Mayu O. Frank

Cellular Immune Suppression in Paraneoplastic Neurologic Syndromes Targeting Intracellular Antigens

BACKGROUND Tumor treatment is the mainstay of therapy for paraneoplastic neurologic disorders (PNDs), but it is only effective in some cases and other treatment options are limited. OBJECTIVE To evaluate the short-term use of a combination of prednisone and tacrolimus for acute neurologic worsening in PND in which intracellular antigens are targeted. DESIGN Retrospective single-center case series of patients with PND treated with tacrolimus. SETTING The Rockefeller University Hospital, a research hospital in New York, New York. PATIENTS Twenty-six patients with PND with high titer (≥1:1000) anti-HuD, anti-Yo, or anti-CRMP5 autoantibodies were enrolled. Patients were referred from Memorial Sloan Kettering Cancer Center or self-referred. Two patients discontinued intervention owing to adverse events. INTERVENTIONS Patients were treated with tacrolimus, 0.15-0.30 mg/kg per day, in 2 divided oral doses with 60 mg per day of oral prednisone, tapered off during 1 to 4 weeks. MAIN OUTCOME MEASURES The primary outcome measure was median survival. Neurologic examinations before and after treatment as well as adverse events are described. RESULTS Median survival time was 52 months from time of diagnosis. Some patients experienced neurologic improvement that was functionally meaningful. The incidence of adverse events was similar to that generally reported with tacrolimus. CONCLUSIONS A short course of prednisone and tacrolimus to target central nervous system T cells in patients with PND with acute neurologic decline in which intracellular antigens are targeted was well tolerated and warrants further study. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00378326.

Harnessing Naturally Occurring Tumor Immunity: A Clinical Vaccine Trial in Prostate Cancer

Background Studies of patients with paraneoplastic neurologic disorders (PND) have revealed that apoptotic tumor serves as a potential potent trigger for the initiation of naturally occurring tumor immunity. The purpose of this study was to assess the feasibility, safety, and immunogenicity of an apoptotic tumor-autologous dendritic cell (DC) vaccine. Methods and Findings We have modeled PND tumor immunity in a clinical trial in which apoptotic allogeneic prostate tumor cells were used to generate an apoptotic tumor-autologous dendritic cell vaccine. Twenty-four prostate cancer patients were immunized in a Phase I, randomized, single-blind, placebo-controlled study to assess the safety and immunogenicity of this vaccine. Vaccinations were safe and well tolerated. Importantly, we also found that the vaccine was immunogenic, inducing delayed type hypersensitivity (DTH) responses and CD4+ and CD8+ T cell proliferation, with no effect on FoxP3+ regulatory T cells. A statistically significant increase in T cell proliferation responses to prostate tumor cells in vitro (p = 0.002), decrease in prostate specific antigen (PSA) slope (p = 0.016), and a two-fold increase in PSA doubling time (p = 0.003) were identified when we compared data before and after vaccination. Conclusions An apoptotic cancer cell vaccine modeled on naturally occurring tumor immune responses in PND patients provides a safe and immunogenic tumor vaccine. (ClinicalTrials.gov number NCT00289341). Trial Registration ClinicalTrials.gov NCT00289341

T cells targeting a neuronal paraneoplastic antigen mediate tumor rejection and trigger CNS autoimmunity with humoral activation.

Paraneoplastic neurologic diseases (PND) involving immune responses directed toward intracellular antigens are poorly understood. Here, we examine immunity to the PND antigen Nova2, which is expressed exclusively in central nervous system (CNS) neurons. We hypothesized that ectopic expression of neuronal antigen in the periphery could incite PND. In our C57BL/6 mouse model, CNS antigen expression limits antigen‐specific CD4+ and CD8+ T‐cell expansion. Chimera experiments demonstrate that this tolerance is mediated by antigen expression in nonhematopoietic cells. CNS antigen expression does not limit tumor rejection by adoptively transferred transgenic T cells but does limit the generation of a memory population that can be expanded upon secondary challenge in vivo. Despite mediating cancer rejection, adoptively transferred transgenic T cells do not lead to paraneoplastic neuronal targeting. Preliminary experiments suggest an additional requirement for humoral activation to induce CNS autoimmunity. This work provides evidence that the requirements for cancer immunity and neuronal autoimmunity are uncoupled. Since humoral immunity was not required for tumor rejection, B‐cell targeting therapy, such as rituximab, may be a rational treatment option for PND that does not hamper tumor immunity.

Dendritic cells loaded with FK506 kill T cells in an antigen-specific manner and prevent autoimmunity in vivo

FK506 (Tacrolimus) is a potent inhibitor of calcineurin that blocks IL2 production and is widely used to prevent transplant rejection and treat autoimmunity. FK506 treatment of dendritic cells (FKDC) limits their capacity to stimulate T cell responses. FK506 does not prevent DC survival, maturation, or costimulatory molecule expression, suggesting that the limited capacity of FKDC to stimulate T cells may be due to inhibition of calcineurin signaling in the DC. Instead, we demonstrate that DC inhibit T cells by sequestering FK506 and continuously releasing the drug over several days. T cells encountering FKDC proliferate but fail to upregulate the survival factor bcl-xl and die, and IL2 restores both bcl-xl and survival. In mice, FKDC act in an antigen-specific manner to inhibit T-cell mediated autoimmune arthritis. This establishes that DCs can act as a cellular drug delivery system to target antigen specific T cells. DOI: http://dx.doi.org/10.7554/eLife.00105.001

A destructive feedback loop mediated by CXCL10 in central nervous system inflammatory disease.

Paraneoplastic neurologic disorders (PND) are autoimmune diseases associated with cancer and ectopic expression of a neuronal antigen in a peripheral tumor. Patients with PND harbor high‐titer antibodies and T cells in their serum and cerebrospinal fluid (CSF) that are specific to the tumor antigen, and treatment with the immunosuppressant FK506 (tacrolimus) decreases CSF white blood cell counts. The objective of this study was to determine the effect of FK506 on CSF chemokine levels in PND patients.

Comparing sequencing assays and human-machine analyses in actionable genomics for glioblastoma.

Objective: To analyze a glioblastoma tumor specimen with 3 different platforms and compare potentially actionable calls from each. Methods: Tumor DNA was analyzed by a commercial targeted panel. In addition, tumor-normal DNA was analyzed by whole-genome sequencing (WGS) and tumor RNA was analyzed by RNA sequencing (RNA-seq). The WGS and RNA-seq data were analyzed by a team of bioinformaticians and cancer oncologists, and separately by IBM Watson Genomic Analytics (WGA), an automated system for prioritizing somatic variants and identifying drugs. Results: More variants were identified by WGS/RNA analysis than by targeted panels. WGA completed a comparable analysis in a fraction of the time required by the human analysts. Conclusions: The development of an effective human-machine interface in the analysis of deep cancer genomic datasets may provide potentially clinically actionable calls for individual patients in a more timely and efficient manner than currently possible. ClinicalTrials.gov identifier: NCT02725684.

Ri/Nova gene‐associated paraneoplastic subacute motor neuronopathy

RI/NOVA GENE-ASSOCIATED PARANEOPLASTIC SUBACUTE MOTOR NEURONOPATHY Flanagan and colleagues describe a patient with subacute lower motor neuronopathy (SMN) that preceded the diagnosis of Hodgkin lymphoma (HL). We encountered a patient with high titers of anti-Ri or anti-neuronal nuclear autoantibody type 2 (ANNA-2). This antibody is usually associated with paraneoplastic opsoclonus myoclonus ataxia (POMA) syndrome and breast cancer instead of SMN. A 49-year-old woman noted fatigue, cramps, twitching, and gait ataxia in early 2010 followed 3 months later by asymmetrical left leg weakness. Detection of a breast lump heralded moderately differentiated ductal carcinoma. A serum anti-Ri (ANNA-2) antibody titer was 1:7680 (normal<1:240) from among a panel of paraneoplastic autoantibodies that were otherwise negative. Treatment with 4 cycles of doxorubicin, cyclophosphamide and dexamethasone, and paclitaxel preceded increased leg weakness and adjustment of chemotherapy to 3 courses of cyclophosphamide, methotrexate, fluorouracil, and dexamethasone. Nystagmus on bilateral gaze, saccadic eye movements, startle myoclonus, and cataplexy supervened. In early 2011, she received radiation to the breast and involved nodes. Soon thereafter, wasting, fasciculation, brisk reflexes, ankle clonus, and left Babinski sign were noted. There was no evidence of cancer recurrence on whole body fluoro-deoxyglucose positron emission tomography/computed tomography (FDG PET-CT) or abnormal gadolinium-enhancement of the brain or spinal cord on contrast enhanced MRI. Lumbar cerebrospinal fluid (CSF) was normal with a CSF anti-Ri titer of 1:256 and a serum anti-Ri titer of 1:960. Left soleus muscle biopsy showed mild neurogenic changes. Sural nerve biopsy showed well populated myelinated fascicles. Treatment with 1.6 g/kg intravenous immunoglobulin (IVIg) monthly for 6 months did not lead to further improvement, however plasma exchange (PE) for an additional 6 months led to sustained improvement in weakness, fasciculation, hyperreflexia of the legs and ankle clonus on last examination in September 2012, at which time the anti-Ri titer was<1:240.

Machine learning integration of rheumatoid arthritis synovial histology and RNAseq data identifies three disease subtypes

In this study, we sought to refine histologic scoring of rheumatoid arthritis (RA) synovial tissue by training with gene expression data and machine learning.

High titer rheumatoid arthritis antibodies preferentially bind fibrinogen citrullinated by peptidyl arginine deiminase 4.

Most patients with rheumatoid arthritis (RA) harbor antibodies to citrullinated autoantigens such as citrullinated fibrinogen. Two isoforms of peptidylarginine deiminase (PAD), PAD type 2 (PAD2) and PAD4, which catalyze citrullination with different substrate specificities, can be detected in the synovium of RA patients. This study was undertaken to determine whether RA antibodies preferentially bind PAD2‐ or PAD4‐citrullinated fibrinogen.

Dendritic cell vaccines containing lymphocytes produce improved immunogenicity in patients with cancer

BackgroundDendritic cells are currently under investigation for their ability to generate anti-cancer immune responses. No consensus has been reached as to the optimal method of dendritic cell vaccine preparation and is a barrier to success in the field.MethodsOver a course of three separate dendritic cell vaccine studies to treat cancer, we tested two different methods for preparing dendritic cells from peripheral blood mononuclear cells: adherence and antibody-selected CD14+ cells.ResultsSurprisingly, we found that patients who received dendritic cell vaccines generated by the adherence method mounted increased T cell proliferation in response to vaccination. This difference could not be accounted for by dendritic cell vaccine dose, cell surface phenotype or dendritic cell function in vitro. One notable difference between the two vaccine preparation methods was that the dendritic cell vaccine cultures generated by the adherence method contained up to 10% lymphocytes, and these lymphocytes were proliferating and producing IFNγ in response to antigen in vitro at the time of administration.ConclusionsEnhanced immunogenicity of adherence dendritic cell vaccinations may be due to the presence of lymphocytes during dendritic cell culture.Trial registrationClinicaltrials.gov identifiers: NCT00289341, NCT00345293, and NCT00893945