Immunotherapy for Viral and Fungal Infections

ORIGINAL ARTICLE Immunotherapy for viral and fungal infections

H Einsele, J Löfﬂer, M Kapp, L Rasche, S Mielke and UG Grigoleit

Allogenic stem cell transplantation (allo-SCT) represents the only curative option for several hematological malignancies. Due to a delayed and dysfunctional immunological recovery infectious complications and residual tumor cells following allo-SCT are still major causes of failure of this procedure. Here we discuss the most common infectious complications of allo-SCT and describe current and future strategies to prophylaxe or treat these complications using novel immunotherapeutic strategies.

Bone Marrow Transplantation (2015) 50, S51–S54; doi:10.1038/bmt.2015.96

INTRODUCTION Suitable combination of antigens/T-cell epitopes will allow for Allogeneic hematopoietic stem cell transplantation (allo-SCT) optimal stimulation and selection of multiple pathogen-specific represents the only curative option for several hematological T cell lines and a characterization of pathogen specificity and malignancies. Although several improvements in conditioning alloreactivity for safety and quality control of the generated regimens and SCT procedures (especially in vivo/ex vivo T-cell T cell lines. depletion) allow to achieve a fast and long-lasting regeneration of Furthermore, for the high-risk patients who are seropositive and hematopoiesis, patients are still suffering from major complica- receive a transplant from a seronegative donor, T-cell priming or tions due to a delayed and dysfunctional immunological recovery. redirection of donor T cells have to be used as well as the transfer of antigen-specific cells from seropositive third party donors. Disease relapse and life-threatening infections with multiple pathogens (for example, CMV, EBV, adenovirus (ADV), Aspergillus spp., Candida spp. and so on) severely affect the ultimate outcome VIRAL INFECTIONS POST TRANSPLANT of SCT. Disease status, previous treatment, patient age and the degree of donor/patient mismatches are critical variables influen- Allo-SCT can cure patients with several hematological malignan- cing the relative risks of relapse and infections. A major strategy to cies but exposes patients to periods of marked immunosuppres- deal with viral and in the future also fungal infection is the clinical sion, during which infections, especially viral and fungal infections, application of T-cell subsets directed against multiple pathogens can cause morbidity and mortality. CMV reactivation/disease has a 1,2 in a patient-tailored approach, able to boost and shape the novel major negative impact on the outcome of SCT. Inspite of novel donor-derived immune system toward proper antigens and anti-CMV drugs (CMX001 and letermovir) with promising activity fi 3 ultimately improve the clinical outcome. and good safety pro le, CMV infection remains a life-threatening Clinical application needs to include central memory T cells, complication and a major cause of infection-related mortality in recipients of an allo-SCT, especially in patients undergoing cord THELPER cells and probably also effector memory T cells. This goal, which represents a major progress for patients with hematological blood or haploidentical SCT as well as patients with severe acute malignancies, will be pursued through the development of or extensive chronic GvHD. innovative strategies of isolation, expansion and manipulation of In addition, ADV infections have been increasingly described in these patients with an incidence up to 29%, again with patients donor T-lymphocyte subpopulations. Adoptive transfer of T cells undergoing a stem cell transplant from an alternative donor being directed against single viral pathogens has been effective in small fi the patient cohort at a highest risk for ADV infection and disease. phase I/II studies but often therapeutic ef cacy was limited not EBV reactivations post SCT can induce life-threatening post- only owing to the lack of persistence and migration of the transplant lymphoproliferative disease. Current data reveal that transferred donor T cells to the site of infection, but also by serotherapy with anti-thymocyte globulin or Campath as well as additional infections not targeted by the transferred T cells. the occurrence of severe acute GvHD and also SCT from an Therefore the aim of adoptive T-cell therapy is the generation of alternative donor or a mismatched related or unrelated donor is polyclonal T-cell populations against multiple pathogens, not only associated with an increased risk for an EBV-related lymphopro- by adding T cells directed against different infectious pathogens, liferative disorder.4 but also by the controlled coordination of a variety of T-cell It is now appreciated that T-cell reconstitution is required for populations and T-cell responses. To favor long-lasting clinical the sustained control of CMV, EBV and ADV infections5,6 and that responses new T-cell selection and manipulation procedures that drug therapy limits the infection, but cannot prevent concurrent favor the generation of antigen-specific central memory and reactivations and may induce major toxicity (hematotoxicity/ memory stem T cells, a recently discovered T-cell subset nephrotoxicity/secondary infections). characterized by a high degree of plasticity, expansion potential An urgent clinical demand for enriched virus, fungal, multivirus and self-renewal capacities has to be pursued. and multipathogen-specific T cells with reduced alloreactivity has

Department of Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany. Correspondence: Professor H Einsele, Department of Internal Medicine II, University Hospital Wuerzburg, Oberduerrbacher Strasse 6, 97080 Wuerzburg, Germany. E-mail: [email protected] This article was published as part of a supplement, supported by WIS-CSP Foundation, in collaboration with Gilead, Milteny Biotec, Gamida cell, Adienne Pharma and Biotech, Medac hematology, Kiadis Pharma, Almog Diagnostic. Immunotherapy for viral/fungal infections H Einsele et al S52 been expressed.6 Several groups have reported potential with the aim of adoptive transfer directed against single antigens protocols,7–10 but only very limited clinical trial activity has been in viral infection, which can lead to reconstitution of antiviral reported so far. immunity after SCT.21–24 So far, logistics have limited the application of cellular therapies and short-term in vivo persistence clearly interferes with the FUNGAL INFECTIONS antiviral efficacy of transferred T cells. Recently, a long-lived Invasive fungal infections are one of the major threats to patients human memory T-cell population has been described with undergoing allo-SCT. The incidence of invasive fungal infection relevance for adoptive T-cell transfer approaches. This subpopula- depending on the geographic localization of the transplantation tion has an enhanced capacity for self-renewal and a multipotent center as well as the percentage of patients belonging to high-risk ability to derive central memory, effector memory and effector group for invasive fungal infection can go beyond 15%. T cells. These cells, specific to multiple viral and self-tumor Yet diagnostic techniques are rather insensitive and not very antigens, were found within a CD45RO-, CCR7+, CD45RA+, CD62L+, reliable—leading to a vast overtreatment of patients—often as a CD27+, CD28+ and IL-7Rα+ T-cell compartment characteristic of prophylaxis—with drugs that are potentially toxic but definitely naive T cells. However, they expressed large amounts of CD95, very expensive. Thus, large transplant centers spend easily 41 IL-2Rβ, CXCR3 and LFA-1, and showed numerous functional Mio € for diagnostic and therapeutic strategies to prevent and attributes distinctive of memory cells. Compared with known treat invasive fungal infection. In spite of these high costs, the memory populations, these lymphocytes had increased prolifera- outcome of invasive fungal infection, especially when lung and tive capacity and more efficiently reconstituted immunodeficient even more important the central nervous system is involved, is hosts and were recently termed memory stem T cells.25 As T-cell rather poor (mortality ranging from 30 to 80% depending on the responses can reconstitute even from a single T cell, repopulating underlying disease and the transplant modality as well as the capacities are of clinical significance for adoptive T-cell transfer occurrence of severe acute and chronic GvHD). approaches.26 However, the starting population/phenotype for so- Thus, new diagnostic and treatment strategies for invasive called ‘giant T-cell clones’27 is still not clear in humans. fungal infection are highly warranted. Adoptive T-cell transfer for CMV reactivation after SCT has been performed over decades with T cell lines generated by repetitive stimulation in vitro.21,28 IMMUNOTHERAPY FOR FUNGAL INFECTIONS New strategies of T-cell selection using antigen-induced T-cell Studies in mice and humans suggest the importance of the stimulation and isolation by cytokine capture assay, streptamer T-helper type 1 (Th1) response in conferring protection against technology29 or via increased expression of activation markers has invasive aspergillosis. Th1 interferon-gamma-secreting cells are been developed.9,10,30 In a recent study, this approach has been believed to increase innate immune responses9 against aspergillus successfully applied to patients with chemorefractory CMV by activating macrophages and neutrophils, and enhance infection and disease.31 Adoptive transfer of antigen-specific antimicrobial activity of respiratory epithelial cells. Mice given T cells for EBV, ADV and CMV is now established at several centers neutralizing antibodies against Th2 cytokines to indirectly in a clinical protocol with the required clinical, immunological, enhance Th1 cytokine production have increased protection virological, technical and regulatory preconditions.6,30 against aspergillosis and Th1 cells obtained from mice previously Selective allodepletion may serve as an improved platform immunized with aspergillus antigens were shown to protect from technology where GvHD-causing T cells are depleted from the aspergillosis following adoptive transfer to otherwise susceptible stem cell allograft enabling the remaining T-cell repertoire to mice. Patients undergoing allo-SCT are also at a high risk to facilitate anti-infectious antimalignant properties in the presence develop invasive aspergillosis and we have shown that a low rate of low or no immunosuppression. Various methods of allodeple- of T-cell proliferation when exposed to aspergillus antigens as well tion have been successfully established, some of which including as a predominant aspergillus-specific Th2 response are associated CD25-immunotoxin-based allodepletion and TH9402-based with a worse outcome of invasive aspergillosis in patients who photodepletion have been already transferred into the clinical have undergone allo-SCT.11 setting.32–36 International multicenter trials are recruiting. Until Several groups have established methods to select and expand now 4100 patients after allo-SCT have been treated against aspergillus-specific T cells and a small clinical trial has shown single pathogens all over Europe with Ag-specific T cells.37,38 promising activity and good safety of the transfer of in vitro However, in vivo persistence of transferred T cells in the recipient stimulated and selected aspergillus-specific T-cell clones to remains a problem of T-cell transfer either due to inherent patients with uncontrolled invasive aspergillosis following allo- properties of the T-cell product or due to immunosuppressive SCT.12 drugs in the recipient. Especially, third-party T-cell transfer from In addition, we and others have shown that also activated HLA-partially matched donors has been shown safe and natural killer cells—which can be easily selected and enriched feasible38,39 but in vivo persistence of T cells is limited. In addition, 13–15 + for—can mediate anti-aspergillus activity. the role of CD4 THELPER cells, which have been emphasized over Data from our group have also demonstrated that isolated many years for the efficacy of adoptive T-cell transfer,9,21,24,40,41 gamma-delta T cells can mediate anti-aspergillus activity.11 still remains to be investigated. Gamma-delta T lymphocytes can be highly enriched for under good manufacturing practice conditions using the Clinimacs device16,17 and also easily be activated and expanded in vivo by SELECTION/GENERATION AND TRANSFER OF stimulation with aminobisphosphonates.18 MULTIPATHOGEN-SPECIFIC T CELLS Thus, this cell population that also mediates antiviral and anti- In the past few years novel screening techniques have revealed tumor activity,19,20 but does not mediate alloreactivity will be a multiple viral and fungal pathogens to emerge as major very attractive option to be used for adoptive immunotherapy for contributors to post-transplant morbidity and mortality, expand- infection and tumor control post transplant. ing from CMV, EBV, ADV) to HSV, BK virus and VZV, also including HHV-6 and several fungal pathogens, for example, Aspergillus spp., Candida spp., especially non-albicans Candida spp. and as an IMMUNOTHERAPY FOR VIRAL INFECTIONS emergent problem also Mucor spp. Antigen-specific T cells against single pathogens (ADV, CMV and Thus, an urgent clinical demand for enriched multivirus and also EBV) have been and are currently investigated by several groups multipathogen-specific T cells with reduced alloreactivity has

Bone Marrow Transplantation (2015) S51 – S54 © 2015 Macmillan Publishers Limited Immunotherapy for viral/fungal infections H Einsele et al S53 been expressed.6 Several groups have reported potential Several hundreds of patients were treated successfully and with protocols,7,8,10,42 but only very limited clinical trial activity has little toxicity with CMV-, EBV- and ADV-specific T cells for refractory been reported so far. virus infection following allo-SCT. In addition, isolation of Broader implementation of multipathogen-specific T-cell multipathogen-specific T cells can be successfully achieved from therapy is restricted by the limited spectrum of immunodominant the seropositive donors using novel selection devices. In some fi viral and fungal proteins and peptides de ned and available that patients multipathogen-specific T cells also were successfully can be targeted in a single T cell line and the logistics of administered and showed antiviral activity and successful control manufacture of these lines. One major problem anticipated in the of CMV, EBV and ADV infection. generation of multipathogen-specific cell lines is the antigenic competition between high- and low-frequency T cells as well as T cells of high and low avidity. Competition for shared APCs may CONFLICT OF INTEREST favor the generation of T cell lines dominated by responses to a single or only a few pathogens, thus limiting the coverage of HE received consulting and lecture fees from Celgene, Janssen, Amgen, Onyx and fi pathogens provided by the T-cell product. In addition, often the Novartis. JL received grant support from P zer Europe. SM has received lecture fees manufacturing process used to generate these multipathogen- from Deutschen Rentenversicherung, Cellex GmbH, Novartis Pharma, Shire, and grant fi support from Wilhelm-Sander-Stiftunq. Germany, Carreras-Leukamie-Stiftunq. The speci c T-cell products is very complex and extremely labor and fl time consuming. Thus, we have established two new strategies to remaining authors declare no con ict of interest. isolate mutlipathogen-specific T cell lines for the treatment of patients at risk for multiple viral and fungal infections post ACKNOWLEDGEMENTS transplant. We are evaluating the use of MHC multimers that reversibly Research Funds were received for this project by EU FP7 T-Control and the Deutsche bind to the TCR of antiviral and antifungal CD8+ and CD4+ T cells. Forschungsgemeinschaft (DFG) CRC/TR 124. 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