Bakgrund: Diffust storcelligt B-cellslymfom (DLBCL) är en högmalign cancersjukdom som drabbar B-lymfocyterna, en typ av vita blodkroppar. Incidensen i Sverige är omkring 600 fall per år. Utan effektiv behandling sker sjukdomsprogressionen med ett snabbt förlopp. Under de senaste två årtiondena har behandlingarna som använts i första och andra linjen kunnat bota 60–70% av patienterna med DLBCL. För patienterna som inte svarat på standardbehandlingarna är prognosen mycket allvarlig. YESCARTA är ett nytt genterapiläkemedel som består av patientens egna T-celler modifierade med en chimär antigen receptor (CAR). När CAR T-cellen binder till B-lymfocyter frisätts inflammatoriska mediatorer som orsakar celldöd av både normala och tumöromvandlade B-lymfocyter. Syfte: Hur påverkar behandling med YESCARTA den totala överlevnaden (OS), responsfrekvensen (ORR), progressionsfri överlevnad (PFS), händelsefri överlevnad (EFS), responsduration (DOR), samt komplett och partiell respons (CR & PR) hos patienter med diffust storcelligt B-cellslymfom (DLBCL)? Detta arbete syftar till att systematiskt sammanställa och utvärdera befintlig vetenskaplig litteratur om YESCARTA för att besvara denna frågeställning. Metod: Litteratursökningen utfördes i PubMed. Samtliga MeSH-termer för läkemedlet YESCARTA konsoliderades och filter för observation- och kliniska studier applicerades. Sökningen genererade 34 artiklar, varav 10 kunde inkluderas. Exklusion skedde huvudsakligen av studier som undersökt annat än den terapeutiska effekten av YESCARTA. Resultat: Majoriteten av studierna var av typen fas II. En fas III-studie med varianter i uppföljningstid och undergruppsanalys inkluderades. YESCARTA förefaller vara överlägsen standardbehandling i alla utfallsmått. Resultatet är mest robust för ORR, EFS och PFS. Cirka fyra av fem patienter kan förväntas uppnå remission efter behandling med YESCARTA. Effektfördelen av YESCARTA i OS och DOR är osäker med avseende på statistisk signifikans. Slutsats: För särskilt utvalda patienter med DLBCL är YESCARTA ett effektivt behandlingsalternativ.

Die Durchflusszytometrie und Fluoreszenzmikroskopie sind zentrale Techniken zur Analyse von Zellen, Geweben und Organen. Besonders in der Immunologie werden sie zur Identifizierung und Charakterisierung von Biomolekülen mittels fluoreszenzmarkierter Antikörper verwendet. Fluoreszenzmarker müssen je nach Anwendung hohe Helligkeit, geringe Größe und minimierte Löschung des Signals aufweisen. Stark markierte Konstrukte leiden jedoch oft unter Fluoreszenzlöschung oder großen Molekularmassen. Diese Arbeit untersucht verzweigtes Polyethylenglykol (PEG) als Träger für Fluorophore. PEG-Ketten wurden als räumliche Trennmittel identifiziert und an Aminodextran gekoppelt, wodurch hochgradig multimerisierte Fluorophor-PEG-Dextran-Zwischenprodukte entstanden. Diese Konjugate, gekoppelt mit Antikörpern, zeigen hohe Fluoreszenzintensität und wurden bei der Detektion von CAR SUP-T1-Zellen erfolgreich eingesetzt. PEG-basierte Reagenzien durchdringen jedoch oft die Zellmembran nicht, was für intrazelluläre Ziele und größere Gewebe wichtig ist. Sequentielle Multiplex-Analysen sind durch unvollständige Spaltung und Restsignale problematisch. Deshalb wurden synthetische Peptide als Rückgrat für die Fluorophor-Multimerisierung untersucht. Diese Konstrukte, verbunden mit Nanokörpern, zeigten erhöhte Helligkeit und Gewebepenetration in der Lichtblattmikroskopie von Mausorganen. Zudem wurde ein dualer Entfernungsmechanismus in die REAdyelease-Technologie integriert. Basierend auf Oligonukleotiden, Disulfiden oder Peptiden in Kombination mit Aminodextran konnte eine schnellere Signalreduktion ermöglicht werden. Dies wurde in der Konfokalmikroskopie an einer Pankreastumorzelllinie demonstriert. / Flow cytometry and fluorescence microscopy are crucial for analyzing cells and tissues, especially in immunology, where immunofluorescence is used for identifying, visualizing, and characterizing biomolecules with fluorescently labeled antibodies. These labels must meet various requirements: high brightness, small size, and the ability to be rendered non-fluorescent. However, highly labeled constructs often suffer from fluorescence self-quenching or high molecular masses, limiting their effectiveness. This work demonstrates that branched polyethylene glycol (PEG) serves as an efficient fluorophore multimerization platform for protein labeling. I explored factors critical for preventing fluorophore self-quenching in multi-fluorophore systems. Fluorescent PEGs were multimerized on an amino-dextran scaffold, generating highly multimerized fluorophore-PEG-dextran intermediates. When conjugated to antibodies, these intermediates allowed bright labeling of biomarkers on cells and tissues and were successfully used in detecting CAR SUP-T1 cells. Despite their strengths, PEG-based reagents often lack deep tissue penetration, essential for intracellular targets and 3D organ imaging. To enhance tissue penetration, I designed small peptide-based backbones for fluorophore multimerization. These constructs, coupled with nanobodies, produced homogeneous fluorescent conjugates that quickly penetrated mouse organs and enabled bright staining in light-sheet microscopy. The final part of the thesis focuses on synthesizing labels for cyclic immunofluorescence. I addressed the issue of incomplete label removal by creating erasable conjugates with two release sites. Fluorescent conjugates based on oligonucleotides, disulfides, or peptides combined with amino-dextran can be rapidly erased from labeled epitopes using a dual-release approach. This method was demonstrated in confocal microscopy and used for iterative imaging of biomarkers on a sample of a pancreatic tumor cell line.

Cancer immunotherapy has recently made remarkable clinical progress. Adoptive transfer of T-cells engineered with a chimeric antigen receptor (CAR) against CD19 has been successful in treatment of B-cell leukemia. Patient’s T-cells are isolated, activated, transduced with a vector encoding the CAR molecule and then expanded before being transferred back to the patient. However some obstacles restrict its success in solid tumors. This thesis explores different aspects to improve CAR T-cells therapy of cancer. Ex vivo expanded T-cells are usually sensitive to the harsh tumor microenvironment after reinfusion. We developed a novel expansion method for T-cells, named AEP, by using irradiated and preactivated allo-sensitized allogeneic lymphocytes (ASALs) and allogeneic mature dendritic cells (DCs). AEP-expanded T-cells exhibited better survival and cytotoxic efficacy under oxidative and immunosuppressive stress, compared to T-cells expanded with established procedures. Integrating retro/lentivirus (RV/LV) used for CAR expressions randomly integrate in the T-cell genome and has the potential risk of causing insertional mutagenesis. We developed a non-integrating lentiviral (NILV) vector containing a scaffold matrix attachment region (S/MAR) element (NILV-S/MAR) for T-cells transduction. NILV-S/MAR-engineered CAR T-cells display similar cytotoxicity to LV-engineered CAR T-cells with undetectable level of insertional event, which makes them safer than CAR T-cells used in the clinic today. CD19-CAR T-cells have so far been successful for B-cell leukemia but less successful for B-cell lymphomas, which present semi-solid structure with an immunosuppressive microenvironment. We have developed CAR T-cells armed with H. pylorineutrophil-activating protein (HP-NAP). HP-NAP is a major virulence factor and plays important role in T-helper type 1 (Th1) polarizing. NAP-CAR T-cells showed the ability to mature DCs, attract innate immune cells and increase secretion of Th1 cytokines and chemokines, which presumably leads to better CAR T-cell therapy for B-cell lymphoma. Allogeneic-DCs (alloDCs) were used to further alter tumor microenvironment. The premise relies on initiation of an allo-reactive immune response for cytokine and chemokines secretion, as well as stimulation of T-cell response by bringing in tumor-associated antigen. We demonstrated that alloDCs promote migration and activation of immune cells and prolong the survival of tumor-bearing mice by attracting T-cells to tumors and reverse the immune suppressive tumor microenvironment.

Immunotherapy for cancer is a young research field progressing at high speed. The first chimera of an antibody and a signaling chain was designed by Zelig Eshhar and was later further developed to enhance existing T cell therapy by combining a single-chain fragment of an antibody with the CD3 zeta chain of the TCR complex. T cells expressing these chimeric antigen receptors (CARs) could recognize and specifically kill tumor cells. However the T cells, lacked in persistence and tumor rejection did not occur. Thus, the CAR constructs have been improved by providing the T cell with costimulatory signals promoting activation. The focus of this thesis has been to evaluate second and third generation αCD19-CAR T cells for the treatment of B cell leukemia and lymphoma. B cell tumors commonly upregulate anti-apoptotic proteins such as Bcl-2, which generates therapy resistance. In the first paper a second generation (2G) αCD19-CD28-CAR T cell was combined with the Bcl-2 family inhibitor ABT-737. ABT-737 sensitized tumor cells to CAR T cell therapy and may be an interesting clinical combination treatment. In paper II, the phenotype and function of a third generation (3G) αCD19-CD28-4-1BB-CAR T cell were evaluated. B cell-stimulated CAR T cells showed increased proliferation and an antigen-driven accumulation of CAR+ T cells. 3G CAR T cells had equal cytotoxic capacity, similar lineage, memory and exhaustion profile phenotype compared to 2G CARs. However, 3G CAR T cells proliferated better and had increased activation of intracellular signaling pathways compared to 2G CAR T cells. In paper III, αCD19-CD28-4-1BB-CAR T cells were used to stimulate immature dendritic cells leading to an upregulation of maturation markers on co-cultured dendritic cells. Hence, CAR T cells may not only directly kill the tumor cells, but may induce bystander immunity that indirectly aids tumor control. This thesis also include supplementary information about the development and implementation of protocols for GMP production of CAR T cell batches for a phase I/IIa clinical trial currently ongoing for patients with refractory B cell leukemia and lymphoma. So far, two patients have safely been treated on the lowest dose.

T cells are a cornerstone of the mammalian adaptive immune system. A range of T-cell subsets exist that can orchestrate the overall immune response to pathogens or cancers, either by directly killing infected cells or licensing other cells to do so. Dysregulation of this important process can result in immunodeficiency or autoimmunity. Although T cells have been studied extensively over many decades, the detailed mechanisms underlying T-cell activation remain to be fully resolved. This thesis describes the development of new optogenetic approaches for the modulation of T-cell signalling dynamics and the interrogation of key events in T-cell activation to help investigate this question. Optogenetics is a rapidly emerging technique whereby light can be used to control the spatial and temporal activation, or inactivation of signalling pathways at unprecedented resolution. The methods described in this work utilise the blue light-responsive LOV2 photo-domain from the common oat A. Sativa, which is the foundation of the both the ‘LOVTRAP’ and ‘TULIPs’ optogenetic toolkits. T-cell antigen receptor (TCR) microclusters arise early during the interaction between T cells and antigen presenting cells (APCs). These TCR signalling platforms contain the proteins necessary for sustained T-cell activation, yet the processes underlying their formation and dissociation are still not fully characterised as they have been difficult to investigate with current chemical and genetic manipulations of T cells. Using two optogenetics systems combining either LOVTRAP or TULIPs and the microcluster- scaffolding protein LAT (Linker for the Activation of T cells), it was possible to modulate early T-cell signalling events and measure functional outputs in real-time. Unfortunately, the biological limitations of these LAT-based systems meant that they could not be used to quantitatively investigate microcluster formation. However, in an alternative approach, a drug-inducible, light-controllable chimeric antigen receptor was successfully developed that yielded important new insights into the rapid rate of signal decay within the TCR signalling pathway and the temporal dynamics of T-cell activation over several timescales. T cell-dependent bispecific antibodies (TDBs) are a new class of immuno-therapeutics that can specifically direct a T-cell response towards tumours, by crosslinking the TCR complex to a surface- expressed target on the cancerous cells. However, their mechanism of action has not been studied in detail. The close apposition of the T cell and target cells driven by the TDB interaction can result in the steric exclusion of phosphatases, such as CD45, away from the TCR at the TDB-generated cell-cell interface due to their large, rigid extracellular domains. Using the myeloma-expressed antigen, FcRH5, it was found that membrane-proximal epitopes of FcRH5 drive more robust TCR clustering and increased CD45 exclusion than membrane distal epitopes, which strongly correlated with effective killing of the target cell. These findings have important implications for therapeutic design and implementation of TDBs.

CD133, a pentaspan glycoprotein, has long been known to represent aggressive, stem-like populations across various human malignancies. While its expression correlates with numerous clinical outcomes including disease progression, metastasis, recurrence, and poor overall survival in numerous cancers, little is currently known about its function. In the brain cancer glioblastoma (GBM), CD133-expressing cells have previously been shown to initiate tumours, evade therapy and interestingly, self-renew, a key property of cancer stem cells. With an implied signalling role in driving self-renewal, we aim to elucidate the role of CD133 in glioblastoma. To understand the role of CD133, we aim to study its protein-protein interactions using the proximity-dependent labelling technique known as miniTurboID. By tagging proteins of interest with a promiscuous biotin ligase at both protein termini, potential interactors can be biotinylated and identified by subsequent mass spectrometry. While miniTurboID has traditionally been performed by synthetic transgenes expressing the tagged proteins of interest in commercial cell lines, overexpression may not recapitulate its native function. Thus, using CRISPR technology, we aim to insert the miniTurboID ligase at both the N- and C-terminus of CD133 in patient-derived human GBM lines. Although little is currently known about CD133 function, development of targeted therapies has presented a promising strategy in pre-clinical studies. In the Singh Lab, we previously developed a chimeric antigen receptor T-cell, or CAR-T, comprised of a T-cell expressing a synthetic receptor capable of recognizing a tumor-associated antigen and activating cytolytic-killing directed towards the target cell. Currently, CAR-T therapies are autologous, or patient-derived, in nature which may host a myriad of concerns including patient-specific qualitative and quantitative T-cell dysfunction, inconsistent generation of CAR products, and availability to rapidly progressing patients. To circumvent this concern, “off-the-shelf”, donor-derived or allogeneic CAR-T products may be generated for use in GBM patients. However, in addition to CAR integration, allogeneic products must be additionally modified to eradicate expression of the endogenous TCR, as this would induce a phenomenon known as graft versus host disease, in which healthy tissues are targeted. Thus, in this thesis, we show gene editing potential in human GBMs to perform an endogenous genomic knock-in of miniTurboID. With the identification of interacting proteins, defining the subsequent functionality of CD133 may elucidate oncogenic cellular programs, and highlight common nodes of interaction within divergent cell signaling pathways. To develop an allogeneic CAR-T product, we designed a two-step approach in which the CAR sequence was integrated into the TCR gene for simultaneous knock-out. We later show early pre-clinical efficacy in comparison to traditional autologous CAR-T in our patient-derived models of human GBM. Thus, by using CD133 as a centralizing concept in this thesis, we ultimately hope to develop our biological understanding of CD133, while testing the therapeutic development of a donor-derived CAR-T therapy. / Thesis / Master of Science (MSc) / Glioblastoma (GBM) is one of the most common malignant brain tumors in adults. Despite an aggressive therapy regimen, almost all patients relapse 7-9 months post-diagnosis. Therapy failure and poor patient outcome may be attributed to a small population of cells known as glioblastoma stem cells, or GSCs, that are able to escape therapy and seed disease recurrence. GSCs are most notably identified by the cell surface protein CD133, which has previously been shown to associate with pro-tumor properties including treatment resistance, tumor growth, maintenance, progression and metastasis. While expression of CD133 in cancer has been heavily characterized, little is currently known about its function. One such avenue to understand its mechanism of action in cancer, and more particularly GBM, is to define its interactions with other proteins. Protein-protein interactions play a pivotal part as the backbone of signalling pathways that drive tumor development and growth. Therefore, defining and mapping the CD133 interaction network may help us understand how this protein governs regulation of GSCs, and ultimately, GBM progression. While the biology of CD133 has yet to be elucidated, targeting CD133 on GSCs has presented a promising therapeutic strategy for patients with GBM. Previously in the Singh Lab, we developed an engineered T-cell therapy, known as a CAR-T, that can recognize CD133 to induce tumor cell death. While this showed success in our animal models of human GBM, other considerations must be addressed on its path to clinical development. As of current, CAR-T therapies are generated from T-cells taken from cancer patients. This hosts a myriad of concerns including the quality of patient T-cells, the time and cost to manufacture, and its availability for patients with rapidly progressing disease. To circumvent this issue, donor-derived CAR-T cells can be genetically engineered for safe usage in GBM patients as a readily available, “off-the-shelf” therapy. To define the function of CD133, we have attempted to use a technique known as BioID, which tags the protein of interest with a smaller biotin ligase. This biotin ligase can subsequently tag proteins that come within the vicinity of CD133, that may later be identified by sequencing as potential interactors. As current use of BioID may not reliably mimic the interaction of CD133, we sought to genetically engineer human GBM lines with the BioID protein to more closely resemble tumor-relevant behaviours of CD133. To develop a donor-derived CAR-T therapy, we similarly used genetic engineering of T-cells to ensure specific targeting of tumor cells with CD133, while sparing healthy tissues. By using CD133 as a centralizing concept in this thesis, we ultimately hope to develop our biological understanding of CD133, while testing the therapeutic development of a donor-derived CAR-T therapy.

<p>  </p> <p>Adoptive cell transfer of chimeric antigen receptors (CAR) T cells has successfully targeted hematological malignancies in human patients. However, unpredicted side effects experienced after injection of the CAR T cells suggests the need for an optimal predictive preclinical animal model. Dogs have intact immune systems and develop solid tumors spontaneously with similar morphology and genetics to humans. I hypothesize that generating CAR T cells for dogs will closely mimic human patients' outcomes, thus providing new understandings of the safety of this immunotherapy. In addition to the dog as a preclinical model, we propose using a universal CAR T cell to overcome various tumor-related immunosuppressive challenges and control the killing of the target cells. To achieve this, we established methods for activating and expanding canine T cells to a clinically relevant scale. Then, we expressed a second-generation anti-FITC-8-41BB-ζ CAR T cell via lentiviral transduction. In the presence of the correct low-molecular-weight bispecific adapter, we showed <em>in-vitro</em> CAR-mediated function. Our results proved that it is feasible to generate functional canine anti-FITC-8-BB-ζ CAR T cells for therapy.</p>

Anti-CD19 CAR-T cell immunotherapy is a hopeful treatment option for patients with B cell lymphomas, however it copes with partly severe adverse effects like neurotoxicity. Single-cell resolved molecular data sets in combination with clinical parametrization allow for comprehensive characterization of cellular subpopulations, their transcriptomic states, and their relation to the adverse effects. We here present a re-analysis of single-cell RNA sequencing data of 24 patients comprising more than 130,000 cells with focus on cellular states and their association to immune cell related neurotoxicity. For this, we developed a single-cell data portraying workflow to disentangle the transcriptional state space with single-cell resolution and its analysis in terms of modularly-composed cellular programs. We demonstrated capabilities of single-cell data portraying to disentangle transcriptional states using intuitive visualization, functional mining, molecular cell stratification, and variability analyses. Our analysis revealed that the T cell composition of the patient’s infusion product as well as the spectrum of their transcriptional states of cells derived from patients with low ICANS grade do not markedly differ from those of cells from high ICANS patients, while the relative abundancies, particularly that of cycling cells, of LAG3-mediated exhaustion and of CAR positive cells, vary. Our study provides molecular details of the transcriptomic landscape with possible impact to overcome neurotoxicity.

T cells modified for expression of Chimeric Antigen Receptors (CARs) were the first genemodified cell products approved for use in cancer immunotherapy. CAR-T cells engineered with gammaretroviral or lentiviral vectors (RVs/LVs) targeting B-cell lymphomas and leukemias have shown excellent clinical efficacy and no malignant transformation due to insertional mutagenesis to date. Large-scale production of RVs/ LVs under good-manufacturing practices for CAR-T cell manufacturing has soared in recent years. However, manufacturing of RVs/LVs remains complex and costly, representing a logistical bottleneck for CAR-T cell production. Emerging gene-editing technologies are fostering a new paradigm in synthetic biology for the engineering and production of CAR-T cells. Firstly, the generation of the modular reagents utilized for gene editing with the CRISPR-Cas systems can be scaled-up with high precision under good manufacturing practices, are interchangeable and can be more sustainable in the long-run through the lower material costs. Secondly, gene editing exploits the precise insertion of CARs into defined genomic loci and allows combinatorial gene knock-ins and knock-outs with exciting and dynamic perspectives for T cell engineering to improve their therapeutic efficacy. Thirdly, allogeneic edited CAR-effector cells could eventually become available as “off-the-shelf” products. This review addresses important points to consider regarding the status quo, pending needs and perspectives for the forthright evolution from the viral towards gene editing developments for CAR-T cells.

La thérapie par cellules T à récepteur d'antigène chimérique (CAR) a produit d'incroyables réponses cliniques contre plusieurs tumeurs malignes, mais elle laisse une marge de manœuvre pour l'échappement de l'antigène. Une nouvelle approche pour surmonter ce problème consisterait à combiner la capacité des CAR à cibler les tumeurs avec la capacité des cellules dendritiques (CD) à amorcer les cellules T afin de générer une thérapie cellulaire qui favorise la propagation de l'épitope plutôt que la destruction directe de la cible. J'ai donc émis l'hypothèse que les cellules dendritiques exprimant les CAR (CAR-CD) peuvent renforcer l'amorçage des cellules T contre les cibles tumorales afin de produire un contrôle adaptatif des tumeurs médié par les cellules T. En utilisant des CD dérivées de la moelle osseuse murine, j'ai d'abord développé un nouveau protocole pour générer des CD. En ajoutant de l'IFNα aux cultures de DC GM-CSF, j'ai généré des CD qui expriment des niveaux plus élevés de molécules stimulant les cellules T et qui induisent une plus forte prolifération des cellules T CD8+ in-vitro par rapport aux CD générées avec le GM-CSF seul. In vivo, ces CD favorisent des réponses effectrices plus fortes, les cellules T CD8+ résultantes exprimant des niveaux plus élevés de marqueurs effectrices, notamment KLRG1 et TIM3, mais des niveaux plus faibles de molécules inhibitrices, notamment PD-1 et CD73. L'expression d'un CAR dans ces DC leur permet de tuer directement des cibles tumorales et d'acquérir des antigènes tumoraux. Plus important encore, ces CAR-CD sont en synergie avec les cellules T CD8+ pour contrôler les cellules tumorales in-vitro, en améliorant la prolifération et la capacité de destruction des cellules T. Chez la souris, les CAR-CD agissent comme un vaccin in vivo en favorisant la génération de réponses de cellules T spécifiques de la tumeur lorsqu'elles sont injectées par voie intratumorale, ce qui permet d'améliorer le contrôle de la tumeur. / Chimeric Antigen Receptor (CAR) T cell therapy has produced unbelievable clinical responses against several malignancies however, this therapy leaves room for antigen escape. One novel approach to overcome this would be to combine the tumor targeting ability of CARs with the T cell priming capacity of dendritic cells (DCs) to generate a cell therapy that provokes endogenous adaptive immunity through epitope spreading rather than just direct target killing. Therefore, I hypothesized that CAR expressing DCs (CAR-DCs) can enhance T cell priming against tumor targets to produce adaptive T cell mediated tumor control. Using murine bone marrow derived DCs, I first developed a new protocol for generating DCs using IFNα. The addition of IFNα to GM-CSF DC cultures generated DCs that express higher levels of T cell stimulatory molecules and induce stronger CD8+ T cell proliferation in-vitro compared to DCs generated with GM-CSF alone. In-vivo, these DCs promote stronger effector responses with the resulting CD8+ T cells expressing higher levels of effector markers including KLRG1 and TIM3 but lower levels of inhibitory molecules including PD-1 and CD73. The expression of a CAR in these DCs allowed them to directly kill tumor targets and acquire tumor antigens. More importantly, these CAR-DCs synergized with CD8+ T cells to control tumor cells in-vitro, enhancing the proliferation and killing capacity of the T cells. In mice, CAR-DCs act as an in-vivo vaccine promoting the generation of tumor specific T cell responses when injected intratumorally, producing enhanced tumor control.