Chapter12: Innovative Aerosol Therapy for Bone Metastasis to the Lung and an Overview of Translational Research
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Description
In this chapter, Dr. Kleinerman describes her work on a novel aerosol therapy for bone metastasis to the lung, weaving in explanations of biological and genetic processes as well as overviews of work in the field.
She explains that her research approach begins with understanding the disease and then she looks for novel alternatives to chemotherapy. She outlines the science involved in this study then sketches the phases of research she developed.
Dr. Kleinerman summarizes how she took basic science and clinical knowledge to development treatment, then gives an overview of her philosophy of translational research and the evolution of this kind of work at MD Anderson.
At the end of this chapter, Dr. Kleinerman talks about the advantages of aerosol therapy for patients.
Identifier
KleinermanES_03_20140604_C12
Publication Date
6-4-2014
City
Houston, Texas
Interview Session
Eugenie Kleinerman, MD, Oral History Interview, June 04, 2014
Topics Covered
The Interview Subject's Story - The ResearcherThe Researcher Overview Definitions, Explanations, Translations Understanding Cancer, the History of Science, Cancer Research The History of Health Care, Patient Care Discovery and Success Offering Care, Compassion, Help Patients
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
Tacey Ann Rosolowski, PhD:
Okay. So we are officially recording now, and the time is eight minutes after ten, and it is the fourth of June, 2014. I’m in the Main Building of the Division of Pediatrics. This is my third session with Dr. Eugenie Kleinerman. Thanks so much for agreeing to see me again.
Eugenie Kleinerman, MD:
A pleasure and honor.
Tacey Ann Rosolowski, PhD:
(laughs) Well, it was really fun to hear the story of MEPACT last time, and we have several other—a few other research areas to cover today, so let’s talk about those. I guess the first one, the intro to the story as we were kind of strategizing before the recorder was on, is you talked about your investigations into the mechanisms of osteosarcoma metastasis, and you mentioned FAS expression. So maybe we could start with that and kind of unfold the story from there.
Eugenie Kleinerman, MD:
Sure. Sure.
Tacey Ann Rosolowski, PhD:
Great.
Eugenie Kleinerman, MD:
The goal of my research has always been let us understand the disease, and then by understanding the biology of the disease, then we can come up with novel ways to treat it that are not chemotherapy, because, as we discussed two sessions ago, chemotherapy is great but we’ve made no progress in twenty-five years. That’s why I’ve started with MEPACT and why I’ve continued. And my goal had been let us understand why is a bone cell growing in the lung. The majority of patients with osteosarcoma die of lung metastases. They have lung metastases and metastases nowhere else. I mean, in my thirty years, I’ve had maybe a couple patients that have brain metastases, one patient had a metastasis to the kidney, one in the pancreas, but it’s always the lung. So what struck me is what is it about a bone cell that will allow it to grow in the lung or not grow in the lung. And in thinking about this and reading, I came across research on a death receptor protein called Fas, F-a-s, and this is a protein that is expressed on cells, and if it comes in contact with another cell, an immune cell—this is also part of the immune cell—an immune cell that expresses the ligand, so you have the receptor and then you have the complementary protein called the ligand. If you get interaction of Fas with the Fas ligand, it starts a signal transduction pathway that leads to cell death. My dad was a pulmonary pathologist, so I had always had great interest in the lung, even though I didn’t want to go into pathology or pulmonary disease. So the lung is one of the few organs—there are only four organs in the body that express the ligand, Fas ligand. And evolutionarily why should this be? Well, as I said, there are four areas in the body: the anterior chamber of the eye, the lung, the GI tract, and the testes. And immune cells kill by invading into an organ and getting rid of bacteria or foreign substances. Let’s think about corneal transplants. Normally in transplants, you have to have identical match, HLA match. You know that. With heart transplant, with kidney transplants, you get rejection if there’s not a match. But when we do corneal transplants, we can take any cornea from anybody and transplant it. Why is that? Why is there not rejection? Well, it turns out that there is constitutive Fas ligand expression in the anterior chamber of the eye. So even if you put a foreign piece of tissue in the anterior chamber, if the lymphocytes, as the immune cells come in, they express Fas, and so the Fas ligand in the tissue, the anterior chamber of the eye, or the testes, will kill the immune cells. So you do not get an inflammatory response. Okay. From an evolutionary point of view, why would the testes? Well, it’s a very delicate organ. You don’t want to have inflammation, because otherwise it leads to sterility. In the gut we’ve got bacteria going all there. If you have chronic inflammatory response, you’re going to have Crohn’s disease or inflammatory bowel disease. And in the lung we’re always breathing in bacteria, viruses, particles. You don’t want a huge immune response in the lung. So I think that’s why these four organs are the only organs that constitutively express Fas, Fas ligands, so that they can quell an immune response that can be damaging to the host. So it struck me that if a tumor cell was going to be able to grow in the lung, it probably should not express Fas, and so we cloned a cell, human osteosarcoma cells. We took a human cell line, and we found that when injected into the mouse, it would form a primary tumor but it wouldn’t form lung metastases. And we did what Dr. Fidler did, is we injected it, and about ten months later, we were able to find one lung metastases. So we took that out, put it in the tissue culture dish, and did the same experiment seven times. So we took it out, and each time we harvested the lung metastases, it was a shorter and shorter time till we got metastases. So went from ten months to six months to four months to eight weeks. And we took those cells and we looked at the expression of Fas, and what we found was that as the cells became more and more metastatic to the lung, the expression of Fas decreased, and we could take the cells that had low Fas expression and make them re-express Fas, and they would make metastases. We found that the gene for Fas had not been deleted, but it had been epigenetically down-regulated. But if we looked at lung metastases both from patients with osteosarcoma and in our animal models, we found that the lung metastases were Fas-negative. In our animal model, we identified several agents that we could treat the animal with that didn’t kill the tumor cell but caused up-regulation of Fas, and if we up-regulated Fas, the lung would take care and get rid of the tumor cell. And we knew it was the lung because there are animals that do not have Fas ligand, that have been genetically manipulated so there’s no or very little Fas ligand, and in those animals, when we treated them with these agents that up-regulated Fas, we didn’t get rid of the lung metastases. So I think that was one of the first demonstrations that the tumor microenvironment can be harnessed as part of the therapy, that maybe we should think about therapies that target the lung microenvironment or any kind of tumor microenvironment and bring them into the equation.
Tacey Ann Rosolowski, PhD:
I just want to—I mean, first, how cool. (laughs) And secondly, I wanted to mention, of course, the connection with Dr. Fidler’s work in the soil and seed theory, which he talks about in his interview.
Eugenie Kleinerman, MD:
Yes.
Tacey Ann Rosolowski, PhD:
So I just want to—and obviously your close work with him had really shaped—
Eugenie Kleinerman, MD:
Oh, absolutely.
Tacey Ann Rosolowski, PhD:
—your framing of this kind of connection and understanding of the context in which these body processes work. So it’s really pretty amazing. So what happened next? Or do you want to talk a little bit about that link with soil and seed theory?
Eugenie Kleinerman, MD:
So I think what that demonstrated to me is that maybe this was a way to investigate new therapies that we could use to treat osteosarcoma that were not cytotoxic chemotherapies. So we began to look for agents that would up-regulate Fas expression on osteosarcoma cells. We also did a lot of basic work, you know, why is the gene being down-regulated, because clearly the gene is there. It’s not like it’s been deleted. It’s there. And what’s the mechanism? And that was another part of my research. And again, that’s also to try to understand the biology, and maybe that can uncover other ways that we can treat. So we began to look for agents that up-regulated Fas, and we identified several. Interleukin 12 was one, and we showed very nicely that you could give Interleukin 12 to the animal and cause up-regulation of Fas and regression of the lung metastases. But then it became the question of if we’re going to use these agents, we’re giving an IV and we want to get it to the lung, we have to give such high doses when we give it IV, and the concentrations that we get in the lung are, of course, much smaller because it’s going through the circulation, and these are expensive proteins. So again I reached back to my training with Dr. Snyderman when I was in medical school when I looked at the effect of influenza on the immune system and was infecting mice with influenza virus by giving it intranasally, and I said maybe we could investigate giving IL-12, the gene IL-12, to start making the protein in the lung doing intranasal delivery. And so we first started to look at that and found very nicely—and the reason we went to the gene therapy is because the goal of this therapy is to make the tumor cells start expressing Fas. So we want to get the protein to the tumor. I don’t care whether the tumor cell starts producing the protein or the lung microenvironment starts producing the protein. It makes no difference as long as the protein is produced and secreted in the lung and the tumor cells get exposed to it; Fas will be up-regulated. Interestingly enough, lung cells, in addition to Fas ligand, they do express Fas. Why they don’t kill themselves, I don’t know, because you have—but anyway. So there was no danger in causing up-regulation of Fas in the lung, because the lung cells already express Fas. So, clearly the defense mechanism was built in. So I thought, let’s deliver the gene to stimulate IL-12 production intranasally. And we showed that you could do it, that you got production of the protein and it resulted in up-regulation of Fas and regression of the tumor.
Tacey Ann Rosolowski, PhD:
Can I ask, for just time frame here, when did you begin this work on Fas and then when did you start thinking about this novel intranasal therapy?
Eugenie Kleinerman, MD:
Probably fifteen, twenty years ago.
Tacey Ann Rosolowski, PhD:
Okay. I’m always struck with how slow these discoveries emerge, how slowly they emerge.
Eugenie Kleinerman, MD:
Right.
Tacey Ann Rosolowski, PhD:
Yeah. (laughs)
Eugenie Kleinerman, MD:
Yeah, there’s no overnight wonders, no. So, unfortunately, IL-12 was on the market, but the drug company had done a Phase 1 and there were severe side effects, and so they decided to stop manufacturing it. Welcome to my world yet again.
Tacey Ann Rosolowski, PhD:
Yes. (laughs)
Eugenie Kleinerman, MD:
At the same time while we were investigated, we realized that intranasal delivery was not going to be a way we could go to the clinic because you waste so much. You don’t really get it deep into the lung, and a lot of these metastases are in the lung. So, again, my training at the NIH was in allergy immunology, so asthma is something that allergy immunologists treat, and we treat asthma mostly by inhalation therapy. So I said, “Well,” to my lab group, “maybe we could think about aerosol delivery and just delivering of the agent through a breathing machine.” And that’s when we launched two investigating ways to give animals aerosol therapy, and I developed a collaboration with investigators over at the Baylor College of Medicine, who were also interested in aerosol therapy for other reasons. So we formed a collaboration, and we showed that in the animals, say, if you could give it, you got it into the lung, you got up-regulation of Fas and rejection of the lung nodules, and there was really no toxicity. Once IL-12 went off the market, I said, “Okay. No more. I’m not looking for any agents that are not already approved and out there.” So that’s what we started to do, and we identified an agent called Gemcitabine, which is a cytotoxic chemotherapy, but it’s not used in osteosarcoma, and something called 9-Nitrocamptothecin, which is another chemotherapy agent that is not used because it is lipophilic and the injection has to be subcutaneous and it’s very painful, and so people didn’t use it. But it’s a perfect agent to use by aerosol, because it’s particulate like liposomal-MTP. So we started investigating could we deliver Gemcitabine and could we deliver 9-Nitrocamptothecin by aerosol and get the same results that we got with IL-12, and the answer was yes, we could get up-regulation of Fas, and with Gemcitabine there was no effect in the animals that were deficient in Fas ligand. So even though this is a cytotoxic chemotherapy, clearly there’s not a whole lot of sensitivity in the osteosarcoma cells. At the same time, there were other investigators in the Children’s Oncology Group, in the Mayo Clinic, who also had basic science partners who were looking at aerosol delivery of Interleukin-2, which is an immune stimulant, and one of the investigators at Mayo Clinic was actually a vet, and as we talked before, dogs get osteosarcoma, and so he showed that he could give aerosol therapy to the dog and that if he used aerosol IL-2, you got regression of the lung metastases. So this became a collaboration not so much in what agent, but in the concept of using aerosol delivery for children.
Tacey Ann Rosolowski, PhD:
Who was this person?
Eugenie Kleinerman, MD:
So the principal investigator of one of the studies was Carola Arndt, A-r-n-d-t, and the veterinarian was Chand Khanna, K-h-a-n-n-a, and he’s now at the NCI. So Carola’s clinical trials was with aerosol GM-CSF. So it’s a cytokine that stimulates the expansion of neutrophils and macrophages. So her concept was, well, if MTP works, we can’t get it here, maybe we can give a cytokine that will expand the microphage pool and that will lead to tumor regression. The study wasn’t successful because I don’t think she designed it correctly, and she didn’t do anything to show that GM-CSF was getting to the lung, you know. So it was a Phase 1 study that showed no—not no toxicity, but there was really no indication that it was going to work, so it was abandoned. As I said, I was afraid with a Phase 2 I’d better design it correctly, otherwise it will be abandoned. Chand is a veterinarian, so he used the aerosol IL-2, but then he finished his—I guess his postdoctoral fellowship, he was a PhD and a vet, and then he moved to NCI. So that work sort of stopped. But we are now, here, getting ready to open an aerosol protocol with Gemcitabine based on the principles from the laboratory.
Tacey Ann Rosolowski, PhD:
In humans?
Eugenie Kleinerman, MD:
In humans, in children, yeah, in relapsed sarcoma patients.
Tacey Ann Rosolowski, PhD:
Wow.
Eugenie Kleinerman, MD:
So that’s sort of the story of how I took the basic science, understanding why cell metastasizes, what allows it to grow in the lung, and saying, okay, can we disrupt that symbiotic relationship between the tumor microenvironment and the tumor for the benefit of getting tumor regression? And, of course, the goal is can we use this in conjunction with a cytotoxic chemotherapy that we know works, give patients combination intravenous cytotoxic chemotherapy and then come in with some of these novel—either an immune-therapy like MEPACT or aerosol therapy aimed at altering the tumor microenvironment relationship.
Tacey Ann Rosolowski, PhD:
Do you think—I mean, what I’ve been hearing as you told the MEPACT story and now as you’ve told this story with these agents that can be useful in aerosol therapies, a particular philosophy of translational research, you know, what is translational research about, and I’m curious of how you feel your philosophy is similar to or differs from other people at this institution, maybe when translational research was first formulated here at MD Anderson, and what it may look like now. So where—I guess I’m asking for kind of an overview about translational research and where your strong notion of what that means sits in that terrain.
Eugenie Kleinerman, MD:
So, to me, translational research is taking the findings in the laboratory and moving it into the clinic by testing the hypothesis in a clinical trial that is designed with understanding of the biology. So that’s a mouthful to say. But I am very tired of reading basic science articles where—and I think we discussed this before—where they make a discovery and they say, “And this can lead to cures in cancer,” having absolutely no concept of how you’re going to test it, what are the controls that you’re going to build in to make sure that you’re delivering the agent. Like with the MEPACT, we actually did technetium labels so we could show it got to the lung. We actually did biologic assays to show that it was doing what it did. So, to me, translational research is understanding the biology, having hypothesis, and then making sure you design the clinical trial knowing all of the parameters that are important and also building in measures to make sure that your therapy actually has a chance of doing what you want it to do. And I think too often people just say, “Oh, here’s a new agent. Let’s throw it into the clinical trial.” I think we may have to get more specific in the types of patients, just like I did with the MEPACT. You just couldn’t have relapsed osteosarcoma. You had to have your lung metastases resected, and you had to have documentation, radiological documentation, that you were, quote, unquote, “disease-free” before you started the immune-therapy. And I think we’re going to have to start getting more specific in the patients that we put on clinical trials with these more specific agents. So that, to me, is what translational research is.
Tacey Ann Rosolowski, PhD:
Mm-hmm. I mean, I’m struck. I mean, as you’ve told this story and then when I’ve heard stories about how clinical investigations were run, say, in [the Department of] Developmental Therapeutics, in the sixties and early seventies, I mean, the arena of knowledge that you’re moving in right now is so much more sophisticated that you can say, “All right, now we need to look at this more carefully, we need to create these kinds of parameters,” and I don’t think anyone had the ability to even think of parameters because the knowledge base simply didn’t exist—
Eugenie Kleinerman, MD:
I agree.
Tacey Ann Rosolowski, PhD:
—at the time.
Eugenie Kleinerman, MD:
I agree.
Tacey Ann Rosolowski, PhD:
I mean, it’s really a fascinating story. Do you—how would you describe—and, I mean, we don’t have to spend a whole lot of time on this, but I’m curious how you see your work in perspective with the work that was done, for example, in developmental therapeutics by Emil Frei and J Freireich in those early years, who kind of defined what it was here at MD Anderson.
Eugenie Kleinerman, MD:
Again, I think they had like a shotgun approach, and not that the hypothesis was bad, but it was just, okay, if we give—I mean, there was some understanding of basic science. There was. Let’s see. In observations, if we give one drug, it works but then it relapses, and if we give another drug, it works and then they relapsed. And if we do things sequentially, it doesn’t work, okay, well, let’s try everything together. So there was very good observation on their part on the patients and how they responded and thinking about how we could build on what we see as successful but not to the extent we wanted to be, but I don’t think there was a lot of understanding about how the drugs worked, why these three drugs together work when in sequence they don’t, is it because they’re different mechanism of reactions or whatever it is. But, you know, they were pioneers, and I think they showed that you’ve got patients that have no other therapeutic options, that it is ethical to try new therapies in that with them.
Tacey Ann Rosolowski, PhD:
Thanks. Is there anything else that you wanted to say about the aerosol project at this point?
Eugenie Kleinerman, MD:
No. I think it’s a concept that can be used for many different types of cancers, anything that metastasizes to the lung, because the advantages when you give aerosol therapy, you can give much lower concentrations because you’re delivering it directly to the tumor microenvironment, so your systemic levels are going to be lower. I think it can be used for immune-therapy because Interleukin 2 is something that augments the activity of T-cells. There’s a lot now about T-cell therapy and NK-cell therapy. IL-2 is a cytokine that allows these specific types of immune cells to expand and live longer. For a long time, Dr. Rosenberg at the NCI is giving LAK cell therapy and systemic IL-2, and you have to give it high, and the patients had edema and a lot of toxic complications. Well, if you’re targeting lung metastases, you can give the cells and then use the aerosol method of delivery to concentrate the IL-2 in the lung, and we’ve shown in the lab that you get very little systemic spillover. You really don’t get any toxic systemic side effects, and you get much higher concentrations in the lung. So I think this is a principle that can be used, as I said, maybe in lung cancer if you have an agent. Why give it in the vein? Give it in the lung.
Tacey Ann Rosolowski, PhD:
What about using it with children? Is it easier to use this kind of therapy with kids or—
Eugenie Kleinerman, MD:
Oh, absolutely. I mean, we have done some studies with aerosol therapy here, and one of our former faculty, Dr. Pete Anderson, who left about two years ago to be chief of pediatric hematology oncology at the Charlotte’s Children’s Hospital—so you never like to lose an innovative physician, translational physician, but when he’s going to run his own show, there’s some pride in that.
Tacey Ann Rosolowski, PhD:
Sure.
Eugenie Kleinerman, MD:
So we’ve used aerosol therapy here, and the kids love it because they can treat themselves. We have to train them, but they can treat themselves, and they can do it in the lounge, and we actually had a setup. The setup, you plug it in, and we have—there’s a little gazebo across where the Faculty Center is, and so we had one patient who sat out in the gazebo and gave herself the aerosol therapy for an hour. So it can be done at home under the direction of a visiting nurse. So I think it’s the way of the future.
Tacey Ann Rosolowski, PhD:
Hmm. Wow. And it’s not—I mean, I’m thinking there’s the whole of idea of breathing something in can be—can choke you, can feel really uncomfortable. I mean, what’s the experience of inhaling these agents?
Eugenie Kleinerman, MD:
Okay. So again, we’re building off the experience of patients with asthma. I mean, when I was an intern, you got subQ epinephrine, IV theophylline, and IV steroids. Now I had a son who had asthma, never went in the hospital. When he had an attack, we went to the doctor’s office and he gave him albuterol, breathing it, breathing it in. And there are very sophisticated devices now to give aerosol therapy, because they’re built for patients with asthma, and there are a lot of asthmatics, both children and adult. Now, we do follow pulmonary function tests, so we make sure that we’re not damaging the lung, and we measure the O2 levels. Again, there’s a very small device that we can monitor the child from home, and if there are things that we don’t like, then we call them in for a full pulmonary function test.
Tacey Ann Rosolowski, PhD:
Now, when you say you monitor them from home, there’s a wireless connection that feeds the info?
Eugenie Kleinerman, MD:
Yes, yes. Exactly.
Tacey Ann Rosolowski, PhD:
And sends the info back. Wow.
Eugenie Kleinerman, MD:
Exactly. Either through the phone or through the computer.
Tacey Ann Rosolowski, PhD:
Wow.
Eugenie Kleinerman, MD:
They hook it up, and they breathe in, and then it sends the information to us.
Tacey Ann Rosolowski, PhD:
Wow. That’s great.
Eugenie Kleinerman, MD:
Yeah.
Tacey Ann Rosolowski, PhD:
So it really enables just a lot of convenience, much more comfort, much more—I hate to use the word “patient compliance,” but [unclear].
Eugenie Kleinerman, MD:
Sure, because, you know, you can take the therapy, go to school, take the therapy, come home, take the therapy, go to sleep, or—yes.
Tacey Ann Rosolowski, PhD:
Right. I mean, a screaming child, “Oh, this hurts,” that interferes with the treatment. (laughs)
Eugenie Kleinerman, MD:
Right. And I think it’s better for the family, too, because you have to remember that at MD Anderson, most of our relapsed patients come from all over the country, and so to chain them to the institution really disrupts the whole family, and that’s something that we’re very sensitive to here.
Tacey Ann Rosolowski, PhD:
Yeah, you mentioned that with the MEPACT trials too. Okay. Great. Well, thank you. What an interesting story.
Recommended Citation
Kleinerman, Eugenie S. MD and Rosolowski, Tacey A. PhD, "Chapter12: Innovative Aerosol Therapy for Bone Metastasis to the Lung and an Overview of Translational Research" (2014). Interview Chapters. 1408.
https://openworks.mdanderson.org/mchv_interviewchapters/1408
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