Chimeric antigen receptor T cell therapy in oncology - Pipeline at a glance: Analysis of the ClinicalTrials.gov database.

There is a rapid growth of published data associated with chimeric antigen receptor (CAR) T-cells, and its evaluation is becoming challenging. We performed a review of the ClinicalTrials.gov database, searching for clinical trials using CAR T-cell therapy in oncology (cut-off December 2019). 593 trials were found. 48 % of trials are from China and 39 % from the USA. 63 % percent focused on hematologic malignancies, while gastrointestinal cancer, breast cancer, and nervous system were the top 3 solid tumors addressed. Common targets in hematologic malignancies are CD19 and BCMA; while mesothelin and CD171 in solid tumors. Second-generation CAR T designs predominate with CD28 or 41BB co-stimulation. Mixed sponsors supported 45 % of trials, and only 19 % received funding exclusively from industry. Current trends suggest that 900 CAR T-cell therapy clinical trials will be registered during 2020-2025. We estimate a two-fold increase in trials that study allogeneic cell products in the next five years.

Ofatumumab and high-dose methylprednisolone for the treatment of patients with relapsed or refractory chronic lymphocytic leukemia.

Ofatumumab is a humanized anti-CD20 monoclonal antibody that has been approved by the FDA for the treatment of patients with chronic lymphocytic leukemia. We conducted a phase II single-arm study at a single center. Patients received ofatumumab (300 mg then 1000 mg weekly for 12 weeks) and methylprednisolone (1000 mg/m(2) for 3 days of each 28-day cycle). Twenty-one patients enrolled, including 29% with unfavorable cytogenetics (del17p or del11q). Ninety percent of patients received the full course without dose reductions or delays. The overall response rate was 81% (17/21) with 5% complete response, 10% nodular partial response, 67% partial response, 14% stable disease and 5% progressive disease. After a median follow-up of 31 months, the median progression-free survival was 9.9 months and the median time to next treatment was 12.1 months. The median overall survival has not yet been reached. The combination of high-dose methylprednisolone and ofatumumab is an effective and tolerable treatment regimen. This regimen may be useful for patients who are unable to tolerate more aggressive therapies, or have not responded to other treatments.

Intratumoral delivery of CD154 homolog (Ad-ISF35) induces tumor regression: analysis of vector biodistribution, persistence and gene expression.

Ad-ISF35 is an adenovirus (Ad) vector that encodes a mouse-human chimeric CD154. Ad-ISF35 induces activation of chronic lymphocytic leukemia (CLL) cells converting them into CLL cells capable of promoting immune recognition and anti-leukemia T-cell activation. Clinical trials in humans treated with Ad-ISF35-transduced leukemia cells or intranodal injection of Ad-ISF35 have shown objective clinical responses. To better understand the biology of Ad-ISF35 and to contribute to its clinical development, we preformed studies to evaluate biodistribution, persistence and toxicity of repeat dose intratumoral administration of Ad-ISF35 in a mouse model. Ad-ISF35 intratumoral administration induced tumor regression in more than 80% of mice bearing A20 tumors. There were no abnormalities in the serum chemistry. Mice receiving Ad-ISF35 presented severe extramedullary hematopoiesis and follicular hyperplasia in the spleen and extramedullary hematopoiesis with lymphoid hyperplasia in lymph nodes. After Ad-ISF35 injection, the vector was found primarily in the injected tumors with a biodistribution pattern that showed a rapid clearance with no evidence of Ad-ISF35 accumulation or persistence in the injected tumor or peripheral organs. Furthermore, pre-existing antibodies against Ad-5 did not abrogate Ad-ISF35 anti-tumor activity. In conclusion, intratumoral administration of Ad-ISF35 induced tumor regression in A20 tumor bearing mice without toxicities and with no evidence of vector accumulation or persistence.

Modulation of cytokine and cytokine receptor/antagonist by treatment with doxycycline and tetracycline in patients with dengue fever.

Dengue virus infection can lead to dengue fever (DF) or dengue hemorrhagic fever (DHF). Disease severity has been linked to an increase in various cytokine levels. In this study, we evaluated the effectiveness of doxycycline and tetracycline to modulate serum levels of IL-6, IL-1B, and TNF and cytokine receptor/receptor antagonist TNF-R1 and IL-1RA in patients with DF or DHF. Hospitalized patients were randomized to receive standard supportive care or supportive care combined with doxycycline or tetracycline therapy. Serum cytokine and cytokine receptor/antagonist levels were determined at the onset of therapy and after 3 and 7 days. Cytokine and cytokine receptor/antagonist levels were substantially elevated at day 0. IL-6, IL-1ß, and TNF remained at or above day 0 levels throughout the study period in untreated patients. Treatment with tetracycline or doxycycline resulted in a significant decline in cytokine levels. Similarly, IL-1RA and TNF-R1 serum concentrations were elevated at baseline and showed a moderate increase among untreated patients. Both drugs resulted in a significant rise in IL-1Ra levels by day 3 in patients. In contrast, treatment did not affect a similar result for TNF-R1. When compared to the control group, however, a significant rise post-treatment was seen upon intragroup analysis. Further analysis demonstrated that doxycycline was significantly more effective at modulating cytokine and cytokine receptor/antagonist levels than tetracycline.

A phase I study of immune gene therapy for patients with CLL using a membrane-stable, humanized CD154.

Ligation of CD40 on chronic lymphocytic leukemia (CLL) cells induces phenotypic and biochemical changes that facilitate CLL cell-T cell interactions and enhances the sensitivity of CLL cells to clearance by adaptive and innate immune-effector mechanisms. CLL cells can be transduced to express CD40 ligand (CD154) using a replication-defective adenovirus vector, thereby cross-linking CD40 on transduced and non-transduced, bystander CLL cells. In a previous study, patients received infusions of autologous CLL cells, transduced to express murine CD154 (mCD154), which induced anti-leukemic immune responses, but also anti-mCD154 antibodies. In this study, we report a phase I study, in which patients were infused with 1 × 10(8), 3 × 10(8) or 1 × 10(9) autologous CLL cells transduced ex vivo to express ISF35, a humanized, membrane-stable CD154. Infusions were well tolerated and consistently followed by reductions in blood lymphocyte counts and lymphadenopathy. After infusion, circulating CLL cells had enhanced or de novo expression of CD95, DR5, p73 and Bid, which enhanced their susceptibility to death-receptor-mediated or drug-induced apoptosis, including CLL cells with deletions at 17p13.1 (del(17p)). Two patients who had CLL with del(17p) had subsequent chemoimmunotherapy and responded well to treatment. In summary, infusions of autologous, ISF35-transduced CLL cells were well tolerated, had biological and clinical activity, and might enhance the susceptibility of CLL cells with del(17p) to chemoimmunotherapy.

Rituximab in combination with high-dose methylprednisolone for the treatment of chronic lymphocytic leukemia.

We observed that high-dose methylprednisolone (HDMP) and rituximab was well tolerated and had promising activity when used in combination to treat patients with fludarabine-refractory chronic lymphocytic leukemia (CLL). This prompted us to evaluate the use of these agents in frontline therapy. A total of 28 patients with a median age of 65 years enrolled in this study. Patients received HDMP at 1 g/m(2) each day for 3 days during each of the three 4-week cycles together with rituximab and prophylactic antimicrobial therapy. The treatment was well tolerated with few adverse events of grade III or higher. The overall response rate was 96% (N=27). Nine patients (32%) achieved a complete remission (CR), two of which were without detectable minimal residual disease (MRD). Six patients with MRD received consolidation with alemtuzumab; five of these patients achieved an MRD-negative CR. With over 3 years of follow-up median progression-free survival was 30.3 months with only 39% of patients requiring additional therapy, and an overall survival was 96%. This study demonstrates that HDMP and rituximab is an effective nonmyelosuppressive treatment combination for patients with CLL that warrants consideration particularly for patients with limited myeloid reserve that might not tolerate standard treatment regimens.

Rituximab in combination with high-dose methylprednisolone for the treatment of fludarabine refractory high-risk chronic lymphocytic leukemia.

We examined the clinical response of fludarabine-refractory CLL patients treated with high-dose methylprednisolone (HDMP) and rituximab. Fourteen patients were treated with three cycles of rituximab (375 mg/m(2) weekly for 4 weeks) in combination with HDMP (1 gm/m(2) daily for 5 days). All patients were refractory to fludarabine and 86% had high-risk disease by the modified Rai classification. In all, 79% of the patients had CLL cells that expressed ZAP-70 and three patients had poor prognostic cytogenetics. The overall response rate was 93% and the complete remission rate was 36%. The median time-to-progression was 15 months and the median time-to-next treatment was 22 months. Median survival has not been reached after a median follow up of 40 months. Four patients have died of progressive disease. Patients tolerated the treatment well and serious adverse events were rare. This allowed patients to receive all planned treatments on schedule with no dose modifications. All but one patient responded to treatment and the overall survival and time-to-progression were superior to those of other published salvage regimens.

Thymidine-phosphorothioate oligonucleotides induce activation and apoptosis of CLL cells independently of CpG motifs or BCL-2 gene interference.

We compared antisense phosphorothioate oligonucleotides (PS-ODN) that target BCL-2 such as Genasense (G3139-PS), with other PS-ODN or phosphodiester-ODN (PO-ODN) in their relative capacity to induce apoptosis of chronic lymphocytic leukemia (CLL) B cells in vitro. Surprisingly, we found that thymidine-containing PS-ODN, but not PO-ODN, induced activation and apoptosis of CLL cells independent of BCL-2 antisense sequence or CpG motifs. All tested thimidine-containing PS-ODN, irrespective of their primary sequences, reduced the expression of Bcl-2 protein and increased the levels of the proapoptotic molecules p53, Bid, Bax in CLL cells. Apoptosis induced by thymidine-containing PS-ODN was preceded by cellular activation, could be blocked by the tyrosine-kinase inhibitor imatinib mesylate (Gleevec), and was dependent on ABL kinase. We conclude that thymidine-containing PS-ODN can activate CLL cells and induce apoptosis via a mechanism that is independent of BCL-2 gene interference or CpG motifs.

Chronic lymphocytic leukemia cells display p53-dependent drug-induced Puma upregulation.

We investigated the apoptosis gene expression profile of chronic lymphocytic leukemia (CLL) cells in relation to (1) normal peripheral and tonsillar B-cell subsets, (2) IgV(H) mutation status, and (3) effects of cytotoxic drugs. In accord with their noncycling, antiapoptotic status in vivo, CLL cells displayed high constitutive expression of Bcl-2 and Flip mRNA, while Survivin, Bid and Bik were absent. Paradoxically, along with these antiapoptotic genes CLL cells had high-level expression of proapoptotic BH3-only proteins Bmf and Noxa. Treatment of CLL cells with fludarabine induced only the proapoptotic genes Bax and Puma in a p53-dependent manner. Interestingly, the degree of Puma induction was more pronounced in cells with mutated IgVH genes. Thus, disturbed apoptosis in CLL is the net result of both protective and sensitizing aberrations. This delicate balance can be tipped via induction of Puma in a p53-dependent matter, the level of which may vary between groups of patients with a different tendency for disease progression.

[Traumatic injuries to the central nervous system and their repair]. / Trauma en el sistema nervioso central y su reparación.

DEVELOPMENT: Brain and spinal cord lesions have an increasing social and economic importance. Accidental trauma of various kinds is the main cause of mortality of children and young adults in developed countries. Only cardiac disease and cancer surpass the number of death caused by accidents and, examining the number of potential work years lost, CNS lesions surpass all other problems. Most brain and spinal cord injuries cause chronic incapacity and frequently occur to individuals under 45 years of age. Edema and other acute events can be efficiently treated and CNS lesions may not be mortal, but are incurable. CONCLUSION: The final outcome of CNS injury depend on the area damaged and the extent of the lesion, but the best present therapies can offer is relief of the symptoms and rehabilitation. This review examines the present state of functional repair of experimental central nervous system trauma.

A piecewise Markov process for analysing survival from breast cancer in different risk groups.

A study of the relapse and survival times for 300 breast cancer patients submitted to post-surgical treatments is presented. After surgery, these patients were given three treatments: chemotherapy; radiotherapy; hormonal therapy and a combination of them. From the data set, a non-homogeneous Markov model is selected as suitable for the evolution of the disease. The model is applied considering two time periods during the observation of the cohort where the disease is well differentiated with respect to death and relapse. The effect of the treatments on the patients is introduced into the model via the transition intensity functions. A piecewise Markov process is applied, the likelihood function is built and the parameters are estimated, following a parametric methodological procedure. As a consequence, a survival table for different treatments is given, and survival functions for different treatments are plotted and compared with the corresponding empirical survival function. The fit of the different curves is good, and predictions can be made on the survival probabilities to post-surgical treatments for different risk groups.

Fas modulation of apoptosis during negative selection of thymocytes.

A major mechanism maintaining immune tolerance is the deletion of potentially autoreactive thymocytes by apoptosis during development in the thymus. Previous reports suggest that apoptosis is induced by high avidity signals transduced via the T cell receptor; however, the role of signals transduced by other cell surface receptors during thymic selection remains poorly understood. Fas, a member of the TNF receptor family, has been shown to induce apoptosis in mature peripheral T cells; however, the effects of Fas on negative selection of thymocytes have not been previously detected. Using a sensitive terminal deoxynucleotidyl transferase method to detect apoptotic cells, we found that mutant Fas molecules in lpr mice decrease the sensitivity of thymocytes to T cell receptor-mediated apoptosis and that blockade of Fas-Fas ligand interactions in vivo can inhibit antigen-induced apoptosis of thymocytes in non-lpr mice. Thus, we have shown that Fas, in conjunction with antigen-specific signals, can modulate apoptosis during negative selection of thymocytes.

Adrenergic ligands trigger intracellular differentiation of trypanosoma cruzi.

Intracellular forms of trypanosoma cruzi, amastigote, could remain in the inner space of mammalian cells for long periods of time and be in contact with various cellular metabolism products. Some of these metabolites could act as signals that trigger parasite differentiation process to trypomastigote form. The present results suggest that increase of intracellular cAMP by adrenergic ligands or cholera toxin in parasite infected cells is able to induce such differentiation process.

Development of bladder tumour containing HPV type 11 DNA after renal transplantation.

We report a case of bladder cancer developing in a patient after renal transplantation in whom it was possible to demonstrate DNA evidence for infection of the tumour with HPV Type 11. The significance of the observation is discussed in relation to the hypothesis that immunosurveillance can control the development of malignancy.

Vesicoureteric reflux following renal transplantation: a simple method of ureteric implantation.

We have used a simple method of ureteroneocystostomy in renal transplant patients. This entails a no-tunnel "drop-in" with a long free segment protruding into the bladder lumen. The incidence of vesicoureteric reflux was investigated in 81 transplant patients who had a follow-up period ranging from 4 months to 15 years (mean 3.7 years); 29 of these patients had recurrent urinary tract infections. Micturating cystography demonstrated reflux in 6 patients (7.4%). In these 6 patients the presence of reflux had no deleterious effect on renal function and the infections were easily controlled with long-term antibiotics. In the 52 patients without injury infection no reflux was demonstrated. The conclusions based on this study indicate that (1) in the absence of recurrent infection there are no indications for micturating cystography and (2) this method of ureteroneocystostomy is expedient and has a low incidence of reflux.

Cystine stones.

We report on 9 patients, 5 men and 4 women, with cystine stones. Eight were seen previously at other hospitals, and a total of 18 operations were performed for stones before the diagnosis of cystinuria was made and medical treatment instituted. The pathogenesis and rational for medical treatment is reviewed, and the need for early diagnosis is emphasized.

Serial urinary and cervical cytological studies in women undergoing renal transplantation.

Cervical dysplasia has been reported to occur more frequently in female renal transplant patients. The incidence of pre-existing dysplasia is unknown. A prospective study of several urinary and cervical cytological screenings of 50 transplant patients was undertaken. Two of 38 patients studied before transplantation had pre-existing dysplasia. No new cases of dysplasia were found during the study (mean surveillance 3 years). A high incidence of urinary viral infection was found, but a relation to cervical dysplasia was not noted. The frequency of cervical abnormalities previously reported might have been due to different immunosuppressive regimes or to failure to exclude pre-existing disease. Despite the low incidence of abnormalities the use of cytological screening provided valuable reassurance to our patients, and its use is recommended.

Immune-complex disease in mice and humans given C. parvum.

The present studies in mice and cancer-bearing patients, treated with C. parvum (CP) immunotherapy, were to determine the effects of CP on the production of immune complexes (IC) and associated disease. Using the Clq-binding assay, circulating immune complexes were detected in mice given a single high dose of CP (466 microgram) and repeated human-equivalent doses (70 microgram). All mice treated with CP developed proliferative glomerulonephritis, the severity of which was dose-related. The histological and immunofluorescent patterns of the nephritis were those attributed to immune-complex disease. The mice had haematuria but were not in renal failure. Fifty patients with inoperable lung cancer were studied. All received radiotherapy. Twenty-two had no other treatment (controls) and 28 were treated with infusions of CP. Using 2 immune-complex assays (Clq binding and monoclonal rheumatoid-factor binding) IC were found in 10/22 control patients but these did not develop haematuria or proteinuria. Twenty-four of the 28 patients treated with CP developed transient haematuria and/or proteinuria with red-cell and hyaline casts, the changes resolving over 5 days. Immune complexes were detected in 5 of these 28 patients before CP treatment. Although 16/28 had IC at the time of haematuria and proteinuria, these findings were difficult to interpret because IC may occur in response to the tumour, the radiotherapy, or the CP. Although no patient developed renal failure, we believe that those treated with CP should have regular assessment of their renal function.