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ABSTRACT: Over the last decades, significant improvements in reducing the toxicities of allogeneic hematopoietic cell transplantation (allo-HCT) have widened its use as consolidation or salvage therapy for high-risk hematological malignancies. Nevertheless, relapse of the original malignant disease remains an open issue with unsatisfactory salvage options and limited rationales to select among them. In the last years, several studies have highlighted that relapse is often associated with specific genomic and nongenomic mechanisms of immune escape. In this review we summarize the current knowledge about these modalities of immune evasion, focusing on the mechanisms that leverage antigen presentation and pathologic rewiring of the bone marrow microenvironment. We present examples of how this biologic information can be translated into specific approaches to treat relapse, discuss the status of the clinical trials for patients who relapsed after a transplant, and show how dissecting the complex immunobiology of allo-HCT represents a crucial step toward developing new personalized approaches to improve clinical outcomes.
Asunto(s)
Trasplante de Células Madre Hematopoyéticas , Leucemia , Medicina de Precisión , Escape del Tumor , Humanos , Medicina de Precisión/métodos , Trasplante de Células Madre Hematopoyéticas/métodos , Leucemia/terapia , Leucemia/inmunología , Microambiente Tumoral/inmunología , Trasplante HomólogoRESUMEN
To study and then harness the tumor-specific T cell dynamics after allogeneic hematopoietic stem cell transplant, we typed the frequency, phenotype, and function of lymphocytes directed against tumor-associated antigens (TAAs) in 39 consecutive transplanted patients, for 1 year after transplant. We showed that TAA-specific T cells circulated in 90% of patients but display a limited effector function associated to an exhaustion phenotype, particularly in the subgroup of patients deemed to relapse, where exhausted stem cell memory T cells accumulated. Accordingly, cancer-specific cytolytic functions were relevant only when the TAA-specific T cell receptors (TCRs) were transferred into healthy, genome-edited T cells. We then exploited trogocytosis and ligandome-on-chip technology to unveil the specificities of tumor-specific TCRs retrieved from the exhausted T cell pool. Overall, we showed that harnessing circulating TAA-specific and exhausted T cells allow to isolate TCRs against TAAs and previously not described acute myeloid leukemia antigens, potentially relevant for T cell-based cancer immunotherapy.
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Leucemia Mieloide Aguda , Agotamiento de Células T , Humanos , Trogocitosis , Receptores de Antígenos de Linfocitos T/genética , Linfocitos T , Antígenos de Neoplasias , Leucemia Mieloide Aguda/terapiaRESUMEN
Acute myeloid leukaemia (AML) relapse after allogeneic haematopoietic cell transplantation (allo-HCT) is often driven by immune-related mechanisms and associated with poor prognosis. Immune checkpoint inhibitors combined with hypomethylating agents (HMA) may restore or enhance the graft-versus-leukaemia effect. Still, data about using this combination regimen after allo-HCT are limited. We conducted a prospective, phase II, open-label, single-arm study in which we treated patients with haematological AML relapse after allo-HCT with HMA plus the anti-PD-1 antibody nivolumab. The response was correlated with DNA-, RNA- and protein-based single-cell technology assessments to identify biomarkers associated with therapeutic efficacy. Sixteen patients received a median number of 2 (range 1-7) nivolumab applications. The overall response rate (CR/PR) at day 42 was 25%, and another 25% of the patients achieved stable disease. The median overall survival was 15.6 months. High-parametric cytometry documented a higher frequency of activated (ICOS+ , HLA-DR+ ), low senescence (KLRG1- , CD57- ) CD8+ effector T cells in responders. We confirmed these findings in a preclinical model. Single-cell transcriptomics revealed a pro-inflammatory rewiring of the expression profile of T and myeloid cells in responders. In summary, the study indicates that the post-allo-HCT HMA/nivolumab combination induces anti-AML immune responses in selected patients and could be considered as a bridging approach to a second allo-HCT. Trial-registration: EudraCT-No. 2017-002194-18.
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Patients with acute myeloid leukemia (AML) often achieve remission after allogeneic hematopoietic cell transplantation (allo-HCT) but subsequently die of relapse driven by leukemia cells resistant to elimination by allogeneic T cells based on decreased major histocompatibility complex II (MHC-II) expression and apoptosis resistance. Here we demonstrate that mouse-double-minute-2 (MDM2) inhibition can counteract immune evasion of AML. MDM2 inhibition induced MHC class I and II expression in murine and human AML cells. Using xenografts of human AML and syngeneic mouse models of leukemia, we show that MDM2 inhibition enhanced cytotoxicity against leukemia cells and improved survival. MDM2 inhibition also led to increases in tumor necrosis factor-related apoptosis-inducing ligand receptor-1 and -2 (TRAIL-R1/2) on leukemia cells and higher frequencies of CD8+CD27lowPD-1lowTIM-3low T cells, with features of cytotoxicity (perforin+CD107a+TRAIL+) and longevity (bcl-2+IL-7R+). CD8+ T cells isolated from leukemia-bearing MDM2 inhibitor-treated allo-HCT recipients exhibited higher glycolytic activity and enrichment for nucleotides and their precursors compared with vehicle control subjects. T cells isolated from MDM2 inhibitor-treated AML-bearing mice eradicated leukemia in secondary AML-bearing recipients. Mechanistically, the MDM2 inhibitor-mediated effects were p53-dependent because p53 knockdown abolished TRAIL-R1/2 and MHC-II upregulation, whereas p53 binding to TRAILR1/2 promotors increased upon MDM2 inhibition. The observations in the mouse models were complemented by data from human individuals. Patient-derived AML cells exhibited increased TRAIL-R1/2 and MHC-II expression on MDM2 inhibition. In summary, we identified a targetable vulnerability of AML cells to allogeneic T-cell-mediated cytotoxicity through the restoration of p53-dependent TRAIL-R1/2 and MHC-II production via MDM2 inhibition.
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Leucemia Mieloide Aguda , Proteína p53 Supresora de Tumor , Animales , Apoptosis , Humanos , Leucemia Mieloide Aguda/genética , Complejo Mayor de Histocompatibilidad , Ratones , Proteínas Proto-Oncogénicas c-mdm2/metabolismo , Trasplante Homólogo , Proteína p53 Supresora de Tumor/genética , Proteína p53 Supresora de Tumor/metabolismo , Regulación hacia ArribaRESUMEN
The major cause of death after allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for acute myeloid leukemia (AML) is disease relapse. We investigated the expression of Inhibitory Receptors (IR; PD-1/CTLA-4/TIM-3/LAG-3/2B4/KLRG1/GITR) on T cells infiltrating the bone marrow (BM) of 32 AML patients relapsing (median 251 days) or maintaining complete remission (CR; median 1 year) after HSCT. A higher proportion of early-differentiated Memory Stem (TSCM) and Central Memory BM-T cells express multiple IR in relapsing patients than in CR patients. Exhausted BM-T cells at relapse display a restricted TCR repertoire, impaired effector functions and leukemia-reactive specificities. In 57 patients, early detection of severely exhausted (PD-1+Eomes+T-bet-) BM-TSCM predicts relapse. Accordingly, leukemia-specific T cells in patients prone to relapse display exhaustion markers, absent in patients maintaining long-term CR. These results highlight a wide, though reversible, immunological dysfunction in the BM of AML patients relapsing after HSCT and suggest new therapeutic opportunities for the disease.
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Anergia Clonal , Regulación Leucémica de la Expresión Génica , Trasplante de Células Madre Hematopoyéticas , Memoria Inmunológica/genética , Leucemia Mieloide Aguda/inmunología , Linfocitos T/inmunología , Adulto , Antígenos CD/genética , Antígenos CD/inmunología , Antineoplásicos/uso terapéutico , Células de la Médula Ósea/inmunología , Células de la Médula Ósea/patología , Antígeno CTLA-4/genética , Antígeno CTLA-4/inmunología , Femenino , Proteína Relacionada con TNFR Inducida por Glucocorticoide/genética , Proteína Relacionada con TNFR Inducida por Glucocorticoide/inmunología , Receptor 2 Celular del Virus de la Hepatitis A/genética , Receptor 2 Celular del Virus de la Hepatitis A/inmunología , Humanos , Leucemia Mieloide Aguda/genética , Leucemia Mieloide Aguda/patología , Leucemia Mieloide Aguda/terapia , Masculino , Persona de Mediana Edad , Receptor de Muerte Celular Programada 1/genética , Receptor de Muerte Celular Programada 1/inmunología , Receptores KIR/genética , Receptores KIR/inmunología , Recurrencia , Inducción de Remisión , Estudios Retrospectivos , Transducción de Señal , Familia de Moléculas Señalizadoras de la Activación Linfocitaria/genética , Familia de Moléculas Señalizadoras de la Activación Linfocitaria/inmunología , Linfocitos T/patología , Trasplante Homólogo , Proteína del Gen 3 de Activación de LinfocitosRESUMEN
Transplantation of hematopoietic cells from a healthy individual (allogeneic hematopoietic cell transplantation (allo-HCT)) demonstrates that adoptive immunotherapy can cure blood cancers: still, post-transplantation relapses remain frequent. To explain their drivers, we analyzed the genomic and gene expression profiles of acute myeloid leukemia (AML) blasts purified from patients at serial time-points during their disease history. We identified a transcriptional signature specific for post-transplantation relapses and highly enriched in immune-related processes, including T cell costimulation and antigen presentation. In two independent patient cohorts we confirmed the deregulation of multiple costimulatory ligands on AML blasts at post-transplantation relapse (PD-L1, B7-H3, CD80, PVRL2), mirrored by concomitant changes in circulating donor T cells. Likewise, we documented the frequent loss of surface expression of HLA-DR, -DQ and -DP on leukemia cells, due to downregulation of the HLA class II regulator CIITA. We show that loss of HLA class II expression and upregulation of inhibitory checkpoint molecules represent alternative modalities to abolish AML recognition from donor-derived T cells, and can be counteracted by interferon-γ or checkpoint blockade, respectively. Our results demonstrate that the deregulation of pathways involved in T cell-mediated allorecognition is a distinctive feature and driver of AML relapses after allo-HCT, which can be rapidly translated into personalized therapies.
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Perfilación de la Expresión Génica , Trasplante de Células Madre Hematopoyéticas , Leucemia Mieloide Aguda/genética , Leucemia Mieloide Aguda/inmunología , Regulación Leucémica de la Expresión Génica , Antígenos de Histocompatibilidad Clase II/genética , Antígenos de Histocompatibilidad Clase II/metabolismo , Humanos , Leucemia Mieloide Aguda/terapia , Activación de Linfocitos/inmunología , ARN Mensajero/genética , ARN Mensajero/metabolismo , Recurrencia , Reproducibilidad de los Resultados , Trasplante HomólogoRESUMEN
The use of posttransplant cyclophosphamide (PT-Cy) as graft-versus-host disease (GVHD) prophylaxis has revolutionized haploidentical hematopoietic stem cell transplantation (HSCT), allowing safe infusion of unmanipulated T cell-replete grafts. PT-Cy selectively eliminates proliferating alloreactive T cells, but whether and how it affects natural killer (NK) cells and their alloreactivity is largely unknown. Here we characterized NK cell dynamics in 17 patients who received unmanipulated haploidentical grafts, containing high numbers of mature NK cells, according to PT-Cy-based protocols in 2 independent centers. In both series, we documented robust proliferation of donor-derived NK cells immediately after HSCT. After infusion of Cy, a marked reduction of proliferating NK cells was evident, suggesting selective purging of dividing cells. Supporting this hypothesis, proliferating NK cells did not express aldehyde dehydrogenase and were killed by Cy in vitro. After ablation of mature NK cells, starting from day 15 after HSCT and favored by the high levels of interleukin-15 present in patients' sera, immature NK cells (CD62L+NKG2A+KIR-) became highly prevalent, possibly directly stemming from infused hematopoietic stem cells. Importantly, also putatively alloreactive single KIR+ NK cells were eliminated by PT-Cy and were thus decreased in numbers and antileukemic potential at day 30 after HSCT. As a consequence, in an extended series of 99 haplo-HSCT with PT-Cy, we found no significant difference in progression-free survival between patients with or without predicted NK alloreactivity (42% vs 52% at 1 year, P = NS). Our data suggest that the majority of mature NK cells infused with unmanipulated grafts are lost upon PT-Cy administration, blunting NK cell alloreactivity in this transplantation setting.
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Ciclofosfamida/uso terapéutico , Trasplante de Células Madre Hematopoyéticas/métodos , Inmunosupresores/uso terapéutico , Células Asesinas Naturales/efectos de los fármacos , Adulto , Anciano , Proliferación Celular/efectos de los fármacos , Femenino , Humanos , Células Asesinas Naturales/citología , Células Asesinas Naturales/trasplante , Recuento de Linfocitos , Masculino , Persona de Mediana Edad , Adulto JovenAsunto(s)
Antígenos de Neoplasias/análisis , Genes MHC Clase II , Genes MHC Clase I , Antígenos HLA-A/análisis , Antígenos HLA-C/análisis , Cadenas beta de HLA-DP/análisis , Trasplante de Células Madre Hematopoyéticas , Reacción en Cadena de la Polimerasa/métodos , Eliminación de Gen , Marcadores Genéticos , Haplotipos , Necesidades y Demandas de Servicios de Salud , Histocompatibilidad , Humanos , Leucemia/inmunología , Leucemia/terapia , Células Madre Neoplásicas/inmunología , Recurrencia , Escape del TumorAsunto(s)
Biomarcadores de Tumor/genética , ADN (Citosina-5-)-Metiltransferasas/genética , Trasplante de Células Madre Hematopoyéticas , Isocitrato Deshidrogenasa/genética , Leucemia Mieloide Aguda/diagnóstico , Reacción en Cadena de la Polimerasa/métodos , Adulto , Anciano , Alelos , Biomarcadores de Tumor/metabolismo , ADN (Citosina-5-)-Metiltransferasas/metabolismo , ADN Metiltransferasa 3A , Diagnóstico Precoz , Femenino , Expresión Génica , Frecuencia de los Genes , Humanos , Isocitrato Deshidrogenasa/metabolismo , Leucemia Mieloide Aguda/genética , Leucemia Mieloide Aguda/patología , Leucemia Mieloide Aguda/terapia , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Mutación , Neoplasia Residual , Reacción en Cadena de la Polimerasa/instrumentación , Recurrencia , Trasplante HomólogoRESUMEN
A major challenge in unrelated hematopoietic stem cell transplantation (HSCT) is the prediction of permissive HLA mismatches, ie, those associated with lower clinical risks compared to their nonpermissive counterparts. For HLA-DPB1, a clinically prognostic model has been shown to be matching for T cell epitope (TCE) groups assigned by cross reactivity of T cells alloreactive to HLA-DPB1∗09:01; however, the molecular basis of this observation is not fully understood. Here, we have mutated amino acids (aa) in 10 positions of HLA-DPB1∗09:01 to other naturally occurring variants, expressed them by lentiviral vectors in B cell lines, and quantitatively measured allorecognition by 17 CD4(+) T cell effectors from 6 unrelated individuals. A significant impact on the median alloresponse was observed for peptide contact positions 9, 11, 35, 55, 69, 76, and 84, but not for positions 8, 56, and 57 pointing away from the groove. A score for the "functional distance" (FD) from HLA-DPB1∗09:01 was defined as the sum of the median impact of polymorphic aa in a given HLA-DPB1 allele on T cell alloreactivity. Established TCE group assignment of 23 alleles correlated with FD scores of ≤0.5, 0.6 to 1.9 and ≥2 for TCE groups 1, 2, and 3, respectively. Based on this, prediction of TCE group assignment will be possible for any given HLA-DPB1 allele, including currently 367 alleles encoding distinct proteins for which T cell cross reactivity patterns are unknown. Experimental confirmation of the in silico TCE group classification was successfully performed for 7 of 7 of these alleles. Our findings have practical implications for the applicability of TCE group matching in unrelated HSCT and provide new insights into the molecular mechanisms underlying this model. The innovative concept of FD opens new potential avenues for risk prediction in unrelated HSCT.
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Linfocitos T CD4-Positivos/inmunología , Epítopos de Linfocito T/inmunología , Cadenas beta de HLA-DP/inmunología , Trasplante de Células Madre Hematopoyéticas , Mutación , Isoformas de Proteínas/inmunología , Alelos , Aminoácidos/química , Aminoácidos/inmunología , Linfocitos B/citología , Linfocitos B/inmunología , Linfocitos T CD4-Positivos/citología , Línea Celular , Células Clonales , Epítopos de Linfocito T/química , Epítopos de Linfocito T/clasificación , Expresión Génica , Cadenas beta de HLA-DP/química , Cadenas beta de HLA-DP/clasificación , Cadenas beta de HLA-DP/genética , Prueba de Histocompatibilidad , Humanos , Isoformas de Proteínas/química , Isoformas de Proteínas/clasificación , Isoformas de Proteínas/genética , Trasplante Homólogo , Donante no EmparentadoRESUMEN
The functional relevance of polymorphisms outside the peptide binding groove of HLA molecules is poorly understood. Here we have addressed this issue by studying HLA-DP3, a common antigen relevant for functional matching algorithms of unrelated hematopoietic stem cell transplantation (HSCT) encoded by two transmembrane (TM) region variants, DPB1(*)03:01 and DPB1(*)104:01. The two HLA-DP3 variants were found at a overall allelic frequency of 10.4% in 201 volunteer stem cell donors, at a ratio of 4.2:1. No significant differences were observed in cell surface expression levels of the two variants on B lymphoblastoid cell lines (BLCL), primary B cells or monocytes. Three different alloreactive T cell lines or clones showed similar levels of activation marker CD107a and/or CD137 upregulation in response to HLA-DP3 encoded by DPB1(*)03:01 and DPB1(*)104:01, either endogenously on BLCL or after lentiveral-vector mediated transfer into the same cellular background. These data provide, for the first time, direct evidence for a limited functional role of a TM region polymorphism on expression and allorecognition of HLA-DP3 and are compatible with the notion that the two variants can be considered as a single functional entity for unrelated stem cell donor selection.
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Cadenas beta de HLA-DP/genética , Cadenas beta de HLA-DP/metabolismo , Alelos , Linfocitos B/inmunología , Linfocitos B/metabolismo , Línea Celular Tumoral , Membrana Celular/metabolismo , Expresión Génica , Frecuencia de los Genes , Variación Genética , Histocompatibilidad/genética , Histocompatibilidad/inmunología , Prueba de Histocompatibilidad , Humanos , Inmunofenotipificación , Subgrupos de Linfocitos T/inmunología , Subgrupos de Linfocitos T/metabolismo , Donante no EmparentadoRESUMEN
Recent developments in cell processing and immunosuppressive strategies has allowed the safe infusion of high numbers of donor T cells in the context of clinical haploidentical hematopoietic stem cell transplantation (HSCT). Haploidentical T cells display an intrinsic ability to recognize and eliminate residual patient leukemic cells, largely due to alloreactivity against the patient-specific human leukocyte antigen (HLA) molecules encoded on the mismatched haplotype. However, recent evidence has shown that leukemia, like many other tumors displaying pronounced genomic instability, is frequently able to evade this potent graft-versus-leukemia effect by undergoing de novo genomic mutations, which result in the permanent loss of only those HLA molecules targeted by haploidentical donor T-cell alloreactivity. This review summarizes the recent clinical and experimental evidence regarding this phenomenon, and its therapeutic and clinical consequences.