Periodic Reporting for period 2 - TheraLymph (Gene Therapy to restore lymphatic flow lymphedema)
Reporting period: 2021-07-01 to 2022-12-31
Lymphedema is a disabling condition induced by the chronic accumulation of fluid and fat in the arms or in the legs. It is an unmet medical need that affects 4 million people in Europe and more than 250 million people worldwide. It is handicapping, painful and impacts substantially the quality of life. In western countries, lymphedema is generally a consequence of cancer i.e. fifteen percent of women will develop lymphedema after breast cancer. The main objective of Theralymph will be to establish a safe, non-integrative gene therapy for women who developed lymphedema after breast cancer.
The Theralymph translational research programme brings together bench scientists and physicians from five European countries to perform a Phase I/II trial focusing on women who developed lymphedema after breast cancer. Our approach is based on combinatorial gene therapy targeting of both superficial lymphatic capillaries and deeper lymphatic collectors.
The project is structured into 7 Research and Innovation work packages (WP), each one managed by a WP leader from a participating centre, and aimed to:
• Determine risk factors for lymphedema and cartography the lymphatic network in lymphedema pathology (WP1,2);
• Decipher whether lymphatic intrinsic molecules or microenvironmental peptides or lipids are modified in the lymphedematous arm to promote lymphatic dysfunction (WP3,4);
• Identify therapeutic targets and validate the best molecular combination that restores the lymphatic drainage in preclinical lymphedema modelsstudies (WP5,6);
• Conduct a Phase I/II gene therapy clinical trial using the innovative LentiFlash® technology based on recently developed non-integrative lentiviral vectors that allow a transient and highly efficient in vivo gene delivery (WP7).
Two additional WPs concern the management and coordination through meetings with partners and scientific boards (WP8) and dissemination of the results and intellectual property management (WP9).
The Theralymph translational research programme brings together bench scientists and physicians from five European countries to perform a Phase I/II trial focusing on women who developed lymphedema after breast cancer. Our approach is based on combinatorial gene therapy targeting of both superficial lymphatic capillaries and deeper lymphatic collectors.
The project is structured into 7 Research and Innovation work packages (WP), each one managed by a WP leader from a participating centre, and aimed to:
• Determine risk factors for lymphedema and cartography the lymphatic network in lymphedema pathology (WP1,2);
• Decipher whether lymphatic intrinsic molecules or microenvironmental peptides or lipids are modified in the lymphedematous arm to promote lymphatic dysfunction (WP3,4);
• Identify therapeutic targets and validate the best molecular combination that restores the lymphatic drainage in preclinical lymphedema modelsstudies (WP5,6);
• Conduct a Phase I/II gene therapy clinical trial using the innovative LentiFlash® technology based on recently developed non-integrative lentiviral vectors that allow a transient and highly efficient in vivo gene delivery (WP7).
Two additional WPs concern the management and coordination through meetings with partners and scientific boards (WP8) and dissemination of the results and intellectual property management (WP9).
The COVID-19 health crisis had added a significant hurdle for the whole project. All Theralymph partners were severely impacted by temporary national lockdowns. A 6-months extension to the original project duration was granted by the Commission. Despite the difficulties faced, the project has made good progress towards its objectives and deliverables were delivered on time.
We identified that both radio- and chemotherapy are major risk factors for developing lymphedema after cancer treatments. We characterized the poorly investigated architecture of the lymphatic collecting network in both human and murine adipose tissue. Using chromatography analysis, we found that lipid components are modified in lymphedema, and in particular specialized lipid mediators involved in the resolution of inflammation. Using RNAseq analysis, we determined the gene expression profile in lymphedema. Candidate genes identified were cloned in lentivectors in association with VEGFC to evaluated the effect in vitro on lymphatic endothelial function and in vivo in mice model of lymphedema. Among them, 4 combinations were transferred in Lentiflash vectors to evaluate the effect on lymphedema. Apelin-VEGFC was the most efficient to reduce lymphedema and was chosen for clinical trial. Different non GMP batches were tested fortheir activities and diffusion. The toxicology and biodistribution analysis necessary for the French national medicine agency application is schedule in April 2023.
WP1 – There is an increase of the main lymphangiogenic factor VEGF-C in radioresistant tumor cells. We determined that chemotherapeutic paclitaxel stimulates VEGFC production without influencing the sensitivity to therapy.
WP2 – Visualisation of collecting lymphatic vessel and transcriptome analysis of lymphatic endothelial cells (LEC) from mouse adipose tissue (AT) were performed and revealed potential therapeutic targets.
WP3 - Lipidomic analysis of dermolipectomies from patients with lymphedema showed changes in the composition of lipid mediators. Co-cultures of LECs and adipocytes revealed increased mRNA levels coding for proteins involved in adipogenesis.
WP4 - Eicosanoid profiles of lymphedematous skin demonstrated differential production of lipid mediators with distinct biological activity on lymphatic vessels.
WP5 - VEGF-C alone (rescue) or in combination with targets identified in WP2-4 were produced to evaluate the synergistic effect of different factor combinations on LEC functions in vitro.
WP6 –. Combination of VEGF-C with 8 potential targets were cloned in multicistronic vectors to produce lentivectors and to evaluated the effect in lymphedema bearing mice. Results indicated potential additive/synergistic activity. Diffusion and Biodistribution of the lentiflash vector was performed to determine the dose and site of injection
WP7 - Multidisciplinary meetings with methodologists, clinical staff, coordinator and scientists were organised to establish the design of the regulatory preclinical studies, clinical trial, information and consent form, synopsis and draft of the clinical protocol.
WP8 – An effective management framework for the Theralymph consortium was up at the beginning of the project. Project Management is following up on work progress, risk management and ethics aspects of the project. The independent external advisory board including an ethics advisor is regularly updated on project advances and consulted on ethical and regulatory issues.
WP9 - The visual identity of the project was developed, i.e. design of the Theralymph logo, and the Theralymph website has been launched. A first version of the Data Management Plan, which covers all types of data to be generated during the Theralymph project was elaborated.
We identified that both radio- and chemotherapy are major risk factors for developing lymphedema after cancer treatments. We characterized the poorly investigated architecture of the lymphatic collecting network in both human and murine adipose tissue. Using chromatography analysis, we found that lipid components are modified in lymphedema, and in particular specialized lipid mediators involved in the resolution of inflammation. Using RNAseq analysis, we determined the gene expression profile in lymphedema. Candidate genes identified were cloned in lentivectors in association with VEGFC to evaluated the effect in vitro on lymphatic endothelial function and in vivo in mice model of lymphedema. Among them, 4 combinations were transferred in Lentiflash vectors to evaluate the effect on lymphedema. Apelin-VEGFC was the most efficient to reduce lymphedema and was chosen for clinical trial. Different non GMP batches were tested fortheir activities and diffusion. The toxicology and biodistribution analysis necessary for the French national medicine agency application is schedule in April 2023.
WP1 – There is an increase of the main lymphangiogenic factor VEGF-C in radioresistant tumor cells. We determined that chemotherapeutic paclitaxel stimulates VEGFC production without influencing the sensitivity to therapy.
WP2 – Visualisation of collecting lymphatic vessel and transcriptome analysis of lymphatic endothelial cells (LEC) from mouse adipose tissue (AT) were performed and revealed potential therapeutic targets.
WP3 - Lipidomic analysis of dermolipectomies from patients with lymphedema showed changes in the composition of lipid mediators. Co-cultures of LECs and adipocytes revealed increased mRNA levels coding for proteins involved in adipogenesis.
WP4 - Eicosanoid profiles of lymphedematous skin demonstrated differential production of lipid mediators with distinct biological activity on lymphatic vessels.
WP5 - VEGF-C alone (rescue) or in combination with targets identified in WP2-4 were produced to evaluate the synergistic effect of different factor combinations on LEC functions in vitro.
WP6 –. Combination of VEGF-C with 8 potential targets were cloned in multicistronic vectors to produce lentivectors and to evaluated the effect in lymphedema bearing mice. Results indicated potential additive/synergistic activity. Diffusion and Biodistribution of the lentiflash vector was performed to determine the dose and site of injection
WP7 - Multidisciplinary meetings with methodologists, clinical staff, coordinator and scientists were organised to establish the design of the regulatory preclinical studies, clinical trial, information and consent form, synopsis and draft of the clinical protocol.
WP8 – An effective management framework for the Theralymph consortium was up at the beginning of the project. Project Management is following up on work progress, risk management and ethics aspects of the project. The independent external advisory board including an ethics advisor is regularly updated on project advances and consulted on ethical and regulatory issues.
WP9 - The visual identity of the project was developed, i.e. design of the Theralymph logo, and the Theralymph website has been launched. A first version of the Data Management Plan, which covers all types of data to be generated during the Theralymph project was elaborated.
We investigate the expression level of VEGF-C in various stages of breast cancer and the influence of radio- and chemotherapy on its expression to evaluate the risk to develop lymphedema for a better care of cancer patients in preventing the pathology. A single cell RNAseq (mouse) and bulk RNAseq (human) identified gene signatures for collecting vessels from normal and lymphedema tissues, and thereby potential therapeutic targets. The production of adipokines by the lymphedema-related adipose tissue identified Apelin as the most affected in lymphedema, it was chosen as candidate for clinical trial. We established that reintroducing downregulated SPM is relevant for targeting chronic inflammation in lymphedema patients instead of using anti-inflammatory drugs.
The effect of VEGF-C combined with identified targets in WP2-4 was evaluated on lymphatic endothelium in vitro to point out the best synergistic effects. Lentivectors containing the combination of lymphatic regulators were generated to evaluate the effect of these molecules in mouse models of lymphedema. The best performers were produced in lentiflash vectors for a pre-clinical study to identify the best combination, VEGFC-Apelin, that will be used in the clinical trial.
The Theralymph clinical study will not only provide therapeutic solution for an unmet medical need that affects millions of patients, but will also considerably improve the quality of life and decrease the health care cost of this chronic incurable disease.
The effect of VEGF-C combined with identified targets in WP2-4 was evaluated on lymphatic endothelium in vitro to point out the best synergistic effects. Lentivectors containing the combination of lymphatic regulators were generated to evaluate the effect of these molecules in mouse models of lymphedema. The best performers were produced in lentiflash vectors for a pre-clinical study to identify the best combination, VEGFC-Apelin, that will be used in the clinical trial.
The Theralymph clinical study will not only provide therapeutic solution for an unmet medical need that affects millions of patients, but will also considerably improve the quality of life and decrease the health care cost of this chronic incurable disease.