Welcome to the Clinical Center Grand Rounds, a weekly series of educational lectures for physicians and health care professionals broadcast from the Clinical Center at the National Institutes of Health in Bethesda, MD. The NIH Clinical Center is the world's largest hospital totally dedicated to investigational research and leads the global effort in training today's investigators and discovering tomorrow's cures. Learn more by visiting us online https://clinicalcenter.nih.gov TODAY WE WELCOME TWO DISTINGUISHED COLLEAGUES FROM THE NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASE, WHO WILL ADDRESS THE TOPIC OF SEVERE COMBINED IMMUNE DEFICIENCY. FIRST IS DR. LUIGI NOTARANGELO, TENURED INVESTIGATOR, AND HEAD OF THE IMMUNE DEFICIENCY GENETICS SECTION AND CHIEF OF THE LABORATORY OF CLINICAL IMMUNOLOGY AND MICROBIOLOGY AT NIAID. MEDICAL DEGREE FROM UNIVERSITY OF PAVIA IN ITALY, FRIENDSHIP IN ALLERGY IMMUNOLOGY AND HUMAN CYTOGENETICS, BEGAN HIS ACADEMIC CAREER AT THE UNIVERSITY IN ITALY, FROM ASSISTANT TO FULL PROFESSOR THE PEDIATRICS, CHAIR OF THE DEPARTMENT OF PEDIATRICS. IN 2006 MOVED TO BOSTON CHILDREN'S HOSPITAL, HE WAS APPOINTED PROFESSOR OF PEDIATRICS AT HARVARD MEDICAL SCHOOL, ASSUMED HIS CURRENT POSITION AT THE NATIONAL INSTITUTES OF HEALTH IN 2016. HIS SCIENTIFIC AND CLINICAL INTERESTS ARE FOCUS 'EM ON PRIMARY IMMUNE DEFICIENCY DISORDERS, IN PARTICULAR DEFINING THE MOLECULAR AND CELLULAR BASIS OF THESE DISORDERS AND DEVELOPING NOVEL APPROACHES TO CORRECT THEM. TODAY IS GENETIC FORMS OF PRIMARY IMMUNODEFICIENCY INCLUDING JAK 3 DEFICIENCY, CD40 DEFICIENCY, DOC 2 DEFICIENCYA, HOIP DEFICIENCY, IDENTIFIED MOLECULAR SIGNATURES OF IMMUNE DYSREGULATION IN PATIENTS WITH RECOMBINANT ACTIVATED GENE DEFICIENCY PRESENTED WITH AUTOIMMUNE FEATURES AND VARIABLE IMMUNODEFICIENCY. WHILE IN BOSTON HE SERVED AS PRINCIPAL INVESTIGATOR OF GENE THERAPY TRIAL FOR X-LINKED SEVERE COMBINED IMMUNE DEFICIENCY, CO-INVESTIGATOR ON GENE THERAPY TRIAL FOR WESTCOT SYNDROME, EDITOR IN CHIEF OF FRONTIERS IN IMMUNOLOGY, SERVED AS PRESIDENT OF YOUR MEAN SOCIETY FOR IMMUNE DEFICIENCIES, CLINICAL IMMUNOLOGY SOCIETY, FOUNDING MEMBER OF THE PRIMARY IMMUNE DEFICIENCY TREATMENT CONSORTIUM, WHICH IS THE PREEMINENT NETWORK OF CENTERS CARING FOR PATIENTS WITH SEVERE FORMS OF PRIMARY IMMUNODEFICIENCY DISORDERS IN NORTH AMERICA. IN 2017, HE RECEIVED THE DISTINGUISHED SCIENTIST AWARD FROM THE AMERICAN ACADEMY OF ALLERGY, ASTHMA AND IMMUNOLOGY. OUR SECOND SPEAKER TODAY IS DR. GENETIC IMMUNOTHERAPY SECTION, DEPUTY CHIEF OF THE LABORATORY OF CLINICAL IMMUNOLOGY AND MICROBIOLOGY -- SORRY, MICROBIOLOGY AT NIAID. DR. MALECH RECEIVED HIS DEGREE FROM YALE UNIVERSITY SCHOOL OF MEDICINE, COMPLETED RESIDENCY IN INTERNAL MEDICINE AT HOSPITAL OF UNIVERSITY OF PENNSYLVANIA, POSTDOCTORAL RESEARCH FELLOWSHIP AT NATIONAL CANCER INSTITUTE, INFECTIOUS DISEASE FELLOWSHIP AT YALE, ASSISTANT AND THEN ASSOCIATE PROFESSOR OF MEDICINE AT YALE, BEFORE RETURNING TO THE NIH WHERE HE HAS BEEN A SENIOR INVESTIGATOR SINCE 1986. DR. MALECH STUDIES AND PROVIDES CARE TO PATIENTS WHO HAVE A VARIETY OF INHERITED IMMUNE DEFICIENCIES, WITH FOCUS ON CHILDREN AND YOUNG ADULTS WITH CHRONIC GRANULOMATOUS DISEASE OR X-LINKED SEVERE IMMUNODEFICIENCY, CONDUCTS CLINICAL TRIALS OF ALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANTATION AND LENTE VECTOR HEMATOPOIETIC STEM THEY WILL GENE THERAPY FOR CHRONIC GRANULOMATOUS DISEASE. IN ADDITION TO BASIC, FOCUS ON HUMAN HEMATOPOIETIC STEM CELLS, INDUCED PLURIPOTENT STEM CELLS, DEVELOPMENT OF NEW GENE TRANSFER VECTORS, METHODS FOR GENE TRANSFER INTO STEM CELLS, DELINEATION OF IMMUNE FACTORS AFFECTING ALLOGENEIC TRANSPLANTATION, INCLUDING GRAFT-VERSUS-HOST DISEASE. DR. MALECH IS CHAIRMAN OF THE NIH INSTITUTIONAL BIOSAFETY COMMITTEE, REVIEWING PROTOCOLS, ADVISORY BOARD OF IMMUNE DEFICIENCY FOUNDATION, SCIENTIFIC BOARD OF ORCID THERAPEUTICS. HE SERVED AS PRESIDENT OF THE AMERICAN SOCIETY OF GENE AND CELL THERAPY FROM 2014 TO 2015. SO, NOW LET'S BEGIN TODAY'S PRESENTATION, WITH DR. NOTARANGELO. >> THANK YOU. GOOD MORNING, EVERYBODY. I AM -- I DON'T HAVE ANY FINANCIAL DISCLOSURES TO SHARE WITH YOU. AND THESE ARE THE EDUCATIONAL OBJECTIVES OF MY TALK. I WANT TO SET THE STAGE FOR WHAT DR. MALECH WILL PRESENT, EXCITING DATA ON GENE THERAPY FOR X-LINKED IMMUNODEFICIENCY. I WILL TRY TO ILLUSTRATE HOW NEWBORN SCREENING HAS CHANGED THE GENETIC LANDSCAPE OF SCID, AND I WILL DISCUSS CURRENT OUTCOME AND CHALLENGES OF HEMATOPOIETIC STEM CELL TRANSPLANTATION, IMPORTANT TO UNDERSTAND WHY GENE THERAPY IS NOW BECOMING SO IMPORTANT. WHAT IS SEVERE COMBINED IMMUNODEFICIENCY, TRULY A GROUP OF DISORDERS THAT REPRESENTS THE MOST SEVERE FORM OF PRIMARY IMMUNODEFICIENCY, NEWBORNS WITH SEVERE COMBINED IMMUNODEFICIENCY APPEAR HEALTHY AT BIRTH, NO SIGNS THAT ALLOW YOU TO SUSPECT ACTUALLY SCID. WHEN YOU DO LOOK FOR THEIR IMMUNE STATUS, TYPICALLY ALL FORMS OF SCID ARE CHARACTERIZED BY ABSENT OR LOW NUMBER OF T CELLS. B AND N K CELLS MAY OR MAY NOT BE THERE. OVER THE YEARS WE LEARN THIS IS NOT A SINGLE CONDITION, IT'S A GENETIC HETEROGENEOUS, AND CLINICAL PHENOTYPE IS CHARACTERIZED BY SEVERE INFECTIONS DUE TO BROAD SPECTRUM OF PATHOGENS, CHRONIC DIARRHEA, FAILURE TO THRIVE. ROTAVIRUS OR POLIO COULD LEAD TO SERIOUS EFFECTS, EVEN DEATH, IF UNTREATED IT IS INEVITABLY FATAL BUT CAN BE SECURED WITH HEMATOPOIETIC STEM CELL SCID APPEARED TO BE INITIALLY HOMOGENOUS IN CLINICAL PRESENTATION, BECAME OBVIOUS IN THE '70s AND EARLY '80s THAT THERE IS A WIDE ARRAY OF HETEROGENEITY WITHIN THE SCID PATIENTS, AND IN PARTICULAR IMMUNOLOGIC HETEROGENEITY WAS IDENTIFIED, LATER ON GENETIC HETEROGENEITY HETEROGENEITY DEFINED. THE FIRST THING I WILL DISCUSS IS THE IMMUNOLOGIC HETEROGENEITY. IT'S VERY SIMPLE TO ACTUALLY IDENTIFY SUCH A HETEROGENEITY. SIMPLY BY STAINING PERIPHERAL BLOOD LYMPHOSATES FOR MARKERS OF T CELLS LIKE CD3, MARKERS OF B CELLS LIKE CD19, MARKERS OF NK CELLS LIKE CD16 OR 56, THE PROFILE OF HEALTHY INFANT WITH MAJORITY ARE T CELLS, CLEARLY B CELLS PRESENT, ALSO NK CELLS PRESENT. LET'S CONTRAST WITH ONE CARTOON OF ONE PATIENT WITH SCID, AND THESE ARE PATIENTS WITH VERY LOW PROPORTION OF T CELLS, NO NK CELLS, ALL OF THE LYMPHOCYTES ARE B CELLS, T MINUS, B+, NK FORM OF SKID. OTHERS IN A SIMILAR WAY, THIS PATIENT HAS NO T CELLS, NO B CELLS, ONLY NK CELLS. THINGS ARE MORE COMPLICATED, FOUR FORMS OF SCID, ALL CHARACTERIZED BY THE LACK OF T CELLS, VERY LOW NUMBER OF T CELLS. IF PRESENT MAY BE OF MATERNAL ORIGIN, AUTOLOGOUS T CELLS ARE PRESENT. THIS IS FOURTH GROUP. EACH FORM MAY BE DUE TO VARIOUS GENE DEFECTS. IN THIS SLIDE I'M SHARING SOME OF THE GENE DEFECTS, MOST COMMON GENE DEFECTS WITHIN THIS GROUP OF RARE DISORDERS, ASSOCIATED WITH SCID. MECHANISMS ARE DIFFERENT, SOME CASES SURVIVAL IS AFFECTED. SOME PATIENTS PROBLEMS WITH REARRANGEMENT, SIGNALING THROUGH T-CELL RECEPTOR SHOWN HERE. AND FINALLY THERE ARE SOME FORMS OF SCID THAT ARE NOT HEMATOPOIETIC IN NATURE. THEY ARE ACTUALLY DUE TO THYMIC PROBLEMS, LIKE DEGEORGE SYNDROME, CHARGE, NEW SCID PHENOTYPE FOXN 1 DEFICIENCY. YOU SEE THEM, MANY OF THEM HERE, BUT ON TOP OF THIS GENETIC HETEROGENEITY IT'S CLEAR SEVERE COMBINED IMMUNODEFICIENCY. I'VE REPORTED THREE CATEGORIES OF SCID, THESE ARE ALL SERIOUSLY AFFECTED INFANTS DEFINED AS HAVING TYPICAL SKID, ATYPICAL OR OMEN SYNDROME, THESE ARE THE ELEMENTS THAT DISTINGUISH DIFFERENT PHENOTYPES. THEY HAVE LOW OR ABSENT NUMBER OF AUTOLOGOUS T CELLS IN PATIENTS IN SLIGHTLY HIGHER NUMBERS, 1500 IS A LOW NUMBER OF T CELLS FOR A HEALTHY NEWBORN. BUT MORE IMPORTANTLY, NO MATTER WHERE THE NUMBER IS THERE ARE VERY FEW NIGH EACH T CELLS. BY CONTRAST PATIENTS WITH OMENN SYNDROME HAVE A VARIABLE NUMBER OF T CELLS, SOMETIMES HIGHER THAN NORMAL, INFILTRATE AND DAMAGE TARGET TISSUES RESULTS IN ORGAN DAMAGE. THE FUNCTION OF THE T CELLS MAY BE COMPROMISED, MORE SEVERELY COME COMPROMISED, AND THERE ARE OTHER SUPPORTING FEATURES OF SCID-LIKE PRESENCE OF MATERNAL T CELLS WHICH SHOULD NOT THERE BE, AT LEAST NOT IN HIGH NUMBER IN NORMAL NEWBORN, AND THEY ARE THERE OFTEN IN 50% OF THE PATIENTS WITH SCID. OF COURSE, MUTATIONS IN SCID-ASSOCIATED GENES AS SHOWN IN PREVIOUS SLIDE. NOW, THERE IS EVEN MORE PHENOTYPIC HETEROGENEITY. MUTATIONS IN THE SAME GENE THAT CAUSE ANY OF THE THREE FORMS I PRESENTED IN THE PREVIOUS SLIDE, ALSO SUMMARIZED HERE, SCID, OMENN, AND ATYPICAL, MAY RESULT IN DELAYED ONSET DISEASE CHARACTERIZED BY IMMUNE DYSREGULATION SHOWN BY VASCULITIS LEADING TO NECROSIS AND GRANULOMA FORMATION. CLASSICAL EXAMPLE OF EXTREME PHENOTYPIC HETEROGENEITY IS REPRESENTED BY MUTATIONS IN RECOMBINATION ACTIVATING GENES, YOU HAVE A WIDE RANGE OF CLINICAL PRESENTATIONS RANGING FROM SEVERE INFECTIONS TO SEVERE AUTOIMMUNITY. NOW, UNTIL TEN YEARS AGO, WHAT WAS REALLY THE WAY TO DIAGNOSE SCID? IN MOST CASE THIS WAS A CLINICAL DIAGNOSIS, IT ACTUALLY -- YOU NEED TO HAVE AN INFANT WITH SERIOUS INFECTIONS AND FAILURE TO THRIVE IN ORDER TO SUSPECT A SEVERE COMBINED IMMUNODEFICIENCY. THE ONLY ALTERNATIVE TO MAKE A PRESYMPTOMATIC DIAGNOSIS WAS IF HAD YOU A POSITIVE FAMILY HISTORY. IN THAT CASE ONE COULD USE ONE OF THE IMMUNOLOGIC TESTS LIKE LOOKING AT FUNCTION OF T CELLS, CELL NUMBER, TO MAKE DIAGNOSIS, THIS IS A MINORITY OF INFANTS. IN MOST CASES, PATIENTS WERE RECOGNIZED BECAUSE OF SERIOUS CLINICAL PROBLEMS. THAT COMES WITH SOME CONSEQUENCES BECAUSE IF YOU HAVE SERIOUS INFECTIONS, ESPECIALLY IF THESE INFECTIONS CONTINUE FOR SOME PERIOD OF TIME, THEN YOU MAY RISK TO DIE EVEN BEFORE TRANSPLANTATION IS ATTEMPTED, A HIGH RATE OF MORTALITY EARLY LIFE, OR YOU MAY DEVELOP IRREVERSIBLE ORGAN DAMAGE SO EVEN IF YOU FIX THE PROBLEM BY HEMATOPOIETIC STEM CELL TRANSPLANTATION YOU CONTINUE TO EXPERIENCE FOR YOUR ENTIRE LIFE SERIOUS CONSEQUENCES. FINALLY, APPLAUSE OF THE INFECTIONS, THERE IS INCREASED RISK WITH USE OF CHEMOTHERAPY OR ONE CANNOT EVEN USE CHEMOTHERAPY AT ALL AND THAT RESULTS IN A SUBOPTIMAL FORM OF TREATMENT FOR SEVERAL FORMS OF SCID. SO OBVIOUSLY MAJOR CHALLENGES WHEN THE DIAGNOSIS OF SCID IS ONLY MADE BASED ON CLINICAL GROUNDS. WHAT REALLY CHANGED WAS DEVELOPMENT OF ASSAY AT THE NIH BY DANNY DUEK, CAPACITY OF THYMUS TO PRODUCE NEW T CELLS, WRONG IN SCID, EXCISION CIRCLES. WHEN IN THE THYMUS WE REARRANGE TO GENERATE T-CELL RECEPTOR ALPHA B DEPOSITED T CELLS, TO DO THAT YOU HAVE TO DELETE THE DELTA LOG LOCATED INSIDE THE ALPHA LOG. YOU FORM CIRCLES, TRECs, IN GERMLINE DNA ARE IN OPPOSITE CONFIGURATION, IN A CIRCLE AMPLIFY THIS REGION, THE TREC. THIS IS EXCISIO CIRCLE ASSAY. WHAT HAPPENS IS THAT, AGAIN, THESE CIRCLES ARE GENERATED IN THE THYMUS, AT A TIME YOU REARRANGE ALPHA LOCUS, THEY ARE CONTAINED WITHIN THE LYMPHOCYTES THAT ARE GENERATED IN THE THYMUS AND THEY REMAIN WITHIN THE CELLS, AND ENTER THE CIRCULATION, PERIPHERAL BLOOD, OUT AS CELLS DIVIDE, NOT NUCLEAR CIRCLES, NOT INTEGRATED INTO GENOMIC DNA. AS CELL DIVIDES NUMBER OF CIRCLES PER CELL DIVIDES ALSO BY HALF AND THEN BY HALF AND HALF. BASICALLY MEASURING BY PCR IN A NEWBORN SCREENING DRY BLOOD SPOT THE AMOUNT OF TRECs WILL TELL YOU CAPACITY TO GENERATE TO NEW T CELLS, THAT'S WHAT YOU NEED TO SUSPECT SEVERE COMBINED IMMUNODEFICIENCY. THE UNITED STATES WAS THE FIRST COUNTRY WORLDWIDE TO APPLY NEWBORN SCREENING FOR SEVERE COMBINED IMMUNODEFICIENCY, THE FIRST STATE IN THE COUNTRY WAS WISCONSIN 2008 FOLLOWED BY MASSACHUSETTS NEXT YEAR. WE SHOULD BE PROUD AS OF DECEMBER 10, 2018, ALL STATES IN THIS COUNTRY ARE EFFECTIVELY SCREENING ALL NEWBORNS FOR SEVERE COMBINED IMMUNODEFICIENCY. THIS WAS THE FIRST COUNTRY WORLDWIDE THAT DID SO. THERE ARE OTHER COUNTRIES NOW THAT HAVE FOLLOWED, SWITZERLAND, MORE RECENTLY, BUT I THINK IT IS IMPORTANT THAT THE UNITED STATES WAS THE FIRST ONE. SO HOW IMPORTANT IS IT? FIRST OF ALL, THIS HAS COMPLETELY CHANGED THE WAY WE DIAGNOSE NOW SCID, AND SO JUST LOOK AT WHAT HAPPENED ONLY NINE YEARS AGO IN 2010, WHERE THE MAJORITY OF SCID BABIES WERE STILL DIAGNOSED BASED ON INFECTION, THE GREEN CIRCLE HERE. IN 2016, NOT EVERY STATE WAS SCREENING FOR SCID AT THAT YEAR, STILL THE PROPORTION OF INFANTS WITH SCID RECOGNIZED BECAUSE OF CLINICAL PROBLEMS WAS AROUND 10%, VAST MAJORITY DIAGNOSED BECAUSE OF NEWBORN SCREENING, 90%. THE OTHER THING WE LEARNED THROUGH NEWBORN SCREENING IF YOU LOOK AT CATEGORIES I SHOWED YOU BEFORE, THE TYPICAL AND ATYPICAL SCID OR OMENN GENOTYPES ARE NOT EQUALLY REPRESENTED. THE DISEASE DR. MALECH WILL TALK TO YOU ABOUT IS THE X-LINKED, DUE TO MUTATION OF THE COMMON GAMMA CHAIN, IL-2 RECEPTOR CHAIN IN BLUE, MOST COMMON CAUSE OF TYPICAL SCID, ACCOUNTS FOR MINORITY OF THE ATYPICAL SCID. LOOK FOR INSTANCE AT RAG-1 AND RAG-2, THIRD MOST COMMON CAUSE OF SCID, BY FAR AND LARGE MOST COMMON CAUSE OF ATYPICAL SCID, MUTATIONS IN DIFFERENT GENES COME WITH DIFFERENT PHENOTYPES, IMMUNOLOGICALLY AND CLINICALLY. BUT THIS IS INTELLECTUAL CURIOUSLY, DOESN'T REALLY HELP IN TERMS OF OUTCOME OF DISEASE. AS I MENTIONED, THE MAINSTAY OF THERAPY FOR SEVERE COMBINED IMMUNODEFICIENCY WAS AND REMAINS HEMATOPOIETIC STEM CELL TRANSPLANTATION. THIS IS THE ORIGINAL PUBLICATION IN 1968 IN "LANCET," FIRST IN HUMANS IN INFANT AFFECTED WITH X-LINKED SEVERE COMBINED IMMUNODEFICIENCY, THAT PATIENT IS ALIVE, HAS CHILDREN ON HIS OWN, SO THAT WAS A SUCCESSFUL CURE. IT WASN'T AN EASY TRANSPLANTS, AN INTERESTING STORY TO READ BUT, YES, PROVED BIOMEDICAL TRANSPLANT CAN FIX SEVERE COMBINED IMMUNODEFICIENCY AND OPENED THE WAY TO WIDESPREAD USE FOR A VARIETY OF HEMATOLOGIC AND NON-HEMATOLOGICAL CONDITIONS. NOW, THERE ARE MANY FACTORS THAT INFLUENCE OUTCOME OF SEVERE COMBINED IMMUNODEFICIENCY. AND THESE ARE LISTED HERE. THERE'S ONE I WANT YOUR ATTENTION TO BE FOCUSED ON, THE AGE AND CLINICAL STATUS OF THE PATIENT AT TIME OF TRANSPLANTATION BECAUSE THIS IS WHERE NEWBORN SCREENING REALLY MATTERS. SO IN THIS SLIDE I'M SHOWING DATA THAT DR. BUCKLEY AT DUKE UNIVERSITY PUBLISHED TEN YEARS AGO. SHE LOOKED AT A SERIES OF INFANTS WITH SEVERE COMBINED IMMUNODEFICIENCY THAT RECEIVED TRANSPLANT AT VERY YOUNG AGE, LESS THAN 3.5 MONTHS, OR AT LATER AGE, MORE THAN 3.5 MONTHS OF AGE. THE KINDS OF TRANSPLANT WAS SIMILAR IN THE TWO GROUPS YET THE OUTCOME WAS SIGNIFICANTLY DIFFERENT, SURVIVAL 95% AT YOUNG, 60 TO 65% IN INFANTS RECEIVED TRANSPLANT AT LATER AGE. IN MORE RECENT YEARS, THE TREATMENT CONSORTIUM HAD A CHANCE TO ANALYZE A LARGER NUMBER OF INFANTS WITH SEVERE COMBINED IMMUNODEFICIENCY, AND LOOKED AT IMPACT OF AGE BUT ALSO IMPACT OF INFECTIONS BECAUSE WHAT AGE REALLY IS REPRESENTING IN DR. BUCKLEY'S SERIES IS A SURROGATE FOR THE CLINICAL STATUS OF THE PATIENT AT THE TIME OF TRANSPLANTATION. IF YOU GO TO TRANSPLANT MUCH EARLIER IN LIFE, THEN THE CHANCE YOU'RE HAVING A SERIOUS INFECTION OR CHRONIC INFECTION IS LOWER. IF YOU WAIT LONGER, INFANTS THAT WENT TO TRANSPLANT AND AGE OVER 3.5 CHANCE OF THEM BEING INFECTED WAS MUCH HIGHER. IN THIS CARTOON PUBLISHED FIVE YEARS AGO IN NEW ENGLAND JOURNAL OF MEDICINE WE REPORTED ACTUALLY, YES, YOUNG AGE AT TRANSPLANTATION WAS ASSOCIATED WITH 95% SURVIVAL, BUT EVEN PATIENTS THAT WERE TRANSPLANTED AT OVER 3.5 MONTHS OF AGE BUT NO INFECTION PRIOR TO TRANSPLANT ALSO HAD GOOD SURVIVAL, BY CONTRAST PATIENTS AT OLDER AGE INACTIVE INFECTION AT TIME OF TRANSPLANTATION HAD POOR OUTCOME. REALLY IT'S THE INFECTION THAT DICTATES WHAT IS YOUR CAPACITY TO SURVIVE FOLLOWING TRANSPLANTATION, THAT TELLS US WHY IT IS SO IMPORTANT THAT WE USE NEWBORN SCREENING, BECAUSE THAT ALLOWS US TO IDENTIFY THESE INFANTS IN PRESYMPTOMATIC PHASE AND IMMEDIATELY TRANSPLANTATION OR GENE THERAPY FOR WHAT DR. MALECH WILL SHOW IN A MINUTE. ARE WE DOING BETTER NOW THAT WE HAVE NEWBORN SCREENING AVAILABLE? YES, WE ARE. THESE ARE DATA THAT REPORT SURVIVAL BY DECADE, BETWEEN 1980 AND 2000, BUT BEFORE ACTUALLY NEWBORN SCREENING BECAME AVAILABLE, SO UNTIL 2000, 2009, THE LAST PATIENT INCLUDED IN THE SLIDE, OVERALL SURVIVAL DID NOT IMPROVE SIGNIFICANTLY IN THIS PERIOD OF TIME. NEWBORN SCREENING AREA, NOW WE HAVE A MUCH BETTER SURVIVAL RATE, AROUND 90%, WITH NO DIFFERENCE BETWEEN TYPICAL AND ATYPICAL SCID, KEEP? MIND MAKING A DIAGNOSIS OF ATYPICAL MAY BE MORE DIFFICULT BECAUSE PATIENTS MAY HAVE T CELLS IN SOME NUMBER, MAY HAVE SOME IMMUNE RESPONSES, SO THEY MAY BE PROTECTED FOR SOME PERIOD OF TIME. SO THOSE ARE OFTEN COMING TO DIAGNOSIS AT LATER TIME IF YOU JUST USE CLINICAL GROUNDS TO MAKE A DIAGNOSIS. SO THIS IS ACTUALLY INDICATING HOW SUCCESSFUL THE NEWBORN SCREENING IS. NOW, HOW DO WE DO TRANSPLANT? IS IT REALLY NECESSARY TO USE CHEMOTHERAPY FOR INFANTS WITH SCID? IF YOU NEED TO DO A TRANSPLANTATION, THAT BABY HAS T CELLS, YOU NEED TO MAKE SPACE IN BONE MARROW, THE ONLY WAY TO GET RID OF THE T CELLS WE MIGHT MEDIATE GRAFT REJECTION, IMMUNOSUPPRESSION, CHEMOTHERAPY TO ELIMINATE AUTOLOGOUS STEM CELLS AND MAKE SPACE SO DONOR DERIVED CELLS CAN ENGRAFT. IN THEORY THERE ARE NO T CELLS, NO NEED THEORETICALLY TO USE IMMUNOSUPPRESSION AND TO USE CHEMOTHRAPY. IN SOME CASES IT MAY BE DANGEROUS TO USE CHEMOTHERAPY, ESPECIALLY IF YOU HAVE ACTIVE INFECTION AT THE TIME OF TRANSPLANTATION. AGAIN, THESE ARE DATA FROM THE CONSORTIUM PUBLISHED FIVE YEARS AGO, NICELY SHOW HOW IF YOU HAVE ACTIVE INFECTIONS AND YOU'RE USING HAPLOIDENTICAL DONOR AND CHEMOTHERAPY, THE OUTCOME IS MUCH WORSE THAN IF YOU USE NEW CHEMOTHERAPY. SO THERE ARE SOMEWHERE ONE HAS TO BE EXTREMELY CAREFUL IN USING CHEMOTHERAPY. THAT SAID, IT'S NOT NECESSARILY A BAD THING TO USE CHEMOTHERAPY. I'M GOING TO SHOW IN THE LAST SLIDES WHY THAT IS IMPORTANT. THESE ARE DATA, RECENT DATA, FROM A SINGLE CENTER STUDY FROM UNIVERSITY IN GERMANY, ONE OF THE LARGER CENTERS FOR TRANSPLANTATION WORLDWIDE. THEY LOOKED AT THE LONG-TERM OUTCOME. WE'RE LOOKING AT 30 YEARS POST TRANSPLANT. THEY WERE LOOKING AT THE CAPACITY OF THESE PATIENTS TO MAINTAIN SUSTAINED LEVELS OF CD4+ T CELLS. AND SUSTAINED LEVELS OF NAIVE CD4 POSITIVE T CELLS, COMPARING PATIENTS THAT RECEIVED AND DIDN'T RECEIVE CONDITIONING. YOU CAN SEE HERE IN THE ABSENCE OF CONDITIONING, OVER TIME, THE CAPACITY OF THE THYMUS TO GENERATE NEW T CELLS OFTEN GOES DOWN, THESE PATIENTS MAY IN FACT PRESENT SOME PROBLEMS THAT I'M SURE DR. MALECH WILL DISCUSS. THAT CORRELATES ALSO WITH MYELOID ENGRAFTMENT AS SURROGATE FOR STEM CELL ENGRAFT; IN ABSENCE OF CHEMOTHERAPY UNABLE TO SUPPORT LONG TERM STEM CELL, WHY IT CANNOT GENERATE FOR A LONG PERIOD OF TIME. WHAT ARE THE CONSEQUENCES OF SUCH IMPAIRED OR, IF YOU WISH, WANING OF T CELL IMMUNITY, MANY YEARS AFTER TRANSPLANTATION? THESE PATIENTS ALL OF A SUDDEN MAY START AGAIN EXPERIENCING RECURRENT INFECTION, MAY DEVELOP LUNG DISEASE, SUFFER FROM AUTOVIRUS, CHRONIC DIARRHEA, WEIGHT LOSS, SEVERE WARTS, INCREASED RISK OF SQUAMOUS CELL CARCINOMA, INFILTRATE DAMAGED TARGET TISSUES, BONE MARROW APLASIA, HIGH RISK OF INCREASED -- OF LYMPHOMA, IN PATIENTS WITH WANING T CELL IMMUNITY FOLLOWING INCOMPLETE DONOR STEM CELL ENGRAFTMENT. THERE IS SOMETHING TO BE DONE ABOUT THESE PATIENTS. AT THIS POINT THEY NEED TREATMENT, THIS IS WHAT DR. MALECH WILL TALK ABOUT. THEY MAY NEED A SECOND TRANSPLANT OR PERHAPS WHEN THEY HAVE GENE DEFECT THAT IS AMENABLE TO GENE THERAPY, GENE THERAPY IS A WAY TO GO. I WANT TO FINISH WITH ONE SLIDE TO REMIND YOU OF DAVID VECTOR, 25 YEARS AFTER HIS DEATH. DAVID WAS A VERY BRAVE CHILD WHO LIVED FOR TEN YEARS WITH HIS SEVERE COMBINED IMMUNODEFICIENCY. HE LIVED MOST OF HIS TIME ISOLATED FROM THE REST OF THE WORLD IN A BUBBLE CREATED FOR HIM BY NASA. AND I THINK HIS STORY, WHICH I INVITE ALL OF YOU TO READ ON PEDIATRIC RESEARCH, SEVERAL ARTICLES ABOUT HIS STORY, THAT WERE PUBLISHED OVER THE YEARS, TELLS US HOW MUCH PROGRESS WE'VE MADE IN THE TREATMENT OF SEVERE COMBINED IMMUNODEFICIENCY AND HOW NOW WE CAN RESCUE BABIES LIKE DAVID SO THAT THEY DON'T HAVE TO LEAVE THE SAME TRAGIC EXPERIENCE AGAIN. I'LL STOP HERE AND LET DR. MALECH TO CONTINUE. [APPLAUSE] I'M DELIGHTED TO HAVE AN OPPORTUNITY TO SPEAK TODAY, AND I'M EXTREMELY GRATEFUL FOR THE PRESENTATION BY DR. NOTARANGELO WHICH SAVES ME SPEAKING ABOUT THE BACKGROUND. SO, I HAVE NO FINANCIAL CONFLICTS. AND I AM SUPPOSED TO SAY THAT I'M GOING TO BE TALKING ABOUT A NON-APPROVED PRODUCT WHICH IS EX VIVO LENTE VECTOR STEM CELLS. THESE ARE LEARNING OBJECTIVES. TALKING ABOUT SCID AND EXPLAINING GENE THERAPY. I'D LIKE TO START INDICATING I'M DEDICATING THIS LECTURE TO THE MEMORY OF BRIAN SORNTINO, FORMER NIH'ER, WE HAD THE FORTUNATE OPPORTUNITY TO WORK WITH HIM SINCE 2006 DEVELOPING THIS LENTE VECTOR GENE THERAPY FOR X-SCID. HE LED THE GROUP AT ST. JUDE WHO TREATED INFANTS, AND DR. MERKATZ SHARED HER SLIDES, I'LL TALK ABOUT THE INFANTS, AND HERE AT THE NIH I'M FORTUNATE TO WORK WITH THOSE WHO HAVE BEEN OUR PARTNERS IN TREATING PATIENTS HERE AT THE NIH. DR. NOTARANGELO PROVIDED DEFINITIONS BUT THERE ARE A FEW MORE THAT MAKE THIS MORE UNDERSTANDABLE IF I EXPLAIN IT. FIRST OF ALL, THERE ARE TWO KINDS OF VECTORS IN A HAVE BEEN USED IN GENE THERAPY. ONE TYPE DEVELOPING IN MURINE GAMMA RETROVIRUS, THE OTHER FROM THE HUMAN IMMUNODEFICIENCY VIRUS, AND THAT'S CALLED LENTIVECTOR, THEY ARE RELATED BUT DIFFERENT ENOUGH THAT THEY HAVE DIFFERENT CHARACTERISTICS AND WAYS OF TARGETING INTEGRATING INTO THE GENOME. WHEN I TALK ABOUT VECTOR COPY NUMBER I'M TALKING ABOUT THE POPULATION AVERAGE OF GENE VECTOR INSERTS PER CELL. AND VERY IMPORTANT THING TO UNDERSTAND, WHICH DR. NOTARANGELO WENT INTO A LITTLE BIT IS IN THESE TRIALS WE'RE USING BUSULFAN FOR MYELOID CONDITIONING TO REDUCE NUMBER OF BONE MARROW HEMATOPOIETIC STEM CELLS, ALLOWING TRANSPLANTED CELLS TO ENGRAFT. IT'S IMPORTANT TO NOTE IT'S NOT WIDELY APPRECIATED THAT BUSULFAN DOESN'T TARGET OR REDUCE T CELLS BUT WILL REDUCE LONG-TERM REPOPULATING STEM CELLS IN THE MARROW. SO, I DON'T HAVE TO TALK A LOT ABOUT X-SCID EXCEPT TO REMIND YOU IT'S A SPECIFIC GENETIC DISORDER, IL-2 RGG GENE, ENCODING A COMMON GAMMA CHAIN, SIGNAL FOR INTERLEUKIN, A LOT OF RECEPTORS ARE NOT WORKING WELL, THIS IS A SEVERE DISORDER RESULTS IN DEFECT IN T,B AND NK CELL IMMUNITY. THERE ARE IMMATURE B CELLS IN REDUCED NUMBERS AND THEY FAIL TO PRODUCE IMMUNOGLOBULINS. THESE PATIENTS AS INDICATED GET LIFE-THREATENING OPPORTUNISTIC INFECTIONS. SEVERE SCID AS INDICATED IS FATAL IN INFANS WITHOUT TRANSPLANT TO PROVIDE IMMUNE RECONSTITUTION, THOSE WITHOUT A MATCHED SIBLING DONOR IN THE PAST AN EVEN CURRENTLY ARE MOST OFTEN RECEIVING A GRAFT FROM A PARENT BUT HISTORICALLY MOST CENTERS HAVE USED ALSO OR NO MYELOID CONDITIONING, AND DR. NOTE RANGLY SHOWED THE STUDY FROM THE GERMAN CENTER, WHAT HAPPENS WHEN YOU DON'T USE ANY CONDITIONING VERSUS WHEN YOU DO. SO MYELOID CONDITIONING IS NOT REQUIRED FOR T CELL RECONSTITUTION. BUT WITHOUT MYELOID CONDITIONING, THERE'S LIMITED OR NO B CELL ENGRAFTMENT, NEED FOR LIFE-LONG IMMUNOGLOBULIN SUPPLEMENTATION, AND AS INDICATED BY THE SLIDES ALSO SHOWN BY DR. NOTARANGELO OVER TIME, IT'S YEARS, NOT TALKING ABOUT ONE OR TWO OR THREE YEARS, WE'RE TALKING OVER 30 YEARS OF LIFE, THERE'S DECREASING DONOR T CELL REPERTOIRE FUNCTION AND NUMBER, CAN HAVE FASTER IN SOME PATIENTS, SLOWER IN OTHERS, HARD TO PREDICT. SOMEBODY AT 9 YEARS OLD CAN BE JUST FINE AND AT 30 CAN HAVE PROBLEMS. SOMEONE AT 3 YEARS OLD CAN HAVE PROBLEMS. IT'S HARD TO PREDICT. BUT IT'S THE PATIENTS WHO DEVELOP CHRONIC MEDICAL PROBLEMS AND LOSS OF THEIR T CELL FUNCTION THAT COME TO SEE US HERE AT THE NIH TO CONSIDER GENE THERAPY. I WON'T READ THE PROBLEMS. DR. NOTARANGELO MENTIONED THAT. WHAT ABOUT PRIOR OUTCOMES USING MURINE GAMMARETROVIRAL VECTORS WITHOUT CONDITIONING? IN A SERIES OF STUDIES, 29 PATIENTS HAVE BEEN TREATED OVER THE LAST 15 TO 18 YEARS, AND 26 HAVE BENEFITED LONG TERM FROM THE GENE THERAPY. GENE THERAPY RESTORED T CELL NUMBER AND FUNCTION WITH NO LONG-TERM GENE MARKING NOR CORRECTION OF B, NK CELLS, SOME DEVELOPED INSERT RELATED LEUKEMIA, ONE PATIENT FAIRLY RECENTLY AT 15 YEARS POST-GENE THERAPY. AND IN STUDIES DONE HERE AND IN LONDON, WHEN WE TRIED TO USE THIS WITH OLDER X-SCID PATIENTS AND YOUNG ADULTS WITH MURINE RETROVIRAL VECTOR THERE WASN'T T CELL RECONSTITUTION, WE HAD NO PROBLEMS BUT NO BENEFITS. THE CONCLUSIONS FROM THOSE PRIOR STUDIES ARE THAT WE NEED SAFER VECTOR SYSTEM, AND WE NEED MYELOID CONDITIONING. IN 2006 AS I MENTIONED OUR GROUP INITIATED COLLABORATION WITH BRIAN SORENTINO AND COLLEAGUES AT SAINT JUDE, DRIVING A CODON OPTIMIZED cDNA, AND CAME UP WITH A PLAN TO USE NON-MYELOABLATIVE CONDITION, HIGHER IN OLDER CHILDREN AND YOUNG ADULTS, MUCH LOWER IN INFANTS, ATTEMPT TO ACHIEVE IMMUNE RECONSTITUTION OF B CELLS AND NK CELLS IN ADDITION TO RESTORATION OF FUNCTIONAL AUTOLOGOUS GENE MARKED T CELLS. AS WE WENT FORWARD, THE SECTOR MADE AT THE ST. JUDE VECTOR PRODUCTION FACILITY WAS USED FOR TWO CLINICAL TRIALS. WE INITIATED TRIAL HERE AT THE NIH TO TREAT OLDER CHILDREN AND YOUNG ADULTS. AND AT ST. JUDE LAGGING A BIT BEHIND IN GETTING STARTED THEY INITIATED A TRIAL TO TREAT NEWLY DIAGNOSED INFANTS BETWEEN 2 AND 12 MONTHS OF AGE. I HAD MENTIONED THE FACT THAT THE ST. JUDE TRIAL INTERACTED CLOSELY WITH THE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO GROUP AND SEATTLE. WE'VE TREATED EIGHT PATIENTS THAT I'M GOING TO TALK ABOUT TODAY. THEY HAVE TREATED EIGHT INFANTS. BOTH OF US HAVE TREATED PATIENTS MORE RECENTLY. IT'S IMPORTANT TO NOTE WE WERE -- ONCE WE TREATED OUR EIGHT PATIENTS WE SORT OF RAN OUT OF THE GOOD VECTOR, AND WE HELD OUR STUDY BECAUSE WHEN NEWLY DIAGNOSED INFANTS COME ON BOARD, THEY CAN'T WAIT. THEY HAVE TO BE TREATED. ALL VECTORS STARTED 2 YEARS OUGHT SHUNTED TO TREAT THE INFANTS, WE NOW HAVE NEW VECTOR AND ARE READY TO START GOING WITH CHILDREN AND OLDER ADULTS. THIS IS AN OUTLINE OF THE TRIAL. LET ME MAKE THIS WORK. YES, OKAY. SO AT NIH WITH THE OLDER CHILDREN AND YOUNG ADULTS WE USED GCFS MOBILIZATION, APHORESE, SELECT CD34 CELLS AND CRYOPRESERVE UNTIL WE HAVE ENOUGH TO GO FORWARD. AT ST. JUDE, THESE ARE INFANTS. THEY HARVEST BONE MARROW, SELECT 34 CELLS, THEY DON'T FREEZE. OUR PROTOCOL TAKES CRYOPRESERVED CELLS, HARVESTS AND GIVES CELLS FRESH. ST. JUDE STUDY THEY PROCESS FRESH, TRANSDUCE WITH LENTIVECTOR. WE TREED WITH 6 MILLIGRAMS PER KILOGRAM, EVERYBODY GETS THE SAME BIOLOGICAL EFFECT. INFANTS GET A LOT LESS BUT THIS 2 MILLIGRAMS AN INFANT IS CLOSER THAN ONE MIGHT THINK TO THE ACTUAL BIOLOGICAL EFFECT OF THE 6 MILLIGRAMS IN THE OLDER CHILDREN AND YOUNG ADULTS. SO AT THE NIH CLINICAL TRIAL, OUR EIGHT OLDER CHILDREN AND YOUNG ADULTS ALL HAD RECEIVED IN INFANCY HAPLOIDENTICAL BONE MARROW TRANSPLANT FROM PARENT WITHOUT MYELOID CONDITIONING, T CELL LINEAGE FROM DONOR, 98 TO 100% OF CIRCULATING C TELLS, GENERALLY THESE WERE T CELLS THAT WEREN'T FUNCTIONING AT FULL CAPACITY. ALL REQUIRED LIFELONG SUPPLEMENTAL IgG. IF A PATIENT WAS IN THEIR EARLY 20s WHEN TREATED BY US, THEY HAVE BEEN ON IgG FOR 20 YEARS, AND NEEDED IT FOR 20 YEARS. SEVEN OF EIGHT HAD LONG-TERM CHRONIC NOROVIRUS INFECTION, BIG PROBLEM. MANY PATIENTS IN FACT WERE DOING FINE UNTIL THEY GOT THEIR NOROVIRUS INFECTION AND THINGS WENT SOUTH IN TERMS OF QUALITY OF LIFE AND EVERYTHING ELSE. ALL HAD WANING T CELL FUNCTION, RECURRENT INFECTION, VARIETY OF MEDICAL PROBLEMS. THIS IS IN A WAY I'M GETTING TO THE END OF THE STUDY, I'LL GO INTO THE DETAILS. SO FROM -- OOPS, FROM 2012 WHEN WE RECRUITED AND TREATED OUR FIRST PATIENT THROUGH 2016 WE TREATED EIGHT PATIENTS, VARIOUS AGES AT THE TIME OF TREATMENT. AND AT THIS POINT, THIS PATIENT, THIS PATIENT, THIS PATIENT, AND THIS PATIENT, FOUR OUT OF EIGHT, NO LONGER NEED IgG SUPPLEMENTATION. AND ARE RESPONDING TO IMMUNIZATION. THESE TWO PATIENTS NEED A LOT LESS IgG AND WE HOPE AT SOME POINT THEY WILL BE ABLE TO COME OFF THEIR IgG. THIS PATIENT IS STILL ON -- WE'RE SEEING SOME CHANGES, WE HOPE WE'LL GET THERE. THIS PATIENT JUST AS YOU'LL SEE IN THE OTHER SLIDES I SHOW YOU, JUST HASN'T REALLY RESPONDED THE WAY WE HOPED, AND WE'RE THINKING ABOUT RETREATING. I'LL GET BACK TO THAT LATER. MORE IMPORTANT, AFTER YEARS OF NOROVIRUS INFECTION, SIX OUT OF SEVEN WHO CAME TO US WITH NOROVIRUS INFECTION ARE NOW CURED OF THEIR NOROVIRUS INFECTION. AT LAST LOOK AT THEIR HOST T CELLS WHICH STARTED OUT AT 0 TO 2%, LIVING ON DONOR T CELLS, BUT NOW THEY HAVE VARIOUS NUMBERS OF THEIR OWN T CELLS THAT COMPRISE THOSE PERCENTS. NOW WE LOOK IN A FINER DETAIL. AND THE POINT OF SHOWING THIS FINER DETAIL HERE, AND THOSE OF YOU WHO USE OUR CRIS SYSTEM, THIS DATA CAME RIGHT OUT OF CRIS, YOU CAN SEE IN PATIENT ONE THINGS HAPPENED SLOWLY AND ARE STILL HAPPENING. AND THAT REALLY SURPRISED US. THIS ISN'T, YOU KNOW, A SUDDEN AND RAPID EVERYTHING'S ALL FIXED, BUT WE KIND OF THOUGHT WE'D REACH A PLATEAU AT A YEAR OR SOMETHING AND THAT WOULD BE IT. IN FACT, PATIENT ONE TELLS US WE DON'T KNOW WHERE HE'S GOING TO END UP IN TERMS OF HOW WELL HE'S GOING TO DO. PATIENT TWO, THE REASON THIS IS 2.5 YEARS, THIS UNFORTUNATE PATIENT HAD EXTREMELY BAD BRONCKYECTASIS, WHICH WE'RE NOT GOING TO FIX WITH GENE THERAPY, QUALITY OF LIFE IMPROVED, HAD HE A SUDDEN BLEED WITH BRONCKYECTASIS AND DIED AT HOME HOSPITAL 2 1/2 YEARS. NO OTHER DEATHS, BUT THAT WAS A TOUGH ONE FOR US. YOU CAN SEE THE SAME THING IN ALL OF THESE, AND SO FOR EXAMPLE HERE IS PATIENT 7, WHO ACTUALLY IS REPLACING HIS DONOR T CELLS VERY QUICKLY. PATIENT 8 AS I SAID IS LAGGING BEHIND. HASN'T REALLY -- MAYBE WE'RE SEEING A HINT OF SOMETHING, MAYBE NOT. I JUST WANT TO TALK ABOUT NK CELLS NOW. THE NK CELLS ARE INTERESTED. THEY HAVE GONE UP IN EVERYBODY, BUT QUITE VARIABLY. IT'S HARD TO PREDICT. I'LL SHOW THE SAME SORT OF SLIDE WITH THE INFANTS, AND YOU'LL SEE THAT THERE'S NO RHYME OR REASON FOR WHO IS MAKING LOTS OF NK CELLS, WHO IS MAKING A FEW, ALL MADE MORE THAN WHEN THEY STARTED. AND YOU CAN SEE THIS TOO IN PATIENT 1 OCCURS OVER A VERY LONG PERIOD OF TIME. SO THE LINE HERE YOU SEE IS 100 PER MICRO LITER, AND THIS LITTLE TRIANGLE IS THE NORMAL LEVEL. IT'S TAKING A LONG TIME BUT HE'S SORT OF TRYING TO REACH TOWARD FULLY NORMAL LEVELS OF NK CELLS, AS I SHOW THE OTHER SET OF PATIENTS AGAIN OUR LAST PATIENT JUST ISN'T REALLY DOING WHAT HE NEEDS TO DO. AND WHAT I REALLY WANT TO SHOW IS DR. NOTARANGELO TALKED ABOUT TRECs, A WAY TO LOOK AT AND DEFINE RECENT THYMIC IMMIGRANTS, NAIVE T CELLS. THERE'S ANOTHER WAY TO LOOK AT IT. CELLS THAT ARE CD3, CD4 POSITIVE, CD45 RA POSITIVE AND CD31 POSITIVE ARE RECENT THYMIC IMMIGRANTS AND OVER TIME LOSE CD31. AGAIN IN THE ADULT, HE STARTED OUT REALLY LOW, TOOK A LONG TIME, I WOULD SAY, YOU KNOW, IF THIS IS WHEN WE LOOKED AT HIM WE WEREN'T TERRIBLY IMPRESSED WITH HIM MAKING NAIVE T CELLS BUT NOW HE'S COMING UP. THIS PATIENT OBVIOUSLY WE DIDN'T FOLLOW VERY LONG, YOU DON'T SEE MUCH. THIS PATIENT 3 IS WAY UP IN THE NORMAL RANGE. THIS PATIENT IS WAY UP IN THE NORMAL RANGE. AND WHAT I'VE DONE IS SAY ADULT, ADULT, CHILD, CHILD, AND YOU CAN SEE THERE'S A BIG DIFFERENCE THERE. SAME THING IN THIS -- IN THE OTHER SET. SO THIS IS A CHILD. THIS IS AN ADULT. THIS IS A CHILD. THIS IS A CHILD. SO, ALTHOUGH WE'RE BENEFITING THESE PATIENTS, IT'S CLEAR THAT YOU'RE GETTING A WHOLE LOT MORE THYMIC FUNCTION OUT OF CHILDREN THAN YOU ARE GETTING OUT OF ADULTS. SO, CLEARLY THE EARLIER WE CAN DO THIS, THE BETTER. AND EVEN BETTER AS YOU'LL SEE TO DO THEM IN INFANCY. BUT HERE AT NIH WE DEAL WITH LEFT BEHINDS, AND THESE ARE LEFT BEHIND CHILDREN AND YOUNG ADULTS, SO WE'VE TAKEN ON THAT TASK. ONE THING OF QUITE INTEREST THAT WE SAW, WHEN WE DID PATIENT 1 YOU COULD IMAGINE OUR EXCITEMENT AND FRIGHT AS HE BEGAN EARLY ON AFTER THE GENE THERAPY TO MAKE IgM. YAY. THEN HE MADE MORE IgM. THEN AMAZING AMOUNT OF IgM. WE SAID, OH, DID WE GIVE THIS PATIENT MYELOMA? AND WE DID ALL THE STUDIES. R. AND SO ON. WE DIDN'T GIVE HIM MYELOMA, HE CAME DOWN IN THE NORMAL RANGE. WATCHING OVER TIME WE'VE COME TO REALIZE WE DON'T UNDERSTAND IT BUT IT'S QUITE PREDICTABLE. AND MORE IMPORTANT, UNTIL THEY GET THEIR IgM SPIKE, THEY DON'T REALLY START MAKING IgG. I DON'T THINK WE FULLY UNDERSTAND, YOU CAN MAKE THINGS UP, I WILL TRY NOT TO DO THAT HERE, BUT CLEARLY SOMETHING VERY IMPORTANT TO LEARN ABOUT THE RECONSTITUTION OF IMMUNITY AND THE FIRST MAKING OF IgM, TOO MUCH IgM, COMING DOWN TO NORMAL, MAKING IgG THEN. AND YOU CAN SEE THE SAME PATTERN, WE'RE STILL WAITING FOR OUR LAST PATIENT, AND AS I SAID WE'RE THINKING OF RETREATING HIM BECAUSE HE'S ABOUT 2 1/2 YEARS OUT NOW. SO WHAT ABOUT VECTOR COPY NUMBER? I'M NOT GOING TO DWELL ON THIS, I WANT TO GET TO THE INFANTS. THE ONLY POINT I WANT TO MAKE IS THAT IT'S OF INTEREST THAT THE NK CELLS CONSTANTLY HAVE A MUCH, MUCH HIGHER COPY NUMBER EVEN THOUGH THERE'S NOT A LOT OF THEM THAN EVERYTHING ELSE. THERE IS A TENDENCY TO HAVE HIGHER COPY NUMBER IN THE T AND B CELLS, SO THERE'S A SELECTIVE OUTGROWTH, BUT IT'S PARTICULARLY PROFOUND IN THE NK CELLS. AGAIN, I COULD MAKE THINGS UP. BUT IT'S SOMETHING WE NEED TO BETTER UNDERSTAND. DO THEY NEED HIGHER COPIES TO MAKE NK CELLS, FOR EXAMPLE? IN OTHER WORDS, DO YOU NEED MORE -- REMEMBER, THE VECTOR ONLY MAKES X AMOUNT OF COMMON GAMMA CHAIN, IF YOU HAVE MORE THAN ONE COPY OF THE VECTOR IN A CELL YOU'RE MAKING PROBABLY TWICE AS MUCH OR THREE TIMES AS MUCH. CLEARLY NK CELLS PROBABLY NEED MORE, SELECTING CELLS WITH HIGHER COPY NUMBER OF THE VECTOR IN THERE. AND, AGAIN, YOU CAN SEE IT'S SORT OF TRUE ACROSS ALL EIGHT PATIENTS. SUMMARY OF THIS IS THAT SIX OF SEVEN PATIENTS WITH CHRONIC NOROVIRUS ACHIEVED CURE. FIVE OF SIX ACHIEVED CURE. SEVEN OR EIGHT ACHIEVED NORMAL IgM, HALF OFF IgG SUPPLEMENTS, RESPONDING TO IMMUNIZATION, SIX OF EIGHT INCREASING NORMAL MEMORY B CELLS, AND SEVEN OF EIGHT INCREASED VECTOR MARK HOST T CELLS THAT IMPROVED T CELL PROLIFERATION RESPONSES. FOUR OUT OF FIVE CHILDREN GENERATED NORMAL LEVELS OF NEW THYMIC IMMIGRANTS. ALL PATIENTS HAVE POLYCLONAL MARKED T, B, NK, MYELOID CELLS. THIS BEARS WATCHING, GIVEN WHAT'S HAPPENED WITH THE MURINE RETROVIRAL VECTORS IT'S A CAUTIONARY NOTE, WE'RE KEEPING AN EYE ON THINGS. WE AND FDA AND REGULATORY BODIES ARE OKAY FOR NOW BUT I JUST NEED TO MAKE SURE THAT EVERYBODY KNOWS THAT WE HAVE THIS PATIENT WE'RE WATCHING. SO WHAT ABOUT THE ST. JUDE STUDY? THEY WERE IDENTIFIED BY NEWBORN SCREENING OR AFTER PRESENTING WITH INFECTION, TWO WITH SIGNIFICANT LEVELS OF MATERNAL T CELLS CAUSING NEUTRIPENIA AND OTHER PROBLEMS. TWO PRESENTED WITH SIGNIFICANT BCG INFECTION BECAUSE THEY CAME FROM COUNTRIES WHERE BCG VACCINATE IN INFANCY. AND I'M NOT GOING TO GO THROUGH THE FINE DETAILS OF THIS SLIDE EXCEPT TO SAY THAT ALL OF THESE PATIENTS EXCEPT ONE WERE UNDER 1 YEAR OF AGE WHEN TREATED, SOME WERE RELATIVELY HEALTHY, BUT SOME LIKE THIS FIRST ONE WITH HIGH MATERNAL ENGRAFTMENT HAD PROBLEMS WITH NEUTRIPENIA AND LOTS OF INFECTIONS, CMV WAS A PARTICULAR PROBLEM, I'LL RETURN TO THAT IN A BIT. YOU CAN SEE THERE WAS A VARIETY OF ISSUES HERE. THERE ARE GENE MARKING, T CELLS, SO REMEMBER UNLIKE THE PATIENTS I TREATED THEY START WITH NOTHING. SO THE ONLY T CELLS THEY ARE GOING TO GET ARE CORRECTED T CELLS. SO IF YOU WATCH THE NUMBER OF -- THIS IS NUMBER OF T CELLS OVER TIME. YOU CAN SEE PATIENT 1 IS LAGGING. LIKE US, THEY HAD ONE PATIENT WHO ISN'T DOING WHAT YOU HOPED THEY WOULD DO. SAME WITH B CELLS. AND INTERESTINGLY WITH NK CELLS PATIENT 1 IS DOING SOMETHING, ALTHOUGH NOT MAKING A WHOLE LOT OF NK CELLS. THE GENE MARKING, AS YOU CAN SEE, IS GOING UP IN THE B CELLS BECAUSE THERE'S SOME SELECTIVE ADVANTAGE IN OUTGROWTH. IN MONOCYTES IT SORT OF COMES UP EARLY, SORT OF STAYS STEADY. WE AND THEY HAVE SEEN SLOW RISES EVEN IN MYELOID CELLS, IN SOME OF THE PATIENTS. RECONSTITUTION OF T CELLS AND NC CELLS SHOWN HERE, I WILL POINT OUT THE SORT OF JUMBLE IN TERMS OF NUMBERS OF NK CELLS COMING UP, KIND OF WHAT WE SAW. NO PREDICTING WHO CAN TELL WHO IS GOING TO HAVE ROBUST T CELL -- I MEAN NK CELLS RESPONSE, WHO IS NOT, SOMETHING FOR US TO UNDERSTAND BUT CLEARLY THE SAME IN THE INFANTS AND IN OUR PATIENT GROUP. THIS JUST SHOWS THAT IN LOOKING AT TRECs, THE OTHER WAY TO LOOK AT IT, THESE GUYS ARE MAKING LOTS OF TRECs. THIS PATIENT, PATIENT 1, SOMEWHAT LESS. THEY RESPOND TO PHA, AND IN THE SPECTRO TYPING THERE'S REALLY NICE T CELL DIVERSITY. VERY IMPORTANT IS THAT LIKE OUR PATIENTS, IF YOU STARE AT THIS YOU CAN SEE, HMM, THERE'S THIS IgM BUMP AND IT'S COMING DOWN. WHATEVER WE SAW IN THE -- THEY WOULD HAVE WORRIED BUT KNEW THEY WERE SEEING THIS IN OUR OLDER -- A BUNCH OF OLDER PATIENTS SO AS I SAY IT'S SOMETHING THAT WE NEED TO BETTER UNDERSTAND. SOME OF THE PATIENTS HAVE BEEN IMMUNIZED. THEY RESPOND TO PNEUMOCOCCAL OR THE DPT OR IN THIS CASE TO POLIO, THE KILLED POLIO VACCINE. SO WHAT ABOUT PATIENT 1 WHO WAS LAGGING BEHIND? SO, SOMEWHERE ABOUT 12 MONTHS, THERE WAS HUGE AMOUNT OF DEBATE, I WAS ON THE PHONE, EVERYBODY WAS ON THE PHONE TRYING TO DECIDE SHOULD WE GIVE THIS LITTLE BOY A BOOST, AND THE DECISION WAS MADE TO GIVE THE BOOST OF GENE-CORRECTED -- AUTOLOGOUS GENE-CORRECTED CELLS BUT NOT TO USE HIS CONDITIONING. THIS WILL WORKED PRETTY WELL. WHAT'S REALLY IMPORTANT IS THAT HE HAD A CHRONIC CMV THAT BY ABOUT SIX MONTHS AFTER THE BOOST DISAPPEARED. SO THAT WAS A VERY NICE RESPONSE. THIS PATIENT'S NOW DOING QUITE WELL. THIS JUST SHOWS FOR THE INFANT STUDIES, BUT SIMILAR IN OUR STUDIES, THIS IS JUST A WAY OF SHOWING DIVERSITY OF INTEGRATION SITES, IF IT'S GRAY IT MEANS THERE'S THAT MANY, THAT PERCENT SINGLE COPY. AND THEN IN THE COLORS ARE CLONAL -- IN OTHER WORDS A SINGLE CLONE REPRESENTS THAT MUCH OF THE LINEAGE. AND THIS IS ACCEPTABLE. SO, OVERALL IN THE CLINICAL OUTCOME I WILL POINT OUT THAT FOUR OF EIGHT, SAME AS US, HALF OF THE PATIENTS, ARE OFF IgG, HAVE BEEN IMMUNIZED AND RESPONDING. THEY RESOLVE BCG, RESOLVE BCG HERE, AND THIS PATIENT ALSO RESOLVED HIS CORONAVIRUS AND CMV. NOW, THIS PATIENT DEVELOPED AN AUTOIMMUNE HEMOLYTIC ANEMIA. YOU MAY REMEMBER OR MAYBE I FORGOT TO MENTION BUT I'LL MENTION HERE THAT ONE OF OUR PATIENTS, PATIENT NUMBER 7, ALSO EARLY ON DEVELOPED AN AUTOIMMUNE HEMOLYTIC ANEMIA, BOTH GOT TREATED, BOTH RESOLVED, BOTH JUST WENT ON SO THIS IS NOT A PROBLEM. AND I'LL -- IN MY WRAP-UP I WILL SAY SOMETHING ABOUT WHAT THAT ALL MEANS. THE OVERALL SUMMARY OF THE OUTCOME OF BOTH TRIALS IN EIGHT INFANTS, AND EIGHT OLDER CHILDREN, YOUNG ADULT, COMMON FEATURES THAT MYELOID MARKING VARIED BETWEEN 10 AND 60%, ALMOST ALL PATIENTS IN BOTH STUDIES ACHIEVED SUBSTANTIAL SUSTAINED GREEN GENE T, B AND NK. FOUR IN EACH GROUP ACTUALLY RESPONDED TO IMMUNIZATION WITH PROTECTIVE IgG TITERS, NO LONGER REQUIRING IgG SUPPLEMENT. PATIENT 1 WAS 23 WHEN TREATED, LIFETIME NEEDING IgG, ENTEROPATHY, ALL THAT WENT AWAY, NOW BEEN FIVE YEARS WITHOUT ANY NEED FOR IgG, RESPONSING TO ALL IMMUNIZATIONS, INCLUDING LIVE VACCINES SUCH AS ZOSTER, THAT'S PRETTY REMARKABLE. AND SO AS I MENTIONED ONE 3-YEAR-OLD CHILD AND UNINFANT DEVELOPED AUTOIMMUNE HEMOLYTIC ANEMIA, LIKELY RESULTED FROM DYSREGULATED FAILURE OR AUTOREACTIVE B CELLS. I DON'T HAVE IT WRITTEN ON HERE, IT IS KNOWN THAT RISK OF AUTOIMMUNE HEMOLYTIC ANEMIA EARLY AFTER TRANSPLANT, JUST REGULAR TRANSPLANT, HAS BEEN SEEN IN A REASONABLE NUMBER OF SCID PATIENTS SO WE THINK THIS IS A GENERAL PRINCIPLE AND APPLIES TO GENE THERAPY AS WELL. MY LAST SLIDE I WANT TO SAY THAT VERY IMPORTANT PRINCIPLE OF THESE TRIALS WITH RESPECT TO MYELOID CONDITIONING IS THAT EVEN WITH DISORDER WHERE THERE'S STRONG SELECTIVE GROWTH AND SURVIVAL ADVANTAGE, PROVIDED TO T, B AND NK CELLS FROM GENE THERAPY COLLECTION, LOW DOES TO SUBABLATIVE CONDITIONING BUT NOT MYELOABLATIVE IS NECESSARY AND SUFFICIENT. I'D LIKE TO AT THIS TIME USE THIS TO ALSO ADVERTISE THAT WITHIN THE PRIMARY IMMUNE DEFICIENCY TREATMENT CONSORTIUM, DR. SUN NUN PI AND PULSIRFER ARE LOOKING AT DOUGH LOWEST BUSULFAN CONDITIONING FOR HAPLOTRANSPLANTS TO SEE WHETHER THEY CAN GET OUTCOME USING THAT APPROACH WE'RE SEEING WITH GENE THERAPY. SO WE'RE VERY EXCITED, WE'RE ENTERING AN ERA WHERE WE'RE GOING TO ADJUST THIS MYELOID CONDITIONING TO GET THE RESULTS WE WANT WITHOUT CAUSING TOO MUCH HARM IN THESE PATIENTS. AND AT THIS POINT I WANT TO END BY SAYING I'M EXTREMELY GRATEFUL TO MY COLLEAGUES AND EVERYONE ELSE IN OUR GROUP WHO PUT SO MUCH EFFORT INTO THE TRIAL HERE AT THE NIH, ONE IS THE P.I. ON THE PROTOCOL. SPECIAL THANKS TO THE CENTER FOR CELLULAR ENGINEERING, I'VE LISTED THE LEADERS BUT SPECIAL THANKS TO THE STAFF WHO PUT SO MUCH TIME AND EFFORT INTO DOING THIS SO WELL. AND OF COURSE, MY DEAR FRIEND AND COLLEAGUE BRIAN SORRENTINO WHOM I HUGELY MISS AND THE P.I. ON THE PROTOCOL THERE, AND SPECIAL THANKS FOR SHARING INFANT SLIDE SET AND OUR COLLEAGUES IN SAN FRANCISCO WHO ALSO HAVE BEEN VERY IMPORTANT TO OUR STUDIES. THANK YOU VERY MUCH. [APPLAUSE] >> OKAY. WE HAVE TIME FOR A COUPLE QUESTIONS, IF YOU COULD COME TO THE MICROPHONES ON THE AISLE PLEASE WE'LL GET STARTED. WHILE WE'RE WAITING FOR FOLKS TO COME, I'M STILL FASCINATED BY THE PHENOMENON OF CONDITIONING, LEADING ULTIMATELY IN THESE PATIENTS TO BETTER OUTCOMES, MANY, MANY, MANY YEARS LATER. AND WHAT IS THE INSIGHT YOU'RE TAKING AWAY FROM THAT? WHY IS THIS HAPPENING FROM YOUR PERSPECTIVE? >> AGAIN, TRUTH IN ADVERTISING, I'M MAKING THINGS UP. WE NEED TO UNDERSTAND -- SO MY SPECULATION IS THAT WITH ALL OF THESE CELL TYPES THAT CONTINUE TO GET BETTER AND BETTER OVER TIME, THERE ARE PROBABLY COMPARTMENTS THAT NEED TO BE FILLED AND THINGS THAT HAPPEN WITH PARTIAL THYMIC FUNCTION AND SO ON THAT MAY HAPPEN SLOWER IN THE ADULT WAS RETENTION OF POOR THYMIC FUNCTION VERSUS THE KIDS, AND I REALLY DON'T FEEL THAT WE ALONE ARE CAPABLE OF DOING ALL THE STUDIES THAT PROBABLY NEED TO BE DONE ON THESE PATIENTS. AND WE CERTAINLY WELCOME COLLABORATORS WHO HAVE IDEAS THAT MIGHT TEACH US THINGS, USING OUR -- YOU KNOW, WORKING WITH US ON THESE PATIENTS. >> OKAY. ALL RIGHT. WELL, LOOKS LIKE WE'RE OUT OF TIME. SORRY, JOHN? >> THANK YOU BOTH. I LIKE TO FANTASIZE, SOUNDS LIKE IN THE OLDER PATIENTS THE PROBLEM IS LOSS OF THYMIC FUNCTION. IS THERE ANY THOUGHTS ON TAKING iPS CELLS AND RECREATING A THYMUS THAT MAYBE COULD GO BACK INTO THOSE PATIENTS? >> JOHN, MY GROUP HAS ACTUALLY GENERATED THYMIC PROGENITOR CELLS FROM iPS, AND WE CAN SEE GOOD PROFILE IN TERMS OF TRANSCRIPTION PROFILE OF THOSE CELLS, BUT WE CANNOT REALLY GET FULLY MATURE THYMIC EPITHELIAL CELLS, PROBABLY THAT PROCESS REQUIRES ALSO CROSS-TALK WITH DEVELOPING LYMPHOCYTES, SO WHEN YOU TRY TO DIFFERENTIATE IN VITRO iPS YOU GET UP TO A STAGE, CAN'T REALLY GO BEYOND THAT STAGE. WOULD THOSE CELLS IF INJECTED INTO A PATIENT BECOME DIFFERENTIATING INTO MATURE, THAT REMAINS TO BE SEEN. THIS WOULD BE HARD TO DO IN HUMANS. HAS BEEN DONE IN NUDE MOUSE MODEL WHERE SOME T CELL PRODUCTION IS OBSERVED. I HAVE YET TO SEE CONVINCING DATA THE CELLS FULLY MATURE, CRITICALLY IMPORTANT NOT ONLY TO ALLOW FULL PRODUCTION OF T CELLS BUT ALSO T CELL TOLERANCE, YOU NEED MATURATION TO DELETE THE CELLS THAT ARE STOCHASTICALLY GENERATED. A LONG WAY TO GO, BUT THERE IS HOPE. >> FINAL QUESTION PLEASE. YES? >> DR. MALECH, I'M SURE YOU KNOW ABOUT REPORT FROM A FRENCH GROUP THAT THERE'S A PROBLEM ABOUT RECONSTITUTING INNATE LYMPHOID CELLS. DID YOU LOOK AT -- >> WELL, SO THAT'S A CONTROVERSIAL PAPER, I'LL SAY. SO, YEAH, PUBLISHED IN "CELL" A COUPLE YEARS AGO THAT YOU DON'T REALLY NEED INNATE LYMPHOID CELLS IN PATIENTS WITH SCID AND IN FACT ILCs ARE NOT RECONSTITUTED IN ABSENCE OF CONDITIONING, THEY DO IF YOU USE CONDITIONING. THEY CLAIM ILCs ARE NOT NECESSARY TO HUMANS BECAUSE THEY DON'T SEE MUCH OF A DIFFERENCE IN TERMS OF CLINICAL PHENOTYPE. PATIENTS DID RECONSTITUTION AND DIDN'T, STILL CONTROVERSIAL, ALSO THERE ARE VERY LITTLE DATA IN THAT PAPER ABOUT THE PRESENCE OF ILCs IN TARGET TISSUES. ILCs ARE IMPORTANT IN PERIPHERAL TISSUES TO MODULATE IMMUNE FUNCTION, IT'S STILL PRELIMINARY, INTRIGUING OBSERVATIONS, THE LAST WORD NOT SAID YET. [APPLAUSE] >> I THANK YOU ALL. WE'LL SEE YOU NEXT WEEK AT GRAND ROUNDS. THANK YOU VERY MUCH.