Fantastic Stuff

 

It certainly is for Judy Perkins, a lady from Florida, who is the subject of a research paper published last week in the journal Nature Medicine by Nikolaos Zacharakis, Steven Rosenberg and their colleagues at the National Cancer Institute in Bethesda, Maryland. Having reached a point where she was enduring pain and facing death from metastatic breast cancer, the paper notes that she has undergone “complete durable regression … now ongoing for over 22 months.”  Wow! Hard to even begin to imagine how she must feel — or, for that matter, the team that engineered this outcome.

How was it done?

Well, it’s a very good example of what I do tend to go on about in these pages — namely that science is almost never about ‘ground-breaking breakthroughs’ or ‘Eureka’ moments. It creeps along in tiny steps, sideways, backwards and sometimes even forwards.

You may recall that in Self Help – Part 2, talking about ‘personalized medicine’, we described how in one version of cancer immunotherapy a sample of a patient’s white blood cells (T lymphocytes) is grown in the lab. This is a way of either getting more immune cells that can target the patient’s tumour or of being able to modify the cells by genetic engineering. One approach is to engineer cells to make receptors on their surface that target them to the tumour cell surface. Put these cells back into the patient and, with luck, you get better tumour cell killing.

An extra step (Gosh! Wonderful GOSH) enabled novel genes to be engineered into the white cells.

The Shape of Things to Come? took a further small step when DNA sequencing was used to identify mutations that gave rise to new proteins in tumour cells (called tumour-associated antigens or ‘neoantigens’ — molecular flags on the cell surface that can provoke an immune response – i.e., the host makes antibody proteins that react with (stick to) the antigens). Charlie Swanton and his colleagues from University College London and Cancer Research UK used this method for two samples of lung cancer, growing them in the lab to expand the population and testing how good these tumour-infiltrating cells were at recognizing the abnormal proteins (neo-antigens) on cancer cells.

Now Zacharakis & Friends followed this lead: they sequenced DNA from the tumour tissue to pinpoint the main mutations and screened the immune cells they’d grown in the lab to find which sub-populations were best at attacking the tumour cells. Expand those cells, infuse into the patient and keep your fingers crossed.

Adoptive cell transfer. This is the scheme from Self Help – Part 2 with the extra step (A) of sequencing the breast tumour. Four mutant proteins were found and tumour-infiltrating lymphocytes reactive against these mutant versions were identified, expanded in culture and infused into the patient.

 

What’s next?

The last step with the fingers was important because there’s almost always an element of luck in these things. For example, a patient may not make enough T lymphocytes to obtain an effective inoculum. But, regardless of the limitations, it’s what scientists call ‘proof-of-principle’. If it works once it’ll work again. It’s just a matter of slogging away at the fine details.

For Judy Perkins, of course, it’s about getting on with a life she’d prepared to leave — and perhaps, once in while, glancing in awe at a Nature Medicine paper that does not mention her by name but secures her own little niche in the history of cancer therapy.

References

McGranahan et al. (2016). Clonal neoantigens elicit T cell immunoreactivity and sensitivity to immune checkpoint blockade. Science 10.1126/science.aaf490 (2016).

Zacharakis, N. et al. (2018). Immune recognition of somatic mutations leading to complete durable regression in metastatic breast cancer. Nature Medicine 04 June 2018.

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Self Help – Part 2

In the second type of cancer immunotherapy a sample of a patient’s T lymphocytes is grown in the lab. This permits either expansion of the number of cells that recognize the tumour or genetic engineering to modify the cells so they express receptors on their surface that target them to the tumour cell surface. Infusion of these manipulated cells into the patient enhances tumour cell killing. We’re now in the realms of ‘personalized medicine’.

A little more of a good thing

The first of these methods picks up a weakness in the patient’s immune system whereby it makes lymphocytes that kill tumour cells but can’t make enough – their protective effect is overwhelmed by the growing cancer. By taking small pieces of surgically removed tumours and growing them in the lab, it’s possible to select those T cells that have killing capacity. These are expanded over a few weeks to make enough cells to keep on growing when they’re infused back into the patient. The upshot is a hefty boost for the natural anti-tumour defence system. The pioneer of this method, called adoptive cell therapy, is Steven Rosenberg (National Cancer Institute, Bethesda) and it has been particularly effective for melanomas. Responses are substantially improved by treatment with drugs that reduce the white cell count before samples are taken for T cell selection – probably because the system responds by making growth factors to restore the balance and these drive the expansion of the infused cells.

A wonderful benefit of this method is its efficacy against metastases – i.e. tumour growths that have spread from the primary site – perhaps not surprising as it’s what Rosenberg calls a “living” treatment, in other words it just gives a helping hand to what nature is already trying to do.

93. Fig. 1Selecting naturally occurring T cells with anti-tumour activity

Tumour fragments are grown in the laboratory: lymphocytes that kill tumour cells are selected and expanded in culture.  About 6 weeks growth yields enough cells to infuse into the patient.

Gene therapy

A more sophisticated approach to boosting innate immunity is to introduce new genes into the genetic material (the genome) of T cells to target them to tumour cells with greater efficiency. An ordinary blood sample suffices as a starting point from which T cells are isolated. One way of getting them to take up novel genes uses viruses – essentially just genetic material wrapped in an envelope. The virus is ‘disabled’ so that it has none of its original disease-causing capacity but retains infectivity – it sticks to cells. ‘Disabling’ means taking just enough of the original genome to make the virus – a viral skeleton – and then inserting your favourite gene, so the engineered form is just a handy vehicle for carrying genes. No need to panic, therefore, if you see a press headline of the “HIV cures cancer” variety: it just means that the human immunodeficiency virus – well and truly disabled – has been used as the gene carrier.

93. Fig. 2

Genetic modification of blood lymphocytes

T cells are isolated from a blood sample and novel genes inserted into their DNA. The engineered T cells are expanded and then infused into the patient.

 This method of re-directing T cells to a desired target was pioneered by Gideon Gross and colleagues at The Weizmann Institute of Science in Israel in the late 1980s and it has led to sensational recent results in treating chronic lymphocytic leukemia (CLL), albeit in just a few patients so far. To the fore have been Renier Brentjens and his group from the Memorial Sloan-Kettering Cancer Center, New York. The genetic modification they used made the patient’s T cells express an artificial receptor on their surface (called a chimeric antigen receptor). This T cell receptor was designed to stick specifically to a protein known to be displayed on the surface of CLL cells. The result was that the T cells, originally unable to ‘see’ the leukemic cells, now homed in on them with high efficiency. Astonishingly, and wonderfully, the modified cells divide in the patient so that, in effect, their immune system has been permanently super-charged.

A critical part of the strategy is that CLL cells carry a known molecular target but the absence of such defined markers for most cancers is currently a severe limitation. On the bright side, however, this type of gene therapy has now been attempted in at least three different centres and, despite inevitable minor differences in method, it clearly works.

One of the leading figures in gene therapy is Carl June of the University of Pennsylvania. Some of his colleagues have made a brilliant video explaining how it works whilst June himself has described in wonderfully humble fashion what it means to work in this field.

References

Rosenberg, S.A. and Restifo, N.P. (2015). Adoptive cell transfer as personalized immunotherapy for human cancer. Science 348, 62-68.

Gross, G., et al. (1989). Expression of immunoglobulin-T-cell receptor chimeric molecules as functional receptorswith antibody-type specificity. Proc. Natl. Acad. Sci. U.S.A. 86, 10024–10028.

Brentjens, R.J., et al. (2013). CD19-Targeted T Cells Rapidly Induce Molecular Remissions in Adults with Chemotherapy-Refractory Acute Lymphoblastic Leukemia. Sci Transl Med., 5, 177ra38. DOI:10.1126/scitranslmed.3005930.

Kalos, M., et al. (2011). T cells with chimeric antigen receptors have potent antitumor effects and can establish memory in patients with advanced leukemia. Sci. Transl. Med. 3, 95ra73.

Kochenderfer, J.N., et al. (2012). B-cell depletion and remissions of malignancy along with cytokine-associated toxicity in a clinical trial of anti-CD19 chimeric-antigen-receptor–transduced T cells. Blood 119, 2709–2720.