Castleman disease (CD) includes a group of rare and heterogeneous disorders with characteristic lymph node histopathological abnormalities. CD can occur in a single lymph node station, which is ...referred to as unicentric CD (UCD). CD can also involve multicentric lymphadenopathy and inflammatory symptoms (multicentric CD MCD). MCD includes human herpesvirus-8 (HHV-8)–associated MCD, POEMS-associated MCD, and HHV-8−/idiopathic MCD (iMCD). The first-ever diagnostic and treatment guidelines were recently developed for iMCD by an international expert consortium convened by the Castleman Disease Collaborative Network (CDCN). The focus of this report is to establish similar guidelines for the management of UCD. To this purpose, an international working group of 42 experts from 10 countries was convened to establish consensus recommendations based on review of treatment in published cases of UCD, the CDCN ACCELERATE registry, and expert opinion. Complete surgical resection is often curative and is therefore the preferred first-line therapy, if possible. The management of unresectable UCD is more challenging. Existing evidence supports that asymptomatic unresectable UCD may be observed. The anti–interleukin-6 monoclonal antibody siltuximab should be considered for unresectable UCD patients with an inflammatory syndrome. Unresectable UCD that is symptomatic as a result of compression of vital neighboring structures may be rendered amenable to resection by medical therapy (eg, rituximab, steroids), radiotherapy, or embolization. Further research is needed in UCD patients with persisting constitutional symptoms despite complete excision and normal laboratory markers. We hope that these guidelines will improve outcomes in UCD and help treating physicians decide the best therapeutic approach for their patients.
•The preferred therapy for UCD is complete surgical resection.•Unresectable asymptomatic UCD may be observed; symptomatic UCD requires rituximab ± steroids or anti–interleukin-6 antibody.
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Highly activated/expanded natural killer (NK) cells can be generated by stimulation with the human leukocyte antigen-deficient cell line K562, genetically modified to express 41BB-ligand and ...membrane-bound interleukin (IL)15. We tested the safety, persistence, and activity of expanded NK cells generated from myeloma patients (auto-NK) or haploidentical family donors (allo-NK) in heavily pretreated patients with high-risk relapsing myeloma. The preparative regimen comprised bortezomib only or bortezomib and immunosuppression with cyclophosphamide, dexamethasone, and fludarabine. NK cells were shipped overnight either cryopreserved or fresh. In 8 patients, up to 1×10⁸ NK cells/kg were infused on day 0 and followed by daily administrations of IL2. Significant in vivo expansion was observed only in the 5 patients receiving fresh products, peaking at or near day 7, with the highest NK-cell counts in 2 subjects who received cells produced in a high concentration of IL2 (500 U/mL). Seven days after infusion, donor NK cells comprised >90% of circulating leukocytes in fresh allo-NK cell recipients, and cytolytic activity against allogeneic myeloma targets was retained in vitro. Among the 7 evaluable patients, there were no serious adverse events that could be related to NK-cell infusion. One patient had a partial response and in another the tempo of disease progression decreased; neither patient required further therapy for 6 months. In the 5 remaining patients, disease progression was not affected by NK-cell infusion. In conclusion, infusion of large numbers of expanded NK cells was feasible and safe; infusing fresh cells was critical to their expansion in vivo.
We hypothesized that consumption of soy protein isolate (SPI) or the soy isoflavone genistein (GEN) would modulate mRNA expression of genes underlying lipid and thyroid hormone metabolism in livers ...and small intestines of young adult male Sprague–Dawley rats. Early pregnant rat dams were placed on AIN-93G diets containing casein (CAS, control protein), SPI, or CAS+GEN. Litters were weaned to the same diet as their dam. SPI-fed (but not GEN-fed) male rats of 48 days of age had significant reductions in body weight, abdominal fat pad weight and hepatic content of lipid droplets and triglycerides. Hepatic peroxisome proliferator-activated receptor α (
Ppara) transcripts were elevated with SPI but not GEN diet. Hepatic pyruvate dehydrogenase kinase-4 (
Pdk4) and cytochrome P450 4A10 (
Cyp4a10) mRNA abundance was reduced with SPI; the SPI effect on
Cyp4a10 was recapitulated by GEN diet. SPI (but not GEN) suppressed
Pdk4 and 3-hydroxy-3-methylglutaryl-CoA synthase 2 (
Hmgcs2) mRNA abundance in duodenum. Liver iodothyronine deiodinase types 1 and 2 (
Dio1 and
Dio2) mRNA levels were increased with SPI diet; the effect on
Dio2, but not
Dio1 mRNAs, also was observed with GEN. SPI and GEN increased hepatic types 1 and 2 iodothyronine deiodinase (D1 and D2) activities. Effects of SPI and GEN on the above gene expression may contribute to the observed reductions in body and adipose tissue weight and liver lipid content in this model. Identification of the regulation, by genistein and soy protein, of iodothyronine deiodinase synthesis has potential applications for treatment and prevention of fatty liver disease and obesity.
Treatment of Idiopathic Castleman Disease van Rhee, Frits; Greenway, Amy; Stone, Katie
Hematology/oncology clinics of North America,
02/2018, Letnik:
32, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Important progress has been made in the treatment of idiopathic multicentric Castleman disease (iMCD) with the introduction of interleukin-6 targeting monoclonal antibodies. This article describes ...the clinical results obtained with different treatment modalities and uses this evidence to provide treatment guidelines for the practicing clinician. Much is still to be learned about the pathophysiology of iMCD and further research is urgently needed to develop novel and curative treatment approaches for all patients.
Introduction. Multicentric Castleman Disease (MCD) is an inflammatory disorder characterized by lymphadenopathy. The clinical course of MCD is variable; some patients have mild symptoms while others ...develop hypercytokinemia progressing to organ failure. Severely ill patients often have the TAFRO-variety of MCD characterized by Thrombocytopenia, Anasarca, Fever, Reticulin marrow fibrosis, and Organomegaly. We report on 76 MCD patients: the largest series from a single institution.
Methods. Data was collected from our institution and outside records via systematic chart review and standardized survey for self-reported symptoms. Laboratory data represent each patient's most severe episode. TAFRO- and non-TAFRO or “classical” iMCD subtypes were grouped (iMCD) for some analyses. Patients were classified as POEMS-associated MCD when they had MCD with full POEMS syndrome or clear features of POEMS.
Results. Forty-nine patients had classical iMCD and 12 TAFRO-iMCD. Fifteen patients had POEMS-associated MCD, of which 8 had coexistent POEMS syndrome. iMCD and POEMS-associated MCD had similar age and sex, but the hyaline vascular variant was more common in iMCD (44.3 vs 6.7%, p=0.006) (Table 1). iMCD patients were more symptomatic in terms of night sweats (61.0 vs 33.3%, p=0.001) and fever (50.8 vs 20%, p=0.031) compared to POEMS-associated MCD, but had similar laboratory characteristics and disease activity (CHAP) scores. TAFRO-iMCD patients were mostly male and had more fever (91.6 vs 42.9%, p=0.002), anasarca (100 vs 24.5%, p<0.0001), higher creatinine (2.6 vs 0.9 mg/dL, p=0.001), poorer CHAP scores (5.5 vs 2.0, p=0.01), and a trend to lower hemoglobin. Interleukin-6 (IL6) levels were not different among groups, but vascular endothelial growth factor (VEGF) was higher in TAFRO-iMCD (328.5 vs 79.5 pg/mL, p=0.034), accounting for anasarca.
Commonly-used treatment regimens for iMCD were the anti-IL6/IL6 receptor antibodies siltuximab and tocilizumab (n=41), rituximab ± steroids (n=23), steroids alone (n=13), and chemotherapy (n=7). There was a high rate of response to anti-IL6 therapy (97%) with a treatment failure (TF) rate of 5%. Two further relapses occurred in patients who discontinued therapy. Steroid monotherapy or rituximab + steroids yielded response rates of 46 and 82%, but were marred by high TF rates (85 and 43%). Chemotherapy responses were noted in 7 instances, but TF occurred twice. There were no significant differences in response to therapy comparing the classical and TAFRO-iMCD groups, but both patients failing anti-IL6 therapy had TAFRO-iMCD. Six TAFRO-iMCD patients received chemotherapy and 2 relapsed. Six patients with POEMS and CD underwent autologous stem cell transplant with major improvement in polyneuropathy and MCD; 2 experienced relapse of their MCD and one died of late myelodysplastic syndrome. One improved post irradiation of a plasmacytoma and 1 died of progressive disease. Most MCD patients with POEMS features received rituximab-based therapies; 6/7 were alive and 1 died of sepsis. There was no difference in overall survival (OS) among the three groups (p=0.35) with a median OS of 5.65 years (4 - 9.2, 95% CI) in the iMCD group, 7.9 years (4.5 - 11.8, 95% CI) in POEMS-associated MCD, and 5.85 years (3.2 - 8.7, 95% CI) in the TAFRO group. The 5-year OS was 91%, 94% and 100% for the iMCD, POEMS-associated MCD and TAFRO groups, respectively.
Conclusions. In a tertiary referral setting, excellent outcomes were achieved in all subgroups, likely attributed to highly selective therapeutic choices. Anti-IL6 therapy for iMCD was reserved for patients with active disease and laboratory evidence of inflammatory syndrome. Some TAFRO-iMCD patients achieved complete responses with anti-IL6 therapy, while others fared well with chemotherapy. Rituximab-based therapy was given to those with more indolent iMCD and those with POEMS-associated MCD. The polyneuropathy of POEMS benefitted most from transplant. Significant differences were noted in VEGF levels both in POEMS-associated MCD and TAFRO-iMCD compared to classical iMCD cases, with each cohort presenting a distinct clinical picture suggesting differing underlying etiologies and cytokine profiles. IL6 levels were not different among groups, though this may be confounded by effects of prior therapy. A better understanding of the pathobiology of the MCD continuum is essential to developing more targeted therapies.
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No relevant conflicts of interest to declare.
Background With the advent of antibodies targeted against CD38 the ability to determine which patients will respond and the mechanism by which such response is mediated is imperative for therapeutic ...success. Immune alterations in multiple myeloma (MM) are known to involve multiple cell types and, therefore we used mass cytometry to study a diverse set of single cells simultaneously. In this work we have studied the immune sequelae of anti-CD38 antibody therapies in a set of multiple myeloma patients.
Methods A series of 12 cases of MM were treated with daratumumab (DARA) in a number of disease settings including post-transplant; all had low tumor burden (bone marrow MM plasma cell range 0.001-9.09%). Of the 12 cases assessed, 2 had a partial response (PR) and 3 were deceased within 1 year after start of DARA treatment. Cryopreserved peripheral blood mononuclear cells (PBMC) from 6 healthy donors and 12 myeloma patients were analyzed pre-DARA and at days 28 and 56 after start of therapy.
A mass cytometry panel comprising 35 cell surface and 3 intracellular antibodies including cell lineage markers and functional markers was developed. Cells were stained with cell surface antibodies, washed and stained with cisplatin for live-dead discrimination, fixed and permeabilized with FOXP3 staining buffers, and stained with intracellular antibodies. Cells were fixed in PFA containing Iridium intercalator for cell identification, washed and resuspended in ddH2O containing 10% EQ beads and acquired on a Helios mass cytometer.
Data were normalized using beads and were transformed using the inverse hyperbolic sine function with a cofactor of 5 and gated for live, intact, singlets for global analysis by manual gating (FCS Express 6) and clustering by viSNE for visualization. Differences in population abundance were identified in an unbiased manner by CITRUS using 13 lineage markers for clustering. Analysis was performed using the multiple testing permutation procedure (SAM), with an FDR of 1% and minimum population size of 1%.
Results Manual gating of immune populations revealed that myeloma cases had significant immune perturbations compared to healthy donor PBMCs including loss of CD8+ effector memory, CD4+ T cells, and B cells. Comparison of pre-treatment MM PBMCs to post-DARA therapy showed a significant loss of activated NK cells, B regulatory cells, plasmacytoid dendritic cells, and plasma cells. Interestingly, a significant loss of T regulatory cells (CD4+CD25hiCD127loFOXP3+) was not observed in this analysis.
CITRUS identified a total of 26 significant clusters that differentiated the 3 timepoints. Based on the evaluation of phenotypic markers within the clusters, CITRUS identified 4 major cell types that were changed including CD8+ T cells (2 groups, 1 up 1 down post-DARA), NK cells (2 groups, reduced post-DARA), myeloid/monocytes (4 groups, 2 up, 2 down post-DARA) and B cells (reduced post-DARA). CD8+ T cells reduced post-DARA were distinguished by the presence of CD38, elevated CD57 and lack of HLA-DR compared to CD8 T cells that increased at D28 but returned to baseline levels by D56. The two NK cell groups were differentiated by the presence of CD16, representing activated cells. The 4 myeloid groups altered were characterized by the phenotype (CD14+CD11b+CD11c+CD33+), and the addition of CD38 in the two groups reduced post-DARA, which may represent myeloid derived suppressor cells and myeloid dendritic cells.
Another CITRUS analysis was performed with identical settings to examine changes in median expression of markers. Two groups of 5 clusters were identified based on CD55 or CD59 intensity, markers associated with complement inhibition. The CD55 group (4 clusters, CD56+CD16+) was upregulated at days 28 and 56 compared to pre-DARA. The CD59 group (1 cluster, CD38hiCD45lo) was reduced overall at day 28 and 56, however the cases were bimodal in terms of the extent of reduction. As this population most likely represents myeloma PCs, CD59 may be a surrogate for the presence of circulating tumor cells.
Conclusions
Significant changes in immune status post-DARA were identified by the comprehensive analysis of immune population abundance and marker intensity using mass cytometry. Significant changes in CD8+ T cells, NK cells, B cells, monocytes and in CD55 and CD59 intensity were observed post-DARA.
Morgan:Takeda: Consultancy, Honoraria; Celgene: Consultancy, Honoraria, Research Funding; Janssen: Research Funding; Bristol-Myers Squibb: Consultancy, Honoraria.
Introduction: Unicentric Castleman disease (UCD) is a rare non-clonal lymphoproliferative disorder affecting one lymph node station. UCD can be an incidental finding on radiologic studies, whilst ...other patients have symptomatology due to compression of vital structures. Surgical extirpation is the preferred therapy and is usually curative, but unresectable UCD can represent a therapeutic challenge. Castleman lymph nodes are often highly vascularized, which offers the opportunity for therapeutic embolization. We report a series of 6 patients with unresectable UCD who were treated with embolization either as sole therapy or supplemented by cryoablation and surgery.
Methods: CT rotational angiography was performed to localize the arterial supply of UCD masses. Feeding vessels were selectively embolized using a 50:50 mixture of lipiodol and alcohol or 300-500 micron embospheres. A second arteriography was performed 2 to 3 months later to identify and embolize any new arterial channels.
Results: Data is summarized in Table 1. Of a cohort of 47 patients with UCD, 6 (13%) were found to have symptomatic, unresectable disease. All patients were HIV and human herpesvirus-8 negative. The median patient age was 34 years (range: 28-34); five patients were male and one was female. Disease was localized to the pelvis (n=3), mediastinum (n=2), and axilla (n=1). In all but one case, the histology was of the hyaline vascular variety. Four patients had failed R-CHOP, rituximab/steroids, or both. In 2 patients, embolization was done as primary therapy, while 3 underwent additional surgery. In 5 patients, embolization was performed twice to ablate secondary arterial channels that had appeared after the first procedure. Adjunctive cryoablation at the time of embolization was applied in 2 patients. All treated patients had major reduction in their lymph node mass. The median reduction in tumor bulk was from 274cc (range:13-969) to 21cc (range: 3-394). One patient with an axillary mass involving the brachial plexus failed therapy and received radiation. A second patient had regrowth of the UCD and responded to combination lenalidomide and obinituzumab. Responses were sustained for at least 2 years in the remaining patients.
Conclusion: A small number of case reports have been described UCD patients treated with arterial embolization as an immediate preoperative adjunct to surgery to limit intraoperative bleeding. In the present series, we utilized embolic devascularization to achieve cytoreduction rather than merely prevent surgical hemorrhage. Embolization was complemented by cryoablation and rendered surgery feasible. This case series highlights that effective disease control can be obtained of unresectable UCD using a multimodality approach in which vascular embolization plays a crucial role.
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No relevant conflicts of interest to declare.
Patients with gene expression profiling-defined high-risk myeloma in relapse have poor outcomes with current therapies. We tested whether natural killer cells expanded by co-culture with K562 cells ...transfected with 41BBL and membrane-bound interleukin-15 could kill myeloma cells with a high-risk gene expression profile in vitro and in a unique model which recapitulates human myeloma.
OPM2 and high-risk primary myeloma tumors were grown in human fetal bone implanted into non-obese diabetic severe combined immunodeficiency mice with a deficient interleukin-2 receptor gamma chain. These mice are devoid of endogenous natural killer and T-cell activity and were used to determine whether adoptively transferred expanded natural killer cells could inhibit myeloma growth and myeloma-associated bone destruction.
Natural killer cells from healthy donors and myeloma patients expanded a median of 804- and 351-fold, respectively, without significant T-cell expansion. Expanded natural killer cells killed both allogeneic and autologous primary myeloma cells avidly via a perforin-mediated mechanism in which the activating receptor NKG2D, natural cytotoxicity receptors, and DNAX-accessory molecule-1 played a central role. Adoptive transfer of expanded natural killer cells inhibited the growth of established OPM2 and high-risk primary myeloma tumors grown in the murine model. The transferred, expanded natural killer cells proliferated in vivo in an interleukin-2 dose-dependent fashion, persisted up to 4 weeks, were readily detectable in the human bone, inhibited myeloma growth and protected bone from myeloma-induced osteolysis.
These studies provide the rationale for testing expanded natural killer cells in humans.
Introduction
We previously reported on the treatment of 8 relapsing high-risk multiple myeloma (HRMM) patients with ex vivo activated/expanded NK cells (ENKs). We demonstrated that interleukin-2 ...(IL2) provided suboptimal cytokine support post adoptive transfer of ENKs. Aiming to improve upon prior data we hypothesize that the novel IL15 superagonist complex ALT-803 will provide superior support compared to IL2 and enhance ENK activity, proliferation and persistence.
Methods
To compare the activity of IL2 and ALT-803 on ENKs, we performed long-term in vitro culture studies. Analogous to the 8-day clinical production method, healthy donor (HD) peripheral blood mononuclear cells (PBMCs) were first co-cultured with the leukemic cell line K562 modified to express both membrane-bound IL15 and the costimulatory molecule 4-1BBL, and high-dose IL2. We deliberately chose to maintain IL2 in the expansion method rather than substituting ALT-803 because our FDA-approved GMP-grade expansion was validated using IL2. On expansion Day 8 (the day clinical ENK products are infused), the ENKs were either maintained at high-dose (300U/mL) IL2, or otherwise cultured at low-dose (20U/mL) IL2 or 35ng/mL ALT-803, in all conditions without K562 stimulator cells. Proliferation (fold-change from baseline) was measured on Days 14, 21, and 28, and expression of key activating and inhibitory markers was assessed via flow cytometry. Relative cytolytic ability was determined via 4-hour chromium (Cr)-release assays against K562 and the MM cell lines OPM2, JJN3, and U266.
Results
Proliferation of ALT-803-ENKs was superior to both IL2-ENK conditions at all assessed time points; on Day 28, fold-expansion of ALT-803-ENKs was 753, versus 156- and 557-fold for ENKs maintained in 20U or 300U/mL IL2, respectively, Figure 1A. Immunophenotyping studies demonstrated significant differences between ENKs cultured in 20U/mL IL2 versus ALT-803-treated ENKs, including activation (CD26, CD69, DNAM1, NKp30) and functional (CD16, perforin, granzyme, TRAIL) molecules. ALT-803-treated ENKs maintained an activated phenotype, whereas IL2 ENKs (20U/mL) exhibited reduced expression of several markers by Day 14, with further decreases noted on Days 21 and 28. Representative examples are depicted in Figure 1B. Morphologically, IL2-ENKs acquired apoptotic features after extended culture, whereas ALT-803-ENKs did not. Though cytolytic ability was variable on Days 14 and 21, the activity of ALT-803-ENKs exceeded that of IL2-ENKs (20U/mL) against K562, OPM2, JJN3, and U266 cell lines on Day 28. High-dose IL2-ENKs exhibited a similar phenotype and cytolytic ability compared to ALT-803-ENKs.
Conclusions
We compared clinically-relevant doses of IL2 and ALT-803 to determine whether ALT-803 is superior at maintaining ENK activity and proliferative capacity. ALT-803 ENKs exhibited robust proliferation through Day 28 and sustained expression of key activation and functional markers, highlighting the superiority of ALT-803 in this setting. After four weeks of continuous culture, ALT-803-ENKs maintained greater cytolytic ability against MM cell lines. Though high-dose IL2 is capable of sustaining ENK activation state in vitro, this dose is not achievable in humans. Unlike IL2, ALT-803 does not induce expansion of T regulatory cells, and has a more favorable toxicity profile. Importantly, ALT-803 stimulated and maintained expression of CD16, indicating that it would be well-suited to pair with monoclonal antibodies for the support of antibody-dependent cellular cytotoxicity. Further studies are in progress to study the effects of ALT-803 on ENKs in the presence of suppressive cytokines/cells to determine if ALT-803 is able to overcome the effects of the tumor microenvironment.
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Wong:Altor BioScience: Employment, Equity Ownership. Jeng:Altor Bioscience: Employment, Equity Ownership. Shrestha:Altor Bioscience: Employment, Equity Ownership. Davies:Janssen: Consultancy, Honoraria; Takeda: Consultancy, Honoraria; Celgene: Consultancy, Honoraria. Morgan:Bristol Myers: Consultancy, Honoraria; Takeda: Consultancy, Honoraria; Celgene: Consultancy, Honoraria, Research Funding.
Recently, we showed reduced atherosclerotic lesions in a hyperlipidemic mouse model fed isoflavone‐free soy protein diet (SPI−) compared to casein (CAS)‐fed mice, despite unchanged serum lipid ...levels. However, the molecular mechanisms contributing to the atheroprotective effect of soy‐based diets is not clear. Atherosclerosis is a chronic inflammatory disease and interactions between endothelial cells and monocytes play a pivotal role in the initiation of atherosclerosis. We hypothesize that soy protein/peptides (SPI−) exert their protective effect by inhibiting inflammatory responses contributing to both acute and chronic inflammatory conditions. To address this hypothesis, a LPS‐induced acute inflammation model in apoE−/− mouse was developed. Dose response studies showed LPS at 20 μg/mouse is sufficient to induce CD54 and CD106, key endothelial cell adhesion molecules, expression in mouse aorta. Western blot analysis showed that aortas of SPI−‐fed mice had reduced expression of CD106 compared to aortas of casein‐fed mice. Further, quantitative RT‐PCR analyses of proximal aorta also showed reduced CD106 mRNA expression in SPI−‐fed compared to casein‐fed mice. These findings suggest that the atheroprotective effect of isoflavone free soy diet is mediated, in part, by blocking inflammatory responses associated with atherosclerosis. USDA‐CRIS‐6251‐5100002‐06S.
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