Chronic lymphocytic leukemia (CLL) involves a profound humoral immune defect and tumor-specific humoral tolerance that directly contribute to disease morbidity and mortality. CD154 gene therapy can reverse this immune defect, but attempts to do this pharmacologically have been unsuccessful. The immunemodulatory agent lenalidomide shows clinical activity in CLL, but its mechanism is poorly understood. Here, we demonstrate that lenalidomide induces expression of functional CD154 antigen on CLL
IntroductionChronic lymphocytic leukemia (CLL) is the most common adult leukemia, and is characterized by an elevated frequency of infections, secondary malignancy, and autoimmune complications compared with the general population. Current treatment options for CLL are palliative and further exacerbate the immune deficiency seen in this disease. Nonetheless, CLL represents an "immunoresponsive" disease as evidenced by extended disease remission and potential cure with reduced intensity allogeneic stem cell transplantation (reviewed in Gribben 1 ). This suggests that strategies that restore immune function have potential to effectively eliminate CLL.The immune defect in CLL is characterized by both humoral and cellular immune defects. Although detailed studies of normal B cells in CLL patients have not been performed due to the difficulty in isolating these cells, hypogammaglobulinemia is often present at diagnosis and becomes worse with disease progression. A profound cellular immune defect 2-4 is present in CLL with significant alterations in genes involved in differentiation, cytoskeleton formation, vesicle trafficking, and cell death. 4 Coculture of CLL cells with normal T cells produces the same T-cell defects observed in CLL patients, 4 suggesting a direct role of the leukemia cells in contributing to the T cell-dependent cellular immune deficiency. The clinical manifestation of the humoral and cellular immune defects in CLL patients includes hypogammaglobulinemia, 5,6 poor response to both polysaccharide-based 7-9 and proteinbased 10 vaccines, and a high predisposition to infections 11,12 that represents a leading cause of death.To date, attempts to reverse the immune defects in CLL have been limited. Most promising has been adenovirus-delivered CD154 gene therapy that in small numbers of patients reversed cellular and humoral tumor tolerance. CD154 is the surface ligand of CD40 and is expressed on activated T cells, natural killer cells, and dendritic cells, but not normal B cells. Activation of T cells promotes increased surface expression of CD154, thereby promoting both activation and antigen presentation in normal and transformed B cells. Congenital mutations in the CD154 gene promote profound cellular and humoral immune deficiency. Although mutations of the CD154 gene have not been described in CLL, these patients have diminished CD154 expression on T cells after CD3 ligation. 13 Transduction of murine or human CD154 into primary CLL cells ex vivo with adenovirus gene therapy vectors, followed by systemic reintr...