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Kim N, Yi E, Lee E, Park HJ, Kim HS. Interleukin-2 is required for NKp30-dependent NK cell cytotoxicity by preferentially regulating NKp30 expression. Front Immunol 2024; 15:1388018. [PMID: 38698855 PMCID: PMC11063289 DOI: 10.3389/fimmu.2024.1388018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/08/2024] [Indexed: 05/05/2024] Open
Abstract
Natural killer (NK) cells are key effectors in cancer immunosurveillance, eliminating a broad spectrum of cancer cells without major histocompatibility complex (MHC) specificity and graft-versus-host diseases (GvHD) risk. The use of allogeneic NK cell therapies from healthy donors has demonstrated favorable clinical efficacies in treating diverse cancers, particularly hematologic malignancies, but it requires cytokines such as IL-2 to primarily support NK cell persistence and expansion. However, the role of IL-2 in the regulation of activating receptors and the function of NK cells expanded for clinical trials is poorly understood and needs clarification for the full engagement of NK cells in cancer immunotherapy. Here, we demonstrated that IL-2 deprivation significantly impaired the cytotoxicity of primary expanded NK cells by preferentially downregulating NKp30 but not NKp46 despite their common adaptor requirement for expression and function. Using NK92 and IL-2-producing NK92MI cells, we observed that NKp30-mediated cytotoxicity against myeloid leukemia cells such as K562 and THP-1 cells expressing B7-H6, a ligand for NKp30, was severely impaired by IL-2 deprivation. Furthermore, IL-2 deficiency-mediated NK cell dysfunction was overcome by the ectopic overexpression of an immunostimulatory NKp30 isoform such as NKp30a or NKp30b. In particular, NKp30a overexpression in NK92 cells improved the clearance of THP-1 cells in vivo without IL-2 supplementation. Collectively, our results highlight the distinct role of IL-2 in the regulation of NKp30 compared to that of NKp46 and suggest NKp30 upregulation, as shown here by ectopic overexpression, as a viable modality to harness NK cells in cancer immunotherapy, possibly in combination with IL-2 immunocytokines.
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Affiliation(s)
- Nayoung Kim
- Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eunbi Yi
- Department of Microbiology, Brain Korea 21 Project, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eunbi Lee
- Department of Microbiology, Brain Korea 21 Project, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyo Jin Park
- Department of Microbiology, Brain Korea 21 Project, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hun Sik Kim
- Department of Microbiology, Brain Korea 21 Project, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Stem Cell Immunomodulation Research Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Khalifa AM, Nakamura T, Sato Y, Harashima H. Vaccination with a combination of STING agonist-loaded lipid nanoparticles and CpG-ODNs protects against lung metastasis via the induction of CD11b highCD27 low memory-like NK cells. Exp Hematol Oncol 2024; 13:36. [PMID: 38553761 PMCID: PMC10981311 DOI: 10.1186/s40164-024-00502-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 03/13/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Natural killer (NK) cells are effective in attacking tumor cells that escape T cell attack. Memory NK cells are believed to function as potent effector cells in cancer immunotherapy. However, knowledge of their induction, identification, and potential in vivo is limited. Herein, we report on the induction and identification of memory-like NK cells via the action of a combination of a stimulator of interferon genes (STING) agonist loaded into lipid nanoparticles (STING-LNPs) and cytosine-phosphorothioate-guanine oligodeoxynucleotides (CpG-ODNs), and the potential of the inducted memory-like NK cells to prevent melanoma lung metastasis. METHODS The antitumor effects of either the STING-LNPs, CpG-ODNs, or the combination therapy were evaluated using a B16-F10 lung metastasis model. The effect of the combined treatment was evaluated by measuring cytokine production. The induction of memory-like NK cells was demonstrated via flow cytometry and confirmed through their preventative effect. RESULTS The combination of STING-LNPs and CpG-ODNs tended to enhance the production of interleukin 12 (IL-12) and IL-18, and exerted a therapeutic effect against B16-F10 lung metastasis. The combination therapy increased the population of CD11bhighCD27low NK cells. Although monotherapies failed to show preventative effects, the combination therapy induced a surprisingly strong preventative effect, which indicates that CD11bhighCD27low cells could be a phenotype of memory-like NK cells. CONCLUSION As far as could be ascertained, this is the first report of the in vivo induction, identification, and confirmation of a phenotype of the memory-like NK cells through a prophylactic effect via the use of an immunotherapeutic drug. Our findings provide novel insights into the in vivo induction of CD11bhighCD27low memory-like NK cells thus paving the way for the development of efficient immunotherapies.
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Affiliation(s)
- Alaa M Khalifa
- Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo, 060-0812, Hokkaido, Japan
| | - Takashi Nakamura
- Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo, 060-0812, Hokkaido, Japan.
| | - Yusuke Sato
- Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo, 060-0812, Hokkaido, Japan
| | - Hideyoshi Harashima
- Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo, 060-0812, Hokkaido, Japan.
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Parvini N, Akbari ME, Hamidieh AA, Fathi F, Amini AA, Ebrahimi M, Vahabzadeh Z. CTLA-4 Blockade of Natural Killer Cells Increases Cytotoxicity against Acute Lymphoid Leukaemia Cells Neda. CELL JOURNAL 2024; 26:150-157. [PMID: 38459732 PMCID: PMC10924838 DOI: 10.22074/cellj.2024.2015187.1444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/02/2024] [Accepted: 01/13/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVE There is interest in using cytotoxic T lymphocyte antigen-4 (CTLA-4) immunotherapy to treat blood cancers. Unfortunately, patients with acute lymphoblastic leukaemia (ALL) frequently exhibit resistance to treatment and natural killer (NK) cell exhaustion. This study aims to increase the cytotoxic potency of natural killer cells by using CTLA-4 to block the Nalm-6 leukaemia cell line. MATERIALS AND METHODS In this experimental study, NK cells were purified from the peripheral blood mononuclear cells (PBMCs) of 10 healthy people and assessed by flow cytometry for purity and viability. The purified cells were activated overnight at 37°C and 5% CO2 with interleukin-15 (IL-15, 10 ng/ml) followed by evaluation of expressions of CTLA-4, activating and inhibitory receptors, and the release of interferon gamma (IFN-γ) and granzyme B (GZM B). CTLA-4 expression on NK cells from recurrent ALL patients was also evaluated. Finally, the cytotoxic activity of NK cells was assessed after the CTLA-4 blockade. RESULTS The purity of the isolated cells was 96.58 ± 2.57%. Isolated NK cells activated with IL-15 resulted in significantly higher CTLA-4 expression (8.75%, P<0.05). Similarly, CTLA-4 expression on the surface of NK cells from patients with ALL was higher (7.46%) compared to healthy individuals (1.46%, P<0.05). IL-15 reduced NKG2A expression (P<0.01), and increased expressions of NKP30 (P<0.05) and NKP46 (P<0.01). The activated NK cells released more IFN-γ (P<0.5) and GZM B (P<0.01) compared to unactivated NK cells. Blockade of CTLA-4 enhanced the NK cell killing potential against Nalm-6 cells (56.3%, P<0.05); however, IFN-γ and GZM B levels were not statistically different between the blocked and non-blocked groups. CONCLUSION Our findings suggest that CTLA-4 blockage of Nalm-6 cells causes an increase in antitumour activity of NK cells against these cells. Our study also provides evidence for the potential of cancer immunotherapy treatment using blocking anti-CTLA-4 mAbs.
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Affiliation(s)
- Neda Parvini
- Student Research Committee, Kurdistan University of Medical Sciences, Sanandaj, Iran
- Cellular and Molecular Research Centre, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
- Department of Stem Cells and Developmental Biology, Cell Science Research Centre, Royan Institute for Stem Cells, ACECR, Tehran, Iran
| | | | - Amir Ali Hamidieh
- Paediatric Cell and Gene Therapy Research Centre, Gene, Cell and Tissue Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Fardin Fathi
- Cellular and Molecular Research Centre, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Abbas Ali Amini
- Department of Immunology, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Marzieh Ebrahimi
- Department of Stem Cells and Developmental Biology, Cell Science Research Centre, Royan Institute for Stem Cells, ACECR, Tehran, Iran
- Department of Regenerative Medicine, Cell Science Research Centre, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran, Iran.
| | - Zakaria Vahabzadeh
- Cellular and Molecular Research Centre, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran .
- Department of Clinical Biochemistry, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
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Kim H, Han M, Kim M, Kim H, Im HJ, Kim N, Koh KN. CD19/CD22 bispecific chimeric antigen receptor‑NK‑92 cells are developed and evaluated. Oncol Lett 2023; 25:236. [PMID: 37153038 PMCID: PMC10161343 DOI: 10.3892/ol.2023.13822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/23/2023] [Indexed: 05/09/2023] Open
Abstract
Anti-CD19 chimeric antigen receptor (CAR)-T cells have improved the outcomes of patients with B cell leukemia and lymphoma. However, their applications and positive outcomes remain limited. CAR-T cells are currently restricted to autologous blood as their source and their use can lead to downregulation of CD19 expression along with complications such as graft-versus-host disease and cytokine release syndrome. The present study aimed to develop anti-CD19/CD22 bispecific CAR structures using an anti-CD22 monoclonal antibody clone from chickens and analyze them in natural killer (NK)-92 cells, a human NK cell line, in vitro and in vivo. Anti-CD19/CD22 CAR-NK-92 cell cytotoxicity was assessed by the survival of target cells and counted using flow cytometry. Anti-CD22/CD19 and loop-structured anti-CD19/CD22 bi-specific CAR-NK-92 cells showed improved efficacy against OCI-Ly7 cells, a human B cell lymphoma cell line, compared with other CAR structures. These results demonstrate the potential of anti-CD19/CD22 bispecific CAR-NK cells and suggested that optimizing CAR structures in NK cells can improve the efficacy of CAR therapy.
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Affiliation(s)
- Hyori Kim
- Department of Convergence Medicine and Asan Institute for Life Sciences, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Mina Han
- Department of Convergence Medicine and Asan Institute for Life Sciences, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Minsong Kim
- Department of Convergence Medicine and Asan Institute for Life Sciences, Asan Medical Center, Seoul 05505, Republic of Korea
| | - Hyeri Kim
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Ho Joon Im
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Nayoung Kim
- Department of Convergence Medicine and Asan Institute for Life Sciences, Asan Medical Center, Seoul 05505, Republic of Korea
- Dr Nayoung Kim, Department of Convergence Medicine and Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic 43-gil, Songpa, Seoul 05505, Republic of Korea, E-mail:
| | - Kyung-Nam Koh
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
- Correspondence to: Professor Kyung-Nam Koh, Division of Pediatric Hematology/Oncology, Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic 43-gil, Songpa, Seoul 05505, Republic of Korea, E-mail:
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Khalifa AM, Nakamura T, Sato Y, Sato T, Hyodo M, Hayakawa Y, Harashima H. Interval- and cycle-dependent combined effect of STING agonist loaded lipid nanoparticles and a PD-1 antibody. Int J Pharm 2022; 624:122034. [PMID: 35863595 DOI: 10.1016/j.ijpharm.2022.122034] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 07/06/2022] [Accepted: 07/15/2022] [Indexed: 10/17/2022]
Abstract
Programmed cell death 1 (PD-1) blockade combination to other drugs have attracted the interest of scientists for treating tumors resistant to PD-1 blockade. In this study, the impact of the interval, order of administration, and number of cycles of immunotherapeutic combination of stimulator of interferon genes (STING) pathway agonist loaded lipid nanoparticle (STING-LNP) and PD-1 antibody for inducing the optimal combined antitumor activity against a melanoma lung metastasis is reported. One cycle had no effect, but two and three cycles resulted in a combinedantitumor effect. The interval between the administration was found to influence the induction of the combined effect. The second and third doses increased the gene expression of the NK cell activation marker, interferon γ (IFN-γ), PD-1 and a ligand of PD-1 (PD-L1), whereas the first dose failed. NK cells in the lung showed an increase in the expression of the activation markers and PD-1 after the second dose. The combined antitumor effect of this combination therapy against melanoma lung metastasis model could be dependent on the interval as well as the number of doses of STING-LNP.These findings suggest the importance of the protocol setting when combining a nano system loaded with an immune adjuvant and PD-1 antibody.
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Affiliation(s)
- Alaa M Khalifa
- Faculty of Pharmaceutical Sciences, Hokkaido University, Sapporo, Hokkaido 060-0812, Japan
| | - Takashi Nakamura
- Faculty of Pharmaceutical Sciences, Hokkaido University, Sapporo, Hokkaido 060-0812, Japan.
| | - Yusuke Sato
- Faculty of Pharmaceutical Sciences, Hokkaido University, Sapporo, Hokkaido 060-0812, Japan
| | - Takanori Sato
- Faculty of Pharmaceutical Sciences, Hokkaido University, Sapporo, Hokkaido 060-0812, Japan
| | - Mamoru Hyodo
- Department of Applied Chemistry, Faculty of Engineering, Aichi Institute of Technology, 1247 Yachigusa, Yakusa-cho Toyota, Aichi 470-0392, Japan
| | - Yoshihiro Hayakawa
- Department of Applied Chemistry, Faculty of Engineering, Aichi Institute of Technology, 1247 Yachigusa, Yakusa-cho Toyota, Aichi 470-0392, Japan
| | - Hideyoshi Harashima
- Faculty of Pharmaceutical Sciences, Hokkaido University, Sapporo, Hokkaido 060-0812, Japan.
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Saad AA. Targeting cancer-associated glycans as a therapeutic strategy in leukemia. ALL LIFE 2022. [DOI: 10.1080/26895293.2022.2049901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Ashraf Abdullah Saad
- Unit of Pediatric Hematologic Oncology and BMT, Sultan Qaboos University Hospital, Muscat, Oman
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Abstract
The discovery of immune checkpoints (ICs) and the development of specific blockers to relieve immune effector cells from this inhibiting mechanism has changed the view of anti-cancer therapy. In addition to cytotoxic T lymphocyte antigen 4 (CTLA4) and programmed death 1 (PD1), classical ICs of T lymphocytes and recently described also on a fraction of natural killer (NK) cells, several NK cell receptors, including killer immunoglobulin-like inhibitory receptors (KIRs) and NGK2A, have been recognized as checkpoint members typical of the NK cell population. This offers the opportunity of a dual-checkpoint inhibition approach, targeting classical and non-classical ICs and leading to a synergistic therapeutic effect. In this review, we will overview and discuss this new perspective, focusing on the most relevant candidates for this role among the variety of potential NK ICs. Beside listing and defining classical ICs expressed also by NK cells, or non-classical ICs either on T or on NK cells, we will address their role in NK cell survival, chronic stimulation or functional exhaustion, and the potential relevance of this phenomenon on anti-tumor immune response. Furthermore, NK ICs will be proposed as possible new targets for the development of efficient combined immunotherapy, not forgetting the relevant concerns that may be raised on NK IC blockade. Finally, the impact of epigenetic drugs in such a complex therapeutic picture will be briefly addressed.
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Miazek-Zapala N, Slusarczyk A, Kusowska A, Zapala P, Kubacz M, Winiarska M, Bobrowicz M. The "Magic Bullet" Is Here? Cell-Based Immunotherapies for Hematological Malignancies in the Twilight of the Chemotherapy Era. Cells 2021; 10:1511. [PMID: 34203935 PMCID: PMC8232692 DOI: 10.3390/cells10061511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 12/14/2022] Open
Abstract
Despite the introduction of a plethora of different anti-neoplastic approaches including standard chemotherapy, molecularly targeted small-molecule inhibitors, monoclonal antibodies, and finally hematopoietic stem cell transplantation (HSCT), there is still a need for novel therapeutic options with the potential to cure hematological malignancies. Although nowadays HSCT already offers a curative effect, its implementation is largely limited by the age and frailty of the patient. Moreover, its efficacy in combating the malignancy with graft-versus-tumor effect frequently coexists with undesirable graft-versus-host disease (GvHD). Therefore, it seems that cell-based adoptive immunotherapies may constitute optimal strategies to be successfully incorporated into the standard therapeutic protocols. Thus, modern cell-based immunotherapy may finally represent the long-awaited "magic bullet" against cancer. However, enhancing the safety and efficacy of this treatment regimen still presents many challenges. In this review, we summarize the up-to-date state of the art concerning the use of CAR-T cells and NK-cell-based immunotherapies in hemato-oncology, identify possible obstacles, and delineate further perspectives.
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Affiliation(s)
- Nina Miazek-Zapala
- Department of Immunology, Medical University of Warsaw, 02-097 Warsaw, Poland; (N.M.-Z.); (A.S.); (A.K.); (M.K.); (M.W.)
- Institute of Physiology and Pathophysiology of Hearing, World Hearing Center, 05-830 Nadarzyn, Poland
| | - Aleksander Slusarczyk
- Department of Immunology, Medical University of Warsaw, 02-097 Warsaw, Poland; (N.M.-Z.); (A.S.); (A.K.); (M.K.); (M.W.)
- Department of General, Oncological and Functional Urology, Medical University of Warsaw, 02-005 Warsaw, Poland;
| | - Aleksandra Kusowska
- Department of Immunology, Medical University of Warsaw, 02-097 Warsaw, Poland; (N.M.-Z.); (A.S.); (A.K.); (M.K.); (M.W.)
| | - Piotr Zapala
- Department of General, Oncological and Functional Urology, Medical University of Warsaw, 02-005 Warsaw, Poland;
| | - Matylda Kubacz
- Department of Immunology, Medical University of Warsaw, 02-097 Warsaw, Poland; (N.M.-Z.); (A.S.); (A.K.); (M.K.); (M.W.)
| | - Magdalena Winiarska
- Department of Immunology, Medical University of Warsaw, 02-097 Warsaw, Poland; (N.M.-Z.); (A.S.); (A.K.); (M.K.); (M.W.)
| | - Malgorzata Bobrowicz
- Department of Immunology, Medical University of Warsaw, 02-097 Warsaw, Poland; (N.M.-Z.); (A.S.); (A.K.); (M.K.); (M.W.)
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Islam R, Pupovac A, Evtimov V, Boyd N, Shu R, Boyd R, Trounson A. Enhancing a Natural Killer: Modification of NK Cells for Cancer Immunotherapy. Cells 2021; 10:cells10051058. [PMID: 33946954 PMCID: PMC8146003 DOI: 10.3390/cells10051058] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/27/2021] [Accepted: 04/27/2021] [Indexed: 12/14/2022] Open
Abstract
Natural killer (NK) cells are potent innate immune system effector lymphocytes armed with multiple mechanisms for killing cancer cells. Given the dynamic roles of NK cells in tumor surveillance, they are fast becoming a next-generation tool for adoptive immunotherapy. Many strategies are being employed to increase their number and improve their ability to overcome cancer resistance and the immunosuppressive tumor microenvironment. These include the use of cytokines and synthetic compounds to bolster propagation and killing capacity, targeting immune-function checkpoints, addition of chimeric antigen receptors (CARs) to provide cancer specificity and genetic ablation of inhibitory molecules. The next generation of NK cell products will ideally be readily available as an “off-the-shelf” product and stem cell derived to enable potentially unlimited supply. However, several considerations regarding NK cell source, genetic modification and scale up first need addressing. Understanding NK cell biology and interaction within specific tumor contexts will help identify necessary NK cell modifications and relevant choice of NK cell source. Further enhancement of manufacturing processes will allow for off-the-shelf NK cell immunotherapies to become key components of multifaceted therapeutic strategies for cancer.
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Affiliation(s)
- Rasa Islam
- Cartherics Pty Ltd., Clayton 3168, Australia; (R.I.); (A.P.); (V.E.); (N.B.); (R.S.); (R.B.)
- Department of Obstetrics and Gynaecology, Monash University, Clayton 3168, Australia
| | - Aleta Pupovac
- Cartherics Pty Ltd., Clayton 3168, Australia; (R.I.); (A.P.); (V.E.); (N.B.); (R.S.); (R.B.)
| | - Vera Evtimov
- Cartherics Pty Ltd., Clayton 3168, Australia; (R.I.); (A.P.); (V.E.); (N.B.); (R.S.); (R.B.)
| | - Nicholas Boyd
- Cartherics Pty Ltd., Clayton 3168, Australia; (R.I.); (A.P.); (V.E.); (N.B.); (R.S.); (R.B.)
| | - Runzhe Shu
- Cartherics Pty Ltd., Clayton 3168, Australia; (R.I.); (A.P.); (V.E.); (N.B.); (R.S.); (R.B.)
| | - Richard Boyd
- Cartherics Pty Ltd., Clayton 3168, Australia; (R.I.); (A.P.); (V.E.); (N.B.); (R.S.); (R.B.)
| | - Alan Trounson
- Cartherics Pty Ltd., Clayton 3168, Australia; (R.I.); (A.P.); (V.E.); (N.B.); (R.S.); (R.B.)
- Department of Obstetrics and Gynaecology, Monash University, Clayton 3168, Australia
- Correspondence:
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