Role of regulatory T cells in acute myeloid leukemia patients undergoing relapse-preventive immunotherapy
Frida Ewald Sander, Malin Nilsson, Anna Rydström, Johan Aurelius, Rebecca E Riise, Charlotta Movitz, Elin Bernson, Roberta Kiffin, Anders Ståhlberg, Mats Brune, Robin Foà, Kristoffer Hellstrand, Fredrik B Thorén, Anna Martner, Frida Ewald Sander, Malin Nilsson, Anna Rydström, Johan Aurelius, Rebecca E Riise, Charlotta Movitz, Elin Bernson, Roberta Kiffin, Anders Ståhlberg, Mats Brune, Robin Foà, Kristoffer Hellstrand, Fredrik B Thorén, Anna Martner
Abstract
Regulatory T cells (Tregs) have been proposed to dampen functions of anti-neoplastic immune cells and thus promote cancer progression. In a phase IV trial (Re:Mission Trial, NCT01347996, http://www.clinicaltrials.gov ) 84 patients (age 18-79) with acute myeloid leukemia (AML) in first complete remission (CR) received ten consecutive 3-week cycles of immunotherapy with histamine dihydrochloride (HDC) and low-dose interleukin-2 (IL-2) to prevent relapse of leukemia in the post-consolidation phase. This study aimed at defining the features, function and dynamics of Foxp3+CD25highCD4+ Tregs during immunotherapy and to determine the potential impact of Tregs on relapse risk and survival. We observed a pronounced increase in Treg counts in peripheral blood during initial cycles of HDC/IL-2. The accumulating Tregs resembled thymic-derived natural Tregs (nTregs), showed augmented expression of CTLA-4 and suppressed the cell cycle proliferation of conventional T cells ex vivo. Relapse of AML was not prognosticated by Treg counts at onset of treatment or after the first cycle of immunotherapy. However, the magnitude of Treg induction was diminished in subsequent treatment cycles. Exploratory analyses implied that a reduced expansion of Tregs in later treatment cycles and a short Treg telomere length were significantly associated with a favorable clinical outcome. Our results suggest that immunotherapy with HDC/IL-2 in AML entails induction of immunosuppressive Tregs that may be targeted for improved anti-leukemic efficiency.
Keywords: Acute myeloid leukemia; IL-2; Immunotherapy; Regulatory T cells.
Conflict of interest statement
Authors Mats Brune and Kristoffer Hellstrand are past or present consultants to the study sponsor (Meda Pharma). Authors Frida Ewald Sander, Kristoffer Hellstrand, Fredrik B. Thorén and Anna Martner hold issued or pending patents protecting the use of histamine dihydrochloride in cancer immunotherapy. Authors Anna Martner, Robin Foà and Fredrik B. Thorén have received honoraria and/or travel grants from the study sponsor. Author Anders Ståhlberg declares stock ownership in TATAA Biocenter. The other authors declare no conflict of interest.
Figures
References
- Knoechel B, Lohr J, Kahn E, Bluestone JA, Abbas AK. Sequential development of interleukin 2-dependent effector and regulatory T cells in response to endogenous systemic antigen. J Exp Med. 2005;202:1375–1386. doi: 10.1084/jem.20050855.
- Kretschmer K, Apostolou I, Hawiger D, Khazaie K, Nussenzweig MC, von Boehmer H. Inducing and expanding regulatory T cell populations by foreign antigen. Nat Immunol. 2005;6:1219–1227. doi: 10.1038/ni1265.
- Yadav M, Stephan S, Bluestone JA. Peripherally induced tregs—role in immune homeostasis and autoimmunity. Front Immunol. 2013;4:232. doi: 10.3389/fimmu.2013.00232.
- Haribhai D, Williams JB, Jia S, et al. A requisite role for induced regulatory T cells in tolerance based on expanding antigen receptor diversity. Immunity. 2011;35:109–122. doi: 10.1016/j.immuni.2011.03.029.
- Wing K, Sakaguchi S. Regulatory T cells exert checks and balances on self tolerance and autoimmunity. Nat Immunol. 2010;11:7–13. doi: 10.1038/ni.1818.
- Lapierre P, Lamarre A. Regulatory T cells in autoimmune and viral chronic hepatitis. J Immunol Res. 2015;2015:479703. doi: 10.1155/2015/479703.
- Littwitz-Salomon E, Akhmetzyanova I, Vallet C, Francois S, Dittmer U, Gibbert K. Activated regulatory T cells suppress effector NK cell responses by an IL-2-mediated mechanism during an acute retroviral infection. Retrovirology. 2015;12:66. doi: 10.1186/s12977-015-0191-3.
- Zou W. Regulatory T cells, tumour immunity and immunotherapy. Nat Rev Immunol. 2006;6:295–307. doi: 10.1038/nri1806.
- Yu P, Lee Y, Liu W, Krausz T, Chong A, Schreiber H, Fu YX. Intratumor depletion of CD4 + cells unmasks tumor immunogenicity leading to the rejection of late-stage tumors. J Exp Med. 2005;201:779–791. doi: 10.1084/jem.20041684.
- Mougiakakos D, Choudhury A, Lladser A, Kiessling R, Johansson CC. Regulatory T cells in cancer. Adv Cancer Res. 2010;107:57–117. doi: 10.1016/S0065-230X(10)07003-X.
- Shang B, Liu Y, Jiang SJ, Liu Y. Prognostic value of tumor-infiltrating FoxP3 + regulatory T cells in cancers: a systematic review and meta-analysis. Sci Rep. 2015;5:15179. doi: 10.1038/srep15179.
- Lai C, August S, Behar R, Polak M, Ardern-Jones M, Theaker J, Al-Shamkhani A, Healy E. Characteristics of immunosuppressive regulatory T cells in cutaneous squamous cell carcinomas and role in metastasis. Lancet. 2015;385(Suppl 1):S59. doi: 10.1016/S0140-6736(15)60374-9.
- Wolf D, Wolf AM, Rumpold H, et al. The expression of the regulatory T cell-specific forkhead box transcription factor FoxP3 is associated with poor prognosis in ovarian cancer. Clin Cancer Res. 2005;11:8326–8331. doi: 10.1158/1078-0432.CCR-05-1244.
- Dohner H, Weisdorf DJ, Bloomfield CD. Acute Myeloid Leukemia. N Engl J Med. 2015;373:1136–1152. doi: 10.1056/NEJMra1406184.
- Martner A, Thoren FB, Aurelius J, Hellstrand K. Immunotherapeutic strategies for relapse control in acute myeloid leukemia. Blood Rev. 2013;27:209–216. doi: 10.1016/j.blre.2013.06.006.
- Shenghui Z, Yixiang H, Jianbo W, Kang Y, Laixi B, Yan Z, Xi X. Elevated frequencies of CD4(+) CD25(+) CD127lo regulatory T cells is associated to poor prognosis in patients with acute myeloid leukemia. Int J Cancer. 2011;129:1373–1381. doi: 10.1002/ijc.25791.
- Szczepanski MJ, Szajnik M, Czystowska M, Mandapathil M, Strauss L, Welsh A, Foon KA, Whiteside TL, Boyiadzis M. Increased frequency and suppression by regulatory T cells in patients with acute myelogenous leukemia. Clin Cancer Res. 2009;15:3325–3332. doi: 10.1158/1078-0432.CCR-08-3010.
- Buggins AG, Milojkovic D, Arno MJ, Lea NC, Mufti GJ, Thomas NS, Hirst WJ. Microenvironment produced by acute myeloid leukemia cells prevents T cell activation and proliferation by inhibition of NF-kappaB, c-Myc, and pRb pathways. J Immunol. 2001;167:6021–6030. doi: 10.4049/jimmunol.167.10.6021.
- Costello RT, Sivori S, Marcenaro E, et al. Defective expression and function of natural killer cell-triggering receptors in patients with acute myeloid leukemia. Blood. 2002;99:3661–3667. doi: 10.1182/blood.V99.10.3661.
- Fauriat C, Just-Landi S, Mallet F, Arnoulet C, Sainty D, Olive D, Costello RT. Deficient expression of NCR in NK cells from acute myeloid leukemia: evolution during leukemia treatment and impact of leukemia cells in NCRdull phenotype induction. Blood. 2007;109:323–330. doi: 10.1182/blood-2005-08-027979.
- Aurelius J, Thoren FB, Akhiani AA, Brune M, Palmqvist L, Hansson M, Hellstrand K, Martner A. Monocytic AML cells inactivate antileukemic lymphocytes: role of NADPH oxidase/gp91(phox) expression and the PARP-1/PAR pathway of apoptosis. Blood. 2012;119:5832–5837. doi: 10.1182/blood-2011-11-391722.
- Hellstrand K, Asea A, Dahlgren C, Hermodsson S. Histaminergic regulation of NK cells. Role of monocyte-derived reactive oxygen metabolites. J Immunol. 1994;153:4940–4947.
- Mellqvist UH, Hansson M, Brune M, Dahlgren C, Hermodsson S, Hellstrand K. Natural killer cell dysfunction and apoptosis induced by chronic myelogenous leukemia cells: role of reactive oxygen species and regulation by histamine. Blood. 2000;96:1961–1968.
- Brune M, Hansson M, Mellqvist UH, Hermodsson S, Hellstrand K. NK cell-mediated killing of AML blasts: role of histamine, monocytes and reactive oxygen metabolites. Eur J Haematol. 1996;57:312–319. doi: 10.1111/j.1600-0609.1996.tb01383.x.
- Asea A, Hermodsson S, Hellstrand K. Histaminergic regulation of natural killer cell-mediated clearance of tumour cells in mice. Scand J Immunol. 1996;43:9–15. doi: 10.1046/j.1365-3083.1996.d01-14.x.
- Kolitz JE, George SL, Benson DM, Jr, et al. Recombinant interleukin-2 in patients aged younger than 60 years with acute myeloid leukemia in first complete remission: results from Cancer and Leukemia Group B 19808. Cancer. 2014;120:1010–1017. doi: 10.1002/cncr.28516.
- Baer MR, George SL, Caligiuri MA, et al. Low-dose interleukin-2 immunotherapy does not improve outcome of patients age 60 years and older with acute myeloid leukemia in first complete remission: cancer and Leukemia Group B Study 9720. J Clin Oncol. 2008;26:4934–4939. doi: 10.1200/JCO.2008.17.0472.
- Blaise D, Attal M, Reiffers J, et al. Randomized study of recombinant interleukin-2 after autologous bone marrow transplantation for acute leukemia in first complete remission. Eur Cytokine Netw. 2000;11:91–98.
- Pautas C, Merabet F, Thomas X, et al. Randomized study of intensified anthracycline doses for induction and recombinant interleukin-2 for maintenance in patients with acute myeloid leukemia age 50 to 70 years: results of the ALFA-9801 study. J Clin Oncol. 2010;28:808–814. doi: 10.1200/JCO.2009.23.2652.
- Lange BJ, Smith FO, Feusner J, et al. Outcomes in CCG-2961, a children’s oncology group phase 3 trial for untreated pediatric acute myeloid leukemia: a report from the children’s oncology group. Blood. 2008;111:1044–1053. doi: 10.1182/blood-2007-04-084293.
- Mao C, Fu XH, Yuan JQ, et al. Interleukin-2 as maintenance therapy for children and adults with acute myeloid leukaemia in first complete remission. Cochrane Database Syst Rev. 2015;11:CD010248.
- Brune M, Castaigne S, Catalano J, et al. Improved leukemia-free survival after postconsolidation immunotherapy with histamine dihydrochloride and interleukin-2 in acute myeloid leukemia: results of a randomized phase 3 trial. Blood. 2006;108:88–96. doi: 10.1182/blood-2005-10-4073.
- Campbell DJ. Control of regulatory T cell migration, function, and homeostasis. J Immunol. 2015;195:2507–2513. doi: 10.4049/jimmunol.1500801.
- Sakaguchi S, Miyara M, Costantino CM, Hafler DA. FOXP3 + regulatory T cells in the human immune system. Nat Rev Immunol. 2010;10:490–500. doi: 10.1038/nri2785.
- Kennedy-Nasser AA, Ku S, Castillo-Caro P, et al. Ultra low-dose IL-2 for GVHD prophylaxis after allogeneic hematopoietic stem cell transplantation mediates expansion of regulatory T cells without diminishing antiviral and antileukemic activity. Clin Cancer Res. 2014;20:2215–2225. doi: 10.1158/1078-0432.CCR-13-3205.
- Kim N, Jeon YW, Nam YS, Lim JY, Im KI, Lee ES, Cho SG. Therapeutic potential of low-dose IL-2 in a chronic GVHD patient by in vivo expansion of regulatory T cells. Cytokine. 2015;78:22–26. doi: 10.1016/j.cyto.2015.11.020.
- Koreth J, Matsuoka K, Kim HT, et al. Interleukin-2 and regulatory T cells in graft-versus-host disease. N Engl J Med. 2011;365:2055–2066. doi: 10.1056/NEJMoa1108188.
- Matsuoka K, Koreth J, Kim HT, et al. Low-dose interleukin-2 therapy restores regulatory T cell homeostasis in patients with chronic graft-versus-host disease. Sci Transl Med. 2013;5:179ra43. doi: 10.1126/scitranslmed.3005265.
- Sander FE, Rydström A, Bernson E, et al. Dynamics of cytotoxic T cell subsets during immunotherapy predicts outcome in acute myeloid leukemia. Oncotarget. 2016;7:7586–7596. doi: 10.18632/oncotarget.7210.
- Martner A, Rydström A, Riise RE, Aurelius J, Anderson H, Brune M, Foa R, Hellstrand K, Thoren FB. Role of natural killer cell subsets and natural cytotoxicity receptors for the outcome of immunotherapy in acute myeloid leukemia. Oncoimmunology. 2016;5:e1041701. doi: 10.1080/2162402X.2015.1041701.
- Martner A, Rydström A, Riise RE, Aurelius J, Brune M, Foa R, Hellstrand K, Thoren FB. NK cell expression of natural cytotoxicity receptors may determine relapse risk in older AML patients undergoing immunotherapy for remission maintenance. Oncotarget. 2015;6:42569–42574. doi: 10.18632/oncotarget.5559.
- Dohner H, Estey EH, Amadori S, et al. Diagnosis and management of acute myeloid leukemia in adults: recommendations from an international expert panel, on behalf of the European LeukemiaNet. Blood. 2010;115:453–474. doi: 10.1182/blood-2009-07-235358.
- Baron U, Floess S, Wieczorek G, et al. DNA demethylation in the human FOXP3 locus discriminates regulatory T cells from activated FOXP3(+) conventional T cells. Eur J Immunol. 2007;37:2378–2389. doi: 10.1002/eji.200737594.
- Bennett CL, Christie J, Ramsdell F, et al. The immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX) is caused by mutations of FOXP3. Nat Genet. 2001;27:20–21. doi: 10.1038/83713.
- Cawthon RM. Telomere length measurement by a novel monochrome multiplex quantitative PCR method. Nucleic Acids Res. 2009;37:e21. doi: 10.1093/nar/gkn1027.
- Morikawa H, Sakaguchi S. Genetic and epigenetic basis of Treg cell development and function: from a FoxP3-centered view to an epigenome-defined view of natural Treg cells. Immunol Rev. 2014;259:192–205. doi: 10.1111/imr.12174.
- Thornton AM, Korty PE, Tran DQ, Wohlfert EA, Murray PE, Belkaid Y, Shevach EM. Expression of Helios, an Ikaros transcription factor family member, differentiates thymic-derived from peripherally induced Foxp3 + T regulatory cells. J Immunol. 2010;184:3433–3441. doi: 10.4049/jimmunol.0904028.
- Wing K, Onishi Y, Prieto-Martin P, Yamaguchi T, Miyara M, Fehervari Z, Nomura T, Sakaguchi S. CTLA-4 control over Foxp3 + regulatory T cell function. Science. 2008;322:271–275. doi: 10.1126/science.1160062.
- Lichtenegger FS, Lorenz R, Gellhaus K, Hiddemann W, Beck B, Subklewe M. Impaired NK cells and increased T regulatory cell numbers during cytotoxic maintenance therapy in AML. Leuk Res. 2014;38:964–969. doi: 10.1016/j.leukres.2014.05.014.
- Moon HW, Kim BH, Park CM, Hur M, Yun YM, Kim SY, Lee MH. CD4 + CD25highFoxP3 + regulatory T-cells in hematologic diseases. Korean J Lab Med. 2011;31:231–237. doi: 10.3343/kjlm.2011.31.4.231.
- Chen Q, Kim YC, Laurence A, Punkosdy GA, Shevach EM. IL-2 controls the stability of Foxp3 expression in TGF-beta-induced Foxp3 + T cells in vivo. J Immunol. 2011;186:6329–6337. doi: 10.4049/jimmunol.1100061.
- Wen Z, Shimojima Y, Shirai T, Li Y, Ju J, Yang Z, Tian L, Goronzy JJ, Weyand CM. NADPH oxidase deficiency underlies dysfunction of aged CD8 + Tregs. J Clin Invest. 2016;126:1953–1967. doi: 10.1172/JCI84181.
- Martelli MF, Di Ianni M, Ruggeri L, et al. HLA-haploidentical transplantation with regulatory and conventional T-cell adoptive immunotherapy prevents acute leukemia relapse. Blood. 2014;124:638–644. doi: 10.1182/blood-2014-03-564401.
- Fessler J, Ficjan A, Duftner C, Dejaco C. The impact of aging on regulatory T-cells. Front Immunol. 2013;4:231. doi: 10.3389/fimmu.2013.00231.
- Bär C, Blasco MA (2016) Telomeres and telomerase as therapeutic targets to prevent and treat age-related diseases. F1000Res. 5. eCollection 2016
- Burnett AK, Goldstone A, Hills RK, Milligan D, Prentice A, Yin J, Wheatley K, Hunter A, Russell N. Curability of patients with acute myeloid leukemia who did not undergo transplantation in first remission. J Clin Oncol. 2013;31:1293–1301. doi: 10.1200/JCO.2011.40.5977.
- Hallett WH, Ames E, Alvarez M, Barao I, Taylor PA, Blazar BR, Murphy WJ. Combination therapy using IL-2 and anti-CD25 results in augmented natural killer cell-mediated antitumor responses. Biol Blood Marrow Transpl. 2008;14:1088–1099. doi: 10.1016/j.bbmt.2008.08.001.
- Bachanova V, Cooley S, Defor TE, et al. Clearance of acute myeloid leukemia by haploidentical natural killer cells is improved using IL-2 diphtheria toxin fusion protein. Blood. 2014;123:3855–3863. doi: 10.1182/blood-2013-10-532531.
- Arenas-Ramirez N, Woytschak J, Boyman O. Interleukin-2: biology, design and application. Trends Immunol. 2015;36:763–777. doi: 10.1016/j.it.2015.10.003.
- Votavova P, Tomala J, Kovar M. Increasing the biological activity of IL-2 and IL-15 through complexing with anti-IL-2 mAbs and IL-15Ralpha-Fc chimera. Immunol Lett. 2014;159:1–10. doi: 10.1016/j.imlet.2014.01.017.
- Perna SK, De Angelis B, Pagliara D, et al. Interleukin 15 provides relief to CTLs from regulatory T cell-mediated inhibition: implications for adoptive T cell-based therapies for lymphoma. Clin Cancer Res. 2013;19:106–117. doi: 10.1158/1078-0432.CCR-12-2143.
Source: PubMed