mechanisms in autoimmunity and cancer

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


Future Congresses


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.


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


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.


Paul Imbach

IVIGWiskott Aldrich

Lancet 1981;1-1228-30IVIG in ITP


Immune thrombocytopenia (ITP)

ITP is an autoimmune disease due to autoantibody to endogenous platelets

Causes plateletdestruction bymacrophagesand bleeding


Michel .D.Kazatchkine

NEJM2001;345;747


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


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.


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


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

)


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


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


AIM :To evaluate theTo evaluate theefficacy of the efficacy of the

antianti--dsDNA antidsDNA anti--idiotypesidiotypesenrichedenriched IVIG IVIG

B.Gilburde

M.Blank


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


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


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

*


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:


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


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


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


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


IVIg: Prevention of Melanoma Metastases

Gamma-globulin inhibits tumor spread in miceYehuda Shoenfeld and Pnina Fishman

International immunology 11: 1247 - 1251, 1999


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


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


IVIg: Prevention of Tumor foci the Peritoneum


IVIg: Prevention of Lung Sarcoma Metastases


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


•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


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)


Shrinkage of Melanoma Metastases Following High dose Intravenous Immunoglobulin Treatment

Shoenfeld Y, Levy Y, Fishman P. IMAJ 3; 698-699, 2001

Human Experience


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


IVIG 25mg/mlIVIG 25mg/ml ControlControl

IVIG Exerts Apoptotic Effect on Nb2-11c Lymphoma cells


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 ?


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


Abso

rban

ce (4

50nm

)


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


Abso

rban

ce (4

50nm

)


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


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


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


Injection of bFGF

VEGF

IVIG as an anti VEGF-Arei Solomon @Y Shoenfled


IVG & bFGF

VEGF

IVIG


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

http://ccbc.unc.edu/faculty/cell_molecular_physiology/james_faber/cover.jpg


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


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)


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


Immunomodulation with subcutaneous Ig

2010


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)


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


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


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.’’

mechanisms in autoimmunity and cancer

Health & Medicine

frcp hon

yehuda shoenfeldmd

shoenfeld ylupus

treatment courses

treatment of sle patientsused

sle patients witha study

pharmaceutical companies

blood donation