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PLENARY PAPER
From Service d'Oncologie Médicale et Maladies du
Sang et Laboratoire d'Immunologie, Centre Hospitalier Régional
et Universitaire de Tours and UPRES-EA 3249 "Cellules
hématopoïétiques, hémostase et greffe,"
Université de Tours; and Service d'Hématologie, Centre
Hospitalier Lyon-Sud et Centre Jean Bernard, Le Mans, France.
Given that the Fc Rituximab (Mabthera, Rituxan) is a chimeric
anti-CD20 immunoglobulin G1 (IgG1) monoclonal antibody consisting of
human In vitro studies suggest that rituximab induces lymphoma cell lysis in
vitro through antibody-dependent cell-mediated cytotoxicity (ADCC),11,12 complement-dependent
cytotoxicity,11,13,14 or direct signaling leading to
apoptosis.15,16 ADCC is an important effector mechanism in
the eradication of intracellular pathogens and tumor cells. It requires
leukocyte receptors for the Fc portion of IgG (Fc Patients and treatment
Monitoring and end points
The primary efficacy end point was the objective response rate, ie, the proportion of patients achieving either complete remission (CR), unconfirmed CR (CRu), or partial response (PR) according to the criteria recently proposed by an international expert committee.28 Clinical response was evaluated at days 50 and 78. Only the maximum response was taken into account, and that assessment time point was named M2. All patients were evaluated for progression at 1 year (M12). Patients in CR or CRu with disappearance of bone marrow infiltration at M2 and reappearance of lymphoma cells in bone marrow at M12 were considered "progressive"; patients in PR with negative bone marrow biopsy at M2 and positive biopsy at M12 were considered in PR. Molecular analysis of the BCL2-JH gene rearrangement was performed by polymerase chain reaction (PCR), as previously described,5 on a lymph node obtained at diagnosis and on both peripheral blood and bone marrow at diagnosis, M2, and M12. FCGR3A-158V/F genotyping Of the 50 patients included in the clinical trial, one patient was excluded after histologic review. Forty-nine patients were therefore available for FCGR3A genotype analysis. All samples were analyzed in the same laboratory, and the DNA was extracted using standard procedures. DNA was isolated from peripheral blood (n = 46) or bone marrow (n = 3). Genotyping of FCGR3A-158V/F polymorphism was performed as described by Koene et al23 using a nested PCR followed by allele-specific restriction enzyme digestion. Briefly, 2 FCGR3A-specific primers (5'-ATATTTACAGAATGGCACAGG-3', 5'-GACTTGGTACCCAGGTTGAA-3') (Eurobio, Les Ulis, France) were used to amplify a 1.2 kilobase fragment containing the polymorphic site. The initial PCR assay was performed with 1.25 µg genomic DNA, 200 ng of each primer, 200 µM of each deoxyribonucleoside triphosphate (dNTP) (MBI Fermentas, Vilnius, Lithuania), and 1 U Taq DNA polymerase (Promega, Charbonnière, France) as recommended by the manufacturer. This first PCR consisted of 10 minutes at 95°C, then 35 cycles (each consisting of steps at 95°C for 1 minute, 57°C for 1.5 minutes, and 72°C for 1.5 minutes), and 8 minutes at 72°C to achieve complete extension. The second PCR used primers (5'-ATCAGATTCGATCCTACTTCTGCAGGGGGCAT-3', 5'-ACGTGCTGAGCTTGAGTGATGGTGATGTTCAC-3') (Eurobio) amplifying a 94 base pair (bp) fragment and creating an NlaIII restriction site only in the FCGR3A-158V allele. This nested PCR was performed with 1 µL of the amplified DNA, 150 ng of each primer, 200 µM of each dNTP, and 1 U of Taq DNA polymerase. The first cycle consisted of 5 minutes at 95°C, then 35 cycles (each consisting of steps at 95°C for 1 minute, 64°C for 1 minute, and 72°C for 1 minute), and 9.5 minutes at 72°C to complete extension. The amplified DNA (10 µL) was then digested with 10 U NlaIII (New England Biolabs, Hitchin, England) at 37°C for 12 hours and separated by electrophoresis on 8% polyacrylamide gel. After staining with ethidium bromide, DNA bands were visualized under UV light. For homozygous FCGR3A-158F patients, only one undigested band (94 bp) was visible. Three bands (94 bp, 61 bp, and 33 bp) were seen in heterozygous individuals, whereas for homozygous FCGR3A-158V patients only 2 digested bands (61 bp and 33 bp) were obtained.FCGR2A-131H/R genotyping Genotyping of FCGR2A-131H/R consisted of PCR followed by an allele-specific restriction enzyme digestion, according to Liang et al.29 The sense primer (5'-GGAAAATCCCAGAAATTCTCGC-3') (Eurobio) was modified to create a BstUI restriction site, in case of an R allele, while the antisense primer (5'-CAACAGCCTGACTACCTATTACGCGGG-3') (Eurobio) was modified to carry a second BstUI restriction site that served as an internal control. PCR amplification was performed in a 50 µL reaction with 1.25 µg genomic DNA, 170 ng of each primer, 200 µM of each dNTP, 0.5 U Taq DNA polymerase, and the manufacturer's buffer. The first cycle consisted of 3 minutes at 94°C followed by 35 cycles (each consisting of 3 steps at 94°C for 15 seconds, 55°C for 30 seconds, and 72°C for 40 seconds) and 7 minutes at 72°C to complete extension. The amplified DNA (7 µL) was then digested with 20 U BstUI (New England Biolabs) at 60°C for 12 hours. Further analysis was performed as described for FCGR3A genotyping. The FCGR2A-131H and -131R alleles were visualized as 337 bp and 316 bp DNA fragments, respectively.Statistical analysis The clinical and laboratory characteristics and the clinical and molecular responses of the patients in the different genotypic groups were compared using the Fisher exact test. A logistic regression analysis including sex, age (> or 60 years), number of extranodal sites involved ( or < 2), bone marrow involvement,
BCL2-JH rearrangement status at diagnosis, and
FCGR3A genotype was used to identify independent prognostic
variables influencing the clinical and molecular responses.
Progression-free survival was calculated using the method of Kaplan and
Meier30 and was measured from the start of treatment until
progression, relapse, or death. Comparison of the progression-free
survival by FCGR3A genotype was performed using the log-rank
test. The significance level was P < .05.
Clinical response Of the 49 patients tested for the FCGR3A-158V/F polymorphism, 10 (20%) and 17 (35%) were homozygous for FCGR3A-158V and FCGR3A-158F, respectively, and 22 (45%) were heterozygous. The 3 groups were not different in terms of sex, disease stage, bone marrow involvement, number of extranodal sites involved, or presence of BCL2-JH rearrangement in peripheral blood and bone marrow at diagnosis (Table 1). No difference was found when homozygous FCGR3A-158V patients were compared with FCGR3A-158F carriers (FCGR3A-158F homozygous and heterozygous patients) or when homozygous FCGR3A-158F patients were compared with FCGR3A-158V carriers (FCGR3A-158V homozygous and heterozygous patients). The objective response rate at M2 was 100% (CR + CRu = 40%), 70% (CR + CRu = 29%), and 64% (CR + CRu = 18%) in FCGR3A-158V homozygous, FCGR3A-158F homozygous, and heterozygous patients, respectively (P = .09). A significant difference in objective response rate was observed between FCGR3A-158V homozygous patients and FCGR3A-158F carriers, with a 67% (CR + CRu = 23%) objective response rate for this latter group (relative risk = 1.5; 95% [confidence interval] CI, 1.2-1.9; P = .03) (Table 2). No difference was observed between FCGR3A-158F homozygous patients and FCGR3A-158V carriers. At M12, the objective response rate was 90% (CR + CRu = 70%), 59% (CR + CRu = 35%), and 45% (CR + CRu = 32%) in FCGR3A-158V homozygous, FCGR3A-158F homozygous, and heterozygous patients, respectively (P = .06). The difference in objective response rate was still present 1 year after treatment between the FCGR3A-158V homozygous group and FCGR3A-158F carriers, with a 51% (CR + CRu = 33%) objective response rate for this latter group (relative risk = 1.7; 95% CI, 1.2-2.5; P = .03). The logistic regression analysis showed that the homozygous FCGR3A-158V genotype was the only predictive factor for clinical response both at M2 (P = .02) and at M12 (P = .01). The progression-free survival at 3 years (median follow-up 35 months; range 31-41) (Figure 1) was 56% in FCGR3A-158V homozygous patients and 35% in FCGR3A-158F carriers (nonsignificant). Of the 45 patients analyzed for FCGR2A-131H/R polymorphism, 9 (20%) and 13 (29%) were homozygous for FCGR2A-131R and FCGR2A-131H, respectively, while 23 (51%) were heterozygous. There was no difference in the characteristics at inclusion or clinical response to rituximab treatment for these 3 groups or for homozygous FCGR2A-131H patients and FCGR2A-131R carriers or for homozygous FCGR2A-131R patients and FCGR2A-131H carriers (data not shown).
Molecular response At diagnosis, BCL2-JH rearrangement was detected in both peripheral blood and in bone marrow in 30 (64%) patients, enabling further follow-up. Twenty-five patients (6 FCGR3A-158V homozygous patients and 19 FCGR3A-158F carriers) and 23 patients (6 FCGR3A-158V homozygous patients and 17 FCGR3A-158F carriers) were analyzed for BCL2-JH rearrangement in both peripheral blood and bone marrow at M2 and at M12 (Table 3). At M2, a cleaning of BCL2-JH rearrangement was observed in 3 of 6 of the FCGR3A-158V homozygous patients and in 5 of 19 of the FCGR3A-158F carriers (nonsignificant). In contrast, the rate of BCL2-JH rearrangement cleaning at M12 was higher (5 of 6) in the FCGR3A-158V homozygous patients than in the FCGR3A-158F carriers (5 of 17) (relative risk = 2.8; 95% CI, 1.2-6.4; P = .03). The logistic regression analysis showed that the FCGR3A-158V homozygous genotype was the only factor associated with a greater probability of exhibiting BCL2-JH rearrangement cleaning at M12 (P = .04). The single homozygous FCGR3A-158V patient still presenting with BCL2-JH rearrangement in peripheral blood and bone marrow at M12 was in CR 23 months after rituximab treatment. In contrast, the molecular responses at M2 and M12 were not influenced by the FCGR2A-131H/R polymorphism (data not shown).
Because of the increasing use of rituximab in B-cell
lymphoproliferative malignancies, enhanced understanding of treatment failures and of the mode of action of rituximab is required. Given the
expected role of NK cell and macrophage Fc This is the first report of an easily assessable genetic predictive
factor for both clinical and molecular responses to rituximab. However,
the genetic association does not demonstrate that the mode of action of
rituximab involves Fc Several in vitro studies argue in favor of direct involvement of
FCGR3A-158V/F polymorphism. First, Koene et al23
have shown that the previously reported differences in IgG binding
among the 3 Fc The in vitro studies suggest a "gene-dose" effect with a level of IgG1 binding to NK cells from FCGR3A heterozygous donors intermediate between that observed with NK cells from FCGR3A-158V and FCGR3A-158F homozygotes.23 However, the clinical response of heterozygous patients appears similar to that of FCGR3A-158F homozygous patients. Further studies with larger groups of patients will be required to conclude against a "gene-dose" effect in vivo. Because Fc Taken together, those results will enable new therapeutic strategies against B lymphoproliferative disorders based upon prior determination of the patient's FCGR3A genotype. Because this polymorphism has the same distribution in various ethnic populations, including blacks and Japanese, such a strategy may be applied worldwide.23,35,36 Furthermore, such a pharmacogenetic approach may also be applied to other intact humanized IgG1 antibodies used in the treatment of B-cell malignancies, such as Campath-1H, or those used in the treatment of other malignancies, such as trastuzumab (Herceptin). Even more generally, this approach may apply to other intact humanized IgG1 developed to deplete target cells.
The authors thank Dr S. Iochman for her technical help in molecular biology assays and Prof G. Thibault and Prof G Paintaud for their critical review of the manuscript.
Submitted June 8, 2001; accepted October 2, 2001.
Supported by grants from the Fondation Langlois and the Comité de l'Indre de la Ligue Nationale Contre le Cancer.
The publication costs of this article were defrayed in part by page charge payment. Therefore, and solely to indicate this fact, this article is hereby marked "advertisement" in accordance with 18 U.S.C. section 1734.
Reprints: Hervé Watier, Laboratoire d'Immunologie, Centre Hospitalier Universitaire, 2 boulevard Tonnellé, 37044 Tours Cedex, France; e-mail: watier{at}med.univ-tours.fr.
1.
Maloney DG, Liles TM, Czerwinski DK, et al.
Phase I clinical trial using escalating single-dose infusion of chimeric anti-CD20 monoclonal antibody (IDEC-C2B8) in patients with recurrent B-cell lymphoma.
Blood.
1994;84:2457-2466 2. McLaughlin P, Grillo-Lopez AJ, Link BK, et al. Rituximab chimeric anti-CD20 monoclonal antibody therapy for relapsed indolent lymphoma: half of patients respond to a four-dose treatment program. J Clin Oncol. 1998;16:2825-2833[Abstract].
3.
Maloney DG, Grillo-Lopez AJ, White CA, et al.
IDEC-C2B8 (Rituximab) anti-CD20 monoclonal antibody therapy in patients with relapsed low-grade non-Hodgkin's lymphoma.
Blood.
1997;90:2188-2195
4.
Hainsworth JD, Burris HA III, Morrissey LH, et al.
Rituximab monoclonal antibody as initial systemic therapy for patients with low-grade non-Hodgkin lymphoma.
Blood.
2000;95:3052-3056
5.
Colombat P, Salles G, Brousse N, et al.
Rituximab (anti-CD20 monoclonal antibody) as first-line therapy of follicular lymphoma patients with low tumor burden: clinical and molecular evaluation.
Blood.
2001;97:101-106
6.
Coiffier B, Haioun C, Ketterer N, et al.
Rituximab (anti-CD20 monoclonal antibody) for the treatment of patients with relapsing or refractory aggressive lymphoma: a multicenter phase II study.
Blood.
1998;92:1927-1932
7.
Foran JM, Rohatiner AZ, Cunningham D, et al.
European phase II study of rituximab (chimeric anti-CD20 monoclonal antibody) for patients with newly diagnosed mantle-cell lymphoma and previously treated mantle-cell lymphoma, immunocytoma, and small B-cell lymphocytic lymphoma.
J Clin Oncol.
2000;18:317-324 8. Anderson DR, Grillo-Lopez A, Varns C, Chambers KS, Hanna N. Targeted anti-cancer therapy using rituximab, a chimaeric anti-CD20 antibody (IDEC-C2B8) in the treatment of non-Hodgkin's B-cell lymphoma. Biochem Soc Trans. 1997;25:705-708[Medline] [Order article via Infotrieve]. 9. Vose J, Link B, Grossbard M, et al. Phase II study of rituximab in combination with CHOP chemotherapy in patients with previously untreated intermediate or high-grade non-Hodgkin's lymphoma (NHL). Ann Oncol. 1999;10:58a.
10.
Berinstein NL, Grillo-Lopez AJ, White CA, et al.
Association of serum Rituximab (IDEC-C2B8) concentration and anti-tumor response in the treatment of recurrent low-grade or follicular non- Hodgkin's lymphoma.
Ann Oncol.
1998;9:995-1001 11. Harjunpaa A, Junnikkala S, Meri S. Rituximab (anti-CD20) therapy of B-cell lymphomas: direct complement killing is superior to cellular effector mechanisms. Scand J Immunol. 2000;51:634-641[CrossRef][Medline] [Order article via Infotrieve].
12.
Reff ME, Carner K, Chambers KS, et al.
Depletion of B cells in vivo by a chimeric mouse human monoclonal antibody to CD20.
Blood.
1994;83:435-445
13.
Idusogie EE, Presta LG, Gazzano-Santoro H, et al.
Mapping of the C1q binding site on rituxan, a chimeric antibody with a human IgG1 Fc.
J Immunol.
2000;164:4178-4184
14.
Golay J, Zaffaroni L, Vaccari T, et al.
Biologic response of B lymphoma cells to anti-CD20 monoclonal antibody rituximab in vitro: CD55 and CD59 regulate complement-mediated cell lysis.
Blood.
2000;95:3900-3908
15.
Shan D, Ledbetter JA, Press OW.
Apoptosis of malignant human B cells by ligation of CD20 with monoclonal antibodies.
Blood.
1998;91:1644-1652 16. Shan D, Ledbetter JA, Press OW. Signaling events involved in anti-CD20-induced apoptosis of malignant human B cells. Cancer Immunol Immunother. 2000;48:673-683[CrossRef][Medline] [Order article via Infotrieve].
17.
Hooijberg E, Sein JJ, van den Berk PC, et al.
Eradication of large human B cell tumors in nude mice with unconjugated CD20 monoclonal antibodies and interleukin 2.
Cancer Res.
1995;55:2627-2634 18. Funakoshi S, Longo DL, Murphy WJ. Differential in vitro and in vivo antitumor effects mediated by anti-CD40 and anti-CD20 monoclonal antibodies against human B-cell lymphomas. J Immunother Emphasis Tumor Immunol. 1996;19:93-101[Medline] [Order article via Infotrieve]. 19. Clynes RA, Towers TL, Presta LG, Ravetch JV. Inhibitory Fc receptors modulate in vivo cytoxicity against tumor targets. Nat Med. 2000;6:443-446[CrossRef][Medline] [Order article via Infotrieve].
20.
Fijen CA, Bredius RG, Kuijper EJ, et al.
The role of Fc
21.
Dijstelbloem HM, Scheepers RH, Oost WW, et al.
Fc
22.
Myhr KM, Raknes G, Nyland H, Vedeler C.
Immunoglobulin G Fc-receptor (Fc
23.
Koene HR, Kleijer M, Algra J, et al.
Fc
24.
Wu J, Edberg JC, Redecha PB, et al.
A novel polymorphism of Fc
25.
Sondermann P, Huber R, Oosthuizen V, Jacob U.
The 3.2-A crystal structure of the human IgG1 Fc fragment-Fc
26.
Harris NL, Jaffe ES, Stein H, et al.
A revised European-American classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group.
Blood.
1994;84:1361-1392
27.
Brice P, Bastion Y, Lepage E, et al.
Comparison in low-tumor-burden follicular lymphomas between an initial no-treatment policy, prednimustine, or interferon alfa: a randomized study from the Groupe d'Etude des Lymphomes Folliculaires. Groupe d'Etude des Lymphomes de l'Adulte.
J Clin Oncol.
1997;15:1110-1117
28.
Cheson BD, Horning SJ, Coiffier B, et al.
Report of an international workshop to standardize response criteria for non-Hodgkin's lymphomas. NCI Sponsored International Working Group.
J Clin Oncol.
1999;17:1244
29.
Jiang XM, Arepally G, Poncz M, McKenzie SE.
Rapid detection of the Fc 30. Kaplan E, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc. 1958;53:457-481[CrossRef].
31.
de Haas M, Koene HR, Kleijer M, et al.
A triallelic Fc
32.
Peltz GA, Grundy HO, Lebo RV, Yssel H, Barsh GS, Moore KW.
Human Fc
33.
Schnackenberg L, Flesch BK, Neppert J.
Linkage disequilibria between Duffy blood groups, Fc
34.
Shields RL, Namenuk AK, Hong K, et al.
High resolution mapping of the binding site on human IgG1 for Fc
35.
Leppers-van de Straat FG, van der Pol W, Jansen MD, et al.
A novel PCR-based method for direct Fc
36.
Lehrnbecher T, Foster CB, Zhu S, et al.
Variant genotypes of the low-affinity Fc
© 2002 by The American Society of Hematology.
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