MEDISCHE CELBIOLOGIE
INHOUDSOPGAVE
1.1 Celtherapie ....................................................................................................................... 1
1.1.1 Definitie ........................................................................................................................... 1
1.1.2 Evolutie............................................................................................................................ 1
1.1.3 Celtherapie: De vierde pijler van de gezondheidszorg ......................................................... 2
1.2 Juridisch kader voor geneesmiddelen voor menselijk gebruik.............................................. 2
1.2.1 54 jaar: mijlpalen in de EU-regelgeving voor geneesmiddelen.............................................. 2
1.2.2 Juridisch kader ATMP van EMA .......................................................................................... 6
1.2.3 Clinical trial...................................................................................................................... 6
1.2.4 Federaal Agentschap voor Geneesmiddelen en Gezondheidsproducten (FAGG) ................. 6
1.3 Advanced Therapy Medicinal Products (ATMPs) .................................................................. 8
1.3.1 ATMP's - Geneesmiddelen voor menselijk gebruik die zijn gebaseerd op genen, weefsels of
cellen 8
1.3.1.1 Gentherapie (GTMP) ...................................................................................................... 8
1.3.1.2 Somatische celtherapie (sCTMP) ................................................................................... 9
1.3.1.3 Tissue-engineered products (TEP) ................................................................................ 10
1.3.1.4 Gecombineerde ATMPs (cATMP) .................................................................................. 10
1.3.2 Regelgeving voor cel-gebaseerde producten .....................................................................11
1.3.3 Celgebaseerde geneesmiddelen zijn heterogeen ..............................................................13
2.1 Good Manufacturing Practices (GMP) ................................................................................ 14
2.1.1 Regelgeving .....................................................................................................................14
2.1.2 Belangrijke verschillen tussen celgebaseerde therapieën en traditionele geneeskunde.......15
2.1.3 Complexiteit van celtherapie ...........................................................................................17
2.1.3.1 Testen van de karakterisering van celproducten............................................................ 17
2.1.3.2 Voorbeeld: gepersonaliseerd dendritisch celvaccin ...................................................... 18
2.1.4 Faciliteit: clean room .......................................................................................................19
2.2 Clinical trials en Good clinical practices (GCP) .................................................................. 20
2.2.1 Overgang van ontdekking naar testen op mensen ..............................................................20
1
, 2.2.2 Clinical trials ...................................................................................................................21
2.2.3 Clinical trial regelgeving ...................................................................................................22
2.2.4 Waarom clinical trial regelgeving voor investigational ATMP (iATMP)? .................................23
2.2.5 Bewustwordingscampagne rond ATMP .............................................................................23
3.1 Hematopoëse .................................................................................................................. 25
3.1.1 Definitie ..........................................................................................................................25
3.1.2 Hematopoëtische hiërarchie............................................................................................25
3.1.3 Hematopoëse oiv groeifactoren .......................................................................................26
3.2 Hematopoëtische stamceltransplantatie (HSCT) ............................................................... 27
3.2.1 Autoloog vs Allogeen .......................................................................................................27
3.2.2 Autologe HSCT ................................................................................................................27
3.2.3 Allogene HSCT ................................................................................................................28
3.2.3.1 Waarom? .................................................................................................................... 28
3.2.3.2 Onderliggend principe ................................................................................................. 29
3.2.3.3 Kans op herval in functie van donor .............................................................................. 29
3.2.3.4 Overzicht .................................................................................................................... 29
3.2.3.5 Hoe?........................................................................................................................... 30
3.2.3.6 Pre-transplantatie (Pre-TX) voorbereiding ..................................................................... 30
3.2.3.7 Conditioning ............................................................................................................... 30
3.2.3.8 Graft-versus-host disease (GvHD) preventie ................................................................. 31
3.2.3.9 Verkrijgen van TX product ............................................................................................ 31
3.2.4 Complicaties ..................................................................................................................32
3.2.5 Effecten op de outcome van allo-HSCT .............................................................................34
3.2.5.1 Het humaan microbioom ............................................................................................. 34
3.2.5.2 Immunologische homeostase in de darm ..................................................................... 34
3.2.5.3 Effecten op de outcome van allo-HSCT ........................................................................ 34
3.3 Immunotherapie .............................................................................................................. 35
3.3.1 Algemeen........................................................................................................................35
3.3.2 Monoklonale antilichamen...............................................................................................35
3.3.3 Antilichaam-geneesmiddelconjugaten .............................................................................35
3.3.4 Immuun checkpoint inhibitoren .......................................................................................36
3.3.5 Bispecifieke T-celbinders (BiTE) .......................................................................................36
2
, 3.3.6 Chimere antigen receptor T-cellen (CAR-T) .......................................................................36
4.1 Inleiding ........................................................................................................................... 38
4.2 Fantastische cellen van het immuunsysteem en hoe ze te verkrijgen .................................. 38
4.2.1 Componenten van het immuunsysteem ...........................................................................38
4.2.1.1 Algemeen - herhaling ................................................................................................... 38
4.2.1.2 Oorsprong van immuuncellen ...................................................................................... 39
4.2.1.3 Antigen-presenterende cellen (APC)............................................................................. 40
4.2.1.4 Interacties tussen het aangeboren en verworven immuunsysteem als respons op een
infectie 41
4.2.1.5 Wat zijn de stappen in celtherapieprocessen? .............................................................. 41
4.2.2 Cel bron ..........................................................................................................................42
4.2.2.1 Wat zijn de soorten celbronnen? .................................................................................. 42
4.2.2.2 Autologe cellen ........................................................................................................... 42
4.2.2.3 Allogene cellen ........................................................................................................... 43
4.2.2.4 Uitdagingen en tactieken voor autologe en allogene therapieën ..................................... 43
4.2.3 Cel isolatie ......................................................................................................................44
4.3 Strategieën voor immuuncelengineering ........................................................................... 46
4.3.1 Enkele concepten in genetische engineering .....................................................................46
4.3.2 Gen transfer ....................................................................................................................47
4.3.2.1 Classificatie van genengineering strategieën ................................................................ 47
4.3.2.2 Virale vectoren ............................................................................................................ 47
4.3.2.3 Non-virale gen delivery ................................................................................................ 49
4.3.3 Gen editing......................................................................................................................50
4.3.3.1 Transposons ............................................................................................................... 50
4.3.3.2 Vergelijking tussen transposons, ZFN, TALEN en CRIPR/Cas9 platformen ...................... 50
4.3.3.3 CRISPR/Cas9 knockouts vs knockins ........................................................................... 51
4.3.3.4 Base editors ................................................................................................................ 52
4.3.3.5 Prime editors .............................................................................................................. 52
4.4 Immunotherapieën ........................................................................................................... 53
4.4.1 Algemeen........................................................................................................................53
4.4.2 Gerichte antilichamen .....................................................................................................53
3
, 4.4.3 Kankervaccins.................................................................................................................54
4.4.4 Adoptieve celtherapieën ..................................................................................................55
4.5 Van T-celreceptoren (TCR) tot chimere antigeenreceptoren (CAR) voor TCR-T en CAR-T
therapie ...................................................................................................................................... 56
4.5.1 TCR-T cellen....................................................................................................................56
4.5.2 CAR-T cellen ...................................................................................................................58
4.5.2.1 Geschiedenis van CAR-T celtherapie ............................................................................ 58
4.5.2.2 Structuur van chimere antigen receptor........................................................................ 59
4.5.2.3 To go or not to go? Logische poorten in genetisch gemodificeerde T-cellen .................... 59
5.1 Het immuunsysteem ........................................................................................................ 62
5.1.1 Algemeen........................................................................................................................62
5.1.2 Het immuunsysteem .......................................................................................................62
5.1.2.1 Balans tussen immuniteit en tolerantie ........................................................................ 62
5.1.2.2 Belangrijkste spelers ................................................................................................... 62
5.1.2.3 Autoimmuniteit – “Horror Autotoxicus” ........................................................................ 63
5.2 Multiple sclerose (MS) ...................................................................................................... 63
5.2.1 MS symptomen ...............................................................................................................63
5.2.2 Immunopathogenese van MS ...........................................................................................64
5.3 Disease-modifying therapies (DMT) ................................................................................... 65
5.3.1 Niet-specifiek ..................................................................................................................65
5.3.1.1 Actief .......................................................................................................................... 65
5.3.1.2 Passief........................................................................................................................ 65
5.3.2 Specifiek .........................................................................................................................66
5.3.2.1 Passief – Monoklonale antilichamen ............................................................................ 66
5.3.2.2 Actief – recombinante proteïnen/peptiden.................................................................... 67
5.3.2.3 Actief – celtherapie (HSC) ............................................................................................ 67
5.3.2.4 Passief – celtherapie (Tregs)......................................................................................... 68
5.3.2.5 Actief – Celtherapie (APC) ............................................................................................ 69
6.1 Introductie ....................................................................................................................... 73
6.1.1 Immunotherapie .............................................................................................................73
6.1.2 Immuunsysteem .............................................................................................................73
4
INHOUDSOPGAVE
1.1 Celtherapie ....................................................................................................................... 1
1.1.1 Definitie ........................................................................................................................... 1
1.1.2 Evolutie............................................................................................................................ 1
1.1.3 Celtherapie: De vierde pijler van de gezondheidszorg ......................................................... 2
1.2 Juridisch kader voor geneesmiddelen voor menselijk gebruik.............................................. 2
1.2.1 54 jaar: mijlpalen in de EU-regelgeving voor geneesmiddelen.............................................. 2
1.2.2 Juridisch kader ATMP van EMA .......................................................................................... 6
1.2.3 Clinical trial...................................................................................................................... 6
1.2.4 Federaal Agentschap voor Geneesmiddelen en Gezondheidsproducten (FAGG) ................. 6
1.3 Advanced Therapy Medicinal Products (ATMPs) .................................................................. 8
1.3.1 ATMP's - Geneesmiddelen voor menselijk gebruik die zijn gebaseerd op genen, weefsels of
cellen 8
1.3.1.1 Gentherapie (GTMP) ...................................................................................................... 8
1.3.1.2 Somatische celtherapie (sCTMP) ................................................................................... 9
1.3.1.3 Tissue-engineered products (TEP) ................................................................................ 10
1.3.1.4 Gecombineerde ATMPs (cATMP) .................................................................................. 10
1.3.2 Regelgeving voor cel-gebaseerde producten .....................................................................11
1.3.3 Celgebaseerde geneesmiddelen zijn heterogeen ..............................................................13
2.1 Good Manufacturing Practices (GMP) ................................................................................ 14
2.1.1 Regelgeving .....................................................................................................................14
2.1.2 Belangrijke verschillen tussen celgebaseerde therapieën en traditionele geneeskunde.......15
2.1.3 Complexiteit van celtherapie ...........................................................................................17
2.1.3.1 Testen van de karakterisering van celproducten............................................................ 17
2.1.3.2 Voorbeeld: gepersonaliseerd dendritisch celvaccin ...................................................... 18
2.1.4 Faciliteit: clean room .......................................................................................................19
2.2 Clinical trials en Good clinical practices (GCP) .................................................................. 20
2.2.1 Overgang van ontdekking naar testen op mensen ..............................................................20
1
, 2.2.2 Clinical trials ...................................................................................................................21
2.2.3 Clinical trial regelgeving ...................................................................................................22
2.2.4 Waarom clinical trial regelgeving voor investigational ATMP (iATMP)? .................................23
2.2.5 Bewustwordingscampagne rond ATMP .............................................................................23
3.1 Hematopoëse .................................................................................................................. 25
3.1.1 Definitie ..........................................................................................................................25
3.1.2 Hematopoëtische hiërarchie............................................................................................25
3.1.3 Hematopoëse oiv groeifactoren .......................................................................................26
3.2 Hematopoëtische stamceltransplantatie (HSCT) ............................................................... 27
3.2.1 Autoloog vs Allogeen .......................................................................................................27
3.2.2 Autologe HSCT ................................................................................................................27
3.2.3 Allogene HSCT ................................................................................................................28
3.2.3.1 Waarom? .................................................................................................................... 28
3.2.3.2 Onderliggend principe ................................................................................................. 29
3.2.3.3 Kans op herval in functie van donor .............................................................................. 29
3.2.3.4 Overzicht .................................................................................................................... 29
3.2.3.5 Hoe?........................................................................................................................... 30
3.2.3.6 Pre-transplantatie (Pre-TX) voorbereiding ..................................................................... 30
3.2.3.7 Conditioning ............................................................................................................... 30
3.2.3.8 Graft-versus-host disease (GvHD) preventie ................................................................. 31
3.2.3.9 Verkrijgen van TX product ............................................................................................ 31
3.2.4 Complicaties ..................................................................................................................32
3.2.5 Effecten op de outcome van allo-HSCT .............................................................................34
3.2.5.1 Het humaan microbioom ............................................................................................. 34
3.2.5.2 Immunologische homeostase in de darm ..................................................................... 34
3.2.5.3 Effecten op de outcome van allo-HSCT ........................................................................ 34
3.3 Immunotherapie .............................................................................................................. 35
3.3.1 Algemeen........................................................................................................................35
3.3.2 Monoklonale antilichamen...............................................................................................35
3.3.3 Antilichaam-geneesmiddelconjugaten .............................................................................35
3.3.4 Immuun checkpoint inhibitoren .......................................................................................36
3.3.5 Bispecifieke T-celbinders (BiTE) .......................................................................................36
2
, 3.3.6 Chimere antigen receptor T-cellen (CAR-T) .......................................................................36
4.1 Inleiding ........................................................................................................................... 38
4.2 Fantastische cellen van het immuunsysteem en hoe ze te verkrijgen .................................. 38
4.2.1 Componenten van het immuunsysteem ...........................................................................38
4.2.1.1 Algemeen - herhaling ................................................................................................... 38
4.2.1.2 Oorsprong van immuuncellen ...................................................................................... 39
4.2.1.3 Antigen-presenterende cellen (APC)............................................................................. 40
4.2.1.4 Interacties tussen het aangeboren en verworven immuunsysteem als respons op een
infectie 41
4.2.1.5 Wat zijn de stappen in celtherapieprocessen? .............................................................. 41
4.2.2 Cel bron ..........................................................................................................................42
4.2.2.1 Wat zijn de soorten celbronnen? .................................................................................. 42
4.2.2.2 Autologe cellen ........................................................................................................... 42
4.2.2.3 Allogene cellen ........................................................................................................... 43
4.2.2.4 Uitdagingen en tactieken voor autologe en allogene therapieën ..................................... 43
4.2.3 Cel isolatie ......................................................................................................................44
4.3 Strategieën voor immuuncelengineering ........................................................................... 46
4.3.1 Enkele concepten in genetische engineering .....................................................................46
4.3.2 Gen transfer ....................................................................................................................47
4.3.2.1 Classificatie van genengineering strategieën ................................................................ 47
4.3.2.2 Virale vectoren ............................................................................................................ 47
4.3.2.3 Non-virale gen delivery ................................................................................................ 49
4.3.3 Gen editing......................................................................................................................50
4.3.3.1 Transposons ............................................................................................................... 50
4.3.3.2 Vergelijking tussen transposons, ZFN, TALEN en CRIPR/Cas9 platformen ...................... 50
4.3.3.3 CRISPR/Cas9 knockouts vs knockins ........................................................................... 51
4.3.3.4 Base editors ................................................................................................................ 52
4.3.3.5 Prime editors .............................................................................................................. 52
4.4 Immunotherapieën ........................................................................................................... 53
4.4.1 Algemeen........................................................................................................................53
4.4.2 Gerichte antilichamen .....................................................................................................53
3
, 4.4.3 Kankervaccins.................................................................................................................54
4.4.4 Adoptieve celtherapieën ..................................................................................................55
4.5 Van T-celreceptoren (TCR) tot chimere antigeenreceptoren (CAR) voor TCR-T en CAR-T
therapie ...................................................................................................................................... 56
4.5.1 TCR-T cellen....................................................................................................................56
4.5.2 CAR-T cellen ...................................................................................................................58
4.5.2.1 Geschiedenis van CAR-T celtherapie ............................................................................ 58
4.5.2.2 Structuur van chimere antigen receptor........................................................................ 59
4.5.2.3 To go or not to go? Logische poorten in genetisch gemodificeerde T-cellen .................... 59
5.1 Het immuunsysteem ........................................................................................................ 62
5.1.1 Algemeen........................................................................................................................62
5.1.2 Het immuunsysteem .......................................................................................................62
5.1.2.1 Balans tussen immuniteit en tolerantie ........................................................................ 62
5.1.2.2 Belangrijkste spelers ................................................................................................... 62
5.1.2.3 Autoimmuniteit – “Horror Autotoxicus” ........................................................................ 63
5.2 Multiple sclerose (MS) ...................................................................................................... 63
5.2.1 MS symptomen ...............................................................................................................63
5.2.2 Immunopathogenese van MS ...........................................................................................64
5.3 Disease-modifying therapies (DMT) ................................................................................... 65
5.3.1 Niet-specifiek ..................................................................................................................65
5.3.1.1 Actief .......................................................................................................................... 65
5.3.1.2 Passief........................................................................................................................ 65
5.3.2 Specifiek .........................................................................................................................66
5.3.2.1 Passief – Monoklonale antilichamen ............................................................................ 66
5.3.2.2 Actief – recombinante proteïnen/peptiden.................................................................... 67
5.3.2.3 Actief – celtherapie (HSC) ............................................................................................ 67
5.3.2.4 Passief – celtherapie (Tregs)......................................................................................... 68
5.3.2.5 Actief – Celtherapie (APC) ............................................................................................ 69
6.1 Introductie ....................................................................................................................... 73
6.1.1 Immunotherapie .............................................................................................................73
6.1.2 Immuunsysteem .............................................................................................................73
4
