Antisense Oligonucleotide Therapy Decreases IL-1β Expression and Prolongs Survival in Mutant Nlrp3 Mice

Antisense oligonucleotides (ASOs) are a novel therapeutic strategy that targets a specific gene and suppresses its expression. The cryopyrin-associated periodic syndromes (CAPS) are a spectrum of autoinflammatory diseases characterized by systemic and tissue inflammation that is caused by heterozygous gain-of-function mutations in the nucleotide-binding and oligomerization domain-like receptor (NLR) family pyrin domain containing 3 (NLRP3) gene. The aim of this study was to investigate the efficacy of an Nlrp3-specific ASO treatment in CAPS. An Nlrp3-specific ASO was designed and tested in murine cell lines and bone marrow-derived macrophages (BMDMs) from wild-type and CAPS mouse models. Nlrp3 knock-in mice were treated in vivo with Nlrp3-specific ASO, survival was monitored, and expression of organ-specific Nlrp3 and IL-1β was measured. Nlrp3-specific ASO treatment of murine cell lines and BMDMs showed a significant downregulation of Nlrp3 and mature IL-1β protein expression. Ex vivo treatment of Nlrp3 mutant mouse-derived BMDMs with Nlrp3-specific ASO demonstrated significantly reduced IL-1β release. In vivo, Nlrp3-specific ASO treatment of Nlrp3 mutant mice prolonged survival, reduced systemic inflammation, and decreased tissue-specific expression of Nlrp3 and mature IL-1β protein. The results of this study demonstrate that Nlrp3-specific ASO treatment downregulates Nlrp3 expression and IL-1β release in CAPS models, suggesting ASO therapy as a potential treatment of CAPS and other NLRP3-mediated diseases.

Dual TLR9 and PD-L1 targeting unleashes dendritic cells to induce durable antitumor immunity

BACKGROUND

Although immune checkpoint inhibitors have been a breakthrough in clinical oncology, these therapies fail to produce durable responses in a significant fraction of patients. This lack of long-term efficacy may be due to a poor pre-existing network linking innate and adaptive immunity. Here, we present an antisense oligonucleotide (ASO)-based strategy that dually targets toll-like receptor 9 (TLR9) and programmed cell death ligand 1 (PD-L1), aiming to overcome resistance to anti-PD-L1 monoclonal therapy.

METHODS

We designed a high-affinity immunomodulatory IM-TLR9:PD-L1-ASO antisense oligonucleotide (hereafter, IM-T9P1-ASO) targeting mouse PD-L1 messenger RNA and activating TLR9. Then, we performed in vitro and in vivo studies to validate the IM-T9P1-ASO activity, efficacy, and biological effects in tumors and draining lymph nodes. We also performed intravital imaging to study IM-T9P1-ASO pharmacokinetics in the tumor.

RESULTS

IM-T9P1-ASO therapy, unlike PD-L1 antibody therapy, results in durable antitumor responses in multiple mouse cancer models. Mechanistically, IM-T9P1-ASO activates a state of tumor-associated dendritic cells (DCs), referred to here as DC3s, which have potent antitumor potential but express the PD-L1 checkpoint. IM-T9P1-ASO has two roles: it triggers the expansion of DC3s by engaging with TLR9 and downregulates PD-L1, thereby unleashing the antitumor functions of DC3s. This dual action leads to tumor rejection by T cells. The antitumor efficacy of IM-T9P1-ASO depends on the antitumor cytokine interleukin-12 (IL-12), produced by DC3s, and Batf3, a transcription factor required for DC development.

CONCLUSIONS

By simultaneously targeting TLR9 and PD-L1, IM-T9P1-ASO amplifies antitumor responses via DC activation, leading to sustained therapeutic efficacy in mice. By highlighting differences and similarities between mouse and human DCs, this study could serve to develop similar therapeutic strategies for patients with cancer.

CHOP-ASO Ameliorates Glomerular and Tubular Damage on Top of ACE Inhibition in Diabetic Kidney Disease

BACKGROUND

Maladaptive endoplasmic reticulum stress signaling in diabetic kidney disease (DKD) is linked to increased glomerular and tubular expression of the cell-death-promoting transcription factor C/EBP homologous protein (CHOP). Here, we determined whether locked nucleic acid (LNA)-modified antisense oligonucleotides (ASOs) targeting CHOP ameliorate experimental DKD.

METHODS

We determined the efficacy of CHOP-ASO in the early and late stages of experimental DKD (in 8- or 16-week-old db/db mice, respectively) alone or with an angiotensin-converting enzyme inhibitor (ACEi), after an in vivo dose-escalation study. We used renal functional parameters and morphologic analyses to assess the effect of CHOP-ASO and renal gene-expression profiling to identify differentially regulated genes and pathways. Several human CHOP-ASOs were tested in hyperglycemia-exposed human kidney cells.

RESULTS

CHOP-ASOs efficiently reduced renal CHOP expression in diabetic mice and reduced markers of DKD at the early and late stages. Early combined intervention (CHOP-ASO and ACEi) efficiently prevented interstitial damage. At the later timepoint, the combined treatment reduced indices of both glomerular and tubular damage more efficiently than either intervention alone. CHOP-ASO affected a significantly larger number of genes and disease pathways, including reduced sodium-glucose transport protein 2 (Slc5a2) and PROM1 (CD133). Human CHOP-ASOs efficiently reduced glucose-induced CHOP and prevented death of human kidney cells in vitro .

CONCLUSIONS

The ASO-based approach efficiently reduced renal CHOP expression in a diabetic mouse model, providing an additional benefit to an ACEi, particularly at later timepoints. These studies demonstrate that ASO-based therapies efficiently reduce maladaptive CHOP expression and ameliorate experimental DKD.

Investigation of the Activity of Antisense Oligonucleotides Targeting Multiple Genes by RNA-Sequencing

Locked nucleic acid-modified antisense oligonucleotides (ASOs) can achieve strongly different degrees of target knockdown despite having similar biophysical properties and 100% homology with their target. The determinants for this observation remain largely unknown. We used multi-specific ASOs that have 100% sequence complementarity with a common target (IDO1) and a different number of diverse targets and investigated their effect on gene expression in a cell line by RNA-sequencing. We observed a significant higher chance for downregulation of long genes compared to short genes, of genes with high compared to lower expression, and of genes that have more than one binding site for the respective ASO. By investigating the expression of genes that have binding sites for more than one ASO we identified the individual binding site being an important determinant for activity. Under the selected experimental conditions we have not seen indications that availability of RNase H is a limiting factor as the number of degraded target RNA molecules correlated significantly with the number of predicted target RNA molecules. Taken together, by using multi-specific ASOs as tool compounds we identified determinants for ASO activity that can be taken into consideration to improve the selection process of highly potent and selective ASOs in the future.

Therapeutic Targeting of Metadherin Suppresses Colorectal and Lung Cancer Progression and Metastasis

Colorectal and lung cancers account for one-third of all cancer-related deaths worldwide. Previous studies suggested that metadherin (MTDH) is involved in the development of colorectal and lung cancers. However, how MTDH regulates the pathogenesis of these cancers remains largely unknown. Using genetically modified mouse models of spontaneous colorectal and lung cancers, we found that MTDH promotes cancer progression by facilitating Wnt activation and by inducing cytotoxic T-cell exhaustion, respectively. Moreover, we developed locked nucleic acid-modified (LNA) MTDH antisense oligonucleotides (ASO) that effectively and specifically suppress MTDH expression in vitro and in vivo. Treatments with MTDH ASOs in mouse models significantly attenuated progression and metastasis of colorectal, lung, and breast cancers. Our study opens a new avenue for developing therapies against colorectal and lung cancers by targeting MTDH using LNA-modified ASO. SIGNIFICANCE: This study provides new insights into the mechanism of MTDH in promoting colorectal and lung cancers, as well as genetic and pharmacologic evidence supporting the development of MTDH-targeting therapeutics.

Preventing ATP Degradation by ASO-Mediated Knockdown of CD39 and CD73 Results in A2aR-Independent Rescue of T Cell Proliferation

The adenosine axis contributes to the suppression of antitumor immune responses. The ectonucleotidase CD39 degrades extracellular adenosine triphosphate (ATP) to adenosine monophosphate (AMP), which is degraded to adenosine by CD73. Adenosine binds to, e.g., the A2a receptor (A2aR), which reportedly suppresses effector immune cells. We investigated effects of ATP, AMP, and adenosine analogs on T cell proliferation, apoptosis, and proinflammatory cytokine secretion. CD39 and CD73 expression were suppressed using antisense oligonucleotides (ASOs), and A2aR was blocked using small molecules. Addition of ATP to T cells reduced proliferation and induced apoptosis. Intriguingly, those effects were reverted by suppression of CD39 and/or CD73 expression but not A2aR inhibition. Adenosine analogs did not suppress proliferation but inhibited secretion of proinflammatory cytokines. Here, we suggest that suppression of T cell proliferation is not directly mediated by A2aR but by intracellular downstream metabolites of adenosine, as blockade of the equilibrative nucleoside transporter (ENT) or adenosine kinase rescued proliferation and prevented induction of apoptosis. In conclusion, adenosine might primarily affect cytokine secretion directly via adenosine receptors, whereas adenosine metabolites might impair T cell proliferation and induce apoptosis. Therefore, inhibition of CD39 and/or CD73 has evident advantages over A2aR blockade to fully revert suppression of antitumor immune responses by the adenosine axis.

A highly efficient modality to block the degradation of tryptophan for cancer immunotherapy: locked nucleic acid-modified antisense oligonucleotides to inhibit human indoleamine 2,3-dioxygenase 1/tryptophan 2,3-dioxygenase expression

Tumors can utilize a diverse repertoire of immunosuppressive mechanisms to evade attack by the immune system. Despite promising success with blockade of immune checkpoints like PD-1 the majority of patients does not respond to current immunotherapies. The degradation of tryptophan into immunosuppressive kynurenine is an important immunosuppressive pathway. Recent attempts to target the key enzymes of this pathway-IDO1 and TDO2-have so far failed to show therapeutic benefit in the clinic, potentially caused by insufficient target engagement. We, therefore, sought to add an alternative, highly efficient approach to block the degradation of tryptophan by inhibiting the expression of IDO1 and TDO2 using locked nucleic acid (LNA)-modified antisense oligonucleotides (ASOs). We show that LNA-modified ASOs can profoundly inhibit the expression of IDO1 and TDO2 in cancer cells in vitro without using a transfection reagent with IC₅₀ values in the sub-micromolar range. We furthermore measured kynurenine production by ASO-treated cancer cells in vitro and observed potently reduced kynurenine levels. Accordingly, inhibiting IDO1 expression in cancer cells in an in vitro system leads to increased proliferation of activated T cells in coculture. We furthermore show that combined treatment of cancer cells in vitro with IDO1-specific ASOs and small molecule inhibitors can reduce the production of kynurenine by cancer cells in a synergistic manner. In conclusion, we propose that a combination of LNA-modified ASOs and small molecule inhibitors should be considered as a strategy for efficient blockade of the degradation of tryptophan into kynurenine in cancer immunotherapy.

Abstract 3275: Inhibition of ER-stress factor C/EBP homologous protein (Chop) with LNAplus™ antisense-oligonucleotides to improve immunotherapy of cancer

The microenvironment generated by tumor cells and suppressive stromal cells creates unfavorable conditions for effector immune cells in order to escape anti-tumor immunity. Besides suppressive pathways like for example the CD39/CD73 axis, mechanisms including nutrient starvation, hypoxia, exposure to high levels of reactive oxygen species and acidosis contribute to the suppression of tumor-reactive immune cells. We have recently discovered that the ER-stress response, in particular the C/EBP homologous protein (Chop) plays an important role in the suppression of tumor-exposed T cells. Furthermore, it is upregulated in activated T cells in vitro and may hamper the efficacy of adoptive T cell therapies. As Chop is a transcription factor it falls into the category of “difficult to drug” and therefore represents an optimal target for antisense-oligonucleotides. In order to revert Chop-induced suppression of T cell activity, we designed locked nucleic acid (LNA) ASOs with specificity for mouse or human Chop using our Oligofyer™ bioinformatics system. Knockdown on mRNA level was investigated in cancer cell lines and in T cells in vitro and the most potent ASOs were selected for further experiments. Downstream effects of Chop knockdown were investigated by mRNA expression analysis and flow cytometry. We furthermore investigated the effect of ex vivo Chop knockdown on the efficacy of adoptively transferred Pmel-specific T cells (recognized target: gp10025-33 peptide) in a B16 melanoma model. Treatment of cells with selected Chop-specific ASO leads to potent knockdown of Chop in vitro. In accordance with observations made in T cells derived from Chop-knockout mice, we observed an increase in T cell-associated transcription factor (Tbet), Interferon-gamma (IFN-γ) and Granzyme B (GZMB) expression in T cells that have been treated with a Chop ASO compared to control oligo treated cells. Strikingly, this translated into improved tumor control by Pmel-specific T cells. We furthermore observed an increase in IFN-γ producing tumor-infiltrating T cells and increased frequency of IFN-γ producing T cells in gp100 restimulated splenocytes from animals that received Chop ASO-treated Pmel-specific T cells. Of note, the impact of Chop knockdown was comparable to the effects that we observed in T cells derived from Chop knockout animals. Taken together, we herein show that Chop is a highly promising novel target in immunotherapy and can effectively be targeted by LNAplus™ ASOs. As shown in a model of adoptive T cell therapy, Chop ASOs have a high potential to optimize the efficacy of T cell therapies, such as chimeric antigen receptor (CAR)- or T cell receptor (TCR)-transgenic T cells. We are currently investigating the effect of systemic Chop ASO treatment in murine tumor models to expand the spectrum of applications of this innovative therapeutic tool.

Citation Format: Richard Klar, Yu Cao, Eslam Mohamed, Sven Michel, Monika Schell, Lisa Hinterwimmer, Stefanie Raith, Paulo Rodriguez, Frank Jaschinski. Inhibition of ER-stress factor C/EBP homologous protein (Chop) with LNAplus™ antisense-oligonucleotides to improve immunotherapy of cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3275.

Key Features Relevant to Select Antigens and TCR From the MHC-Mismatched Repertoire to Treat Cancer

Adoptive transfer of T cells transgenic for tumor-reactive T-cell receptors (TCR) is an attractive immunotherapeutic approach. However, clinical translation is so far limited due to challenges in the identification of suitable target antigens as well as TCRs that are concurrent safe and efficient. Definition of key characteristics relevant for effective and specific tumor rejection is essential to improve current TCR-based adoptive T-cell immunotherapies. We here characterized in-depth two TCRs derived from the human leukocyte antigen (HLA)-mismatched allogeneic repertoire targeting two different myeloperoxidase (MPO)-derived peptides presented by the same HLA-restriction element side by side comprising state of the art biochemical and cellular in vitro, in vivo, and in silico experiments. In vitro experiments reveal comparable functional avidities, off-rates, and cytotoxic activities for both TCRs. However, we observed differences especially with respect to cytokine secretion and cross-reactivity as well as in vivo activity. Biochemical and in silico analyses demonstrate different binding qualities of MPO-peptides to the HLA-complex determining TCR qualities. We conclude from our biochemical and in silico analyses of peptide-HLA-binding that rigid and high-affinity binding of peptides is one of the most important factors for isolation of TCRs with high specificity and tumor rejection capacity from the MHC-mismatched repertoire. Based on our results, we developed a workflow for selection of such TCRs with high potency and safety profile suitable for clinical translation.

Antisense oligonucleotide targeting CD39 improves anti-tumor T cell immunity

Background

Cancer cells are known to develop mechanisms to circumvent effective anti-tumor immunity. The two ectonucleotidases CD39 and CD73 are promising drug targets, as they act in concert to convert extracellular immune-stimulating ATP to adenosine. CD39 is expressed by different immune cell populations as well as cancer cells of different tumor types and supports the tumor in escaping immune recognition and destruction. Thus, increasing extracellular ATP and simultaneously reducing adenosine concentrations in the tumor can lead to effective anti-tumor immunity.

Methods

We designed locked nucleic acid (LNA)-modified antisense oligonucleotides (ASOs) with specificity for human or mouse CD39 that do not need a transfection reagent or delivery system for efficient target knockdown. Knockdown efficacy of ASOs on mRNA and protein level was investigated in cancer cell lines and in primary human T cells. The effect of CD39 knockdown on ATP-degrading activity was evaluated by measuring levels of ATP in tumor cell supernatants and analysis of T cell proliferation in the presence of extracellular ATP. The in vivo effects of CD39-specific ASOs on target expression, anti-tumor immune responses and on tumor growth were analyzed in syngeneic mouse tumor models using multi-color flow cytometry.

Results

CD39-specific ASOs suppressed expression of CD39 mRNA and protein in different murine and human cancer cell lines and in primary human T cells. Degradation of extracellular ATP was strongly reduced by CD39-specific ASOs. Strikingly, CD39 knockdown by ASOs was associated with improved CD8⁺ T cell proliferation. Treatment of tumor-bearing mice with CD39-specific ASOs led to dose-dependent reduction of CD39-protein expression in regulatory T cells (Tregs) and tumor-associated macrophages. Moreover, frequency of intratumoral Tregs was substantially reduced in CD39 ASO-treated mice. As a consequence, the ratio of CD8⁺ T cells to Tregs in tumors was improved, while PD-1 expression was induced in CD39 ASO-treated intratumoral CD8⁺ T cells. Consequently, CD39 ASO treatment demonstrated potent reduction in tumor growth in combination with anti-PD-1 treatment.

Conclusion

Targeting of CD39 by ASOs represents a promising state-of-the art therapeutic approach to improve immune responses against tumors.

Electronic supplementary material

The online version of this article (10.1186/s40425-019-0545-9) contains supplementary material, which is available to authorized users.

Abstract 5909: Inhibition of Cd39 and Cd73 by 3rd-generation antisense oligonucleotides to improve immunity against tumors

During the last decades it became obvious that the immune system can be utilized to evoke effective antitumor responses. However, cancer cells develop mechanisms to circumvent this. The two ectonucleotidases CD39 and CD73 are promising drug targets, as they act in concert to convert extracellular immune-stimulating ATP to immunosuppressive adenosine. CD39 and CD73 are expressed on different immune cells as well as on a range of cancer cells and the latter are recognized to co-opt both ectonucelotidases for circumventing antitumor immune responses. In order to enhance immunity against tumors it would be favorable to increase extracellular ATP- and to simultaneously reduce adenosine concentrations in the tumor microenvironment. We designed antisense oligonucleotides (ASOs) with specificity for human and mouse CD39 and CD73. Knockdown efficacy of ASOs on mRNA and protein level was investigated in cancer cell lines and primary human T cells. CD39 and CD73 activity was evaluated by measuring levels of ATP, AMP and adenosine in cell supernatants. As functional readout we analyzed T cell proliferation and viability in presence of extracellular ATP and adenosine. The impact of ASO-mediated target knockdown in vivo on antitumor immune responses was analyzed in a syngeneic mouse tumor model. CD39- and CD73-specific ASOs suppressed expression of CD39 and CD73 mRNA and protein in different cancer cell lines and in primary human T cells without the need of any transfection reagent in vitro. Furthermore, degradation of extracellular ATP or AMP was significantly blocked by CD39- or CD73-specific ASOs while formation of adenosine was suppressed. Supplementation of cell culture medium with ATP impaired proliferation and viability of CD39- expressing CD8+ T cells. Strikingly, CD39-knockdown by ASO reversed the inhibitory effects of ATP on cell proliferation and viability. Extracellular AMP strongly inhibited proliferation and viability of CD73-expressing CD4+ T cells. Notably, AMP-mediated inhibition of proliferation was considerably less pronounced in cells treated with CD73-specific ASO. Systemic treatment of mice with CD39- and CD73-specific ASOs resulted in a knockdown of CD39 and CD73 mRNA expression in spleen and liver. Moreover, CD39-ASO treatment of tumor-bearing mice significantly reduced CD39-protein expression on tumor-associated macrophages, as well as intratumoral CD8+ T cells and Tregs. Remarkably, frequency of intratumoral Tregs was potently reduced by ASO-mediated CD39 knockdown. Taken together, targeting of CD39 and CD73 by ASOs represents a very promising state-of-the art therapeutic approach to improve immunity against tumors.

Citation Format: Tamara Hilmenyuk, Sandra Kallert, Richard Klar, Lisa Hinterwimmer, Monika Schell, Marina Van Ark, Alfred Zippelius, Frank Jaschinski. Inhibition of Cd39 and Cd73 by 3rd-generation antisense oligonucleotides to improve immunity against tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5909.

Computer-based Training and Electronic Publishing in the Health Sector: Tools and Trends

CBT (computer-based training) applications and hypermedia publications are two different approaches to the utilisation of computers in medical education.

Medical CBT software continues to playa minor role in spite of the increasing availability, whereas hypermedia have become very popular through the World Wide Web (WWW). Based on the HTML format they can be designed by non-programmers using inexpensive tools while the production of CBT applications requires programming expertise. HTML documents can be easily developed to be distributed by a web-server or to run as local applications.

In developed countries CBT and hypermedia have to compete with an abundance of printed or audio-visual media and a wealth of lectures, conferences, etc., whereas in developing countries these media are scarce and expensive. Here CBT programs, and hypermedia publications in particular, may be a cost-effective way to improve quality of education in the health sector.

Ein Programm zur Diagnosenverschlüsselung im Dialogverkehr

Zur Unterstützung der Diagnosendokumentation bieten sieh die Methoden der Klartextverarbeitung oder der Verschlüsselung an. Die Klartextverarbeitimg mit ihren Problemen, vor allem im multi-disziplinären Einsatz, erscheint der Diagnosenverschlüsselung noch nicht überlegen. Es wurde daher eine EDV-gestützte Diagnosenverschlüsselung in Form eines Bildschirmdialogs entwickelt, die den ICD-kompatiblen »Klinischen Diagnosenschlüssel« (KDS) mit einer Erweiterung durch ein Suffix und eine Synonymkennimg benutzt. Die frei eingegebenen Diagnosentexte werden von Stop Wörtern befreit und aus den übrigen Wörtern die ersten fünf Zeichen (Infix) als Suchmerkmale in einer Datenbank genutzt. Alle im KDS enthaltenen Diagnosen, die die gesuchten Infixe enthalten, werden zur Auswahl mit dem Lichtstift am Bildschirm angeboten. Zur hierfür benötigten Schnittmengenbildung wird ein schnelles Direktzugriffsverfahren eingesetzt. Im KDS fehlende Diagnosen können vorläufig verschlüsselt und anschließend ergänzt werden. Blättern, Korrigieren und Direkteingabe einer bekannten Schlüsselausprägung des klinischen Diagnosenschlüssels sind möglich. Das Programm ist Teil eines umfassenden Informationssystems für ein Großklinikum.

A Computerized Information System for a Pain Clinic

The concept of the pain clinic constitutes a recent medical development requiring a thorough documentation of patient-related data in order to achieve reasonable standards in diagnosis and treatment, to ensure that the follow-up maintains these standards and to supply necessary data for research on the epidemiology, etiology, and therapy of chronic pain. We, therefore, developed a set of medical questionnaires for pain patients together with a microcomputer system for the storage and analysis of the data obtained. The main features of our approach are the problem-oriented medical records, the multi-user system and the immediate availability of the supplied data to every therapist using the system.

Conversion Problems concerning Automated Mapping from lCD-10 to lCD-9

The increasing parallel use of ICD-9 and ICD-10 complicates the comparability of coded diagnoses. This is the reason why we developed a symmetric table for interactive conversion between ICD-9 and ICD-10, based on a vector space text-retrieval method that resulted in unambiguous mapping from ICD-9 to ICD-10 in 64%, from ICD-10 to ICD-9 in 87% of all three- and four-character classes of the tabular list. Out of the remaining 13% of multi-valued relations, a table for automated mapping from ICD-10 to ICD-9 was created. In 9% of cases, the selection offered no problems. A compromise between preserving information content and maintaining the logical integrity had to be found in 2.4%; in 1.6% automated mapping was impossible because of newly defined concepts and structural differences between ICD-9 and ICD-10 that are not counterbalanced by a consistent system of residual categories. We recommend that in a future revision of the ICD, compatibility with the then existing classification system should be considered.

Selected Impressions on the Beginning of the Electronic Medical Record and Patient Information

Objectives: To present an overview of early European and American work on Electronic Medical Records and patient information.

Method: The invited lectures of “pioneers of electronic patient information” given at the farewell symposium of Wolfgang Giere in Frankfurt, Germany, are summarized and discussed.

Results: The origin of medical record writing goes back to Hippocrates and over many centuries this important medical duty was regarded as an annoying, laborious and error-prone task. First steps towards a better medical record started in 1936 with punch cards. In the 1960s the minimum basic data set, a unique patient ID was introduced and even for outpatients first com-puterized medical record systems were developed applying some important standards and well accepted data structures. Nowadays multimedia are included in patient record systems, highly specialized subsystems e.g. for radiology or cardiology are available, and semantic and statistic mining techniques as well as medical classifications and standardized terminologies support evaluation. All these methods should primarily improve the quality of care, reduce errors, improve communication between multiple specialists, reduce wait times for patients and improve efficiency.

Conclusions: Over decades it became obvious that the structure of a medical record notably for coded data but also for narrative text and pictures must be carefully modelled. Well maintained standardized health terminologies and medical classifications are important issues for a user-friendly electronic medical record, which bring benefits for clinicians and patients.

In-depth Characterization of a TCR-specific Tracer for Sensitive Detection of Tumor-directed Transgenic T Cells by Immuno-PET

A number of different technologies have been developed to monitor in vivo the distribution of gene-modified T cells used in immunotherapy. Nevertheless, in-depth characterization of novel approaches with respect to sensitivity and clinical applicability are so far missing. We have previously described a novel method to track engineered human T cells in tumors using ⁸⁹Zr-Df-aTCRmu-F(ab')₂ targeting the murinized part of the TCR beta domain (TCRmu) of a transgenic TCR. Here, we performed an in-depth in vitro characterization of the tracer in terms of antigen affinity, immunoreactivity, influence on T-cell functionality and stability in vitro and in vivo. Of particular interest, we have developed diverse experimental settings to quantify TCR-transgenic T cells in vivo. Local application of ⁸⁹Zr-Df-aTCRmu-F(ab')₂-labeled T cells in a spot-assay revealed signal detection down to approximately 1.8x10⁴ cells. In a more clinically relevant model, NSG mice were intravenously injected with different numbers of transgenic T cells, followed by injection of the ⁸⁹Zr-Df-aTCRmu-F(ab')₂ tracer, PET/CT imaging and subsequent ex vivo T-cell quantification in the tumor. Using this setting, we defined a comparable detection limit of 1.0x10⁴ T cells. PET signals correlated well to total numbers of transgenic T cells detected ex vivo independently of the engraftment rates observed in different individual experiments. Thus, these findings confirm the high sensitivity of our novel PET/CT T-cell tracking method and provide critical information about the quantity of transgenic T cells in the tumor environment suggesting our technology being highly suitable for further clinical translation.

Direct identification of clinically relevant neoepitopes presented on native human melanoma tissue by mass spectrometry

Although mutations may represent attractive targets for immunotherapy, direct identification of mutated peptide ligands isolated from human leucocyte antigens (HLA) on the surface of native tumour tissue has so far not been successful. Using advanced mass spectrometry (MS) analysis, we survey the melanoma-associated immunopeptidome to a depth of 95,500 patient-presented peptides. We thereby discover a large spectrum of attractive target antigen candidates including cancer testis antigens and phosphopeptides. Most importantly, we identify peptide ligands presented on native tumour tissue samples harbouring somatic mutations. Four of eleven mutated ligands prove to be immunogenic by neoantigen-specific T-cell responses. Moreover, tumour-reactive T cells with specificity for selected neoantigens identified by MS are detected in the patient's tumour and peripheral blood. We conclude that direct identification of mutated peptide ligands from primary tumour material by MS is possible and yields true neoepitopes with high relevance for immunotherapeutic strategies in cancer.

Abstract 3202: Transgenic antigen-specific, HLA-A*02:01-allo-restricted cytotoxic T cells recognize tumor-associated target antigen STEAP1 with high specificity

Background: Pediatric cancers, including Ewing sarcoma (ES), are only weakly immunogenic and the tumor-patients immune system often is devoid of effector T cells for tumor elimination. Based on expression profiling technology targetable tumor associated antigens (TAA) are identified and exploited for engineered T cell therapy. Here, the specific recognition and lytic potential of transgenic, allo-restricted CD8+ T cells directed against the ES-associated antigen STEAP1 was examined.

Methods: Following repetitive STEAP1130 peptide-driven stimulations with HLA-A*02:01+ dendritic cells, allo-restricted HLA-A*02:01- CD8+ T cells were sorted with HLA-A*02:01/peptide multimers and expanded by limiting dilution. After functional analysis of suitable T cell clones via ELISpot, flow cytometry and xCELLigence assay, TCR α- and β-chains were identified. They were cloned into retroviral vectors, codon optimized, transfected into HLA-A*02:01- primary T cell populations and tested again for specificity and lytic capacity in vitro and in a Rag2-/-γc-/- mouse model.

Results: Initially generated and transgenic T cells specifically recognized STEAP1130-pulsed or transfected cells in the context of HLA-A*02:01 with minimal cross-reactivity as determined by specific IFNγ release. They lysed cells and inhibited growth of HLA-A*02:01+ ES lines more effectively than HLA-A*02:01- ES lines. In vivo tumor growth was inhibited more effective with transgenic STEAP1130-specific T cells than with unspecific T cells.

Conclusion: Our results identify TCRs capable of recognizing and inhibiting growth of STEAP1 expressing HLA-A*02:01+ ES cells in vitro and in vivo in a highly restricted manner. As STEAP1 is overexpressed in a wide variety of cancers, we anticipate these STEAP1-specific TCRs to be potentially useful for immunotherapy of other STEAP1 expressing tumors.

Citation Format: David Schirmer, Richard Klar, Oxana Schmidt, Dirk Wohlleber, Wolfgang Uckert, Uwe Thiel, Felix Bohne, Dirk H. Busch, Angela M. Krackhardt, Stefan Burdach, Günther H. Richter. Transgenic antigen-specific, HLA-A*02:01-allo-restricted cytotoxic T cells recognize tumor-associated target antigen STEAP1 with high specificity. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3202.

Immuno-PET Imaging of Engineered Human T Cells in Tumors

Sensitive in vivo imaging technologies applicable to the clinical setting are still lacking for adoptive T-cell-based immunotherapies, an important gap to fill if mechanisms of tumor rejection or escape are to be understood. Here, we propose a highly sensitive imaging technology to track human TCR-transgenic T cells in vivo by directly targeting the murinized constant TCR beta domain (TCRmu) with a zirconium-89 ((89)Zr)-labeled anti-TCRmu-F(ab')2 fragment. Binding of the labeled or unlabeled F(ab')2 fragment did not impair functionality of transgenic T cells in vitro and in vivo Using a murine xenograft model of human myeloid sarcoma, we monitored by Immuno-PET imaging human central memory T cells (TCM), which were transgenic for a myeloid peroxidase (MPO)-specific TCR. Diverse T-cell distribution patterns were detected by PET/CT imaging, depending on the tumor size and rejection phase. Results were confirmed by IHC and semiquantitative evaluation of T-cell infiltration within the tumor corresponding to the PET/CT images. Overall, these findings offer a preclinical proof of concept for an imaging approach that is readily tractable for clinical translation. Cancer Res; 76(14); 4113-23. ©2016 AACR.

Transgenic antigen-specific, HLA-A*02:01-allo-restricted cytotoxic T cells recognize tumor-associated target antigen STEAP1 with high specificity

Pediatric cancers, including Ewing sarcoma (ES), are only weakly immunogenic and the tumor-patients' immune system often is devoid of effector T cells for tumor elimination. Based on expression profiling technology, targetable tumor-associated antigens (TAA) are identified and exploited for engineered T-cell therapy. Here, the specific recognition and lytic potential of transgenic allo-restricted CD8(+) T cells, directed against the ES-associated antigen 6-transmembrane epithelial antigen of the prostate 1 (STEAP1), was examined. Following repetitive STEAP1(130) peptide-driven stimulations with HLA-A*02:01(+) dendritic cells (DC), allo-restricted HLA-A*02:01(-) CD8(+) T cells were sorted with HLA-A*02:01/peptide multimers and expanded by limiting dilution. After functional analysis of suitable T cell clones via ELISpot, flow cytometry and xCELLigence assay, T cell receptors' (TCR) α- and β-chains were identified, cloned into retroviral vectors, codon optimized, transfected into HLA-A*02:01(-) primary T cell populations and tested again for specificity and lytic capacity in vitro and in a Rag2(-/-)γc(-/-) mouse model. Initially generated transgenic T cells specifically recognized STEAP1(130)-pulsed or transfected cells in the context of HLA-A*02:01 with minimal cross-reactivity as determined by specific interferon-γ (IFNγ) release, lysed cells and inhibited growth of HLA-A*02:01(+) ES lines more effectively than HLA-A*02:01(-) ES lines. In vivo tumor growth was inhibited more effectively with transgenic STEAP1(130)-specific T cells than with unspecific T cells. Our results identify TCRs capable of recognizing and inhibiting growth of STEAP1-expressing HLA-A*02:01(+) ES cells in vitro and in vivo in a highly restricted manner. As STEAP1 is overexpressed in a wide variety of cancers, we anticipate these STEAP1-specific TCRs to be potentially useful for immunotherapy of other STEAP1-expressing tumors.

Norepinephrine transporter heterozygous knockout mice exhibit altered transport and behavior

The norepinephrine (NE) transporter (NET) regulates synaptic NE availability for noradrenergic signaling in the brain and sympathetic nervous system. Although genetic variation leading to a loss of NET expression has been implicated in psychiatric and cardiovascular disorders, complete NET deficiency has not been found in people, limiting the utility of NET knockout mice as a model for genetically driven NET dysfunction. Here, we investigate NET expression in NET heterozygous knockout male mice (NET(+/-) ), demonstrating that they display an approximately 50% reduction in NET protein levels. Surprisingly, these mice display no significant deficit in NET activity assessed in hippocampal and cortical synaptosomes. We found that this compensation in NET activity was due to enhanced activity of surface-resident transporters, as opposed to surface recruitment of NET protein or compensation through other transport mechanisms, including serotonin, dopamine or organic cation transporters. We hypothesize that loss of NET protein in the NET(+/-) mouse establishes an activated state of existing surface NET proteins. The NET(+/-) mice exhibit increased anxiety in the open field and light-dark box and display deficits in reversal learning in the Morris water maze. These data suggest that recovery of near basal activity in NET(+/-) mice appears to be insufficient to limit anxiety responses or support cognitive performance that might involve noradrenergic neurotransmission. The NET(+/-) mice represent a unique model to study the loss and resultant compensatory changes in NET that may be relevant to behavior and physiology in human NET deficiency disorders.

Isolation of human MHC class II-restricted T cell receptors from the autologous T-cell repertoire with potent anti-leukaemic reactivity

Adoptive transfer of T cells genetically modified with tumour-specific T-cell receptors (TCR) is a promising novel approach in the treatment of cancer. We have previously isolated an allorestricted MHC class I-restricted TCR with specificity for Formin-like protein 1 (FMNL1) with potent activity against chronic lymphocytic leukaemia cells. CD4(+) T cells have been described to be highly important for tumour elimination although TCR derived from CD4(+) T cells with anti-tumour reactivity have been only rarely described. In this study we aimed to isolate MHC class-II-restricted CD4(+) T cells and TCR with specificity for leukaemia antigens. We used professional antigen-presenting cells pulsed with the leukaemia-associated and tumour-associated antigen FMNL1 for stimulation of autologous T cells in vitro. We isolated two CD4(+) HLA-DR-restricted T-cell clones and T-cell-derived TCR with so far unknown specificity but high reactivity against lymphoma cells and native malignant cells derived from HLA-matched patients with diverse leukaemias. Moreover, characterization of the TCR after TCR gene transfer revealed that specific characteristics of isolated TCR as reactivity in response to Toll-like receptors were transferable on effector cells. Our results have a major impact on the development of novel immunotherapies. They demonstrate that TCR with potent HLA-DR-restricted anti-leukaemic reactivity against so far undefined self-restricted antigens can be isolated from the healthy autorestricted CD4(+) T-cell repertoire and these TCR are highly interesting candidate tools for novel immunotherapies.

E-Learning in der ärztlichen Aus- und Weiterbildung

E-learning has been established in the education and training of physicians in various types: linear sequential and hyper-textual forms of multimedia presentations and texts, tutorial systems and simulations. Case-based e-learning systems are of special importance in medicine because they allow for mediation of process and practical knowledge by presentation of authentic medical cases in a simulated environment. The integration into the medical education and advanced professional training is crucial for the long-term success of e-learning; in case-based systems this can be accomplished by blended learning approaches which combine elements of traditional teaching with e-learning. Learning management systems (LMS) support integration of traditional teaching and e-learning by serving as an organizational platform for content of teaching. Further, they provide means of communication for trainers and trainees, authoring tools, interactive components, course management and role-based sharing concept. The dissemination of e-learning can be fostered by attention to requirements and user analysis, early adoption to organizational structures, curricular integration and continuous cooperation with students. Summarized, didactic and organizational aspects determine the success of our own e-learning offers as well as they influence the general further development of e-learning more than technical features.

Selected impressions on the beginning of the electronic medical record and patient information

OBJECTIVES

To present an overview of early European and American work on Electronic Medical Records and patient information.

METHOD

The invited lectures of "pioneers of electronic patient information" given at the farewell symposium of Wolfgang Giere in Frankfurt, Germany, are summarized and discussed.

RESULTS

The origin of medical record writing goes back to Hippocrates and over many centuries this important medical duty was regarded as an annoying, laborious and error-prone task. First steps towards a better medical record started in 1936 with punch cards. In the 1960s the minimum basic data set, a unique patient ID was introduced and even for outpatients first computerized medical record systems were developed applying some important standards and well accepted data structures. Nowadays multimedia are included in patient record systems, highly specialized subsystems e.g. for radiology or cardiology are available, and semantic and statistic mining techniques as well as medical classifications and standardized terminologies support evaluation. All these methods should primarily improve the quality of care, reduce errors, improve communication between multiple specialists, reduce wait times for patients and improve efficiency.

CONCLUSIONS

Over decades it became obvious that the structure of a medical record notably for coded data but also for narrative text and pictures must be carefully modelled. Well maintained standardized health terminologies and medical classifications are important issues for a user-friendly electronic medical record, which bring benefits for clinicians and patients.

[Electronic distribution of patient records and images through PACS: implementation of data protection at the University Hospital in Freiburg]

In large installations of a Picture Archiving and Communication System (PACS), data protection becomes an issue. Above all, not every employee should have access to all data stored in the system. At the Freiburg University Hospital, we developed a concept of dynamic assignment of authorization, assuring that every physician is authorized to the data of all patients under his care. We describe the technical implementation of data protection developed for the integration of PACS and electronic patient records in Freiburg. The system was installed in January 2001 and the experience of its two years in operation is reported.

Health informatics world wide--a WWW service for the health informatics community

Health Informatics World Wide, a Web index of research and educational institutions in the fields of Health Informatics and Medical Informatics has been available to WWW users since 1995. In this paper we report on the original conception of this service, its subsequent modifications and address its maintenance and related problems. Access statistics are presented which demonstrate its relevance as well as the geographical focus of Health Informatics research and development.

[Virtual conferences in medicine]

The Internet and high-speed communication facilities have tremendously simplified the exchange of multimedia data. E-mail and World Wide Web have become important tools for everyday information and communication. In recent years there have been numerous attempts to exploit web technology for virtual conferences. However, in the medical domain, only few virtual conferences could be established. We describe the architecture and typical features of virtual conferences, their organizational and technical requirements and discuss prerequisites for their successful implementation.

Semantic analysis of medical free texts

The semantic interpretation of natural language utterances is usually based on a large number of transformation rules which map syntactic structures (parse trees) onto some kind of meaning representation. However, those interpretation rules exhibit an insufficient degree of abstraction so that the scalability and portability of such natural language processing systems is hard to maintain. In this paper, we introduce an approach that is able to cope with a wide variety of semantic interpretation patterns in medical free texts by applying a small inventory of abstract semantic interpretation schemata. These schemata address generalized graph configurations within syntactic dependency parse trees, which abstract away from specific syntactic constructions.

Realization of a CPR using HL7 queries from communication server to information server

A communication server is often used in Germany to interface legacy systems. It handles the translation, duplication, and transmission of messages to all systems that might need this information. Based on the principles of "for every data there is only one master" and "information on demand" we have built an information server that reduces the messages required and simplifies the handling of messages, the update of data already sent compared to a communication server. It also allows to implement a security policy as required by the German data privacy legislature.