Reduced anticancer efficacy of cyclophosphamide and platinum salts has been reported in animals treated with anti-Gram-positive antibiotics. These effects were related to translocation of ...Gram-positive bacteria during mucositis with subsequent induction of cytotoxic oxygen reactive species and tumor invasion by pathogenic Th17 cells. To assess these hypotheses in a clinical setting, we identified patients receiving cyclophosphamide for chronic lymphocytic leukemia (CLL) and cisplatin for relapsed lymphoma. Data originated from the CLL8 trial (NCT00281918) and the Cologne Cohort of Neutropenic Patients (NCT01821456). Relevant antibiotics were defined as compounds with primary activity against Gram-positive bacteria. We evaluated their impact on response, progression-free survival (PFS) and overall survival (OS) by Kaplan-Meier methodology and Cox proportional hazards regression analysis. Among 800 available CLL patients, those receiving anti-Gram-positive antibiotics (n = 45/800) achieved a significantly lower overall response rate (OR 74.3% vs. 90.2%, p = 0.007). Patients with anti-Gram-positive antibiotics progressed significantly earlier, had a reduced OS (median PFS 14.1 vs. 44.1 mo, p < 0.001; median OS 56.1 vs. 91.7 mo, p < 0.001) and multivariate analysis showed that administration of anti-Gram-positive antibiotic treatment was independently associated with reduced PFS (Hazard ratio (HR) 2.090, p = 0.001) and OS (HR 2.966, p < 0.001). Of 122 patients with relapsed lymphoma, those treated with anti-Gram-positive antibiotics (n = 21/122) achieved a significantly lower OR rate (70.3% vs. 42.9%, p = 0.016). Patients with anti-Gram-positive antibiotics progressed significantly earlier than others (median PFS 2.3 vs. 11.5 mo, p = 0.001). As for multivariate analysis, the use of anti-Gram-positive antibiotics was independently associated with reduced PFS (HR 2.237, p = 0.012) and OS (HR 7.831, p < 0.001). Our data supports a potential negative impact of anti-Gram-positive antibiotics on the anticancer activity of cyclophosphamide and cisplatin in a clinical setting.
The purpose of this analysis was to provide 6-year follow-up of the CLL3X trial, which studied reduced-intensity allogeneic hematopoietic stem cell transplantation (HSCT) in patients with poor-risk ...chronic lymphocytic leukemia (CLL), and to investigate the effect of TP53, SF3B1, and NOTCH1 mutations on HSCT outcome. For 90 allografted patients, 6-year overall survival (OS) was 58% and 6-year event-free survival (EFS) was 38%. TP53, SF3B1, and NOTCH1 mutations were found in 30%, 26%, and 14% of the trial population, respectively. By univariate and multivariate analyses, the mutational status of the TP53, SF3B1, and NOTCH1 genes had no significant effect on OS and EFS. Studies of minimal residual disease confirmed durability of CLL eradication in mutated patients. We conclude that HSCT can provide long-term disease control in patients with poor-risk CLL independent of the presence of TP53, SF3B1, and NOTCH1 mutations. The trial has been registered at the US National Cancer Institute as #EU-20554, NCT00281983.
•This trial update shows that allotransplantation can provide long-term minimal residual disease–negative disease control in poor-risk chronic lymphocytic leukemia.•Six-year survival is close to 60% and is independent of the presence of TP53, SF3B1, and NOTCH1 mutations in the tumor clone.
The pathogenesis of autoimmune complications triggered by SARS‐CoV2 has not been completely elucidated. Here, we performed an analysis of the cellular immune status, cell ratios, and monocyte ...populations of patients with COVID‐19 treated in the intensive care unit (ICU) (cohort 1, N = 23) and normal care unit (NCU) (cohort 2, n = 10) compared with control groups: patients treated in ICU for noninfectious reasons (cohort 3, n = 30) and patients treated in NCU for infections other than COVID‐19 (cohort 4, n = 21). Patients in cohort 1 presented significant differences in comparison with the other cohorts, including reduced frequencies of lymphocytes, reduced CD8+T‐cell count, reduced percentage of activated and intermediate monocytes and an increased B/T8 cell ratio. Over time, patients in cohort 1 who died presented with lower counts of B, T, CD4+T, CD8+T‐lymphocytes, NK cells, and activated monocytes. The B/T8 ratio was significantly lower in the group of survivors. In cohort 1, significantly higher levels of IgG1 and IgG3 were found, whereas cohort 3 presented higher levels of IgG3 compared to controls. Among many immune changes, an elevated B/T8‐cell ratio and a reduced rate of activated monocytes were mainly observed in patients with severe COVID‐19. Both parameters were associated with death in cohort 1.
Patients with severe COVID‐19 present a particular set of immune changes in comparison to patients with mild disease and controls. These include consumption of certain monocyte and lymphocyte populations and an elevated B/T8 Ratio. COVID‐19 patients in general share a proinflammatory immunoglobulin profile with elevated proportions of IgG1 and/or IgG3.
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Fludarabine, cyclophosphamide and rituximab (FCR) was compared to bendamustine and rituximab (BR) in an international, randomized, open label, ...phase 3 trial in 561 previously untreated, fit patients with chronic lymphocytic leukemia (CLL) without del (17p). Primary endpoint was progression free survival (PFS). The final primary endpoint analysis after 37.1 months median follow up failed to show the non‐inferiority of BR as compared with FCR. With extended median follow up of 58.2 months, median PFS was 42.3 months in BR‐treated patients versus 57.6 months for FCR‐treated patients (Hazard Ratio HR 1.593; 95% CI 1.271–1.996; p < 0.0001). For patients > 65 years, median PFS was 48.5 months with BR versus 57.9 months with FCR without reaching statistical significance (HR 1.352; 95% CI 0.912–2.006; p = 0.134). Median OS was not reached for both arms with 5‐year OS rates of 80.1% vs 80.9%, respectively (HR 1.108; 95% CI 0.755–1.627; p = 0.599). No statistically significant difference was found in the time to secondary malignancy between the 2 groups (at 5 years, 86.6% free from secondary malignancies in the BR group vs 83.8% in the FCR group HR 0.801; 95% CI 0.507–1.267; p = 0.344). In patients >65 years secondary neoplasia occurred more frequently after FCR treatment 28 of 86 (32.6%) patients as compared with BR 18 of 107 (16.8%) patients; p = 0.011. Health‐related quality of life was similar in both treatments. Despite the improved PFS for FCR, OS did not differ. These results also suggest an increase in secondary neoplasia associated with FCR in elderly fit CLL patients.
Genomic markers are among the strongest prognostic factors in chronic lymphocytic leukemia (CLL). Chromosomal aberrations, IGHV and TP53 mutation status are well-established and essential to ...discriminate between a more indolent course of disease and a high-risk CLL, which requires an alternative treatment regimen. In addition, a variety of gene mutations with unclear prognostic value have been identified: SF3B1, ATM, and BIRC3 may describe CLL with adverse outcome, whereas NOTCH1 is predictive for resistance against CD20 antibodies. Integration of novel drivers into a small set of key pathways forms the basis for future pathogenetic and therapeutic implications.
Apoptosis is controlled by the expression levels and interplay of pro- and anti-apoptotic BCL-2 family proteins. The specific BCL-2 inhibitor Venetoclax (VEN) showed high efficiency in BCL-2 ...dependent cancers like chronic lymphocytic leukemia (CLL) or mantle cell lymphoma (MCL). Despite its high efficiency in CLL and MCL, refractory disease can develop. BCL-2 mutations have been described to mediate resistance in CLL cases, however these mutations are only found in a proportion of VEN resistant cases and in a fraction of cells. In order to design alternative therapeutic strategies to overcome drug resistance, a better understanding of the mechanisms mediating resistance to VEN is necessary.
VEN-resistant (VEN-R) MCL cell lines (MINO and MAVER-1) were generated by chronic exposure to increasing amounts of VEN (up to 3µM). A significant and stable upregulation of BCL-XL mRNA and protein was seen in the MINO and MAVER-1 resistant cell lines (2 and 4 fold increase in mRNA and 2.6 and 4.5 fold increase in protein, respectively). We used BH3 profiling in combination with VEN treatment for 4h to investigate the differences in anti- and pro-apoptotic signaling in parental and VEN-R cell lines. Additionally, sensitivity to VEN was restored upon shRNA-mediated knockdown of BCL-XL. These results confirmed the importance of BCL-XL upregulation in mediating resistance. Furthermore, we did not detect mutations in BCL-2 upon resistance to VEN via targeted NGS, which is in contrast to results obtained in VEN-R CLL patients (Blombery et al., Cancer Discovery 2019 and Tausch et al., Hematologica 2019).
However, the results obtained by dynamic BH3-profiling (VEN treatment in combination with BH3 Profiling) suggest that increase in BCL-XL is most likely not the only alteration necessary to render cells resistant to VEN. In addition, reduced activation of pro-apoptotic proteins like BAX and BAK might contribute to resistance to VEN.
In order, to investigate if VEN resistance can be overcome by drug mediated inhibition of BCL-XL we used different therapeutic approaches. Combinational treatment with the BCL-XL inhibitor A-1331852 and VEN or the single treatment with Navitoclax, a combined inhibitor of BCL-2, BCL-W and BCL-XL for 48h reduced cell viability in VEN-R MINO and MAVER-1 cell lines. Furthermore, BDA-366, a BH4 domain BCL-2 inhibitor effectively reduced the cell viability after 48h of treatment in a dose dependent manner in both parental and VEN-R cell lines. The binding of BDA-366 to the anti-apoptotic BCL-2 protein leads to a conformational change into a pro-apoptotic molecule by the exposure of the BH3 domain of the protein.
Despite mediating apoptosis in a TP53-independent manner, VEN treatment in CLL has been associated with inferior outcome in the presence of TP53 aberrations. In order to address the role of TP53 dysfunction in mediating resistance to VEN, we generated p53 knock out cell lines (N=2) by CRISPR/Cas9 gene editing. This significantly decreased the sensitivity to VEN compared to p53 WT cell lines. Additionally, the sensitivity to BDA-366 was significantly reduced upon knockout of p53, suggesting an interference of p53 downstream of BCL-2.
Overall, VEN resistance is mediated by a permanent increase in BCL-XL mRNA and protein level in MCL. Importantly, BDA-366, which converts the anti-apoptotic BCL-2 molecule into a BAX-like death molecule, could be a potential alternative treatment strategy for BCL-2 dependent cancers even when resistant to VEN. Despite mediating apoptosis in a p53 independent manner, VEN seems to be less effective in p53 deficient cells, underlining the importance of further investigations of treatment combinations in these groups.
Tausch:Roche: Consultancy, Honoraria, Speakers Bureau; AbbVie: Consultancy, Honoraria, Other: travel support, Speakers Bureau. Döhner:AbbVie, Agios, Amgen, Astellas, Astex, Celator, Janssen, Jazz, Seattle Genetics: Consultancy, Honoraria; AROG, Bristol Myers Squibb, Pfizer: Research Funding; Celgene, Novartis, Sunesis: Honoraria, Research Funding. Stilgenbauer:Janssen: Consultancy, Honoraria, Research Funding, Speakers Bureau; Gilead: Consultancy, Honoraria, Research Funding, Speakers Bureau; Novartis: Consultancy, Honoraria, Research Funding, Speakers Bureau; Hoffmann La-Roche: Consultancy, Honoraria, Research Funding, Speakers Bureau; Pharmacyclics: Other: Travel support; Amgen: Consultancy, Honoraria, Research Funding, Speakers Bureau; AbbVie: Consultancy, Honoraria, Research Funding, Speakers Bureau; AstraZeneca: Consultancy, Honoraria, Research Funding, Speakers Bureau; Celgene: Consultancy, Honoraria, Research Funding, Speakers Bureau; GSK: Consultancy, Honoraria, Research Funding, Speakers Bureau. Schneider:Celgene: Other: travel grant.
In patients with insufficient T-cell responses to the human cytomegalovirus (HCMV), reactivation can occur which significantly contributes to morbidity and mortality after allogeneic stem cell ...transplantation (HSCT). Despite the event of new therapeutics like letermovir, HCMV infection remains a major complication after stem cell and solid organ transplantation. HCMV infected cells process HCMV proteins intracellularly and present HCMV-peptides on the cell surface in the context of HLA class I complexes. Antibodies naturally do not bind to peptides that are presented in HLA complexes and immunity against HCMV is mostly dependent on T-cells recognizing HLA I/HCMV-peptide complexes via their T-cell receptor. Antibodies that are generated to bind to peptides that are presented in HLA complexes are termed T-cell receptor like (TCR-like) antibodies. It has recently been shown that the T-cell response against an HLA-C*07:02 presented HCMV-peptide (CRVLCCYVL) derived from the IE-1 antigen is particularly strong. Also, HLA-C*07:02 is less susceptible to viral immune evasion than HLA-B and HLA-A molecules making it an attractive target for TCR-like antibodies. Here, we set out to obtain and characterize HLA-C*07:02 restricted, HCMV-specific antibodies.
Antibody Fab fragments (Fabs) specific for the HLA-C*07:02 restricted HCMV-peptide CRVLCCYVL were identified using phage display technology. For selection, phages were incubated for 1 hour with biotinylated HLA-C*07:02/CRVLCCYVL complexes at decreasing concentrations (15, 5 and 1 µg/ml). Before each round a pre-absorption using HLA-C*07:02 complexes folded with control-peptide was performed. Selected phages were eluted and used to infect E. coli bacteria of the strain TG1 to produce soluble Fabs, which were then tested for binding to HCMV-peptide (CRVLCCYVL) and control-peptide pulsed lymphoblastoid cell lines (LCLs) and lymphocytes expressing HLA-C*07:02. As control, selected Fabs were tested for binding to HCMV-peptide (CRVLCCYVL) and control-peptide loaded LCLs and lymphocytes expressing different HLA-C alleles.
By this, we were able to identify 3 different Fabs (4/4, 7/3 and 13/2) that bound to HLA-C*07:02 expressing LCLs and blood lymphocytes loaded with the HCMV-peptide CRVLCCYVL. All Fabs proofed to be highly specific since they showed no binding properties towards HLA-C*07:02 positive LCLs and lymphocytes that were loaded with no peptide or a control peptide. Furthermore, only LCLs and lymphocytes expressing the HLA-C*07:02 allele could be stained by our Fabs after HCMV-peptide loading. LCLs and lymphocytes of different HLA-C alleles that were pulsed with the HCMV-peptide CRVLCCYVL or a control peptide were not bound by the selected Fabs.
Using phage display technology, we identified 3 TCR-like antibody fragments that target specifically HLA-C*07:02 positive LCLs and lymphocytes when loaded with the IE-1 derived HCMV-peptide CRVLCCYVL. The Fabs 4/4, 7/3 and 13/2 seem to be highly specific and to our knowledge the described Fabs are the first TCR-like antibodies that target an HLA-C presented peptide. Further studies are underway to determine binding properties to HCMV infected fibroblasts and affinity of the identified HLA-C*07:02 restricted and HCMV-specific Fabs and to explore their therapeutic potential.
Held:Bristol-Myers Squibb: Consultancy, Other: Travel support, Research Funding; Roche: Consultancy, Other: Travel support, Research Funding; Amgen: Research Funding; Acrotech: Research Funding; MSD: Consultancy. Stilgenbauer:AbbVie, AstraZeneca, Celgene, Gilead Sciences, Inc., GSK, Hoffmann La-Roche, Janssen, Novartis: Consultancy, Honoraria, Research Funding, Speakers Bureau.
Introduction: Genome-wide association studies showed that a single-nucleotide polymorphism (SNP) affecting the transcription factor Eomesodermin (Eomes) is associated with a significantly increased ...risk to develop chronic lymphocytic leukemia (CLL). Eomes and its paralogue T-bet are known master regulators of CD8+ effector T cells and CD4+ T helper cells and critical for T cell-mediated immune responses against pathogens and cancer. While Eomes has been shown to be essential for effector function of CD8 T cells, its role in CD4 T cells is less well understood. Recent work suggested that Eomes drives the development of IL-10 and IFNγ co-producing, FoxP3-negative, regulatory T cells, named Tr1 cells, a population that was found enriched in inflamed tissues in patients with chronic inflammatory disorders. In CLL, the T cell compartment is altered with an enrichment of effector and memory T cells that were shown to control leukemia development in a mouse model, but also to acquire a dysfunctional or exhausted state.
Methods: We investigated Eomes-expressing CD4 and CD8 T cells in blood and lymph node (LN) samples of patients with CLL, as well as in the Eµ-TCL1 mouse model of CLL by flow cytometry, CyTOF, mRNA sequencing, and ex vivo functional assays. The role and function of these cells was explored in bone marrow-chimeric mice harbouring an Eomes-deficient hematopoietic microenvironment that were used for adoptive transfer of TCL1 leukemia, as well as by co-transfer experiments of Eomes- or IL-10R-deficent CD4 or CD8 T cells with TCL1 leukemia cells in Rag2-/- mice lacking B and T cells.
Results: We detected an accumulation of Eomes-expressing CD4 and CD8 T cells in CLL patients, which was more severe in LN compared to blood samples, and significantly stronger in CLL LN compared to reactive LN samples as non-cancer control (Fig. 1A). This was in line with an observed expansion of Eomes-positive T cells in the spleen of leukemic Eµ-TCL1 mice and upon adoptive transfer of TCL1 leukemia.
Eomes expression in CD8 T cells correlated with the expression of CD69, IFNγ and PD-1, suggesting a link between Eomes and CD8 T cell activation and function in CLL. The importance of Eomes in CD8 T cell-mediated control of CLL was demonstrated in mice that were transplanted with TCL1 leukemia, where Eomes-deficient CD8 T cells failed to control leukemia development. As we detected significantly less Eomes-deficient CD8 T cells in these mice compared to respective wildtype controls, and a lower percentage of them was positive for the proliferation marker Ki-67, we conclude that Eomes drives the differentiation and expansion of CD8 T cells in mice with CLL-like disease.
We further explored Eomes-expressing CD4 T cells in CLL by transcriptome analysis, flow cytometry and ex vivo functional assays, and observed increased expression of IFNγ and IL-10, as well as inhibitory receptors, like PD-1, BLIMP-1 and LAG3, features that are described for Tr1 cells. Transfer of Eomes-deficient or wildtype CD4 T cells in Rag2-/- mice that were injected with TCL1 leukemia cells, lead to a comparable expansion of CD4 T cells independent of Eomes. But even though wildtype CD4 T cells were able to control leukemia development in this setting, Eomes-deficient CD4 T cells failed to do so (Fig. 1B). As Eomes is a known driver of IL-10 expression, we tested whether IL-10R signalling in CD4 T cells is involved in the anti-tumor activity by performing respective CD4 T cell transfer experiments comparing this time wildtype with IL-10R-deficent CD4 T cells. Interestingly, lack of IL-10R in CD4 T cells lead to a reduction in anti-tumor control (Fig. 1C) and therefore suggests that IL-10 is involved in Eomes-driven regulation of CD4 T cell-mediated immune control.
Conclusions: In summary, we conclude that Eomes is required for CD8 T cell-mediated control of CLL, and Eomes+ PD-1+ IL-10-producing CD4 T cells contribute to adaptive immunity in CLL. The increased risk of developing CLL in individuals harbouring a SNP in the Eomes gene might be therefore explained by a negative impact of this alteration on CD4 and/or CD8 T cell-mediated immune control of CLL.
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Stilgenbauer:Novartis: Consultancy, Honoraria, Research Funding, Speakers Bureau; Amgen: Consultancy, Honoraria, Research Funding, Speakers Bureau; Celgene: Consultancy, Honoraria, Research Funding, Speakers Bureau; Gilead: Consultancy, Honoraria, Research Funding, Speakers Bureau; GSK: Consultancy, Honoraria, Research Funding, Speakers Bureau; Hoffmann La-Roche: Consultancy, Honoraria, Research Funding, Speakers Bureau; Pharmacyclics: Other: Travel support; AbbVie: Consultancy, Honoraria, Research Funding, Speakers Bureau; Janssen: Consultancy, Honoraria, Research Funding, Speakers Bureau; AstraZeneca: Consultancy, Honoraria, Research Funding, Speakers Bureau.
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