Pharm-Immunology-14 & 15

Immunology of Cancer & Transplants

Hussein
 Introduction
• Immunological surveillance is proposed as
means of detection of transformed cells by
the immune system.
• Immune reactions could be induced at later
stage and contribute to limiting of tumor
development.
• Third, therapeutic use of the immune
system is more than a possibility
 Objectives
1. Know the basis of immune recognition of tumors
2. Know the immune responses to tumors
3. Know the concept of immunosurveillance
4. Know the mechanisms of immunological escape
5. Understand the potential of immunological
cancer therapy
6. Understand the principles of immunological
cancer diagnosis
 Evidence supporting the concept that the
immune system reacts against tumors
Fig. 10-1

• Several lines of clinical and experimental evidence indicate

that defense against tumors is mediated by reactions of the
adaptive immune system
 Immune Recognition
• Tumor cells undergo some changes that include some
surface antigens enabling the immune system to recognize
them as different from normal cells. Examples:
1. Cancers associated with viral infections might express viral
encoded antigens
2. Normally silent genes are expressed in tumor cells
Oncofetal antigens:
a) -fetoprotein (AFP) in hepatic cancer
b) carcinoembryonic Ag (CEA) in intestinal cancers
3. Ags resulting from mutations (point mutations; e.g. p53)
4. Abnormal surface carbohydrates with new antigenic activity
5. Changes on the surface of cycling cells
1. Cancer cells are faster dividing than normal cells
2. Important: 95 kDa glycoprotein, F19 in sarcomas & several carcinoma
6. CALLA is an antigen associated with childhood leukemia
 CALLA (CD10)
1. Common Acute
Lymphoblastic
Leukemia Antigen
normally expressed
only on B-cell
progenitors
(lymphoblast)
• They make up
< 1% of normal
bone marrow
cells
2. CALLA becomes
more abundant in the
commonest childhood
leukemia
 Immune Responses
• T Lymphocytes:
– CD8+ CTLs rejection of transplanted tumors
• MHC I peptide presentation is necessary for
recognition & killing
• Tumor-infiltrating lymphocytes (TILs) contain
CTLs capable of lysing the tumor of origin
• CD4+ helper T cells provide:
– cytokines, including:
i) tumor necrosis factor (TNF),
ii) interferon- (IFN-)
Specificity of tumor • Production of a highly
immunogenic (tum-) variant
immunity tumor in DBA2 mice and Tc
cells specific for it:
– Inducing mutation by
irradiating of the parent
cells
– Subclone tumor cells:
• Some subclones (tum-)
are no longer able to
grow in DBA2 mice
• Spleen Tc from mice
tum- injected with these
tum- cells could kill
tum- but not the
parent tumor
 • Tc cells taken from a
Tc specificity mouse immunized
with a tum- variant
tumor: (in vitro)
– kill tumor cells
coated with a
peptide from the
tum- gene
sequence
– They do not kill
tumor cells
coated with the
homologous
peptide from the
parental tumor
• The two peptides
differ in one amino
acid
 Immune Responses
Natural Killer Cells:
i. Kill by lysis
• no expression of T cell antigen receptors
• MHC independent killing
ii. Kill viral infected cells & hematopoietic tumors in
vitro
iii. Express low-affinity Fc-receptors for IgG
iv. Cytokines (IFNs, TNF, IL-2, IL-12) increase the
tumoricidal capacity of NK cells
v. IL-2 activated NK cells are called lymphokine-
activated killer (LAK) cells
vi. Role in immunosurveillance: Nude mice w/o high
incidence of spontaneous tumors
 Immune Responses
• Macrophages mechanisms of killing:
1. release of lysosomal enzymes
2. reactive O2 metabolites
3. nitric oxide in mice
4. TNF secretion. By what mechanisms does TNF kill tumor
cells?
• TNF [also called cachectin] is a polypeptide cytokine,
produced by endotoxin-activated macrophages, which
1. has the ability to modulate adipocyte metabolism,
2. lyse tumor cells in vitro, and
3. induce hemorrhagic necrosis of certain transplantable
tumors in vivo
 Immune Responses

Antibodies:
• There is some evidence that cancer patients
produce antibodies against their own tumors
• Humoral immune response is far less important
than the cellular in anticancer defense
 Immunosurveillance

• It is performed by the immune system using

the same mechanisms discussed above to
discover any developing cancer and destroy it
• NK cells play an important role in surveillance
• It does not work all the time
– Proof: there are cancer patients
Evasion Of The Immune System/Escape mechanisms
1- Down-regulation of MHC I on tumor cells
2- Lack of MHC II in human tumors  no direct activation of CD4+
helper T cells
3- Lack of costimulators (B7) may impair T cell activation
4- Suppression of anti-tumor immune responses by tumor products
5- Host tolerance to tumor antigens due to
a) neonatal exposure or
b) presenting antigens in tolerigenic form
6- Selection of mutant tumor cells lacking immunogenic peptide-MHC
complexes.
7- Antigenic modulation due to endocytosis or shedding of the antigen-
antibody complexes
8- "Sneaking through" phenomenon based on the kinetics of tumor
growth that allow establishment of resistant tumors.
9- Hiding of tumor cell surface antigens by glycocalyx molecules and
others such as coagulation induction  fibrin cocoon.
 Fig 10-4
How tumors evade
immune responses?
• Antitumor immunity develops
when T cells recognize tumor
antigens and are activated
• Tumor cells may evade
immune responses by:
– losing expression of antigens
– loosing MHC molecules
– producing immunosuppressive
cytokines
 Tumor Ag presentation to T cells in 3 ways:
1. Directly in the absence of necessary co-stimuli, resulting in anergy.
2. Directly by a tumor which expresses co-stimulatory molecules, resulting
in Tc cell activation.
3. Directly by tumor cells and indirectly via specialized APCs, resulting in
activation of both Tc and TH cells

TCR
 Cancer Immunotherapy
1- Active immunization by using oncogenic viral proteins as
vaccines against this class of tumors.
2- Protection against some tumors can be achieved by immunization
with chronic lymphocytic leukemia (CLL) cells idiotype fused
with GM-CSF
3- Transfection of weakly immunogenic tumors with costimulatory
molecules (B7) and cytokines (IFN, IL-2, IL-4, IL-7)
4- Monoclonal antibodies as magic bullets when conjugated with
toxins or radionuclides to target tumor cells or antigens on
malignant fibroblasts.
5- Harnessing of innate immune mechanisms:
i.LAK against renal carcinoma;
ii.IFN- and  very effective against T-cell disorders (hairy cell
leukemia & mycosis fungoides);
less effective against Kaposi's sarcoma & various lymphomas
iii.Combining therapies with synergistic effects.
 Strategies for
enhancing antitumor
immune responses
Tumor-specific immune
responses may be
stimulated by:
A. Vaccinating with host Fig 10-5
dendritic cells that
have been pulsed with
tumor antigens
B. Vaccinating with
plasmids containing
cDNA encoding tumor
Ags that are injected
directly into patients or
used to transfect
dendritic cells
C. Vaccinating with
tumor cells transfected
with genes encoding
B7 costimulators or
the T cell growth factor
IL-2
Pulsing of dendritic cells
Antihelminthic, immune Response
enhancer
Augmenting the host response by specific
immunotherapy
 Therapeutic modification of mAbs
1. Genetically engineered
chimeric Abs with
human Fc portion
attached to mouse Fab 2
1. reduce the risk of an
immune response to
the mAb
2. Human Fc will also
recruit human
effector mechanisms
2. Molecules that can be
coupled to mAbs
1. Toxins: Ricin
2. Cytotoxic drugs or
enzymes capable of
activating drugs
3. Radioactive isotopes
 In vitro purging of tumor-infiltrated bone marrow
• Bone marrow containing
tumor cell can be purged
using:
1. mAbs and complement,
2. Ab-toxin conjugates or
3. Ab coupled to magnetic
beads
• Store purged marrow
• Treat patient with
radiation and chemotherapy
• Treat purged marrow with anti-tumor Ab
• Return bone marrow to patient
• Therapy results are encouraging in leukemia and lymphoma
patients who where not helped by conventional therapy
 Immunodiagnosis
1- Circulating tumor markers are diagnostic:
i. -fetoprotein (AFP) hepatic carcinoma
ii. Carcinoembryonic Ag (CEA) colorectal carcinoma
iii. GM1 monosialoganglioside in 96% of patients with pancreatic
carcinoma
2- Monoclonal Ab to tumor surface antigens can provide a basis for
imaging. Good targets include:
i. F19 glycoprotein on reactive stromal fibroblasts
ii. Certain tumor mucins/epithelial cancers (T antigen)
iii. Cytokeratin on carcinoma cells
3- Detection of bone marrow micrometastasis using
immunocytochemistry techniques provides information on:
i. Prognosis
ii. Efficacy of a new therapy
iii. Eventual recurrence of treated cancer
NORMAL RANGE 
 Immune Response Against Transplant
• Know the evidence for the immune nature of transplant
rejections
• Describe MHC Ags as the principal targets of rejection
• Know the the types of graft rejection:
– Acute
– Hyperacute
– Chronic
• Understand the role of immunosuppressive drugs such as
cyclosporine in organ transplantation
• Describe the principle of mixed lymphocyte reaction
(MLR)
• Know blood transfusion
• Know the bone marrow transplantation and the associated
graft-versus-host (GvH) disease
 Types of grafts
• Syngeneic grafts (syngraft)
– Donor and recipient are genetically identical  No rejection
• Identical twins
• Inbred mice
• Their Ags are called isoantigens
• Isoantibodies
• Allogeneic grafts (allograft)
– Donor and recipient are genetically different members of the
same species  Rejection
• Their Ags are called alloantigens
• Their Abs & T cells are alloreactive (alloantibodies)
• Xenogeneic (xenograft)
– Donor and recipient are from different species  Rejection
• Their Ags are called xenoantigens
• Their Abs & T cells are xenoreactive
 Types of Grafts
1. Autograft: Autogenic,
autologous tissue
2. A. Syngraft:
Syngeneic tissue
B. Isograft: Isologous
tissue
3. Allograft
(Homograft):
Allogeneic tissue
4. Xenograft
(Heterograft):
Xenogeneic
(Heterologous) tissue
 Transplantation Laws
1. Syngrafts are accepted
2. Allografts are rejected
3. Transplants from parent to F1 hybrid are
accepted; reverse rejected
4. Transplants from F2 individuals to F1 are
accepted*
5. Transplants from either parent are mostly
rejected, but accepted in some
 Evidence indicating that the rejection of tissue
transplants is an immune reaction

• Clinical and experimental evidence indicates that rejection

of grafts is a reaction of the adaptive immune system
Recognition of allogeneic
MHC molecules by T
lymphocytes.
• Recognition of allogeneic MHC
molecules may be thought of as a
cross reaction in which a T cell
specific for a self MHC
molecule-foreign peptide
complex (A) also recognizes an
allogeneic MHC molecule whose
structure resembles that of a self
MHC molecule-foreign peptide
complex (B, C)
• Donor peptides derived from the
graft may not contribute to
allorecognition (B), or
• They may form part of the
complex that the T cell sees (C)
• The type of T cell recognition
depicted in B and C is called
direct allorecognition
 Direct and indirect recognition of alloantigens
• A. Direct alloantigen recognition occurs when T cells bind directly to
intact allogeneic MHC molecules on professional APCs in a graft
• B. Indirect alloantigen recognition occurs when allogeneic MHC
molecules from graft cells are taken up & processed by recipient APC
and peptide fragments of the allogeneic MHC molecules are presented
by recipient (self)
MHC molecules Graft
APC
• Recipient APCs may
also process &
present graft proteins
other than allogeneic
MHC molecule
 Mechanisms of graft rejection:
Hyperacute rejections

• In hyperacute rejection, preformed antibodies react with

– alloantigens on the vascular endothelium of the graft,
– activate complement, and
– trigger rapid intravascular thrombosis and necrosis of the vessel
wall
 Mechanisms of graft rejection: Acute rejection

• In acute cellular rejection, CD8+ T lymphocytes reactive with

alloantigens on graft endothelial cells and parenchymal cells cause
damage to these cell types
• Endothelium inflammation is sometimes called "endothelialitis"
• Alloreactive antibodies may also contribute to vascular injury
 Chronic Graft Rejection
1. Months or years after Transplant
2. Example:
– Kidneys gradual loss of function
3. Biopsy reveals rejection process while
progressing slowly
Mechanisms of graft rejection: Chronic rejection

• In chronic rejection with graft arteriosclerosis, T cells reactive with

graft alloAgs produce cytokines that induce endothelial & intimal
smooth muscle cells proliferation, leading to luminal occlusion
• This is probably a chronic DTH reaction to alloantigens in the vessel
wall
 Graft Rejection Displays Immunological Memory

• Left:
– A human skin allograft @ day 5 is fully vascularized & cells are
dividing
• Middle:
– Graft is totally destroyed by day 12
• Right:
– Second-set graft from the same donor fails to vascularize and is
destroyed rapidly by day 7 because the first graft sensitized the
recipient Immunological memory
 Graft-versus-Host Reaction (GvHR)
1. The graft rejects the host
2. Graft cells are immunocompetent
3. Recipient is immunoincompetent
4. Conditions for GvHR:
i. Histoincompatibility
ii. Transfer of immunocompetent (T) cells
iii. Immunodeficient recipient
5. GvHR occurs after bone marrow transplantation for
stem cell replacement in:
i. Aplastic anemia
ii. Acute leukemia
iii. Combined immunodeficiencies
 Mixed lymphocyte reaction
• MLR is an in vitro test for T cell recognition of
alloantigens
• T cells from the potential recipient of a transplant
are cultured with WBCs from the potential donor
• The response of the T cells is assayed
– If the response with lysis and cell damage is strong
the matching between the two individuals is weak
– The weaker the response, the greater the match
• This is a rough predictor of the transplant’s
outcome: rejection or acceptance
 ABO blood groups & blood transfusion
• Blood group Ags are a major barrier for blood transfusion
• ABO Ags are glycosphingolipids mainly on surface of RBC
– Group A has N-acetylgalactoseamine Ag & anti-B Ab
– Group B has galactose Ag & anti-A Ab
– Group AB has both Ags & no Abs
– Group O has neither Ag & both Abs (anti-A & anti-B)
– Transfusion reaction occurs when donor has Ags that are not
present in the recipient
• The Abs are sometimes called natural Abs and thought to
be made against intestinal bacteria and capable of cross-
reaction with the blood group Ags
• Rh groups are important especially in cases of pregnancy
where the mother is Rh- and the baby is Rh+
– In the second pregnancy the baby will have problems of blood
lysis
 Treatments for
(Tacrolimus)
graft rejection
• Agents that are commonly
used to treat the rejection
of organ grafts, and the
mechanisms of action of
these agents, are listed
• FK506 is a drug that
works like cyclosporine,
but FK506 is not used as
widely
Brendan Doran