Pathogenic activation of the LMO2 protooncogene by an oncoretroviral vector insertion in a clinical trial for X-linked severe combined immunodeficiency (X-SCID) has prompted safety concerns. We used an adeno-associated virus vector to achieve targeted insertion of a ␥-retroviral long terminal repeat (LTR) driving a GFP expression cassette with flanking loxP sites in a human T-cell line at the precise location of vector integration in one of the patients with X-SCID. The LTR-GFP cassette was inserted into the first intron of the LMO2 gene, resulting in strong activation of LMO2. Cre-mediated cassette exchange was used to replace the original LTR-GFP cassette with one flanked by insulator elements leading to a several fold reduction in LMO2 expression. The LTR-GFP cassette was also replaced with a globin gene regulatory cassette that failed to activate the LMO2 gene in lymphoid cells. A ␥-retroviral vector with 2 intact LTRs resulted in activation of the LMO2 gene when inserted into the first intron, but a self-inactivating lentiviral vector with an internal cellular promoter and flanking insulator elements did not activate the LMO2 gene. Thus, this system is useful for comparing the safety profiles of vector cassettes with various regulatory elements for their potential for proto-oncogene activation.
IntroductionRetroviral vectors are potentially useful for gene therapy of blood disorders because they are capable of permanently integrating a therapeutic gene into stem cells and achieving long-term expression in differentiating hematopoietic cells. The initial clinical trials for severe combined immunodeficiency (SCID) secondary to adenosine deaminase deficiency (ADA) were either targeted to T lymphocytes 1 or resulted in too low a frequency of gene transfer into stem cells to produce clinical benefit. 2 Improved transduction conditions have now resulted in clinical benefit after stem cell-targeted gene transfer for patients with SCID secondary to ADA deficiency 3 or secondary to a deficiency in the common ␥ chain of interleukin receptors (X-SCID). [4][5][6] In addition, 2 severely affected patients with chronic granulomatous disease (CGD) achieved clearance of life-threatening infections by gene-corrected granulocytes derived from transduced stem cells. 7 In the context of these successful clinical trials, unequivocal evidence of the genotoxicity of retroviral vector integration has emerged in that 3 of the patients with X-SCID in one clinical trial 8,9 have developed leukemia. In 2, activation of the proto-oncogene, LMO2, was directly implicated as a genotoxic event. 8 In addition, the 2 patients with CGD exhibited striking clonal dominance with most of their gene-corrected cells having insertions into or near one or more of the MDS1-EVI1, PRDM16, or SETBP1 loci. Evidence indicated that these retroviral insertion events had activated the nearby proto-oncogene. 7 This experience emphasizes that the genotoxicity of retroviral integration is a relevant factor to be considered in designing vectors for future clinic...