Allogeneic hematopoietic cell transplantation led to the discovery of the allogeneic GVL effect, which remains the most convincing evidence that immune cells can cure cancer in humans. However, despite its great paradigmatic and clinical relevance, induction of GVL by conventional allogeneic hematopoietic cell transplantation remains a quite rudimentary form of leukemia immunotherapy. It is toxic and its efficacy is far from optimal. It is therefore sobering that since the discovery of the GVL effect 3 decades ago, the way GVL is induced and manipulated has practically not changed. Preclinical and clinical studies suggest that injection of T cells primed against a single Ag present on neoplastic cells could enhance the GVL effect without causing any GVHD. We therefore contend that Ag-targeted adoptive T-cell immunotherapy represents the future of leukemia immunotherapy, and we discuss the specific strategies that ought to be evaluated to reach this goal. Differences between these strategies hinge on 2 key elements:
IntroductionThe GVL reaction refers to the ability of donor immune cells to eliminate host leukemic cells after allogeneic hematopoietic cell transplantation (AHCT). In 1956, Barnes et al 1 were the first to report cure of leukemia in mice after total body irradiation and AHCT. Further studies of GVL in animal models were pioneered by Bortin et al 2 in the 1970s. 3 The relevance of the GVL reaction in humans was established by the Seattle group in 1979, and key insights into its mechanisms were reported in a landmark study from the International Bone Marrow Transplant Registry in 1990. 4,5 Strikingly, the latter study that was based on data from 2254 subjects treated by 142 teams showed that GVL was abrogated if T cells were depleted from the graft or if the AHCT donor was an identical twin. 5 On the basis of these data, it was therefore inferred that GVL depended on donor T cells and on the existence of histocompatibility differences between the donor and its recipient (absent among identical twins). Because the International Bone Marrow Transplant Registry study involved HLA-identical siblings, the sole histocompatibility differences between donors and recipients were minor histocompatibility Ags (MiHAs). 6 The molecular nature of MiHAs was elucidated in 1990, and the first human MiHA was sequenced in 1995. 7,8 Increasing recognition that cure after AHCT for leukemia is largely because of the GVL effect led to the introduction of nonmyeloablative conditioning regimens and donor lymphocyte infusions (DLIs). 9,10 Remarkably, DLI can eradicate Յ 10 12 neoplastic cells in patients with chronic myelogenous leukemia, 11,12 and the allogeneic GVL effect represents the most convincing evidence that immunotherapy can cure human neoplasias. 13,14 Nowadays, AHCT can be viewed primarily as a quest for the GVL effect. 12 In AHC transplant recipients, the effect of GVL on leukemia-free survival is so important that it supersedes the deleterious effect of GVHD and protracted immunodeficiency.
After conven...