Patent Application
20160303209
This invention is related to the area of immunotherapy. In particular, it relates to the area of immunotherapy and cancer.
Systemic sclerosis (scleroderma) is a chronic autoimmune rheumatic disease associated with widespread obliterative vasculopathy and tissue fibrosis (1, 2). One of the most striking features of this disease is the temporal clustering of scleroderma and cancer that has been observed in patients with autoantibodies to RPC1 but not in patients with autoantibodies to topoisomerase 1 (TOP1) or centromere protein B (CENPB) (3). A variety of potential mechanisms could explain the occurrence of cancers in scleroderma patients with autoantibodies to RPC 1 (4). For example, it is possible that a defective immune system responsible for the autoimmune disease predisposes to neoplasia, and that this effect is more prominent in patients with antibodies to RPC1 than in the other subgroups. Alternatively, it is possible that the cytotoxic, mutagenic therapies used to treat scleroderma patients with more fulminant disease leads to cancer in these individuals; patients with RPC1 antibodies tend to have more severe disease than those with other antibodies. Finally, the reverse scenario is possible: cancer might trigger scleroderma in patients with antibodies to RPC1. In particular, we considered the possibility that occasional cancers might harbor missense mutations in the POLR3A gene. If the altered protein encoded by the mutant POLR3A gene were recognized by the patient's immune system, an immune response against the tumor could theoretically be generated. If cross-reactive with the normal RPC1 protein, this immune response could in turn injure selected tissues thereby inducing scleroderma.
There is a continuing need in the art to develop successful therapies for preventing and treating cancers.
According to one embodiment of the invention a method is provided. A peptide of 10-40 contiguous amino acid residues of an antigen is administered to a patient. The antigen is one to which humans can raise an autoimmune response, i.e., a human autoimmune antigen. The peptide comprises a variant residue relative to the wild-type antigen and binds with high affinity to an HLA protein of the patient.
According to another embodiment, an isolated peptide of 10-40 contiguous amino acid residues of an antigen is provided. The antigen is one to which humans can raise an autoimmune response, i.e., a human autoimmune antigen. The peptide comprises a variant residue relative to the wild-type antigen and binds with high affinity to an human HLA protein.
These and other embodiments which will be apparent to those of skill in the art upon reading the specification provide the art with new tools for combatting cancers in humans.
The inventors have found somatic mutations in autoimmune protein targets in cancer cells in patients that have both an autoimmune disease and a cancer. Patient sera contain T cells specific for the autoimmune protein targets and antibodies specific for the autoimmune protein targets. The autoantibodies do not distinguish between mutant and wild-type forms of the antigen and do not bind to peptides containing the mutant or wild-type residue. However, some CD4+ T cells are reactive with such mutant peptides. Moreover, the cancer cells containing the somatic mutations appear to comprise only a subset of the cancer cells in the patient, i.e., they are subclonal. These findings have implications for the pathogenesis of autoimmune diseases and for the immunological control of naturally occurring cancers.
Autoantigens are antigens to which humans can raise an autoimmune response.
Autoantigens are a family of proteins that have been found to be targets of an anti-self immune response associated with diseases. Examples of such diseases are scleroderma, auoimmune rheumatic diseases, such as myositis, vasculitis, and SLE, Sjogren's syndrome, and lupus. Autoantigens known to be involved in such diseases include, but are not limited to the following:
Additional in Sjogren's syndrome
Myositis
Scleroderma
Vasculitis
General/RA/Other
Mutant peptides may display any change in amino acid sequence from the wild type. This can be conveniently determined with regard to the patient's own normal tissues. Alternatively, wild type found in reference data bases can be used to compare to potential mutant peptides. A mutant peptide may have one or more single nucleotide substitutions, deletions, or insertions. Typically the peptide will have a single nucleotide substitution, deletion, or insertion. In general, it will have less than four, less than three, or less than two nucleotide substitutions, deletions, or insertions. Other than the substitution, deletion, or insertion, the sequence of the peptide will be that of a contiguous stretch of amino acid residues of an autoimmune target antigen. The contiguous stretch will typically be less than 50, less than 40, less than 30, less than 20, less than 18, less than 17, or less than 16 amino acid residues. The contiguous stretch will typically be at least 8, at least 10, at least 12, or at least 13, or at least 14 amino acid residues. An isolated peptide may be made by any means that is practical, including by chemical synthesis, enzymatic synthesis, or in vivo biosysnthesis. Isolated peptides are not in a cell or in a whole cell lysate. Typically an isolated peptide is a predominant constituent in a composition, i.e., greater than 10, 20, 30, 40, or 50% of the active ingredients in a composition. A mutant peptide may also be in admixture with a full length protein of the autoimmune antigen. In such case the peptide and the protein may collectively be the predominant constituents in the composition. A peptide may have other moieties attached to the contiguous stretch of autoimmune target antigen sequence. Such moieties may be, for example, radioactive, fluorescent, enzymatic, or adjuvant moieties.
Cancers which can be treated by use of the mutant peptides include any to which humans are subject. These include solid and hematological cancers, such as breast, lung, ovarian, colorectal, and B cell lymphoma. Other cancers which can be treated include Adenoid Cystic Carcinoma, Adrenal Gland Tumor, Amyloidosis, Anal Cancer, Appendix Cancer, Astrocytoma-Childhood, Ataxia-Telangiectasia, Attenuated Familial Adenomatous Polyposis, Beckwith-Wiedemann Syndrome, Bile Duct Cancer, Birt-Hogg-Dubé Syndrome, Bladder Cancer, Bone Cancer, Brain Stem Glioma-Childhood, Brain Tumor, Breast Cancer, Breast Cancer-Inflammatory, Breast Cancer-Male, Breast Cancer-Metaplastic, Carcinoid Tumor, Carney Complex, Central Nervous System-Childhood, Cervical Cancer, Childhood Cancer, Colorectal Cancer, Cowden Syndrome, Craniopharyngioma-Childhood, Desmoplastic Infantile Ganglioglioma-Childhood Tumor, Endocrine Tumor, Ependymoma-Childhood, Esophageal Cancer, Ewing Family of Tumors-Childhood, Eye Cancer, Eyelid Cancer, Fallopian Tube Cancer, Familial Adenomatous Polyposis, Familial Malignant Melanoma, Familial Non-VHL Clear Cell Renal Cell Carcinoma, Gallbladder Cancer, Gardner Syndrome, Gastrointestinal Stromal Tumor-GIST, Germ Cell Tumor-Childhood, Gestational Trophoblastic Tumor, Head and Neck Cancer, Hereditary Breast and Ovarian Cancer, Hereditary Diffuse Gastric Cancer, Hereditary Leiomyomatosis and Renal Cell Cancer, Hereditary Mixed Polyposis Syndrome, Hereditary Pancreatitis, Hereditary Papillary Renal Cell Carcinoma, HIV and AIDS-Related Cancer, Islet Cell Tumor, Juvenile Polyposis Syndrome, Kidney Cancer, Lacrimal Gland Tumor, Laryngeal and Hypopharyngeal Cancer, Leukemia-Acute Lymphoblastic-ALL-Childhood, Leukemia-Acute Lymphocytic-ALL, Leukemia-Acute Myeloid-AML, Leukemia-Acute Myeloid-AML-Childhood, Leukemia-B-cell Prolymphocytic Leukemia and Hairy Cell Leukemia, Leukemia-Chronic Lymphocytic-CLL, Leukemia-Chronic Myeloid-CML, Leukemia-Chronic T-Cell Lymphocytic, Leukemia-Eosinophilic, Li-Fraumeni Syndrome, Liver Cancer, Lung Cancer, Lymphoma-Hodgkin, Lymphoma-Hodgkin-Childhood, Lymphoma-Non-Hodgkin, Lymphoma-Non-Hodgkin-Childhood, Lynch Syndrome, Mastocytosis, Medulloblastoma-Childhood, Melanoma, Meningioma, Mesothelioma, Muir-Tone Syndrome, Multiple Endocrine Neoplasia Type 1, Multiple Endocrine Neoplasia Type 2, Multiple Myeloma, Myelodysplastic Syndromes-MDS, MYH-Associated Polyposis, Nasal Cavity and Paranasal Sinus Cancer, Nasopharyngeal Cancer, Neuroblastoma-Childhood, Neuroendocrine Tumor, Neurofibromatosis Type 1, Neurofibromatosis Type 2, Nevoid Basal Cell Carcinoma Syndrome, Oral and Oropharyngeal Cancer, Osteosarcoma-Childhood, Ovarian Cancer, Pancreatic Cancer, Parathyroid Cancer, Penile Cancer, Peutz-Jeghers Syndrome, Pituitary Gland Tumor, Pleuropulmonary Blastoma-Childhood, Prostate Cancer, Retinoblastoma-Childhood, Rhabdomyosarcoma-Childhood, Salivary Gland Cancer, Sarcoma, Sarcoma-Alveolar Soft Part and Cardiac, Sarcoma-Kaposi, Skin Cancer (Non-Melanoma), Small Bowel Cancer, Stomach Cancer, Testicular Cancer, Thymoma, Thyroid Cancer, Tuberous Sclerosis Syndrome, Turcot Syndrome, Unknown Primary, Uterine Cancer, Vaginal Cancer, Von Hippel-Lindau Syndrome, Vulvar Cancer, Waldenström's Macroglobulinemia, Werner Syndrome, Wilms Tumor-Childhood, and Xeroderma Pigmentosum.
Binding to human HLA proteins and measurement of the binding can be performed according to any methods known in the art. One method which can be employed uses in silico tools such as Immune Epitope Database (IEDB) analysis resource Consensus tools (7-9). High affinity binding is assessed when the IC50 is <50 nM. Moderately high affinity binding is assessed when the IC50 is <125 nM. Extremely high affinity binding is assessed when the IC50 is <10 nM. Ascertainment of the type of HLA proteins present in a human can be performed using any methods known in the art. Exemplary methods include serotyping, cellular typing, gene sequencing, and phenotyping.
A subset of patients with scleroderma and other autoimmune rheumatic diseases manifest cancer around the time of autoimmune disease diagnosis, suggesting that the two processes might be linked mechanistically (3), (4), (17). In scleroderma, this temporal clustering of scleroderma and cancer appears limited to the subgroup of patients with antibodies to RPC1 (3). In the current work, we demonstrated that the POLR3A locus is genetically altered (by somatic mutation or LOH) in six of eight cancers of patients with antibodies to RPC1, but not in cancers from scleroderma patients with other autoantibody specificities. Moreover, T cells reactive with the mutant forms of RPC1 could be identified in the peripheral blood of two of the three patients tested. These T cells did not simply cross-react with the wild-type form of the peptides, because T cells from subject SCL-4 were not stimulated by the wild type form, and the sequence of the TCRs conferring responsiveness to the wild type and mutant peptides in SCL-42 were largely unrelated.
These genetic and immunologic findings suggest mutation in POLR3A as the initiator of the immune response to RPC1 in an important subset of scleroderma patients. The only tenable alternative to this conclusion is that the onset of scleroderma and the cancer genomes of these patients were unrelated and that the missense mutations and T cell responses directed against the same mutations were coincidental. We believe this alternative is unlikely given the rarity of POLR3A mutations in cancer in general (0.7%, p<10−20, cosmic database, (18), and the absence of alterations at this locus in scleroderma patients without RPC antibodies (p<0.01). Additionally, in patient SCL-42, there were multiple different nucleotide sequences encoding TCRs with the identical amino acid sequence in T cells stimulated by the mutant peptide (Table 3). This provides strong support for the conclusion that the mutant POLR3A gene product acted as an immunogen initiating the anti-RPC1 immune response in vivo.
Antibodies from all patients with POLR3A mutations recognized wild type and mutant versions of RPC 1 similarly, and no antibodies directed specifically against the wild type or mutant peptides could be demonstrated. This suggests that the humoral response does not directly target the area of the mutation or discriminate between mutant and wild type versions of RPC 1. The inability of autoantibodies to discriminate between the mutant and wt forms of the antigen is consistent with previous studies showing that a crossreactive humoral response is typical when a novel form of an antigen initially stimulates T cells that specifically recognize the modified antigen (19, 20). The antibody cross-reactivity might contribute to B cell-mediated diversification of autoimmunity, spreading T cell responses to the wild type autoantigen (21, 22).
Our data therefore suggest that the “foreign” antigen triggering the autoimmune response in scleroderma patients is actually a tumor antigen. This complements previous observations indicating cancers can elicit immune responses. It is known that some cases of paraneoplastic syndrome are caused by autoimmunity to proteins expressed in tumors (23); these responses are directed exclusively to the normal protein and there is no evidence that the gene(s) are mutated in the tumors. Conversely, it has been shown that mutant genes in human tumors can elicit an immune response against the mutant gene product (24-26); these immune responses have not been shown to elicit a cross-reactive response to the normal gene product that could result in autoimmunity. Finally, it has been shown that an in vitro-generated protein containing multiple (but not single) mutations, when injected into mice, can elicit a broad, cross-reactive immune response against the normal protein that results in autoimmunity (27). In these mice, tumor cells expressing only the wt protein can also be targeted by the subsequent immune response. Our results show that an analogous situation appears to occur in humans when a single, strongly immunogenic epitope is created by somatic mutation in a patient with an appropriate MHC type. However, the generation of an autoreactive immune response alone may not be sufficient to generate the self-sustaining tissue injury seen in scleroderma, and additional factors (genetic, environmental, or target tissue-specific) may be required (28).
Our cohort included cancer patients without anti-RPC1 antibodies (Table 1). While the interval between scleroderma and cancer onset for patients in these patients was long (median of 14.2 years), there were two, patients (SCL-8 and SCL-32) who had relatively short intervals. We did not identify genetic alterations of TOPO1 or CENPB in these two patients. Whether their cancers were adventitious, related to therapy, or due to mutations in genes encoding homologs of TOPO1 or CENPB or proteins that interact with them is unknown but are intriguing hypotheses for future study. Similar factors could also explain the absence of genetic alterations of POLR3A in two of the eight patients with antibodies to RPC1.
The relatively low fraction of neoplastic cells with genetic alterations in the cancers from some of these patients (Tables 1 and 2) suggests that immunoediting of the cancer had occurred, with cells containing these mutations selected against during tumor growth (29). The emergence of cancer in RPC1-positive scleroderma patients may thereby represent escape of the tumor from immune pressure. We speculate that cancers harboring POLR3A mutations had stimulated scleroderma in most patients with the RPC1 form of the disease. However, in the majority of these patients, the immune response had eradicated the cancer by the time scleroderma developed. Patients with a short cancer-autoimmune disease interval have also been described for other autoimmune rheumatic disease phenotypes (e.g. myositis, vasculitis, SLE) and similar mechanisms may be operative in these diseases (17, 30, 31). Given the ubiquitous presence of somatic mutations in solid tumors (32), these new data add credence to the idea that immunoediting could play a major role in limiting the incidence of human cancer—an old hypothesis (33, 34) that has recently garnered more attention (35-37). The data also suggest that this family of autoantigens might be used to generate biologically effective anti-tumor immunity.
The above disclosure generally describes the present invention. All references disclosed herein are expressly incorporated by reference. A more complete understanding can be obtained by reference to the following specific examples which are provided herein for purposes of illustration only, and are not intended to limit the scope of the invention.
Genetic Analysis
We began by searching for missense mutations in the POLR3A gene in tumors from scleroderma patients. We were able to collect tumor and normal tissue samples from eight scleroderma patients who had autoantibodies to RPC1. We also evaluated eight scleroderma patients who had autoantibodies to TOP1 or to CENPB and developed cancers (Table 1). Five of the patients with antibodies to RPC1 developed cancer prior to scleroderma (median of 0.4 years before scleroderma onset), while the remaining 3 developed cancer 0.3-2.5 years after the onset of scleroderma (Table 1). In contrast, patients with autoantibodies to CENPB or TOP1 who developed cancers only did so a median of 14.2 years after the onset of their scleroderma (Table 1). The characteristics of the 16 scleroderma patients, including tumor type, age of diagnosis of cancer, cancer-scleroderma interval, and autoantibody status, are listed in Table 1; additional clinical information is provided in table S1 and (5).
Formalin-fixed, paraffin-embedded tumors from each of the 16 patients were microdissected to enrich for neoplastic cell content, and DNA was purified, blunt-ended, and ligated to adapters suitable for library preparation (5). Libraries from peripheral blood cells of each patient were similarly prepared. Following amplification of the 32 libraries (16 tumor, 16 matched normal), the PCR products were captured using PCR-generated fragments containing all coding sequences of the POLR3A, TOP1, and CENPB genes (5). The captured fragments were evaluated by sequencing on an Illumina instrument, achieving an average coverage of 516 reads per base of the 53 coding-exons of the three genes (range 95- to 2011-fold).
This sequence revealed three somatic, missense variants in POLR3A and none in TOP1 or CENPB (Table 1). All three variants were in the patients with autoantibodies to RPC1. The three somatic mutations were each validated by massively parallel sequencing of PCR products generated from the regions surrounding the mutations (5). Of note, both the capture approach and the direct-PCR sequencing approach showed that one of the three somatic mutations was decidedly subclonal, that is, was present in only a subset of the neoplastic cells: the fraction of mutant alleles in the lung cancer from patient SCL-2 was only 4.3%, far less than the estimated fraction of neoplastic cells in the microdissected sample used for DNA purification (Table 1) (5).
In light of the subclonal nature of one of these mutations, we considered the possibility that cells containing these mutations were selected against during tumor growth, perhaps even disappearing as a result of an immune response. The most frequent way to lose a mutant allele in human cancers is through a gross chromosomal event that results in loss of the entire gene and the surrounding chromosomal region (loss of heterozygosity, LOH) (6). To search for such losses, we designed 19 primer pairs that could each amplify a small fragment containing at least one common single nucleotide polymorphism (SNP) within or surrounding the POLR3A gene (table S2). These primer pairs were used in a multiplexed protocol to evaluate all 16 tumors (5). Five of the eight tumors from scleroderma patients with autoantibodies to RPC1 exhibited LOH (Table 2). These five tumors included three that did not contain a detectable somatic mutation of POLR3A (Table 1). The fraction of neoplastic cells that had undergone LOH could be estimated from the allelic ratios of the SNP data, and in four of the five cases, was subclonal (Table 2). Importantly, none of the tumors from patients with antibodies to TOP1 or CENPB exhibited LOII of the region containing POLR3A (Table 2). As an additional control, we evaluated 21 SNPs within or surrounding the TOP1 locus on chromosome 20 (table S2) and found that none of the 16 tumors from scleroderma patients, regardless of autoantibody status, had undergone LOH of this region (table S3).
In summary, six of eight tumors from scleroderma patients with autoantibodies to RPC 1 harbored genetic alterations affecting the POLR3A locus compared to zero of eight tumors from scleroderma patients without anti-RPC1 antibodies (p<0.01, Fisher Exact Probability Test, two-tailed).
Immunological Analysis
We began the immunological analysis of these patients by addressing whether RPC1 autoantibodies recognized the mutated protein differently from the wild type (wt) form of the protein. Each of the three abnormal forms of the protein found in scleroderma patients was synthesized by in vitro transcription-translation (IVTT) (5). Wild type and patient-matched mutant RPC1 were then subjected to immunoprecipitation analysis with sera from patients or from normal individuals (control sera). In each case, mutant and wt proteins were precipitated similarly by patient serum, but not precipitated by control sera (
We next constructed a custom peptide microarray to comprehensively identify linear antigenic regions of the RPC1 protein. We synthesized 276 overlapping peptides of 15 amino acids in length, each offset by five amino acids from the previous peptide and covering the entire length of RPC1 (table S4). Peptides that contained each of the three somatic mutations described above were also synthesized (three peptides for each mutant; table S4). These peptides were printed on microarrays and used to assess serum from the three patients with antibodies to RPC1 (SCL-02, SCL-04, and SCL-42) whose cancers harbored POLR3A mutations, and four control patients (SCL-200, SCL-201, SCL-202, SCL-203) who had scleroderma and antibodies to RPC1 but who did not have cancers. Each of the seven serum samples displayed reactivity with at least two of the peptides on the array (
Having shown that there was no demonstrable humoral immune response specific to the mutant RPC1 proteins, we sought to determine if there was a cellular immune response directed against the mutants. We first performed high-resolution class I and II HLA typing on the three scleroderma patients in whom somatically mutated POLR3A genes were identified (table S5). IEDB analysis resource Consensus tools (7-9) were then used to determine whether peptides containing the specific mutations in individual patients were likely to bind with high affinity to that patient's HLA alleles. In patient SCL-42, both wild type and mutant epitopes were predicted to bind with high affinity to both alleles of the patient's class II DR HLA (table S6). This was particularly dramatic for HLA-DR*0701, where the predicted IC50 was <1 nM for both the mutant (FHVGYFRAVIGTLQMI; SEQ ID NO: 95) and wild type peptides (FHVGYFRAVIGILQMI; SEQ ID NO: 96; table S6). High affinity binding of the wild type and mutant peptides to this patient's other DR allele (HLA-DR*1001) was also predicted (table S6). In patient SCL-4, the mutant peptide was predicted to bind to this patient's HLA-DR*0101 allele with an affinity of 4 nM, 18-fold higher than the affinity of the wt peptide (table S6). The wild type peptide in this region was also predicted to bind, albeit less strongly, to this patient's second allele (26 nM to HLA-DR*1101). Neither wild type nor mutant peptides were predicted to bind with high affinity to the class II molecules of patient SCL-2 (table S6). The algorithms also predicted binding of patient-matched wild type and mutant peptides to a single HLA class I allele in each patient, though the binding affinities were only moderate (27 to 78 nM, table S6).
CD4 cells are known to recognize peptides presented by MHC class II alleles and play central roles in both tumor immunity and autoimmunity (10, 11). In light of this knowledge and our finding that the predicted affinities for class II peptides were much higher than for class I peptides, we searched for CD4 T cells recognizing the predicted peptides in PBMCs from patients whose tumors contained POLR3A mutations. CD154 expression at 18 hours after peptide stimulation was used to identify peptide-activated CD4+ T cells (12, 13). In patient SCL-4, CD4 T cell activation was observed in response to the patient-matched mutant peptide but not to the wt peptide (
The experimental data also confirmed the predicted reactivity of T cells from patient SCL-42, with a 2-fold increase in the number of CD4+ CD154+ T cells in response to both the wt and mutant SCL-42 peptides over control conditions. The frequency of responding cells was about a log lower in SCL-42 compared to SCL-4, with ˜1:5,000 CD4 T cells responding (
These data document the existence of CD4 T cells reactive with peptides containing the RPC1 mutations in two of the three patients studied. The reactivity was patient, peptide, and HLA-type specific. The frequencies of mutant peptide-reactive CD4 T cells observed in these scleroderma patients (˜1:600 to ˜1:5000,
It was possible that the CD4 T cells that were activated in response to the mutant peptide in SCL-42 were the same as those responding to the wt peptide. To evaluate this issue, we performed TCR spectratyping of T cells stimulated by either wt or mutant peptides. Out of the 22 Vβ families analyzed, 12 displayed a similar distribution of their CDR3 lengths in response to wt and mutant peptides including Vβ8, Vβ17, and Vβ20 (
To characterize the TCRs in more detail, we determined the sequence of the CDR3 regions in the Vβ7, Vβ12 and Vβ24 PCR products (5). Two striking findings were revealed by massively parallel sequencing of these regions. First, the sequences of the dominant TCRs generated from Tcells stimulated with the wt peptide were completely distinct from those stimulated by the mutant peptide (Table 3). In 5 of 6 dominant TCR's identified by sequencing, the wt- and mutant-specific CDR3 sequences were precisely the lengths predicted by the spectratype analysis (Table 3). The sequencing results therefore strongly supported the conclusion from spectratyping that the mutant and wt peptides had stimulated many distinct T cell clones. Second, there was a high degree of redundancy among the amino acid sequences—but not the nucleotide sequences—of the TCRs identified in this experiment. For example, we identified 17 different nucleotide sequences (represented by 2066 clusters on the sequencing instrument) that encoded the identical CDR3 amino acid sequence in T cells stimulated by the mutant peptide (Table 3). As T cells, unlike B-cells, do not undergo continued evolution once a successful VDJ rearrangement has occurred (15, 16), these data document the existence of multiple, independent T cell clones responding, and presumably binding, to the same mutant peptide.
Finally, we developed CDR3-specific Taqman assays to verify that distinct populations of wt and mutant-specific T cells were present in the peripheral blood of SCL-42 prior to the short-term cultures used in the experiments described above. The Vβ24 TCRs were chosen for this experiment because their CDR3 sequences were the most abundant in the sequencing analysis and were each encoded by multiple distinct nucleotide sequences (Table 3). The TCRs expected to bind the mutant and wild type peptides were detected in uncultured SCL-42 PBMCs (
Materials and Methods
Clinical Methods
Consenting scleroderma patients with confirmed cancer diagnoses were recruited from the Johns Hopkins Scleroderma Center. Scleroderma patients met the American College of Rheumatology criteria for scleroderma (38). Existing cancer pathology specimens were obtained from prior surgical procedures performed as part of routine clinical care. The closest serum sample to cancer diagnosis was studied in all patients, and DNA and PBMC samples were obtained in consenting participants. The Johns Hopkins Institutional Review Board approved the acquisition of clinical data and all biological samples for this study.
Demographic and clinical data were abstracted from the Johns Hopkins Scleroderma Center database and careful medical record review. Cancer diagnosis dates and histology were determined by review of the initial diagnostic pathology report. The clinical onset of scleroderma was defined by the first scleroderma symptom, either Raynaud's or non-Raynaud's. The interval between scleroderma onset and cancer diagnosis was calculated for each subject (cancer date—scleroderma onset date). The scleroderma cutaneous subtype and modified Rodnan skin score were defined by established criteria (39, 40). All sera were tested for autoantibodies against RPC1, TOP1, and CENPB as previously described (3). Demographic and clinical data were compared across autoantibody groups, and differences in continuous and dichotomous/categorical variables were assessed by the Kruskal-Wallis and Fisher's exact tests, respectively.
The clinical features and cancer types of the 16 patients evaluated in this study are listed in Table 1. Eight patients were positive for anti-RPC1 antibodies, five for anti-TOP1 antibodies and three for anti-CENPB antibodies. Enhanced nucleolar staining with the anti-RPC1 antibodies (3) was observed in the tumors of all eight patients. No subject was positive for more than one autoantibody. Clinical phenotypic characteristics were representative of those expected in each autoantibody group (e.g. severe diffuse disease in RPC1-positive patients), and patients with RPC1 autoantibodies had a shorter interval between scleroderma onset and cancer diagnosis (median of −0.1 years vs. 13.4 years for patients with TOP1 autoantibodies and 34.0 years for patients with CENPB autoantibodies; p=0.05). Seven of the 16 patients had a short interval (+/−2 years) between scleroderma onset and cancer diagnosis, and 6 of these 7 patients (85.7%) were positive for anti-RNA polymerase III antibodies.
Preparation of Illumina Genomic DNA Libraries
Genomic DNA libraries were prepared following Illumina's (Illumina, San Diego, Calif.) suggested protocol with the following modifications. (1) 50 to 75 microliters (μl) of genomic DNA from tumor or normal cells in a total volume of 100 μl TE was fragmented in a Covaris sonicator (Covaris, Woburn, Mass.) to a size of 100 to 500 bp. DNA was purified with a Nucleospin Extract II kit (Cat #740609, Macherey-Nagel, Germany) and eluted in 50 μl of elution buffer included in the kit. (2) 45 μl of purified, fragmented DNA was mixed with 40 μμl of H2O, 10 μμl End repair reaction buffer and 5 μl of End Repair enzyme. All reagents used for this step and those described below were from New England Biolabs (NEB cat# E6040, Ipswich, Mass.) unless otherwise specified. The 100 μl end-repair mixture was incubated at 20° C. for 30 min, purified by a PCR purification kit (Cat #28104, Qiagen) and eluted with 42 μl of elution buffer (EB). (3) To A-tail, all 42 μl of end-repaired DNA was mixed with 5 μl of 10×dA-Tailing Reaction buffer and 3 μl of Klenow Fragment (3′ to 5′ exo-). The 50 μl mixture was incubated at 37° C. for 30 min before DNA was purified with a MinElute PCR purification kit (Cat #28004, Qiagen). Purified DNA was eluted with 27 μl of 70° C. EB. (4) For adaptor ligation, 25 μl of A-tailed DNA was mixed with 10 μl of PE-adaptor (Illumina), 10 μl of 5x Ligation buffer and 5 μl of Quick T4 Ligase. The ligation mixture was incubated at room temperature (RT) or 20° C. for 15 min. (5) To purify adaptor-ligated DNA, 50 μl of ligation mixture from step (4) was mixed with 200 μl of NT buffer from NucleoSpin Extract II kit (cat #636972, Clontech, Mountain View, Calif.) and loaded into a NucleoSpin column. The column was centrifuged at 14000 g in a desktop centrifuge for 1 min, washed once with 600 μl of wash buffer (NT3 from Clontech), and centrifuged again for 2 min to dry completely. DNA was eluted in 50 μl elution buffer included in the kit. (6) To obtain an amplified library, ten or twenty PCRs of 50 μl each were set up, each including 30 μl of H2O, 2.5 μl dimethyl sulfoxide (DMSO), 10 μl of 5x Phusion HF buffer, 1.0 μl of a dNTP mix containing 10 mM of each dNTP, 0.5 μl of Illumina PE primer #1, 0.5 μl of Illumina PE primer #2, 0.5 μl of Hot Start Phusion polymerase, and 2.5 or 5 μl of the DNA from step (5). The PCR program used was: 98° C. 1 minute; 10 to 16 cycles of 98° C. for 20 seconds, 65° C. for 30 seconds, 72° C. for 30 seconds; and 72° C. for 5 min. To purify the PCR product, 250 μl PCR mixture (from the ten PCR reactions) was mixed with 500 μl NT buffer from a NucleoSpin Extract II kit and purified as described in step (5). Library DNA was eluted with 70° C. elution buffer and the DNA concentration was estimated by absorption at 260 nm.
Target DNA Enrichment
The targeted regions included all 53 exons of CENPB, POLR3A, TOP1. Capture probes were designed (41) to capture both the plus and the minus strand of the DNA and had a 33-base overlap and were custom-synthesized by Agilent Technologies en masse on a solid phase and used for capture, essentially as described (42). Approximately 3 μg of library DNA was used per capture. After washing, the captured libraries were ethanol-precipitated and redissolved in 20 μl of Tris-EDTA (TE) buffer. The DNA was then amplified in a PCR mix containing 51 μl of distilled water (dH2O), 20 μl of 5x Phusion buffer, 5 μl of dimethyl sulfoxide (DMSO), 2 μl of 10 mM dNTPs, 50 pmol of Illumina forward and reverse primers, and 1 μl of HotStart Phusion enzyme (New England Biolabs) with the following cycling program: 98° C. for 30 s; 15 cycles of 98° C. for 25 s, 65° C. for 30 s, 72° C. for 30 s; and 72° C. for 5 min. The amplified PCR product was purified with a NucleoSpin column (Macherey Nagel Inc.) according to the manufacturer's suggested protocol, except that the NT buffer was not diluted and the DNA bound to the column was eluted in 45 μl of elution buffer. The captured libraries were quantified using an Agilent BioAnalyzer.
Somatic Mutation Identification and LOH Analysis
Captured DNA libraries were sequenced with the Illumina GAIIx Genome Analyzer. Sequencing reads were analyzed and aligned to human genome hg18 with the Eland algorithm in CASAVA 1.6 software (Illumina). A mismatched base was identified as a mutation only when (i) it was identified by ten or more distinct pairs; (ii) the number of distinct tags containing a particular mismatched base was at least 2.5% of the total distinct tags; and (iii) it was not present in >0.5% of the tags in the matched normal sample. Mutations were confirmed by amplification of the relevant region with a single primer pair and evaluated as described in (43). LOH analysis was performed in a similar way, using the primer pairs described in table S3. A patient was considered “informative’ for the SNP if DNA from the normal tissue of that patient was heterozygous for the SNP. A tumor was determined to have undergone LOH if >75% of the informative primer pairs in that patient had an allelic ratio less than the mean minus 2 standard deviations of those measured in control individuals without scleroderma. Note that this analysis can only assess allelic imbalance, i.e., a gain in one allele or a loss in the other allele, though it is often (including in the current study) interpreted as LOH, i.e., loss of an allele.
Peptide Microarray
All experiments with the peptide microarray were performed at ProImmune Inc. (Oxford, UK). Peptides were synthesized as 15-mers with 10 overlapping amino acids from the previous peptide, spanning the entire RPC1 protein. Peptides were printed on glass slides with multiple arrays per slide separated with gaskets, allowing for multiple donor sera to be tested per slide. Donor serum was diluted 1:100, 1:500 and 1:1000 and incubated on the array. A fluorescent anti-Human IgG antibody was used as a secondary antibody, results were detected using a CCD camera and analysis was done using MS Excel. Peptides were determined to be potential binders if the normalized average signal intensity was greater than 4× the respective background negative control. Binding was considered positive if the signal intensity was 4× background for all three serum dilutions.
Autoantibody Analysis
RPC1 antibodies were assayed by ELISA using a commercially available kit (Inova
Diagnostics). CENP and TOP1 autoanitibody assays were performed as described in (3). To define whether patient antibodies recognized patient-specific mutated forms of RPC1, full-length wild type human POLR3A cDNA was purchased from Origene, and site-directed mutagenesis was performed to generate the three different RPC1 mutants, each with a single point mutation: E1072Q, K1365N and 1104T, corresponding to the tumor mutations detected in patients SCL-2, SCL-4 and SCL-42, respectively. All were sequence verified before use. 35S-methionine-labeled products were generated from the wild type and mutant DNAs by IVTT reactions (Promega kit). Prior to use in immunoprecipitations, the radiolabeled proteins were electrophoresed on SDS-PAGE gels and visualized by fluorography. The radiolabeled signal generated by each of these products was similar (1 μl E1072Q equivalent to: 1.1, 1.2 and 1.7 μl of I104T, wt and K1365N, respectively). Equivalent radioactive amounts 35S-methionine-labeled wt and mutated RPC1 proteins were used in immunoprecipitations performed as described in (44) with sera from three cancer scleroderma patients. One μl of each serum was used to immunoprecipitate the wild-type form of RPC1 as well as the specific RPC1 mutation found in the tumor from that patient.
Cell Culture, Stimulation and Flow Cytometry
PBMCs were freshly isolated from whole blood by density-gradient centrifugation (Ficoll-Paque Plus, GE Healthcare), and were used fresh (SCL-42) or frozen (SCL4 and SCL2). For each patient, PBMCs from a donor expressing one matching HLA-DRB1 allele was selected and used as a control. Cells were resuspended to a concentration of 1.5×106 cells/150 μl in RPMI medium supplemented with serum, 2 mM L-glutamine, 100 U/ml penicillin, and 100 μg/ml streptomycin, and were plated onto 96-well flat bottom plates. 1 μg/ml anti-human CD40 blocking antibody (G28.5, Biolegend) was added, and after 30 minutes, cells were stimulated for 18 hours as indicated: 4 μg/ml wild-type or mutant patient-matched RPC1 peptide, 4 μg/ml of peptidyl arginine deiminase 4 (PAD4) peptide as a negative control, or 4 μg/ml of a pool of class-II peptides from infectious agents antigens (CEFT) (Axxora) as a positive control. Peptide storage buffer was used for the unstimulated control. HLA restriction was assessed by stimulating cells in the presence of 1 μg/ml anti-HLA-DR blocking antibody (L243, Biolegend) or 1 μg/ml IgG-2a κ isotype control (MOPC-173, Biolegend).
Cells were washed with PBS after stimulation, stained with live/dead fixable blue dead cell stain (Molecular Probes), and then stained with BV510-conjugated CD3 antibody (OKT3, BioLegend), Pacific Blue-conjugated anti-CD4 antibody (RPA-T4, BD Pharmingen), APC-H7-conjugated anti-CD8 (SK1, BD), and PE-conjugated anti-CD154 antibody (TRAP1, BD Pharmingen). FACS analysis was performed on FACSAria flow cytometer-cell-sorter using FACSDiva (Becton Dickinson) and FlowJo software (Tree Star Inc. Ashland, Oreg., USA).
TCR Spectratyping
The diversity of CDR3 regions for 22 TCR Vβ regions was assessed using the TCRExpress Quantitative Analysis Kit (Biomed Immunotech, Tampa Fla.). Briefly, RNA was isolated from SCL-42 PBMCs after culture for 6 days with wt or mutant peptides (Invitrogen, Carlsbad Calif.), and cDNA was generated using random hexamers (Invitrogen) and You Prime First Strand Beads (GE, Buckinghamshire UK) following the manufacturers protocols. CDR3 regions were amplified from cDNA using two rounds of PCR with Vβ-family specific PCR primers as per the manufacturer's instructions. Fragment length analysis was performed by the Johns Hopkins DNA analysis facility. The distribution of CDR3 lengths for each Vβ-family was determined and expressed as “proportion of TCR”. Peaks were considered to be antigen-driven when the observed proportion of a given fragment size differed by more than 10% between wt and mutant-stimulated cells.
TCR Sequencing
TCR libraries were prepared for sequencing using a Truseq sample preparation kit following the manufacturer's suggestions with the following modifications. Input DNA was prepared from the PCR products obtained from spectratyping analysis. Product from wells using primers specific to the CDR3 regions of Vβ3, Vβ5, Vβ7, Vβ12, Vβ16 and Vβ24 were purified using a Qiagen PCR purification kit. DNA was eluted in 30 ul of 65° C. elution buffer. After A-tailing and igation to adaptors, the library was amplified in six reactions with a PCR mix containing 10 ul H20, 1.5 ul DMSO, 6 ul 5X Phusion buffer, 6 ul dNTPs, 3 ul each of Forward and Reverse Primers, 3 ul Phusion polymerase (2 U/ul) and 2 ul ligation reactions, and cycled using the following program, 98° C. for 30 s; 14 cycles of 98° C. for 10 s, 65° C. for 30 s, 72° C. for 30 s; and 72° C. for 5 min. The resulting product was purified using Ampure beads, quantified with an Agilent Bioanalyzer, and sequenced using an Illumina instrument.
qPCR Detection of Specific TCRs
Custom Taqman assays for specific TCRs were developed using Primer express v2.0 software and synthesized by Applied Biosystems. For detection of the Vβ24 Jβ1.1 wt TCR, a FAM-labeled probe (ACTGAAGCTTTCTTTGGAC; SEQ ID NO: 1), forward primer (GCACCGGGACAGTGATGAA; SEQ ID NO: 2), and reverse primer (GGTCCTCTACAACTGTGAGTTTGGT; SEQ ID NO: 3) were synthesized. For detection of the Vβ24 Jβ1.5 mutant TCR, a FAM-labeled probe (ACAGTAAATCAGCCCCAGC; SEQ ID NO: 4), forward primer (TGTGTGCCACCAGCAGAGA; SEQ ID NO: 5), and reverse primer (AGTCGAGTCCCATCACCAAAA; SEQ ID NO: 6) were synthesized. cDNA from Day 0 SCL-42 PBMCs was prepared as described and was amplified by one round of PCR using Vβ24-family specific PCR primers (Biomed Immunotech, Tampa Fla.). Expression of the specific Vβ24 TCRs was determined in triplicate using standard ABI chemistry and reagents.
Clinical Descriptions of Anti-RPC1 Positive Patients
As detailed below, the anti-PRC1 positive scleroderma patients with cancer shared many features, including a short interval between the first clinical signs of scleroderma and cancer diagnosis, aggressive cutaneous disease, and a high risk of scleroderma renal crisis.
Patient SCL-1
Patient 1 palpated a breast mass in the summer of 2005 and was diagnosed with a breast invasive ductal carcinoma on 7/26/05. Around the time of her diagnosis, she developed hypertension, thrombocytopenia, seizures, and renal failure that progressed despite blood pressure control. She ultimately initiated peritoneal dialysis. Her breast cancer was treated with lumpectomy, radiation therapy, and doxorubicin. In October of 2005, she began to notice Raynaud's phenomenon, and in October of 2007, she developed skin thickening. When first seen in our Center on 2/4/08, she was noted to have extensive and severe scleroderma skin thickening with a modified Rodnan skin score (mRSS) of 41 (range is 0-51 with 51 representing most severe disease possible).
Patient SCL-2
Patient 2 was noted to have a mass on a chest radiograph, leading to a diagnosis of a small cell carcinoma of the lung on 3/22/06. She clearly had Raynaud's phenomenon by April 2006. She was treated with chemotherapy (completed 7/06) and radiation therapy with prophylactic brain irradiation (completed 9/06). By April of 2007, she began to notice worsening of her Raynaud's phenomenon and swelling of her hands followed by the onset of rapid, diffuse skin thickening. She was initially treated for her cutaneous disease with mycophenolate mofetil and was noted to have a mRSS of 47 on her visit to our Center on 9/6/07. She later required therapy with cyclophosphamide due to concern for interstitial lung disease, and by 12/13/11, her mRSS had decreased significantly to 5.
Patient SCL-4
Patient 4 had a known BRCA1 mutation and underwent a prophylactic oophorectomy based on her genetic risk. During this procedure, she was found to have stage III ovarian adenocarcinoma with papillary serous features (4/5/06). She completed 6 cycles of paclitaxel and cisplatin in 8/2006, and around this time developed Raynaud's phenomenon. Her chemotherapy course was complicated by the development of pericarditis with tamponade physiology requiring drainage and a pericardial window, and there was no evidence of an infected or malignant effusion. When first seen here on 1/10/08, she was noted to have significant skin disease (mRSS 21), numerous tendon friction rubs, a myopathy, and scleroderma renal crisis with a Cr of 1.9. In 2008-2009, she was treated with a number of immunosuppressive agents targeting her cutaneous, muscle, and joint disease including mycophenolate, methotrexate, azathioprine and hydroxychloroquine, and her skin disease was significantly improved by 8/08. In October 2011, she developed a small bowel obstruction with imaging findings consistent with serosal implants in the context of a rising CA 125 level. She began weekly carboplatin, and her CA 125 level had normalized by April 2012.
Patient SCL-13
Patient 13 noticed bilateral hand and ankle swelling in May 2005 and Raynaud's phenomenon in August 2005. She was diagnosed with invasive ductal carcinoma of the breast on 8/24/05. She was treated with a mastectomy followed by doxorubicin and cyclophosphamide from 10-12/05. In 01/06, she developed worsening skin thickening in her hands, arthralgias and myalgias and began therapy with d-penicillamine and later methotrexate. She also initiated paclitaxel and trastuzumab for her cancer in 01/06. She was seen at our Center Apr. 16, 2007 and was noted to have progressive skin disease (mRSS 30); she was transitioned to mycophenolate for her cutaneous disease and gradually had an improvement in her skin disease (mRSS in 2012 was 2).
Patient SCL-35
Patient 35 was diagnosed with breast ductal carcinoma in situ on Aug. 16 2004, treated with a mastectomy. In April 2006, she developed symptoms consistent with carpal tunnel syndrome, and by 8/06, she had lower extremity skin thickening and tendon friction rubs. Raynaud's phenomenon developed in 1/07. When first seen at our Center in 6/07, her mRSS was 48, and she was on letrozole for her malignancy. After therapy with cyclophosphamide and mycophenolate, her cutaneous disease significantly improved (mRSS 3 by 3/11).
Patient SCL-42
Patient 42 developed arthralgias and skin thickening in her fingers in 3/2007 that rapidly progressed to diffuse skin thickening. In 4/2007 she developed Raynaud's phenomenon also. By 10/07, she developed hypertension requiring ACE-inhibitor therapy, and her mRSS was 18. Despite therapy with mycophenolate, her cutaneous disease progressed, and by 3/08, her mRSS had increased to 37. In 4/08, methotrexate was added to her regimen with some improvement in flexibility and new hair growth; however her mRSS remained at 35 in 7/08. In 9/08, in the setting of increased cutaneous activity, she was diagnosed with a stage II, triple negative, invasive ductal cancer of the breast. She was treated with mastectomy (10/08) and chemotherapy with cyclophosphamide and docetaxel (12/08-2/09). Her cutaneous symptoms gradually improved in the setting of IVIG therapy, and by 12/11 her mRSS was 8.
Patient SCL-81
Patient 81 was diagnosed with an adenocarcinoma of the colon with positive lymph nodes in 5/05 requiring bowel resection and 5-FU and platinum chemotherapy. In 7/09, he developed diffuse cutaneous skin disease and by 11/09 had Raynaud's phenomenon. In 3/10, his mRSS was 46.
Patient SCL-82
Patient 82 developed Raynaud's phenomenon and hand swelling in 1/08 and was noted to have a mRSS of 14 in 8/08 while on methotrexate therapy. By 1/09, the patient was on combination mycophenolate and methotrexate therapy for a mRSS of 18. By 1/10, her skin disease was significant improved (mRSS 5), but she was diagnosed with a ductal carcinoma in situ (DCIS) of the breast on Jun. 28, 2010 and treated with a mastectomy.
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This invention was made using funds from the U.S. National Institutes of Health. The U.S. government retains certain rights according to the terms of grants K23 AR061439, P30-AR053503, CA43460, CA 57345, and CA 62924.
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/US14/68635 | 12/4/2014 | WO | 00 |
| Number | Date | Country | |
|---|---|---|---|
| 61911626 | Dec 2013 | US |
