derived peptides are naturally processed and presented by hematologic tumors. Healthy OFA-iLRP-negative target cells (CD14+ monocytes, activated B cells, DCs, bone marrow cells) were not attacked by OFA-iLRP-specific CTLs. Furthermore, in an established murine B-cell lymphoma model (A20), treatment with syngeneic DCs transfected with OFA-iLRP-coding RNA resulted in powerful antitumor effects in a significant portion of mice. For the first time, these data show that OFA-iLRP can be used as a target for T-cell-based immunotherapeutic strategies against hematologic malignancies.

Adoptive T-cell therapy for Epstein-Barr virus-positive Hodgkin's disease

Immunotherapy approaches with antigen-specific cytotoxic T lymphocytes (CTLs) have proved safe and effective prophylaxis and treatment of Epstein-Barr virus (EBV)-associated lymphomas arising after bone marrow transplantation. EBV is also associated with other malignancies including about 40% of cases of Hodgkin's disease making this tumor another potential target for EBV-targeted immunotherapy. While studies with autologous EBV-specific CTLs have shown antiviral activity and immune effects, the clinical responses have been less impressive than those observed in post-transplant lymphomas. There are several possible reasons why the malignant cells in EBV-positive Hodgkin's disease may be less susceptible to immunotherapy approaches, including the fact that they express a more restricted array of EBV-encoded antigens and possess many immune evasion strategies. A number of approaches to overcome these tumor evasion strategies including targeting CTLs to the expressed antigens and genetic modification of CTLs are being evaluated.

Virally targeted therapies for EBV-associated malignancies

In Epstein-Barr virus (EBV)-positive lymphomas, the presence of the EBV genome in virtually all tumor cells, but very few normal cells, suggests that novel, EBV-targeted therapies could be used to treat these malignancies. In this paper, we review a variety of different approaches currently under development that specifically target EBV-infected cells for destruction. EBV-based strategies for treating cancer include prevention of viral oncogene expression, inducing loss of the EBV episome, the purposeful induction of the lytic form of EBV infection, and enhancing the host immune response to virally encoded antigens.

Immunotherapy for Epstein-Barr virus-associated cancers in children

Latent Epstein-Barr virus (EBV) infection is associated with several malignancies, including Burkitt's lymphoma, Hodgkin's disease, nasopharyngeal carcinoma, and post-transplant lymphoproliferative disease (LPD). The presence of EBV antigens in these tumors provides a target for immunotherapy approaches, and immunotherapy with EBV-specific cytotoxic T cells (CTLs) has proved effective in post-transplant LPDs, which are highly immunogenic tumors expressing type III latency. The malignant cells in Hodgkin's disease and nasopharyngeal carcinoma express type II latency and hence a more restricted pattern of EBV antigens. Trials with autologous EBV-specific CTL responses are under way in both of these diseases, and while some activity has been seen, no patient has yet been cured. This reduced CTL efficacy may reflect either downregulation of immunodominant EBV proteins, which are major CTL targets, or the ability of these tumors to evade the immune response by secreting inhibitory cytokines. Further improvement of EBV-specific CTL therapy for these type II latency tumors will require improved methods to activate and expand CTLs specific for the subdominant EBV genes expressed and to genetically modify the expanded CTLs to render them resistant to inhibitory cytokines. If these strategies to improve the therapeutic potential of immunotherapy for EBV-associated tumors prove successful, this type of treatment may be adapted to other tumors expressing known (viral) antigens.

Identification of a naturally processed HLA-DR-restricted T-helper epitope in Epstein-Barr virus nuclear antigen type 1

Epstein-Barr virus nuclear antigen type 1 (EBNA1), the only viral protein that is unequivocally expressed in all Epstein-Barr virus (EBV)-associated malignant diseases, is essential for viral DNA replication and maintenance of the viral episome in infected cells. A glycine-alanine repeat domain inhibits antigen processing through the ubiquitin-proteasome pathway for presentation on human leukocyte antigen (HLA) class I molecules. EBNA1 is not protected from the HLA class II processing pathway, and CD4+ HLA class II-restricted T cells recognize the antigen. CD4+ T-helper (Th) cells play critical roles in initiating, regulating, and maintaining immune responses against viral infections and tumors, so that inclusion of EBNA1 as a target antigen may improve immunotherapy for EBV-associated cancers. In this study, the authors used the TEPITOPE software program to predict promiscuous class II epitope candidates. After several HLA-DR-restricted peptides were identified by in vitro analysis of the T-cell response to synthetic peptides, a T-cell clone was established that was specific for one of the peptides. Functional studies were performed with this clone. The CD4+ T helper cells specific for the HLA-DR15-restricted peptide EBNA1(482) (AEGLRALLARSHVER) recognized naturally processed EBNA1 protein. This epitope was presented by several HLA-DR alleles, including DR4, DR7, and DR11. The inclusion of the promiscuous, naturally processed EBNA1(482) epitope in vaccine constructs could enhance immune responses against EBV-positive cancers.

The B subunit of Escherichia coli heat-labile enterotoxin enhances CD8+ cytotoxic-T-lymphocyte killing of Epstein-Barr virus-infected cell lines

Epstein-Barr virus (EBV) is associated with a number of important human cancers, including nasopharyngeal carcinoma, gastric carcinoma, and Hodgkin's lymphoma. These tumors express a viral nuclear antigen, EBV nuclear antigen 1 (EBNA1), which cannot be presented to T cells in a major histocompatibility complex class I context, and the viral latent membrane proteins (LMPs). Although the LMPs are expressed in these tumors, no effective immune response is made. We report here that exposure to the cholera-like enterotoxin B subunit (EtxB) in EBV-infected lymphoblastoid cell lines (LCLs) enhances their susceptibility to killing by LMP-specific CD8(+) cytotoxic T lymphocytes (CTLs) in a HLA class I-restricted manner. CTL killing of LCLs is dramatically increased through both transporter-associated protein-dependent and -independent epitopes after EtxB treatment. The use of mutant B subunits revealed that the enhanced susceptibility of LCLs to CTL killing is dependent on the B subunit's interaction with GM(1) but not its signaling properties. These important findings could underpin the development of novel approaches to treating EBV-associated malignancies and may offer a general approach to increasing the presentation of other tumor and viral antigens.

Gene Therapy for Pediatric Cancer: State of the Art and Future Perspectives

While modern treatments have led to a dramatic improvement in survival for pediatric malignancy, toxicities are high and a significant proportion of patients remain resistant. Gene transfer offers the prospect of highly specific therapies for childhood cancer. "Corrective" genes may be transferred to overcome the genetic abnormalities present in the precancerous cell. Alternatively, genes can be introduced to render the malignant cell sensitive to therapeutic drugs. The tumor can also be attacked by decreasing its blood supply with genes that inhibit vascular growth. Another possible approach is to modify normal tissues with genes that make them more resistant to conventional drugs and/or radiation, thereby increasing the therapeutic index. Finally, it may be possible to attack the tumor indirectly by using genes that modify the behavior of the immune system, either by making the tumor more immunogenic, or by rendering host effector cells more efficient. Several gene therapy applications have already been reported for pediatric cancer patients in preliminary Phase 1 studies. Although no major clinical success has yet been achieved, improvements in gene delivery technologies and a better understanding of mechanisms of tumor progression and immune escape have opened new perspectives for the cure of pediatric cancer by combining gene therapy with standard therapeutic available treatments.

Hodgkin's lymphoma

Hodgkin's lymphoma was first described in 1832, but the nature of the pathognomic Reed-Sternberg cell, on which diagnosis of the disease is based, has only been elucidated in the past few years. Radiotherapy has been used to treat localised disease since the 1940s, and in the 1960s, effective combination chemotherapy regimens were introduced for anatomically advanced disease. The past three decades have witnessed continued improvement in outcome to such an extent that Hodgkin's lymphoma is now one of the most curable of all non-cutaneous malignancies. With improved survival and extended follow-up, relevance of treatment-induced late effects has become apparent, and modern therapeutic strategies must fully account for these effects. We review the pathology of Hodgkin's lymphoma, and its clinical presentation, investigation, present management, and natural history, including late effects of treatment.

Generating CTLs against the subdominant Epstein-Barr virus LMP1 antigen for the adoptive immunotherapy of EBV-associated malignancies

The Epstein-Barr virus (EBV)-encoded LMP1 protein is expressed in EBV-positive Hodgkin disease and is a potential target for cytotoxic T-lymphocyte (CTL) therapy. However, the LMP1-specific CTL frequency is low, and so far the generation of LMP1-specific CTLs has required T-cell cloning. The toxicity of LMP1 has prevented the use of dendritic cells (DCs) for CTL stimulation, and we reasoned that an inactive, nontoxic LMP1 mutant (DeltaLMP1) could be expressed in DCs and would enable the activation and expansion of polyclonal LMP1-specific CTLs. Recombinant adenoviral vectors expressing LMP1 or DeltaLMP1 were tested for their ability to transduce DCs. LMP1 expression was toxic within 48 hours whereas high levels of DeltaLMP1 expression were achieved with minimal toxicity. DeltaLMP1-expressing DCs were able to reactivate and expand LMP1-specific CTLs from 3 healthy EBV-seropositive donors. LMP1-specific T cells were detected by interferon-gamma (IFN-gamma) enzyme-linked immunospot assay (ELISPOT) assays using the HLA-A2-restricted LMP1 peptide, YLQQNWWTL (YLQ). YLQ-specific T cells were undetectable (less than 0.001%) in donor peripheral blood mononuclear cells (PBMCs); however, after stimulation the frequency increased to 0.5% to 3.8%. Lysis of autologous target cells by CTLs was dependent on the level of LMP1 expression. In contrast, the frequency of YLQ-specific CTLs in EBV-specific CTLs reactivated and expanded using lymphoblastoid cell lines was low and no LMP1-specific cytotoxic activity was observed. Thus, DeltaLMP1 expression in DCs is nontoxic and enables the generation of LMP1-specific CTLs for future adoptive immunotherapy protocols for patients with LMP1-positive malignancies such as EBV-positive Hodgkin disease. Targeting LMP1 in these malignancies may improve the efficacy of current adoptive immunotherapy approaches.

Tetramer-assisted identification and characterization of epitopes recognized by HLA A*2402-restricted Epstein-Barr virus-specific CD8+ T cells

We determined cytotoxic T lymphocyte (CTL) epitopes through screening with a computer-assisted algorithm and an enzyme-linked immunospot (ELISPOT) assay using in vitro-reactivated polyclonal Epstein-Barr virus (EBV)-specific CD8(+) T cells as responders. In addition, to confirm that the epitopes were generated after endogenous processing and presentation of the EBV proteins, a novel T-cell receptor (TCR) down-regulation assay was introduced, in which a fluorescent tetrameric major histocompatibility complex (MHC)/peptide complex was employed for detecting TCR down-regulation after stimulation with the epitope presented on antigen-presenting cells. Through such screening, 3 HLA A*2402-restricted epitopes were identified: IYVLVMLVL, TYPVLEEMF, and DYNFVKQLF, derived from LMP2, BRLF1, and BMLF1 proteins, respectively. TCR down-regulation assays disclosed that, in contrast to the other 2 epitopes, IYVLVMLVL was not presented on HLA A24-positive fibroblast cells infected with recombinant vaccinia viruses expressing LMP2. Furthermore, ELISPOT assays with an epitope-specific CTL clone demonstrated that the presentation was partially restored by pretreatment of the fibroblast cells with interferon-gamma. The epitope was presented on transporters associated with antigen processing (TAP)-negative T2 cells transfected with plasmids encoding HLA A*2402 and the minimal epitope, indicating that the presentation is TAP independent. In conclusion, the 3 epitopes thus defined could be useful for studying EBV-specific CD8(+) T-cell responses among populations positive for HLA A*2402.

Nasopharyngeal carcinoma and the EBV-specific T cell response: prospects for immunotherapy

T cells specific for Epstein-Barr virus (EBV) can effectively target the virus-transformed B lymphoproliferative lesions that arise in immunosuppressed transplant patients. This review explores the possibility of developing similar T cell-based strategies to treat an EBV-positive epithelial tumour, nasopharyngeal carcinoma (NPC), which arises in relatively immunocompetent individuals and where EBV antigen expression in the tumour is more limited.

Treatment of Epstein-Barr virus-associated malignancies with specific T cells

Latent Epstein-Barr virus (EBV) infection is associated with a heterogeneous group of malignancies, including Burkitt's lymphoma, Hodgkin's disease, nasopharyngeal carcinoma, and lymphoproliferative disease (LPD). The development of adoptive immunotherapies for these malignancies is being fueled by the successful generation of allogeneic donor derived EBV-specific cytotoxic T cells (CTL) for the prevention and treatment of EBV-LPD after hematopoietic stem cell transplantation. This approach is being extended to EBV-LPD after solid organ transplantation by use of autologous and haploidentical EBV-specific CTL. For other EBV-associated malignancies, there is only limited clinical experience with EBV-specific CTL. With few exceptions, only patients with recurrent Hodgkin's disease have been treated with autologous EBV-specific CTL, and although the results have been promising, they do not include cures. Lack of CTL efficacy may reflect either down-regulation of immunodominant EBV proteins, which are major CTL targets, or the presence of inhibitory cytokines. Further improvement of EBV-specific CTL therapy for Hodgkin's disease will require improved methods to activate and expand CTL specific for the latent EBV genes expressed in Hodgkin's disease and to genetically modify the expanded CTL to render them resistant to inhibitory cytokines. If effective, such strategies could be applied not only to other EBV-associated malignancies, but also to a broad range of human tumors with defined tumor antigens and similar immune evasion strategies.

Antigen presenting cells transfected with LMP2a RNA induce CD4+ LMP2a-specific cytotoxic T lymphocytes which kill via a Fas-independent mechanism

Recent reports have demonstrated that EBV can be used as a target of specific CTL-based treatments in severe chronic EBV, immunoblastic B cell lymphoma and Hodgkin's disease (HD). Based upon the promising results form these in vivo studies, it has been suggested that an antigen-specific CTL-based immunotherapy may be of benefit in treating EBV-associated tumors such as HD and nasopharyngeal carcinoma (NPC) which express the potentially immunogenic antigens, LMP1 and LMP2a. Recent work form our group has demonstrated that LMP2a-specific CTLs may be generated in vitro using autologous antigen presenting cells which have been transfected with polyadenylated LMP2a RNA in the presence of a cationic lipid. In this study, we demonstrate that the presence of the lipid enhances dendritic cell (DC) transfection efficiency and appears to protect the intracellular LMP2a RNA from degradation by cellular RNAses. Significantly, these improvements resulted in the transfected DCs having a superior ability to stimulate autologous T cell proliferation. These LMP2a + DCs were used to stimulate LMP2a-specific effector cells which were predominantly a mixture of cytotoxic and helper CD4+ T cells. The molecular mechanisms whereby these CD4+ T cells lyzed their LMP2a-expressing targets was investigated and we show that, although expressing Fas ligand on their surface, LMP2a-specific CD4+ effector cells kill their targets using the Ca2+-dependent perforin/granzyme pathway which is the same mechanism used by CD8+ CTLs.

Emerging clinical applications of RNA

RNA is a versatile biological macromolecule that is crucial in mobilizing and interpreting our genetic information. It is not surprising then that researchers have sought to exploit the inherent properties of RNAs so as to interfere with or repair dysfunctional nucleic acids or proteins and to stimulate the production of therapeutic gene products in a variety of pathological situations. The first generation of the resulting RNA therapeutics are now being evaluated in clinical trials, raising significant interest in this emerging area of medical research.

Guidelines for interpreting EBER in situ hybridization and LMP1 immunohistochemical tests for detecting Epstein-Barr virus in Hodgkin lymphoma

Histochemical stains demonstrate Epstein-Barr virus (EBV) in approximately 40% of all Hodgkin hymphomas, suggesting a role in tumorigenesis and the potentialfor EBV-targeted therapy. As research progresses, it is important to define criteria for interpreting histochemical stains. Four hematopathologists independently interpreted EBV-encoded RNA (EBER) and latent membrane protein 1 (LMP1) histochemical stains from 40 cases of Hodgkin lymphoma and then reviewed the stains as a group to resolve discrepancies and to develop interpretation guidelines. To call a Hodgkin case EBV-related, the EBER and/or LMP1 signal must be unequivocally present in Reed-Sternberg/Hodgkin (RS/H) cells. The cytologic features and distribution of stained cells should be matched with those on the corresponding H&E-stained slide to help interpret whether the EBER or LMP1 signal is in malignant or reactive cells. The EBER signal is localized to the nucleus, whereas LMP1 is in the cytoplasm and surface membrane. In some cases, only a fraction of RS/H cells express these factors for technical or biologic reasons. Before calling a case EBER-negative, it is essential to show that tumor cell RNA is preserved and available for hybridization. LMP1 staining, although usually strong among all tumor cells in a given case, may alternatively be focal and weak, contributing to false-negative interpretation. EBER and LMP1 assays in combination are more effective than either assay alone for identifying EBV-related Hodgkin lymphoma.