Background and objectives: The humanized CD20 mono- clonal antibody, rituximab, has significant anti-tumor activity in patients with B-cell non-Hodgkin's lymphoma and induces depletion of B-cells in vivo. It was the objective of this study to define the contribution of the different mechanisms of action of rituximab on primary normal and malignant B-cells.
Design and methods: Primary human B-lymphocytes and effector cell fractions were isolated from peripheral blood of normal donors using an immunomagnetic separation technique. Blood samples from 20 patients with chronic lymphocytic leukemia (CLL) were studied and the B-lymphoblastoid Daudi cell line was used as a control. B-cells were cultured in the presence or absence of rituximab adding a secondary hyper-crosslinking antibody, serum as source of complement or different effector cell fractions. The cells were analyzed by immunofluorescence staining and flow cytometry.
Results: In contrast to the B-lymphoblastoid Daudi cell line, the number of highly purified normal peripheral blood CD19+ cells was only minimally affected by rituximab in the presence of autologous serum. A significant reduction in the number of B-cells was observed when mononuclear cells from peripheral blood were added back. To identify the cell type which mediates this effect, CD3+ T-cells, CD56+ cells, and CD14+ monocytes were added to selected CD22+ B-cells. A marked B-cell decrease was only observed in the presence of CD56+ and CD14+ cells in an effector to target ratio of 10:1. The experiments with mononuclear cells from patients with CLL showed a B-cell reduction by rituximab, which was significantly enhanced following addition of granulocyte-macrophage colony-stimulating factor (GM-CSF).
Interpretation and conclusions: These data support the important role of cell-mediated mechanisms in the B-cell-depleting action of rituximab and suggest that pre-treatment with GM-CSF could improve the response to rituximab in patients with CLL.