Ubiquitination is essential for recovery of cellular activities after heat shock – Science Magazine

Tailoring stress responses

When faced with environmental stress, cells respond by shutting down cellular processes such as translation and nucleocytoplasmic transport. At the same time, cells preserve cytoplasmic messenger RNAs in structures known as stress granules, and many cellular proteins are modified by the covalent addition of ubiquitin, which has long been presumed to reflect degradation of stress-damaged proteins (see the Perspective by Dormann). Maxwell et al. show that cells generate distinct patterns of ubiquitination in response to different stressors. Rather than reflecting the degradation of stress-damaged proteins, this ubiquitination primes cells to dismantle stress granules and reinitiate normal cellular activities once the stress is removed. Gwon et al. show that persistent stress granules are degraded by autophagy, whereas short-lived granules undergo a process of disassembly that is autophagy independent. The mechanism of this disassembly depends on the initiating stress.

Science, abc3593 and abf6548, this issue p. eabc3593 and p. eabf6548; see also abj2400, p. 1393

In response to many types of stress, eukaryotic cells initiate an adaptive and reversible response that includes down-regulation of key cellular activities along with sequestration of cytoplasmic mRNAs into structures called stress granules. Accompanying these stress responses is a global increase in ubiquitination that has been conventionally ascribed to the need for degradation of misfolded or damaged proteins. However, detailed characterization of how the ubiquitinome is reshaped in response to stress is lacking. Furthermore, it is unclear whether stress-dependent ubiquitination plays a more complex role in the larger stress response beyond its known protective function in targeting hazardous proteins for proteasomal degradation.

To explore the role of ubiquitination in the stress response, we used tandem ubiquitin binding entity (TUBE) proteomics to investigate changes to the ubiquitination landscape in response to five different types of stress in cultured mammalian cells, including human induced pluripotent stem cell (iPSC)derived neurons. The discovery of unanticipated patterns of ubiquitination prompted a detailed analysis of the ubiquitination pattern specifically induced by heat shock by using diGly ubiquitin remnant profiling along with tandem mass tag quantitative proteomics in combination with additional total proteome and transcriptome analyses. Insights from this newly defined heat shock ubiquitinome guided subsequent investigation of the functional importance of this posttranslational modification in the cellular response to heat shock.

Each of the five different types of stress induced a distinctive pattern of ubiquitination. The heat shock ubiquitinome in human embryonic kidney 293T cells was defined by ubiquitination of specific proteins that function within cellular activities that are down-regulated during stress (e.g., translation and nucleocytoplasmic transport), and this pattern was similar in U2OS cells, primary mouse neurons, and human iPSC-derived neurons. The heat shock ubiquitinome was also enriched in protein constituents of stress granules. Suprisingly, this stress-induced ubiquitination was dispensable for the formation of stress granules and shutdown of cellular pathways; rather, heat shockinduced ubiquitination was a prerequisite for p97/valosin-containing protein (VCP)mediated stress granule disassembly and for resumption of normal cellular activities, including nucleocytoplasmic transport and translation, upon recovery from stress. Many ubiquitination events were specific to one or another stress. For example, ubiquitination was required for disassembly of stress granules induced by heat stress but dispensable for disassembly for stress granules induced by oxidative (arsenite) stress.

Ubiquitination patterns are specific to different types of stress and indicate additional regulatory functions for stress-induced ubiquitination beyond the removal of misfolded or damaged proteins. Specifically, heat shockinduced ubiquitination primes the cell for recovery from stress by targeting specific proteins involved several pathways down-regulated during stress. Furthermore, some key stress granule constituents are ubiquitinated in response to heat stress but not arsenite stress, thus engaging a mechanism of VCP mediateddisassembly of heat shockinduced granules that is not shared by arsenite stressinduced granules. Finally, our deep proteomics datasets provide a rich community resource illuminating additional aspects of the roles of ubiquitination in response to stress.

(A) Proteomics-based ubiquitinome profiling reveals that different stresses induce distinct patterns of ubiquitin conjugation. TEV, tobacco etch virus protease cleavage site; Ub, ubiquitin; UBA, ubiquitin-associated domain; UV, ultraviolet. (B) Heat stressinduced ubiquitination targets proteins associated with cellular activities down-regulated during stress, including nucleocytoplasmic (NC) transport and translation, as well as stress granule constituents. This ubiquitination is required for the timely resumption of biological activity and stress granule disassembly after the removal of stress. mRNP, messenger ribonucleoprotein.

Eukaryotic cells respond to stress through adaptive programs that include reversible shutdown of key cellular processes, the formation of stress granules, and a global increase in ubiquitination. The primary function of this ubiquitination is thought to be for tagging damaged or misfolded proteins for degradation. Here, working in mammalian cultured cells, we found that different stresses elicited distinct ubiquitination patterns. For heat stress, ubiquitination targeted specific proteins associated with cellular activities that are down-regulated during stress, including nucleocytoplasmic transport and translation, as well as stress granule constituents. Ubiquitination was not required for the shutdown of these processes or for stress granule formation but was essential for the resumption of cellular activities and for stress granule disassembly. Thus, stress-induced ubiquitination primes the cell for recovery after heat stress.

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Ubiquitination is essential for recovery of cellular activities after heat shock - Science Magazine

The CCL2-CCR2 astrocyte-cancer cell axis in tumor extravasation at the brain – Science Advances

INTRODUCTION

An estimated 20% of all cancer patients develop metastatic tumors at the brain (1). Highly lethal with a 30% 5-year survival rate (2), these metastases stem from circulating tumor cells (TCs) in brain capillaries, originating predominantly from lung, breast, melanoma, or colorectal primary cancers (3), that transmigrate into the parenchyma. This occurs despite the fact that the interface between brain capillaries and tissue, also termed blood-brain barrier (BBB), is one of the tightest vascular barriers in humans and is characterized by highly regulated transport mechanisms (4).

The vast majority of studies on the mechanisms of brain metastasis have focused on TC survival and proliferation following transmigration, once cells are lodged in the brain tissue (59). For instance, interactions, in the brain parenchyma, between TCs and brain astrocytes (ACs) have been shown to promote the secretion of inflammatory factors by ACs via connexin 43 gap junctions, which, in turn, support tumor growth and chemoresistance (6). Although these findings provide insights into cellular interactions and signaling pathways used by metastatic cancer cells to survive and proliferate in the brain tissue, extravasation precedes growth at the secondary site and is a rate-regulating event in the metastatic cascade, where ~40% of extravasated TCs are able to colonize and successfully establish metastases within the brain (10, 11). Despite the importance of extravasation in the development of metastases and the significant fraction of cancer patients that develop brain metastases, the processes that govern extravasation from blood to brain remain poorly understood.

Difficulties in disentangling the mechanisms responsible for the extravasation step from those promoting colonization and outgrowth in the brain have impeded in-depth understanding of the processes underlying brain metastasis. In addition, conducting high spatiotemporal resolution imaging in vivo has been challenging. To address these limitations, a few studies have used in vitro models to investigate the mechanisms of TC extravasation at the brain. Among these models, two-dimensional (2D) Transwell coculture systems have been and continue to be frequently used, including cocultures of ACs with human umbilical vein endothelial cells (ECs) (12) or brain ECs (13). These high-throughput 2D in vitro extravasation platforms (12, 13) have revealed important insights into the molecular mechanisms mediating extravasation at the brain; however, they cannot recapitulate TC circulation, arrest, and extravasation from three-dimensional (3D) brain capillaries, which occur in vivo (1214). To overcome the major limitations of current in vivo and in vitro brain extravasation models, we used a 3D platform designed by our group (15) that recapitulates BBB capillaries with microvascular networks (MVNs) composed of induced pluripotent stem cellderived ECs (iPS-ECs), brain pericytes (PCs), and ACs into which we perfused circulating TCs to study extravasation at the brain.

In addition to the triculture BBB model, we used three variants incorporating different combinations of iPS-ECs and brain stromal cells to dissect the individual roles of PCs, ACs, and their secreted factors on TC extravasation. The all-inclusive triculture model with iPS-ECs, PCs, and ACs (15) was found to be the most robust system, faithfully recapitulating the extravasation microenvironment of the human BBB in vivo.

In this triculture 3D BBB platform, where distinct cellular and molecular interactions governing extravasation can be observed and quantified in real time or by end point analysis, we uncovered a central role for the C-C motif chemokine ligand 2 (CCL2)C-C chemokine receptor type 2 (CCR2) signaling pathway in brain extravasation, where ACs directly promote TC transmigration through CCL2 secretion. These findings were further validated in vivo, confirming that this moderate-throughput human BBB-on-a-chip system can provide unparalleled strength in dissecting cellular and molecular mechanisms underlying the extravasation of cancer cells at the brain and could serve as a robust, complementary method to in vivo approaches.

To investigate mechanisms governing TC extravasation at the brain and the roles of different stromal cells in this rate-limiting step of brain metastasis, we designed four MVN platforms in a single gel-channel microfluidic device (1517): (i) a monoculture of iPS-EC, (ii) a coculture of iPS-EC and PC, (iii) a coculture of iPS-EC and AC, and (iv) a triculture of iPS-EC, PC, and AC as our BBB microvascular model (Fig. 1A). Notably, iPS-ECs are used in this assay owing to their superior plasticity and ability to self-assemble into perfusable MVNs in both the presence and absence of PCs and/or ACs compared to other EC lines (18, 19). The sequential addition of PCs and ACs allowed us to isolate their individual contributions on TC extravasation.

(A) Schematic of the microfluidic chip used in the study to generate four MVN platforms from the sequential addition of PCs and ACs to iPS-ECs. (B) MDA-MB-231 (MDA-231) cells perfused in the triculture MVNs and left to extravasate for 6 hours. Examples of extravasated and intravascular TCs are shown. (C) Extravasation efficiencies of breast MDA-231, breast SKBR3, lung A549, and prostate 22Rv1 in the four MVN platforms at 24 hours after perfusion. (D) MVN permeability to 40 kDa of dextran in the four platforms considered. Permeability is also assessed in the presence of MDA-231 TCs and their conditioned media (CM). (E) Representative images of triculture MVNs perfused with 40-kDa fluorescein isothiocyanatedextran (green) with and without MDA-231 TCs. *P < 0.05, **P < 0.01, ***P < 0.001, and ****P < 0.0001; not significant; n.s.#, not significant across all conditions (pairwise).

The step-wise incorporation of PCs and ACs progressively improved the morphology and barrier permeability of the MVNs (15), and the all-inclusive, triculture MVNs highly recapitulated key morphological and functional properties of the natural BBB, particularly its cellular organization, its expression of junctional proteins, and its deposition of a functional basement membrane and glycocalyx (fig. S1, A to C, and table S1) (20, 21). Notably, the vessel structures of the triculture MVN model closely resembled in vivo brain capillaries (22) compared to all other in vitro BBB models to date (19, 2326).

To evaluate the robustness of our 3D in vitro BBB model as a surrogate platform to study brain metastasis, we used well-established in vivo and in vitro models from previous studies as our benchmarks (12, 27). In these studies, both parental breast cancer cells (MDA-MB-231, abbreviated here as MDA-Par or MDA-231) and lung metastatic cells derived from the parental line (MDA-LM2-4175 or MDA-LM) (27) exhibited reduced ability to form brain metastases after intracardiac injection, in sharp contrast to the brain metastatic line derived from the parental line (MDA-BrM2a or MDA-BrM) (12). In our platforms, while both MDA-BrM and MDA-LM demonstrated superior extravasation ability compared to parental MDA-231 in the monoculture iPS-EC MVNs, this was not the case in the triculture system, where only MDA-BrM cells displayed increased extravasation levels compared to both parental MDA-231 and MDA-LM. This suggests that the triculture MVN model functionally recapitulates other in vivo models of brain metastasis (fig. S2, A and B).

The highly expressed ST6GALNAC5 (ST6) in MDA-BrM cells was found to promote cancer cell extravasation in the brain in a 2D in vitro model (12), and knockdown (KD) of ST6 reduced brain metastasis formation after intracardiac injection. To further validate the triculture MVN model and its use as a tumor extravasation platform, we knocked down ST6 in MDA-BrM cells (fig. S2, C, D, F, and G) and validated that their extravasation efficiency was reduced compared to control cells (fig. S2E). However, their reduced extravasation levels remained greater than those of parental MDA-231 cells, as previously found in the in vivo model, but unlike prior observations in 2D in vitro models (12). Our triculture 3D BBB model, therefore, more closely recapitulates the features of in vivo models of brain metastasis compared to 2D in vitro brain extravasation assays, and, importantly, these findings suggest that ST6GALNAC5 is not the only factor affecting TC extravasation at the brain.

Breast cancer, lung cancer, and melanoma are the leading causes of brain metastasis among all cancer patients (3). In addition, brain metastases are also observed in patients with prostate cancer (28). Hence, we used breast cancer cell lines (MDA-231 and SKBR3), lung cancer cell line (A549), and prostate cancer cell line (22Rv1) in this study, aiming to identify general mechanisms of cancer cell extravasation into the brain. Following TC perfusion under transient flow in the MVNs (Fig. 1A) (17), all cells observed to partially or completely cross the endothelium were classified as extravasated (Fig. 1B). Despite differences in the baseline extravasation efficiency of each cell line in the iPS-EC alone MVNs (fig. S3A), the sequential addition of brain stromal cells always resulted in significant increases in extravasation after 24 hours (Fig. 1C and fig. S2A). Similar trends were observed 6 hours following perfusion (fig. S3B). These results are in line with prior evidence of the prometastatic role of PCs and ACs when TCs are lodged in the brain tissue after extravasation (57, 9).

Next, we sought to assess whether stromal-tumor cell interactions at the brain and the subsequent increase in extravasation were caused by changes in barrier integrity. The latter was evaluated using solute permeability to fluorescent dextran (29, 30). For each of the four MVN platforms considered, the permeability to either 10 or 40-kDa dextrans in MVNs remained unaltered despite the presence of TCs, up to 24 hours after TC perfusion (Fig. 1D and fig. S3C). In addition, the treatment of the MVNs with conditioned media (CM) from MDA-231 for 24 hours resulted in similar observations. This, coupled with a visible lack of focal leaks in the microvasculature following extravasation (Fig. 1E), confirmed that barrier integrity in each of four platforms considered remains intact despite TC transmigration or the presence of TC-secreted factors. This suggests that increased extravasation efficiencies in the presence of PCs and ACs are not caused by disruptions in endothelial junctions, which would increase paracellular transport and result in increased permeability values to lowmolecular weight dextrans (29).

On the basis of these results, we hypothesized that brain stromal cells act directly on intravascular cancer cells and their ability to transmigrate without needing to alter barrier integrity. To test this, monoculture iPS-EC MVNs were perfused with TCs and treated with conditioned medium from PCs or ACs, cultured either alone (PC and AC CM) or in Transwell systems above MDA-231 [PC (+MDA-231) CM and AC (+MDA-231) CM] (Fig. 2A). The addition of stromal cell CM, particularly when PCs and ACs are activated by the cancer cells in the case of PC (+MDA-231) CM and AC (+MDA-231) CM, significantly increased the extravasation efficiency of TCs (Fig. 2, B and C), suggesting that PC- and AC-secreted factors play important roles in the ability of cancer cells to extravasate.

(A) Schematic of the collection of PC and AC CM and subsequent treatment of the MVNs before TC perfusion. (B) Extravasation efficiencies of breast MDA-231 in monoculture MVNs with or without CM treatment at 24 hours after perfusion. (C) Representative images of breast MDA-231 in monoculture MVNs with or without CM treatment at 24 hours after perfusion. (D) Heatmap for cytokine array showing relative magnitudes of secreted factors from MDA-231, iPS-EC, PC, and AC alone, as well as iPS-EC, PC, and AC cultured in Transwell inserts with MDA-231 cells after 24 hours of culture. (E) Relative magnitude of significantly up-regulated cytokines/chemokines by PC or AC cultured in inserts with MDA-231 compared to iPS-EC cultured with MDA-231.(F) Representative images of 2D immunofluorescence staining for F-actin + DAPI, CCL2, and PDGF-BB in iPS-ECs, PCs, and ACs, cultured with MDA-231 in Transwell inserts. *P < 0.05, **P < 0.01, ***P < 0.001, and ****P < 0.0001; not significant; n.s.#, not significant across all conditions (pairwise).

Cytokine arrays on conditioned medium from iPS-ECs, PCs, and ACs, in the presence or absence of MDA-231, revealed several highly expressed factors, notably inflammatory and chemotactic cytokines such as interleukin-6 (IL-6), IL-8, and CCL2 (Fig. 2D). Since cancer cell extravasation was significantly increased in the presence of brain stromal cells and their secreted factors compared to monoculture iPS-EC MVNs (Figs. 1C and 2B and fig. S3B), we postulated that up-regulated cytokines by PC (+MDA-231) and AC (+MDA-231) compared to iPS-EC (+MDA-231) could play a role in increasing extravasation (Fig. 2E). Several of these were commonly up-regulated by both PCs and ACs, such as insulin-like growth factorbinding protein 4 (IGFBP-4), platelet-derived growth factor (PDGF)BB, and CCL26, while some were specific to each brain stromal cell, such as IL-6 for PCs or CCL2 and osteopontin (OPN) for ACs. These findings were validated by immunofluorescence staining for PDGF-BB, CCL2, and IGFBP-4 (Fig. 2F and fig. S4A).

CCL2 was found to be specifically up-regulated by AC (+MDA-231) compared to iPS-EC (+MDA-231) and PC (+MDA-231), whereas PDGF-BB was found to be up-regulated by both stromal cells compared to iPS-ECs (fig. S4B). Similar results were obtained for iPS-ECs, PCs, and ACs cultured in the absence of MDA-231 cancer cells (fig. S4, C and D). Having established that the cytokine profiles of PCs and ACs exhibit notable differences compared to those of iPS-ECs, we next investigated the role of the identified up-regulated factors in cancer cell extravasation.

To uncover the key secreted factors responsible for the proextravasation effect, we used a panel of blocking antibodies against candidate cytokines previously identified (Fig. 2E) (31). Only CCL2 blockade significantly reduced TC transmigration in the triculture BBB MVNs (Fig. 3A). As evidenced in media collected from triculture devices, the concentration of CCL2 is the largest of all secreted cytokines (~2700 pg/ml) (fig. S5, A and B) and is primarily expressed by ACs as shown from cytokine array results (Fig. 2D), immunofluorescence staining (Fig. 3B), and quantitative reverse transcription polymerase chain reaction (qRT-PCR) (fig. S5A). In addition, increasing the concentration of blocking antibody for CCL2 from 10 to 50 g/ml did not affect cancer cell extravasation, suggesting that the concentration used in the blocking antibody panel (10 g/ml) was sufficient to elicit a response (fig. S5C).

(A) Extravasation efficiency of MDA-231 TCs in triculture MVNs with neutralizing antibodies at 6 hours after perfusion. Abs, antibodies. (B) Representative CCL2 staining in triculture MVNs and quantification of the CCL2 MFI per cell volume in iPS-ECs, PCs, and ACs. (C) Extravasation efficiency of MDA-231 in triculture MVNs with ACs treated with CCL2 small interfering RNA (siRNA) or control siRNA before device seeding. (D) Representative images of MDA-231 in triculture MVNs stained with anti-CD31 at 6 hours after perfusion, in the case of MVNs seeded with ACs treated with CCL2 siRNA or control siRNA. (E) Extravasation efficiency of MDA-231 in triculture MVNs treated with anti-CCR2 and/or anti-CCR4, and the appropriate control at three time points. Significance is assessed with respect to the control [dimethyl sulfoxide (DMSO)] condition. (F) Extravasation efficiency of MDA-231 in triculture MVNs, in the case of MDA-231 treated with anti-CCR2 and/or anti-CCR4, and the appropriate control at three time points. Significance is assessed with respect to the control (DMSO) condition. (G) Representative images of MDA-231 in triculture MVNs stained with anti-CD31, in the case of TCs treated with anti-CCR2 or the appropriate control at 6 hours after perfusion. (H) Representative images of A549 in triculture MVNs stained with anti-CD31, in the case of TCs treated with anti-CCR2 or the appropriate controlat 6 hours after perfusion. (I) Extravasation efficiency of A549 in triculture MVNs, in the case of A549 cells treated with anti-CCR2 and/or anti-CCR4, and the appropriate control at three time points. Significance is assessed with respect to the control (DMSO) condition. (J) Extravasation fold of all four TCs between iPS-EC + AC MVNs and the monoculture iPS-EC MVNs at 24 hours (left) and relative CCR2 gene expression [normalized by glyceraldehyde phosphate dehydrogenase (GAPDH)] for all four TCs measured via qRT-PCR (right). *P < 0.05, **P < 0.01, ***P < 0.001, and ****P < 0.0001; not significant; n.s.#, not significant across all conditions (pairwise).

The role of AC-derived CCL2 on transmigration was further validated by treating coculture MVNs of iPS-EC + PC and iPS-EC + AC with blocking antibody for CCL2. Extravasation was significantly reduced only in the case of MVNs cultured with ACs, confirming that these brain stromal cells constitute the main source of CCL2 in the devices (fig. S5D). This was also demonstrated by immunofluorescence staining, whereby the mean fluorescent intensity (MFI) for CCL2 was the highest in ACs in the different MVN platforms compared to PCs and iPS-ECs (fig. S5E). CCL2 levels were significantly higher in ACs in the triculture BBB MVNs compared to the coculture iPS-EC + AC MVNs. This could indicate that cellular interactions among all three cell types, occurring when the human BBB is recapitulated in the in vitro devices, are conducive to increases in CCL2 chemokine production by ACs. It is useful to note that while FGF-2 (fibroblast growth factor 2) was found at an average concentration of ~2900 pg/ml (greater than that of CCL2 in the triculture MVNs), it is a major component of the iPS-EC culture medium used in the devices (present at 5000 pg/ml) and was thus assumed not to be significantly secreted by any of the cells in the BBB MVNs (fig. S5B). Furthermore, KD of CCL2 in ACs before device seeding resulted in significant reductions in TC extravasation in the triculture MVNs at both 6 and 24 hours after perfusion (Fig. 3, C and D, and fig. S5F), highlighting the importance of AC-specific contributions of CCL2 in tumor transmigration at the BBB. Together, these findings suggest that, of all up-regulated cytokines by PCs and ACs compared to iPS-ECs, only AC-secreted CCL2 plays a role in cancer cell extravasation. We thus focused our investigation on this chemokine and its observed effect on the transmigration of circulating TCs at the brain.

CCL2 is known to preferentially bind CCR2 (32). It has also been reported to bind CCR4 on cytotoxic T lymphocytes and regulatory T cells in the context of their recruitment to melanoma tumors, although with lower affinity compared to CCR2 (33, 34). Considering these two receptors, we next evaluated whether blocking the CCL2-CCR2 or CCL2-CCR4 axes would result in any changes in TC extravasation.

Prior evidence suggests that intravascular colon cancer cells secrete CCL2 to activate the endothelium, increase its permeability via the Janus kinase 2signal transducer and activator of transcription 5 and p38 mitogen-activated protein kinase pathways, up-regulate E-selectin expression, and ultimately promote cancer cell adhesion and extravasation from the vasculature (35). We thus first investigated whether AC-derived CCL2, in our case, could similarly activate the endothelium to promote extravasation. To assess whether AC-derived CCL2 affects the vasculature in the context of extravasation, we treated the triculture MVNs with CCR2 and CCR4 antagonists before TC perfusion. Blocking either receptor or both in the ECs did not result in any changes in the extravasation potential of MDA-231 (Fig. 3E).

Next, we assessed the direct effect of CCR2 and CCR4 on cancer cells by blocking CCR2, CCR4, or both, on the MDA-231 cells, before perfusion. Here, blocking CCR2 or both receptors resulted in a significant decrease in TC extravasation (Fig. 3, F and G). In contrast, CCR4 blockade did not affect MDA-231 extravasation, suggesting that AC-TC interactions are mostly occurring via the CCR2 receptor on TCs.

This was also validated in MDA-BrM cells, where CCR2 blockade alone resulted in greater reductions of extravasation efficiencies compared to KD of ST6 alone (fig. S6, A and B). Similar observations were made in the parental MDA-231 line (fig. S6, C and D); however, blockade of ST6 did not result in significant reductions in extravasation compared to control cells. KD of CCR2 alone in MDA-BrM was sufficient to reduce extravasation levels below those of parental MDA-231, which was not the case when ST6 was knocked down alone (fig. S6A). These findings, coupled with increased CCR2 levels in parental MDA-231 and MDA-BrM (fig. S6, E to H), attest to the significance of AC-secreted CCL2 in promoting their extravasation at the brain through their CCR2 receptor.

To validate our observations on the role of CCR2 in other cell lines, we treated SKBR3, A549, and 22Rv1 cell lines with the same antagonist combinations (CCR2 and/or CCR4). Consistent with our hypothesis, both SKBR3 and 22Rv1 exhibited similar trends as MDA-231 TCs in their extravasation potential (fig. S7, A to C); however, the extravasation efficiencies of A549 were not affected by any of the antagonist treatments (Fig. 3, H and I). Notably, A549 cells exhibited the lowest fold change in extravasation efficiency between iPS-EC + AC and iPS-EC alone compared to other cell lines examined and also expressed the lowest CCR2 levels compared to the three other lines (Figs. 3J and 1C). This is consistent with our hypothesis that the proextravasation effect of ACs is indeed mediated through CCR2 expressed by cancer cells.

Prior evidence suggests that autocrine secretion of CCL2 promotes cancer cell transmigration, invasion, and metastasis in colon cancer (35), prostate cancer, and cervical carcinoma (36, 37). To exclude this possibility, we blocked the endogenous secretion of CCL2 in MDA-231 with the use of small interfering RNA (siRNA) probes, as performed with ACs before device seeding (Fig. 3, C and D). Perfusion in the monoculture or triculture MVNs did not result in any significant differences in the extravasation potential of MDA-231 treated with siRNA for CCL2 or control siRNA (fig. S8, A and B). Consistently, enzyme-linked immunosorbent assay (ELISA) revealed more than 100-fold larger secretions of CCL2 in the triculture MVNs with ACs compared with MDA-231 cells (~15 to 25 pg/ml for MDA-231 compared to ~2700 pg/ml in the triculture BBB, which had comparable numbers of cells at the time of analysis) (figs. S8C and S5B), validating that AC-secreted CCL2 plays a crucial role in TC transmigration in our system.

We next compared CCL2 levels across cancer cell lines. qRT-PCR results showed that A549 expressed the highest levels of CCL2, followed by SKBR3, MDA-231, and 22Rv1 (fig. S8D). We then examined whether blocking TC-secreted CCL2 in SKBR3, A549, and 22Rv1 would give rise to similar results as MDA-231 cells. Treatment with anti-CCL2 before TC perfusion resulted in significant reductions in the transmigration potential of A549 and SKBR3 only (fig. S9E), suggesting that there exists a correlation between autocrine CCL2 levels and TC transmigration at the brain. Given that ACs express significantly larger levels of CCL2 compared to all cancer cells (fig. S8D), endogenous CCL2 in A549 and SKBR3 must be directly affecting their transmigration without having major consequences on the endothelium, contrary to prior findings on colorectal and prostate TC-derived CCL2 on endothelial permeability and extravasation (35, 37).

Given its important role on TC transmigration, we next investigated the mechanism of action of AC-derived CCL2. First, we verified that the secreted chemokine could reach the intravascular TC. Immunofluorescence staining of triculture MVNs for CCL2 with and without perfused MDA-231 showed that although the overall CCL2 MFI per region of interest (ROI) remained constant, the presence of TCs resulted in significant decreases in CCL2 MFI per cell volume in ACs only (Fig. 4A and fig. S9A). This could be explained by an exchange of CCL2 between ACs and TCs, ultimately inducing transmigration.

(A) Representative CCL2 staining in triculture MVNs with and without MDA-231 cells and quantification of the CCL2 MFI per cell volume with and without TCs. CCL2 is shown in white, iPS-EC in red, PC in green, and AC in yellow. A.U., arbitrary units. (B) Heatmap of the CCL2 concentration in the 3D MVNs surrounded by ACs with an intravascular TC. Only diffusion is considered here given the absence of luminal fluid flow in the MVNs. (C) AC-TC distance near extravasating TCs over time in triculture MVNs with anti-CCL2 on MVNs or anti-CCR2 on TCs. (D) Representative images of extravasating TCs and its surrounding ACs over time in triculture MVNs with and without anti-CCR2 on TCs. The blue, green, and orange arrows at the different time points refer to individual ACs moving closer to the TC in the control case, or away from it in the anti-CCR2 case. (E) Extravasation efficiency of MDA-231 in monoculture iPS-EC and coculture iPS-EC + PC MVNs at 6 hours after perfusion, in the case of MVNs treated with different recombinant human CCL2 (rhCCL2) concentrations. (F) Average speed of MDA-231 before and after extravasation in the triculture MVNs treated with anti-CCL2 or for the case of TC treatment with anti-CCR2. (G) Average 2D migration speed of MDA-231 with or without rhCCL2 treatment at different concentrations. *P < 0.05, **P < 0.01, ***P < 0.001, and ****P < 0.0001; not significant; n.s.#, not significant across all conditions (pairwise).

To validate these results further, we developed a computational model of CCL2 transport from ACs located near an intravascular TC (table S2). Simulation results verified that a constant flux of CCL2 from the ACs led to diffusive transport through the endothelial barrier via paracellular and transcellular pathways, reaching the TC and allowing its local consumption (TC surface concentration of ~4.5 108 mol/m3) (Fig. 4B) (38). Given that our MVNs are not subjected to fluid flow as is the case in vivo (39), we validated that the presence of convection (fluid velocity of ~0.5 mm/s) (40), in addition to diffusion (fig. S9B), resulted in CCL2 internalization by the intravascular TC within the same time frame and at similar surface concentration levels (~5 108 mol/m3) (fig. S9C). Because astrocytic sources of CCL2 are also located upstream from the cancer cells, CCL2 diffuses into the traveling bulk fluid ensuring that the chemokine is carried via convection to the downstream adhered TC. Thus, in the presence of microvascular convective phenomena, the CCL2 cytokine would still reach its target. It should be noted, however, that this transport analysis disregards the source/consumption kinetics of other cell types present in the in vivo microenvironment, such as neurons, microglia, or blood components (41, 42). Nevertheless, their effects were rendered negligible, given their low consumption rates and greater intercellular distances compared to AC-TC interactions.

Having confirmed that AC-derived CCL2 reaches the TCs, we next evaluated whether blocking the CCL2-CCR2 pathway resulted in any changes in the physical interactions between ACs and TCs. We transduced iPS-ECs, PCs, and ACs to express stable fluorescent tags before seeding the microfluidic chips to visualize cellular interactions in real time with high resolution (fig. S9D). The CCL2-CCR2 axis was blocked using a blocking antibody for CCL2 in the MVNs or an antagonist for CCR2 on TCs. Strikingly, distances between ACs and extravasating MDA-231 were found to increase over time when CCL2 was prevented from reaching the TCs (Fig. 4C and fig. S9E). This was not the case in the control MVNs, where ACs maintained close proximity with extravasating TCs (Fig. 4D). In addition to increased AC-TC distances over time, the number of ACs near MDA-231 was found to decrease when the CCL2-CCR2 pathway was blocked (fig. S9F). Conversely, in the control triculture MVNs, ACs were recruited near TCs during extravasation, attesting to the presence of spatial interactions that are dependent on the CCL2-CCR2 axis between the two cells.

CCL2, also referred to as monocyte chemoattractant protein-1 (MCP-1), is an established chemotactic factor that controls the infiltration of monocytes and macrophages (43). It has also been implicated in improvements in the motility and migration of chondrosarcoma cells, as well as gastric and bladder cancer cells (4446). We sought to understand whether these mechanisms were also observed at the BBB and whether CCL2-dependent chemotaxis between ACs and TCs was similarly responsible for increases in extravasation. To recapitulate the presence of CCL2 in the extracellular space of the MVNs where ACs are found, mono- and coculture devices with iPS-EC alone and iPS-EC + PC (no ACs) were treated with different concentrations of recombinant human CCL2 (rhCCL2) for 30 min before washing and TC perfusion. Given that CCL2 (~2700 pg/ml) is secreted in the triculture BBB MVNs, mostly by ACs compared to iPS-ECs and PCs (fig. S5A), we subjected the mono- and coculture devices to rhCCL2 [0 ng/ml (control), 1 ng/ml (low), 3 ng/ml (BBB MVN level), and 10 ng/ml (high)]. Washing the MVNs before perfusion removed all intravascular rhCCL2 to establish a chemokine gradient between luminal and interstitial spaces. Extravasation efficiencies of MDA-231 at 6 hours were found to significantly increase in the presence of 3 and 10 ng/ml compared to the control MVNs (Fig. 4E), confirming that the increase in TC transmigration can be partly explained by chemotaxis, where the astrocytic source of CCL2 is present in the extracellular matrix.

The average speed of MDA-231 in the triculture BBB MVNs was significantly lower when the CCL2-CCR2 axis was blocked (from ~11 m/hour in control MVNs to ~7 m/hour with anti-CCL2 or anti-CCR2) (Fig. 4F). This was the case for both intravascular and extravasated MDA-231, which were found to travel significantly less in the vessel and surrounding matrix (fig. S10A). These findings suggest that MDA-231 cells respond to chemokinetic cues in the BBB MVNs, whereby their speed is affected by available levels of the CCL2 chemokine (47, 48). The speed of ACs, on the other hand, was not altered when the CCL2-CCR2 axis was blocked, near intravascular or extravasated TCs (fig. S10B). This result was expected, given that MVN treatment with anti-CCL2 solely targets soluble chemokines in the devices without affecting their source (ACs in our case). In BBB MVNs not perfused with MDA-231, ACs also maintained the same average speed (~20 to 25 m/hour) (fig. S10C), suggesting that their migration patterns are independent of the presence of TCs and their secreted factors.

To further validate the chemokinesis hypothesis, MDA-231 were plated in 2D and subjected to different concentrations of rhCCL2 for 6 hours. Even minute amounts of rhCCL2 (1 ng/ml) resulted in significant increases in the speed of MDA-231, which plateaued at ~5 m/hour for 3 and 10 ng/ml compared to ~3.3 m/hour for 0 ng/ml (control) (Fig. 4G). TCs also spanned larger areas throughout their migration in 2D, as evidenced by their x-y displacement tracks over time for the four different treatments (fig. S10D). Together, these results indicate that TCs, via their CCR2 receptor, respond to both chemotactic and chemokinetic cues from AC-derived CCL2 in the MVNs. These cues ultimately trigger TC migration and transmigration from the brain vasculature and into the extracellular space.

Having established the role of ACs on TC extravasation via the CCL2-CCR2 pathway in an in vitro BBB MVN model, we next sought to validate our findings in vivo by knocking down CCR2 in MDA-231 cells (Fig. 5A). CCR2 KD short hairpin RNA (shRNA) MDA-231 transmigrated significantly less than control shRNA MDA-231 for all time points considered (6, 12, and 24 hours) (Fig. 5B), demonstrating that the shRNA KD can mimic the effects of the CCR2 antagonist applied on MDA-231 in vitro (Fig. 3F).

(A) Relative CCR2 gene expression normalized by GAPDH in control shRNA and CCR2 KD shRNA MDA-231 cells as measured by qRT-PCR. (B) Extravasation efficiency of control shRNA and CCR2 KD shRNA MDA-231 in triculture MVNs at three different time points. (C) Schematic of the TC intracardiac injection in mice, followed by brain harvesting, sectioning, immunofluorescence staining, and imaging. (D) Number of control shRNA and CCR2 KD shRNA MDA-231 cells remaining in mouse brains at 24 and 48 hours following intracardiac injection. (E) Representative images of brain sections perfused with MDA-231 (control shRNA and CCR2 KD shRNA) and stained with anti-CD31 at different time points. (F) Extravasation efficiency of control shRNA and CCR2 KD shRNA MDA-231 in mouse brains at 24 and 48 hours following intracardiac injection. (G) Representative images (collapsed z-stacks) of extravasated (orange arrows) and intravascular (blue arrows) MDA-231 (control shRNA and CCR2 KD shRNA) in mouse brains stained with anti-CD31 at 48 hours. (H) Representative images with cross sections of extravasated (orange arrows) and intravascular (blue arrows) MDA-231 (control shRNA and CCR2 KD shRNA) in mouse brains stained with anti-CD31 at 48 hours. *P < 0.05, **P < 0.01, ***P < 0.001, and ****P < 0.0001; not significant; n.s.#, not significant across all conditions (pairwise).

Following the in vitro confirmation that CCR2 KD reduces extravasation, CCR2 KD shRNA or control shRNA MDA-231 cells were injected in athymic nude (NU/J) mice via ultrasound-guided intracardiac injections (49). Prior studies suggested that lung and melanoma cancer cells are able to extravasate at the brain as early as 24 hours after injection in mice (11). We thus chose 24 and 48 hours after injection as our time points for this study. At both time points, significantly fewer CCR2 KD shRNA MDA-231 were found in the mouse brain vessels or parenchyma compared to the control shRNA cells (Fig. 5, D and E, and fig. S11A). Given that arrest in the microcirculation is a necessary initial step of the metastatic cascade (10, 50), the decreased number of CCR2 KD shRNA MDA-231 remaining in the mouse brains over time suggests that these cells do not seem to be stimulated at this secondary site, potentially because of their lack of activation/interaction with cellular and molecular cues in the brain microenvironment (50).

We next quantified the transmigration potential of CCR2 KD shRNA and control shRNA MDA-231 in the mouse brain capillaries. The overall extravasation efficiencies of the control shRNA MDA-231 at 24- and 48-hour time points were comparable to previous reports of lung and melanoma cancer cells (11). On the other hand, CCR2 KD significantly impaired MDA-231 extravasation at 24 and 48 hours (Fig. 5F). In addition, while the extravasation potential of control shRNA MDA-231 increased over time (from ~12% at 24 hours to ~21% at 48 hours), that of CCR2 KD shRNA MDA-231 remained relatively constant (~5% at 24 hours and ~7% at 48 hours), consistent with our hypothesis that the latter are not activated in the brain microenvironment. Extravasated control shRNA MDA-231 were found to remain in close proximity with brain capillaries following transmigration (Fig. 5, G and H, and fig. S11B), adopting a perivascular position as formerly observed in the case of lung and melanoma TCs in mouse brains (11). Although early in the metastatic cascade, our results are in agreement with previous findings, suggesting that TCs aim to co-opt the vasculature following transmigration to form successful metastases (11, 51, 52).

To investigate one of the rate-limiting steps of brain metastasis formation, namely, extravasation across the BBB, the tightest vascular barrier in the body, we used a 3D in vitro human BBB model to evaluate, in real time, the mechanisms influencing cancer cell extravasation. Progress in this area has previously been hampered by the lack of proper in vivo and in vitro platforms to model TC extravasation and to identify relevant players in this key step of the metastatic cascade. Our in vitro human BBB MVN model overcomes major limitations of currently available models by improving the relevance to human physiology with a 3D cellular architecture and morphology recapitulating brain capillaries, increasing the experimental throughput and spatiotemporal resolution, and allowing for the isolation and identification of cellular and molecular factors directly affecting TC extravasation (15, 53, 54). We also validated our platform as a tumor model assay through a comparison to in vivo and 2D in vitro findings from previous studies (12). MDA-BrM exhibited increased extravasation efficiencies in the triculture BBB MVNs compared to MDA-LM and parental MDA-231, and we verified ST6GALNAC5 to be one of the important factors promoting extravasation, as observed in previous in vivo and in vitro studies (12).

Through the sequential integration of brain stromal cells in the 3D MVNs, we were able to identify some of the key cellular and molecular players in TC transmigration across the BBB. ACs were found to promote extravasation at the brain through secretion of CCL2, which targets the CCR2 receptor expressed by TCs. Via CCL2-driven chemotaxis and chemokinesis, the extravasation and migratory potentials of TCs were considerably enhanced in the BBB MVNs. The KD of AC-secreted CCL2 or tumor-expressing CCR2 resulted in significant decreases in extravasation, attesting to the central role of the CCL2-CCR2 AC-cancer cell axis in metastasis at the brain. CCR2 blockade alone was sufficient to reduce the extravasation levels of MDA-BrM below those of the parental MDA-231 line, which was not the case when ST6GALNAC5 was individually silenced. The significance of the CCL2-CCR2 axis in brain extravasation was validated in vivo, where CCR2 KD in TCs reduced extravasation efficiencies and cancer cell numbers in the brain after intracardiac injection compared to control TCs. These results suggest that the CCL2-CCR2 axis is one of the important mediators of TC extravasation at the brain.

The CCL2-CCR2 axis has been shown to play a role in colorectal cancer cell extravasation at the lung, where endogenous secretion of CCL2 by TCs resulted in altered barrier properties and improved transmigration (35). In addition, up-regulated CCL2 secretions by ACs in response to inflammatory conditions such as brain metastasis (9), glioma (55), epilepsy (56), or autoimmune diseases (57, 58) have been shown to promote trafficking of immune cell, including CCR2-positive T cells, monocytes, and myeloid cells. These studies are consistent with our findings that increased secretion of CCL2 by ACs plays an important role in promoting extravasation at the brain.

However, elevated CCL2 levels at the brain during inflammation (59), particularly in the context of ischemia (60, 61), have been found to disrupt the adherens junctions of the BBB, hence its permeability. Unexpectedly, however, triculture MVNs with PCs and ACs exhibited reduced rather than increased vascular permeabilities compared to vessels composed of iPS-ECs alone. The permeability values in our triculture BBB MVNs (table S1) are comparable to those found in vivo by other groups (61, 62). Even in the presence of extravasating TCs or upon incubation with CM from TCs for up to 24 hours, barrier permeability remained unchanged in all four MVN platforms. This suggests that BBB integrity is not significantly altered during the time that most TCs extravasated and that inflammation of the brain endothelium is not responsible for the increased cancer cell transmigration observed in the triculture system. Rather, the direct interactions between ACs and TCs through the CCL2-CCR2 pathway, via both chemotaxis and chemokinesis, are major contributors to extravasation in our model.

In summary, the in vitro 3D BBB MVN model is a unique platform to functionally interrogate molecular and cellular mechanisms during brain extravasation. With this model, we revealed the central role of ACcancer cell interactions via the CCL2-CCR2 pathway, in promoting TC extravasation across the BBB. Inhibition of CCR2 in cancer cells resulted in greater reductions of their extravasation efficiencies compared to inhibition of the previously identified ST6GALNAC5 signaling pathway (12). In the future, combinatory inhibitions of both CCR2 and ST6GALNAC5 would be worth exploring as prevention treatments for brain metastasis.

The objective of this study was to investigate the role of human brain ACs in TC extravasation in an in vitro microvascular BBB model and to validate these findings in vivo. CCL2 was found to be up-regulated by ACs and was found to promote extravasation through CCR2 expressed on TCs, via both chemotaxis and chemokinesis. In addition, ST6GALNAC5, previously found to promote brain metastases in mice, was validated to play a role in extravasation in the in vitro microvascular BBB model. The dual KD of CCR2 and ST6GALNAC5 further reduces extravasation and could be exploited in the clinic. In all in vitro experiments, six devices per condition were used unless otherwise indicated.

These findings were validated in mouse, where CCR2 KD in circulating TCs significantly reduced their transmigration at the brain. In all in vivo mice experiments, four mice per time point and per condition were used. All animal studies were approved by the Massachusetts Institute of Technology (MIT) Institutional Animal Care and Use Committee.

Human iPS-ECs [Cellular Dynamics International (CDI)], human brain PCs (catalog no. 1200, ScienCell), and human brain ACs (catalog no. 1800, ScienCell) were cultured as described previously (15) and used at passage 5 for all experiments. For time-lapse imaging, iPS-ECs were stably transduced with the LentiBrite GFP Control Lentiviral Biosensor (Millipore Sigma), PCs were transduced with a tagBFP plasmid (Lenti-ef1a-dcas9-vp64-t2a-tagBFP; catalog no. 99371, Addgene; gift from the Jacks laboratory, MIT), and ACs were transduced with a tdTomato plasmid (PGK-Luc-EFS-tdTomato; gift from the Jacks laboratory, MIT).

For the extravasation assays, breast MDA-MB-231 [American Type Culture Collection (ATCC)], brain metastatic variant MDA-BrM2a, and lung metastatic variant MDA-LM2-4175 were obtained from the Massagu group (12, 27) following stable transduction with a triple modality reporter gene, thymidine kinase, green fluorescent protein (GFP), and luciferase (TGL), as previously described (63, 64). The Massagu cells were maintained in Dulbeccos Modified Eagles Medium (DMEM) (catalog no. 11995073, Gibco) supplemented with 10% fetal bovine serum (FBS; catalog no. 26140-079, Invitrogen). Breast SKBR3 (ATCC) and lung A549 (ATCC) were stably transduced with the LentiBrite RFP Control Lentiviral Biosensor (Millipore Sigma) and maintained in DMEM supplemented with 10% FBS. Prostate 22Rv1 (ATCC) were maintained in RPMI supplemented with 10% FBS and were stained with the CellTracker Orange CMRA (Invitrogen) at 1 M in phosphate-buffered saline (PBS) for 10 min at 37C and 5% CO2. The shRNA-mediated KD of CCR2 was performed on MDA-231 with CCR2 MISSION shRNA bacterial glycerol stock [clone ID: NM_001123041.2-1247s21c1 (human), Millipore Sigma]. Control MDA-231 cells were treated with nontarget shRNA control plasmid DNA MISSION TRC2 pLKO.5-puro (SHC216, Millipore Sigma). Target sequences are shown in table S1.

The 3D microfluidic devices used in this study were fabricated using soft lithography as previously described (16, 17) and comprise a single microchannel for cell seeding and two adjacent media channels with dimensions outlined in detail elsewhere (15). To recapitulate the in vivo organization of the BBB and isolate the effects of the different stromal cells on barrier characteristics and TC extravasation, four MVN platforms were used by culturing different combinations of iPS-ECs, PCs, and ACs in a fibrinogen-thrombin gel (Fig. 1A) (15). For all four platforms, iPS-ECs were resuspended at 5 million cells/ml in the fibrin hydrogel. For the coculture of iPS-EC + AC and the triculture of iPS-EC + PC + AC, ACs were resuspended at 1 million cells/ml and mixed in the fibrinogen-thrombin gel with the iPS-ECs or with both the iPS-ECs and PCs, respectively. For the coculture of iPS-EC + PC, PCs were resuspended at 1 million cells/ml in the fibrin hydrogel and mixed with iPS-ECs. The PC cell density was decreased to 0.5 million cells/ml in the triculture of iPS-EC + PC + AC to ensure a final PC-to-EC ratio on day 7 similar to that found in in vivo mice brains. The triculture iPS-EC + PC + AC model was found to recapitulate the in vivo BBB most closely (table S2). To test the influence of AC-secreted CCL2 on TC extravasation, the KD of CCL2 in ACs was performed before device seeding using a Silencer Select siRNA probe at 10 M (s12567, Thermo Fisher Scientific) with Lipofectamine RNAiMAX reagent (13778030, Thermo Fisher Scientific) in Opti-MEM reduced serum medium (31985062, Thermo Fisher Scientific). A Silencer Select Negative Control siRNA was used as a control (no. 2, 4390843, Thermo Fisher Scientific). ACs were treated twice more than 48 hours with siRNA probes and left to rest for an additional 24 hours in fresh media before device seeding with iPS-ECs and PCs to form triculture BBB MVNs. Total RNA from ACs was collected at day 0 (MVN seeding) and at day 7 (TC extravasation experiments) from replated ACs following device seeding, as described below. The KD of CCL2 in the ACs was confirmed via qRT-PCR using the protocol and the CCL2 TaqMan Gene Expression Assay mentioned below.

All devices were cultured in VascuLife media (Lifeline Cell Technology) supplemented with 10% FBS and 2% l-glutamine, according to the protocol developed by CDI. For the first 4 days of culture, this media was supplemented with vascular endothelial growth factorA (VEGF-A) (50 ng/ml) (catalog no. 100-20, PeproTech) in each of the four platforms to promote vasculogenesis following cell seeding. The addition of VEGF-A (50 ng/ml) was performed identically and consistently in all MVN platforms, and the results were compared across platforms.

iPS-ECs, PCs, ACs, and MDA-231 cells were plated onto six-well plates in their respective media until 60% confluence, after which media was replaced with VascuLife basal media (without growth factors). Cells were incubated for 24 hours, and CM was collected as previously described (31) and stored at 80C until use. To test the influence of MDA-231 on the cytokine production of iPS-ECs, PCs, and ACs, a six-well plate with Transwell inserts was used. MDA-231 were added to the bottom compartment, and iPS-ECs, PCs, and ACs were plated onto the insert at a 7:1 ratio with the TCs, as determined via cell quantification in 3D triculture MVNs perfused with MDA-231. Media was replaced with basal VascuLife once the iPS-ECs, PCs, or ACs reached 60% confluence, and cells were incubated for an additional 24 hours before CM collection. The CM of iPS-ECs, PCs, and ACs cultured above MDA-231 was collected exclusively from the inserts and labeled as iPS-EC (+MDA-231), PC (+MDA-231), and AC (+MDA-231).

To assess the MVN permeability, a monolayer of iPS-ECs was added to both media channels of the microfluidic device on day 4 following cell seeding by perfusing 50 l of iPS-ECs resuspended at 1 million cells/ml in VascuLife (29). Permeability was measured on day 8 using 10- and 40-kDa fluorescein isothiocyanate (FITC)dextrans at 0.1 mg/ml (FD10S, FD40S, Millipore Sigma), as previously described (29), via imaging using a confocal laser scanning microscope (FV1000, Olympus) with an environmental chamber maintained at 37C and 5% CO2. Following automatic thresholding and segmentation using the Fiji distribution of ImageJ [National Institutes of Health (NIH)], z-stack images were used to generate a 3D mask of the microvasculature as previously defined (29). At times, MVNs were perfused with MDA-231 on day 7, and the permeability was assessed 24 hours following perfusion on day 8. In addition, CM from MDA-231 was collected as described above and used to treat MVNs on day 7 in a 1:1 ratio with iPS-EC media. The permeability was assessed 24 hours following incubation with CM on day 8. Average vessel diameter and other MVN dimensions (average branch length, average cross-sectional area, surface area of the vessels, and 3D volume of the vessels) were computed as previously described (15, 29) by using the 3D mask generated from the MVN perfusion with dextran in ImageJ.

Cells plated in 2D or in Transwell inserts were fixed with 2% paraformaldehyde for 10 min, permeabilized with 0.1% Triton-X for 5 min, and blocked with 4% bovine serum albumin (BSA) and 0.5% goat serum in PBS overnight at 4C on a shaker. Relevant cytokines were observed by staining the fixed 2D plated cells with anti-CCL2 (MAB279, R&D Systems), anti-IGFBP4 (18500, Proteintech), antiPDGF-BB (PA5-19524, Invitrogen), anti-CCR2 (711255, Thermo Fisher Scientific), and anti-ST6GALNAC5 (MAB67151, R&D Systems) at 1:200 in PBS overnight at 4C. Microfluidic chips were fixed with 4% paraformaldehyde for 15 min, permeabilized with 0.1% Triton-X for 5 min, and blocked with 4% BSA and 0.5% goat serum in PBS overnight at 4C on a shaker. Following a PBS wash, protein visualization was achieved by staining the fixed devices with anti-CD31 (ab3245, Abcam), anti-PDGF receptor b (ab69506, Abcam), anti-GFAP (ab10062, Abcam), and antiCCL2/MCP-1 (2D8, Invitrogen) at 1:200 in PBS overnight at 4C on a shaker. After washing, cells and devices were incubated with secondary antibodies at 1:200 in PBS (Alexa Fluor 488 goat anti-rabbit A-11008, 568 goat anti-rabbit A-11011, or 633 goat anti-mouse A-21052; Invitrogen) and 4,6-diamidino-2-phenylindole (DAPI) (D1306, Invitrogen) at 1:1000 in PBS overnight at 4C on a shaker. Imaging was performed with a confocal laser scanning microscope (FV1000, Olympus).

Following staining of CCL2 in devices with fluorescently labeled iPS-ECs, PCs, and ACs, MFI per cell volume was computed by collecting stacks covering the full gel thickness containing MVNs using a 20 objective at a resolution of 800 800 pixels with a z-spacing of 5 m. For each channel corresponding to each cell type (iPS-ECs, PCs, or ACs), automatic thresholding and segmentation were performed using the Fiji distribution of ImageJ (NIH) as described previously (29). The 3D masks generated for each cell type were used to compute the total cell volume and determine MFI, when applied on the channel with CCL2 staining. For 2D staining, MFI per cell area was computed by measuring the mean intensity of the antibody of interest per area and normalizing over DAPI intensity.

Mice brains were harvested at two different time points (24 and 48 hours) following ultrasound-guided intracardiac perfusion of TCs and immediately fixed whole with 4% paraformaldehyde (v/v) in PBS at room temperature for 48 hours. Fixing with paraformaldehyde perfusion was avoided to prevent the high flow rates of perfusion from detaching intravascular TCs. Fixed brains were sectioned in 100-m-thick slices with a vibrating blade microtome (VT1000S, Leica Biosystems) and washed with a wash buffer constituted of 1% Triton X (v/v) in PBS on a shaker. Brain slices were incubated with blocking buffer [10% goat serum (v/v) with 1% Triton X (v/v) in PBS] for 4 hours at room temperature on a shaker. Following washing in wash buffer, samples were incubated in mouse anti-CD31 (553370, BD Biosciences) at 1:100 in wash buffer for 5 days at room temperature on a shaker to visualize the brain microvasculature (65). Brain slices were washed in wash buffer and incubated in secondary antibody (Alexa Fluor 633 goat anti-rat A-21094, Invitrogen) at 1:250 for 5 days at room temperature on a shaker. Samples were washed in wash buffer and placed on a glass coverslip for confocal imaging (FV1000, Olympus). Images were acquired using a 60 oil objective to visualize individual TCs and the brain vasculature.

Undiluted CM from MDA-231 and iPS-ECs, PCs, and ACs with or without MDA-231 was assayed using a human 80-cytokine array (AAH-CYT-5, RayBiotech) following the manufacturers protocol. Cytokine levels were also evaluated with the Human Cytokine Array/Chemokine Array 42-Plex (HD42, Eve Technologies Corp.) from undiluted media pooled from the media channels of three microfluidic chips per experimental repeat.

ST6GALNAC5 protein levels were measured with a human a-N-acetylgalactosaminide a-2,6-sialyltransferase 5 (ST6GALNAC5) ELISA kit (AMS.E01A1995, Amsbio) from cell lysates obtained from TCs cultured in 2D in 24-well plates. Four wells per TC were used for this assay.

Gene expression was quantified via real-time qRT-PCR. Cells were plated in 2D in wells of a 24-well plate, and total RNA was isolated and purified using the RNeasy Mini Kit (74104, Qiagen) according to the manufacturers instructions. The concentration of total RNA was measured using a NanoDrop 1000 spectrophotometer. cDNA was synthesized using the High-Capacity RNA-to-cDNA Kit (4387406, Thermo Fisher Scientific) according to the manufacturers protocol. Real-time qRT-PCR was performed on the 7900HT Fast Real-Time PCR System using the TaqMan Fast Advanced Master Mix (4444556, Thermo Fisher Scientific) as previously described (30). Glyceraldehyde phosphate dehydrogenase (GAPDH) was used as a housekeeping gene, and the following genes with respective TaqMan Gene Expression Assays (Thermo Fisher Scientific) were used: GAPDH (Hs01921207_s1), ST6GALNAC5 (Hs05018504_s1), CCR2 (Hs00704702_s1), CCL2 (Hs00234140_m1), CCR4 (Hs00747615_s1), IL-8 (Hs00174103_m1), CXCR1 (Hs01921207_s1), and CXCR2 (Hs01891184_s1).

TC extravasation assays were performed on day 7 once the vasculature was stabilized morphologically (15, 54). TCs were resuspended at 1 million cells/ml and a 20-l suspension volume was perfused in the MVNs as previously described (17, 31) via a 10-min hydrostatic pressure drop between the two media channels of the device. Media was replenished, and extravasation was quantified as described (66) at different time points following perfusion. TCs observed to cross the endothelium partially or completely were classified as extravasated cells, and the percentage of extravasation or extravasation efficiency was measured as the ratio of extravasated cells to the total number of TCs per device for each time point and MVN condition.

The effect of PC- or AC-secreted factors on TC extravasation was determined by treating monoculture MVNs of iPS-EC alone with PC, PC (+MDA-231), AC, or AC (+MDA-231) CM obtained as described above. TCs were perfused in the MVNs in a 1:1 ratio of CM and iPS-EC media (necessary for MVN stability), and extravasation was quantified at different time points.

The KD of ST6GALNAC5 in the TCs was performed with Silencer Select siRNA probes at 10 M [s224888 as siRNA #1 (human) and s37827 as siRNA #2 (human); Thermo Fisher Scientific] using Lipofectamine RNAiMAX reagent (13778030, Thermo Fisher Scientific) in Opti-MEM reduced serum medium (31985062, Thermo Fisher Scientific). Silencer Select Negative Control siRNAs were used as controls (nos. 1 and 2; 4390843, Thermo Fisher Scientific). TCs were treated twice more than 48 hours with siRNA probes and left to rest for an additional 24 hours in fresh media before perfusion in the MVNs. KD was validated with qRT-PCR using TaqMan Gene Expression Assays GAPDH (Hs01921207_s1, Thermo Fisher Scientific) as control and ST6GALNAC5 (Hs05018504_s1, Thermo Fisher Scientific).To test the influence of various relevant cytokines on TC extravasation, MVNs were incubated with anti-CCL2 at 10 g/ml (MAB279), antiIL-8 at 1 g/ml (MAB208), antiIGFBP-4 at 20 g/ml (MAB8041), anti-CCL26 at 15 g/ml (MAB653), antiIL-6 at 3 g/ml (MAB2061), anti-OPN at 12 g/ml (AF1433), and antiPDGF-BB at 3 g/ml (AF220), either individually or altogether (R&D Systems). Incubation was performed for 30 min at 37C and 5% CO2 before TC perfusion, without washing. At times, TCs were also incubated with anti-CCL2 at 10 g/ml (MAB279) for 30 min at 37C and 5% CO2 followed by a PBS wash and perfusion in untreated MVNs. Extravasation was quantified 6 hours following perfusion. To block CCR2 or CCR4, MVNs or TCs were incubated with a CCR2 antagonist at 50 M (227016, Millipore Sigma) and/or a CCR4 antagonist at 500 nM (21885, Cayman Chemical). Incubation was performed 24 hours before TC perfusion and repeated 1 hour before perfusion, followed by a PBS wash. Antagonists were resuspended in dimethyl sulfoxide (DMSO) before dilution in MVN or TC media. A DMSO control was used on both MVNs and TCs when quantifying extravasation. TC extravasation was quantified at 6, 12, and 24 hours after perfusion.

To test the influence of CCL2 in the MVNs on TC extravasation, rhCCL2 at various concentrations (279-MC-010, R&D Systems) was used to treat MVNs, followed by a PBS wash before perfusion. The KD of CCL2 in the TCs was also performed with Silencer Select siRNA probes at 10 M (s12566 and s12567, Thermo Fisher Scientific) using Lipofectamine RNAiMAX reagent (13778030, Thermo Fisher Scientific) in Opti-MEM reduced serum medium (31985062, Thermo Fisher Scientific). Silencer Select Negative Control siRNAs were used as controls (nos. 1 and 2; 4390843, Thermo Fisher Scientific). TCs were treated twice more than 48 hours with siRNA probes and left to rest for an additional 24 hours in fresh media before perfusion in the MVNs. The KD of CCL2 in the TCs was confirmed via ELISA (DCP00, R&D Systems).

To test the influence of CCL2 on migration in 2D, MDA-231 were plated in a 24-well glass-bottom plate and treated with different concentrations of rhCCL2 (279-MC-010, R&D Systems). Time-lapse images of TC migration in 2D were obtained at 15-min intervals for 6 hours following treatment using a confocal microscope (Olympus) with environmental chamber maintained at 37C and 5% CO2. Resulting TC speeds and migration tracks in 2D (x and y displacements) were graphed for 50 randomly selected TCs per rhCCL2 condition.

To quantify migration of TCs and ACs in 3D, time-lapse images of extravasating TCs were obtained with fluorescently labeled triculture MVN cells at 30-min intervals. At times, MVNs were treated with anti-CCL2 or TCs were treated with an antagonist for CCR2 as defined above before TC perfusion and live imaging with a confocal microscope (Olympus) with environmental chamber maintained at 37C and 5% CO2.

Over the course of extravasation, distances between the centers of ACs and extravasating TCs were quantified. Given that the average vessel branch length of the triculture MVNs is ~200 m, ACs located within a 200 m diameter centered on the TC were classified as near the TC and were considered in the distance measurements. The speeds of TCs, ACs near extravasating TCs, and ACs in control MVNs without TCs were also measured over time. Using the 3D time-lapse images of TC extravasation in the triculture MVNs, speeds and AC-TC distances were quantified over time via the Manual Tracking function of the TrackMate plugin in the Fiji distribution of ImageJ (NIH). Briefly, the x-y-z coordinates of the centers of TCs and ACs were tracked at each time point, and their speeds were obtained in micrometers per hour. The AC-TC distances were obtained in micrometer by averaging the distances of all ACs found near extravasating TCs. A time frame of 90 min before and after extravasation was considered to quantify the fold change in AC-TC distance (with respect to the first time point, 90 min before extravasation).

The number of ACs near extravasating TCs was also quantified by counting ACs located within a 200-m diameter centered on the TC. As for AC-TC distances, this count was presented as a fold change in number of ACs with respect to the first time point 90-min before extravasation.

A finite element model was developed to evaluate the spatial distribution of CCL2 in the MVNs using the COMSOL Multiphysics software. A bifurcating microvascular geometry similar as previous models from our group (31) was used, with a diameter and branch length corresponding to values measured in this study. A TC was modeled as a solid sphere of similar size adjacent to a wall within the vascular domain. Similarly, ACs were modeled as spheres with the same surface area as ex vivo measurements from electron micrographs (67). A total of seven ACs were distributed across the extracellular domain with an average distance of 10 m from the vascular walls, both number and distance corresponding to experimental measurements in the MVNs.

CCL2 was modeled as a species with a similar molecular weight (10 kDa) to approximate its diffusion coefficient (D = 150 m2/s). A constant flux of the species was ascribed to the surface of the modeled ACs, and a surface consumption of 0.5 s1 C was applied to the TC, as previously done in studies modeling TC morphogen consumption (68, 69). To account for the transvascular transport of CCL2, a thin diffusion barrier was introduced between the extracellular and vascular domains, through which both paracellular and transcellular transports of the species were considered. The relative flux of the species through this barrier is given by product of the differential concentration across the domains and the species-specific permeability (P) (Nvasc = PCCL2 C). This permeability value accounts for the diffusive transport between endothelial junctions and CCR2-regulated transcytosis of CCL2 (70). The former was obtained from permeability measurements of 10-kDa FITC-dextran performed in this study. The transcellular contribution was approximated from our previous study in MVNs (29). For the computational models incorporating convection due to fluid flow in the MVNs, an incompressible Stokes flow behavior was appliedP=2uu=0where is the viscosity, P is the pressure across the system, and u is the velocity vector field. Within the vascular domain, the inlet fluid velocity was set at a physiological value of 0.5 mm/s (40). Mass conservation resulted in the same velocity at the outlet, and a no-slip boundary condition was applied to the internal vascular walls. A symmetry boundary condition (nN = 0) was applied on the lateral boundaries of the extracellular domain given the periodic pattern of the vessels across the microfluidic device. A no-flux condition was applied at the top and bottom boundaries since they are situated close to the upper and lower walls of the device (n DC = 0).

A quasi-steady state assumption was made for all the models, given that the diffusion and convection time scales (~1 to 10 s) are two to three orders of magnitude lower than the cellular movement time scales (~1000 s), obtained from measurements in the MVNs. It was thus assumed that the species achieves a steady distribution before the onset of cell migration. The mass conservation and transport equations are reduced toN=RN=DC+uCwhere N is the flux, R accounts for the source and consumption of the species, and C is the molar concentration. The models were numerically solved using the Transport of Diluted Species module in COMSOL, and the concentration profiles were visualized by generating heatmaps of the species concentration in the MVNs with a lodged TC and ACs in the surrounding matrix.

All animal studies were approved by the MIT Institutional Animal Care and Use Committee. Athymic nude (NU/J) mice were purchased from the Jackson laboratory. MDA-231 cells were treated with the CCR2 MISSION shRNA Bacterial Glycerol Stock or the nontarget shRNA control plasmid DNA MISSION TRC2 pLKO.5-puro as a control shRNA (Millipore Sigma), and CCR2 gene expression was validated via real-time qRT-PCR. Once CCR2 KD was confirmed, mice were injected with a 100-l suspension of TCs in PBS at 0.5 million cells/ml via ultrasound-guided intracardiac injections (49). Half of the mice were injected with the CCR2 KD MDA-231, and the other half were injected with the control shRNA MDA-231. Mice were sacked, and their brains were collected at two different time points following intracardiac injection (24 and 48 hours). Whole brains were fixed via immersion in 4% paraformaldehyde in PBS at room temperature for 48 hours. Brains were sliced, stained, and mounted on coverslips for imaging as described above. Eight 100-m brain slices per mouse were imaged via confocal microscopy using a 10 objective to quantify number of TCs lodged in the brain capillaries or parenchyma. To quantify TC extravasation, confocal imaging was performed using a 60 oil-based objective for adequate visualization of TCs and extravasation events over the entire 100-m-thick brain slices. Two randomly selected ROIs per brain slice were imaged for each mouse (eight slices total), and extravasation was computed as the ratio of extravasated cells to total number of TCs per mouse, as done in vitro.

All data are plotted as means SD, unless indicated otherwise. All boxes show quartiles, center lines show means, and whiskers show SDs. Statistical significance was assessed using Students t tests performed with the software OriginPro when comparing two conditions/groups. When comparing more than two groups, significance was assessed using one-way analysis of variance (ANOVA) with Tukey post hoc test (if the unequal variance assumption holds, as measured by Levenes test for homogeneity of variance) or using Brown-Forsythe and Welch ANOVA with Dunnetts T3 post hoc test (if the unequal variance assumption is violated) with the software GraphPad Prism. Significance is represented as follows: n.s. stands for not significant, n.s.# stands for not significant across all conditions (pairwise), *P < 0.05, **P < 0.01, ***P < 0.001, and ****P < 0.0001. In all in vitro experiments, six devices per condition were used unless otherwise indicated. In all in vivo mice experiments, four mice per time point and per condition were used.

Acknowledgments: We thank M. Gillrie for the help transfecting iPS-ECs with the GFP construct; Y. Chen for the help transfecting MDA-MB-231 with the CCR2 KD and control shRNA constructs; N. Henning, V. Spanoudaki, and the Preclinical Imaging and Testing core facility for the help in mice intracardiac tumor cell injections; A. Burds Connor and the Preclinical Modeling Facility for the help in mice brain harvests; K. Cormier for histology support; and the Swanson Biotechnology Center for the exceptional core facilities. We also thank all the members of the Kamm laboratory for helpful discussions while developing this work. Funding: C.H. is supported by the Ludwig Center for Molecular Oncology Graduate Fellowship and by grant U01 CA202177 from the National Cancer Institute (NCI). Y.S. acknowledges support from Cure Alzheimers Fund. J.C.S. is supported by a National Science Foundation (NSF) graduate research fellowship. L.L. was supported by the Swiss National Science Foundation (SNSF) Early and Advanced Postdoc Mobility Fellowships and the Hope Funds Postdoctoral Fellowship. T.J. is a Howard Hughes Medical Institute investigator, a David H. Koch professor of Biology, and a Daniel K. Ludwig scholar. T.J. also acknowledges support from the Ludwig Center for Molecular Oncology and Cancer Center Support Grant (CCSG) P30 CA14501 from the NCI. Author contributions: C.H., Y.S., and R.D.K. designed the study. C.H., Y.S., and L.L. performed the experiments. J.C.S. performed the computational simulations. C.H. and L.L. analyzed the data. T.J. and R.D.K. supervised the work. C.H. and R.D.K. wrote the manuscript, and all authors contributed to its final form. Competing interests: R.D.K. is a cofounder of AIM Biotech that markets microfluidic systems for 3D culture. R.D.K. also receives financial support from Amgen, Biogen, and Gore. T.J. is a member of the Board of Directors of Amgen and Thermo Fisher Scientific. He is also a cofounder of Dragonfly Therapeutics and T2 Biosystems. T.J. serves on the Scientific Advisory Board of Dragonfly Therapeutics, SQZ Biotech, and Skyhawk Therapeutics. None of these affiliations represent a conflict of interest with respect to the design or execution of this study or interpretation of data presented in this manuscript. T.J. laboratory currently also receives funding from the Johnson & Johnson Lung Cancer Initiative and the Lustgarten Foundation for Pancreatic Cancer Research, but this funding did not support the research described in this manuscript. The authors declare that they have no other competing interests. Data and materials availability: All data needed to evaluate the conclusions in the paper are present in the paper and/or the Supplementary Materials. Additional data related to this paper may be requested from the authors.

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The CCL2-CCR2 astrocyte-cancer cell axis in tumor extravasation at the brain - Science Advances

Pharmacogenomic approach to cure the pain of the ‘burning man’ – Lab + Life Scientist

Inherited erythromelalgia is a rare and potentially devastating syndrome associated with severe burning pain in the hands and feet, creating a major unmet medical need.

More than 100 million Americans suffer from chronic pain of varying degrees, with the lack of effective but non-addictive painkillers partially contributing to the national substance abuse crisis. Potent opiates are often addictive, while other painkillers may be associated with poor tolerability, resulting in suboptimal pain control from many indications. Developing next-generation painkillers, therefore, has enormous value.

While chronic pain is often caused by injury, it can also be caused by genetic variants that naturally occurred in humans, such as in inherited erythromelalgia (IEM). Also called Man on Fire syndrome, it is associated with chronic burning pain in the hands and feet that cannot be relieved by common painkillers. Research from my work and others has led to new insights into pain pathophysiology in patients with IEM, as well as advancements in therapy.

The pain associated with IEM is caused by a genetic mutation in the SCN9A gene, which produces a hyperactive Nav1.7 sodium channel. The Nav1.7 channel is considered a pain channel since it is directly involved in many human pain syndromes. Through extensive research, we identified more than two dozen SCN9A mutations that lead to IEM. Consequently, for these patients, one-size-fits-all pain medication does not work. Currently, IEM treatment is a matter of trial and error. One of our major research goals, therefore, was to develop a precision medicine approach to treating these patients based on their genetic background.

While most patients with IEM do not respond to any available pain medications, there are exceptions. In the clinic, it was found that patients with one particular mutation on the SCN9A gene, V400M, responded to a non-selective sodium channel blocker that is traditionally used to treat seizures called carbamazepine (CBZ). Using patch-clamp analysis, it was found that CBZ normalises activation of the hyperactive Nav1.7 mutant and therefore makes it act more like wide-type.

The responsiveness of V400M to CBZ was encouraging and motivated us to identify additional mutations that might respond to the drug. To do this, we constructed a human Nav1.7 3D structure model to locate IEM mutations. Using this approach, we identified another common IEM-associated mutation, S241T, located very close to V400M. The proximity between these two mutations led us to suspect that they may be affected by CBZ in a similar manner.

To study the functional consequence of these mutations in intact pain-sensing neurons, and to test how these neurons responded to CBZ, we used microelectrode array (MEA) technology.

An MEA is a grid of tightly spaced microelectrodes, and theyre often used in the study of neural activity or circuits. They may be placed in the brains of living animals, but they can also be embedded in the wells of a multi-well cell culture plate allowing for in vitro modelling (Figure 1).

Figure 1: (Left) Image of a neuron grown over an MEA electrode. Voltage activity from the neuron is recorded (green) and individual neural signals or action potentials (white) are automatically tracked. (Right) In an MEA culture dish, the location and time of every recorded action potential (AP) is assigned a tick mark. The relationship between tick marks (or APs) reveals deep insights about how the neurons are interacting. Watch the full video here.

This arrangement allows us to culture sensory neurons in vitro and record the electrical activity noninvasively over weeks to months of these cultured pain-sensing neurons. Also, this technique enables us to grow replicates of the culture and simultaneously test multiple genetic, pharmacological and environmental manipulations (Figure 2). For example, we could study multiple mutations at once, and since IEM is triggered by warmth, we could also test the effect of temperature on the model using a built-in precise temperature control of the MEA system.

Figure 2: (Left) Multiwell solutions allow scientist to track up to 96 neural cell cultures simultaneously, accelerating scientific discovery and changing the way scientists ask questions. (Right) 48-well CytoView MEA plate being docked into a Maestro Pro MEA system, with built-in precise temperature and CO2 control.

Using this MEA system, we performed experiments to address our main question: can we develop a personalised medicine approach to guide the drug selection process for IEM patients based on their genetic background?

We grew neuron cultures harbouring one of several IEM-associated mutations. In neurons featuring the S241T mutation, CBZ significantly reduced the firing frequency, as well as the number of active DRG sensory neurons, when compared to vehicle treatment. We found this difference to be statistically significant. Conversely, when we performed this same test on a different F1449V mutation, we found that CBZ does not have a major effect on these neurons.

Figure 3: Pain in a dish. (Top row) Neurons expressing the Nav1.7S241T mutation fire significantly more action potentials than wild-type (WT) neurons, and this effect is exacerbated with increasing temperatures. (Bottom row) When these neurons were treated with carbamazepine (CBZ), the firing frequency was greatly reduced, suggesting CBZ as a potential treatment for IEM patients with S241T mutations. Watch the webinar here.

Altogether, we demonstrated that the effect of CBZ is mutant-specific, suggesting the need for a more personalised approach towards treating IEM. The data suggests that the mutation Nav1.7S241T may respond to CBZ.

Next, we aimed to take our research findings and test them in the clinic. After a nationwide search, we identified two IEM patients carrying the Nav1.7S241T mutation who were eager to participate in our study. Together with our colleagues, we designed a randomised, placebo-controlled double-blind crossover clinical trial for these two patients. We gave the patients either a placebo or CBZ for six weeks and we recorded their responses in several ways.

We found that CBZ reduced pain more than the placebo did. Specifically, it reduced total pain duration, episode duration and the number of times it woke the patient up during sleep. Together with our colleagues, we also performed functional MRI and found that while the patient on placebo showed brain activity in areas associated with chronic pain, the patient on CBZ showed brain activity in brain areas associated with acute pain a pattern that indicates that CBZ affects how the brain responds to pain signals in patients harbouring the SCN9AS241T mutation.

These results show that precision medicine, guided by genomic analysis and functional profiling, provides a promising way to transform pain treatment. With continued research and analysis, we aim to shift the paradigm of a trial-and-error approach to identify effective painkillers to a personalised medicine approach based on the genetic make-up of individual patients to treat chronic pain in the near future.

*Dr Yang Yang is currently an Assistant Professor at Purdue University in the Department of Medicinal Chemistry and Molecular Pharmacology, also affiliated with Purdue Institute for Integrative Neuroscience. His current research focuses on pharmacogenomics, induced pluripotent stem cells (iPSCs) and neurological diseases, including chronic pain, epilepsy, autism and neurodegenerative diseases. Using state-of-the-art technologies, Y Lab aims to understand how genetic mutations of key genes including ion channels contribute to neurological diseases, and to develop novel pharmacogenomic approaches for disease intervention.

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Pharmacogenomic approach to cure the pain of the 'burning man' - Lab + Life Scientist

The Stem Cell Assay Market To Grow Through Mergers Amongst Market Participants The Courier – The Courier

The healthcare arm, with GDPR and HIPPA in effect, will focus on well-being analysis, thereby putting it as a market enabler. This regulated and organized practice is bound to give the Stem Cell Assay Market analysts and consultants an edge over the conventional practices of healthcare.

The undifferentiated biological cells that can differentiate into specialized cells are called as stem cells. In the human body during early life and growth phase, stem cells have the potential to develop into other different cell types. Stem cells can differ from other types of cells in the body. There are two types of stem cells namely the embryonic stem cells and adult stem cells. Adult stem cells comprise of hematopoietic, mammary, intestinal, neural, mesenchymal stem cells, etc. All stem cells have general properties such as capability to divide and renew themselves for long period. Stem cells are unspecialized and can form specialized cell types. The quantitative or qualitative evaluation of a stem cells for various characteristics can be done by a technique called as stem cell assay. The identification and properties of stem cells can be illustrated by using Stem Cell Assay.

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The new developments in the field of stem cell assay research related to the claim of stem cell plasticity have caused controversies related to technical issues. In the study of stem cell assay, most conflicting results arise when cells express stem cell characteristics in one assay but not in another. The most important factor is that the true potential of stem cells can only be assessed retrospectively. The retrospective approach refers to back drop analysis which provides quantitative or qualitative evaluation of stem cells. The development in embryonic & adult stem cells assay will be beneficial to the global stem cell assay market.

Stem cell assays find applications in pharmaceutical & biotechnology companies, academic & research institutes, government healthcare institutions, contract research organizations (CROs) and others. The influential factors like chronic diseases, increased investment in research related activities, and technological advancements in pharmaceutical & biotech industry is anticipated to drive the growth of the global stem cell assay market during the forecast period. The cost of stem cell based therapies could be one of the major limiting factor for the growth of the global stem cell assay market.

The global stem cell assay market has been segmented on the basis of kit type, application, end user and region. The global stem cell assay market can be differentiated on the basis of kit type into human embryonic stem cell kits and adult stem cell kits. The adult stem cell kit includes hematopoietic stem cell kits, mesenchymal stem cell kits, induced pluripotent stem cell kits (IPSCs), and neuronal stem cell kits. The adult stem cell kits are projected to witness the highest CAGR during the forecast period due to the ease of use, cost & effectiveness of this type of kit in stem cell analysis.

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Based on application global stem cell assay market is based on drug discovery and development, therapeutics and clinical research. The therapeutics segment includes oncology, dermatology, cardiovascular treatment, orthopedic & musculoskeletal spine treatment, central nervous system, diabetes and others.

Depending on geographic segmentation, the global stem cell assay market is segmented into five key regions: Asia Pacific, North America, Europe, Latin America, and Middle East & Africa. North America is expected to contribute significant share to the global stem cell assay market. The stem cell assay market in Europe, has gained impetus from the government & industrial initiatives for stem cell based research and the market in Europe is expected to grow at a remarkable pace during the forecast period.

The major players in the global stem cell assay market include GE Healthcare, Promega Corporation, Thermo Fisher Scientific Inc., Merck KGaA, Cell Biolabs, Inc., Hemogenix Inc., Stemcell Technologies Inc., Bio-Rad Laboratories Inc., R&D Systems Inc., and Cellular Dynamics International Inc.

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The Stem Cell Assay Market To Grow Through Mergers Amongst Market Participants The Courier - The Courier

Investing in stem cells, the building blocks of the body – MoneyWeek

Imagine being able to reverse blindness, cure multiple sclerosis (MS), or rebuild your heart muscles after a heart attack. For the past few decades, research into stem cells, the building blocks of tissues and organs, has raised the prospect of medical advances of this kind yet it has produced relatively few approved treatments. But that could be about to change, says Robin Ali, professor of human molecular genetics of Kings College London. Just as gene therapy went from being a fantasy with little practical value to becoming a major area of treatment, stem cells are within a few years of reaching the medical mainstream. Whats more, developments in synthetic biology, the process of engineering and re-engineering cells, could make stem cells even more effective.

Stem cells are essentially the bodys raw material: basic cells from which all other cells with particular functions are generated. They are found in various organs and tissues, including the brain, blood, bone marrow and skin. The primary promise of adult stem cells lies in regenerative medicine, says Professor Ali.

Stem cells go through several rounds of division in order to produce specialist cells; a blood stem cell can be used to produce blood cells and skin stem cells can be used to produce skin cells. So in theory you can take adult stem cells from one person and transplant them into another person in order to promote the growth of new cells and tissue.

In practice, however, things have proved more complicated, since the number of stem cells in a persons body is relatively limited and they are hard to access. Scientists were also previously restricted by the fact that adult stem cells could only produce one specific type of cell (so blood stem cells couldnt produce skin cells, for instance).

In their quest for a universal stem cell, some scientists initially focused on stem cells from human embryos, but that remains a controversial method, not only because harvesting stem cells involves destroying the embryo, but also because there is a much higher risk of rejection of embryonic stem cells by the recipients immune system.

The good news is that in 2006 Japanese scientist Shinya Yamanaka of Kyoto University and his team discovered a technique for creating what they call induced pluripotent stem cells (iPSC). The research, for which they won a Nobel Prize in 2012, showed that you can rewind adult stem cells development process so that they became embryo-like stem cells. These cells can then be repurposed into any type of stem cells. So you could turn skin stem cells into iPSCs, which could in turn be turned into blood stem cells.

This major breakthrough has two main benefits. Firstly, because iPSCs are derived from adults, they dont come with the ethical problems associated with embryonic stem cells. Whats more, the risk of the body rejecting the cells is much lower as they come from another adult or are produced by the patient. In recent years scientists have refined this technique to the extent that we now have a recipe for making all types of cells, as well as a growing ability to multiply the number of stem cells, says Professor Ali.

Having the blueprint for manufacturing stem cells isnt quite enough on its own and several barriers remain, admits Professor Ali. For example, we still need to be able to manufacture large numbers of stem cells at a reasonable cost. Ensuring that the stem cells, once they are in the recipient, carry out their function of making new cells and tissue remains a work in progress. Finally, regulators are currently taking a hard line towards the technology, insisting on exhaustive testing and slowing research down.

The good news, Professor Ali believes, is that all these problems are not insurmountable as scientists get better at re-engineering adult cells (a process known as synthetic biology). The costs of manufacturing large numbers of stem cells are falling and this can only speed up as more companies invest in the area. There are also a finite number of different human antigens (the parts of the immune system that lead a body to reject a cell), so it should be possible to produce a bank of iPSC cells for the most popular antigen types.

While the attitude of regulators is harder to predict, Professor Ali is confident that it needs only one major breakthrough for the entire sector to secure a large amount of research from the top drug and biotech firms. Indeed, he believes that effective applications are likely in the next few years in areas where there are already established transplant procedures, such as blood transfusion, cartilage and corneas. The breakthrough may come in ophthalmology (the treatment of eye disorders) as you only need to stimulate the development of a relatively small number of cells to restore someones eyesight.

In addition to helping the body repair its own tissues and organs by creating new cells, adult stem cells can also indirectly aid regeneration by delivering other molecules and proteins to parts of the body where they are needed, says Ralph Kern, president and chief medical officer of biotechnology company BrainStorm Cell Therapeutics.

For example, BrainStorm has developed NurOwn, a cellular technology using peoples own cells to deliver neurotrophic factors (NTFs), proteins that can promote the repair of tissue in the nervous system. NurOwn works by modifying so-called Mesenchymal stem cells (MSCs) from a persons bone marrow. The re-transplanted mesenchymal stem cells can then deliver higher quantities of NTFs and other repair molecules.

At present BrainStorm is using its stem-cell therapy to focus on diseases of the brain and nervous system, such as amyotrophic lateral sclerosis (ALS, also known as Lou Gehrigs disease), MS and Huntingtons disease. The data from a recent final-stage trial suggests that the treatment may be able to halt the progression of ALS in those who have the early stage of the disease. Phase-two trial (the second of three stages of clinical trials) of the technique in MS patients also showed that those who underwent the treatment experienced an improvement in the functioning of their body.

Kern notes that MSCs are a particularly promising area of research. They are considered relatively safe, with few side effects, and can be frozen, which improves efficiency and drastically cuts down the amount of bone marrow that needs to be extracted from each patient.

Because the manufacture of MSC cells has become so efficient, NurOwn can be used to get years of therapy in one blood draw. Whats more, the cells can be reintroduced into patients bodies via a simple lumbar puncture into the spine, which can be done as an outpatient procedure, with no need for an overnight stay in hospital.

Kern emphasises that the rapid progress in our ability to modify cells is opening up new opportunities for using stem cells as a molecular delivery platform. Through taking advantage of the latest advances in the science of cellular therapies, BrainStorm is developing a technique to vary the molecules that its stem cells deliver so they can be more closely targeted to the particular condition being treated. BrainStorm is also trying to use smaller fragments of the modified cells, known as exosomes, in the hope that these can be more easily delivered and absorbed by the body and further improve its ability to avoid immune-system reactions to unrelated donors. One of BrainStorms most interesting projects is to use exosomes to repair the long-term lung damage from Covid-19, a particular problem for those with long Covid-19. Early preclinical trials show that modified exosomes delivered into the lungs of animals led to remarkable improvements in their condition. This included increasing the lungs oxygen capacity, reducing inflammation, and decreasing clotting.

Overall, while Kern admits that you cant say that stem cells are a cure for every condition, there is a lot of evidence that in many specific cases they have the potential to be the best option, with fewer side effects. With Americas Food and Drug Administration recently deciding to approve Biogens Alzheimers drug, Kern thinks that they have become much more open to approving products in diseases that are currently considered untreatable. As a result, he thinks that a significant number of adult stem-cell treatments will be approved within the next five to ten years.

Adult stem cells and synthetic biology arent just useful in treatments, says Dr Mark Kotter, CEO and founder of Bit Bio, a company spun out of Cambridge University. They are also set to revolutionise drug discovery. At present, companies start out by testing large numbers of different drug combinations in animals, before finding one that seems to be most effective. They then start a process of clinical trials with humans to test whether the drug is safe, followed by an analysis to see whether it has any effects.

Not only is this process extremely lengthy, but it is also inefficient, because human and animal biology, while similar in many respects, can differ greatly for many conditions. Many drugs that seem promising in animals end up being rejected when they are used on humans. This leads to a high failure rate. Indeed, when you take the failures into account, it has been estimated that it may cost as much to around $2bn to develop the typical drug.

As a result, pharma companies are now realising that you have to insert the human element at a pre-clinical stage by at least using human tissues, says Kotter. The problem is that until recently such tissues were scarce, since they were only available from biopsies or surgery. However, by using synthetic biology to transform adult stem cells from the skin or other parts of the body into other types of stem cells, researchers can potentially grow their own cells, or even whole tissues, in the laboratory, allowing them to integrate the human element at a much earlier stage.

Kotter has direct experience of this himself. He originally spent several decades studying the brain. However, because he had to rely on animal tissue for much of his research he became frustrated that he was turning into a rat doctor.

And when it came to the brain, the differences between human and rat biology were particularly stark. In fact, some human conditions, such as Alzheimers, dont even naturally appear in rodents, so researchers typically use mice and rats engineered to develop something that looks like Alzheimers. But even this isnt a completely accurate representation of what happens in humans.

As a result of his frustration, Kotter sought a way to create human tissues. It initially took six months. However, his company, Bit Bio, managed to cut costs and greatly accelerate the process. The companys technology now allows it to grow tissues in the laboratory in a matter of days, on an industrial scale. Whats more, the tissues can also be designed not just for particular conditions, such as dementia and Huntingdons disease, but also for particular sub-types of diseases.

Kotter and Bit Bio are currently working with Charles River Laboratories, a global company that has been involved in around 80% of drugs approved by the US Food and Drug Administration over the last three years, to commercialise this product. They have already attracted interest from some of the ten largest drug companies in the world, who believe that it will not only reduce the chances of failure, but also speed up development. Early estimates suggest that the process could double the chance of a successful trial, effectively cutting the cost of each approved drug by around 50% from $2bn to just $1bn. This in turn could increase the number of successful drugs on the market.

Two years ago my colleague Dr Mike Tubbs tipped Fate Therapeutics (Nasdaq: FATE). Since then, the share price has soared by 280%, thanks to growing interest from other drug companies (such as Janssen Biotech and ONO Pharmaceutical) in its cancer treatments involving genetically modified iPSCs.

Fate has no fewer than seven iPSC-derived treatments undergoing trials, with several more in the pre-clinical stage. While it is still losing money, it has over $790m cash on hand, which should be more than enough to support it while it develops its drugs.

As mentioned in the main story, the American-Israeli biotechnology company BrainStorm Cell Therapeutics (Nasdaq: BCLI) is developing treatments that aim to use stem cells as a delivery mechanism for proteins. While the phase-three trial (the final stage of clinical trials) of its proprietary NurOwn system for treatment of Amyotrophic lateral sclerosis (ALS, or Lou Gehrigs disease) did not fully succeed, promising results for those in the early stages of the disease mean that the company is thinking about running a new trial aimed at those patients. It also has an ongoing phase-two trial for those with MS, a phase-one trial in Alzheimers patients, as well as various preclinical programmes aimed at Parkinsons, Huntingtons, autistic spectrum disorder and peripheral nerve injury. Like Fate Therapeutics, BrainStorm is currently unprofitable.

Australian biotechnology company Mesoblast (Nasdaq: MESO) takes mesenchymal stem cells from the patient and modifies them so that they can absorb proteins that promote tissue repair and regeneration. At present Mesoblast is working with larger drug and biotech companies, including Novartis, to develop this technique for conditions ranging from heart disease to Covid-19. Several of these projects are close to being completed.

While the US Food and Drug Administration (FDA) controversially rejected Mesoblasts treatment remestemcel-L for use in children who have suffered from reactions to bone-marrow transplants against the advice of the Food and Drug Administrations own advisory committee the firm is confident that the FDA will eventually change its mind.

One stem-cell company that has already reached profitability is Vericel (Nasdaq: VCEL). Vericels flagship MACI products use adult stem cells taken from the patient to grow replacement cartilage, which can then be re-transplanted into the patient, speeding up their recovery from knee injuries. It has also developed a skin replacement based on skin stem cells.

While earnings remain relatively small, Vericel expects profitability to soar fivefold over the next year alone as the company starts to benefit from economies of scale and runs further trials to expand the range of patients who can benefit.

British micro-cap biotech ReNeuron (Aim: RENE) is developing adult stem-cell treatments for several conditions. It is currently carrying out clinical trials for patients with retinal degeneration and those recovering from the effects of having a stroke. ReNeuron has also developed its own induced pluripotent stem cell (iPSC) platform for research purposes and is seeking collaborations with other drug and biotech companies.

Like other small biotech firms in this area, it is not making any money, so it is an extremely risky investment although the rewards could be huge if any of its treatments show positive results from their clinical trials.

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Investing in stem cells, the building blocks of the body - MoneyWeek

Catalent to Acquire RheinCell Therapeutics, Strengthening a Path Towards Industrialization of Induced Pluripotent Stem Cell-based Therapies – PR Web

RheinCell's facility in Langenfeld, near Dsseldorf, Germany

SOMERSET, N.J. (PRWEB) June 24, 2021

Catalent, the leading global provider of advanced delivery technologies, development, and manufacturing solutions for drugs, biologics, cell and gene therapies, and consumer health products, today announced that it has reached an agreement to acquire RheinCell Therapeutics GmbH, a developer and manufacturer of GMP-grade human induced pluripotent stem cells (iPSCs). Upon completion, the acquisition will build upon Catalents existing custom cell therapy process development and manufacturing capabilities with proprietary GMP cell lines for iPSC-based therapies. The deal will enable Catalent to offer the building blocks to scale iPSC-based cell therapies while reducing barriers to entry to the clinic for therapeutic companies and is expected to close before the end of 2021, subject to customary conditions. Financial details of the transaction have not been disclosed.

iPSCs are cells that can be differentiated into various cell types to address a wide range of therapeutic indications. Founded in 2017, RheinCell has undertaken significant research and development of full GMP human leukocyte antigen (HLA)-matched cell banks with superior genomic integrity, as well as investing in development-scale operational capabilities. RheinCell is based in Langenfeld, near Dsseldorf, Germany. Upon closing, RheinCells current employees will join Catalents Cell & Gene Therapy business.

We formed RheinCell based on our deep scientific and regulatory expertise in the promising field of cell-based therapies, commented Juergen Weisser, Chief Executive Officer, RheinCell Therapeutics. He added, We are convinced Catalent will be able to substantially accelerate RheinCells future growth and help to support customers around the globe that are interested in our GMP-grade iPSC lines and iPSC-based services to feed their development pipelines in this exciting and highly demanding new therapeutic field.

By offering a renewable, and standardized, source of cells for further product development, iPSCs have the potential to be a disruptive technology that could fuel the development of the next generation of cell therapies and substantially enhance the ability to manufacture at scale, said Julien Meissonnier, Vice President and Chief Scientific Officer, Catalent. He added, Catalent is committed to building a full-scale value chain for emerging modalities and accelerating their path to market through expertise and innovation. This acquisition further strengthens Catalents position in these new therapeutic areas, by pioneering tools and techniques to substantially advance scale-up to meet the demands of clinical and commercial manufacturing.

This latest acquisition fuels the extraordinary growth of Catalent Cell & Gene Therapy, and the expertise and deep knowledge in iPSC cell lines that RheinCell brings will immediately boost our cell therapy portfolio, allowing us to offer iPSC banks to our customers as a premium source for their therapeutic development pathway, said Manja Boerman, Ph.D., President, Catalent Cell & Gene Therapy. She added, The addition of the RheinCell team to our growing cell therapy network will create an opportunity to share cutting-edge expertise across our global centers of excellence.

Since 2020, Catalent has invested in its cell therapy capabilities with four strategic expansions at its Gosselies, Belgium, campus the location of its European Center of Excellence for cell and gene therapy. Together with its U.S. cell and gene therapy facilities across Texas and Maryland, Catalent continues to increase its clinical and commercial-scale manufacturing capabilities across the full range of cell and gene therapy activity.

About RheinCell Therapeutics GmbH RheinCell develops and manufactures GMP-grade human induced pluripotent stem cells (iPSCs) for the next generation of cell therapies. Its production pipeline focuses on high immune compatibility and low rejection potential, with a spotlight on solutions for off-the-shelf, allogenic therapeutics. RheinCell provides exclusive access to clinically approved and consented cord blood cells, proprietary cell reprogramming protocols, state-of-the-art cleanroom and cell culture facilities, GMP-compliant manufacturing processes, and a first-class community of iPSC workflow experts who also develop GMP-compliant differentiation protocols in close cooperation with customers. For more information, visit http://www.rheincell.de

About Catalent Cell & Gene Therapy Catalent Cell & Gene Therapy is an industry-leading technology, development, and manufacturing partner for advanced therapeutics. Its comprehensive cell therapy portfolio includes a wide range of expertise across a variety of cell types including CAR-T, TCR, TILs, NKs, iPSCs, and MSCs. With deep expertise in viral vector development, scale-up and manufacturing for gene therapies, Catalent is a full-service partner for plasmid DNA, adeno-associated viral (AAV), lentiviral and other viral vectors, oncolytic viruses, and live virus vaccines. An experienced and innovative partner, Catalent Cell & Gene Therapy has a global network of dedicated, small- and large-scale clinical and commercial manufacturing facilities, including an FDA-licensed viral vector facility, and fill/finish capabilities located in both the U.S. and Europe.

About Catalent Catalent is the leading global provider of advanced delivery technologies, development, and manufacturing solutions for drugs, biologics, cell and gene therapies, and consumer health products. With over 85 years serving the industry, Catalent has proven expertise in bringing more customer products to market faster, enhancing product performance and ensuring reliable global clinical and commercial product supply. Catalent employs over 15,000 people, including approximately 2,400 scientists and technicians, at more than 45 facilities, and in fiscal year 2020 generated over $3 billion in annual revenue. Catalent is headquartered in Somerset, New Jersey. For more information, visit http://www.catalent.com

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Catalent to Acquire RheinCell Therapeutics, Strengthening a Path Towards Industrialization of Induced Pluripotent Stem Cell-based Therapies - PR Web

Discrepancies Between Real-World Patterns of Care and Recommendations Based on Clinical Trials Exist in MCL – OncLive

Results from a retrospective, observational study, presented during the 2021 ASCO Annual Meeting, showed that such discrepancies were notable in patients aged 65 years and younger, in that only 30.5% were treated with a cytarabine-containing chemotherapy regimen, and 23.3% underwent stem cell transplant. Additionally, among patients who were aged 65 years or older, approximately 65% received treatment with bendamustine and rituximab (Rituxan) or R-CHOP.

Moreover, the real-world median time to next treatment for patients younger than 65 years was 28 months and 22.3 months in patients older than 65 years, which appeared worse than what has been reported with standard therapies in this population. These results suggest a need to focus on developing treatments that can be delivered effectively in the real-world setting, according to Martin.

MCL is clearly a complicated [disease], and many different presentations and patient factors are worth consideration. Community physicians have their work cut out for them when they are dealing with someone who has MCL, Martin said. Fortunately, there are many who are willing to help, and more educational programs than ever before. Many of us who work in community or academic practices are easy to get ahold of and happy to see someone, talk to them, and give them [our opinions].

In an interview with OncLive, Martin, chief of the Lymphoma Program at the Meyer Cancer Center and an associate professor of medicine at Weill Cornell Medicine, discussed discrepancies in real-world patterns of care for patients with MCL and what can be done to overcome them.

Martin: Over the past decade, we have seen some significant improvements in the outcomes of patients with MCL who are treated in the context of clinical trials. This, of course, [includes] generally younger patients treated with more intensive induction, consolidation, and maintenance strategies, [as well as] older patients treated with bendamustine and rituximab-based strategies. [However,] we know very little about how patients in the real world are managed in the United States, particularly those who are [receiving care] outside of major academic centers. We performed this study to evaluate patterns of care.

Additionally, we were interested in the treatment outcomes of patients treated with standard-of-care regimens outside of academic centers. Separately, we were interested in [knowing more about] the role that stem cell transplantation plays in younger patients.

This was a retrospective, observational study that used the Flatiron data set. The Flatiron group extracts medical records, in this case, for [patients with] MCL; this roughly [included] about 4000 patients treated from January 2011 to January 2021. Eighty percent of these patients were treated in community practice settings, and those data were then [plugged] into computer software, which helped us perform statistical analysis.

There were really 3 highlights. [First], we found that the practice patterns that you might expect based on clinical trials were not necessarily met [in clinical practice]. For example, among older patients, we found that [approximately] 40% were treated with bendamustine/rituximab-based therapy. Of the younger patients, only one-quarter were treated with high-dose cytarabine, and there might be different reasons for that. One reason might be that we have not done the best job of communicating with general practitioners about what kinds of therapies they should be using; that is one possible scenario. Another scenario is that many of the patients we are seeing in community practices are not the types of patients who were typically enrolling on clinical trials held at academic centers. Both of those, may play some role [in this discrepancy], and both have significant implications with respect to how we approach future research studies and educational programs.

Second, potentially related to that, we found that outcomes in patients in the Flatiron dataset were not consistent with the outcomes that we have found in clinical trials. They are, unfortunately, not as good. That [finding] suggests that we need to [consider] how we can develop treatment regimens that are likely to be administered more broadly and have the potential to be more effective.

Lastly, we defined a patient population who were stem cell transplant eligible; these were patients who were younger than 65 years of age and who had not received other lines of therapy within 6 months of treatment initiation. These were, theoretically, patients who responded to their induction treatment, and who could have gone on to receive a stem cell transplant. Interestingly, when we looked at those patients, no difference in outcomes associated with receipt of stem cell transplantation [was observed].

The most relevant finding is directed toward those who are designing clinical trials. When we design clinical trials, it is important for us to understand that these trials are being developed to treat patients who [will] be treated in the community. If we design regimens that cannot be delivered there, either because the patients [are] not being eligible for them, or we design something that is too complicated, then we have not done anyone any real favors. We need to think about that.

Another related question that we asked from the same data set was the role of rituximab maintenance therapy [on outcomes], particularly after bendamustine-based induction therapy. We know that rituximab maintenance after R-CHOPbased therapy in older patients has been associated with an improvement in overall survival [OS]. Similarly, rituximab maintenance after autologous stem cell transplant has been associated with an improvement in OS. There has only been 1 randomized trial after bendamustine induction therapy, and this was a very small trial with [approximately] 50 patients in each arm; it did not show a benefit in terms of either progression-free survival [PFS] or OS. That is, frankly, a little bit unexpected based on the other data that exist.

Since then, several groups around the world have attempted to look at observational, retrospective datasets, and that is exactly what we did here. Those data were presented at the 2021 EHA Virtual Congress and they do, in fact, suggest that there may be a benefit to rituximab maintenance therapy after bendamustine/rituximab induction.

That is also consistent with the data that we saw from the phase 2 E1411 trial [NCT01415752], which [examined] bendamustine/rituximab-based induction followed by rituximab-based maintenance [and showed that] the median PFS was approximately 5 years; that is a little bit better than what we would expect [to see] from bendamustine/rituximab, [which] would typically be more like 3 years. We may not have randomized trials, but from my perspective, if we do not have a reason to not treat someone with rituximab, then we probably should.

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Discrepancies Between Real-World Patterns of Care and Recommendations Based on Clinical Trials Exist in MCL - OncLive

Disparities in Utilization of Autologous Stem Cell Transplantation as Consolidative Therapy for Multiple Myeloma: A Single Institution Retrospective…

This article was originally published here

Clin Lymphoma Myeloma Leuk. 2021 May 25:S2152-2650(21)00149-X. doi: 10.1016/j.clml.2021.04.006. Online ahead of print.

ABSTRACT

BACKGROUND: Most guidelines recommend induction therapy followed by autologous hematopoietic cell transplantation. A Surveillance, Epidemiology, and End Results-Medicare database analysis from 2000 to 2011 noted a lower use of HCT and bortezomib among Black patients, despite adjusting for care barriers, and this practice was associated with a poorer outcome. The goal of this study was to evaluate patterns of acceptance of HCT as consolidative therapy for MM.

METHODS: Cox proportional hazards model was used to investigate the association between the survival time of the patients (overall survival) and age of the diagnosis, race, socioeconomic status, disease cytogenetic, and initial induction regimens. A total of 194 patients with a confirmed diagnosis of MM who were referred for HCT between January 1, 2009, and June 30, 2019, were included in this study. Patients who received autologous stem cell transplant for relapsed MM were excluded.

RESULTS: We found that income category was not significantly associated with overall survival, time to transplant or transplant-/relapse-related mortality. High-risk cytogenetic was significantly associated with shorter overall survival, higher transplant-related mortality and relapse-related mortality (P < .002). The use of aggressive induction choices was associated with poorer transplant outcomes (P = .02). Time to transplant tended to be shorter in African American compared with other ethnic groups (P = .07).

CONCLUSION: There was no significant difference in the use rate of the HCT between Caucasians and AA patients with MM. Further comparative studies of MM induction therapy and access to clinical trials in African Americans and other racial minorities are warranted.

PMID:34148850 | DOI:10.1016/j.clml.2021.04.006

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Vita Therapeutics Raises $32 Million in Oversubscribed Series A Financing Led by Cambrian Biopharma to Advance the Development of Therapies to Treat…

BALTIMORE, Md.--(BUSINESS WIRE)--Vita Therapeutics, a cell engineering company harnessing the power of genetics to develop cellular therapies that follow an autologous and universal hypoimmunogenic approach, today announced the completion of an oversubscribed $32 million Series A. The financing was led by Cambrian Biopharma with participation from Kiwoom Bio, SCM Life Sciences, and Early Light Ventures.

At Vita Therapeutics our mission is to deliver long-term disease-modifying cell engineered treatments for patients living with muscular dystrophies and other high unmet medical needs, said Douglas Falk, M.S., Chief Executive Officer of Vita Therapeutics. We are pleased this high-caliber group of new and existing investors share our enthusiasm and belief in Vitas ability to progress our innovative treatments to help these patients. This oversubscribed round of financing will enable the company to take the next steps toward achieving our mission.

"Cell therapies have two grand challenges - getting enough cells and differentiating them into the right cell type to make a long-term impact on a patient's disease," said James Peyer, PhD., newly appointed board member of Vita and Chief Executive Officer of Cambrian Biopharma. By mastering the transition from iPSC to muscle stem cell, Vita can make an unlimited amount of carefully defined muscle stem cells, which has never been possible before. I am so glad to count Vita as a Cambrian affiliate, and I have no doubt Vita will become a genre-defining cell therapy company.

Vitas lead therapy, VTA-100, is currently undergoing investigational new drug (IND)-enabling studies for the treatment of limb-girdle muscular dystrophy (LGMD) 2A/R1. It is designed to be an autologous treatment that combines gene correction and induced pluripotent stem cell (iPSC) technology to help repair and replace muscle cells. Vitas second therapeutic, VTA-200, is a genetically engineered iPSC derived hypoimmunogenic treatment designed to treat multiple types of muscular dystrophy.

The Series A financing will support the completion of all remaining IND-enabling studies for VTA-100 and its subsequent IND submission to the U.S. Food and Drug Administration. This funding will also support the manufacturing of cells needed for clinical evaluation as well as patient recruitment efforts for the first clinical trial. In addition, this financing will be used to further the development of VTA-200 and the development of VTA-300, an undisclosed cell type.

About Limb-Girdle Muscular Dystrophy

Limb-girdle muscular dystrophy (LGMD) is a group of disorders that cause weakness and wasting of muscles closest to the body (proximal muscles), specifically the muscles of the shoulders, upper arms, pelvic area, and thighs. The severity, age of onset, and disease progression of LGMD vary among the more than 30 known sub-types of this condition and may be inconsistent even within the same sub-type. As the atrophy and muscle weakness progresses, individuals with LGMD begin to have trouble lifting objects, walking, and climbing stairs, often requiring the use of assistive mobility devices. There is currently no cure for LGMD, with treatments limited to supportive therapies such as corticosteroids.

About Vita Therapeutics

Vita Therapeutics, a Cambrian Biopharma affiliate, is a cell engineering company harnessing the power of genetics to develop cellular therapies that follow a dual manufacturing strategy, first beginning autologously before moving to a universal hypoimmunogenic cell line. Vita was originally founded out of the labs of Dr. Gabsang Lee and Dr. Kathryn Wagner at Johns Hopkins University and the Kennedy Krieger Institute in 2019 by Douglas Falk, M.S. and Peter Andersen, PhD. The company utilizes induced pluripotent stem cell (iPSC) technology to engineer specific cell types designed to replace those that are defective in patients. We are currently working to progress our lead therapeutic, VTA-100, for the treatment of limb-girdle muscular dystrophy (LGMD), into clinical trials. For more information and important updates, please visit http://www.vitatx.com or follow us on Twitter @Vita_Tx and LinkedIn.

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Vita Therapeutics Raises $32 Million in Oversubscribed Series A Financing Led by Cambrian Biopharma to Advance the Development of Therapies to Treat...

Updates in the treatment of peripheral T-cell lymphomas | JEP – Dove Medical Press

Introduction

Peripheral T-cell Lymphomas (PTCLs) represent a relatively rare disease accounting for 610% of all cases of non-Hodgkin lymphomas (NHLs) in western countries.1 The incidence of PTCLs exhibits a geographical dependence, reaching 2025% of NHLs in some parts in Asia and South America.2 PTCLs constitute a heterogeneous group of hematologic malignancies that differ in clinical behavior and anatomical location. The World Health Organization (WHO) recognizes at least 29 distinct entities of mature post thymic T-cell NHLs in the updated classification of hematological and lymphoid neoplasms.3 The last classification proposed several provisional subtypes and introduced the T-follicular helper (TFH) phenotype. TFH lymphoma and nodal T-cell lymphoma with TFH phenotype are thus separate subtypes different from PTCLs not otherwise specified (PTCL-NOS). PTCLs could be anatomically classified as nodal, extranodal, cutaneous and leukemic forms (Table 1). The most frequent subtypes are PTCL-not otherwise specified (NOS) (30% of PTCLs), angioimmunoblastic T-cell lymphoma (AILT; 1530% of PTCLs), anaplastic large T-cell lymphoma (ALCL; 15% of PTCLs), extranodal natural killer (NK) cell/T cell lymphoma (ENKTCL; 10% of PTCLs), and intestinal T cell lymphomas (~56% of PTCLs, including enteropathy-associated T cell lymphoma (EATL) and monomorphic epitheliotropic intestinal T cell lymphoma (MEITL).4 Adult T-cell leukemia/lymphoma (ATLL) is most commonly diagnosed in countries with a high prevalence of human T-cell lymphotropic virus type 1 (HTLV-1) infection, especially in Japan and the Caribbean.5 The intrinsic variability of PTCLs and their scarcity had stymied progress in the treatment outcome. Despite the recent major advances in the understanding of PTCLs, including new laboratory methods for diagnosis and new therapeutic approaches, the prognosis of the majority of PTCLs remains poorer than with aggressive B-cell lymphoma, except for anaplastic lymphoma kinase (ALK)-positive ALCL. The 5-year overall survival (OS) for ALK+ ALCL, ALK- ALCL, AITL, and PTCL-NOS is 80.2%, 44.7%, 35.4%, and 25.4%, respectively.6 This review aims to discuss the molecular and genetic patterns of PTCLs, first-line treatment including bone marrow transplantation, as well as treatment of relapsed/refractory PTCLs and future therapeutic directions.

Table 1 Mature T-Cell and NK-Cell Neoplasm Based on the WHO 2016 Classification

As previously mentioned, there are 29 different subtypes of PTCLs according to the 2016 WHO classification. PTCL-NOS harbors no specific characteristic immunophenotype. However, two subgroups have been identified using the Gene Expression Profiles (GEPs) with different gene expression driven by the transcription factors TBX-21 or GATA-3. The GATA-3 PTCL-NOS subgroup has significantly poor survival outcomes.7,8

Patients with ALK+ ALCL most frequently present t(2;5) that fuses nucleophosmin gene (NPM) with the ALK gene leading to an oncogenic tyrosine kinase (NPM-ALK) that promotes signaling of the JAK/STAT pathway. GEPs showed hyperactivation of STAT3 in ALCL caused mainly by ALK rearrangements or activating mutations in the JAK/STAT pathway. Based on rearrangements revealed by cytogenetics, ALK negative patients could be classified into three groups: DUSP22 +, TP63 +, and triple negative group (ALK-, DUSP22- and TP63-). ALK-negative ALCLs have chromosomal rearrangements of DUSP22 or TP63 in 30% and 8% of the cases respectively. DUSP22-rearranged cases have favorable outcomes similarly to ALK+ ALCLs, whereas other genetic variants have inferior outcomes.9

The molecular profiling of other PTCLs revealed several mutations of genes involved in DNA methylation such as TET2, IDH2 and DNMT3.10 TET2 mutations have been described in 47% of patients with AITL, and in 38% of patients with PTCL-NOS. This high incidence in PTCL-NOS is probably related to the TFH phenotype being included in this subgroup in the previous 2008 WHO classification.11 Furthermore, 76% of patients with AITL have TET2 mutations.10 DNMT3A mutations occurred in 33% of patients with AITL, and are frequently associated with TET2 mutations (100% of the patients with reference to Odejide et al). IDH2 mutations, initially reported in patients with acute myeloid leukemia (AML) and Glioblastoma Multiforme, had also been found in 20 to 45% of patients with AITL, and were detected in different loci.12 Moreover, IDH2 mutations co-occur frequently with TET2 mutations.10 These mutations are highly reported in patients with AITL (67%), and less frequently in patients with PTCL-NOS (18%). RHOA mutations do not seem to have an epigenetic influence, despite being associated with T-cell proliferation and invasiveness.13,14 GEPs revealed multiple mutations in patients with ATLL such as RHOA, TET2, loss-of-function mutations in TP53, and overexpression of PD-L1.15

Other interesting mutations in PTCLs are those affecting T-cell receptor (TCR)-related genes such as PLCG1 (14%), CD28 (9%, exclusively in AITL), PI3K elements (7%), CTNNB1 (6%), and GTF2I (6%). More importantly, most variants in TCR-related genes represent gain-of-function mutations that could be addressed by new potential drugs.16

Activating mutations in TCR pathway genes had also been reported especially in patients with AITL and PTCL-NOS leading to lymphomagenesis by activating NF-kB pathway. The most common mutation leads to PLCG1 and was also described in CTCL.17

Due to the paucity of randomized clinical trials in this setting, no clear gold standard exists for the treatment of patients with newly diagnosed PTCLs. Treatment regimens are extrapolated from those initially developed in aggressive B-cell lymphoma. CHOP (cyclophosphamide, Adriamycin, vincristine and prednisolone) or CHOP-like regimens have been widely considered as the standard of care in patients with newly diagnosed PTCLs. Controlled studies are rare and the largest studies in PTCLs are retrospective. Up to one-third of patients with PTCLs may progress during first-line treatment.18 The adoption of CHOP regimen was initially based on the results of a large randomized phase III clinical trial of patients with high-grade and/or advanced stage B-cell or T-cell NHLs. This study compared CHOP with more dose-dense regimens (MACOP-B, ProMACE-CytaBOM and m-BACOD), and failed to demonstrate a significant benefit when compared to CHOP.19 Reyes et al found that ACVBP was superior to CHOP in patients with low-risk localized aggressive lymphoma.20 More intense chemotherapy regimens such as hyperCVAD (hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone followed by methotrexate and cytarabine) and DA-EPOCH (dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab) showed good results in terms of response rate and progression-free survival (PFS), but at the cost of higher myelosuppression rates leading to poor treatment adherence and early deaths.21,22 Retrospective and non-randomized studies suggested that the addition of etoposide to CHOP (CHOEP) in young and fit patients could be associated with a better outcome.23,24

More recently, the results of the first multicenter, double blind, randomized, placebo-controlled phase III trial in PTCLs were reported. The ECHELON-2 compared brentuximab vedotin (BV), cyclophosphamide, doxorubicin and prednisone (BV + CHP) with the standard CHOP regimen in previously untreated CD30+ PTCLs. The study met its primary endpoint of PFS, demonstrating the superiority of BV containing regimen. At a median follow-up of 36 months, BV + CHP was associated with significantly longer PFS than CHOP: 48.2 months (95% CI, 35.2-not reached) vs 20.4 months (95% CI, 12.747.6), with a hazard ratio 0.71 (95% CI, 0.540.93, p=0.0110). The 3-year PFS rate was 57.1% (95% CI, 49.963.7%) for the BV + CHP arm versus 44.4% (95% CI, 37.650.9%) for the CHOP arm. The two groups had similar adverse events, including incidence and severity of febrile neutropenia (41 [18%] patients in the BV + CHP group and 33 [15%] in the CHOP group) and peripheral neuropathy (117 [52%] in the BV + CHP group and 124 [55%] in the CHOP group).25 In addition, more than 70% of patients included in the trial had ALCL including ALK+ or ALK- disease, an entity characterized by high expression of CD30. Importantly, the inclusion criteria of the ECHELON-2 trial required an expression of at least 10% of CD30 on tumor cells. Based on the results of this trial, The Food and Drug Administration (FDA) approved the BV + CHP regimen in patients with CD30+ PTCLs in November 2018.26 Nowadays, most experts recognize BV + CHP treatment as standard of care for patients with any level CD30+ ALCL. However, the debate concerning the extrapolation of the results to other histologic subtypes continues since the ECHELON-2 trial was not powered enough to answer this question by performing histology-based subgroup analysis. In fact, the European Medicines Agency (EMA) restricted the approval of BV + CHP to the patients with CD30+ systemic ALCL only.

Histone deacetylase inhibitor (HDACi) romidepsin can be combined with CHOP in the first-line setting.27 It has been investigated in a phase III randomized double-blind trial in comparison with standard CHOP. The addition of romidepsin to CHOP did not improve PFS, the primary endpoint of the study. In addition, response rates and OS were similar with the combination.28 Other combinations are ongoing in for previously untreated PCTLs patients, and are summarized in Table 2.

Table 2 Novel Combinations Under Investigation in Previously Untreated PTCLs

The role of autologous stem cell transplantation (ASCT) in patients with PTCLs is controversial due to limited data, heterogeneous populations in the current studies, and the lack of randomized trials clearly evaluating ASCT procedure. ASCT has been investigated to prevent the high relapse rate in chemosensitive patients.29 The largest prospective studies based on cohort or registry were conducted by the Nordic Lymphoma Group, the German Group, Lysa French group, and United States of America group. The Nordic Lymphoma Group trial enrolled 160 patients with a confirmed diagnosis of PTCLs excluding those with ALK+ ALCL. Patients received 6 cycles of biweekly CHOEP-14 except for those aged 60 years and older who received CHOP-14. One hundred fifteen patients underwent ASCT. At a median follow-up of 60.5 months, OS rate was 51% and PFS rate was 44%. Patients with ALK ALCL had the highest OS and PFS (70% and 61%, respectively) compared with other histological subtypes (PTCL-NOS, AITL and EATL). The differences between the four groups were not statistically significant.30 In the German study, the second largest prospective trial reported by Reimer et al, 83 patients with newly diagnosed PTCLs were enrolled. Patients received 4 to 6 cycles of CHOP followed by mobilization, and those who were in CR or PR underwent myeloablative chemo-radiotherapy (fractionated total-body irradiation and high-dose cyclophosphamide) and ASCT. Fifty-five (66%) of the 83 patients received transplantation. The main reason for not receiving ASCT was progressive disease. At a median follow-up of 33 months, the estimated 3-year OS was 48% for the intention-to treat population. Failure to achieve CR was associated with markedly inferior results.31 More recently, the role of up-front ASCT in PTCLs for responders after induction was reported by the French LYSA study. Two hundred sixty-nine patients were analyzed; they had mostly PTCL-NOS, AITL, or ALK+ ALCL with partial (N = 52, 19%) or complete response (N = 217, 81%) after induction. One hundred and thirty-four patients were allocated to ASCT in ITT, and 135 were not. The median PFS was 3.7 years, and the median OS was 8.4 years for the entire cohort. No OS difference was observed according to histological subtype. The authors failed to depict a survival advantage in favor of ASCT as a consolidation procedure for patients who responded after induction. Subgroup analyses did not reveal any further difference for patients with respect to response status, stage disease, or risk category.29 Moreover, a large multi-center prospective study was reported from the COMPLETE registry (Comprehensive Oncology Measures for Peripheral T-cell Lymphoma Treatment).This cohort compared the survival outcomes in patients with nodal PTCLs who received or not consolidative ASCT in the upfront setting. The authors did not find any statistical difference in terms of survival between the ASCT and non-ASCT groups. They also suggested that subgroups of patients with nodal PTCLs, especially those with AITL and/or high-risk features (advanced-stage disease or intermediate-to-high IPI scores), might benefit from consolidative ASCT in terms of initial complete response.32

Collectively, these results did not sufficiently support the use of ASCT for up-front consolidation in patients with PTCLs in complete or partial response after induction therapy. The role of consolidative ASCT after first remission needs to be defined in prospective randomized trials.

Evidence for ASCT in the relapsed/refractory (R/R) setting is scarce and comes from registry data and retrospective studies. The results suggest that the outcomes could be improved with the use of consolidation HSCT, with the most benefiting group being the ALCL subtype, reaching a 3-years OS of 50% and a PFS of 65%.33 Data from the CIBMTR registry revealed no significant difference in survival between ASCT and allogenic stem cell transplantation (SCT), although a 34% TRM was reported with allogenic SCT by contrast to only 6% with ASCT.34 All these results show that SCT could be considered for eligible patients in the salvage setting and in chemotherapy-sensitive patients who have never had it before.

The role of allogenic SCT has been investigated recently by a randomized Phase 3 trial comparing ASCT and allogenic SCT as part of first-line therapy in poor-risk PTCL patients.35 Patients received conventional chemotherapy with 4 cycles of CHOEP and 1 cycle of DHAP followed by intensification. Patients were randomized to receive BEAM followed by ASCT or myeloablative conditioning (fludarabine, busulfan, cyclophosphamide) followed by allogenic SCT from a matched related or unrelated donor. One hundred and three patients were enrolled (ASCT: 54, allogenic SCT: 49), of whom 36 35%) could not proceed to transplantation mostly due to early disease progression. The 3-year event-free survival (EFS) and OS did not significantly differ between allogenic SCT and ASCT (EFS: 43% vs 38%, p=0.58, and 57% vs 70%, p=0.41 respectively). However, the treatment-related mortality (TRM) after allogenic SCT was 31%, with no reported deaths after ASCT. In younger patients with T-cell lymphoma, standard chemotherapy consolidated by either autologous or allogeneic transplantation result in comparable survival, thus eliminating a role for allogenic stem cell transplantation in the first-line setting.35 These results are in line with the retrospective analysis of the MD Anderson Cancer Center for patients with PTCLs that failed to show any difference in outcomes between ASCT and allogenic SCT. In addition, a CR prior to SCT initiation was associated with improved outcomes.36

In a prospective Phase II trial, Corradini et al evaluated the graft-versus-lymphoma effect of reduced-intensity conditioning (RIC) (thiotepa, cyclophosphamide and fludarabine) followed by allogenic SCT in relapsed PTCLs. Seventeen patients were enrolled, of whom two had chemo-refractory disease and 15 had relapsed disease. Eight patients (47%) had disease relapse after ASCT. Salvage therapy consisted of 4 to 6 cycles of DHAP followed by RIC and allogenic SCT. At a median follow-up of 28 months, the estimated 3-year OS and PFS rates were 81% and 64% respectively, and the transplantation-related mortality rate was 12%. Donor lymphocyte infusions induced a response in two patients progressing after transplantation, suggesting the existence of a graft-versus-lymphoma effect.37

Zain et al retrospectively reported the results of a case series of patients with R/R PTCLs, undergoing related or unrelated donors allogenic SCT between 2000 and 2007. Thirty-seven pretreated patients were enrolled, 68% (25 patients) of whom had either relapsed or progressive disease. All patients were ineligible for ASCT. Thirteen patients received fully ablative conditioning regimens, while 24 patients underwent reduced-intensity conditioning. The 5-year OS and PFS were 52.2% and 46.5%, respectively. At the time of analysis, nine (24.3%) patients had either relapsed (n = 6) or progressed (n = 3) post allogenic SCT. At 5 years, the cumulative incidences of non-relapse and relapse/progression mortality were 28.9% and 24.3%, respectively. There were no statistically significant predictors for survival or relapse by univariate Cox regression analysis of disease and patient characteristics; differences between CTCL and other histologies were not significant. The relapse/progression curves reached and maintained a plateau after 1 year post-transplant, demonstrating that long-term disease control is possible after allogenic SCT in patients with PTCLs with advanced disease.38 Collectively, these results indicate that allogenic SCT remains an option in patients with R/R PTCLs.

In relapsing patients, the subsequent treatment is not clearly defined. Conventional chemotherapy and/or autologous or allogenic SCT may result in disease control in a small number of patients. New drug development is the most promising way to improve survival for patients with R/R disease. Over the past decade, the FDA approved 4 new agents for the treatment of R/R PTCLs: pralatrexate, romidepsin, belinostat, and brentuximab vedotin. Two other drugs are approved in China and Japan. These molecules showed a single-agent activity based on the results of published phase II trials summarized in Table 3. However, the EMA did not recognize pralatrexate, romidepsin, and belinostat for the treatment of patients with PTCLs. In fact, these agents were associated with a good response rate, yet the PFS remains largely unchanged in this high risk group of patients.

Table 3 Approved Agents for the Treatment of PTCLs

Pralatrexate, a novel folate analogue metabolic inhibitor with high affinity for reduced folate carrier type 1 (RFC-1), was the first drug approved for the treatment of relapsed and/or refractory PTCLs in September 2009 based on the results of the PROPEL study (Pralatrexate in Patients with Relapsed or Refractory Peripheral T-Cell Lymphoma). Pralatrexate was given intravenously weekly at a dosage of 30mg/m2 for 6 weeks in a 7-week cycle. The ORR was 29%.39 Maruyama et al reported the results of a Japanese phase I/II trial evaluating pralatrexate in 20 patients with R/R PTCLs. The ORR was 45%, including two CR; median PFS was 150 days. The median duration of response (DOR) and OS were not reached, and the safety profile was comparable to the PROPEL study.40 More recently, Hong et al published the outcomes of a single-arm multicenter study of 71 patients with R/R PTCLs after a median of two previous treatment lines. The ORR was 52% with a median DOR of 8.7 months, median PFS of 4.8 months, and median OS of 18.0 months.41 This suggests that earlier treatment with pralatrexate may be associated with better clinical outcome.

Romidepsin is a bicyclic class 1 selective HDAC inhibitor. It has been isolated form Chromobacterium violaceum. In June 2011, the FDA approved romidepsin for the treatment of patients with R/R PTCLs who have progressed after at least one systemic therapy regimen. In a phase II trial conducted by the National Cancer Institute, the ORR with romidepsin in patients with R/R PTCLs was 38%, and the median DOR was 8.9 months.42 The pivotal registration-directed phase II trial enrolled 130 patients who were treated with romidepsin 14mg/m2 intravenously on days 1, 8 and 15 every 28-day cycle. Coiffier et al reported an ORR of 25% including 15% CR/CRu (unconfirmed CR) with a median PFS of 4 months and median DOR of 28 months among responders, leading to an accelerated FDA approval.43

Belinostat, a hydroxamic acid-derived pan-class I and II HDAC inhibitor, has also been approved by the FDA in July 2014 for the treatment of patients with R/R PTCLs who failed at least one previous treatment line. This was based on the results of the pivotal phase II BELIEF trial, a multicenter open label trial of belinostat in patients with relapsed or refractory T-cell lymphoma. A total of 129 patients were enrolled and received 1000mg/m2 of belinostat on days 15 in 21-day cycles. The median number of previous treatment lines was 2, and the authors reported an ORR of 25.8% including 10.8% CRs. Patients with PTCL-NOS achieved an ORR of 23%, those with AITL had an ORR of 46%, and patients with ALK- ALCL had an ORR of 15%. The median DOR, PFS and OS were 13.6 months, 1.6 months, and 7.9 months, respectively.44

Chidamide is an oral class I/II HDAC inhibitor that has been studied in a pivotal Chinese phase II trial in patients with R/R PTCLs (mainly PTCL-NOS, ALCL, ENKTL, and AITL). Eighty-three patients had been enrolled and received chidamide 30 mg orally twice per week. The ORR was 28% including 14% of CR/CRu. The median PFS was 2.1 months and the median OS was 21.4 months.45 Based on these results, chidamide was approved only in China for the treatment of patients with R/R PTCLs.

Brentuximab vedotin is the fourth drug approved by the FDA for the treatment of patients with R/R ALCL in August 2011, and extended for primary CTCL and CD30-expressing Mycosis Fungoides in November 2017. In a pivotal phase II trial, BV was evaluated for patients with R/R systemic ALCL. It was administered intravenously as single-agent at a dose of 1.8mg/kg every 3 weeks for up to 16 cycles. Fifty-eight patients were enrolled; the ORR was 86% with 57% of CR, and the median PFS was 13.6 months. Among patients who achieved CR, 5-year OS was 79% and 5-year PFS was 57%.46 These data led to approval of BV in the USA, European Union, and Japan for patients with sALCL. Many ongoing trials are evaluating the combination of BV with other drugs in both relapsed and upfront settings.

Mogamulizumab is a defucosylated humanized IgG1 monoclonal antibody that targets CC chemokine receptor 4 (CCR4) which is mainly expressed in ALK- ALCL, PTCL-NOS, AITL, and transformed mycosis fungoides. It was approved in Japan for patients with R/R CCR4+ ATLL and cutaneous T-cell lymphoma based on the results of a multicenter phase II trial evaluating mogamulizumab for the treatment of patients with relapsed ATLL. The study enrolled 28 patients who received intravenous infusions of mogamulizumab once per week for 8 weeks at a dose of 1.0 mg/kg. The ORR was 50% including 30% of CR. Median PFS and OS were 5.2 months and 13.7 months, respectively.47 Furthermore, mogamulizumab was approved in the USA for the treatment of R/R mycosis fungoides and Sezary syndrome.

Crizotinib, an oral ALK-ROS1-MET inhibitor, was associated with an ORR of 90% in a pediatric study of 26 patients having R/R ALK+ ALCL with a good safety profile. Among the 23 patients who achieved a response, 39% maintained their response for at least 6 months, and 22% maintained their response for at least 12 months.48 Crizotinib was approved by the FDA for the treatment of patients with R/R ALK+ ALCL in children and young adults in January 2021.

Duvelisib, an oral PI3K-delta-gamma inhibitor was associated with an ORR of 50% in PTCL, and 31.6% in CTCL with 3 complete responses in a phase II trial when used as monotherapy for patients with R/R PTCLs.49 Everolimus, an oral mammalian target of rapamycin (mTOR) pathway inhibitor, given at 10 mg daily continuously resulted in an ORR of 44% in a phase II trial of 16 patients with R/R PTCL. The median PFS was 4.1 months and the median OS was 10.2 months. Six patients (38%) required a dose reduction to 5mg daily.50

Hypomethylating agents (HMAs), initially approved for the treatment of AML and myelodysplastic syndrome, have been studied in R/R PTCLs. HMAs are the pharmacologic counterbalance of epigenetics modified tumor by IDH2, TET2 and DNMT3A mutations.12 5-Azacitidine used as monotherapy at a dose of 75 mg/m2 subcutaneously for 7 consecutive days every 28-days cycle in patients with AITL was associated with an ORR of 75% (9/12) and CR rate of 50% (6/12). Patients presented durable responses with a median PFS and OS of 15 and 21 months, respectively.51 An ongoing phase III trial is comparing oral 5-Azacitidine with investigators choice therapy (romidepsin, bendamustine or gemcitabine) in patients with R/R AITL (NCT03593018).

Lenalidomide, an immunomodulatory agent targeting cereblon and aiolos/ikaros transcription factors and approved in B-cell NHL and multiple myeloma, has shown modest activity when used as monotherapy in the EXPECT phase II trial with an ORR of 22%.52 In patients with R/R ATLL, lenalidomide demonstrated clinically meaningful antitumor activity with an ORR of 42% including 4 CR and 1 unconfirmed CR in a multicenter phase II trial.53

Programmed death-ligand 1 (PD-L1) was mainly detected in AITL (>90%) and PTCL-NOS (3060%), and rarely in other subtypes.54 In NKTCL, PD-L1 expression ranged between 56 and 93% in different studies, while PD-1 level was consistently low.55 In addition, Kataoka et al demonstrated that PD-L1 amplifications represent a strong genetic predictor of worse outcomes in patients with both aggressive and indolent ATLL.56 The efficacy of nivolumab, a PD-1 inhibitor, was evaluated in a Phase I, open-label, dose-escalation, cohort expansion trial for the treatment of patients with R/R TCL. Twenty-three patients were enrolled. The ORR among these patients was 17%.57 In a retrospective case series, pembrolizumab, another PD-1 inhibitor, showed high efficacy (100%) in 7 patients with R/R NK/T cell lymphoma that relapsed after treatment with L-asparaginase. Complete response was observed in 5 patients (71%), and this was sustained after a median follow-up of 6 months.58 In a multicenter single-arm phase II trial, pembrolizumab given at a dosage of 200mg intravenously every three weeks, was evaluated for patients with R/R PTCLs. Of 18 enrolled patients, 13 were evaluable for the primary endpoint. The ORR was 33%, with 4 patients showing a CR. The median PFS was 3.2 months and the median OS was 10.6 months. The median duration of response was 2.9 months. Two of the 4 patients who presented CR remained in remission for at least 15 months. The trial was halted early after a preplanned interim futility analysis.59 PD-1 inhibitors had modest activity when used as monotherapy and these drugs could be more active when combined with another agent such as HDAC inhibitors, HMAs, or antifolates. Table 4 summarizes the major clinical trials evaluating novel combinations of immunotherapy in R/R PTCLs.

Table 4 Novel Combinations of Immunotherapy Under Investigation in R/R PTCLs

A new strategy was adopted for the treatment of patients with R/R PTCLs based on the combination of approved and non-approved medications in the field. Available data concerning these combinations are summarized in Table 5. However, most of these data are reported from small single-center studies without central pathology review.

Table 5 Experimental Combinations of Approved Agents in R/R PTCLs

Romidepsin is an HDAC inhibitor approved for R/R PTCLs. In preclinical models of PTCLs, romidepsin and pralatrexate showed a potent synergy in in-vitro and in-vivo models at dose levels of 50% of the maximal tolerated dose (MTD).60 Amengual et al reported the results of the first Phase I trial evaluating the combination of these two drugs to determine the MTD, pharmacokinetic profile, and response rate. Pralatrexate 25mg/m2 and romidepsin 12 mg/m2 administered concurrently every other week were recommended for the Phase 2 trial. In this phase I study, the ORR for all patients was 57% (13/23), whereas the response rate in patients with PTCLs was 71% (10/14), and 33% (3/9) in patients with B-cell lymphoma.61 The phase II trial is still ongoing (NCT01947140).

The combination of HDACi and HMAs could be a novel approach for the treatment of PTCLs, targeting the epigenetic dysregulation of the disease. Marchi et al demonstrated a marked synergy between HDACi and HMAs in preclinical models of PTCLs.62 The encouraging results of a multicenter phase I trial evaluating the combination of romidepsin and oral 5-Azacitidine in R/R PTCLs were recently reported. The ORR for all patients was 32%, for non-TCL was 10%, and 73% for patients with T-cell lymphoma. The CR rates were 23%, 5% and 55%, respectively. The MTD retained for phase 2 trial was 5-Azacitidine 300mg on days 1 to 14 and romidepsin 14mg/m2 on days 8, 15 and 22 of a 35-day cycle.63 The phase II trial is still ongoing (NCT01998035).

A novel interesting combination in the treatment of R/R PTCLs is the association of HDACi and duvelisib. The results of the phase I/II trial evaluating the association of duvelisib and romidepsin were reported in an abstract form by Horwitz et al The MTD of duvelisib was 75mg BID on days 1 to 28, given with romidepsin 10mg/m2 on days 1, 8 and 15 of a 28-day cycle. The ORR was 55%, and CR occurred in 27% of the patients. Grade 3 or higher adverse events were seen in 65% of patients.64 These results suggest that romidepsin + duvelisib could be a potential therapeutic strategy to be evaluated in larger studies.

Another experimental combination was the association of HDACi and proteasome inhibitors based on the activity and the efficacy of these two classes in PTCLs. Tan et al reported the results of a phase II trial evaluating the combination of panobinostat and bortezomib. Patients received 20 mg oral panobinostat three times a week and 13 mg/m(2) intravenous bortezomib two times a week, both for 2 of 3 weeks for up to eight cycles. The ORR was 43% (10 of 23 patients), and the CR rate was 22% (5 of 23 patients). However, the PFS was very limited, which can be attributed to the short response time in highly aggressive disease.65

The management of patients with PTCLs remains challenging, with slow progress being made in the field, and only few drugs are currently approved. This is mainly due to the rarity of the disease and its aggressiveness, much complicating trial recruitment. Furthermore, given the various biological and molecular patterns, and the increasingly precise dissection of the molecular and immunological abnormalities of the disease, international collaboration seems crucial, and pan T-cell lymphomas trials are more and more regarded as a failed strategy. Innovative drugs targeting epigenetic mechanisms, immune checkpoint modulations, CD30 and TCR abnormalities with cellular therapies portend much hope to improve the outcomes of these patients in the upcoming years.

Dr Jean-Marie Michot reports being a principal/sub-investigator of clinical trials for Abbvie, Amgen, Astex, AstraZeneca, Debiopharm, Lilly, Roche, and Xencor, during the conduct of the study. Dr Vincent Ribrag reports non-financial support from Astex, Abbvie, BMS, Sanofi, and Servier, grants and non-financial support from Argenx, personal fees from Gilead, Roche, Incyte, and Nanostring, and personal fees and non-financial support from MSD and AZ, during the conduct of the study. The authors report no other potential conflicts of interest for this work.

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