Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Lymphopoiesis wikipedia , lookup
Molecular mimicry wikipedia , lookup
Adaptive immune system wikipedia , lookup
Innate immune system wikipedia , lookup
Psychoneuroimmunology wikipedia , lookup
Sjögren syndrome wikipedia , lookup
Monoclonal antibody wikipedia , lookup
Polyclonal B cell response wikipedia , lookup
Cancer immunotherapy wikipedia , lookup
1 Title page 2 3 Immunological reconstitution in children after completing conventional chemotherapy of 4 acute lymphoblastic leukaemia is marked by impaired B cell compartment 5 Koskenvuo Minna, MD, PhD1, 4, Ilse Ekman, PhD student5, Emmi Saha, MD student1, Salokannel 6 Ellinoora, MD1, Jaakko Matomäki, PhD2, Jorma Ilonen, MD, PhD5, Kainulainen Leena, MD, PhD1, 7 Arola Mikko, MD, PhD3, Lähteenmäki Päivi Maria, MD, PhD1. 8 9 1. Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of 10 Turku and Turku University Hospital, Turku, Finland 11 2. Clinical Research Centre, Turku University Hospital 12 3. Department of Pediatrics, Division of Pediatric Hematology and Oncology, Tampere 13 14 15 16 University Hospital, Tampere, Finland 4. Department of Pediatrics, Division of Pediatric Hematology and Oncology and Stem Cell Transplantatio, Children’s Hospital, University of Helsinki, Helsinki, Finland 5. Immunogenetics Laboratory, University of Turku, Turku, Finland 17 Corresponding author: 18 Minna Koskenvuo, MD, PhD 19 Division of Pediatric Hematology and Oncology and Stem Cell Transplantation 20 Children’s Hospital, University of Helsinki 21 Stenbäckinkatu 11, 00290 Helsinki, Finland 22 phone: +358 9 471 72720, gsm: +358 50 427 0424, fax: +358 9 471 74707 23 Email [email protected] 24 25 Word counts: Abstract 90, main text 1261 26 Tables and figures: 2 figures, 1 supplemental figure, 1 supplemental table 27 Key words: leukemia, chemotherapy, immune recovery, B cell, T cell 28 Running title: Immune recovery of children with standard and intermediate risk ALL. 29 Abstract 30 Humoral and cellular immunity were studied in 28 children completing conventional treatment of 31 standard or intermediate risk ALL. Both naïve and memory B cells were most severely affected and 32 showed slow recovery during the two-year follow-up while T cell compartment showed only minor 33 changes. Immunoglobulins and their subclasses, complements and antibodies against vaccine- 34 preventable diseases were not significantly affected. In conclusion, immune recovery after 35 conventional chemotherapy for standard and intermediate risk acute lymphoblastic leukemia is 36 marked by B cell depletion but otherwise did not show any severe deficiencies in lymphocyte 37 function. 38 39 Introduction 40 The consequences of currently used pediatric ALL treatment protocols on immune recovery are 41 largely unknown. There are reports of reduction in naïve T cells while the memory compartment 42 survives relatively well resulting in only mild defect in overall number of T cells 1-4. The data 43 on B-cell recovery are sparse. Previous studies have shown considerable B cell decline both in 44 bone marrow and peripheral blood followed by rapid recovery after cessation of chemotherapy 45 5-6. On the other hand, there are reports suggesting long-term impairment of particular B-cell 46 subpopulations leading to significant defects in B-cell function and humoral immunity even 47 years after the ALL treatment 7. 48 The aim of our two-year prospective study was to evaluate the rate and quality of the 49 immunological recovery of children after cessation of conventional treatment for standard and 50 intermediate risk ALL. 51 52 Results 53 Patients 54 Between November 2008 and August 2011 28 children (mean age 8.5 years, range 4.3 – 19.2 55 years) with precursor-B-ALL treated according to the NOPHO ALL-2000 and NOPHO ALL- 56 2008 protocols at two centres in Finland, Turku and Tampere University Hospitals, were 57 prospectively analysed for their immune recovery after completing the conventional 58 chemotherapy for standard (SR) and intermediate risk (IR) ALL. The immunological status was 59 evaluated at the time of cessation of chemotherapy and 3-monthly during the first year and 6- 60 monthy during the second year post-ALL treatment.The study was approved by the Ethics 61 Committee of Turku University Hospital. Informed consent was obtained from all patients and 62 their guardians. 63 64 Evaluation of cellular immunity 65 None of the patients had severe neutropenia (neut < 0.5 10E9/l), and the median lymphocyte 66 counts stayed within normal range (median 1.14 x 10E9/l in SR and 1.12 in IR) during the whole 67 two-year follow-up, although some children in both risk groups had lymphopenia in single time- 68 points during the first year of the follow-up (Supplemental Table I). 69 70 Analysis of lymphocytes was performed using conjugated monoclonal antibodies (BioLegend, 71 San Diego, CA) specific for CD4, CD8, CD45RA, CD25, CD27, CCR7, CD19 and CD127 cells. 72 The absolute cell counts of lymphocyte subpopulations are presented in the Figure 1 and 2 and in 73 the supplemental Figure 3. Due to lymphopenia and due to prospective approach of the study we 74 could not analyse all the samples per time-points. The number of the patients analysed per time- 75 point were 18/28 (0 m), 23/28 (3 m), 24/28 (6 m), 23/28 (9 m), 22/28 (12 m), 19/28 (18 m) and 76 14/28 (24 m). At the time of the cessation of leukemia treatment, children in SR group had 77 significantly higher naïve CD4+ and CD8+ T cell counts compared to IR group (p= 0.005 and p= 78 0.02). After that, there were no significant differences between the two groups in any of the 79 following time-points in any T cell subpopulations studied and there were no differences 80 according to the time either. 81 82 In the CD19+ B-cell population, the absolute cell counts of the total CD19+ B-cells, naïve B- 83 cells (CD19+CD27low), and the memory B-cells (CD19+CD27+) were notably low during the 84 whole study period, and significantly lower in IR group compared to SR group (p < 0.001 in 85 each population) (Figure 2). The increase of the B cell populations over the follow-up time was 86 statistically significant (p < 0.001) for both of the patient populations. 87 88 89 Evaluation of humoral immunity 90 By the 3-month time-point, all the children in SR group reached the normal age-related levels in 91 IgG, IgA, IgM, and IgG subclasses 1-4 (Central Laboratory of Turku and Tampere University 92 Hospitals). In the IR group, the normal levels in IgG and IgG subclasses 1-4 were reached by 3- 93 month time-point while in IgA and IgM by 6-month time-point. The levels of the 94 immunoglobulins and their subclasses significantly increased over the time, except the IgG3 95 levels (p 0.05) (Supplemental Table I). 96 97 All the patients had protective levels of antibodies against Clostridium tetani ( 0.1 IU/ml) but 98 the antibody levels against Corynebacterium diphteriae ( 0.1 IU/ml) and Bordetella pertussis 99 ( 50 IU/ml) resulted in non-protective levels in 79% and 76% of the patients vaccinated before 100 the leukemia occurred (Department of Microbiology of Turku University by EIA). There were 101 no differences between the risk groups (data not shown). Between 6 and 12 months after the 102 cessation of leukemia treatment, nine children got pneumococcal vaccination (7 valent 103 pneumococcal conjugate vaccine Prevenar), and all of them developed protective levels of the 104 antibodies against the vaccine serotypes ( 0.2 g/ml). 105 106 Complement pathways 107 Lectine deficiency was found in 4 children out of 27 (15%) by gene test. There was no difference 108 in the activity of different complement pathways according to the time or between the two 109 groups at any of the time-points. Altogether 8 children had activities under the normal 60% in 110 alternative pathway in the first measurement time-point but all these activities normalized during 111 the study period (Department of Medical Microbiology and Immunology, University of Turku, 112 Finland) [8]. Complement activity was assessed by measuring neoantigen of the terminal 113 complex using monoclonal, enzyme-linked antibody (COMPL 300 Wielisa kit, Wieslab, Lund, 114 Sweden). 115 116 117 Statistical methods 118 Continuous variables were compared using mixed models repeated measures analysis with time, 119 risk group and interaction between time and risk group as predictor variables. Right skewed 120 response variables were transformed before the analysis using log-transformation. Comparisons 121 between two categorical variables were done using Fisher's exact test. Differences were 122 considered statistically significant when p value was < 0.05. Data were analysed using SAS. 123 124 Discussion 125 In the present study, we report 28 children with standard or intermediate risk leukemia (ALL) 126 completing the conventional chemotherapy and their immunological recovery during the two- 127 year follow-up. Substantially, both naïve and memory B cells were severely affected and showed 128 slow recovery during the two-year follow-up while T cell compartment showed only minor 129 changes. Immunoglobulins and their subclasses, complement activity, and antibodies against 130 previously given tetanus and conjugated pneumococcal vaccines were not significantly affected 131 or showed rapid recovery after the cessation of leukemia treatment. The rate of the immune 132 recovery did not differ markedly between the standard or intermediate risk groups. 133 134 While T-cell recovery in both children and adults after antineoplastic treatment, specifically after 135 stem cell transplantations, has been studied intensively, only few reports have been available 136 regarding the B-cell compartment. Recently, Wiegering and co-workers found significant 137 reduction in B-cells, specifically in naïve B-cells, during and after the standard and medium risk 138 ALL treatment 7. The abnormal B-cell distribution and on-going reconstitution was still found 139 5 years after the end of the therapy. 140 141 The defects in B-cell immunity have major clinical significance leading to the increased 142 susceptibility of viral and bacterial infections, or incomplete antibody response to vaccinations. 143 Recently, guidelines on vaccinations in pediatric hematology and oncology patients were 144 reviewed by Cesaro and co-workers 9. Their recommendation was to start booster vaccinations 145 after 6 months from the end of cancer treatment. Requirement for a successful revaccination is 146 sufficient B cell recovery and presenting CD4 T-helper cells 9-11. On the other hand, 147 Lehrnbecher et al suggest that children with ALL should be revaccinated with non-live vaccines 148 as early as 3 months after chemotherapy 10. In our study, T-cell compartment was relatively 149 well preserved but it took 3 to 6 months for the B-cell compartment to recover based on serum 150 immunoglobulin levels and normal antibody responses against conjugated pneumococcal 151 vaccinations. Because of the limited number of the patients we can not make any 152 recommendations for re-vaccination after completing conventional leukemia treatment in 153 children. 154 155 Conclusions 156 In conclusion, our study showed that the immune recovery after conventional chemotherapy for 157 standard and intermediate risk acute lymphoblastic leukemia is marked by B cell depletion but 158 otherwise it did not show any severe deficiencies in lymphocyte functions. 159 160 Acknowledgements 161 We thank the Foundation of Pediatric Research in Finland, Finnish Cancer Society, and 162 Foundation of Cancer Research of Moikoinen, Turku, Finland for their financial support. We 163 also thank the research nurse Merja Vuorinen for assisting to carry out the study protocol. 164 165 Declaration of conflicts of interest 166 The authors declare no conflicts of interest. 167 168 169 170 171 172 173 174 175 176 References 1. Van Tilburg CM, van der Velden VHJ, Sanders EAM, Wolfs TFW, Gaiser JF, de Haas V, 177 Pieters R, Bloem AC, Bierings MB. Reduced versus intensive chemotherapy for childhood 178 acute lymphoblastic leukemia: Impact on lymphocyte compartment composition. Leukemia 179 Research 2011;35:484-491. 180 2. Van Tilburg CM, van Gent R, Bierings MB, Otto SA, Sanders EAM, Nibbelke EE, Gaiser 181 JF, Janssens-Korpela PL, Wolfs TF, Bloem AC, Borghans JA, Tesselaar K. Immune 182 reconstitution in children following chemotherapy for haematological malignancies: a long- 183 term follow-up. British Journal of Haematology 2010;152:201-210. 184 3. Eyrich M, Wiegering V, Lim A, Schrauder A, Winkler B, Schlegel PG. Immune function in 185 children under chemotherapy for standard risk acute lymphoblastic leukaemia – a 186 prospective study of 20 paediatric patients. British Journal of Haematology 2009;147:360- 187 370. 188 4. Haining WN, Neuberg DS, Keczkemethy HL, Evans JW, Rivoli S, Gelman R, Rosenblatt 189 HM, Shearer WT, Guenaga J, Douek DC, Silverman LB, Sallan SE, Guinan EC, Nadler 190 LM. Antigen-specific T-cell memory is preserved in children treated for acute lymphoblastic 191 leukemia. Blood. 2005;106:1749-54. 192 5. Alanko S, Pelliniemi TT, Salmi TT. Recovery of blood B-lymphocytes and serum 193 immunoglobulins after chemotherapy for childhood acute lymphoblastic leukemia. Cancer 194 1992;69:1481-86. 195 6. van Wering ER, van der Linden-Schrever BE, Szczepanski T, Willemse MJ, Baars EA, 196 Wijngaarde-Schmitz HM, Kamps WA, van Dongen JJ. Regenerating normal B-cell 197 precursors during and after treatment of acute lymphoblastic leukemia: implications for 198 monitoring of minimal residual disease. Br J Haematol. 2000;110:139-146. 199 7. Wiegering V, Frank J, Freudenberg S, Morbach H, Schlegel PG, Eyrich M, Winkler B. 200 Impared B-cell reconstitution in children after chemotherapy for standard or medium risk 201 acute precursor B-lymphoblastic leukemia. Leuk Lymphoma 2014;55:870-875. 202 8. Seelen MA, Roos A, Wieslander J, Mollnes TE, Sjöholm AG, Wurzner R, Loos M, Tedesco 203 F, Sim RB, Garred P, Alexopoulos E, Turner MW, Daha MR. Functional analysis of the 204 classical, alternative, and MBL pathways of the complement system: standardization and 205 validation of a simple ELISA. J Immunol Methods 2005; 296:187-198 206 9. Cesaro S, Giacchino M, Fioredda F, Barone A, Battisti L, Bezzio S, Frenos S, De Santis R, 207 Livadiotti S, Marinello S, Zanazzo AG, Caselli D. Guidelines on vaccinations in paediatric 208 haematology and oncology patients. BioMed Res Int 2014;2014:707691. 209 10. Lehrnbecher T, Schubert R, Allwinn R, Dogan K, Koehl U, Grüttner HP. Revaccination of 210 children after completing of standard chemotherapy for acute lymphoblastic leukaemia: a 211 pilot study comparing different schedules. Br J Haematol. 2011; 152:754-57. 212 11. Patel SR, Ortin M, Cohen BJ, Borrow R, Irving D, Sheldon J, Heath PT. Revaccination of 213 children after completion of standard chemotherapy for acute leukemia. Clin Infect Dis 214 2007; 44:635-42. 215 12. Morbach H, Eichhorn EM, Liese JG, Girschick HJ. Reference values for B cell 216 subpopulations from infancy to adulthood. Clinical and Experimental Immunology 217 2010;162:271-279. 218 13. Van Gent R, van Tilburg CM, Nibbelke EE, Otto SA, Gaiser JF, Janssens-Korpela PL, 219 Sanders EAM, Borghans JAM, Wulffraat NM, Bierings MB, Bloem AC, Tesselaar K. 220 Refined characterization and reference values of the pediatric T- and B-cell compartments. 221 Clinical Immunology 2009;133:95-107. 222 223 224 Figure 1. The absolute cell counts of different CD4+ T cell subpopulations according to the time 225 presented separately by standard (SR) and intermediate (IR) risk groups. SR group is shown as 226 clear boxes and IR group as dark grey boxes. The following cell populations are shown: naïve 227 CD4+ T cells (CD4+CD45RA+CCR7+), central memory CD4+ T cells (CD4+CD45RA- 228 CCR7+), effector memory CD4+ T cells (CD4+CD45RA-CCR7-), late effector memory CD4+ 229 T cells (CD4+CD45RA+CCR7-), Treg (CD4+CD25+ CD127low). The counts are presented as 230 109/l in blood for the total CD+ counts. The number of the patients analysed per time-point are 231 18/28 (0 m), 23/28 (3 m), 24/28 (6 m), 23/28 (9 m), 22/28 (12 m), 19/28 (18 m) and 14/28 (24 232 m). The blue line represents the estimated normal mean value and the red line the lowest range 233 of healthy children between 6 and 10 years of age 12 -13. 234 235 Figure 2. The absolute cell counts of total CD19+ B cells, naïve B cells (CD19+CD27-) and 236 memory B cells (CD19+CD27) according to the time are presented separately by standard (SR) 237 and intermediate (IR) risk groups. The counts are presented as 109/l in blood for the total CD19+ 238 cell counts. The number of the patients analysed per time-point are 18/28 (0 m), 23/28 (3 m), 239 24/28 (6 m), 23/28 (9 m), 22/28 (12 m), 19/28 (18 m) and 14/28 (24 m). The blue line represents 240 the estimated normal mean value and the red line the lowest range of healthy children between 6 241 and 10 years of age 12 - 13. 242 243 Supplemental Figure 3. The absolute cell counts of different CD8+ T cell subpopulations 244 according to the time presented separately by standard (SR) and intermediate (IR) risk groups. 245 SR group is shown as clear boxes and IR group as dark grey boxes. The following cell 246 populations are shown: naïve CD8+ T cells (CD8+CD45RA+CCR7+), central memory CD8+ T 247 cell (CD8+CD45RA-CCR7+), effector memory CD8+ T cells (CD8+CD45RA-CCR7-), late 248 effector memory CD8+ T cells (CD8+CD45RA+CCR7-). The counts are presented as 109/l in 249 blood for the total CD+ counts. The number of the patients analysed per time-point are 18/28 (0 250 m), 23/28 (3 m), 24/28 (6 m), 23/28 (9 m), 22/28 (12 m), 19/28 (18 m) and 14/28 (24 m). The 251 blue line represents the estimated normal mean value and the red line the lowest range of healthy 252 children between 6 and 10 years of age 12 -13. 253 254 Supplemental Table I. The median peripheral blood cell counts and immunoglobulin levels 255 including the subclasses according to the time (0, 3, 6, 9, 12, 18, and 24 months after cessation of 256 the leukemia treatment) of standard risk (SR) and intermediate risk (IR) children with leukemia. 257 The ranges are presented within ( ). The n – value represents the number of the samples per time- 258 point (some patients had more than one sample). 259 260 261