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8/9/2019 Infectia Cu Virus Herpetic a Creierului
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H ERPES S IMPLEX VIRUSINFECTIONS OF THE BRAIN:
F ROM ENCEPHALITIS TO GENETHERAPY
RJ Whitley(USA)
1999 The International Herpes Management Forum, all
rights reserved .
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VIRAL GENE TRANSFER SYSTEMSVIRAL GENE TRANSFER SYSTEMS
Retroviruses
Adenovirus
Adeno-associated virus (AAV)
Herpes simplex virusVaccinia virus
Polio virus
Sindbis and other R A viruses
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HERPES SIMPLEX ENCEPHALITISHERPES SIMPLEX ENCEPHALITIS
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OUTCOME OF PATIENTS WITH HSEOUTCOME OF PATIENTS WITH HSENO OR INEFFECTIVE THERAPY NO OR INEFFECTIVE THERAPY
%Patients
Mo ta!it" Mo #i$it" S& 'i'o s
())*ea$
Se'e e
Mo$e ate
No +a! Mi!$
,)-).)
/)0)1)2)3)
())
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WHY AN HSV VECTOR4WHY AN HSV VECTOR4
eurovirulent
Recombinants!revertants
P os
"ar#ets neuronal tissue
$an remove neurovirulence #ene(s)% & thymidine 'inase
& *+,
ar#e codin# capacity
Cons
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GENETICALLY ENGINEERE* HSV:GENETICALLY ENGINEERE* HSV:POSSIBLE APPLICATIONSPOSSIBLE APPLICATIONS
Attenuated vaccine
"umor therapy (i+e+ #lioblastoma) .orei#n #ene expression
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HSV THERAPY OF BRAIN TUMORS:HSV THERAPY OF BRAIN TUMORS:HISTORY HISTORY
(,0) % Passa#ed /ild-type viruses retainvirulence 0or surroundin# normal brain tissue(,,( % "hymidine-'inase ne#ative virus lac'ssi#ni1cant oncolytic activity(,,3 &(,,/ % HSV deletions in ( *+, #enestudied 0or sa0ety and e2cacy(,,- % Human trials
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HSV5( GENOMEHSV5( GENOME
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( 2160 Gene2160 Gene
ocated in the inverted lon# repeats o0 the 3 L se#ment4iploid #ene5 re#ulated as a #ene67$ rich5 promoter located in the 8a9 se:uenceProtein product is ;< aa lon#5 molecular /ei#ht* =4a$onsists o0 a lar#e amino terminus domain ( ,>aa)? a lin'er!s/ivel re#ion o0 aa Ala-"hr-Pro
repeated @ times? and a carboxy terminaldomain o0 *aa
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FUNCTIONS OF THEFUNCTIONS OF THE ( 2160 GENE2160 GENE
*+, #ene encodes 0or the neurovirulence o0 HSVViruses de0ective in *+, #ene re:uire anincrease in
dose over /ild type virus to 'ill animals byintracerebralor peripheral inoculationViruses de0ective in *+, #ene have diminshedcapacity to establish latency and be reactivated
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ABLATION OF HSVABLATION OF HSVNEUROVIRULENCENEUROVIRULENCE
VIRUSHSV- (.)4eletion o0 ( *+,Stop codon insert
into *+,HSV- (.) repaired
PFU L* 0)@@@
B @@@ @@@B @ @@@ @@@
@@
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MALIGNANT GLIOBLASTOMAMALIGNANT GLIOBLASTOMA
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CENTRAL NERVOUS SYSTEMCENTRAL NERVOUS SYSTEMTUMORSTUMORS
Cali#nant #liomas are the most common $ StumorB ,?@@@ ne/ cases annually (3SA)
"herapies & cytoreductive? radiation?chemotherapy &have not chan#ed outcomeCedian survival is year
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EXPERIMENTAL MURINE MO*ELEXPERIMENTAL MURINE MO*EL
Human tumors studied in mice that haveno eDective immune response (S$E4 mice)Emmune competent mice studied 0orcyto'ine expression to document immuneresponse
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BRAIN TUMOR MO*ELSBRAIN TUMOR MO*ELS
Entracranial% S$E4 mice& C", >C6 (mouse)
& 3;, C6 (human)
& 4,*C6 (human)Entracranial% immune competent mice & 6 ;< (mouse)EnFect cells? establish tumor (, days)? inoculate vector
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HUMAN TUMOR 7*01MG8 IN SCI*HUMAN TUMOR 7*01MG8 IN SCI*MOUSEMOUSE
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HISTOPATHOLOGY OF *01MGHISTOPATHOLOGY OF *01MGTUMOR IN SCI* MOUSETUMOR IN SCI* MOUSE
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HSV R1)), TREATMENT OF *01MG5HSV R1)), TREATMENT OF *01MG5BEARING SCI* MIICEBEARING SCI* MIICE
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HSV R1)), TREATMENT OFHSV R1)), TREATMENT OFU30(MG5BEARING SCI* MICEU30(MG5BEARING SCI* MICE
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ABSENCE OF TUMOR IN LONG5TERM SURVIVORSABSENCE OF TUMOR IN LONG5TERM SURVIVORS
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HSV THERAPY OF HUMAN TUMORSHSV THERAPY OF HUMAN TUMORSIN SCI* MICE: SUMMARY IN SCI* MICE: SUMMARY
Survival prolon#edon#-term survivors are disease 0reeHSV 4 A detected by P$R in brain
tissue$an /e do betterG
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FOREIGN GENE EXPRESSION IN HSV:FOREIGN GENE EXPRESSION IN HSV:RATIONALERATIONALE
o sin#le modality o0 therapy has proven to beeDective3nli'ely to be able to inFect enou#h virus to
in0ect all tumor cells.orei#n #ene expression could%& modulate immune response& introduce en ymes to activate prodru#s& introduce tumor suppressor #enes
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SELECTE* CYTO9INE GENESSELECTE* CYTO9INE GENES
Inse t E e;tsE -; Re#ulates "h cellsE -* Re#ulates "h; cells? I cells? and
macropha#es? enhances diDerentiation o0
" cells and promotes anti#lioma eDectsE -, Emmune-enhancementE - @ 4o/n re#ulates "h cyto'ine expression?
promotes tumor #ro/th
SCHEMATIC *IAGRAM OFSCHEMATIC *IAGRAM OF 21602160 HSVHSV
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SCHEMATIC *IAGRAM OFSCHEMATIC *IAGRAM OF (( 21602160 HSVHSVEXPRESSING INTERLEU9INSEXPRESSING INTERLEU9INS
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HSV CYTO9INE EXPRESSIONHSV CYTO9INE EXPRESSION ININVITROVITRO
C"to
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HSV5INTERLEU9IN TREATE* C0.BL /HSV5INTERLEU9IN TREATE* C0.BL /MICE BEARING GL53/( GLIOMASMICE BEARING GL53/( GLIOMAS
IMMUNE5RELATE* INFLAMMATORY CELLSIMMUNE5RELATE* INFLAMMATORY CELLS
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IMMUNE5RELATE INFLAMMATORY CELLSIMMUNE5RELATE INFLAMMATORY CELLSINFILTRATING GL53/( GLIOMAS IN C0.BL /INFILTRATING GL53/( GLIOMAS IN C0.BL /
MICE . *AYS AFTER HSV THERAPY MICE . *AYS AFTER HSV THERAPY
T>e a?" C*1@ C*-@Ma; o?>a es
T ;e!!s T ;e!!s
Saline @+, L + L + + L*+;
R < < *+K L, @+; 7*+; >+; L,
RK @< ; + L*+K ; +K L*+*(E -*)
RK @K *+K L + +K 7 + +K L
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HISTOPATHOLOGIC CHANGES FOLLOWHISTOPATHOLOGIC CHANGES FOLLOWHSV CYTO9INE EXPRESSION IN TUMORSHSV CYTO9INE EXPRESSION IN TUMORS
7216058 IL51 IL5()
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PRIMUM NON NOCEREPRIMUM NON NOCERE
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HUMAN GLIOBLASTOMAHUMAN GLIOBLASTOMA
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PHASE ( TRIAL OF GENETICALLY ENGINEERE*PHASE ( TRIAL OF GENETICALLY ENGINEERE*HSV: THERAPY OF GLIOBLASTOMAHSV: THERAPY OF GLIOBLASTOMA
$onstruct% 6;@ac's both copies o0 *+,Ribonucleotide reductase #ene
mutated /ith acM insertion$annot replicate in post-mitotic cells(e+#+ neurons)
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PRE5CLINICAL SAFETY OF G53).PRE5CLINICAL SAFETY OF G53).
6enetic stability% miceatency and reactivation% mice and rabbitseurovirulence% Aotus nancymai
VAGINAL INOCULATION OF WIL*5TYPE ORVAGINAL INOCULATION OF WIL*5TYPE OR
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VAGINAL INOCULATION OF WIL*5TYPE ORVAGINAL INOCULATION OF WIL*5TYPE ORGENETICALLY ENGINEERE* HSV 7AOTUS8GENETICALLY ENGINEERE* HSV 7AOTUS8
A *OSE ESCALATING PHASE ( STU*Y OF AA *OSE ESCALATING PHASE ( STU*Y OF A
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GENETICALLY ENGINEERE* HSV5( IN THEGENETICALLY ENGINEERE* HSV5( IN THETREATMENT OF MALIGNANT GLIOMATREATMENT OF MALIGNANT GLIOMA
James Car'ert? C+4+ Cichael Cedloc'? C+4+3niversity o0 Alabama at 6eor#eto/n 3niversityIirmin#ham? Iirmin#ham? Cedical $enter? Alabama
Washin#ton? 4$
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STU*Y OB ECTIVESSTU*Y OB ECTIVES
PRIMARY OB ECTIVE "o determine the sa0ety and tolerance o0 stereotacticintracerebral inFection o0 escalatin# doses o0 6;@
SECON*ARY OB ECTIVE "o obtain preliminary in0ormation about the potentialbene1t o0 6;@ in the treatment o0 patients /ithrecurrent mali#nant #liomas (reduction in tumor
volume)
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STU*Y *ESIGNSTU*Y *ESIGN
Patients /ith mali#nant #lioma /ho have 0ailedsur#ery!biopsy and radiation%
&may have had chemotherapy or other treatment
Cust have pro#ression or recurrence by CRE atleast * /ee's a0ter radiation
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PHASE ( CLINICAL TRIAL OF G53).PHASE ( CLINICAL TRIAL OF G53).
Patients *ose Vo!&+e7+!8Lo;a!
x @ @+x @ @+x @ K @+x @ K @+x @ > @+
x @ > @+ ,x @ > @+ @
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CLINICAL TRIAL SUMMARYCLINICAL TRIAL SUMMARY
* patients treated over months%
& no patient developed encephalitis& tumor re#ression 0our patients
(:uantitative CRE)& one death (secondary to tumor)& next sta#e /ill involve multiloci inoculation
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FUTURE APPROACHES IN HUMANSFUTURE APPROACHES IN HUMANS
$ombination /ith radiation therapy
Viruses expressin# cyto'ines or other 0orei#n #enes
COMBINATION VIRUS AN*COMBINATION VIRUS AN*
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COMBINATION VIRUS ANCOMBINATION VIRUS ANRA*IATION THERAPY RA*IATION THERAPY
FRACTIONAL TUMOR VOLUME D ()% INITIALFRACTIONAL TUMOR VOLUME D ()% INITIALTUMOR VOLUME U30(MG REGRESSION RATETUMOR VOLUME U30(MG REGRESSION RATE
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TUMOR VOLUME U30(MG REGRESSION RATETUMOR VOLUME U30(MG REGRESSION RATEBASE* ON ENGINEERE* HSV TREATMENTBASE* ON ENGINEERE* HSV TREATMENT
T eat+ent Vi &s ( 7%8 Vi &s 27%8
$ontrol @! (@) @! ; (@)
R" alone ! K ( ) @! ; (@)
Virus !; ( *) ! ; (K)
Virus 7R" !; (, ) >! @ (>@)
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CONTRIBUTING INVESTIGATORSCONTRIBUTING INVESTIGATORS
Uni'e sit" o= A!a#a+aatBi +in >a+Suman Iharana
6 Nancey 6illespie James Car'ert Jac'ie Par'erRichard Whitley
Uni'e sit" o=C>i;a oSunil AdvaniIin He
Iernard Roi manRalph Weichselbaum