A phase II study of allogeneic natural killer cell therapy to treat patients with recurrent ovarian and breast cancer
Introduction
Human natural killer (NK) cells are a subset of peripheral blood lymphocytes defined by the expression of CD56 or CD16 and the absence of T-cell receptor (CD3) (1., 2., 3., 4., 5., 6., 7., 8., 9., 10.). NK cells play a role in tumor surveillance and can recognize unhealthy cells with decreased expression of class I major histocompatibility complex (MHC) molecules, referred to as ‘loss of self’ (11,12). In a number of tumor types generally considered unresponsive to chemotherapy, a series of well-publicized trials at the National Cancer Institute (NCI, Bethesda, MD, USA) has documented anti-tumor effects in patients using adoptive cellular immunotherapy (ACT). (13,14). This approach involves harvesting mononuclear cells from patients via lymphapheresis, incubation of the cells ex vivo using high concentrations of the lymphokine interleukin (IL)-2, and administration of the expanded and IL-2-activated cells (lymphokine-activated killer, or LAK, cells) to the patient along with IL-2 administration. Early clinical trials showed modest clinical success using autologous LAK with high-dose IL-2 in lymphoma, melanoma and renal cancers, with the majority of cytotoxicity attributed to NK cells (15). The rationale for this study was the potent function of IL-2-activated allogeneic NK cells, compared with autologous NK cells, against ovarian and breast cancer (16., 17., 18., 19., 20.). We now understand that the failure of autologous NK therapy is partially because of the down-regulation of NK cell killing that occurs with recognition of self-class I MHC on tumor cells, making allogeneic cell transfer more attractive (11,12,21).
Murine models show that depletion of immune cells before ACT enhances the anti-tumor efficacy of transferred donor cells, with a direct correlation between the extent of lymphodepletion and in vivo anti-tumor effect of the transferred cells (22). Lymphodepletion has been shown to augment innate immunity by increasing exposure to homeostatic cytokines (IL-7 and IL-15), eliminating competing elements of the immune system (‘cytokine sinks’) and limiting the number of regulatory T lymphocytes (Treg) and myeloid-derived suppressor cells (23,24). Lymphodepletion followed by ACT has produced approximately 20% complete and partial responses in initial trials at the NCI, with responses occurring primarily in melanoma, renal cell cancers and non-Hodgkin lymphoma (15). A clinical trial assessing the safety and efficacy of related donor, HLA-haplo-identical, allogeneic NK-enriched peripheral blood cell infusion in patients with poor prognosis acute myeloid leukemia (AML) has been completed at the University of Minnesota (25). We learned that infusion of related donor haplo-identical allogeneic NK cell infusions is safe and that successful in vivo donor NK cell expansion, which correlates with efficacy in AML, requires a high-dose cyclophosphamide and fludarabine lymphodepleting preparative regimen (Hi-Cy/Flu). More recently, accumulating data in animal models suggest that further lymphodepletion may improve ACT persistence and efficacy (23,26). Dudley et al. (22) evaluated the efficacy and safety of adding total body irradiation (TBI) to a non-myeloablative chemotherapy preparative regimen in patients with metastatic melanoma. They reported an objective response rate of 50–70%. Additionally, they found increases in homeostatic cytokines IL-7 and IL-15, hypothesized to lead to the persistence, proliferation and activation of the adoptively transferred cells.
Based on the above findings, we evaluated the in vivo expansion and clinical efficacy of an adoptively transferred haplo-identical donor NK cell product in a solid tumor setting following a preparative regimen with and without total body irradiation (TBI).
Section snippets
Patient eligibility
Patients over the age of 18 years with refractory metastatic breast or ovarian cancer with adequate performance status, organ function [total bilirubin, Aspartate transaminase(AST)/Alanine transaminase(ALT) ≤ 5 times upper limits of normal, and creatinine < 2.0 mg/dL, or calculated creatinine clearance ≥50 mL/min for patients with creatinine levels above normal] and hematologic reserve (platelet count greater than 80,000/μL, hemoglobin level greater than 9 gm/dL, and an absolute neutrophil count
Characteristics of the NK cell products
The apheresis products contained a median of 9.5% CD56+ CD3− NK cells (range 4.0–29.6%) prior to manipulation. Following enrichment by CD3 depletion, the final products contained a median of 33% NK cells (range 23.1–55.5%), resulting in a median infused NK cell dose of 2.15 × 107 NK cells/kg (range 8.33 × 106−3.94 × 107). The products were significantly T-cell depleted after processing, with a median of 0.11% CD3+ cells (range 0.03–1.9%), giving a median infused T-cell dose of 5.59 × 104 CD3+
Discussion
We tested the use of adoptively transferred haplo-identical NK cells to treat patients with solid tumors. Following preparation with a Hi-Cy/Flu regimen, donor DNA was detectable 7 days after the NK cell infusion in 79% (15/19) of patients. Although most patients had high percentages of NK cells at day +7, the absolute lymphocyte count was essentially immeasurable at that time-point. After completion of the IL-2 course 14 days after NK cell infusions, the small numbers of donor NK cells found
Acknowledgments
We would like to thank Dixie Lewis and Megan Whitmore for their excellence in study coordination and patient care during this trial, and Giordi Orreggio for his skills in data management. Additionally, we thank Jessica Kuehn-Hajder, MD, for her radiologic expertise in this trial.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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