Clinical Research Directory

UNDERSTANDING THE T-CELL AND B-CELL RECEPTOR REPERTOIRE IN CHILDREN AND YOUNG ADULTS WITH ANTI-DRUG ANTIBODIES AGAINST PEG ASPARAGINASE

The aim of this sub study is to identify biomarkers in children and young adults with ALL with hypersensitivity to PEG-asparaginase. Evidence strongly implicates humoral immunity in asparaginase immunogenicity with neutralizing antibodies18. Asparaginase is a bacterial enzyme not naturally present in the human body, and therefore highly immunogenic. Upon administration, antigen-presenting cells internalize and present fragments of the enzyme to naïve T cells, driving their differentiation into Th2 helper cells signaling differentiation of B-cells. A subset of activated B-cells matures into long-lived plasma cells that home to the bone marrow (BM), where they continuously secrete anti-asparaginase antibodies (AAA). Others differentiate into memory B-cells that enable rapid antibody responses. This immunological memory means that once sensitization occurs, re-exposure to asparaginase triggers strong hypersensitivity reactions that make further treatment unsafe. Yet, despite the clinical importance, only one study exists on TCR repertoire in response to AAA, but no studies to date have directly profiled the B-cell receptor (BCR) repertoire in children with AAA14. The BCR sequencing has recently been developed. By integrating BCR-seq from blood and BM with serum proteomics (Ig-Seq), we can directly link specific plasma cell clones to circulating AAA. This approach will provide mechanistic insight into drug immunogenicity and enable the identification of molecular biomarkers of hypersensitivity risk in children and young adults with ALL. Methods: We will perform a longitudinal Danish cohort study in pediatric and young adult ALL patients receiving PEG-asparaginase as part of induction and post-consolidation therapy treated on the A2G-1. We will include 20 patients with hypersensitivity and 20 without. Biological samples will be collected at baseline, during early post-exposure with PEG-asparaginase, at clinical hypersensitivity, and at follow-up timepoints according to the A2G-1. We will pair these samples with EDTA-plasma samples from the same timepoints. We will perform enrichment of plasma cells together with bulk TCR and BCR repertoire and clonotype sequencing. From plasma we will perform serum proteomics to identify peptide fragments of circulating AAA. We will align Ig-Seq peptides with BCR sequences from PBMC and BM to map specific antibodies to their clonal plasma cell origin. This approach yields a direct functional link between repertoire data and pathogenic antibodies. We will compare BM repertoires with blood samples to determine whether circulating clones reflect the dominant marrow-resident plasma cells. If AAA-specific BCRs can be reliably detected in blood, this may serve as a non-invasive biomarker, reducing the need for bone marrow sampling.

CiproPAL (Ciprofloxacin Prophylaxis in Acute Leukaemia)

CiproPAL is a randomised trial comparing daily ciprofloxacin with local standard care during the induction phase of paediatric ALL treatment, and aims: 1. To assess the efficacy of ciprofloxacin prophylaxis in the reduction of infection during the induction phase of treatment for paediatric Acute Lymphoblastic Leukaemia within the ALLTogether-1 Trial. 2. To evaluate the impact of ciprofloxacin prophylaxis on antimicrobial resistance, both of invasive infections and colonising organisms.