京都大学 / 新制・課程博士 / 博士(人間健康科学) / 甲第24292号 / 人健博第107号 / 新制||人健||8(附属図書館) / 京都大学大学院医学研究科人間健康科学系専攻 / (主査)教授 藤井 康友, 教授 岡 昌吾, 教授 滝田 順子 / 学位規則第4条第1項該当 / Doctor of Human Health Sciences / Kyoto University / DFAM

INTRODUCTION: Multiple myeloma (MM) is a disease that results in the production of ineffective immunoglobulins and monoclonal proteins in the blood and urine, leading to insufficient organ function or death. Currently, there is a 5-year survival rate of 47% for patients diagnosed with MM, with a proportion of patients ultimately succumbing to the disease. The current standard of care for MM includes toxic combinations of chemotherapy. The evolution of chimeric antigen receptor (CAR) T-cell therapy for hematologic cancers such as lymphoma, leukemia, and now myeloma has provided another effective treatment option for patients who have relapsed after standard treatments for MM. Idecabtagene Vicleucel (ide-cel), was approved in March 2021 for patients with relapsed and refractory MM. While CAR T-cell treatment appears to be far less toxic than standard chemotherapy, this therapy comes with its own associated toxicities, mainly cytokine release syndrome (CRS) and neurotoxicity (NT). In clinical trials, ide-cel demonstrated to be an effective treatment in some patients, leading to the FDA approval for patients who have exhausted multiple other lines of therapy. Currently, it is unclear why patients respond differently to CAR T-cell treatment and why some patients present with more severe toxicity than others. Therefore, this study aims to examine patient factors such as demographics, age, and treatment history to determine if such characteristics may influence the CAR T-cell response; also, we assess the efficacy of ide-cel in a real-world experience outside of a clinical trial. METHODS: In this study, 14 patients’ medical records were reviewed after receiving commercial CAR T-cell therapy between August 2021 and January 2022. Eligible patients for the therapy were determined by strict inclusion criteria, including having a confirmed diagnosis of MM and exhausting at least four prior lines of therapy, as well as exclusion criteria, such as excluding individuals who have received CAR T-cells prior in a clinical trial setting. Approximately one month before preparation lymphodepletion chemotherapy, eligible patients underwent leukapheresis and had their blood sent to a laboratory to extract T-cells and genetically modify them to express the CAR for reinfusion. On 3 and 5 days prior to CAR T-cell infusion, patients underwent lymphodepletion using fludarabine and cyclophosphamide. Patients remained in the hospital for approximately one week following infusion, pending adverse reactions. After discharge, patients returned to the hospital for routine follow-ups. Data analysis was then performed on collected clinical readouts such as: prior treatments, bone marrow biopsies, response rates, laboratory values from blood samples, and pre- and post-infusion scans of various tissues within the body. RESULTS: At a median follow-up time of 15 weeks, six patients (43%) achieved a complete response (CR), three patients demonstrated a partial response (PR, 21%), and four patients showed disease progression (PD, 28%). Post-infusion scans were not available for one subject (7%) as they were still in the hospital. These results are similar to the phase I and phase II trials in which 45% and 33% of patients demonstrated a CR post-infusion, respectively. As for associated toxicities, 10 patients (71%) experienced CRS and one patient (7%) presented with ICANS. All patients that achieved a CR experienced ide-cel related toxicities, compared with only 38% of those with less favorable or unknown outcomes, which indicates that systemic immune system activation which causes CRS may be required to achieve a CR but CRS is not always linked with a CR outcome. There were 28 different chemotherapy regimens used as the standard of care treatment prior to ide-cel therapy. We assessed the most recent chemotherapeutic regimen in each patient to assess whether there is an association with most recent treatment and response. Of the six patients that achieved a CR to ide-cel, all were previously treated with RVD or CyBorD regimens, compared to the four patients who had disease progression who were mainly treated with salvage DCEP chemotherapy. Four patients (29%) received DCEP as their final chemotherapy regimen, and 3 of these 4 (75%) demonstrated progressive disease after ide-cel. Two patients received Belantamab-Mafodotin prior to ide-cel treatment, with one patient presenting with disease progression and the other patient achieving CR. 71% of patients experienced CRS following ide-cel infusion, which is resembles the phase II trial of ide-cel in which 84% of patients demonstrated CRS. In this study, only 7% of patients experienced neurological toxicity, which is comparable to the 18% of patients that demonstrated to have ICANS in the phase II study. CONCLUSIONS: We found similar performance of the ide-cel CAR-T therapy in the real world setting as in the clinical trial. Also, the complete responses were achieved by subjects with an array of characteristics, including varying recent chemotherapeutic treatments, IgG, IgA, and light-chain only subtypes of MM, and diverse demographics and other characteristics. The characteristic that demonstrated the most predictability and somewhat unique to subjects with CR was the associated toxicities from ide-cel. Development of these associated toxicities may attest that substantial immune activation, of CAR T-cells and other immune cells, leads to the efficacy of the product in eliminating cancer cells. Further analysis will need to be completed as more individuals enroll in this study to be able to determine if there are significant associations between demographics and prior lines of treatment with response to ide-cel CAR-T therapy. Lastly, future studies should assess the immune cell effector functions that are generated in CR patients that will help to specify the association between ide-cel activation, experienced associated toxicities, and its efficacy.

Changes in the microenvironment have been implicated in the transition of pre-invasive ductal carcinoma in-situ (DCIS) to invasive breast cancer. Normal myoepithelial cells have a tumour suppressor phenotype but they are altered in DCIS and ultimately lost with transition to invasive cancer. A consistent change in DCIS is up-regulation of the integrin αvβ6 in myoepithelial cells. Preliminary observations identified a correlation between myopeithelial αvβ6 and an increased peri-ductal inflammatory infiltrate. The hypothesis of this study is that the altered myoepithelial phenotype influences the peri-ductal inflammatory environment, which in turn mediates a pro-apoptotic effect on myoepithelial cells contributing to their loss. To investigate this, the inflammatory infiltrate was characterised in a series of DCIS tissue in relation to αvβ6 status. This demonstrated significantly higher levels of CD4+ve and FOXP3+ve T cells around αvβ6+ve DCIS ducts compared to αvβ6-ve ducts (P=<0.01), suggesting an increase in Treg cells. In-vivo, Matrigel plugs containing injected into the flanks of female C57/Blk6 normal mice generated influx of higher levels of CD4+ve cells (p=0.005) and FOXP3+ T cells (p=0.007) in the presence of αvβ6+ve myoepithelial cells compared to αvβ6-ve cells, supporting the findings in human tissue samples. Since Treg cells produce TRAIL that can induce apoptosis, we investigated the influence of αvβ6 on myoepithelial cells on the levels of TRAIL in T cells and the hypothesis that αvβ6-positive myoepithelial ells may be more susceptible to TRAIL-induced apoptosis, leading to loss of the myoepithelial barrier. Firstly, levels of TRAIL in Jurkat and primary T cell populations co-cultured with β4 (ii) or β6 myoepithelial cells were measured. This demonstrated a higher level of TRAIL in primary T cells co-cultured β6 myoepithelial cells compared to those co-cultured with β4 myoepithelial cells. β6+ve and β6-ve myoepithelial cells were exposed to TRAIL, and this demonstrated that TRAIL enhanced apoptosis, measured by cleaved PARP, in β6+ve cells. Furthermore, these cells showed loss of the anti-apoptotic protein Galectin-7, and knockdown of Galectin-7 in normal β6-ve myoepithelial cells rendered them more susceptible to TRAIL-induced apoptosis. In DCIS tissues, an inverse relationship between αvβ6 and Galectin-7 in myoepithelial cells was demonstrated, and Cytokine Array analysis showed that αvβ6+ve myoepithelial cells express higher levels of IL-16, which has a role in Treg cell recruitment. Taken together these results suggest that expression of αvβ6 by myoepithelial cells in DCIS generates a tumour-promoter peri-ductal inflammatory infiltrate through altered cytokine release, is associated with reduced galectin-7 expression and enhances myoepithelial cell apoptosis in response to TRAIL. This provides a potential mechanism by which myoepithelial cells may be lost during evolution of DCIS and so contribute to progression to invasive disease.

The aim of cancer immunotherapy is to eradicate tumours by inducing a tumour-specific immune response. This thesis focuses on how antibodies and peptides can improve antigen presentation and the subsequent tumour-specific T cell response. Tumour recognition by the immune system can be promoted through delivery of antigen in the form of a vaccine. One example is the development of a therapeutic peptide vaccine containing both CD4+ and CD8+ T cell epitopes. So far, peptide vaccinations have shown limited success in clinical trials and further improvements are needed, such as choice of adjuvant and T cell epitopes, as well as targeted delivery of peptides and adjuvants to the same DC. In paper I, we describe the development of a peptide-peptide conjugate (with a tumour T cell epitope) that, via immune complex formation and FcγR binding, enhance antigen uptake and activation of DCs. The conjugate consists of three tetanus toxin-derived linear B cell epitopes (MTTE) that were identified based on specific IgG antibodies in human serum. Three MTTE peptide sequences were conjugated to a synthetic long peptide (SLP) that consists of a T cell epitope derived from the desired target tumour. In paper II, the conjugate was evaluated in a modified Chandler loop model containing human blood, mimicking blood in circulation. The conjugate was internalised by human monocytes in an antibody-dependent manner. A conjugate containing the model CMV-derived T cell epitope pp65NLV generated recall T cell responses dependent on MTTE-specific antibodies and the covalent conjugation of the three MTTE with the SLP. In paper III, a CD40-specific antibody was characterised for local treatment of solid tumours. The antibody eradicated bladder tumours in mice and induced T cell-mediated immunological memory against the tumour. In paper IV, we characterised the Chandler loop model (used in paper II) for its potential use in predicting cytokine release syndrome (CRS) in response to monoclonal antibodies (mAbs). Superagonistic antibodies (e.g., OKT3) induced rapid cytokine release whereas no cytokine release was induced by antibodies (e.g., cetuximab) associated with low incidence of CRS in the clinic. In conclusion, this thesis work demonstrates proof-of-concept of improved strategies for antibody- and peptides-based cancer immunotherapies and their potential use in multiple cancer indications.

PURPOSE OF REVIEW: This review article aims to explore the GI changes induced by SARS-CoV-2 and how gut microbial homeostasis can influence these changes and affect the lung-gut axis and its relationship with the induction of the cytokine release syndrome in severe COVID-19 patients. RECENT FINDINGS: Coronavirus disease 2019 (COVID-19) affects not only the respiratory system but can produce multi-systemic damage. The expression of angiotensin-converting enzyme 2 (ACE-2) receptors in the gastrointestinal (GI) tract, the high prevalence of GI symptoms in severely ill COVID-19 patients, and the abnormalities described in the gut microbiome in these patients have raised concerns about the influence of GI tract as a risk factor or as a potential modulator to reduce the severity of COVID-19. Understanding the mechanisms by which gut dysbiosis may influence viral transmission and disease progression in COVID-19 may help in shaping how accessible therapies, like diet modulation, can potentially help beat the devastating consequences of COVID-19.

Lectinas consistem de um vasto grupo de proteínas de origem não-imunológica e de caráter não enzimático, que reconhecem carboidratos de modo específico e não-covalente. Além disso, essas proteínas participam de vários eventos fisiológicos e patológicos, com embriogenese, resposta imunológica, apoptose, diferenciação celular e câncer. Recentemente, foi purificada da peçonha da serpente Bothrops atrox uma lectina do tipo-C, ligante de lactose, com propriedades bioquímicas e funcionais semelhantes à de outras lectinas de serpentes do gênero, denominada Galatrox. O presente projeto teve como objetivos a investigação do envolvimento da Galatrox no processo inflamatório agudo através de experimentos in vivo e in vitro e a produção de anticorpos policlonais anti-Galatrox. A lectina isolada foi obtida através de dois processos cromatográficos, apresentando um valor final de recuperação protéica de 0,3% (mg) em relação ao conteúdo protéico da peçonha bruta. De modo interessante, a Galatrox conjugada ao fluorocromo FITC (8µg/mL) foi capaz de ligar-se a superfície de neutrófilos (91,47%±0,5650). Além disso, está proteína reconheceu a laminina imobilizada, e não a fibronectina, uma glicoproteína da matriz extracelular que contém sequencias de poli-N-acetillactosamina. Avaliando seu potencial inflamatório, Galatrox mostrou-se capaz de induzir a migração de neutrófilos humanos in vitro de forma dose-dependente, tendo máxima atividade quimiotática na concentração de 32µg/mL (41,57±3,42 neutrófilos por campo). Apesar da Galatrox induzir um discreto nível de burst oxidativo em neutrófilos humanos não primados, ela apresentou um efeito três vezes maior quando essas células foram primadas com fMLP. Esta lectina quando injetada na cavidade peritoneal de camundongos Balb/C provocou migração leucocitária, sendo que na dose (50g/cavidade) e no tempo (4 horas) ótimos ocorreu um influxo celular de 2,05x106±0,101 leucócitos/mL. Ainda, esse infiltrado celular mostrou-se, basicamentre, composto por neutrófilos. Avaliando o perfil de mediadores da resposta inflamatória nesse ensaio in vivo, nos lavados peritoneais foi indicada a liberação máxima de IL-1 e IL-6 após 4 horas de tratamento, mas não foram detectadas a presença de TNF- e óxido nitrico em qualquer tempo de resposta. Células de baços murinos tratados com Galatrox produziram as citocinas pró-inflamatórias TNF- e IFN- e não produziram IL-10 ou NO. A produção de anticorpos policlonais foi realizada por imunização de camundongos e purificação cromatografia de afinidade em colunas com Galatrox imobilizada. A monitoração por ELISA e Western blot comprovaram a produção de anticorpos da classe IgG anti-Galatrox reconhecedores da lectina em sua forma nativa e desnaturada além de suas formas monoméricas e diméricas. Em todos os ensaios biológicos que a Galatrox foi testada na presença da lactose (carboidrato ligante da Galatrox, 20 mM) ocorreram inibições significativas das atividades dessa lectina, indicando que o seu domínio de reconhecimento de carboidrato participa das funções dessa molécula. Com base nos resultados obtidos é possível sugerir que a Galatrox participe da resposta imune inata por mediar eventos biológicos da resposta inflamatória aguda. No entanto, a lectina mostrou-se como um moderado agente pró-inflamatória, quando relacionada à peçonha bruta tendo em vista a fisiopatologia inflamatória do envenenamento. O anticorpo anti-Galatrox poderá ser usado como uma importante ferramenta estudos moleculares e funcionais dessa lectina de serpente. / Lectins are proteins with no enzymatic activity and are able to bind specifically and non-covalently (reversible manner) to carbohydrates. In addition, these proteins are involved in several physiological and pathological events, as embryogenesis, immune response, cancer, and others. Galatrox, a lactose-binding protein, was purified from Bothrops atrox snake venom and partially characterized concerning its biochemical and functional properties. The present work aimed to investigate the involvement of Galatrox in the inflammatory process. In addition, was carry out the production of a polyclonal antibody against Galatrox. This lectin was purified by one chromatographic step with yield around 0.3% (w/w) of total protein from Bothrops atrox crude venom. Interestingly, Galatrox-FITC (8g/mL) binds on human neutrophil surface (91.47% ± 0.5650). Also, this lectin recognized laminin, but not fibronectin, a glycoprotein of the extracellular matrix that contains poly-N-acetyllactosamine sequences. Galatrox was able to induce human neutrophils migration in vitro in a dose-dependent manner, with maximum chemotactic activity at 32g/mL (41.57 ± 3.42 neutrophils per well). Galatrox is more efficient to induce oxidative burst on fMLP primed neutrophils rather than non-primed neutrophils. When injected into mouse peritoneal cavity, Galatrox induced dose and time-dependent leukocyte migration, with optimal effect at 50g/animal after 4 hours of the injection (2.05x106±0.101 leukocytes/mL). Galatrox also induced release of IL-1 and IL-6 up to 12 hours after injection in the peritoneal cavity. However, TNF- and NO were not detected. The treatment of splenocytes with Galatrox in vitro promotes the production of INF- and TNF-. The biological activities of Galatrox were inhibited by lactose (specific sugar, 20 mM), indicating that its recognition carbohydrate domain participates of its functions. The production of polyclonal antibody anti-Galatrox was performed by immunization of mice and purified by affinity chromatography using immobilized Galatrox resin. Gamma-globulins against Galatrox were able to recognize this lectin under native and reduced conditions, using ELISA and Western-blot, respectively. The antibody anti-Galatrox can be use as important tool to further molecular and functional characterization of this snake venom lectin. These results suggest that Galatrox is immunogenic and may participate in the acute inflammatory process, acting as a pro-inflammatory agent through its lectin property.

Lectinas consistem de um vasto grupo de proteínas de origem não-imunológica e de caráter não enzimático, que reconhecem carboidratos de modo específico e não-covalente. Além disso, essas proteínas participam de vários eventos fisiológicos e patológicos, com embriogenese, resposta imunológica, apoptose, diferenciação celular e câncer. Recentemente, foi purificada da peçonha da serpente Bothrops atrox uma lectina do tipo-C, ligante de lactose, com propriedades bioquímicas e funcionais semelhantes à de outras lectinas de serpentes do gênero, denominada Galatrox. O presente projeto teve como objetivos a investigação do envolvimento da Galatrox no processo inflamatório agudo através de experimentos in vivo e in vitro e a produção de anticorpos policlonais anti-Galatrox. A lectina isolada foi obtida através de dois processos cromatográficos, apresentando um valor final de recuperação protéica de 0,3% (mg) em relação ao conteúdo protéico da peçonha bruta. De modo interessante, a Galatrox conjugada ao fluorocromo FITC (8µg/mL) foi capaz de ligar-se a superfície de neutrófilos (91,47%±0,5650). Além disso, está proteína reconheceu a laminina imobilizada, e não a fibronectina, uma glicoproteína da matriz extracelular que contém sequencias de poli-N-acetillactosamina. Avaliando seu potencial inflamatório, Galatrox mostrou-se capaz de induzir a migração de neutrófilos humanos in vitro de forma dose-dependente, tendo máxima atividade quimiotática na concentração de 32µg/mL (41,57±3,42 neutrófilos por campo). Apesar da Galatrox induzir um discreto nível de burst oxidativo em neutrófilos humanos não primados, ela apresentou um efeito três vezes maior quando essas células foram primadas com fMLP. Esta lectina quando injetada na cavidade peritoneal de camundongos Balb/C provocou migração leucocitária, sendo que na dose (50g/cavidade) e no tempo (4 horas) ótimos ocorreu um influxo celular de 2,05x106±0,101 leucócitos/mL. Ainda, esse infiltrado celular mostrou-se, basicamentre, composto por neutrófilos. Avaliando o perfil de mediadores da resposta inflamatória nesse ensaio in vivo, nos lavados peritoneais foi indicada a liberação máxima de IL-1 e IL-6 após 4 horas de tratamento, mas não foram detectadas a presença de TNF- e óxido nitrico em qualquer tempo de resposta. Células de baços murinos tratados com Galatrox produziram as citocinas pró-inflamatórias TNF- e IFN- e não produziram IL-10 ou NO. A produção de anticorpos policlonais foi realizada por imunização de camundongos e purificação cromatografia de afinidade em colunas com Galatrox imobilizada. A monitoração por ELISA e Western blot comprovaram a produção de anticorpos da classe IgG anti-Galatrox reconhecedores da lectina em sua forma nativa e desnaturada além de suas formas monoméricas e diméricas. Em todos os ensaios biológicos que a Galatrox foi testada na presença da lactose (carboidrato ligante da Galatrox, 20 mM) ocorreram inibições significativas das atividades dessa lectina, indicando que o seu domínio de reconhecimento de carboidrato participa das funções dessa molécula. Com base nos resultados obtidos é possível sugerir que a Galatrox participe da resposta imune inata por mediar eventos biológicos da resposta inflamatória aguda. No entanto, a lectina mostrou-se como um moderado agente pró-inflamatória, quando relacionada à peçonha bruta tendo em vista a fisiopatologia inflamatória do envenenamento. O anticorpo anti-Galatrox poderá ser usado como uma importante ferramenta estudos moleculares e funcionais dessa lectina de serpente. / Lectins are proteins with no enzymatic activity and are able to bind specifically and non-covalently (reversible manner) to carbohydrates. In addition, these proteins are involved in several physiological and pathological events, as embryogenesis, immune response, cancer, and others. Galatrox, a lactose-binding protein, was purified from Bothrops atrox snake venom and partially characterized concerning its biochemical and functional properties. The present work aimed to investigate the involvement of Galatrox in the inflammatory process. In addition, was carry out the production of a polyclonal antibody against Galatrox. This lectin was purified by one chromatographic step with yield around 0.3% (w/w) of total protein from Bothrops atrox crude venom. Interestingly, Galatrox-FITC (8g/mL) binds on human neutrophil surface (91.47% ± 0.5650). Also, this lectin recognized laminin, but not fibronectin, a glycoprotein of the extracellular matrix that contains poly-N-acetyllactosamine sequences. Galatrox was able to induce human neutrophils migration in vitro in a dose-dependent manner, with maximum chemotactic activity at 32g/mL (41.57 ± 3.42 neutrophils per well). Galatrox is more efficient to induce oxidative burst on fMLP primed neutrophils rather than non-primed neutrophils. When injected into mouse peritoneal cavity, Galatrox induced dose and time-dependent leukocyte migration, with optimal effect at 50g/animal after 4 hours of the injection (2.05x106±0.101 leukocytes/mL). Galatrox also induced release of IL-1 and IL-6 up to 12 hours after injection in the peritoneal cavity. However, TNF- and NO were not detected. The treatment of splenocytes with Galatrox in vitro promotes the production of INF- and TNF-. The biological activities of Galatrox were inhibited by lactose (specific sugar, 20 mM), indicating that its recognition carbohydrate domain participates of its functions. The production of polyclonal antibody anti-Galatrox was performed by immunization of mice and purified by affinity chromatography using immobilized Galatrox resin. Gamma-globulins against Galatrox were able to recognize this lectin under native and reduced conditions, using ELISA and Western-blot, respectively. The antibody anti-Galatrox can be use as important tool to further molecular and functional characterization of this snake venom lectin. These results suggest that Galatrox is immunogenic and may participate in the acute inflammatory process, acting as a pro-inflammatory agent through its lectin property.

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