mechanisms in autoimmunity and cancer
DESCRIPTION
Harnessing the innate immunity to modulate autoimmunity and cancer, IVIG; The Myth and Reality Presented by Professor Yehuda Shoenfeld, MD, FRCP at CONPO Barcelona 2013 IVIG *Definitive way of preparation; produced by 25 pharmaceutical companies (very expensive). *Clinical applications: treatment of severe immune deficiency diseases and a variety of autoimmune conditions. *Pooled IgG (immunologlobulin G) from 6,000--20,000 blood donation. Intravenous Immunoglobulin-IVIg *Pooled IgG (immunologlobulin G) from 6,000- 20,000 blood donation (representing the Innate Immune repertoire) *Definitive way of preparation; produced by 25 pharmaceutical companies (very expensive) *Clinical applications: Treatment of severe immune deficiency diseases and a variety of autoimmune conditions CONCLUSIONS: IVIg- the myth and reality * IVIG is effective in autoimmune conditions –multiple mechanisms * IVIg anti -cancer effects in; melanoma, carcinoma, sarcoma and lymphoma * IVIG representing the innate immune system affect tumors by diverse mechanismsTRANSCRIPT
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Yehuda Shoenfeld MD,FRCP,
IVIG;The myth and realityIVIG;The myth and reality
IVIG
CONPO Barcelona2013
Harnessing the innate immunity to modulate autoimmunity and cancer
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Future Congresses
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Definitive way of preparation; produced by 25 Definitive way of preparation; produced by 25 pharmaceutical companies (very expensive).pharmaceutical companies (very expensive).Clinical applications: treatment of severe immune Clinical applications: treatment of severe immune deficiency diseases and a variety of autoimmune deficiency diseases and a variety of autoimmune conditions.conditions.Pooled IgG (immunologlobulin G) from 6,000Pooled IgG (immunologlobulin G) from 6,000--20,000 20,000 blood donation. blood donation.
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Intravenous Immunoglobulin-IVIg
Pooled IgG (immunologlobulin G) from 6,000- 20,000 blood donation (representing the Innate Immune
repertoire)Definitive way of preparation; produced by 25 pharmaceutical companies (very expensive)Clinical applications: Treatment of severe immune deficiency diseases and a variety of autoimmune conditions
Yehuda Shoenfeld, MD,FRCP ( Hon.)
IVIg IVIg THERAPYTHERAPY
High-dose: 2-g/kg body weight IVIg.
The preparation: Octapharma,MedImmune,
Sclavo, BPL, tegeline , endobuline, gammagard ,ZLB,Omrix)
A 5-days schedule.
A monthly interval.
Every patient received 1-6 treatment courses.
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Paul Imbach
IVIGWiskott Aldrich
Lancet 1981;1-1228-30IVIG in ITP
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Immune thrombocytopenia (ITP)
ITP is an autoimmune disease due to autoantibody to endogenous platelets
Causes plateletdestruction bymacrophagesand bleeding
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Michel .D.Kazatchkine
NEJM2001;345;747
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Successful IVIG treatment in Successful IVIG treatment in autoimmune diseasesautoimmune diseases
ITPITP
Autoimmune hemolytic anemia
Viral-associated red-cell aplasia
Guillain-Barre syndrome
Myastenia gravis
Polymyositis
Dermatomyositis
Kawasaki disease
ANCA-positive systemic vasculitis
Antiphospholipid syndrome
Recurrent spontaneous abortions
Multiple sclerosis
Felty’s syndrome
Juvenile RA
SLE
GVHD
Multiple sclerosis
IDDM
Steroid-dependent asthma
Steroid dependent severe atopic dermatitis
Crohn’s disease
Chronic Inflamatory Demyelinating Polyneuropathy
Yehuda Shoenfeld, MD,FRCP ( Hon.)
A study of 20 SLE patients with A study of 20 SLE patients with intravenous immunoglobulin intravenous immunoglobulin
clinical and serologic responseclinical and serologic response Yair Levy, Yaniv Sherer, Alaa Ahmed, Pnina Langevitz, Jacob GeorYair Levy, Yaniv Sherer, Alaa Ahmed, Pnina Langevitz, Jacob George, ge, Fabizio Fabbrizzi, Jeff Terryberry, Martyna Meissner, Margalit LFabizio Fabbrizzi, Jeff Terryberry, Martyna Meissner, Margalit Lorber, orber,
James B Peter, James B Peter, Yehuda Shoenfeld. Yehuda Shoenfeld. Lupus 8, 705Lupus 8, 705--712, 1999712, 1999
A beneficial clinical response following IVIg treatment was noted in 17 out of 20 patients (85%).
Some clinical manifestations responded more to treatment: arthritis, fever, thrombocytopenia, and neuropsychiatric lupus.
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Successful treatment of early secondary Successful treatment of early secondary myelofibrosis myelofibrosis
in SLE with IVIG.in SLE with IVIG.Aharon A, Levy Y, Bar Dayan Y, Afek A, Zandman-Goddard, Skurnik
Y, Fabrrizzi F, Shoenfeld YLupus 6: 408-411,1997.
IVIG
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Reduced proteinuria following Reduced proteinuria following repeated courses of IVIGrepeated courses of IVIG
02468
2 mon bf
1 mon bf
1st cy
cle2n
d cycle
3rd cy
cle4th
cycle
5th cy
cle6 cy
cle12 m
on af18 m
on af30 m
on afU
rina
ry p
rote
in
extr
actio
n (g
/24h
)
Yehuda Shoenfeld, MD,FRCP ( Hon.)
A Comparison Between Prednisone Doses A Comparison Between Prednisone Doses used for the Treatment of SLE Patients used for the Treatment of SLE Patients
Before and After IVIgBefore and After IVIg
0102030405060
Before IVIG After 6 cycles of IVIG
P<0.05P<0.05
Yehuda Shoenfeld, MD,FRCP ( Hon.)
2. Anti2. Anti--idiotypic idiotypic Abs Abs Anti-Id Ab
Pathogenic auto- Ab
Anti-Id Abs modulates the immune system by suppressing auto-Abs production
Yehuda Shoenfeld, MD,FRCP ( Hon.)
AIM :To evaluate theTo evaluate theefficacy of the efficacy of the
antianti--dsDNA antidsDNA anti--idiotypesidiotypesenrichedenriched IVIG IVIG
B.Gilburde
M.Blank
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Affinity purification of antiAffinity purification of anti--dsDNA dsDNA antianti--ID from IVIGID from IVIG
Anti-dsDNA-Sepharose
Loading dialyzedIVIG
YY
YYYY
YY
YY
YY YYYY
YYYY
YY
YY Elution withHCl-glycine
16 hours at 4oC
YYYYYYYYYYYY
YYYYYY
antianti--dsDNA antidsDNA anti--IDID
YY
YYYY
YY
YY
YY
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Treatment of NZB/W F1 mice with IVIG-ID
Three weekly injections to the tail vein of NZB/W F1 mice:IVIG-ID : 2 mg/kg = 60 µg/mouseIVIG: 400 mg/kg = 12 mg/mouse
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Proteinuria in NZB/W F1 mice Proteinuria in NZB/W F1 mice treated with SUPERIVIG and IVIGtreated with SUPERIVIG and IVIG
05
1015202530
IVIG-ID IVIG CONTROL
G/L
*
Yehuda Shoenfeld, MD,FRCP ( Hon.)
IVIG-IDIVIG-ID IVIGIVIG NON-TREATEDNON-TREATED
Prevention of mesangial mouse IgG deposits in NZB/W F1 mice
treated (early treatment) with:
Prevention of mesangial mouse IgG Prevention of mesangial mouse IgG deposits in NZB/W F1 micedeposits in NZB/W F1 mice
treated (early treatment) with:treated (early treatment) with:
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Cumulative number of deaths with Cumulative number of deaths with concomitant proteinuria in NZB/W F1 miceconcomitant proteinuria in NZB/W F1 mice
Weeks of ageWeeks of age25 30 35 40 45
0
2
4
6
8
10
12
IVIGIVIG--ID ID
IVIG IVIG
Control Control N
umbe
r of d
eath
sN
umbe
r of d
eath
s
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Efficacy of IVIG affinityEfficacy of IVIG affinity--purified antipurified anti-- doubledouble--stranded DNA antistranded DNA anti--idiotypic idiotypic
antibodies in the treatment of an antibodies in the treatment of an experimental murine model of experimental murine model of systemic lupus erythematosus.systemic lupus erythematosus.
Shoenfeld Y, Shoenfeld Y, Rauova L, Gilburd BRauova L, Gilburd B, Kvapil F, , Kvapil F, Goldberg I, Kopolovic J, Rovensky J, Goldberg I, Kopolovic J, Rovensky J, Blank M.Blank M.
Int Immunol. 2002 ;14:1303Int Immunol. 2002 ;14:1303--1111
Yehuda Shoenfeld, MD,FRCP ( Hon.)
YYYY
YY
YYYYYY YY
YY
AntiAnti-- dsDNAdsDNA
SLESLE
YYYY
YY
YY YYYY YY
YY
AntiAnti--2GPI2GPI
Antiphospholipd Antiphospholipd syndromesyndrome
Myasthenia Myasthenia
GravisGravis
YYYY
YYYYYYYY YY
YY
AntiAnti-- AChRAChR
A u t o i m m u n e D i s e a s e S p e c i f i c I V I g : A u t o i m m u n e D i s e a s e S p e c i f i c I V I g : Low Dose, High EfficacyLow Dose, High Efficacy
Special types of IVIg for autoimmune diseases
PemphigusPemphigusvulgarisvulgaris
YYYY
YY
YYYYYYYY YY
AntiAnti--desmoglein
desmoglein 1/31/3
Yehuda Shoenfeld, MD,FRCP ( Hon.)
IVIG Treatment of Cancer
Y. Shoenfeld, Sheba Medical Center, Israel
Reactivity of the human IVIG with a panel of human cell line
Human bladder carcinoma cell line T24, human glioma cell line U-138MG, human head-and-neck cancer cell line PCI-13, human lymphoid cell line LG2 and human
melanoma cell lines 501, 553B, 836,1379, Colo38 and Mel-1386 at 4oC for 2 hours.Reactivity of the humanized antibody IVIG with a panel of cell lines
0
1
2
T2 4 8 3 6 C o lo 3 8 M el-13 8 6 DAM -M B -2 3 1
553 B 2 9 3 / KDR 13 79 P C I-13 LG2 50 1 U-13 8 M G
Cell lines
OD
at 4
50nm
IV IG
control
Yehuda Shoenfeld, MD,FRCP ( Hon.)
IVIg: Prevention of Melanoma Metastases
Gamma-globulin inhibits tumor spread in miceYehuda Shoenfeld and Pnina Fishman
International immunology 11: 1247 - 1251, 1999
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Effect of IVIg (I.V.) on the Development of Melanoma Metastases
6 IVIG - Presentation, Oct 95
0
25
50
75
100
125
No.
of f
oci
(% o
f con
trol
)
Control 0 0,4 0,4,9
DAYS OF IVIG TREATMENT
P<0.001 P<0.001 P<0.001
Yehuda Shoenfeld, MD,FRCP ( Hon.)
IVIg Prolongs the Survival of Tumor Bearing Mice
0
20
40
60
80
100
0 20 40 60 80 100
Days after amputation
% s
urvi
val
TreatedControl
a - Sarcoma
0
20
40
60
80
100
0 20 40 60 80 100
Days after amputation
% s
urvi
val
TreatedControl
b - Melanoma
Sarcoma Melanoma
Yehuda Shoenfeld, MD,FRCP ( Hon.)
IVIg: Prevention of Tumor foci the Peritoneum
Yehuda Shoenfeld, MD,FRCP ( Hon.)
IVIg: Prevention of Lung Sarcoma Metastases
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Inhibitory effect of IVIg on in vitro CT26 cell Inhibitory effect of IVIg on in vitro CT26 cell proliferation proliferation
* p < 0.05
** p < 0.01
*** p < 0.001
0
10
20
30
40
50
60
70
80
1 5 15 40
IVIg concentration (mg/ml)
% o
f inh
ibiti
on 24h48h72h
**
***
*
**
***
Time course and dose responseTime course and dose response
Yehuda Shoenfeld, MD,FRCP ( Hon.)
•Matrigel resultsEffect of IVIg on CT26 cell invasiveness
The invasive capacity of CT26 cells was decreased by IVIgThe invasive capacity of CT26 cells was decreased by IVIg
(time(time-- and doseand dose--dependent effect)dependent effect)
39.70
0
10
20
30
40
50
60
48h 72h
% o
f inh
ibiti
on o
f inv
asio
n
IVIg 20mg/ml
IVIg 40mg/ml
p < 0.001
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Dose Dependent Effect of IVIg on the Proliferation of Human Colon Carcinoma, HCT-116 Cells
0
20
40
60
25 10 5 2.5 1.25IVIg Concentration (mg/ml) .
[H3 ] T
hym
idin
e in
corp
orat
ion
(% o
f inh
ibiti
on)
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Shrinkage of Melanoma Metastases Following High dose Intravenous Immunoglobulin Treatment
Shoenfeld Y, Levy Y, Fishman P. IMAJ 3; 698-699, 2001
Human Experience
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Total remission of thymus carcinoma after treatment with
intravenous immunoglobulinMurieMurie--Fernandez M, et al. Clin Transl Oncol. 2006; 8: 697Fernandez M, et al. Clin Transl Oncol. 2006; 8: 697--99
42 year-old woman with myasthenia gravis associated with a malignant thymoma.
A complete remission of the thymoma was confirmed by FDG-PET after four cycles of immunoglobulins.
IVIg as a natural anti cancer agent
Mechanisms
Yehuda Shoenfeld, MD,FRCP ( Hon.)
IVIG 25mg/mlIVIG 25mg/ml ControlControl
IVIG Exerts Apoptotic Effect on Nb2-11c Lymphoma cells
Yehuda Shoenfeld, MD,FRCP ( Hon.)
IVIG IVIG Inhibits MMPInhibits MMP--9 mRNA9 mRNA expression in expression in mouse Melanoma cellsmouse Melanoma cells
0
0.5
1
1.5
MM
P-9
mR
NA
IVIG (mg/ml)663300
2.8 kbMMP-9
G3PDH 1.4 kb
IVIG concentration
Shapiro S, Shoenfeld Y, Gilburd B, Sobel E, Lahat N. Intravenous gamma globulin inhibits the production of matrix metalloproteinase-9 in macrophages. Cancer. 2002, 95: 2032 – 2037.
ANTI-VEGF ACTIVITY OF IVIg
IVIGIVIG
IVIg as an anti-angiogenic agent ?IVIg as an antiIVIg as an anti--angiogenic agent ?angiogenic agent ?
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Binding of IVIg to the recombinant VEGF
Anti-VEGF activity in an IVIg preparation(ELISA)
0.0
0.5
1.0
1.5
2.0
2.5
3.0
0.0 0.4 0.8 1.6 3.1 6.3 12.5 25.0 50.0
IVIg concentration (mg/ml)
Abso
rban
ce (4
50nm
)
Anti-VEGF activity in an IVIg preparation(ELISA)
0.0
0.5
1.0
1.5
2.0
2.5
3.0
0.0 0.4 0.8 1.6 3.1 6.3 12.5 25.0 50.0
IVIg concentration (mg/ml)
Abso
rban
ce (4
50nm
)
Anti-VEGF activity in an IVIg preparation(ELISA)
0.0
0.5
1.0
1.5
2.0
2.5
3.0
0.0 0.4 0.8 1.6 3.1 6.3 12.5 25.0 50.0
IVIg concentration (mg/ml)
Abso
rban
ce (4
50nm
)
2000 2
38 kD
IVIg (µg/ml)
VEGF samples were loaded onto 12% SDS-PAGE and blotted on to
nitrocellulose membranes
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Competition of MAV and IVIg for binding to the VEGF in an immunoblot
••g/ml) µ(10 incubated with MAV-pre(2mg/ml) to the VEGF IVIgIVIgBinding of Lane 1:Lane 1:••(2mg/ml)incubated with IVIg-preg/ml) to the VEGF µ(10MAVMAVBinding of Lane 2:Lane 2:
••(2mg/ml) to the VEGFIVIgIVIgof Direct bindingLane 3:Lane 3:••g/ml) to the VEGFµ(10 MAVMAVof Direct bindingLane 4.Lane 4.
1 2 3 4
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Injection of bFGF
VEGF
IVIG as an anti VEGF-Arei Solomon @Y Shoenfled
Yehuda Shoenfeld, MD,FRCP ( Hon.)
IVG & bFGF
VEGF
IVIG
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Anti-VEGF activity of IVIg in vivo
IVIG inhibits VEGF- induced blood perfusion in mouse hind-limb ischemia
0.40
0.50
0.60
0.70
0.80
0.90
1.00
1.10
T0 T7 T14 T21
Days post surgery
Per
fusi
on
ratio
without VEGFwith VEGFwith VEGF + IVIg
IVIG inhibits VEGF- induced blood perfusion in mouse hind-limb ischemia
0.40
0.50
0.60
0.70
0.80
0.90
1.00
1.10
T0 T7 T14 T21
Days post surgery
Per
fusi
on
ratio
without VEGFwith VEGFwith VEGF + IVIg
Blood flow recorded by Laser Blood flow recorded by Laser Doppler Perfusion ImagingDoppler Perfusion Imaging
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Control IVIg treated
A rich vascular bed and the growing tumor mass.
Complete eradication of tumor mass.
Corneal insemination of CT26 colon carcinoma cells
Effect of IVIg on colon carcinomaEffect of IVIg on colon carcinomaprimary tumor growing potentialprimary tumor growing potential
After10 daysAfter10 days
Damianovich M, Solomon A S, Blank M, Shoenfeld Y. Ann N Y Acad Sci 2007; 1110:567–577
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Mechanisms for IVIg as Anti- metastatic Agent
Increased secretion of Il-12
Increased activity of NK
Induction of apoptosis in tumor cells
Direct binding - cytostatic (cytotoxic)?
- c’ dependent?
Anti-MMP-9,Cathepsin D
Anti –VEGF
Anti –Blyss ( BAFF)
Yehuda Shoenfeld, MD,FRCP ( Hon.)
ConclusionsGammaGamma--globulins from an globulins from an IVIgIVIg preparation preparation
contain a subcontain a sub--fraction of fraction of antianti--VEGF AbsVEGF Abs with a with a possible antipossible anti--angiogenicangiogenic activityactivity
VEGF specific activity of IVIg may VEGF specific activity of IVIg may suggest suggest by which IVIg may suppress by which IVIg may suppress a new action mechanisma new action mechanism
autoimmune diseasesautoimmune diseasesand some and some cancer
IVIgIVIg
Yehuda Shoenfeld, MD,FRCP ( Hon.)
Immunomodulation with subcutaneous Ig
2010
Yehuda Shoenfeld, MD,FRCP ( Hon.)
BAFF, a New Target for Intravenous BAFF, a New Target for Intravenous Immunoglobulin in Autoimmunity and Immunoglobulin in Autoimmunity and
CancerCancerLe Pottier L, Bendaoud B, Dueymes M, Daridon C, Youinou P, ShoenLe Pottier L, Bendaoud B, Dueymes M, Daridon C, Youinou P, Shoenfeld Y, feld Y,
Pers JO. Pers JO. J Clin Immunol. 2007J Clin Immunol. 2007
The excess in serum level and/or tissue production of BAFF in:
SLE (Zhang J, et al. Cutting edge: A role for B lymphocyte stimulator in systemic lupus erythematosus. J Immunol 2001; 166: 6–10)
SSc (Matsushita T, et al. Elevated serum BAFF levels in patients with systemic sclerosis: Enhanced BAFF signaling in systemic sclerosis B lymphocytes. Arthritis Rheum 2006; 54: 192–201)
MS(Thangarajh M, et al. Expression of B-cell-activating factor of the TNF family (BAFF) and its receptors in multiple sclerosis. J Neuroimmunol 2004; 152:183–190)
B-CLL (Novak AJ, et al. Aberrant expression of B lymphocyte stimulator by B chronic lymphocytic leukemia cells: A mechanism for survival. Blood 2002; 100: 2973–2979)
Yehuda Shoenfeld, MD,FRCP ( Hon.)
BAFF, a new target for intravenous immunoglobulin in autoimmunity and
cancer. Le Pottier L, Bendaoud B, Dueymes M, Daridon C, Youinou P, Le Pottier L, Bendaoud B, Dueymes M, Daridon C, Youinou P,
Shoenfeld Y, Pers JO. J Clin Immunol. 2007 ;27 : 257Shoenfeld Y, Pers JO. J Clin Immunol. 2007 ;27 : 257--265265
Nonglycosylated recombinant BAFF, glycosylated affinity-purified BAFF, and recombinant APRIL (but not TNFalpha), were recognized by certain IgG in IVIg, and their F(ab')(2) fragments.
The presence of anti-BAFF and anti-APRIL Abs in IVIg.
IVIG as Anti BLISS ( BAFF)(Functional)
J Clin Immunol 2007
Negi V et al., J Clin Immunol 2007
Anti-Mechanisms of IVIG
3/17/2012 54Confidential - not to be distributed without prior approval
Yehuda Shoenfeld, MD,FRCP ( Hon.)
ADVERSE EFFECTS AND VIRAL SAFETY OF INTRAVENOUS IMMUNOGLOBULIN THERAPY
IN 56 PATIENTS WITH AUTOIMMUNE DISEASES
Yaniv Sherer, Yair Levy, Pnina Langevitz, Fabrizio Fabbrizzi, Yehuda Shoenfeld
Department of Medicine ‘B’ and Center of Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, and Sackler Faculty of Medicine, Tel-Aviv
University, Israel Pharmacology 2001; 62: 133-137
Yehuda Shoenfeld, MD,FRCP ( Hon.)
CONCLUSIONS: IVIg- the myth and reality
IVIG is effective in autoimmune conditions –multiple mechanisms
IVIg anti -cancer effects in; melanoma, carcinoma, sarcoma and lymphoma
IVIG representing the innate immune system affect tumors by diverse mechanisms
IVIG
Gallileo
Einstein
Five Jews change the way we see the world:Moses: ‘’the Law is everything.’’
Jesus: ‘’Love is everything.’’Marx: ‘’Money is everything.’’
Freud: ‘’Sex is everything.’’Einstein: ‘’Everything is relative.’’