WO2018124512A2 - 압타머-약물 콘쥬게이트 및 그 용도 - Google Patents
압타머-약물 콘쥬게이트 및 그 용도 Download PDFInfo
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- C12N2310/00—Structure or type of the nucleic acid
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- C12N2310/16—Aptamers
Definitions
- the present invention relates to the [ anti -nucleolin GRO aptamer] -Toxin conjugate and its synthesis for the treatment of target cancer.
- the invention relates to those of [anti -nucleolin aptamer]
- the use of -Toxin conjugate showing the excellent effect in the treatment of cancer that verify the in vitro / vivo efficacy.
- Anticancer drugs are generally used near the maximum tolerated dose to obtain clinical therapeutic effects. Anticancer drugs only kill rapidly proliferating cells and do not differentiate between normal and tumor cells or tumor tissues. Such chemotherapy has the drawback that the therapeutic index and therapeutic window of anticancer drugs are very low because of non-tumor specific systemic toxicity and cytotoxicity. In addition, there is an urgent need for improved new therapies that can cause resistance to anticancer drugs in long-term treatments, thereby accurately delivering and killing cytotoxic drugs only to cancer cells.
- ADCs antibody-drug conjugated antibodies
- ADCs Antibody-Drug Conjugates
- ADCs have recently completed Phase III clinical trials at Seattle Genetics and Imunog, have been approved by the FDA and brought to market a new treatment.
- antibodies are composed of large proteins, which have many problems in QC, such as the location of drug attachment, the number of drugs attached (1-6, average 3.5), and the location of attachment.
- aptamer-drug conjugates and the therapeutic properties of aptamers that can be compared with antibodies has the advantage that chemical reactions can be easily controlled to control the number and location of the agent. Therefore, by combining the superiority of the aptamer relative to the antibody, it is considered that the possibility of success in the clinical can be increased.
- Aptamer-Drug Conjugates are highly toxic and difficult to use in clinical practice, so that the target-oriented aptamers can be delivered to the drug to deliver them only to cancer cells without any side effects. It is expected that you can expect to maximize.
- ADC is a technology that focuses on drugs specifically targeting cancer cells by taking full advantage of antibody specificities (non-toxicity in circulation and pharmacokinetics).
- ADC consists of three components, including a monoclonal antibody drug and a linker linking the antibody to the drug.
- ADC technology uses antibodies that specifically bind to specific antigens expressed on the surface of cancer cells. It is a method of delivering drugs to tumor cells.
- ADCs enter cells by binding to a target with an antibody that specifically binds to the target.
- the ADC moved into the cell falls off the target, fuses with other vesicles in the cell, and then proceeds through the endosome-lysosome pathway.
- the proteases in the acidic environment of endosomes then cleave the linker, and the active "free" drug passes through the lysosomal membrane to the cytoplasm and binds to the drug's molecular target, thereby stopping the cell cycle of tumor cells and apoptosis.
- a certain amount of the drug is either passive diffusion in the cell, active transport, or flows out of the cell through dead cells. At this time, when the spilled drug passes through the cell membrane permeability, the so-called by-stander cell killing may also occur in surrounding cells, which may cause side effects to the patient.
- ADC Antibody-Drug Conjugate
- Antibody (Tmab) has 88 lysines to which Drug (DM1) can attach. It is not easy to identify the conjugation site where the average of 3.5 drugs (DM1) is attached to the lysine of 88 lysine. In other words, trypsin digestion and Asp-N protease digestion to find the conjugation site, and these fragments are compared with the results of ESI-TOFMS analysis to determine the extent of drug (DM1) conjugation.
- ADC Antibody-Drug Conjugate
- Antibody reaches the target-bound drug to cancer cells and shows therapeutic effect by the drug, but the drug that reaches the cancer cell by antibody is only 2% or less.
- a safe, anti-cancer drug with clinical approval such as Doxorubicine, is selected as a drug that binds to antibodies with high toxic agents that are 100 to 1,000 times higher because of their low efficacy.
- Aptamers are DNA or RNA oligonucleotides that can be diagnosed or targeted by binding selectively to biomarks that cause diseases such as cancer with similar properties to antibodies. That is, aptamers have unique three-dimensional structures according to the target material, and these three-dimensional structures bind strongly to labeling proteins (cancer-induced proteins and biomarks) to target treatment, It is a new bio-capturing material capable of personalized diagnosis or missile therapy.
- the most successful target therapies are antibodies.
- 30 antibody targeted therapies are available with FDA approval and 300 clinical trials are in progress.
- the cost of development is too high and saturated, and advanced pharmaceutical companies are already moving to the development of new treatments.
- Antibodies are made of proteins and must be made in vivo.However, aptamers are new bio-capturing reagents called “Chemical Antibodies” that can lead to discovery of lead compounds in vitro faster and easier synthesis and modification. It is expected.
- Macugen is a treatment for age-related Macular Degeneration (AMD), a cause of blindness caused by presbyopia, which causes abnormal blood vessel growth due to VEGF (vascular endothelial growth factor), which inhibits VEGF (vascular endothelial growth factor). It has a therapeutic effect.
- AMD age-related Macular Degeneration
- VEGF vascular endothelial growth factor
- VEGF vascular endothelial growth factor
- Ribomic began to develop new drugs for aptamers.
- Aptamers are also called “chemically antibodies” and have higher target binding and selectivity than antibodies, and are biologically produced in a chemically synthetic way as compared to antibodies, resulting in more efficient drug attachment and very simple QC. Has an advantage. If the low target reach rate of the antibody can be solved with aptamer, it is possible to overcome the low efficiency of the ADC (Antibody-Drug conjugate).
- ADC Antibody-Drug conjugate
- Aptamer-Drug conjugates are also expected to be a new therapeutic area, but research to develop them is still in its infancy. Recently, the Aptamer-Drug conjugate (Sgc8c-Dox conjugate), which combines doxorubicin (Dox) anticancer with aptamer (Sgc8c) at the University of Florida at Weihong Tangroup, was compared with Doxorubicin. It was difficult to separate / purify Sgc8c-Dox conjugate from naked aptamer Sgc8c, so that high purity Sgc8c-Dox conjugate was not obtained, and both Sgc8c-Dox conjugate and doxorubicin had similar cytotoxic effects (20%). Showed.
- GRO Guanine-Rich Oligonucleotide
- aptamers are very unstable in vivo, so PEGTylation of invert dT at 5 'position to PEG position to increase nuclease residence or circulation time in vivo (PEG-aptamer) -idT) is used in the clinic.
- GRO aptamers have a unique structure called G-quardruplex, which are highly stable and specifically bind to nucleolins that are highly expressed in cancer cells.
- GRO aptamers inhibit nucleolin expression by interfering with the molecular interactions and functions of nucleus, cytoplasma and membranes, thereby inducing cancer cell necrosis by promoting the expression of p53, a tumor suppressor protein due to antiproliferative effects. Let's do it.
- AS1411 is a GRO aptamer that is currently undergoing phase 2 clinical trials for non-small cell and kidney cancer in (Anti) Antisoma, and is specifically bound to nucleolins expressed in almost all cancers. It is very stable aptamer with anticancer effect.
- AS1411 currently being developed as an anti -nucleoline aptamer drug in Antisoma, is a GRO DNA aptamer with a ggtggtggtggttgtggtggtggtg base sequence and successfully completed phase II clinical trials for the treatment of renal and non-small cell lung cancer. Due to uncertainty in the efficacy test, Antisoma (Young) is no longer in Phase III clinical trial for non-small cell cancer, but is moving to Advanced Cancer Therapeutics Inc. to prepare Phase III clinical trial with ACT-GRO-777 (renamed AS1411). .
- Oligo-drugs including GRO aptamers, currently in development and in clinical use, are rapidly degraded by nuclease-degrading enzymes present in large quantities in plasma in vivo.
- the therapeutic agent by injection is known to be destroyed more quickly if not treated chemically stable.
- the rate of destruction can be reduced by chemically altering the oligonucleotides or by forming complexes in combination with appropriate carriers.
- Various chemical modifications such as replacing ribose 2'-OH with 2'F or 2'OMe groups or changing phospho backbone from PO to PS to resist nucleases, have been successfully used in antisense and siRNA applications.
- Macugen the first commercially available aptamer treatment licensed by the FDA in 2004, was also optimized after aptamer discovery.
- GRO aptamers are also important for the specificity of nucleolin targeting, and it is necessary to minimize the "off-target effect" of binding to proteins other than nucleolinic proteins to reduce their efficacy. Recently, Antisoma (Young) has not completed the Phase II clinical trial of AS1411 for non-small cell carcinoma (AML) as the first GRO aptamer. It is considered a disadvantage of not being seen.
- AS1411-Drug conjugates were found to be more effective in cancer treatment in vitro and in vivo than when used.
- the cancer target therapeutic agent of the present invention has the following Drug (R) -linker (L) -AS1411 structure.
- the position where the drug is linked is particularly preferably 12 and 13 positions or 12 or 13 positions.
- the drug R used here is monomethyl oristin E (MMAE), monomethyl oristin F (MMAF), cytarabine, gemcitabine, maytansine, DM1, DM4, calicheamicin and its derivatives, doxorubicin, Preference is given to duocarmycin and its derivatives, pyrrolobenzodiazepine (PBD), SN-38, ⁇ -amantine, Tubulysin analogs and the like.
- MMAE monomethyl oristin E
- MMAF monomethyl oristin F
- cytarabine gemcitabine
- maytansine DM1, DM4, calicheamicin and its derivatives
- doxorubicin Preference is given to duocarmycin and its derivatives, pyrrolobenzodiazepine (PBD), SN-38, ⁇ -amantine, Tubulysin analogs and the like.
- L is composed of X-Y [R-Y-X-AS1411],
- Y is maleimidocaproyl-valine-citrulline-p-aminobenzoyloxycarbonyl (MC-Val-Cit-PAB), hydrazone, peptide, disulfide, thioether, valine-citrulline, N -maleimidomethylcyclohexane -1-carboxylate (MCC), maleimidocaproyl, mercaptoacetamidocaproyl, N-succinimidyl 4- (2-pyridyldithio) pentanoate (SPP), SMCC, succinimi Diyl 4- (N-maleimidomethyl) cyclohexane-1-carboxylate (SMCC), N-succinimidyl 4- (2-pyridylthio) pentanoate (SPDB), phosphodiester bonds, and Is selected from the group consisting of nucleotides,
- X is 5'-thiol-modifier C6 , thiol-modifier C6 SS, dithiol serinol, PC amino-modifier, 5'-amino-modifier C3, 5'-amino-modifier C6, 5'-amino-modifier C12 , 5'-amino-modifier TEG, amino-modifier C2 dT, amino-modifier C6 dT, S-Bz- thiol-modifier C6-dT, phosphodiester bonds, and nucleotides.
- AS1411-drug conjugates of the present invention are more effective in treating cancer targets in vitro and in vivo than when using drugs alone.
- FIG. 6 shows MTT assay results for Mv4-11 cell lines of citrabin- (GLFG-MC-S-C6) -T 3 -AS1411 and citrabin- (GLFG-MC-S-C6) -T 3 -CRO.
- FIG. 7 is a FDG PET image taken before treatment of A549 lung cancer cell line injected mice (tumor with FDG intake in left thigh).
- FIG. 8 shows FDG PET images obtained 30 days after MMAE- (PAB-Cit-Val-MC-S-C6) -T 3 -AS1411 treatment in mice injected with A549 lung cancer cell lines (confirmed that tumor FDG intake is reduced).
- FIG 9 is a FDG PET image taken before treatment for A549 lung cancer cell line-injected mice (tumors with FDG intake in the left thigh region are observed).
- FIG. 14 shows FDG PET images obtained 30 days after citrabin- (GLFG-MC-S-C6) -T 3 -AS1411 treatment for Mv4-11 AML cell line injected mice (determined tumor FDG uptake).
- Figure 15 shows Mv4-11 AML cell line injection mice FDG PET image taken before treatment (tumor with FDG intake in left thigh).
- FDG PET images obtained 30 days after MMAE treatment (confirmed increased tumor FDG intake).
- FIG. 18 shows MMAE- (PAB-Cit-Val-MC-S-C6) -T 3 -AS1411, 12 or 13- (MMAE-PAB-Cit-Val-MC-S-C6) -AS1411 and 12,13- (MMAE-PAB-Cit-Val-MC-S-C6) MTT assay results for the A549 cell line of 2- AS1411.
- RSS-C6-tttggtggtggtggtggttgtggtggtggtggtgg was removed by centrifugation of the remaining DTT after about 3 hours reduction reaction in the presence of DTT and exchanged with SB17 buffer to HS-C6-tttggtggtggtggttgtggtggtggtgg [HS -C6-T 3 -AS141].
- MC-Val-Cit-PAB-MMAE dissolved in a small amount of DMSO was added and shaken overnight. Separation / purification via reverse phase HPLC (Waters-Xbridge OST C18 10 ⁇ 50 mm, 65, TEAE / CAN buffer).
- MC-Val-Cit-PAB-MMAE dissolved in a small amount of DMSO was added and shaken overnight. Separation / purification via reverse phase HPLC (Waters-Xbridge OST C18 10 ⁇ 50 mm, 65, TEAE / CAN buffer).
- MC-Val-Cit-PAB-MMAE dissolved in a small amount of DMSO was suspended and shaken overnight.
- Purified via reverse phase HPLC (Waters-Xbridge OST C18 10X50mm, 65, TEAE / CAN buffer) 12,13- (MMAE-PAB-Cit-Val-MC-S-C6) 2 -AS1411 and 12 or 13- (MMAE -PAB-Cit-Val-MC-S-C6) -AS1411 was obtained.
- RSS-C6-tttggtggtggtggtggttgtggtggtggtggtgg [RSS-C6-T 3 -AS141] was removed after about 3 hours of reduction reaction in the presence of DTT through the centrifuge and exchanged with SB17 buffer.
- Mal-GPLG-citrabin dissolved in a small amount of DMSO was suspended and shaken overnight. Purification was performed through reverse phase HPLC (Waters-Xbridge OST C18 10X50mm, 65, TEAE / CAN buffer) to obtain citrabin- (GLFG-MC-S-C6) -T 3 -AS1411.
- MMAE- (PAB-Cit-Val-MC-S-C6) -T 3 -AS1411 in A549 cell line which is a nucleolin protein overexpressed lung cancer cell line
- MMAE- (PAB-Cit-Val-MC-S-C6) -T 3 -AS1411 showed almost the same efficacy as MMAE.
- A549 cell (ATCC, IMDM + 10% FBS) is determined by the cell test to determine the appropriate cell concentration 2.5 ⁇ 5X10 5 Seed dogs / well in 96well plate and grow one day.
- MMAE- (PAB-Cit-Val-MC-S-C6) -T 3 -AS1411 and MMAE- (PAB-Cit-Val-MC-S-C6) -T 3 -CRO are heated to 95 ° C for 5 minutes at room temperature. After cooling slowly at each concentration was treated immediately in each well.
- the treated A549 cells were incubated for 72 h in a 5% CO 2 incubator, followed by 20 uL of reagent solution (Cell Proliferation kit II, Roche) for MTT assay, incubated with time (10 min, 30 min, 1 hr) and absorbed at 490 nm using ELISA reader. It was measured (FIG. 5).
- citrabin- (GLFG-MC-S-C6) -T 3 -AS1411 conjugate showed almost the same effect as the citrabin.
- Mv4-11 cell (ATCC, IMDM + 10 % FBS) is determined through a test cell to determine the appropriate cell concentration cell number 2.5 ⁇ 5X10 5 Seed dogs / well in 96well plate and grow one day.
- Citrabin- (GLFG-MC-S-C6) -T 3 -AS1411 and Citrabin- (GLFG-MC-S-C6) -T 3 -CRO are heated at 95 °C for 5 minutes and then cooled slowly at room temperature. Each well was treated immediately.
- the treated A549 cells were incubated for 72 h in a 5% CO 2 incubator, followed by 20 uL of reagent solution (Cell Proliferation kit II, Roche) for MTT assay, incubated with time (10 min, 30 min, 1 hr) and absorbed at 490 nm using ELISA reader. It was measured (FIG. 6).
- MMAE- (PAB-Cit-Val-MC-S-C6) -T 3 -AS1411 and MMAE were administered to A549 lung cancer cell line injected mice for 30 days, and the tumor size was confirmed by PET image. 6.1x10 ⁇ 6 cells / ml of A549 lung cancer cells were injected subcutaneously into the right mouse thigh. Tumor size was measured 3-4 weeks after injection, and microPET was taken before treatment when the diameter reached 0.8cm. For PET imaging, images were obtained after intraperitoneal injection of F-18 FDG 0.2mCi.
- MMAE- (PAB-Cit-Val-MC-S-C6) -T 3 -AS1411 was intravenously injected four times at five day intervals in five experimental groups. 7.5 mg / kg, 0.5 mg / kg of MMAE). After 30 days of treatment, microPET was taken in the same manner as before treatment. After injection of MMAE- (PAB-Cit-Val-MC-S-C6) -T 3 -AS1411 for 30 days in mice injected with A549 lung cancer cell line, tumors significantly reduced FDG intake when PET image was confirmed. It was confirmed that (Figs. 7 and 8).
- MMAE was injected into the A549 lung cancer cell line-injected mice for 30 days, followed by PET image. 6.1x10 ⁇ 6 cells / ml of A549 lung cancer cells were injected subcutaneously into the right mouse thigh. Tumor size was measured 3-4 weeks after injection, and microPET was taken before treatment when the diameter reached 0.8cm.
- images were obtained after intraperitoneal injection of F-18 FDG 0.2mCi. (Siemens Inveon) After confirming the tumor's FDG uptake in the pre-treatment images, five mice were intravenously injected with MMAE four times at 5-day intervals (0.5 mg / kg). Photographed. It was confirmed that the FDG uptake of tumors was increased in the FDG PET images after the treatment compared with the MMAE treatment (FIGS. 9 and 10).
- A549 lung cancer cells implanted mice standing MMAE- (PAB-Cit-Val- MC-S-C6) -T 3 -AS1411 show that the inhibitory effect is superior than cancer when administered alone as MMAE. It was confirmed that MMAE- (PAB-Cit-Val-MC-S-C6) -T 3 -AS1411 inhibited cancer by 80% more than MMAE alone. Tumor size was measured in the horizontal and vertical axis at intervals of 5 days after the start of treatment, and tumors of each group were extracted 30 days after the start of treatment. Tumor sizes of MMAE- (PAB-Cit-Val-MC-S-C6) -T 3 -AS1411 and MMAE were compared by dividing the images by group as shown below (FIGS. 11 and 12).
- Mv4-11 AML cell line injection mice were administered with citrabin- (GLFG-MC-S-C6) -T 3 -AS1411 and MMAE for 30 days by IV injection, and the tumor size was confirmed by PET image. 6.1 ⁇ 10 6 cells / ml of Mv4-11 AML cells were injected subcutaneously into the nude mouse right thigh. Tumor size was measured 3-4 weeks after injection, and microPET was taken before treatment when the diameter reached 0.8cm. For PET imaging, images were obtained after intraperitoneal injection of F-18 FDG 0.2mCi.
- citrabin- (GLFG-MC-S-C6) -T 3 -AS1411 was intravenously injected 4 times at 5 day intervals in 5 experimental mice (7.5 mg / kg, 0.5 mg / kg of MMAE). 30 days after the start of treatment, microPET was photographed in the same manner as before treatment (FIGS. 13 and 14).
- Mv4-11 AML cell line injection mice were injected with MMAE for 30 days by IV injection, and then PET image was confirmed. 6.1 ⁇ 10 6 cells / ml of Mv4-11 AML cells were injected subcutaneously into the nude mouse right thigh. Tumor size was measured 3-4 weeks after injection, and microPET was taken before treatment when the diameter reached 0.8cm. For PET imaging, images were obtained after intraperitoneal injection of F-18 FDG 0.2mCi. (Siemens Inveon) After confirming the tumor's FDG uptake in the pre-treatment image, five mice were injected intravenously with MMAE four times at five day intervals.
- A549 cell (ATCC, IMDM + 10% FBS) is determined by the cell test to determine the appropriate cell concentration 2.5 ⁇ 5X10 5 Seed dogs / well in 96well plate and grow one day.
- A549 cells were incubated for 72h in a 5% CO 2 incubator, followed by 20uL of reagent solution (Cell Proliferation kit II, Roche) for MTT assay, incubated with time (10min, 30min, 1hr), and then absorbed at 490nm using ELISA reader. It was measured (FIG. 17).
- reagent solution Cell Proliferation kit II, Roche
- time 10min, 30min, 1hr
- FIG. 18 shows MMAE- (PAB-Cit-Val-MC-S-C6) -T 3 -AS1411, 12 or 13- (MMAE-PAB-Cit-Val-MC-S-C6) -AS1411 and 12,13- (MMAE-PAB-Cit-Val-MC-S-C6)
- Figure 2 shows the results of the MTT assay for the A549 cell line of AS1411.
- AS1411-drug conjugates of the present invention can be usefully used as a cancer target therapeutic agent.
Abstract
Description
MMAE-Linker-Aptamer 콘쥬게이트 | |
A | MMAE-(PAB-Cit-Val-MC-S-C6)-T3-CRO |
B | MMAE-(PAB-Cit-Val-MC-S-C6)-T3-AS1411 |
C | 12 또는 13-(MMAE-PAB-Cit-Val-MC-S-C6)-AS1411 |
D | 12,13-(MMAE-PAB-Cit-Val-MC-S-C6)2-AS1411 |
Claims (4)
- 약물-링커-AS1411 구조를 포함하는 암 표적 치료제.
- 제 1항에 있어서, 약물은 모노메틸 오리스타틴 E(MMAE), 모노메틸 오리스타틴 F(MMAF), 시타라빈, 젬시타빈, 메이탄시네, DM1, DM4, 칼리키아미신 및 그 유도체, 독소루비신, 듀오카르마이신 및 그 유도체, 피롤로벤조디아제핀(PBD), SN-38, α-아만틴, 및 투불루신 유사체(Tubulysin analog)로부터 선택되는 것을 특징으로 하는 암 표적 치료제.
- 제 1항에 있어서, 링커는 X-Y로 구성되고,여기에서 Y는, 말레이미도카프로일-발린-시트룰린-p-아미노벤조일옥시카르보닐(MC-Val-Cit-PAB), 히드라존, 펩티드, 디설파이드, 티오에테르, 발린-시트룰린, N-말레이미도메틸시클로헥산-1-카르복실래이트 (MCC), 말레이미도카프로일, 머캅토아세트아미도카프로일, N-숙신이미딜 4-(2-피리딜디티오) 펜타노에이트(SPP), SMCC, 숙신이미딜 4-(N-말레이미도메틸) 시클로헥산-1-카르복실래이트(SMCC), N-숙신이미딜 4-(2-피리딜티오) 펜타노에이트(SPDB), 포스포디에스테르 결합, 및 뉴클레오타이드로 이루어지는 그룹으로부터 선택되며,X는, 5'-티올-개질제 C6, 티올-개질제 C6 S-S, 디티올 세리놀, PC 아미노-개질제, 5'-아미노-개질제 C3, 5'-아미노-개질제 C6, 5'-아미노-개질제 C12, 5'-아미노-개질제 TEG, 아미노-개질제 C2 dT, 아미노-개질제 C6 dT, S-Bz- 티올-개질제 C6-dT, 포스포디에스테르 결합, 및 뉴클레오타이드로 이루어지는 그룹으로부터 선택 선택되는 것을 특징으로 하는 암 표적 치료제.
- 제 1항에 있어서, 상기 링커는 AS1411의 12 또는 13 위치, 또는 12와 13 위치 양쪽에 연결되는 것을 특징으로 하는 암 표적 치료제.
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EP17887935.9A EP3560517A4 (en) | 2016-12-26 | 2017-12-04 | APTAMER INGREDIENT CONJUGATE AND USE OF IT |
US16/473,771 US11458120B2 (en) | 2016-12-26 | 2017-12-04 | Aptamer-drug conjugate and use thereof |
JP2019555545A JP7067802B2 (ja) | 2016-12-26 | 2017-12-04 | アプタマー-薬物コンジュゲート及びその用途 |
CN201780080822.7A CN110167597A (zh) | 2016-12-26 | 2017-12-04 | 适配体-药物缀合物及其用途 |
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WO1984003285A1 (en) * | 1983-02-22 | 1984-08-30 | Molecular Biosystems Inc | Defined sequence single strand oligonucleotides incorporating reporter groups, process for the chemical synthesis thereof, and nucleosides useful in such synthesis |
FR2786398B1 (fr) | 1998-11-30 | 2002-12-27 | Synt Em | Composition pharmaceutique anti-cancereuse et anti-chimioresistance comprenant un agent anticancereux et au moins un peptide |
CA2494105C (en) * | 2002-07-31 | 2013-04-02 | Seattle Genetics, Inc. | Drug conjugates and their use for treating cancer, an autoimmune disease or an infectious disease |
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