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Erschienen in: International Journal of Hematology 3/2010

01.04.2010 | Original Article

Separation of antileukemic effects from graft-versus-host disease in MHC-haploidentical murine bone marrow transplantation: participation of host immune cells

verfasst von: Atsushi Satake, Takayuki Inoue, Shuji Kubo, Yuki Taniguchi, Takehito Imado, Tatsuya Fujioka, Marika Horiuchi, Yunfeng Xu, Kazuhiro Ikegame, Satoshi Yoshihara, Katsuji Kaida, Hiroya Tamaki, Masaya Okada, Haruki Okamura, Hiroyasu Ogawa

Erschienen in: International Journal of Hematology | Ausgabe 3/2010

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Abstract

Allogeneic hematopoietic stem cell transplantation (HSCT) is associated with both graft-versus-host disease (GVHD) and graft-versus-leukemia (GVL) effects. In clinical studies of HLA-mismatched HSCT, strong GVL effects have been reported. In the present study, we addressed the mechanism of the GVL and GVH response using MHC-haploidentical murine bone marrow transplantation (BMT) models. Recipient BDF1 (H-2b/d) mice received T cell-depleted bone marrow and spleen cells from B6C3F1 (H-2b/k) or C57BL/6 (H-2b) mice with or without P815 mastocytoma cells (H-2d) after receiving lethal total body irradiation. B6C3F1 → BDF1 (hetero-to-hetero type) recipients showed more powerful antileukemic effects with less severe GVHD than C57BL/6 → BDF1 (parent-to-F1 type) recipients. Compared with C57BL/6 → BDF1 recipients, significantly higher in vitro cytotoxic activity against P815 cells was observed in B6C3F1 → BDF1 recipients. Significantly lower CXCR3 expression on donor T cells and higher interferon (IFN)-γ expression were considered to be associated with strong antileukemic effects with less severe GVHD in B6C3F1 → BDF1 recipients. Furthermore, host immune cells, especially natural killer cells and CD8+ T cells, were found to contribute remarkably to high IFN-γ production in B6C3F1 → BDF1 recipients. Thus, in MHC-haploidentical HSCT, host immune cells may change the balance between GVH and GVL response through IFN-γ production.
Literatur
1.
Zurück zum Zitat Thomas ED. Karnofsky memorial lecture. Marrow transplantation for malignant diseases. J Clin Oncol. 1983;1:517–31.PubMed Thomas ED. Karnofsky memorial lecture. Marrow transplantation for malignant diseases. J Clin Oncol. 1983;1:517–31.PubMed
2.
Zurück zum Zitat Bortin MM, Rimm AA. Increasing utilization of bone marrow transplantation. Transplantation. 1986;42:229–34.CrossRefPubMed Bortin MM, Rimm AA. Increasing utilization of bone marrow transplantation. Transplantation. 1986;42:229–34.CrossRefPubMed
4.
Zurück zum Zitat Ringden O, Nilsson B. Death by graft-versus-host disease associated with HLA mismatch, high recipient age, low marrow cell dose, and splenectomy. Transplantation. 1985;40:39–44.PubMedCrossRef Ringden O, Nilsson B. Death by graft-versus-host disease associated with HLA mismatch, high recipient age, low marrow cell dose, and splenectomy. Transplantation. 1985;40:39–44.PubMedCrossRef
5.
Zurück zum Zitat Ikegame K, Tanji Y, Kitai N, Tamaki H, Kawakami M, Fujioka T, et al. Successful treatment of refractory T-cell acute lymphoblastic leukemia by unmanipulated stem cell transplantation from an HLA 3-loci mismatched (haploidentical) sibling. Bone Marrow Transplant. 2003;31:507–10.CrossRefPubMed Ikegame K, Tanji Y, Kitai N, Tamaki H, Kawakami M, Fujioka T, et al. Successful treatment of refractory T-cell acute lymphoblastic leukemia by unmanipulated stem cell transplantation from an HLA 3-loci mismatched (haploidentical) sibling. Bone Marrow Transplant. 2003;31:507–10.CrossRefPubMed
6.
Zurück zum Zitat Ogawa H, Ikegame K, Kawakami M, Tsuboi A, Kim EH, Hosen N, et al. Powerful graft-versus-leukemia effects exerted by HLA-haploidentical grafts engrafted with a reduced-intensity regimen for relapse following myeloablative HLA-matched transplantation. Transplantation. 2004;78:488–9.CrossRefPubMed Ogawa H, Ikegame K, Kawakami M, Tsuboi A, Kim EH, Hosen N, et al. Powerful graft-versus-leukemia effects exerted by HLA-haploidentical grafts engrafted with a reduced-intensity regimen for relapse following myeloablative HLA-matched transplantation. Transplantation. 2004;78:488–9.CrossRefPubMed
7.
Zurück zum Zitat Ogawa H, Ikegame K, Yoshihara S, Kawakami M, Fujioka T, Masuda T, et al. Unmanipulated HLA 2–3 antigen-mismatched (haploidentical) stem cell transplantation using nonmyeloablative conditioning. Biol Blood Marrow Transplant. 2006;12:1073–84.CrossRefPubMed Ogawa H, Ikegame K, Yoshihara S, Kawakami M, Fujioka T, Masuda T, et al. Unmanipulated HLA 2–3 antigen-mismatched (haploidentical) stem cell transplantation using nonmyeloablative conditioning. Biol Blood Marrow Transplant. 2006;12:1073–84.CrossRefPubMed
8.
Zurück zum Zitat Ogawa H, Ikegame K, Kaida K, Yoshihara S, Fujioka T, Taniguchi Y, et al. Unmanipulated HLA 2–3 antigen-mismatched (haploidentical) bone marrow transplantation using only pharmacological GVHD prophylaxis. Exp Hematol. 2008;36:1–8.CrossRefPubMed Ogawa H, Ikegame K, Kaida K, Yoshihara S, Fujioka T, Taniguchi Y, et al. Unmanipulated HLA 2–3 antigen-mismatched (haploidentical) bone marrow transplantation using only pharmacological GVHD prophylaxis. Exp Hematol. 2008;36:1–8.CrossRefPubMed
9.
Zurück zum Zitat Murai M, Yoneyama H, Ezaki T, Suematsu M, Terashima Y, Harada A, et al. Peyer’s patch is the essential site in initiating murine acute and lethal graft-versus-host reaction. Nat Immunol. 2003;4:154–60.CrossRefPubMed Murai M, Yoneyama H, Ezaki T, Suematsu M, Terashima Y, Harada A, et al. Peyer’s patch is the essential site in initiating murine acute and lethal graft-versus-host reaction. Nat Immunol. 2003;4:154–60.CrossRefPubMed
10.
Zurück zum Zitat Welniak LA, Blazar BR, Anver MR, Wiltrout RH, Murphy WJ. Opposing roles of interferon-gamma on CD4+ T cell-mediated graft-versus-host disease: effects of conditioning. Biol Blood Marrow Transplant. 2000;6:604–12.CrossRefPubMed Welniak LA, Blazar BR, Anver MR, Wiltrout RH, Murphy WJ. Opposing roles of interferon-gamma on CD4+ T cell-mediated graft-versus-host disease: effects of conditioning. Biol Blood Marrow Transplant. 2000;6:604–12.CrossRefPubMed
11.
Zurück zum Zitat Yang YG, Qi J, Wang MG, Sykes M. Donor-derived interferon gamma separates graft-versus-leukemia effects and graft-versus-host disease induced by donor CD8 T cells. Blood. 2002;99:4207–15.CrossRefPubMed Yang YG, Qi J, Wang MG, Sykes M. Donor-derived interferon gamma separates graft-versus-leukemia effects and graft-versus-host disease induced by donor CD8 T cells. Blood. 2002;99:4207–15.CrossRefPubMed
12.
Zurück zum Zitat Wang H, Asavaroengchai W, Yeap BY, Wang MG, Wang S, Sykes M, et al. Paradoxical effects of IFN-gamma in graft-versus-host disease reflect promotion of lymphohematopoietic graft-versus-host reactions and inhibition of epithelial tissue injury. Blood. 2009;113:3612–9.CrossRefPubMed Wang H, Asavaroengchai W, Yeap BY, Wang MG, Wang S, Sykes M, et al. Paradoxical effects of IFN-gamma in graft-versus-host disease reflect promotion of lymphohematopoietic graft-versus-host reactions and inhibition of epithelial tissue injury. Blood. 2009;113:3612–9.CrossRefPubMed
13.
Zurück zum Zitat Brok HP, Heidt PJ, van der Meide PH, Zurcher C, Vossen JM. Interferon-gamma prevents graft-versus-host disease after allogeneic bone marrow transplantation in mice. J Immunol. 1993;151:6451–9.PubMed Brok HP, Heidt PJ, van der Meide PH, Zurcher C, Vossen JM. Interferon-gamma prevents graft-versus-host disease after allogeneic bone marrow transplantation in mice. J Immunol. 1993;151:6451–9.PubMed
14.
Zurück zum Zitat Burman AC, Banovic T, Kuns RD, Clouston AD, Stanley AC, Morris ES, et al. IFNγ differentially controls the development of idiopathic pneumonia syndrome and GVHD of the gastrointestinal tract. Blood. 2007;110:1064–72.CrossRefPubMed Burman AC, Banovic T, Kuns RD, Clouston AD, Stanley AC, Morris ES, et al. IFNγ differentially controls the development of idiopathic pneumonia syndrome and GVHD of the gastrointestinal tract. Blood. 2007;110:1064–72.CrossRefPubMed
15.
Zurück zum Zitat Cooke KR, Kobzik L, Martin TR, Brewer J, Delmonte J Jr, Crawford JM, et al. An experimental model of idiopathic pneumonia syndrome after bone marrow transplantation. I. The roles of minor H antigens and endotoxin. Blood. 1996;88:3230–9.PubMed Cooke KR, Kobzik L, Martin TR, Brewer J, Delmonte J Jr, Crawford JM, et al. An experimental model of idiopathic pneumonia syndrome after bone marrow transplantation. I. The roles of minor H antigens and endotoxin. Blood. 1996;88:3230–9.PubMed
16.
Zurück zum Zitat Yoshida Y, Hirano T, Son G, Iimuro Y, Imado T, Iwasaki T, et al. Allogeneic bone marrow transplantation for hepatocellular carcinoma: hepatocyte growth factor suppresses graft-vs.-host disease. Am J Physiol Gastrointest Liver Physiol. 2007;293:G1114–23.CrossRefPubMed Yoshida Y, Hirano T, Son G, Iimuro Y, Imado T, Iwasaki T, et al. Allogeneic bone marrow transplantation for hepatocellular carcinoma: hepatocyte growth factor suppresses graft-vs.-host disease. Am J Physiol Gastrointest Liver Physiol. 2007;293:G1114–23.CrossRefPubMed
17.
Zurück zum Zitat Kubo S, Seleme MC, Soifer HS, Perez JL, Moran JV, Kazazian HH Jr, et al. L1 retrotransposition in nondividing and primary human somatic cells. Proc Natl Acad Sci USA. 2006;103:8036–41.CrossRefPubMed Kubo S, Seleme MC, Soifer HS, Perez JL, Moran JV, Kazazian HH Jr, et al. L1 retrotransposition in nondividing and primary human somatic cells. Proc Natl Acad Sci USA. 2006;103:8036–41.CrossRefPubMed
18.
Zurück zum Zitat Nakagomi N, Nakagomi T, Kubo S, Nakano-Doi A, Saino O, Takata M, et al. Endothelial cells support survival, proliferation and neuronal differentiation of transplanted adult ischemia-induced neural stem/progenitor cells after cerebral infarction. Stem Cells. 2009;27:2185–95.CrossRefPubMed Nakagomi N, Nakagomi T, Kubo S, Nakano-Doi A, Saino O, Takata M, et al. Endothelial cells support survival, proliferation and neuronal differentiation of transplanted adult ischemia-induced neural stem/progenitor cells after cerebral infarction. Stem Cells. 2009;27:2185–95.CrossRefPubMed
19.
Zurück zum Zitat Barrett T, Koyama Y, Hama Y, Ravizzini G, Shin IS, Jang BS, et al. In vivo diagnosis of epidermal growth factor receptor expression using molecular imaging with a cocktail of optically labeled monoclonal antibodies. Clin Cancer Res. 2007;13:6639–48.CrossRefPubMed Barrett T, Koyama Y, Hama Y, Ravizzini G, Shin IS, Jang BS, et al. In vivo diagnosis of epidermal growth factor receptor expression using molecular imaging with a cocktail of optically labeled monoclonal antibodies. Clin Cancer Res. 2007;13:6639–48.CrossRefPubMed
20.
Zurück zum Zitat Iwasaki T, Fujiwara H, Shearer GM. Loss of proliferative capacity and T cell immune development potential by bone marrow from mice undergoing a graft-vs-host reaction. J Immunol. 1986;137:3100–8.PubMed Iwasaki T, Fujiwara H, Shearer GM. Loss of proliferative capacity and T cell immune development potential by bone marrow from mice undergoing a graft-vs-host reaction. J Immunol. 1986;137:3100–8.PubMed
21.
Zurück zum Zitat Jaksch M, Remberger M, Mattsson J. Increased gene expression of chemokine receptors is correlated with acute graft-versus-host disease after allogeneic stem cell transplantation. Biol Blood Marrow Transplant. 2005;11:280–7.CrossRefPubMed Jaksch M, Remberger M, Mattsson J. Increased gene expression of chemokine receptors is correlated with acute graft-versus-host disease after allogeneic stem cell transplantation. Biol Blood Marrow Transplant. 2005;11:280–7.CrossRefPubMed
22.
Zurück zum Zitat Sackstein R. A revision of Billingham’s tenets: the central role of lymphocyte migration in acute graft-versus-host disease. Biol Blood Marrow Transplant. 2006;12:2–8.CrossRefPubMed Sackstein R. A revision of Billingham’s tenets: the central role of lymphocyte migration in acute graft-versus-host disease. Biol Blood Marrow Transplant. 2006;12:2–8.CrossRefPubMed
23.
Zurück zum Zitat Hill GR, Ferrara JL. The primacy of the gastrointestinal tract as a target organ of acute graft-versus-host disease: rationale for the use of cytokine shields in allogeneic bone marrow transplantation. Blood. 2000;95:2754–9.PubMed Hill GR, Ferrara JL. The primacy of the gastrointestinal tract as a target organ of acute graft-versus-host disease: rationale for the use of cytokine shields in allogeneic bone marrow transplantation. Blood. 2000;95:2754–9.PubMed
24.
Zurück zum Zitat Snijders A, Kalinski P, Hilkens CM, Kapsenberg ML. High-level IL-12 production by human dendritic cells requires two signals. Int Immunol. 1998;10:1593–8.CrossRefPubMed Snijders A, Kalinski P, Hilkens CM, Kapsenberg ML. High-level IL-12 production by human dendritic cells requires two signals. Int Immunol. 1998;10:1593–8.CrossRefPubMed
25.
Zurück zum Zitat Afkarian M, Sedy JR, Yang J, Jacobson NG, Cereb N, Yang SY, et al. T-bet is a STAT1-induced regulator of IL-12R expression in naïve CD4+ T cells. Nat Immunol. 2002;3:549–57.CrossRefPubMed Afkarian M, Sedy JR, Yang J, Jacobson NG, Cereb N, Yang SY, et al. T-bet is a STAT1-induced regulator of IL-12R expression in naïve CD4+ T cells. Nat Immunol. 2002;3:549–57.CrossRefPubMed
26.
Zurück zum Zitat Martín-Fontecha A, Thomsen LL, Brett S, Gerard C, Lipp M, Lanzavecchia A, et al. Induced recruitment of NK cells to lymph nodes provides IFN-γ for TH1 priming. Nat Immunol. 2004;5:1260–5.CrossRefPubMed Martín-Fontecha A, Thomsen LL, Brett S, Gerard C, Lipp M, Lanzavecchia A, et al. Induced recruitment of NK cells to lymph nodes provides IFN-γ for TH1 priming. Nat Immunol. 2004;5:1260–5.CrossRefPubMed
27.
Zurück zum Zitat Moretta A. Natural killer cells and dendritic cells: rendezvous in abused tissues. Nat Rev Immunol. 2002;2:957–64.CrossRefPubMed Moretta A. Natural killer cells and dendritic cells: rendezvous in abused tissues. Nat Rev Immunol. 2002;2:957–64.CrossRefPubMed
28.
Zurück zum Zitat Pelot MR, Pearson DA, Swenson K, Zhao G, Sachs J, Yang YG, et al. Lymphohematopoietic graft-vs.-host reactions can be induced without graft-vs.-host disease in murine mixed chimeras established with a cyclophosphamide-based nonmyeloablative conditioning regimen. Biol Blood Marrow Transplant. 1999;5:133–43.CrossRefPubMed Pelot MR, Pearson DA, Swenson K, Zhao G, Sachs J, Yang YG, et al. Lymphohematopoietic graft-vs.-host reactions can be induced without graft-vs.-host disease in murine mixed chimeras established with a cyclophosphamide-based nonmyeloablative conditioning regimen. Biol Blood Marrow Transplant. 1999;5:133–43.CrossRefPubMed
29.
Zurück zum Zitat Rottman M, Soudais C, Vogt G, Renia L, Emile JF, Decaluwe H, et al. IFN-gamma mediates the rejection of haematopoietic stem cells in IFN-gammaR1-deficient hosts. PLoS Med. 2008;5:e26.CrossRefPubMed Rottman M, Soudais C, Vogt G, Renia L, Emile JF, Decaluwe H, et al. IFN-gamma mediates the rejection of haematopoietic stem cells in IFN-gammaR1-deficient hosts. PLoS Med. 2008;5:e26.CrossRefPubMed
30.
Zurück zum Zitat Böhm W, Thoma S, Leithäuser F, Möller P, Schirmbeck R, Reimann J. T cell-mediated, IFN-gamma-facilitated rejection of murine B16 melanomas. J Immunol. 1998;161:897–908.PubMed Böhm W, Thoma S, Leithäuser F, Möller P, Schirmbeck R, Reimann J. T cell-mediated, IFN-gamma-facilitated rejection of murine B16 melanomas. J Immunol. 1998;161:897–908.PubMed
31.
Zurück zum Zitat Sayers TJ, Brooks AD, Lee JK, Fenton RG, Komschlies KL, Wigginton JM, et al. Molecular mechanisms of immune-mediated lysis of murine renal cancer: differential contributions of perforin-dependent versus Fas-mediated pathways in lysis by NK and T cells. J Immunol. 1998;161:3957–65.PubMed Sayers TJ, Brooks AD, Lee JK, Fenton RG, Komschlies KL, Wigginton JM, et al. Molecular mechanisms of immune-mediated lysis of murine renal cancer: differential contributions of perforin-dependent versus Fas-mediated pathways in lysis by NK and T cells. J Immunol. 1998;161:3957–65.PubMed
32.
Zurück zum Zitat Puliaev R, Nguyen P, Finkelman FD, Via CS. Differential requirement for IFN-gamma in CTL maturation in acute murine graft-versus-host disease. J Immunol. 2004;173:910–9.PubMed Puliaev R, Nguyen P, Finkelman FD, Via CS. Differential requirement for IFN-gamma in CTL maturation in acute murine graft-versus-host disease. J Immunol. 2004;173:910–9.PubMed
33.
Zurück zum Zitat Sayers TJ, Wiltrout TA, McCormick K, Husted C, Wiltrout RH. Antitumor effects of alpha-interferon and gamma-interferon on a murine renal cancer (Renca) in vitro and in vivo. Cancer Res. 1990;50:5414–20.PubMed Sayers TJ, Wiltrout TA, McCormick K, Husted C, Wiltrout RH. Antitumor effects of alpha-interferon and gamma-interferon on a murine renal cancer (Renca) in vitro and in vivo. Cancer Res. 1990;50:5414–20.PubMed
34.
Zurück zum Zitat Badovinac VP, Tvinnereim AR, Harty JT. Regulation of antigen-specific CD8+ T cell homeostasis by perforin and interferon-gamma. Science. 2000;17:1354–8.CrossRef Badovinac VP, Tvinnereim AR, Harty JT. Regulation of antigen-specific CD8+ T cell homeostasis by perforin and interferon-gamma. Science. 2000;17:1354–8.CrossRef
35.
Zurück zum Zitat Harrington LE, Hatton RD, Mangan PR, Turner H, Murphy TL, Murphy KM, et al. Interleukin 17-producing CD4+ effector T cells develop via a lineage distinct from the T helper type 1 and 2 lineages. Nat Immunol. 2005;6:1123–32.CrossRefPubMed Harrington LE, Hatton RD, Mangan PR, Turner H, Murphy TL, Murphy KM, et al. Interleukin 17-producing CD4+ effector T cells develop via a lineage distinct from the T helper type 1 and 2 lineages. Nat Immunol. 2005;6:1123–32.CrossRefPubMed
36.
Zurück zum Zitat Sawitzki B, Kingsley CI, Oliveira V, Karim M, Herber M, Wood KJ. IFN-gamma production by alloantigen-reactive regulatory T cells is important for their regulatory function in vivo. J Exp Med. 2005;201:1925–35.CrossRefPubMed Sawitzki B, Kingsley CI, Oliveira V, Karim M, Herber M, Wood KJ. IFN-gamma production by alloantigen-reactive regulatory T cells is important for their regulatory function in vivo. J Exp Med. 2005;201:1925–35.CrossRefPubMed
37.
Zurück zum Zitat Polchert D, Sobinsky J, Douglas GW, Kidd M, Moadsiri A, Reina E, et al. IFN-γ activation of mesenchymal stem cells for treatment and prevention of graft versus host disease. Eur J Immunol. 2008;38:1745–55.CrossRefPubMed Polchert D, Sobinsky J, Douglas GW, Kidd M, Moadsiri A, Reina E, et al. IFN-γ activation of mesenchymal stem cells for treatment and prevention of graft versus host disease. Eur J Immunol. 2008;38:1745–55.CrossRefPubMed
38.
Zurück zum Zitat English K, Barry FP, Field-Corbett CP, Mahon BP. IFN-gamma and TNF-alpha differentially regulate immunomodulation by murine mesenchymal stem cells. Immunol Lett. 2007;110:91–100.CrossRefPubMed English K, Barry FP, Field-Corbett CP, Mahon BP. IFN-gamma and TNF-alpha differentially regulate immunomodulation by murine mesenchymal stem cells. Immunol Lett. 2007;110:91–100.CrossRefPubMed
Metadaten
Titel
Separation of antileukemic effects from graft-versus-host disease in MHC-haploidentical murine bone marrow transplantation: participation of host immune cells
verfasst von
Atsushi Satake
Takayuki Inoue
Shuji Kubo
Yuki Taniguchi
Takehito Imado
Tatsuya Fujioka
Marika Horiuchi
Yunfeng Xu
Kazuhiro Ikegame
Satoshi Yoshihara
Katsuji Kaida
Hiroya Tamaki
Masaya Okada
Haruki Okamura
Hiroyasu Ogawa
Publikationsdatum
01.04.2010
Verlag
Springer Japan
Erschienen in
International Journal of Hematology / Ausgabe 3/2010
Print ISSN: 0925-5710
Elektronische ISSN: 1865-3774
DOI
https://doi.org/10.1007/s12185-010-0545-5

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