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Journal of Clinical Oncology, Vol 24, No 13 (May 1), 2006: pp. e20-e22 © 2006 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.05.9964
Treatment of Metastatic Renal Cell Carcinoma With Autologous T-Lymphocytes Genetically Retargeted Against Carbonic Anhydrase IX: First Clinical ExperienceDepartments of Medical Oncology, Pharmacy, and Pathology, Erasmus University Medical Center–Daniel den Hoed Cancer Center, Rotterdam, the Netherlands
Department of Experimental Urology, University Medical Center, Nijmegen, the Netherlands To the Editor: Adoptive transfer of autologous T-lymphocytes that are gene transduced to express antigen-specific receptors represents an experimental therapy to provide tumor-specific immunity to cancer patients. We studied safety and the proof of this concept in patients with metastatic renal cell carcinoma (RCC), and have encountered toxicity that is likely to be antigen specific. We have constructed a single-chain antibody-type (scFv) –receptor based on murine monoclonal antibody (mAb) G250.1 This mAb recognizes an epitope on carboxy-anhydrase-IX (CAIX), which is frequently overexpressed on clear cell RCC. Following retroviral introduction of the scFv(G250) transgene into primary human T-cells, the scFv(G250) receptor is expressed on the surface of these cells, which enables them to recognize CAIX and to exert antigen-specific effector functions, such as cytokine production after exposure to CAIX and the killing of CAIX+ RCC cell lines.2,3 We treated patients with scFv(G250)-transduced T-cells in an inpatient dose-escalation scheme of intravenous (IV) doses of 2 x 107 cells at day 1; 2 x 108 cells at day 2; 2 x 109 cells at days 3 through 5 (treatment cycle 1); and 2 x 109 cells at days 17 to 19 (treatment cycle 2), in combination with human recombinant interleukin-2 (IL-2; Chiron Corporation, Amsterdam, the Netherlands), subcutaneously, 5 x 105 U/m2 twice daily administered at days 1 to 10 and days 17 to 26. This protocol was approved by the governmental regulatory authorities and the institutional medical ethical review board. Adaptations to this protocol were implemented only after approval by these boards. Written informed consent was obtained from all patients.
In this letter, we report on the clinical experiences of the first three patients. The patients had CAIX+ metastatic clear cell RCC, had undergone tumor nephrectomy, and had progressive disease after 6 to 17 months of interferon alfa (IFN-
We transiently detected both scFv(G250)+ T-cells and scFv(G250) DNA copies in the circulation of all three patients from day 3 of treatment onward, using flow cytometry and quantitative real-time polymerase chain reaction (PCR). The time period during which the transduced cells were detected in the circulation depended on the method used, that is, up to 32 days by flow cytometry and up to 53 days by PCR4 (Table 1).
Before treatment, peripheral blood mononuclear cells did not show scFv(G250)-mediated functions, that is, specific cytolysis of CAIX+ target cells and production of IFN- All three patients developed low levels of anti-scFv(G250) antibodies between 37 and 100 days after the start of T-cell therapy, which were directed against the G250 idiotype (id). Remarkably, these responses were less frequent in RCC patients treated with weekly IV infusions of 50 mg chimeric G250 mAb (ie, in 6% to 30% of patients),5,6 indicating that the expression of scFv(G250) on the cell membrane of T-cells elicits a relatively efficient immune response against the murine G250-id. Such response may hamper the effective clinical use of murine-human chimeric receptors, and may require construction of receptors from completely human mAbs. In summary, our data show clear in vivo reactivity of autologous T-cells that have been genetically retargeted using a single-chain antibody-type receptor. The observed liver toxicity is most likely due to the reactivity of transduced T-cells against the target antigen expressed on normal tissue, that is, the epithelial cells lining the bile ducts, and thereby hinders administration of T-cells in numbers that can be expected to yield antitumor activity. We consider our observations, together with those from T-cell therapies directed against self-antigens,7,8 relevant for other studies involving T-cell retargeting for therapeutic purposes. Ideally, the target antigens for such studies should be carefully chosen, so as to be expressed only by malignant cells and not by normal cells. Alternatively, strategies need to be developed to attenuate activity of retargeted T-cells against normal tissues expressing target antigen to circumvent the observed adverse events. In order to prevent liver toxicity in future patients, we have modified our clinical protocol into a conventional phase I study, and have included an infusion of 5 mg cG250 antibody 3 days before the first infusion of gene-modified T-cells. The rationale of this amended protocol is that repeated administration of cG250 has not only been shown to be clinically safe and well-tolerated by more than 200 patients,9 but more importantly, cG250 localizes to RCC metastasis but not to the liver, after having saturated uptake by liver tissue (but not RCC metastasis) by a single low dose of cG250.6,10,11 By pretreating patients with a single, low dose of cG250, we aim to protect the bile duct epithelium from the damaging effects exerted by scFv(G250)+ T-cells. The Dutch regulatory authorities have approved this amended protocol and accrual of patients is currently ongoing. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
ACKNOWLEDGMENTS This letter was supported by the Dutch Cancer Foundation (Grant No. DDHK99-1865), European Commission Grant No. QLK3-1999-01262, and the Cancer Research Institute, New York, NY (clinical investigation grant "Immunogene therapy of metastatic renal cell cancer patients"). This letter was presented in part at the European Society of Gene Therapy 2004 meeting in Tampere, Finland and at the International Society for Cellular Therapy 2005 meeting in Vancouver, British Columbia, Canada. REFERENCES 1. Weijtens MEM, Willemsen RA, Valerio D, et al: Single chain Ig/gamma gene-redirected human T lymphocytes produce cytokines, specifically lyse tumor cells, and recycle lytic capacity. J Immunol 157:836-843, 1996[Abstract] 2. Lamers CH, Willemsen RA, Luider BA, et al: Protocol for gene transduction and expansion of human T lymphocytes for clinical immunogene therapy of cancer. Cancer Gene Ther 9:613-623, 2002[CrossRef][Medline] 3. Lamers CHJ, Willemsen RA, van Elzakker P, et al: Phoenix-ampho outperforms PG13 as retroviral packaging cells to transduce human T cells with tumor-specific receptors: Implications for clinical immunogene therapy of cancer. Cancer Gene Ther 10.1038/sj.cgt.7700916 (Epub ahead of print on November 11, 2005) 4. Lamers CHJ, Gratama JW, Pouw N, et al: Parallel detection of transduced T lymphocytes following immuno-gene therapy of renal cell cancer by flow cytometry and real-time PCR: Implications for loss of transgene expression. Hum Gene Ther 16:1452-1462, 2005[Medline] 5. Divgi CR, O'Donoghue JA, Welt S, et al: Phase I clinical trial with fractionated radioimmunotherapy using 131I-labeled chimeric G250 in metastatic renal cancer. J Nucl Med 45:1412-1421, 2004 6. Brouwers AH, Mulders PF, de Mulder PH, et al: Lack of efficacy of two consecutive treatments of radioimmunotherapy with 131I-cG250 in patients with metastasized clear cell renal cell carcinoma. J Clin Oncol 23:6540-6548, 2005 7. Rosenberg SA, Dudley ME: Cancer regression in patients with metastatic melanoma after the transfer of autologous antitumor lymphocytes. Proc Natl Acad Sci U S A 101:14639-14645, 2004 (suppl 2) 8. Dudley ME, Wunderlich JR, Yang JC, et al: Adoptive cell transfer therapy following non-myeloablative but lymphodepleting chemotherapy for the treatment of patients with refractory metastatic melanoma. J Clin Oncol 23:2346-2357, 2005 9. Bleumer I, Knuth A, Oosterwijk E, et al: A phase II trial of chimeric monoclonal antibody G250 for advanced renal cell carcinoma patients. Br J Cancer 90:985-990, 2004[CrossRef][Medline] 10. Steffens MG, Boerman OC, Oyen WJ, et al: Intratumoral distribution of two consecutive injections of chimeric antibody G250 in primary renal cell carcinoma: Implications for fractionated dose radioimmunotherapy. Cancer Res 59:1615-1619, 1999 11. Steffens MG, Oosterwijk-Wakka JC, Zegwaart-Hagemeier NE, et al: Immunohistochemical analysis of tumor antigen saturation following injection of monoclonal antibody G250. Anticancer Res 19:1197-1200, 1999[Medline]
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Copyright © 2006 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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) treatment. From all, we successfully generated functional scFv(G250)+ T-cells ex vivo (
on stimulation with such cells. After infusions of scFv(G250)-transduced T cells, these activities became detectable in all three patients (
