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Making Learning Relevant With Case Studies
The open-ended problems presented in case studies give students work that feels connected to their lives.
To prepare students for jobs that haven’t been created yet, we need to teach them how to be great problem solvers so that they’ll be ready for anything. One way to do this is by teaching content and skills using real-world case studies, a learning model that’s focused on reflection during the problem-solving process. It’s similar to project-based learning, but PBL is more focused on students creating a product.
Case studies have been used for years by businesses, law and medical schools, physicians on rounds, and artists critiquing work. Like other forms of problem-based learning, case studies can be accessible for every age group, both in one subject and in interdisciplinary work.
You can get started with case studies by tackling relatable questions like these with your students:
- How can we limit food waste in the cafeteria?
- How can we get our school to recycle and compost waste? (Or, if you want to be more complex, how can our school reduce its carbon footprint?)
- How can we improve school attendance?
- How can we reduce the number of people who get sick at school during cold and flu season?
Addressing questions like these leads students to identify topics they need to learn more about. In researching the first question, for example, students may see that they need to research food chains and nutrition. Students often ask, reasonably, why they need to learn something, or when they’ll use their knowledge in the future. Learning is most successful for students when the content and skills they’re studying are relevant, and case studies offer one way to create that sense of relevance.
Teaching With Case Studies
Ultimately, a case study is simply an interesting problem with many correct answers. What does case study work look like in classrooms? Teachers generally start by having students read the case or watch a video that summarizes the case. Students then work in small groups or individually to solve the case study. Teachers set milestones defining what students should accomplish to help them manage their time.
During the case study learning process, student assessment of learning should be focused on reflection. Arthur L. Costa and Bena Kallick’s Learning and Leading With Habits of Mind gives several examples of what this reflection can look like in a classroom:
Journaling: At the end of each work period, have students write an entry summarizing what they worked on, what worked well, what didn’t, and why. Sentence starters and clear rubrics or guidelines will help students be successful. At the end of a case study project, as Costa and Kallick write, it’s helpful to have students “select significant learnings, envision how they could apply these learnings to future situations, and commit to an action plan to consciously modify their behaviors.”
Interviews: While working on a case study, students can interview each other about their progress and learning. Teachers can interview students individually or in small groups to assess their learning process and their progress.
Student discussion: Discussions can be unstructured—students can talk about what they worked on that day in a think-pair-share or as a full class—or structured, using Socratic seminars or fishbowl discussions. If your class is tackling a case study in small groups, create a second set of small groups with a representative from each of the case study groups so that the groups can share their learning.
4 Tips for Setting Up a Case Study
1. Identify a problem to investigate: This should be something accessible and relevant to students’ lives. The problem should also be challenging and complex enough to yield multiple solutions with many layers.
2. Give context: Think of this step as a movie preview or book summary. Hook the learners to help them understand just enough about the problem to want to learn more.
3. Have a clear rubric: Giving structure to your definition of quality group work and products will lead to stronger end products. You may be able to have your learners help build these definitions.
4. Provide structures for presenting solutions: The amount of scaffolding you build in depends on your students’ skill level and development. A case study product can be something like several pieces of evidence of students collaborating to solve the case study, and ultimately presenting their solution with a detailed slide deck or an essay—you can scaffold this by providing specified headings for the sections of the essay.
Problem-Based Teaching Resources
There are many high-quality, peer-reviewed resources that are open source and easily accessible online.
- The National Center for Case Study Teaching in Science at the University at Buffalo built an online collection of more than 800 cases that cover topics ranging from biochemistry to economics. There are resources for middle and high school students.
- Models of Excellence , a project maintained by EL Education and the Harvard Graduate School of Education, has examples of great problem- and project-based tasks—and corresponding exemplary student work—for grades pre-K to 12.
- The Interdisciplinary Journal of Problem-Based Learning at Purdue University is an open-source journal that publishes examples of problem-based learning in K–12 and post-secondary classrooms.
- The Tech Edvocate has a list of websites and tools related to problem-based learning.
In their book Problems as Possibilities , Linda Torp and Sara Sage write that at the elementary school level, students particularly appreciate how they feel that they are taken seriously when solving case studies. At the middle school level, “researchers stress the importance of relating middle school curriculum to issues of student concern and interest.” And high schoolers, they write, find the case study method “beneficial in preparing them for their future.”
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NYCDOE: Passport to Social Studies - grade 3, Nigeria case study
Note to Teachers: To help with remote and hybrid learning, digital materials for this unit are available on the NYCDOE TeachHub. Access these materials by following these instructions .
This is a sample case study of Nigeria relating to the grade three scope and sequence, titled Nigeria Case Study. It was developed by a team of NYCDOE staff and teachers, in collaboration with scholars of the humanities and social sciences as well as museum curators. Students will immerse themselves in the topic by discussing focus questions, reading and analyzing a rich collection of diverse primary and secondary sources, examining artifacts, and interpreting images, such as paintings and photographs, maps, and political cartoons.
This guide offers a multitude of perspectives on the geography, history and cultural practices of Africa’s most populous country. Topics of representative lessons in this unit include the researching and comparing of Nigerian cultural and linguistic groups, exploring economic concepts like “scarcity” as it applies to the Nigerian marketplace, and analyzing and exploring traditional adire cloth and designs, especially through the work of Nike Davies Okundaye. Lessons also have students analyzing the meaning and story elements of Nigerian myths and how they reflect their values and belief systems, exploring the history of Nigerian trade and traditional Nigerian art, developing opinions about the benefits and costs of their considerable oil and natural gas reserves, and gaining an understanding of current events in terms of human rights, deforestation and land degradation in Nigeria.
To evaluate student mastery of content knowledge, cognitive processes, and critical thinking skills, this unit includes formative assessments, and a performance-based assessment activity, which has students writing a compare-and-contrast informational essay about daily life in the United States and Nigeria by organizing evidence about each country using vocabulary they have developed throughout the unit in self-compiled dictionaries and notebooks.
Please note: the complete set of NYCDOE K-8: Passport to Social Studies Core Curriculum materials include a wide-range of trade books and primary documents, in addition to this unit of study. In order to support rigorous social studies instruction and student inquiry, we recommend that teachers integrate these resources into their daily instruction and assessment plans.
Access a version of this resource compatible with assistive technology and screen-readers.
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What Is a Case Study?
An in-depth study of one person, group, or event
Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."
Cara Lustik is a fact-checker and copywriter.
Verywell / Colleen Tighe
Benefits and Limitations
Types of case studies, how to write a case study.
A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in various fields, including psychology, medicine, education, anthropology, political science, and social work.
The purpose of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.
While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, it is important to follow the rules of APA format .
A case study can have both strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.
One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult to impossible to replicate in a lab. Some other benefits of a case study:
- Allows researchers to collect a great deal of information
- Give researchers the chance to collect information on rare or unusual cases
- Permits researchers to develop hypotheses that can be explored in experimental research
On the negative side, a case study:
- Cannot necessarily be generalized to the larger population
- Cannot demonstrate cause and effect
- May not be scientifically rigorous
- Can lead to bias
Researchers may choose to perform a case study if they are interested in exploring a unique or recently discovered phenomenon. The insights gained from such research can help the researchers develop additional ideas and study questions that might be explored in future studies.
However, it is important to remember that the insights gained from case studies cannot be used to determine cause and effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.
Case Study Examples
There have been a number of notable case studies in the history of psychology. Much of Freud's work and theories were developed through the use of individual case studies. Some great examples of case studies in psychology include:
- Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
- Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
- Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language could be taught even after critical periods for language development had been missed. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.
Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse had denied her the opportunity to learn language at critical points in her development.
This is clearly not something that researchers could ethically replicate, but conducting a case study on Genie allowed researchers the chance to study phenomena that are otherwise impossible to reproduce.
There are a few different types of case studies that psychologists and other researchers might utilize:
- Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those living there.
- Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
- Explanatory case studies : These are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
- Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
- Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
- Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic cast study can contribute to the development of a psychological theory.
The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.
The type of case study that psychology researchers utilize depends on the unique characteristics of the situation as well as the case itself.
There are also different methods that can be used to conduct a case study, including prospective and retrospective case study methods.
Prospective case study methods are those in which an individual or group of people is observed in order to determine outcomes. For example, a group of individuals might be watched over an extended period of time to observe the progression of a particular disease.
Retrospective case study methods involve looking at historical information. For example, researchers might start with an outcome, such as a disease, and then work their way backward to look at information about the individual's life to determine risk factors that may have contributed to the onset of the illness.
Where to Find Data
There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:
- Archival records : Census records, survey records, and name lists are examples of archival records.
- Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
- Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
- Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
- Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
- Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.
Section 1: A Case History
This section will have the following structure and content:
Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.
Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.
Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.
Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.
Section 2: Treatment Plan
This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.
- Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
- Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
- Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
- Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.
This section of a case study should also include information about the treatment goals, process, and outcomes.
When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research.
In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?
Here are a few additional pointers to keep in mind when formatting your case study:
- Never refer to the subject of your case study as "the client." Instead, their name or a pseudonym.
- Read examples of case studies to gain an idea about the style and format.
- Remember to use APA format when citing references .
A Word From Verywell
Case studies can be a useful research tool, but they need to be used wisely. In many cases, they are best utilized in situations where conducting an experiment would be difficult or impossible. They are helpful for looking at unique situations and allow researchers to gather a great deal of information about a specific individual or group of people.
If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines that you are required to follow. If you are writing your case study for professional publication, be sure to check with the publisher for their specific guidelines for submitting a case study.
Simply Psychology. Case Study Method .
Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100
Gagnon, Yves-Chantal. The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.
Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.
By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."
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Case Study Assignment Components and Grading
INDIVIDUAL Case Study Assignments
Case Study Issue Interest Survey
You will find the “Case Study Issue Interest Survey" under the Case Study Assignments sub heading in the Modules tab. All students should complete the survey.
Case Study Individual Submissions for Part I, II, and III
As noted in the Case Study description, you must submit your individual contribution to each Case Study assignment prior to when the full group assignment is due. This is required in order to provide the team leader time to integrate the assignments together. All due dates are on the Course Calendars.
Team Assessment of Contribution
You will find the “ Team Assessment of Contribution ” survey under the Modules tab. Not graded, but all students are required to complete the survey. (The individual case study final grade will be penalized 1 point for late, incomplete or missing survey results.)
Case Study Q & A
Case Studies will be presented in the Q&A Discussion Forum. Each student will participate in the Discussion forum by leaving comments. Participation will be graded on an individual basis.
TEAM Case Study Assignments
The Team will receive one grade for Parts I and III of the Case Study. Part II will be graded individually. These grades will not be posted to the grade book.
After all parts of the Case Study are submitted, the Team will be given one total Case Study score. Each Part is weighted equally.
Scoring for each Part of the Case Study is based on:
All sources and references MUST be identified and properly referenced. Failure to do so can result in a failing grade and other possible sanctions. See College of Earth, Mineral and Sciences Academic Integrity and Research Ethics .
After all parts of the Case Study are submitted, each member of the team will complete a team assessment survey of individual contributions by each team member, including themselves. At the discretion of the instructor, the team assessments may result in an adjustment of your case study grade up or down from the grade that is calculated for the team. Any student whose grade is adjusted because of the team assessment will receive a written explanation from the instructor.
The Team Case Study is worth 30% of your course grade .
If you have questions, please post to the "Questions about EME 444?" Discussion Forum. I'll be happy to help you!
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Child development case study of 3 year old.
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Cassidy is a very outgoing three-year-old little girl. Cassidy attends head start where she has numerous friends. I chose Cassidy to observe for my case study because she is my friend's niece and she is a lot of fun to watch. Physical Development. Characteristics: Cassidy is 3"1"" and weighs 33 pounds. She is average size compared to the other children in her class and she has very good posture. Motor Coordination: Cassidy has achieved many fine and gross motor skills. She is able to ride a bike with training wheels and she loved to help bathe herself. She feeds herself with a small spoon and fork. She can zip, unzip and button her coat without assistance. She draws circle and heart shapes. She is able to twist and partially braid her doll's hair. Health: Cassidy is in pretty good health. She has not missed any days of school and has only been to the doctor's office for check-ups. . Nutrition and Food Habits: Cassidy is a picky eater. She does not finish her meals unless they are her favorites, macaroni and cheese, pizza, or french fries. She will not even finish a Chicken McNugget Happy Meal. She loves to drink milk and orange juice and to snack on peanut butter and crackers. . Rest: Cassidy goes to bed at different times due to her mother's schedule and because she likes to be the last one in bed. When she stays up late, she takes longer naps at school. She doesn't take naps later in the day too often because her mother likes to try to get her into bed at a decent time. She has one older brother who is 14 and one older sister who is 7 and she tries to stay awake with them or even try to keep them awake at night. Physical Skills: Cassidy loves to tumble and do cheers. She says that she wants to be a cheerleader. She also likes to run and ride her scooter. Sometimes she puts on her brother's football helmet and shoulder pads and tries to hit him. She is very adventurous and there is almost nothing that she won't try.
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Class 9 Science Case Study Questions Chapter 3 Atoms and Molecules
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Case study Questions in Class 9 Science Chapter 3 are very important to solve for your exam. Class 9 Science Chapter 3 Class 9 Science Case Study Questions have been prepared for the latest exam pattern. You can check your knowledge by solving case study-based questions for Class 9 Science Chapter 3 Atoms and Molecules
In CBSE Class 9 Science Paper, Students will have to answer some questions based on Assertion and Reason. There will be a few questions based on case studies and passage-based as well. In that, a paragraph will be given, and then the MCQ questions based on it will be asked.
Atoms and Molecules Case Study Questions With Answers
Here, we have provided case-based/passage-based questions for Class 9 Science Chapter 3 Atoms and Molecules
Case Study/Passage-Based Questions
Case Study 1: The knowledge of the valencies of various radicals helps us to write the formulae of chemical compounds. The total positive charge on positive ions (cations) is equal to the total negative charge on negative ions (anions) in a molecule. Therefore, in writing the formula of a compound, the positive and negative ions are adjusted in such a way that the total number of positive charges of positive ions (cations) becomes equal to the total number of negative charges of negative ions (anions). There is another simple method for writing the formulae of ionic compounds. In this method, the valencies (or positive or negative charges) of the ions can be ‘crossed over’ to give subscripts. The purpose of crossing over of charges is to find the number of ions required to equalise the number of positive and negative charges.
Element X has two valencies 5 and 3 and Y has valency 2. The elements X and Y are most likely to be respectively (a) copper and sulphur (b) sulphur and iron (c) phosphorus and fluorine (d) nitrogen and iron.
Answer: (d) nitrogen and iron.
The formula of the sulphate of an element X is X 2 (SO 4 ) 3 . The formula of nitride of element X will be (a) X 2 N (b) XN 2 (c) XN (d) X 2 N 3
Answer: (c) XN
The formula of a compound is X 3 Y. The valencies of elements X and Y will be respectively (a) 1 and 3 (b) 3 and 1 (c) 2 and 3 (d) 3 and 2
Answer: (a) 1 and 3
Case Study/Passage Based Questions
Case Study 2: A mole of an atom is a collection of atoms whose total mass is the number of grams equal to the atomic mass. Since an equal number of moles of different elements contain an equal number of atoms it becomes convenient to express the amounts of the elements in terms of moles. A mole represents a definite number of particles viz, atoms, molecules, ions or electrons. This definite number is called the Avogadro number or Avogadro constant which is equal to 6.022 × 1023. Hence a mole represents 6.022 × 1023 particles of the substance. One mole of a substance represents one gram-formula of the substance. One mole of a gas at standard temperature and pressure occupies 22.4 litres.
How many grams of sodium must be taken to get 1 mole of the element? (a) 23 g (b) 35.5 g (c) 63.5 g (d) 46 g
Answer: (a) 23 g
What is the mass in grams of a single atom of chlorine? (Atomic mass of chlorine = 35.5) (a) 6.54 × 10 23 g (b) 5.9 × 10 –23 g (c) 0.0025 g (d) 35.5 g
Answer: (b) 5.9 × 10–23 g
How many number of moles are there in 5.75 g of sodium ? (Atomic mass of sodium = 23) (a) 0.25 (b) 0.5 (c) 1 (d) 2.5
Answer: (a) 0.25
What is the mass in grams of 2.42 mol of zinc? (Atomic mass of Zn = 65.41) (a) 200 g (b) 25 g (c) 85 g (d) 158 g
Answer: (d) 158 g
Case Study 3: According to Dalton’s atomic theory, all matter whether an element, a compound, or a mixture is composed of small particles called atoms which can neither be created nor destroyed during a chemical reaction. Dalton’s theory provides a simple explanation for the laws of chemical combination. He used his theory to explain the law of conservation of masses, the law of constant proportions, and the law of multiple proportions, based on various postulates of the theory. Dalton was the first scientist to use the symbols for the elements in a very specific sense. When he used a symbol for an element he also meant a definite quantity of that element, that is one atom of that element.
Which postulate of Dalton’s atomic theory is the result of the law of conservation of mass? (a) Atoms can neither be created nor destroyed. (b) Each element is composed of extremely small particles called atoms. (c) All the atoms of a given element are identical. (d) During chemical combination, atoms of different elements combine in simple ratios.
Answer: (a) Atoms can neither be created nor destroyed.
Which postulate of Dalton’s atomic theory explains law of definite proportions? (a) Atoms of an element do not change during a chemical reaction. (b) An element consists of atoms having fixed mass and the number and kind of atoms in a given compound is fixed. (c) Different elements have different kind of atoms. (d) Atoms are of various kinds
Answer: (b) An element consists of atoms having fixed mass and the number and kind of atoms in a given compound is fixed.
“If 100 g of calcium carbonate (whether in the form of marble or chalk) is decomposed, 56 g of calcium oxide and 44 g of carbon dioxide are formed.” Which law of chemical combination is illustrated by this statement? (a) Law of constant proportions (b) Law of conservation of mass (c) Law of multiple proportions (d) Law of conservation of energy
Answer: (b) Law of conservation of mass
When 5 g calcium is burnt in 2 g oxygen, 7 g of calcium oxide is produced. When 5 g of calcium is burnt in 20 g of oxygen, then also 7 g of calcium oxide is produced. Which law of chemical combination is being followed? (a) Law of conservation of mass (b) Law of multiple proportions (c) Law of constant proportions (d) No law is being followed.
Answer: (c) Law of constant proportions
Case Study 4: Atoms and molecules are the building blocks of matter. An atom is the smallest unit of an element that retains its chemical properties, while a molecule is a group of two or more atoms held together by chemical bonds. Atoms consist of a positively charged nucleus, which contains protons and neutrons, surrounded by negatively charged electrons in energy levels or shells. The number of protons in an atom determines its atomic number and defines its unique identity as an element. The electrons in an atom occupy specific energy levels, and the outermost shell is known as the valence shell. Atoms gain, lose, or share electrons to achieve a stable electron configuration, forming chemical bonds and giving rise to molecules. Understanding the concept of atoms and molecules is crucial for comprehending various chemical reactions and the composition of substances.
What is the smallest unit of an element that retains its chemical properties? a) Proton b) Electron c) Nucleus d) Atom Answer: d) Atom
What is a group of two or more atoms held together by chemical bonds called? a) Element b) Compound c) Molecule d) Nucleus Answer: c) Molecule
What are the positively charged particles present in the nucleus of an atom called? a) Electrons b) Protons c) Neutrons d) Valence electrons Answer: b) Protons
Which part of an atom contains electrons in energy levels or shells? a) Protons b) Neutrons c) Nucleus d) Valence shell Answer: d) Valence shell
What do atoms do to achieve a stable electron configuration? a) Gain, lose, or share electrons b) Absorb protons c) Increase their atomic number d) Create chemical bonds Answer: a) Gain, lose, or share electrons
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Phase I non-randomized clinical trial of allogeneic natural killer cells infusion in acute myeloid leukemia patients
- Mohammad Ahmadvand 1 na1 ,
- Mahdieh Shokrollahi Barough 2 na1 ,
- Maryam Barkhordar 1 ,
- Ali Faridfar 2 ,
- Afshin Ghaderi 4 ,
- Hasan Jalaeikhoo 3 ,
- Mohsen Rajaienejad 2 ,
- Keivan Majidzadeh 5 ,
- Ardeshir Ghavamzadeh 2 , 6 &
- Ramin Sarrami-Forooshani 2
BMC Cancer volume 23 , Article number: 1090 ( 2023 ) Cite this article
A new type of immune cell transplantation called allogeneic NK cell infusion is proposed as a potential universal off-the-shelf cell product for adoptive immune cell therapy in hematologic malignancies.
A multicentral phase I non-randomized clinical trial was conducted to assess the safety, feasibility, and potential efficacy of adoptively infused NK cells in patients with refractory/relapsed AML. We evaluated the feasibility of the trial by considering cell production, patient selection, and treatment protocol.
Allogeneic NK cells were produced from random healthy unrelated donors; 10 patients were selected according to the inclusion criteria and were included in two groups in case of NK cell dose escalation. Two cell infusions were given, spaced 7 days apart, following a lymphodepletion conditioning regimen of fludarabin-endoxan administered 7 days before the first infusion. The intervention safety was scored using Common Terminology Criteria for Adverse Events (CTCAE) based on variations in vital signs due to cell infusion. NK cell chimerism, tumor burden, and duration of relapse were considered to be components of efficacy. The pilot feasibility evaluation was checked using the CONSORT platform.
The NK cell infusion procedure was well tolerated, and no grade 2–5 toxicities related (possible or probable) to PB-NK cell infusion were observed. Four patients developed grade 1 transient chills, headaches, vomiting, and bone pain following each PB-NK cell infusion that were not required hospitalization. One of these patients (p01) died because of severe acute respiratory syndrome. Of 9 evaluable patients, 6 (66.6%) showed stable disease (SD) and 3 (33.3%) presented progressive disease (PD). Of 6 SD patients, 2 (p08 and p09) remained alive in SD and 3 patients (p04, p05 and p07) converted to PD at 9 months after infusion of NK cells, and 1 (p03) was not evaluable due to follow-up loss. No patient achieved complete remission.
The study demonstrated the feasibility and safety of adoptive transfer of random healthy unrelated donor PB-NK cells in refractory/relapsed AML patients and supports continued study in phase II clinical trials in relapsed/refractory AML patients.
Peer Review reports
AML is a hematologic malignancy that frequently affects elderly individuals, with a median diagnosis age of 68 years. However, the survival rate within a five-year timeframe is only 26%, which is concerning [ 1 , 2 ]. Although survival rates for AML patients have not improved much in the last 30 years, certain chemotherapy treatments can lead to complete remission (CR) in younger patients. However, these remissions are not long-lasting, and consolidation treatment is necessary for a better long-term outcome [ 1 ]. In addition to conventional treatments, allogeneic hematopoietic stem cell transplantation (HSCT) is an efficient treatment for patients. This treatment acts by CD34 + healthy cell replacement in line with antileukemia immune response stimulation that is mediated by natural killer (NK) and alloreactive T cell responses. Due to the greater risk of treatment-related complications and death, many elderly patients with AML are ineligible for allo-HSCT. Innovative therapies using immune cells that offer graft-versus-leukemia (GVL) effects similar to those of NK or T cells show great potential as a means of providing cell-based treatments for AML without the need for allo-HSCT [ 3 ].
AML prognosis at a younger age is worst, and patient-related studies have shown that the disease is fatal in younger adults; however, bone marrow transplantation is well tolerated in young people, so advanced therapy with alloimmune cell transplantation might be very promising in this category [ 4 ]. Allogeneic NK cell transplantation as one of these advanced therapies is prescribed via intravenous injection of ex vivo expanded NK cells. The scientific background of NK cells indicates that they are one of the most valuable categories of intrinsic immunity against tumors, which have a significant capacity to lyse malignant cells both in vitro [ 5 ] and in vivo [ 6 ]. It has been shown that cytotoxic activity of NK cells is associated with a reduced frequency of cancer [ 7 ], suggesting that NK cells contribute to tumor immune surveillance [ 8 ]. In clinical trials, there is sufficient evidence that allogeneic NK cells can contribute to GVL effects in the context of allo-HSCT [ 9 , 10 , 11 ], paving the way for assessing NK cell-based approaches to treat hematologic malignancies [ 12 ].
In recent decades, numerous methods have been explored to utilize NK cells in therapeutic applications [ 13 ]. Published trials on adoptive allogeneic NK cell therapy in a transplant and non-transplant setting have displayed well-tolerated outcomes after NK cell infusion in line with PR/CR in some patients [ 14 , 15 , 16 , 17 , 18 , 19 ]. In order for NK cell graft improvement, a conditioning regimen should be used, in addition to the mild tumor burden decrement, it can cause bone marrow depletion and reinforce the NK cell grafting [ 16 ].
The most studied trial for NK cell transplantation is for haploidentical sources, and the safety and efficacy of allogeneic NK cell infusion were confirmed in patients with hematologic malignancy from haploidentical donors. The haploidentical selection was performed to avoid NK cell transplant rejection and potential immune stimulation. However, studies have proven that allogeneic cells are also well tolerated in the recipient’s body, which is due to killer-cell immunoglobulin-like receptors (KIRs) [ 16 ]. (KIR/KIR-ligand mismatch), can recognize and react to this missing self and mediate cytotoxicity, so has a crucial impact on alloreactivity, which is favorable to tumor cell elimination [ 20 ]. There is poor evidence regarding non-related allogeneic NK cell transplantation in malignancy disorders, especially in AML. Our previous study on non-related allogeneic NK cell infusion in acute SARS-COV2 infection with low respiratory symptoms was a safety and feasibility evaluation in a pilot phase 1 non-randomized clinical trial. The results of the study showed no adverse effect due to the intervention [ 21 ]. Although that project had no conditioning regimen and the aim of the study was to investigate the antiviral adjuvant function of NK cell therapy, we became passionate about focusing on the adverse effect evaluation of non-related allogeneic NK cell infusion in AML patients with bone marrow depleting regimen. However, this is the first report of ex vivo-expanded allogenic NK cells derived from healthy unrelated donors in Iranian patients with refractory/relapsed AML. Therefore, on the basis of the GVL effects of peripheral blood NK (PB-NK) cells, we performed an efficient method for the large-scale ex vivo expansion of NK cells from peripheral blood mononuclear cells (PBMC) from random healthy unrelated donors under good manufacturing practice (GMP) conditions [ 22 , 23 ].
Here, we report the results of a phase I adoptive cancer immune cell therapy with two infusions from ex vivo expanded random unrelated healthy donors PB-NK cells administered to patients with refractory/relapsed AML, which can result in some cells having a complete donor–recipient KIR ligand mismatch. This is a pilot study for safety and dose escalation analysis that focuses on the feasibility of production, administration, performance, safety, and follow-up for short-period efficacy analysis.
We deliberately focused on the KIR mismatch in this pilot project to obtain evidence of the association of this characteristic with the intervention outcome. This approach not only permits the extended feasibility of MHC class I mismatch but also overcomes the limitations of small potential donor pools.
The primary objectives were to determine the safety and feasibility of this adoptive cell therapy in patients with pre-conditioned AML, and the secondary objective was to evaluate the probable antitumor efficacy of PB-NK cells. This study should be executed as a non-randomized trial because it is a controlled study to evaluate the feasibility of production, implementation, safety, and access to patient follow-up, and blinding or randomization might complicate the evaluation of the main objective. One significant drawback of this study is its small sample size. It only provides sufficient data to assess feasibility. To obtain more accurate and comprehensive results, a phase 2 study with a one-year follow-up is necessary. However, the publication of these findings will take time, and we are passionate about reporting these preliminary data until phase II report completion.
Materials and methods
This is a non-parallel, pilot clinical trial that was performed as a non-randomized, non-blinded study. It is a multi-central trial that has been registered in the Iranian clinical trial data set (IRCT) coded IRCT20200621047859N3 on 30/12/2020 and achieved the ethics code before patient enrollment (IR.ACECR.IBCRC.REC.1398.015) 16/10/2019. There was no preference in the selection of patients for dose administration, and patient enrollment was done in chronological order and was performed on a timeline from the beginning of the project.
This study was executed by Motamed Cancer Institute and Cell Therapy and Hematopoietic Stem Cell Transplantation Research Center of Shariati Hospital of Tehran University of Medical Sciences. Cell infusion was administered in the Department of Oncology of Imam Reza Hospital. NK cell chimerism was performed on days 2, 7, and 28 after infusion, as previously described [ 17 ]. Chimerism investigations of immunologically sorted NK cells were performed using a standard variable number of tandem repeat methods [ 24 ].
Due to the dose escalation evaluation, all patients were enrolled in cohorts of 5 per dose level. Both groups were selected based on the same inclusion criteria and treated with a unique conditioning regimen, and the PB-NK-cell product was administered at days 0 and + 7. Cohort 1 was initiated with an adoptive transfer dose of 2 × 10 6 cells/kg for the first injection and 5 × 10 6 cells/kg for the second infusion (once weekly, two infusions). Cohort 2: Patients received 5 × 10 6 cells/kg for the first infusion and 10 × 10 6 cells/kg for the second infusion, once weekly, two infusions). The Cohort 1 intervention was performed earlier than that of Cohort 2, and the Cohort 2 study was started after the safety assessment completion of Cohort 1.
Feasibility evaluation criteria
Due to the CONSORT guidelines, the major evaluated parameters for the pilot study were considered follows [ 25 ].
Sample size evaluation : 5 patients’ enrollment in each cohort was considered minimal statistical patients that can be evaluated in case of safety and follow-up accessibility. The availability of patient files and regular monitoring is another parameter for study feasibility evaluation. Because finding the eligible patient to replace the excluded patients does not have a certain period of time, the minimum number of available patients is considered in determining the feasibility of the study, which is one of the criteria to ensure the feasibility of the sample size. We used the previous checklist that was filled out in the COVID-19 pilot study. For this evaluation, the categorical scoring was allocated according to the entered and excluded number of patients into special care units; 1, every two days admission; 2, every day admission; 3, every day two patients’ admission (Supplementary file 1 ).
Patient-related data accessibility is considered another important criterion to evaluate feasibility, and it was graded as follows: 1, demographic information of a patient; 2, the patient’s hardcopy file; 3, local access to the patient’s digital file; 4, Web-based full access to the patient’s information for long-term follow-up; 5, full access to patient information. (Supplementary file 1 )
Death cause evaluation data in the hospital or personal physician report was graded from 0 to 2 for the exanimate patients: 0, no access to cause of death; 1, general information of death causes that are included in the patient’s file; 2, professional death causes declared by the evaluation of medical doctorate, which was associated with the trial. Both cohorts were evaluated for clinical symptoms using patient-related samples. A completed questionnaire was used for all assessments, and the main liaison researcher conducted them. The questionnaire was reviewed by the Ethics Committee (Supplementary file 1 ).
Cell production : The feasibility of cell production was evaluated using production-related quality control and NK cell immunophenotyping, characterizing, and functional assays using K562 co-culture.
The Common Terminology Criteria for Adverse Events (CTCAE) Version 4.03 in blood and hematologic disease was considered for safety assessment analysis. The CTCAE parameters based on clinical symptoms and vital signs were listed as heart attack, changes in respiratory capacity, fever, rash, and anaphylactic shock symptoms that were checked using remote patient monitoring (RPM) devices during cell infusion until 48 h. The patient ’s vital signs, laboratory readings, and physical recovery progress were closely monitored, recorded in their medical files, and graded using the CTCEA checklist (Supplementary file 2 ).
Donor selection and blood sampling
Allogeneic unrelated healthy donors were randomly chosen from healthy volunteers after signing the consent form. All volunteers have been proven to have a negative active infection of SARS-COV2 via the gold standard RT-PCR test. The HIV, HBV, HCV, and blood culture examinations were also performed for all donors, and all results were negative. Finally, 70 ml of whole blood was obtained from the donors by intravenous blood sampling using blood collection syringes and injectors in heparinized falcon tubes. The samples were immediately transferred to a cleanroom under cold conditions. Donor selection is based on whether donors have either maximum KIR incompatibility against recipients or a potent KIR B haplotype.
Ten patients aged 18–70 years with refractory/relapsed AML were enrolled in this trial. All included patients had failed standard therapy and were not candidates for further induction chemotherapy or eligible for allo-HSCT because of inadequate disease control or chemorefractory (Table 1 ). The included patients were eligible with PS ≥ 2 [Performance Status (PS)] and [glomerular filtration rate (GFR)] GFR ≥ 60 or creatinine ≥ 2 mg/dl, ALT < 2.5XULN / Bid ≤ 2, O2Sat > 92% in room air, cardiac classification status (III > NHC) or [ejection fraction] EF > 50%. The primary endpoints were the safety and feasibility of adoptive transfer of allogeneic donor NK cells in patients with refractory/relapsed AML. Secondary endpoints included assessment of probable antitumor response. 5 patients (No time preference) were admitted to Imam Reza Hospital and 5 other patients were admitted to Yasouj Hospital. The signed consent forms were checked by the ethics committee after each intervention.
Preparation of NK cell-enriched products
Peripheral blood mononuclear cells (PBMCs) were isolated from healthy unrelated donors, and PB-NK cells were expanded as described previously [ 21 , 22 ]. Briefly, CD3 + T-cell–depleted PBMCs (using the Miltenyi CliniMACS system) were expanded at a seeding density of 2 × 10 5 cells/mL in X-VIVO 10 medium with 5% AB serum, 2 × 10 6 irradiated autologous PBMCs ((2,500 rad), 10 ng/mL anti-CD3 monoclonal antibody (OKT3; Orthoclon-USA), and 500 IU/mL of MACS GMP recombinant human IL-2 (Miltenyi Biotec-USA). OKT3 was supplemented just once at the beginning of the expansion to stimulate the T cell population in the irradiated feeder cells. NK cells were fed fresh medium with 500 IU/mL of IL2 every 2–3 days to maintain cellular concentration at 1–2 × 10 6 until they were harvested on day 21.
NK cell product characterization
After expansion on culture day 20, cells were harvested and PB-NK cell purity was evaluated by flow cytometry (CD3 − /CD56 + ). K562 cells were obtained from the Iranian biological resource center (IBRC-Iran) and cultured in RPMI-1640 medium (Life Science-USA) supplemented with 10% FBS (Life Science-USA).
To evaluate the functional status of the PB-NK cells using intracellular flow cytometry [interferon (IFN)-γ], CD107a degranulation (all antibodies were purchased from Biolegend-USA), and lactate dehydrogenase (LDH) release assay (Sigma-Germany) against K562 (IBRC-Iran)) as described previously [ 26 ] as targets. The cells were then washed using the Sepax System (Biosafe, Eysins, Switzerland) and suspended in 100 ml PlasmaLyte supplemented with 0.5% human serum albumin (HSA). All NK cell products met release criteria including negative Gram staining, endotoxin assay < 5 EU/kg patient weight, mycoplasma contamination, and visual inspection negative for contamination and cell viability of ≥ 80%.
The conditioning regimen was initiated at day 7 from NK-cell infusion and consisted of one infusion of fludarabine (f; 25 mg/m2) per day for the first 4 days (days − 7 to -4) followed by one infusion of cyclophosphamide (c; 25 mg/kg) per day (days-3 to-2). Fresh PB-NK cells were infused on day 0. The remaining PB-NK cells were cryopreserved (40% Plasmalyte, 50% human AB serum, 10% dimethyl sulfoxide) and thawed, washed, and infused on days + 7 (Fig. 1 ). After NK cell infusion, patients were followed weekly through month 1 and biweekly through month 3. To minimize unwanted side effects from intensive induction chemotherapy regimen in this heavily pretreated patient group with expected high treatment–related morbidity and possible mortality, we used a less toxic primary lymphodepletion regimen and omitted IL-2 subcutaneous administration.
Patient monitoring and laboratory findings
The total white blood cell count (WBC) was reported for each patient before cell therapy (at the hospitalization date) and after cell therapy (1 week after cell therapy). The blast cell percentage was evaluated for each patient before cell therapy and 3 months after cell infusion.
The levels of alkaline phosphatase (ALP) with a normal range of 44 to 147 international units per liter (IU/L), aspartate aminotransferase (AST, SGOT) with a normal range of 12–38 U/L, alanine aminotransferase (ALT, SGPT) with a normal range of 53–120 µmol/L and potassium (K) with a normal range of 3.6–5.3 mEq/L, and sodium (Na) with a normal range of 40–220 mmol/day were evaluated every day, and the results before the first cell infusion and 48 h after cell injection were reported for each patient.
Patients, Disease characteristics, and treatment schedule
10 patients with relapsed/refractory AML were included in this trial, and their disease characteristics are demonstrated in Table 1 . 10 patients with refractory or relapsed AML enrolled in the study were considered ineligible for HSCT at the time of inclusion in the trial. The median age of the enrolled patients was 50.5 years (range, 29–61 years), and all patients had previously received multiple therapies for AML. All patients received lymphodepletion chemotherapy before the infusion of PB-NK cells. All recipients’ NK cells had transient engraftment of NK cells (median, 8 days; range, 2 to 28 days), with NK cell chimerism of 6% donor (range, 2–21%; Table 1 ). Four patients continued to have measurable donor NK cells on day 28 (range,8%to 21%).
PB-NK cell product
PB-NK cell expansion to the target dose was reached in all 10 patients with a mean NK cell purity of 94.8% (91.3– 97.5%), and we were able to evaluate the cytotoxicity of these cells in some patients (5/10). In line with our preclinical data, the NK cells were highly functional with CD107a degranulation IFN-γ production in response to the K562 cell line (Fig. 1 A) as well as in vitro cytotoxicity against K562 and AML cell lines (Fig. 1 B).
Expanded PB-NK cells reveal an active phenotype before infusion. A , Characterization of CD56 + cells in case of IFN-γ and CD107a expression against K562 targets (E:T ratio = 1:1). B , NK: K562 co-culture with the final product of NK cell expansion
Safety and feasibility assessment
None of the 10 patients experienced dose-limiting toxicity (DLT) during PB-NK cell infusion or during the 28 days of the post-infusion observation period. One of these patients (P01) died 8 weeks after PB-NK cell infusion because of severe acute respiratory syndrome with a positive test for SARS-COV2 seven days after 2nd infusion. No grade 2–5 toxicities related (possible or probable) to PB-NK cell infusion occurred. Four patients developed grade 1 transient chills, headaches, vomiting and bone pain following each PB-NK cell infusion that were not required hospitalization (Table 2 ). In all cases, these impairments were reversible and responsive to supportive care, antipyretics, and intravenous hydration. On the basis of these data, we conclude that PB-NK cell infusion was safe and feasible, with 4 out of 10 patients having transient (< 6 h) and treatable adverse events (chill, headache, vomiting and bone pain) attributed to cell infusion.
The feasibility-related criteria were evaluated in three steps: before the project running and patient selection, during the execution of the trial, and after sampling termination. The number of patients referred to Shariati, Imam Reza, and Yasuj hospitals who were in elapsed/remission status was one case per month, which was the suitable interval for cell production and other patients’ follow-up. Data access in all patients were well access except in P01, where died. (Supplementary file2). NK cell production feasibility was proved by NK cell co-culture results and NK cell immunophenotyping.
Possible clinical efficacy
All 10 patients received all 2 planned PB-NK-cell infusions; One patient (p01) was not assessable because of COVID-19 infection. Nine patients were evaluated for response assessment after PB-NK cell infusion (Table 3 ). Of 9 evaluable patients, 6 (66.6%) showed stable disease (SD) and 3 (33.3%) presented progressive disease (PD). In 6 SD patients, the blast percentage within 3 months remained stable after the first and second courses of therapy with PB-NK cells (Table 3 ). Of 6 SD patients, 2 (p08 and p09) remained alive in SD and 3 patients (p04, p05 and p07) converted to PD at 9 months after infusion of NK cells, and 1 (p03) was not evaluable due to follow-up loss. Patients were followed until death, and all of them (except P03) had died at last follow up due to progressive disease (Table 3 ).
The laboratory finding
The WBC count of all patients decreased immediately after conditioning regimen administration. Liver enzymes such as SGOT, SGPT, creatinine, and ALP were in the normal range from hospitalization until discharge, and our intervention had no significant impact on these values. Electrolyte non-difference was a marker of normal homeostasis due to the intervention. Descriptive results are shown in Table 4 for each patient.
Acute myeloid leukemia is one of the most lethal hematologic malignancies, for which many advanced therapies are used worldwide. Employing natural killer cells as the main arm of innate immunity can be effective as a complementary treatment. Allogeneic off-the-shelf cell therapy using natural killer cells can change the patients’ fate, and its developmental studies are essential for commercialization after safety, feasibility and efficacy study [ 27 ].
In this project, we expanded PB-NK cells by stimulation with irradiated autologous feeder cells to produce expanded and functional PB-NK cells [ 22 ]. The functionality and viability of all products were checked using experimental methods such as CD107a and IFN-g measurement.
This phase I study using allogeneic NK cells allowed us to draw some clinical insights for patients with relapsed/refractory AML. The original hypothesis for this trial was that, given the previous successful therapy of leukemia by NK cells from alloreactive haploidentical KIR ligand-mismatched cells, administration of MG4101 would be safe and display improved clinical benefit over other treatments [ 14 , 23 , 28 , 29 ].
Organ function characterized by biochemical assays in patients’ serum. The serum levels of SGOT, SGPT, Cr, and ALP were in the normal range in all patients except one of those patients (P01) who died due to COVID-19; hence, she was not evaluated. Normal liver function showed that there is no side effect of conditioning regimen and cell infusion on normal homeostasis [ 30 , 31 ].
These results agree with those of previous studies of individuals treated with adoptive allogenic NK cell therapy [ 11 , 18 , 32 , 33 , 34 ]. Our differences in the current study are the use of random healthy unrelated donor NK cells for two doses in relapsed/refractory AML, conditioning regimen without total lymphoid irradiation (TLI) and to avoid Tregs stimulation subcutaneous IL2 administration was omitted. Allogeneic NK cells derived from potential entirely random donors, using it for treatment could result in GVHD; however, these results support the safety and feasibility of this product in relapsed/refractory AML patients. Consistent with our finding [ 14 , 15 , 16 , 17 , 23 , 29 ], GVHD, cytokine release syndrome, and neurotoxicity were not observed. Dose escalation was well tolerated, and the target cell dose was 10 × 10 6 / kg. For allogenic NK cell in vivo persistence reasons, our protocols included immunosuppressive regimens that would have not prohibited the outgrowth of allogenic NK cells derived from random unrelated donors. However, the in vivo persistence of NK cells can be enhanced through several approaches. These results agree with those of previous studies of individuals treated with adoptive NK cell therapy. Miller et al. [ 16 ] treated AML patients with IL2-activated CD3-depleted haploidentical NK cells after Flu/Cy –induced immunosuppression and detected notable in vivo proliferation and persistency of infused NK cells. However, we could not display in vivo expansion or prolonged persistence, possibly because of the absence of IL-2 administration and subsequent rejection by autologous lymphocytes.
Some groups are exploring allogenic NK cell expansion using platforms with and without feeder [ 23 , 29 ]. Yang et al. [ 23 ] treated 20 patients with allogenic NK cells derived from random healthy donor cells. Of 17 assessable patients, eight (47.1%) displayed stable disease and nine (52.9%) displayed progressive disease. Adoptive NK cells were well tolerated, with only transient adverse events observed in all cases. However, these findings require larger-scale studies to confirm allogenic NK cell infusion efficacy in relapsed/refractory AML. Patients with relapsed/refractory AML might benefit from adoptive NK cell infusions to restore dysfunctional autologous NK cell response, at least in part, GVL. Haploidentical NK cells have been previously assessed in phase I and II in patients with AML both in the transplant and non-transplant settings [ 34 , 35 , 36 ]. NK-cell alloreactivity based on KIR mismatching using the receptor–ligand model in patients with AML undergoing haploidentical HSCT displayed improved survival rates [ 37 , 38 ]. Adoptive transfer of allogenic NK cells along with conditioning regimens promotes expansion of the haploidentical NK cells with administration of IL-2-induced CR in relapsed and refractory AML patients [ 14 , 16 , 17 ]. In addition, several investigations have revealed that increased frequencies of Tregs can be directly associated with tumor progression [ 39 ]. In particular, Tregs can inhibit NK activation through TGFβ secretion. In considering allogenic NK cell infusion, it is necessary to consider the use of a conditioning regimen to enhance NK cell expansion and approaches to promote NK function post-infusion, such as depletion of T regulatory cells or the use of cytokines [ 16 ]. In this study, such an approach was used as PB-NK cells were transferred to a deeply immunosuppressive milieu already compromised by the conditioning regimen.
For patients with AML that are not candidates for HSCT and are chemo-refractor, treatment options are limited. Because PB-NK cells mediate strong GVL, their transfer may be beneficial for patients with relapsed/refractory AML. We conducted a phase 1 trial that demonstrated that PB-NK cell delivery was safe and feasible. No DLT was observed in relapsed/refractory AML patients who received 10 infusions of PB-NK cells. Some cases that developed infusion-related toxicity were responsive to supportive care.
We expected that the transfer of PB-NK cells would result in at least stable disease in relapsed/refractory AML due to leukemia blast reduction by transferred PB-NK cells. Thus, the patients’ leukemia blast status was monitored before and after therapy. After allogenic NK cell infusion, in some patients, no significant change in the percentage of leukemia blasts was detected. The most important goal of this project was the feasibility and safety assessment of NK cell production and infusion after conditioning regimen in patients with AML. Due to the CONSORT checklist, our study evaluates well in case of feasibility parameters.
This trial was not designed to characterize PB-NK cells after administration. This limitation will be evaluated by a complete analysis of donor NK-cell persistence and blood cytokines on infused PB-NK cells in a planned phase II trial. Chimerism levels of NK cells at 7 or 14 days after administration have been correlated with CR after IL-2-activated haploidentical NK cells [ 40 ].
In summary, this trial supports the safety and feasibility of expanded PB-NK cells for effective “off-the-shelf” immunotherapy, while their innate alloreactivity can be safely harnessed to potentiate allogeneic cell therapy. This capability, together with the apparently minimal HLA-matching requirements between the donor and recipient of NK cells, may pave the way for a truly off-the-shelf product that could increase treatment accessibility for more patients. The most important limitation in this study was the small sample size, and it was about the aim of study in case of NK cell infusion safety and feasibility evaluation in dose escalation setting. Eventually, since 10 × 10 6 cells were well tolerated in all patients, we can design a randomized clinical trial for efficacy assessment.
All data generated or analyzed during this study have been included in this published article.
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The authors thank all the patients recruited from Imam Reza Hospital for participating in the research that made this study possible.
National Institute for Medical Research Development Grant No.984062.
Mohammad Ahmadvand and Mahdieh Shokrollahi Barough researchers are equally the first author.
Authors and Affiliations
Cell Therapy and Hematopoietic Stem Cell Transplantation Research Center, Research Institute for Oncology, Hematology and Cell Therapy, Tehran University of Medical Sciences, Tehran, Iran
Mohammad Ahmadvand & Maryam Barkhordar
ATMP Department, Breast Cancer Research Center, Motamed Cancer Institute, ACECR, P.O. BOX: 15179/64311, Tehran, Iran
Mahdieh Shokrollahi Barough, Ali Faridfar, Mohsen Rajaienejad, Ardeshir Ghavamzadeh & Ramin Sarrami-Forooshani
Research Center for Cancer Epidemiology and Screening, Aja University of Medical Sciences, Tehran, Iran
Department of Internal Medicine, Hematology and Medical Oncology Ward, Yasuj University of Medical Sciences, Yasuj, Iran
Genetics Department, Breast Cancer Research Center, Motamed Cancer Institute, ACECR, Tehran, Iran
Cancer and cell therapy research center, Tehran University of Medical Sciences, Tehran, Iran
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MA: the study design, investigation, methodology, analysis, writing original draft. MSH: investigation and analysis. MB: Supervision. AF: data interpretation, review of the manuscript. AGH: Supervision. HJ: Flow cytometry analyses. MR: Funding acquisition. KM: The study conception, study design, review & editing. AGH: data interpretationRSF: data interpretation. All authors reviewed the manuscript.
Correspondence to Mohammad Ahmadvand , Ardeshir Ghavamzadeh or Ramin Sarrami-Forooshani .
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All volunteers provided written informed consent, and the protocol was reviewed and approved by the Institutional Review Board of Tehran University of Medical Sciences. All methods were performed in accordance with relevant guidelines and regulations.
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Ahmadvand, M., Barough, M.S., Barkhordar, M. et al. Phase I non-randomized clinical trial of allogeneic natural killer cells infusion in acute myeloid leukemia patients. BMC Cancer 23 , 1090 (2023). https://doi.org/10.1186/s12885-023-11610-x
Received : 17 June 2023
Accepted : 03 November 2023
Published : 10 November 2023
DOI : https://doi.org/10.1186/s12885-023-11610-x
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- Acute Myeloid Leukemia (AML)
- Allogeneic NK cell therapy
- Adoptive transfer
- Cellular therapy