PMC:4939752 / 9208-20119 JSONTXT

{"target":"http://pubannotation.org/docs/sourcedb/PMC/sourceid/4939752","sourcedb":"PMC","sourceid":"4939752","source_url":"https://www.ncbi.nlm.nih.gov/pmc/4939752","text":"Development of novel anti-CD20 mAbs\nThe development of anti-CD20 mAbs against lymphoma diseases were started from concept of magic bullets in 1879. The main induction of monoclonal antibodies technology or generation was initiated after the Kohler and Milstein. His scientific work directed to a great expectation that mAbs would provide effective targeted therapy for cancer. Although the CD20 specific antibody B1 (renamed tositumomab) was first discovered in 1981. However rituximab became the first mAb approved by the U.S. Food and Drug Administration (FDA) for use in relapsed and indolent lymphoma [8,20]. It is a chimeric (human-mouse) mAb used to treatment of CD20 positive B-cell malignancies; eg. non-Hodgkin lymphoma and chronic lymphocytic leukemia (CLL) and for some autoimmune diseases including rheumatoid arthritis [8,21]. Rituximab is the first generation CD20 mAb. It can induce complement-dependent cytotoxicity (CDC), antibody-dependent cellular cytotoxicity (ADCC) and direct programmed cell death as well as showed cell growth inhibition [22,23]. It is widely used for lymphoma therapy alone or in combination regimens mainly for relapsed and refractory lymphomas [24,25]. R-CHOP chemotherapy remains the typical regimen for recently diagnosed DLBCL [26–28]. Ibritumomab tiuxetan (Zevalin) and tositumumab (Bexxar) both are murine based mAbs also used as radio-immunotherapeutic agents against indolent NHL and follicular lymphoma (FL) patients respectively [9,10,29]. However, the efficacy of rituximab is modest and often variable especially when used for CLL treatment with an objective response rates ranged between 25% and 35% [30,31]. Despite the unparalleled success of rituximab some patients still failed to respond or more commonly relapsed and become resistant after receiving rituximab administration.\nWhile successes, limitations and elucidations of the mechanism of action of rituximab have increased our understanding or knowledge and helped in our goal to improve the efficacy and decreasing the associated adverse effects as well as providing effective therapies for those patients who have developed resistance to rituximab. The interest in development of anti-CD20 mAbs continues to provide a major focus for scientific and clinical investigators alike and it seems to be highly probable that this research interest will continue to grow as the new generation of anti-CD20 mAbs have developed and tested clinically. Currently, there are several new generation anti-CD20 mAbs have been engineered and/or modified to improve antitumor activity and Fc binding affinity and provide advantages over rituximab that are currently undergoing clinical investigation. They may be grouped in two categories: second or third generation anti-CD20 mAb.\nSecond generation mAbs designed as humanized or fully human with unmodified Fc domain, the purpose of reducing immunogenicity compared to chimeric mAb rituximab. Second generation mAbs include Ocrelizumab, veltuzumab and ofatumumab. Ocrelizumab and veltuzumab are humanized while ofatumumab is fully human antibody. Ocrelizumab (PRO70769, 2H7) is a humanized type I anti-CD20 IgG1 mAb. It has differences in several amino acid positions within the CDRs variable regions of the light and heavy chain as compared to rituximab. Thus it demonstrated superior binding affinity for the low-affinity variants of the FcγRIIIa receptor (CD16). Moreover it showed higher ADCC and lower CDC activity as compared to rituximab toward lymphoid malignancies. Currently, this mAb has been evaluated through a phase I/II study in patients with relapsed/ refractory follicular lymphoma (FL) after rituximab failed therapy and showed superior efficacy and safety [32,33]. Veltuzumab is another humanized type I anti-CD20 IgG1 mAb identical to rituximab with single amino acid substitution (Asp101 instead of Asn101) within the CDR3 of the variable heavy chain resulting showed reduced off-rate [13,34]. It also showed anti-proliferative, apoptotic and ADCC effects in vitro similar to rituximab but this modification results more potent binding avidities and a stronger effects on CDC as compared to rituximab [32,35]. In addition, the administration of very low doses either intravenous or subcutaneous routes it showed a potent anti B-cell lymphoma activity in cynomolgus monkeys (Macaca fascicularis) and reduced tumor growth in mice bearing human B-cell lymphomas [34]. Moreover, it achieves efficient delivery into the blood and pharmacologically active when administration subcutaneously compared to other routes. Of these novel mAbs, ofatumumab is at the most advance stage of clinical development with slow off-rate and high CDC activity. Ofatumumab (OFA) is a fully human type I anti-CD20 IgG1κ mAb. It recognizes an overlapping epitope on the small and big extracellular loop of CD20. Moreover, it showed better complement activation as compared to rituximab against both rituximab sensitive and resistant non-Hodgkin lymphomas cell lines expressing high levels of complement defense proteins and low levels of CD20 antigen which failed to undergo CDC with rituximab [36–42]. In addition, it showed higher potential activity than rituximab because of the high capacity for C1q activation. It also showed better response against relapsed/ refractory FL and successively in a phase I/II dose escalation study with an overall response rate (ORR) of 43% [43]. Importantly, in a phase I/II studies on lymphoma and leukemia (specially on CLL) also showed increased complement activity without further increase in toxicity [40,43]. Possibly, the ofatumumab may be give rises to superior efficacy in combination with chemotherapy for tumor clearance and this is being investigated in ongoing trials in both FL and DLBCL.\nLikewise, the third generation humanized mAbs are modified mAbs in the Fc region. The Fc domain was engineered with the glycol or protein. The main goal of this modification is to improving the therapeutic efficacy in all patients; particularly patients in which expression with low affinity version of the Fc receptor are found on their tumor cells.\nThird generation anti-CD20 mAbs include AME133v, Pro131921 (v114), GA101, R603/EMAB-6 and TRU-015. They are ongoing in early phases of clinical development. AME-133v (LY2469298, ocaratuzumab) is an Fc protein engineered humanized type I IgG1 mAb which currently being evaluated in a Phase I/II dose escalation study in patients with relapsed/refractory follicular B-cell NHL [44]. In vitro study suggested that it has 13 to 20 fold more binding affinity with CD20 and 5–7 fold higher avidity to the low affinity (F/F and F/V) variants of FcγRIIIa receptor thereby improving killing of B-cell NHL ~10 fold as compared to rituximab [44–46]. Although, the clinical trial with AME-133v are currently ongoing and it will need to be compared to rituximab in randomized clinical trials to substantiate its potential clinical advantages. Pro131921 (v114) is derived from 2H7. It is another humanized IgG1 Fc protein engineered antibody and displays 30-fold more binding affinity to the low variant of FcγR (RIIIa: FF or FV) over rituximab [47–49]. In vitro study revealed that it has higher binding affinity showed improved ADCC activity about 10 fold more as compared to rituximab. Although, preclinical studies in non-human primates (cynomolgus monkeys; Macaca fascicularis) revealed that treatment with Pro13192 is associated in a dose-dependent reversible neutropenia and thrombocytopenia [49]. However, Phase I/II clinical studies demonstrated better anti-tumor efficacy in patients with relapsed and /or refractory indolent lymphoma who failed rituximab containing regimens [50]. But, clinical development has been recently terminated due to assess safety of escalating doses of Pro13192 in patients with NHL and CLL. LFB-R603/EMAB-6 (Ublituximab, LFP) is another chimeric glyco-engineered IgG1 mAb showed enhanced FcγRIII affinity. It was raised in rat cell lines YB2/0 using EMABLING technology thus resulting in naturally low fucose contents in its Fc region [51]. LFB-R603/EMAB-6 has similar CDC and PCD activities whereas ADCC response rate found about 35% higher at 50ng/ml while rituximab induced less than 5% at the same concentration in low CD20 expressing CLL cells [51]. Furthermore, preclinical studies also revealed that it can disrupt NF-κB/Snail/RKIP/PTEN/AKT signaling in B-cell NHL cell lines that are resistant to chemotherapy and immuno-chemotherapy [52]. It is currently in a Phase I/II clinical study in CLL. In contrast to the other anti-CD20 mAbs GA101 (RO5072759, obinutuzumab) also known as the gazyva is the first fully humanized type II IgG1 mAb which have glycol-engineered Fc domain with non-fucosylated oligosaccharides to enhance the interaction with FcγRs particularly FcγRIIIa (CD16) therefore showed enhancing ADCC activity compared to other anti-CD20 mAbs [53–56]. Recently (in November 2013) it has FDA approved mAb for use in combination with chlorambucil to treat patients with previously untreated chronic lymphocytic leukemia (CLL). Preclinical studies suggested that the modified Fc region of GA101 improved about 50 fold binding affinity to FcγRIII and 10 to 100 fold increased cell death through ADCC mechanism against CD20 positive NHL cell lines [57–60]. Moreover, in vitro study also demonstrated that modification in elbow hinge regions promotes direct programmed cell death mechanism in several NHL cell lines and primary malignant B-cells [12,49]. However, these modifications result in reduced CDC activity [61]. GA101 has also showed superior therapeutic efficacy in subcutaneous lymphoma xenograft models of diffuse large B-cell lymphoma and mantle cell lymphoma when used as monotherapy or in combination with cyclophosphamide [62–65]. As compared to rituximab GA101 showed significantly superior B-cell depletion not only in peripheral blood but also in spleen and lymph nodes in non-human primates and hCD20 transgenic mice [61,63,64,66–68]. GA101 demonstrated a favorable safety profile with no dose-limiting toxicities during phase I/II study in patients with relapsed/refractory CD20 positive cells including CLL, DLBCL and other NHLs [69]. Moreover, the pharmacokinetics of GA101 is mostly comparable to those of rituximab and dose-dependent. However, the significant inter and intra-patient variabilities have been observed. Therefore, the clinical relevance further will need to be investigation. TRU-015 ((CytoxB20G) is a single chain anti- CD20 molecule that is a small modular immuno-pharmaceutical drug composed of human IgG1 Fc and CH2 and CH3 hinge regions which linked directly to an anti-CD20 specific Fv regions [70–72]. It has high ADCC and low CDC activating potential. It is currently in Phase II clinical development for inflammatory disease is ongoing particularly against rheumatoid arthritis 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