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Dijkstra KK, Cattaneo CM, Weeber F, Chalabi M, van de Haar J, Fanchi LF, Slagter M, van der Velden DL, Kaing S, Kelderman S, van Rooij N, van Leerdam ME, Depla A, Smit EF, Hartemink KJ, de Groot R, Wolkers MC, Sachs N, Snaebjornsson P, Monkhorst K, Haanen J, Clevers H, Schumacher TN, Voest EE. Generation of Tumor-Reactive T Cells by Co-culture of Peripheral Blood Lymphocytes and Tumor Organoids. Cell 2018; 174:1586-1598.e12. [PMID: 30100188 DOI: 10.1016/j.cell.2018.07.009] [Citation(s) in RCA: 565] [Impact Index Per Article: 94.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 05/24/2018] [Accepted: 07/05/2018] [Indexed: 02/07/2023]
Abstract
Cancer immunotherapies have shown substantial clinical activity for a subset of patients with epithelial cancers. Still, technological platforms to study cancer T-cell interactions for individual patients and understand determinants of responsiveness are presently lacking. Here, we establish and validate a platform to induce and analyze tumor-specific T cell responses to epithelial cancers in a personalized manner. We demonstrate that co-cultures of autologous tumor organoids and peripheral blood lymphocytes can be used to enrich tumor-reactive T cells from peripheral blood of patients with mismatch repair-deficient colorectal cancer and non-small-cell lung cancer. Furthermore, we demonstrate that these T cells can be used to assess the efficiency of killing of matched tumor organoids. This platform provides an unbiased strategy for the isolation of tumor-reactive T cells and provides a means by which to assess the sensitivity of tumor cells to T cell-mediated attack at the level of the individual patient.
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Affiliation(s)
- Krijn K Dijkstra
- Department of Molecular Oncology and Immunology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - Chiara M Cattaneo
- Department of Molecular Oncology and Immunology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - Fleur Weeber
- Department of Molecular Oncology and Immunology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - Myriam Chalabi
- Department of Molecular Oncology and Immunology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands; Department of Gastroenterologic Oncology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - Joris van de Haar
- Department of Molecular Oncology and Immunology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - Lorenzo F Fanchi
- Department of Molecular Oncology and Immunology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - Maarten Slagter
- Department of Molecular Oncology and Immunology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - Daphne L van der Velden
- Department of Molecular Oncology and Immunology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - Sovann Kaing
- Department of Molecular Oncology and Immunology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - Sander Kelderman
- Department of Molecular Oncology and Immunology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - Nienke van Rooij
- Department of Molecular Oncology and Immunology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterologic Oncology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - Annekatrien Depla
- Department of Gastroenterology and Hepatology, EC Slotervaart Hospital, 1066 CX Amsterdam, the Netherlands
| | - Egbert F Smit
- Department of Thoracic Oncology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - Koen J Hartemink
- Department of Surgery, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - Rosa de Groot
- Department of Hematopoeisis, Sanquin Research, 1066 CX Amsterdam, the Netherlands
| | - Monika C Wolkers
- Department of Hematopoeisis, Sanquin Research, 1066 CX Amsterdam, the Netherlands; Landsteiner Laboratory, Amsterdam Medical Center, 1105 AZ Amsterdam, the Netherlands
| | - Norman Sachs
- Hubrecht Institute, University Medical Center Utrecht, 3584 CT Utrecht, the Netherlands
| | - Petur Snaebjornsson
- Department of Pathology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - Kim Monkhorst
- Department of Pathology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - John Haanen
- Department of Molecular Oncology and Immunology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands
| | - Hans Clevers
- Hubrecht Institute, University Medical Center Utrecht, 3584 CT Utrecht, the Netherlands; Princess Maxima Center for Pediatric Oncology, 3584 CS Utrecht, the Netherlands; Oncode Institute, the Netherlands
| | - Ton N Schumacher
- Department of Molecular Oncology and Immunology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands; Oncode Institute, the Netherlands
| | - Emile E Voest
- Department of Molecular Oncology and Immunology, the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, the Netherlands.
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Strønen E, Toebes M, Kelderman S, van Buuren MM, Yang W, van Rooij N, Donia M, Böschen ML, Lund-Johansen F, Olweus J, Schumacher TN. Targeting of cancer neoantigens with donor-derived T cell receptor repertoires. Science 2016; 352:1337-41. [PMID: 27198675 DOI: 10.1126/science.aaf2288] [Citation(s) in RCA: 331] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 05/04/2016] [Indexed: 12/14/2022]
Abstract
Accumulating evidence suggests that clinically efficacious cancer immunotherapies are driven by T cell reactivity against DNA mutation-derived neoantigens. However, among the large number of predicted neoantigens, only a minority is recognized by autologous patient T cells, and strategies to broaden neoantigen-specific T cell responses are therefore attractive. We found that naïve T cell repertoires of healthy blood donors provide a source of neoantigen-specific T cells, responding to 11 of 57 predicted human leukocyte antigen (HLA)-A*02:01-binding epitopes from three patients. Many of the T cell reactivities involved epitopes that in vivo were neglected by patient autologous tumor-infiltrating lymphocytes. Finally, T cells redirected with T cell receptors identified from donor-derived T cells efficiently recognized patient-derived melanoma cells harboring the relevant mutations, providing a rationale for the use of such "outsourced" immune responses in cancer immunotherapy.
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Affiliation(s)
- Erlend Strønen
- Department of Cancer Immunology, Oslo University Hospital Radiumhospitalet, Oslo, Norway. K. G. Jebsen Centers for Cancer Immunotherapy and for Inflammation Research, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mireille Toebes
- Division of Immunology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Sander Kelderman
- Division of Immunology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Marit M van Buuren
- Division of Immunology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Weiwen Yang
- Department of Cancer Immunology, Oslo University Hospital Radiumhospitalet, Oslo, Norway. K. G. Jebsen Centers for Cancer Immunotherapy and for Inflammation Research, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Nienke van Rooij
- Division of Immunology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Marco Donia
- Center for Cancer Immune Therapy, Department of Hematology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Maxi-Lu Böschen
- Department of Cancer Immunology, Oslo University Hospital Radiumhospitalet, Oslo, Norway. K. G. Jebsen Centers for Cancer Immunotherapy and for Inflammation Research, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Fridtjof Lund-Johansen
- K. G. Jebsen Centers for Cancer Immunotherapy and for Inflammation Research, Institute for Clinical Medicine, University of Oslo, Oslo, Norway. Department of Immunology and Transfusion Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Johanna Olweus
- Department of Cancer Immunology, Oslo University Hospital Radiumhospitalet, Oslo, Norway. K. G. Jebsen Centers for Cancer Immunotherapy and for Inflammation Research, Institute for Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Ton N Schumacher
- Division of Immunology, Netherlands Cancer Institute, Amsterdam, Netherlands.
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3
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Kelderman S, Heemskerk B, Fanchi L, Philips D, Toebes M, Kvistborg P, van Buuren MM, van Rooij N, Michels S, Germeroth L, Haanen JBAG, Schumacher NM. Antigen-specific TIL therapy for melanoma: A flexible platform for personalized cancer immunotherapy. Eur J Immunol 2016; 46:1351-60. [DOI: 10.1002/eji.201545849] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 02/01/2016] [Accepted: 03/14/2016] [Indexed: 12/31/2022]
Affiliation(s)
- Sander Kelderman
- Division of Immunology; The Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Bianca Heemskerk
- Division of Immunology; The Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Lorenzo Fanchi
- Division of Immunology; The Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Daisy Philips
- Division of Immunology; The Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Mireille Toebes
- Division of Immunology; The Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Pia Kvistborg
- Division of Immunology; The Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Marit M. van Buuren
- Division of Immunology; The Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Nienke van Rooij
- Division of Immunology; The Netherlands Cancer Institute; Amsterdam The Netherlands
| | - Samira Michels
- Division of Immunology; The Netherlands Cancer Institute; Amsterdam The Netherlands
| | | | - John B. A. G. Haanen
- Division of Immunology; The Netherlands Cancer Institute; Amsterdam The Netherlands
| | - N. M. Schumacher
- Division of Immunology; The Netherlands Cancer Institute; Amsterdam The Netherlands
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4
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Schreibelt G, Bol KF, Westdorp H, Wimmers F, Aarntzen EHJG, Duiveman-de Boer T, van de Rakt MWMM, Scharenborg NM, de Boer AJ, Pots JM, Olde Nordkamp MAM, van Oorschot TGM, Tel J, Winkels G, Petry K, Blokx WAM, van Rossum MM, Welzen MEB, Mus RDM, Croockewit SAJ, Koornstra RHT, Jacobs JFM, Kelderman S, Blank CU, Gerritsen WR, Punt CJA, Figdor CG, de Vries IJM. Effective Clinical Responses in Metastatic Melanoma Patients after Vaccination with Primary Myeloid Dendritic Cells. Clin Cancer Res 2016; 22:2155-66. [PMID: 26712687 DOI: 10.1158/1078-0432.ccr-15-2205] [Citation(s) in RCA: 174] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/30/2015] [Indexed: 11/16/2022]
Abstract
PURPOSE Thus far, dendritic cell (DC)-based immunotherapy of cancer was primarily based on in vitro-generated monocyte-derived DCs, which require extensive in vitro manipulation. Here, we report on a clinical study exploiting primary CD1c(+) myeloid DCs, naturally circulating in the blood. EXPERIMENTAL DESIGN Fourteen stage IV melanoma patients, without previous systemic treatment for metastatic disease, received autologous CD1c(+) myeloid DCs, activated by only brief (16 hours) ex vivo culture and loaded with tumor-associated antigens of tyrosinase and gp100. RESULTS Our results show that therapeutic vaccination against melanoma with small amounts (3-10 × 10(6)) of myeloid DCs is feasible and without substantial toxicity. Four of 14 patients showed long-term progression-free survival (12-35 months), which directly correlated with the development of multifunctional CD8(+) T-cell responses in three of these patients. In particular, high CD107a expression, indicative for cytolytic activity, and IFNγ as well as TNFα and CCL4 production was observed. Apparently, these T-cell responses are essential to induce tumor regression and promote long-term survival by stalling tumor growth. CONCLUSIONS We show that vaccination of metastatic melanoma patients with primary myeloid DCs is feasible and safe and results in induction of effective antitumor immune responses that coincide with improved progression-free survival. Clin Cancer Res; 22(9); 2155-66. ©2015 AACR.
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Affiliation(s)
- Gerty Schreibelt
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kalijn F Bol
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands. Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Harm Westdorp
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands. Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Florian Wimmers
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Erik H J G Aarntzen
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands. Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands. Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Tjitske Duiveman-de Boer
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mandy W M M van de Rakt
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Nicole M Scharenborg
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Annemiek J de Boer
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jeanette M Pots
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michel A M Olde Nordkamp
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Tom G M van Oorschot
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jurjen Tel
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Katja Petry
- Miltenyi Biotec GmbH, Bergisch Gladbach, Germany
| | - Willeke A M Blokx
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michelle M van Rossum
- Department of Dermatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marieke E B Welzen
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Roel D M Mus
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Sandra A J Croockewit
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rutger H T Koornstra
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joannes F M Jacobs
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Sander Kelderman
- Department of Immunology, Netherlands Cancer Institute NKI-AVL, Amsterdam, the Netherlands
| | - Christian U Blank
- Department of Immunology, Netherlands Cancer Institute NKI-AVL, Amsterdam, the Netherlands
| | - Winald R Gerritsen
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Cornelis J A Punt
- Department of Medical Oncology, Academic Medical Center, Amsterdam, the Netherlands
| | - Carl G Figdor
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - I Jolanda M de Vries
- Department of Tumor Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands. Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands.
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5
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Kelderman S, Kvistborg P. Tumor antigens in human cancer control. Biochim Biophys Acta Rev Cancer 2016; 1865:83-89. [DOI: 10.1016/j.bbcan.2015.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 10/27/2015] [Accepted: 10/30/2015] [Indexed: 01/10/2023]
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Kelderman S, Bies L, Van Buuren MM, Van Rooij N, Haanen J, Kvistborg P, Schumacher T. Abstract 4704: Neo-antigen enriched TIL therapy mediates superior tumor eradication in a patient-derived xenograft model of human melanoma. Cancer Res 2015. [DOI: 10.1158/1538-7445.am2015-4704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
The mutational load in melanoma is high relative to that in most other human malignancies, resulting in the possible expression of large numbers of patient-specific mutated antigens. This may, in part, explain the immunogenicity of this disease and the high rate of responsiveness to immunotherapeutic strategies such as tumor-infiltrating lymphocyte (TIL) therapy. Indeed, recent data have shown that cytotoxic T-cell reactivity targeting neo antigens may be common in human melanoma TILs. Importantly though, the clinical relevance of neo-antigen specific T cell populations remains uncertain.
To directly address the tumoricidal potential of defined neo-antigen specific T cell populations, we first identified two neo-antigen specific T-cell populations within a bulk melanoma TIL culture by the combination of exome sequencing and MHC multimer-based T cell screens. Subsequently, we generated TIL products that are highly enriched for these neo-antigen reactivities and we compared the anti-tumor activity of these neo-antigen enriched TIL with that of ‘standard’ bulk TIL in NSG mice bearing the autologous tumor. We observed outgrowth of the tumors in mice treated with standard TIL. In contrast, tumors in mice treated with enriched TILs were controlled long-term. Additional experiments showed that this superior activity of neo-antigen enriched TIL was caused by the increased numbers of T cells with a high anti-tumor activity, rather than the depletion of cell populations with inhibitory activity. Furthermore, once tumors eventually recurred these were still recognized in vitro by cells from the initially infused TIL culture.
Together, these preclinical data demonstrate that neo-antigen reactive T cells within bulk TIL cultures form a critical component of anti-tumor reactivity and provide a further basis to target mutated antigens with cancer immunotherapy.
Citation Format: Sander Kelderman, Laura Bies, Marit M. Van Buuren, Nienke Van Rooij, John Haanen, Pia Kvistborg, Ton Schumacher. Neo-antigen enriched TIL therapy mediates superior tumor eradication in a patient-derived xenograft model of human melanoma. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4704. doi:10.1158/1538-7445.AM2015-4704
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Affiliation(s)
| | - Laura Bies
- Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | - John Haanen
- Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Pia Kvistborg
- Netherlands Cancer Institute, Amsterdam, Netherlands
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7
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Visser R, Kelderman S, de Jongh FHC, van der Palen J, Thio BJ. Reversibility of pulmonary function after inhaling salbutamol in different doses and body postures in asthmatic children. Respir Med 2015; 109:1274-9. [PMID: 26341548 DOI: 10.1016/j.rmed.2015.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/21/2015] [Accepted: 07/22/2015] [Indexed: 10/23/2022]
Abstract
RATIONALE Pulmonary medication is often delivered in the form of medical aerosols designed for inhalation. Recently, breath actuated inhalers (BAI's) gained popularity as they can be used without spacers. A major drawback of BAI's is the impaction in the upper airway. Stretching the upper airway by a forward leaning body posture with the neck extended ("sniffing position") during inhalation may reduce upper airway impaction and improve pulmonary deposition. Aim of this study was to investigate the reversibility of lung function with different doses salbutamol inhaled with a BAI in the forward leaning posture compared to the standard posture in asthmatic children. METHODS 22 clinically stable asthmatic children, 5-14 years old, performed four reversibility measurements. Children inhaled 200 μg or 400 μg salbutamol with a BAI in the standard or in the forward leaning posture with the neck extended in a randomized single-blinded cross-over design. RESULTS Reversibility of lung function after inhaling salbutamol in the forward leaning posture was not significantly different compared to inhalation in the standard posture. Mean FEV1 reversibility was significantly greater after inhaling 400 μg salbutamol compared to 200 μg salbutamol in the standard posture (9.4% ± 9.5% versus 4.5% ± 7.5%, difference 4.9% (95CI 0.9; 9.0%); p = 0.021). CONCLUSION In clinically stable asthmatic children, inhalation of salbutamol with a BAI in a forward leaning posture does not increase reversibility of lung function. Inhalation of 400 μg compared to 200 μg salbutamol with a BAI does improve reversibility.
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Affiliation(s)
- R Visser
- Department of Pediatrics, Medisch Spectrum Twente, P.O. Box 50 000, 7500 KA Enschede, The Netherlands.
| | - S Kelderman
- Department of Pediatrics, Medisch Spectrum Twente, P.O. Box 50 000, 7500 KA Enschede, The Netherlands; University Medical Centre Groningen, The Netherlands
| | - F H C de Jongh
- Department of Pulmonary Function, Medisch Spectrum Twente, Enschede, The Netherlands
| | - J van der Palen
- Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands; Department of Research Methodology, Measurement and Data Analysis, University of Twente, Enschede, The Netherlands
| | - B J Thio
- Department of Pediatrics, Medisch Spectrum Twente, P.O. Box 50 000, 7500 KA Enschede, The Netherlands
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Abstract
Immune checkpoint-blocking therapies have yielded positive clinical data in a series of human malignancies. Recent work from Le and colleagues strongly supports the use of these therapies for mismatch repair-deficient tumors, independent of underlying tumor type. These data suggest the importance of sensing the consequences of DNA damage in cancer immunotherapy.
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Affiliation(s)
- Sander Kelderman
- Division of Immunology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Ton N Schumacher
- Division of Immunology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands
| | - Pia Kvistborg
- Division of Immunology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands.
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9
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Becattini S, Latorre D, Mele F, Foglierini M, De Gregorio C, Cassotta A, Fernandez B, Kelderman S, Schumacher TN, Corti D, Lanzavecchia A, Sallusto F. Functional heterogeneity of human memory CD4+ T cell clones primed by pathogens or vaccines. Science 2014; 347:400-6. [DOI: 10.1126/science.1260668] [Citation(s) in RCA: 250] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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10
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Kvistborg P, Philips D, Kelderman S, Hageman L, Ottensmeier C, Joseph-Pietras D, Welters MJP, van der Burg S, Kapiteijn E, Michielin O, Romano E, Linnemann C, Speiser D, Blank C, Haanen JB, Schumacher TN. Anti-CTLA-4 therapy broadens the melanoma-reactive CD8+ T cell response. Sci Transl Med 2014; 6:254ra128. [PMID: 25232180 DOI: 10.1126/scitranslmed.3008918] [Citation(s) in RCA: 293] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Anti-CTLA-4 treatment improves the survival of patients with advanced-stage melanoma. However, although the anti-CTLA-4 antibody ipilimumab is now an approved treatment for patients with metastatic disease, it remains unknown by which mechanism it boosts tumor-specific T cell activity. In particular, it is unclear whether treatment amplifies previously induced T cell responses or whether it induces new tumor-specific T cell reactivities. Using a combination ultraviolet (UV)-induced peptide exchange and peptide-major histocompatibility complex (pMHC) combinatorial coding, we monitored immune reactivity against a panel of 145 melanoma-associated epitopes in a cohort of patients receiving anti-CTLA-4 treatment. Comparison of pre- and posttreatment T cell reactivities in peripheral blood mononuclear cell samples of 40 melanoma patients demonstrated that anti-CTLA-4 treatment induces a significant increase in the number of detectable melanoma-specific CD8 T cell responses (P = 0.0009). In striking contrast, the magnitude of both virus-specific and melanoma-specific T cell responses that were already detected before start of therapy remained unaltered by treatment (P = 0.74). The observation that anti-CTLA-4 treatment induces a significant number of newly detected T cell responses-but only infrequently boosts preexisting immune responses-provides strong evidence for anti-CTLA-4 therapy-enhanced T cell priming as a component of the clinical mode of action.
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Affiliation(s)
- Pia Kvistborg
- The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, Netherlands.
| | - Daisy Philips
- The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, Netherlands
| | - Sander Kelderman
- The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, Netherlands
| | - Lois Hageman
- The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, Netherlands
| | - Christian Ottensmeier
- National Institute for Health Research Southampton Experimental Cancer Medicine Centre and Southampton University Hospitals, Tremona Road, Southampton, Hampshire SO16 6YD, UK
| | - Deborah Joseph-Pietras
- National Institute for Health Research Southampton Experimental Cancer Medicine Centre and Southampton University Hospitals, Tremona Road, Southampton, Hampshire SO16 6YD, UK
| | - Marij J P Welters
- Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Sjoerd van der Burg
- Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Ellen Kapiteijn
- Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Olivier Michielin
- Ludwig Center for Cancer Research, Department of Oncology, University of Lausanne, Rue Pierre-Decker 4, 1011 Lausanne, Switzerland
| | - Emanuela Romano
- Ludwig Center for Cancer Research, Department of Oncology, University of Lausanne, Rue Pierre-Decker 4, 1011 Lausanne, Switzerland
| | - Carsten Linnemann
- The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, Netherlands
| | - Daniel Speiser
- Ludwig Center for Cancer Research, Department of Oncology, University of Lausanne, Rue Pierre-Decker 4, 1011 Lausanne, Switzerland
| | - Christian Blank
- The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, Netherlands
| | - John B Haanen
- The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, Netherlands
| | - Ton N Schumacher
- The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, Netherlands.
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11
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Abstract
A number of immunotherapies, in particular immune checkpoint targeting antibodies and adoptive T-cell therapies, are starting to transform the treatment of advanced cancers. The likelihood to respond to these immunotherapies differs strongly across tumor types, with response rates for checkpoint targeting being the highest in advanced melanoma, renal cell cancer and non-small cell lung cancer. However, also non-responsiveness is observed, indicating the presence of intrinsic resistance or naturally acquired resistance. In addition, a subgroup of patients that do initially respond to immunotherapy will later recur, thereby also pointing towards a role of therapy-induced acquired resistance. Here, we review our current understanding of both intrinsic and acquired resistance mechanisms in cancer immunotherapy, and discuss potential strategies to overcome them.
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Affiliation(s)
- Sander Kelderman
- The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Ton N M Schumacher
- The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - John B A G Haanen
- The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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Kelderman S, Heemskerk B, van Tinteren H, van den Brom RRH, Hospers GAP, van den Eertwegh AJM, Kapiteijn EW, de Groot JWB, Soetekouw P, Jansen RL, Fiets E, Furness AJS, Renn A, Krzystanek M, Szallasi Z, Lorigan P, Gore ME, Schumacher TNM, Haanen JBAG, Larkin JMG, Blank CU. Lactate dehydrogenase as a selection criterion for ipilimumab treatment in metastatic melanoma. Cancer Immunol Immunother 2014; 63:449-58. [PMID: 24609989 PMCID: PMC11029318 DOI: 10.1007/s00262-014-1528-9] [Citation(s) in RCA: 145] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 02/22/2014] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Ipilimumab, a cytotoxic T lymphocyte-associated antigen-4 blocking antibody, has improved overall survival (OS) in metastatic melanoma in phase III trials. However, about 80 % of patients fail to respond, and no predictive markers for benefit from therapy have been identified. We analysed a 'real world' population of patients treated with ipilimumab to identify markers for treatment benefit. METHODS Patients with advanced cutaneous melanoma were treated in the Netherlands (NL) and the United Kingdom (UK) with ipilimumab at 3 mg/kg. Baseline characteristics and peripheral blood parameters were assessed, and patients were monitored for the occurrence of adverse events and outcomes. RESULTS A total of 166 patients were treated in the Netherlands. Best overall response and disease control rates were 17 and 35 %, respectively. Median follow-up was 17.9 months, with a median progression-free survival of 2.9 months. Median OS was 7.5 months, and OS at 1 year was 37.8 % and at 2 years was 22.9 %. In a multivariate model, baseline serum lactate dehydrogenase (LDH) was demonstrated to be the strongest predictive factor for OS. These findings were validated in an independent cohort of 64 patients from the UK. CONCLUSION In both the NL and UK cohorts, long-term benefit of ipilimumab treatment was unlikely for patients with baseline serum LDH greater than twice the upper limit of normal. In the absence of prospective data, clinicians treating melanoma may wish to consider the data presented here to guide patient selection for ipilimumab therapy.
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Affiliation(s)
- Sander Kelderman
- Netherlands Cancer Institute NKI-AVL, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Bianca Heemskerk
- Netherlands Cancer Institute NKI-AVL, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Harm van Tinteren
- Netherlands Cancer Institute NKI-AVL, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | | | - Geke A. P. Hospers
- University Medical Center Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | | | - Ellen W. Kapiteijn
- Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | | | - Patricia Soetekouw
- Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Rob L. Jansen
- Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Edward Fiets
- Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD Leeuwarden, The Netherlands
| | | | - Alexandra Renn
- Royal Marsden Hospital, 197 Fulham Road, London, SW3 6JJ UK
| | - Marcin Krzystanek
- Technical University of Denmark, Anker Engelunds Vej 1, 2800 Kongens Lyngby, Denmark
| | - Zoltan Szallasi
- Technical University of Denmark, Anker Engelunds Vej 1, 2800 Kongens Lyngby, Denmark
| | - Paul Lorigan
- Christie Hospital, 550 Wilmslow Road, Manchester, M20 4BX UK
| | - Martin E. Gore
- Royal Marsden Hospital, 197 Fulham Road, London, SW3 6JJ UK
| | - Ton N. M. Schumacher
- Netherlands Cancer Institute NKI-AVL, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - John B. A. G. Haanen
- Netherlands Cancer Institute NKI-AVL, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | | | - Christian U. Blank
- Netherlands Cancer Institute NKI-AVL, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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Kelderman S, Heemskerk B, Toebes M, van Buuren M, van Rooij N, Bies L, Fanchi L, Germeroth L, Kvistborg P, Schumacher T. Antigen-specific TIL therapy for melanoma: a flexible platform for personalized cancer immunotherapy. J Immunother Cancer 2013. [PMCID: PMC3990297 DOI: 10.1186/2051-1426-1-s1-p19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Kelderman S, van der Kooij MK, van den Eertwegh AJM, Soetekouw PMMB, Jansen RLH, van den Brom RRH, Hospers GAP, Haanen JBAG, Kapiteijn E, Blank CU. Ipilimumab in pretreated metastastic uveal melanoma patients. Results of the Dutch Working group on Immunotherapy of Oncology (WIN-O). Acta Oncol 2013; 52:1786-8. [PMID: 23607756 DOI: 10.3109/0284186x.2013.786839] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Sander Kelderman
- Division of Immunology, Netherlands Cancer Institute (NKI-AVL) , Amsterdam
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Haanen JBAG, Kvistborg P, Philips D, Kelderman S, Heemskerk B, Ottensmeier C, Speiser DE, Michielin OA, Romano E, Blank CU, Schumacher T. Dissection of anti-CTLA4-induced cytotoxic T-cell responses in melanoma. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.9078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
9078 Background: There is strong evidence that melanoma-reactive T cells induced by immunotherapeutic interventions such as anti-CTLA4 therapy can exert clinically effects. However, there is very little information on how these therapies influence tumor-specific T cell responses. Furthermore, as the number of potential melanoma-associated antigens to which these responses can be directed is very high, classical strategies to map cytotoxic T cell reactivity do not suffice. Knowledge of such reactivities would be useful to design targeted strategies, selectively aiming to induce immune reactivity against these antigens. Methods: We have addressed these issues by designing MHC class I molecules occupied with UV-sensitive ‘conditional’ ligands, thereby allowing the production of very large collections of pMHC complexes for T cell detection. Secondly, we have developed a ‘combinatorial coding’ strategy that allows parallel detection of dozens of different T cell populations within a single sample. The combined use of MHC ligand exchange and combinatorial coding allows the high-throughput dissection of disease- and therapy-induced CTL immunity. We have used this platform to monitor immune reactivity against a panel of 145 melanoma-associated epitopes in patients receiving Ipilimumab treatment. Results: Comparison of PBMC samples from 32 melanoma patients pre- and post-therapy indicated a significant increase in the number of detectable melanoma-associated T cell responses (p=0.004). Furthermore, kinetic data on T cell responses during therapy suggests that this broadening generally occurs within weeks after start of therapy. The magnitude of melanoma-specific T cell responses that was detectable prior to start of therapy was not significantly altered (p=0.8). Conclusions: These results establish the pattern of melanoma-specific T-cell reactivity induced by anti-CTLA4 treatment and form a benchmark for evaluation of other immunotherapeutic interventions, like anti-PD1 treatment, that are currently undergoing clinical evaluation. Furthermore, our data suggests that the clinical activity of Ipilimumab may be mostly due to epitope spreading, rather than through enhancement of pre-existing immune activity.
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Affiliation(s)
- John B. A. G. Haanen
- The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Pia Kvistborg
- Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Daisy Philips
- Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Bianca Heemskerk
- The Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | | | | | | | | | - Christian U. Blank
- The Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Ton Schumacher
- The Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Amsterdam, Netherlands
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Blank CU, Kelderman S, van Tinteren H, Heemskerk B, van den Brom R, Hospers GA, van den Eertwegh AJM, Kapiteijn E, De Groot JW, Jansen RL, Fiets WE, Krzystanek M, Szallasi Z, Furness AJS, Renn A, Gore ME, Lorigan P, Schumacher T, Haanen JBAG, Larkin JMG. Serum lactate dehydrogenase (LDH) as a prognostic selection criterion for ipilimumab treatment in metastatic melanoma. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.3036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
3036 Background: Ipilimumab, a CTLA4 blocking antibody, has been shown to improve survival in metastatic melanoma patients in phase III trials. However, only a subset of patients experiences long-term survival benefit. Therefore, we analysed two independent retrospective sets of patients treated in ‘real world’ settings to identify prognostic factors that correlate with better outcome after ipilimumab therapy. Methods: Advanced melanoma patients, eligible for ipilimumab therapy, were treated in the Dutch and UK Expanded Access Programs (EAP) and after European licensing on the 3mg/kg schedule. Baseline characteristics and peripheral blood parameters were assessed and patients were monitored for the occurrence of adverse events and responses. Results: A total of 166 patients were enrolled in the Dutch EAP. Best overall response rate and disease control rate were (DCR) 17% and 35%. Median follow-up was 17.9 months, with a median progression free survival of 2.9 months. Median overall survival (OS) was 7.5 months, and OS at 1 year 37.8% and at 2 years 22.9%. Univariate analysis revealed that gender, age, Breslow thickness, baseline and week 6 lymphocyte count (ALC), and prior treatment had no influence on OS, while mWHO, M stage, baseline LDH, S100, erythrocyte sedimentation rate (ESR), and the slope of ALC did. In a multivariate model only baseline LDH and ESR remained as significant independent prognostic factors. The relevance of LDH was validated in an independent cohort of 68 patients from the UK. Stratifying the patients in the NL cohort according to LDH levels (≤upper limit normal (ULN), 54.4% of patients versus >2xULN, 16.9% of patients) separated into groups of patients observing DCR of 48% versus 14%, and median OS of 13.7 versus 3.1 months, while toxicity was similar in both groups (48% and 41%). None of the patients was alive at 15 months after treatment if baseline LDH was >2xULN in both the NL and UK cohorts. Conclusions: Overall survival upon ipilimumab treatment is lower in an expanded access population as compared to phase III trials. LDH >2xULN at baseline is a potential prognosticator in patients receiving ipilimumab and should be considered in guiding ipilimumab treatment initiation.
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Affiliation(s)
- Christian U. Blank
- The Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | | | - Harm van Tinteren
- Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Bianca Heemskerk
- The Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | | | - Geke A. Hospers
- Department of Medical Oncology, University Medical Center Groningen/University of Groningen, Groningen, Netherlands
| | | | | | | | - Rob L. Jansen
- Department of Medical Oncology, Maastricht University Medical Center, Maastricht, Netherlands
| | | | | | | | | | - Alex Renn
- The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Paul Lorigan
- The Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
| | - Ton Schumacher
- The Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - John B. A. G. Haanen
- The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
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Urbanska K, Lanitis E, Poussin M, Lynn RC, Gavin BP, Kelderman S, Yu J, Scholler N, Powell DJ. A universal strategy for adoptive immunotherapy of cancer through use of a novel T-cell antigen receptor. Cancer Res 2012; 72:1844-52. [PMID: 22315351 DOI: 10.1158/0008-5472.can-11-3890] [Citation(s) in RCA: 225] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Adoptive immunotherapies composed of T cells engineered to express a chimeric antigen receptor (CAR) offer an attractive strategy for treatment of human cancer. However, CARs have a fixed antigen specificity such that only one tumor-associated antigen (TAA) can be targeted, limiting the efficacy that can be achieved because of heterogeneous TAA expression. For this reason, a more generalized and effective application of CAR therapy would benefit from the capability to produce large panels of CARs against many known TAAs. In this study, we show a novel strategy to extend the recognition specificity potential of a bioengineered lymphocyte population, allowing flexible approaches to redirect T cells against various TAAs. Our strategy employs a biotin-binding immune receptor (BBIR) composed of an extracellular-modified avidin linked to an intracellular T-cell signaling domain. BBIR T cells recognized and bound exclusively to cancer cells pretargeted with specific biotinylated molecules. The versatility afforded by BBIRs permitted sequential or simultaneous targeting of a combination of distinct antigens. Together, our findings show that a platform of universal T-cell specificity can significantly extend conventional CAR approaches, permitting the tailored generation of T cells of unlimited antigen specificity for improving the effectiveness of adoptive T-cell immunotherapies for cancer.
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Affiliation(s)
- Katarzyna Urbanska
- Department of Obstetrics and Gynecology, Ovarian Cancer Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Kelderman S, Steenvoorde P, van der Valk PDLPM. [Sternoclavicular joint tuberculosis]. Ned Tijdschr Geneeskd 2012; 156:A3315. [PMID: 22551751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
A 24-year old woman presented with an abscess localized at the median side of the right clavicle. There were no clinical signs of tuberculosis and radiological evaluation was normal. PCR-assay on tuberculosis following aspiration of the pus collection was positive for Mycobacterium tuberculosis. She responded well on regular anti-tuberculosis treatment.
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Affiliation(s)
- Sander Kelderman
- Medisch Spectrum Twente, Afd. Heelkunde, Enschede, the Netherlands.
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