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Elaileh A, Saharia A, Potter L, Baio F, Ghafel A, Abdelrahim M, Heyne K. Promising new treatments for pancreatic cancer in the era of targeted and immune therapies. Am J Cancer Res 2019; 9:1871-1888. [PMID: 31598392 PMCID: PMC6780661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/05/2019] [Indexed: 06/10/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer mortality among men and women in the United States. Its incidence has been on the rise, with a projected two-fold increase by 2030. PDAC carries a poor prognosis due to a lack of effective screening tools, limited understanding of pathophysiology, and ineffective treatment modalities. Recently, there has been a revolution in the world of oncology with the advent of novel treatments to combat this disease. However, the 5-year survival of PDAC remains unchanged at a dismal 8%. The aim of this review is to bring together several studies and identify various recent modalities that have been promising in treating PDAC.
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Affiliation(s)
- Ahmed Elaileh
- Department of General Surgery, Houston Methodist HospitalHouston, Texas, USA
| | - Ashish Saharia
- Department of General Surgery, Houston Methodist HospitalHouston, Texas, USA
| | - Lucy Potter
- Department of General Surgery, Houston Methodist HospitalHouston, Texas, USA
| | - Flavio Baio
- Department of General Surgery, Houston Methodist HospitalHouston, Texas, USA
| | - Afnan Ghafel
- Department of Radiology, The University of JordanAmman, Jordan
| | - Maen Abdelrahim
- Department of General Surgery, Houston Methodist HospitalHouston, Texas, USA
| | - Kirk Heyne
- Department of General Surgery, Houston Methodist HospitalHouston, Texas, USA
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52
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Sapalidis K, Kosmidis C, Funtanidou V, Katsaounis A, Barmpas A, Koimtzis G, Mantalobas S, Alexandrou V, Aidoni Z, Koulouris C, Pavlidis E, Giannakidis D, Surlin V, Pantea S, Strambu V, Constantina RO, Amaniti A, Zarogoulidis P, Mogoantă S, Kesisoglou I, Sardeli C. Update on current pancreatic treatments: from molecular pathways to treatment. J Cancer 2019; 10:5162-5172. [PMID: 31602269 PMCID: PMC6775621 DOI: 10.7150/jca.36300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 07/29/2019] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cancer is still diagnosed at a late stage although we have novel diagnostic tools. Pancreatic cancer chemotherapy treatment resistance is observed and therefore novel treatments are in need. Anti-cancer stem cell therapy, combination of chemotherapy and/or radiotherapy with immunotherapy, proteins/enzymes and gene therapy are currently under evaluation. Targeted treatment with tyrosine kinase inhibitors is also administered and novel inhibitors are also under evaluation. In the current review we present recent data from our search within the year 2018.
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Affiliation(s)
- Konstantinos Sapalidis
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Christoforos Kosmidis
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Varvara Funtanidou
- Anesthesiology Department, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Athanasios Katsaounis
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Amastasios Barmpas
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Georgios Koimtzis
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Stylianos Mantalobas
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Vyron Alexandrou
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Zoi Aidoni
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Charilaos Koulouris
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Efstathios Pavlidis
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Dimitrios Giannakidis
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Valeriu Surlin
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | | | - Victor Strambu
- General Surgery Department, "Dr Carol Davila", University of Medicine and Pharmacy, Bucuresti, Romania
| | | | - Aikaterini Amaniti
- Anesthesiology Department, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Paul Zarogoulidis
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
- Anesthesiology Department, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Stelian Mogoantă
- Department of Pharmacology and Department of Surgery, Faculty of Dentistry, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Isaak Kesisoglou
- 3rd Department of Surgery, “AHEPA” University Hospital, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Chrysanthi Sardeli
- Clinical Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Immunoevolution of mouse pancreatic organoid isografts from preinvasive to metastatic disease. Sci Rep 2019; 9:12286. [PMID: 31439856 PMCID: PMC6706454 DOI: 10.1038/s41598-019-48663-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 08/09/2019] [Indexed: 12/12/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDA) has a highly immunosuppressive microenvironment, which is contributed by the complex interaction between cancer cells and a heterogeneous population of stromal cells. Therefore, facile and trackable models are needed for integrative and dynamic interrogation of cancer-stroma interaction. Here, we tracked the immunoevolution of PDA in a genetically-defined transplantable model of mouse pancreatic tumour organoids that recapitulates the progression of the disease from early preinvasive lesions to metastatic carcinomas. We demonstrated that organoid-derived isografts (ODI) can be used as a biological source of biomarkers (NT5E, TGFB1, FN1, and ITGA5) of aggressive molecular subtypes of human PDA. In ODI, infiltration from leukocytes is an early event during progression of the disease as observed for autochthonous models. Neoplastic progression was associated to accumulation of Maf+ macrophages, which inversely correlated with CD8+ T cells infiltration. Consistently, levels of MAF were enriched in human PDA subtypes characterized by abundance of macrophage-related transcripts and indicated poor patients' survival. Density of MAF+ macrophages was higher in human PDA tissues compared to preinvasive lesions. Our results suggest that ODIs represent a suitable system for genotypic-immunophenotypic studies and support the hypothesis of MAF+ macrophages as a prominent immunosuppressive population in PDA.
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54
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Pancreatic ductal adenocarcinoma: biological hallmarks, current status, and future perspectives of combined modality treatment approaches. Radiat Oncol 2019; 14:141. [PMID: 31395068 PMCID: PMC6688256 DOI: 10.1186/s13014-019-1345-6] [Citation(s) in RCA: 251] [Impact Index Per Article: 50.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 07/24/2019] [Indexed: 01/18/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a highly devastating disease with poor prognosis and rising incidence. Late detection and a particularly aggressive biology are the major challenges which determine therapeutic failure. In this review, we present the current status and the recent advances in PDAC treatment together with the biological and immunological hallmarks of this cancer entity. On this basis, we discuss new concepts combining distinct treatment modalities in order to improve therapeutic efficacy and clinical outcome - with a specific focus on protocols involving radio(chemo)therapeutic approaches.
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55
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Tumour microenvironment of pancreatic cancer: immune landscape is dictated by molecular and histopathological features. Br J Cancer 2019; 121:5-14. [PMID: 31110329 PMCID: PMC6738327 DOI: 10.1038/s41416-019-0479-5] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 07/03/2018] [Accepted: 04/17/2019] [Indexed: 12/17/2022] Open
Abstract
Pancreatic cancer is a lethal disease, with fewer than 7% of patients surviving beyond 5 years following diagnosis. Immune responses are known to influence tumour progression. The dynamic interaction between cancer cells and immune cells in the tumour microenvironment (TME) can not only result in, or be influenced by, different tumour characteristics, but it can also lead to diverse mechanisms of immune evasion. At present, there is much interest in classifying pancreatic cancer according to its morphologic, genetic and immunologic features in order to understand the significant heterogeneity of this tumour type. Such information can contribute to the identification of highly needed novel prognostic and predictive biomarkers, and can be used for accurate patient stratification and therapy guidance. This review focuses on the characteristics of the local immune contexture of pancreatic ductal adenocarcinoma and the interaction between tumour cells and immune cells within the TME, by simultaneously taking into account the histomorphologic and genetic features of the tumours. The emerging opportunities for approaches that could predict the most-effective therapeutic modalities towards more targeted, personalised treatments to improve patient care are also discussed.
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56
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Dréau D, Moore LJ, Wu M, Roy LD, Dillion L, Porter T, Puri R, Momin N, Wittrup KD, Mukherjee P. Combining the Specific Anti-MUC1 Antibody TAB004 and Lip-MSA-IL-2 Limits Pancreatic Cancer Progression in Immune Competent Murine Models of Pancreatic Ductal Adenocarcinoma. Front Oncol 2019; 9:330. [PMID: 31114758 PMCID: PMC6503151 DOI: 10.3389/fonc.2019.00330] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 04/11/2019] [Indexed: 12/19/2022] Open
Abstract
Immunotherapy regimens have shown success in subsets of cancer patients; however, their efficacy against pancreatic ductal adenocarcinoma (PDA) remain unclear. Previously, we demonstrated the potential of TAB004, a monoclonal antibody targeting the unique tumor-associated form of MUC1 (tMUC1) in the early detection of PDA. In this study, we evaluated the therapeutic benefit of combining the TAB004 antibody with Liposomal-MSA-IL-2 in immune competent and human MUC1 transgenic (MUC1.Tg) mouse models of PDA and investigated the associated immune responses. Treatment with TAB004 + Lip-MSA-IL-2 resulted in significantly improved survival and slower tumor growth compared to controls in MUC1.Tg mice bearing an orthotopic PDA.MUC1 tumor. Similarly, in the spontaneous model of PDA that expresses human MUC1, the combination treatment stalled the progression of pancreatic intraepithelial pre-neoplastic (PanIN) lesion to adenocarcinoma. Treatment with the combination elicited a robust systemic and tumor-specific immune response with (a) increased percentages of systemic and tumor infiltrated CD45+CD11b+ cells, (b) increased levels of myeloperoxidase (MPO), (c) increased antibody-dependent cellular cytotoxicity/phagocytosis (ADCC/ADCP), (d) decreased percentage of immune regulatory cells (CD8+CD69+ cells), and (e) reduced circulating levels of immunosuppressive tMUC1. We report that treatment with a novel antibody against tMUC1 in combination with a unique formulation of IL-2 can improve survival and lead to stable disease in appropriate models of PDA by reducing tumor-induced immune regulation and promoting recruitment of CD45+CD11b+ cells, thereby enhancing ADCC/ADCP.
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Affiliation(s)
- Didier Dréau
- Department of Biological Sciences, UNC Charlotte, Charlotte, NC, United States
| | | | - Mike Wu
- OncoTab Inc., Charlotte, NC, United States
| | | | | | - Travis Porter
- Department of Biological Sciences, UNC Charlotte, Charlotte, NC, United States
| | - Rahul Puri
- OncoTab Inc., Charlotte, NC, United States
| | - Noor Momin
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - K Dane Wittrup
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Pinku Mukherjee
- Department of Biological Sciences, UNC Charlotte, Charlotte, NC, United States.,OncoTab Inc., Charlotte, NC, United States
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57
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Abstract
Chemotherapy is an important part of multimodality pancreatic cancer treatment. After curative resection, adjuvant chemotherapy can significantly improve disease free survival and overall survival. The current standard of care is six months adjuvant chemotherapy with modified folinic acid, 5-fluorouracil, irinotecan and oxaliplatin (mFOLFIRINOX) in patients fit enough for this protocol, otherwise six months of gemcitabine and capecitabine based on the European Study Group for Pancreatic Cancer (ESPAC)-4 study. In patients with metastatic disease, combination chemotherapy according to the FOLFIRINOX protocol or with gemcitabine plus nab-paclitaxel is an important improvement to gemcitabine monotherapy that was the standard for many years. Patients not fit for combination chemotherapy however may still benefit from gemcitabine. Patients with good performance status may benefit from second-line chemotherapy. Chemoradiation has long been used in locally advanced pancreatic cancer but is now tempered following the LAP07 study. This trial showed no difference in overall survival in those patients with stable disease after four months of gemcitabine (with or without erlotinib) randomized to either continuation of gemcitabine therapy or chemoradiation (54Gy with capecitabine). As an alternative to radiation, other forms local therapies including radiofrequency ablation, irreversible electroporation, high-intensity focused ultrasound, microwave ablation and local anti-KRAS therapy (using siG12D-LODER) are currently under investigation. Given the systemic nature of pancreas cancer from an early stage, the success of any local approach other than complete surgical resection (with adjuvant systemic therapy) is likely to be very limited. In patients with locally advanced, irresectable cancer, chemotherapy may offer the chance for secondary resection with a survival similar to patients with primary resectable disease. Downstaging regimens need to be evaluated in prospective randomized trials in order to make firm recommendations. Selection of patient groups for specific therapy including cytotoxics is becoming a reality using assays based on drug cellular transport and metabolism, and molecular signatures. Going forward, high throughput screening of different chemotherapy agents using molecular signatures based on patients' derived organoids holds considerable promise.
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58
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Tiriac H, Plenker D, Baker LA, Tuveson DA. Organoid models for translational pancreatic cancer research. Curr Opin Genet Dev 2019; 54:7-11. [PMID: 30844513 DOI: 10.1016/j.gde.2019.02.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 02/02/2019] [Indexed: 12/18/2022]
Abstract
Despite recent advances in the treatment of cancer, pancreatic ductal adenocarcinoma (PDAC) still retains the worst survival rate of common malignancies. Late diagnosis and lack of curative therapeutic options are the most pressing clinical problems for this disease. Therefore, there is a need for patient models and biomarkers that can be applied in the clinic to identify the most effective therapy for a patient. Pancreatic ductal organoids are ex-vivo models of PDAC that can be established from very small biopsies, enabling the study of localized, advanced, and metastatic patients. Organoids models have been applied to pancreatic cancer research and offer a promising platform for precision medicine approaches.
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Affiliation(s)
- Hervé Tiriac
- Cold Spring Harbor Laboratory, NCI-designated Cancer Center, 1 Bungtown Rd., Cold Spring Harbor, NY 11724, United States; University of California San Diego, Department of Surgery, NCI-designated Comprehensive Cancer Center, 3855 Health Sciences Drive, La Jolla, CA 92093-0987, United States.
| | - Dennis Plenker
- Cold Spring Harbor Laboratory, NCI-designated Cancer Center, 1 Bungtown Rd., Cold Spring Harbor, NY 11724, United States
| | - Lindsey A Baker
- Cold Spring Harbor Laboratory, NCI-designated Cancer Center, 1 Bungtown Rd., Cold Spring Harbor, NY 11724, United States
| | - David A Tuveson
- Cold Spring Harbor Laboratory, NCI-designated Cancer Center, 1 Bungtown Rd., Cold Spring Harbor, NY 11724, United States.
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59
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Liu J, Jiang W, Zhao K, Wang H, Zhou T, Bai W, Wang X, Zhao T, Huang C, Gao S, Qin T, Yu W, Yang B, Li X, Fu D, Tan W, Yang S, Ren H, Hao J. Tumoral EHF predicts the efficacy of anti-PD1 therapy in pancreatic ductal adenocarcinoma. J Exp Med 2019; 216:656-673. [PMID: 30733283 PMCID: PMC6400540 DOI: 10.1084/jem.20180749] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 11/05/2018] [Accepted: 12/18/2018] [Indexed: 12/12/2022] Open
Abstract
EHF transcriptionally inhibits the expressions of TGFβ1 and GM-CSF to decrease T reg cell and MDSC accumulation, making it a promising biomarker to evaluate the immune microenvironment in PDAC. EHF overexpression may improve the efficacy of checkpoint immunotherapy in PDAC. Pancreatic ductal adenocarcinoma (PDAC) is a highly immune-suppressive tumor with a low response rate to single checkpoint blockade therapy. ETS homologous factor (EHF) is a tumor suppressor in PDAC. Here, we report a novel function of EHF in pancreatic cancer immune microenvironment editing and efficacy prediction for anti-PD1 therapy. Our findings support that the deficiency of tumoral EHF induced the accumulation of regulatory T (T reg) cells and myeloid-derived suppressor cells (MDSCs) and a decrease in the number of tumor-infiltrating CD8+ T cells. Mechanistically, EHF deficiency induced the conversion and expansion of T reg cells and MDSCs through inhibiting tumor TGFβ1 and GM-CSF secretion. EHF suppressed the transcription of TGFB1 and CSF2 by directly binding to their promoters. Mice bearing EHF overexpression tumors exhibited significantly better response to anti-PD1 therapy than those with control tumors. Our findings delineate the immunosuppressive mechanism of EHF deficiency in PDAC and highlight that EHF overexpression may improve PDAC checkpoint immunotherapy.
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Affiliation(s)
- Jing Liu
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China.,Department of Breast Oncoplastic Surgery, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, Key Laboratory of Breast Cancer Prevention and Therapy, Tianjin Medical University, Ministry of Education, China
| | - Wenna Jiang
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China.,Department of Clinical Laboratory, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, Tianjin's Clinical Research Center for Cancer, China
| | - Kaili Zhao
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Hongwei Wang
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Tianxing Zhou
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Weiwei Bai
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Xiuchao Wang
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Tiansuo Zhao
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Chongbiao Huang
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Song Gao
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Tai Qin
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Wenwen Yu
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Bo Yang
- Department of Pathology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Xin Li
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Danqi Fu
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Wei Tan
- Biosion, Inc., Jiangsu, China
| | - Shengyu Yang
- Department of Cellular and Molecular Physiology, Penn State College of Medicine, Hershey, PA
| | - He Ren
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
| | - Jihui Hao
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, China
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60
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Batista IA, Melo SA. Exosomes and the Future of Immunotherapy in Pancreatic Cancer. Int J Mol Sci 2019; 20:ijms20030567. [PMID: 30699928 PMCID: PMC6387297 DOI: 10.3390/ijms20030567] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/25/2019] [Indexed: 12/26/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a devastating disease, associated with a late diagnosis and a five-year survival rate of 8%. Currently available treatments fall short in improving the survival and quality of life of PDAC patients. The only possible curative option is still the surgical resection of the tumor. Exosomes are extracellular vesicles secreted by cells that transport proteins, lipids, and nucleic acids to other cells, triggering phenotypic changes in the recipient cells. Tumor cells often secrete increased amounts of exosomes. Tumor exosomes are now accepted as important players in the remodeling of PDAC tumor stroma, particularly in the establishment of an immunosuppressive microenvironment. This has sparked the interest in their usefulness as mediators of immunomodulatory effects for the treatment of PDAC. In fact, exosomes are now under study to understand their potential as nanocarriers to stimulate an immune response against cancer. This review highlights the latest findings regarding the function of exosomes in tumor-driven immunomodulation, and the challenges and advantages associated with the use of these vesicles to potentiate immunotherapy in PDAC.
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Affiliation(s)
- Ines A Batista
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Portugal (i3S), 4200-135 Porto, Portugal.
- Institute of Molecular Pathology & Immunology of the University of Porto (IPATIMUP), 4200-135 Porto, Portugal.
| | - Sonia A Melo
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Portugal (i3S), 4200-135 Porto, Portugal.
- Institute of Molecular Pathology & Immunology of the University of Porto (IPATIMUP), 4200-135 Porto, Portugal.
- Medical Faculty of the University of Porto (FMUP), 4200-319 Porto, Portugal.
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61
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Uzunparmak B, Sahin IH. Pancreatic cancer microenvironment: a current dilemma. Clin Transl Med 2019; 8:2. [PMID: 30645701 PMCID: PMC6333596 DOI: 10.1186/s40169-019-0221-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 01/09/2019] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cancer is one of the leading causes of cancer-related death in the United States and survival outcomes remain dismal despite significant advances in molecular diagnostics and therapeutics in clinical practice. The microenvironment of pancreatic cancer carries unique features with increased desmoplastic reaction and is infiltrated by regulatory T cells and myeloid-derived suppressor cells which negatively impact the effector immune cells. Current evidence suggests that stellate cell-induced hypovascular stroma may have direct effects on aggressive behavior of pancreatic cancer. Preclinical studies suggested improvement in drug delivery to cancer cells with stroma modifying agents. However these findings so far have not been confirmed in clinical trials. In this article, we elaborate current-state-of-the science of the pancreatic cancer microenvironment and its impact on molecular behavior of cancer cells, chemotherapy resistance and druggability of stroma elements in combination with other agents to enhance the efficacy of therapeutic approaches.
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Affiliation(s)
| | - Ibrahim Halil Sahin
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, USA.
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62
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Immunotherapy, Radiotherapy, and Hyperthermia: A Combined Therapeutic Approach in Pancreatic Cancer Treatment. Cancers (Basel) 2018; 10:cancers10120469. [PMID: 30486519 PMCID: PMC6316720 DOI: 10.3390/cancers10120469] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 11/20/2018] [Accepted: 11/20/2018] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cancer (PC) has the highest mortality rate amongst all other cancers in both men and women, with a one-year relative survival rate of 20%, and a five-year relative survival rate of 8% for all stages of PC combined. The Whipple procedure, or pancreaticoduodenectomy, can increase survival for patients with resectable PC, however, less than 20% of patients are candidates for surgery at time of presentation. Most of the patients are diagnosed with advanced PC, often with regional and distant metastasis. In these advanced cases, chemotherapy and radiation have shown limited tumor control, and PC continues to be refractory to treatment and results in a poor survival outcome. In recent years, there has been intensive research on checkpoint inhibitor immunotherapy for PC, however, PC is characterized with dense stromal tissue and a tumor microenvironment (TME) that is highly immunosuppressive, which makes immunotherapy less effective. Interestingly, when immunotherapy is combined with radiation therapy (RT) and loco-regional hyperthermia (HT), it has demonstrated enhanced tumor responses. HT improves tumor killing via a variety of mechanisms, targeting both the tumor and the TME. Targeted HT raises the temperature of the tumor and surrounding tissues to 42–43 °C and makes the tumor more immunoresponsive. HT can also modulate the immune system of the TME by inducing and synthesizing heat shock proteins (HSP), which also activate an anti-tumor response. It is well known that HT can enhance RT-induced DNA damage in cancer cells and simultaneously help to oxygenate hypoxic regions. Thus, it is envisaged that combined HT and RT might have immunomodulatory effects in the PC-TME, making PC more responsive to immunotherapies. Moreover, the combined tripartite approach of immunotherapy, RT, and HT could reduce the overall toxicity associated with each individual therapy, while concomitantly enhancing the immunotherapeutic effect of overall individual therapies to treat local and metastatic PC. Thus, the use of a tripartite combinatorial approach could be promising and more efficacious than monotherapy or dual therapy to treat and increase the survival of the PC patients.
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63
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Gong J, Hendifar A, Tuli R, Chuang J, Cho M, Chung V, Li D, Salgia R. Combination systemic therapies with immune checkpoint inhibitors in pancreatic cancer: overcoming resistance to single-agent checkpoint blockade. Clin Transl Med 2018; 7:32. [PMID: 30294755 PMCID: PMC6174117 DOI: 10.1186/s40169-018-0210-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 09/24/2018] [Indexed: 12/16/2022] Open
Abstract
Immune checkpoint inhibitors have demonstrated broad single-agent antitumor activity and a favorable safety profile that render them attractive agents to combine with other systemic anticancer therapies. Pancreatic cancer has been fairly resistant to monotherapy blockade of programmed cell death protein 1 receptor, programmed death ligand 1, and cytotoxic T-lymphocyte associated protein 4. However, there is a growing body of preclinical evidence to support the rational combination of checkpoint inhibitors and various systemic therapies in pancreatic cancer. Furthermore, early clinical evidence has begun to support the feasibility and efficacy of checkpoint inhibitor-based combination therapy in advanced pancreatic cancer. Despite accumulating preclinical and clinical data, there remains several questions as to the optimal dosing and timing of administration of respective agents, toxicity of combination strategies, and mechanisms by which immune resistance to single-agent checkpoint blockade are overcome. Further development of biomarkers is also important in the advancement of combination systemic therapies incorporating checkpoint blockade in pancreatic cancer. Results from an impressive number of ongoing prospective clinical trials are eagerly anticipated and will seek to validate the viability of combination immuno-oncology strategies in pancreatic cancer.
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Affiliation(s)
- Jun Gong
- Department of Gastrointestinal Malignancies, Cedars-Sinai Medical Center, 8700 Beverly Blvd, AC 1042C, Los Angeles, CA, 90048, USA
| | - Andrew Hendifar
- Department of Gastrointestinal Malignancies, Cedars-Sinai Medical Center, 8700 Beverly Blvd, AC 1042C, Los Angeles, CA, 90048, USA
| | - Richard Tuli
- Department of Radiation Oncology, Cedars-Sinai Medical Center, 8700 Beverly Blvd, AC 1023, Los Angeles, CA, 90048, USA
| | - Jeremy Chuang
- Department of Internal Medicine, Harbor-UCLA Medical Center, 1000 W Carson St, Box 400, Torrance, CA, 90509, USA
| | - May Cho
- Department of Internal Medicine, Division of Hematology and Oncology, UC Davis Comprehensive Cancer Center, 4501 X Street, Ste 3016, Sacramento, CA, 95817, USA
| | - Vincent Chung
- Department of Medical Oncology, City of Hope National Medical Center, 1500 E Duarte Rd, Bldg 51, Duarte, CA, 91010, USA
| | - Daneng Li
- Department of Medical Oncology, City of Hope National Medical Center, 1500 E Duarte Rd, Bldg 51, Duarte, CA, 91010, USA
| | - Ravi Salgia
- Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Building 51, Room 101, 1500 E Duarte St, Duarte, CA, 91010, USA.
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Hayashi H, Tanishima S, Fujii K, Mori R, Okamura Y, Yanagita E, Matsuoka R, Amano T, Kinoshita I, Komatsu Y, Dosaka-Akita H, Nishihara H. Genomic testing for pancreatic cancer in clinical practice as real-world evidence. Pancreatology 2018; 18:647-654. [PMID: 30055942 DOI: 10.1016/j.pan.2018.07.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/20/2018] [Accepted: 07/12/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Precision medicine guided by comprehensive genome sequencing represents a potential treatment strategy for pancreatic cancer. However, clinical sequencing for pancreatic cancer entails several practical difficulties. We have launched an in-house clinical sequencing system and started genomic testing for patients with cancer in clinical practice. We have analyzed the clinical utility of this system in pancreatic cancer. METHODS We retrospectively reviewed 20 patients with pancreatic cancer who visited our division. Genomic DNA was extracted from both tumor tissue and peripheral blood mononuclear cells obtained from the patients. We performed a comprehensive genomic testing using targeted amplicon sequencing for 160 cancer-related genes. The primary endpoints were the detection rates of potential actionable and druggable gene alterations. The secondary endpoints were the detection rate of secondary germline findings, the rate of re-biopsy required for genome sequencing, survival time after the initial visit (post-sequencing survival time), and turnaround time. RESULTS Although re-biopsy was required for 25% (5/20) of all patients, genomic testing was performed in all patients. Actionable and druggable gene alterations were detected in 100% (20/20) and 35% (7/20) of patients, respectively, whereas secondary germline findings were detected in 5% (1/20) of patients. The median turnaround times for physicians and patients were 20 and 26 days, respectively. The median post-sequencing survival time was 10.3 months. Only 10% (2/20) of all patients were treated with therapeutic agents based on the outcomes of genomic testing. CONCLUSIONS The clinical application of comprehensive genomic testing for pancreatic cancer was feasible and promising in clinical practice.
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Affiliation(s)
- Hideyuki Hayashi
- Division of Clinical Cancer Genomics, Hokkaido University Hospital, Sapporo, Japan.
| | - Shigeki Tanishima
- Department of Biomedical Informatics Development, Mitsubishi Space Software Co., Ltd, Tokyo, Japan
| | - Kyoko Fujii
- Division of Clinical Cancer Genomics, Hokkaido University Hospital, Sapporo, Japan
| | - Ryo Mori
- Department of Biomedical Informatics Development, Mitsubishi Space Software Co., Ltd, Tokyo, Japan
| | - Yasunobu Okamura
- Department of Biomedical Informatics Development, Mitsubishi Space Software Co., Ltd, Tokyo, Japan
| | - Emmy Yanagita
- Division of Clinical Cancer Genomics, Hokkaido University Hospital, Sapporo, Japan
| | - Ryosuke Matsuoka
- Division of Clinical Cancer Genomics, Hokkaido University Hospital, Sapporo, Japan
| | - Toraji Amano
- Hokkaido University Hospital Clinical Research and Medical Innovation Center, Sapporo, Japan
| | - Ichiro Kinoshita
- Department of Medical Oncology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yoshito Komatsu
- Department of Cancer Chemotherapy, Hokkaido University Hospital Cancer Center, Sapporo, Japan
| | - Hirotoshi Dosaka-Akita
- Division of Clinical Cancer Genomics, Hokkaido University Hospital, Sapporo, Japan; Department of Medical Oncology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroshi Nishihara
- Division of Clinical Cancer Genomics, Hokkaido University Hospital, Sapporo, Japan
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Wartenberg M, Cibin S, Zlobec I, Vassella E, Eppenberger-Castori S, Terracciano L, Eichmann MD, Worni M, Gloor B, Perren A, Karamitopoulou E. Integrated Genomic and Immunophenotypic Classification of Pancreatic Cancer Reveals Three Distinct Subtypes with Prognostic/Predictive Significance. Clin Cancer Res 2018; 24:4444-4454. [PMID: 29661773 DOI: 10.1158/1078-0432.ccr-17-3401] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/26/2018] [Accepted: 04/09/2018] [Indexed: 11/16/2022]
Abstract
Purpose: Current clinical classification of pancreatic ductal adenocarcinoma (PDAC) is unable to predict prognosis or response to chemo- or immunotherapy and does not take into account the host reaction to PDAC cells. Our aim is to classify PDAC according to host- and tumor-related factors into clinically/biologically relevant subtypes by integrating molecular and microenvironmental findings.Experimental Design: A well-characterized PDAC cohort (n = 110) underwent next-generation sequencing with a hot spot cancer panel while next-generation tissue microarrays were immunostained for CD3, CD4, CD8, CD20, PD-L1, p63, hyaluronan-mediated motility receptor (RHAMM), and DNA mismatch repair proteins. Previous data on FOXP3 were integrated. Immune cell counts and protein expression were correlated with tumor-derived driver mutations, clinicopathologic features (TNM 8th edition, 2017), survival, and epithelial-mesenchymal transition (EMT)-like tumor budding.Results: Three PDAC subtypes were identified: the "immune escape" (54%), poor in T and B cells and enriched in FOXP3+ regulatory T cells (Treg), with high-grade budding, frequent CDKN2A, SMAD4, and PIK3CA mutations, and poor outcome; the "immune rich" (35%), rich in T and B cells and poorer in FOXP3+ Tregs, with infrequent budding, lower CDKN2A and PIK3CA mutation rate, and better outcome and a subpopulation with tertiary lymphoid tissue (TLT), mutations in DNA damage response genes (STK11 and ATM), and the best outcome; and the "immune exhausted" (11%), with immunogenic microenvironment and two subpopulations-one with PD-L1 expression and a high PIK3CA mutation rate and a microsatellite-unstable subpopulation with a high prevalence of JAK3 mutations. The combination of low budding, low stromal FOXP3 counts, presence of TLTs, and absence of CDKN2A mutations confers significant survival advantage in patients with PDAC.Conclusions: Immune host responses correlate with tumor characteristics, leading to morphologically recognizable PDAC subtypes with prognostic/predictive significance. Clin Cancer Res; 24(18); 4444-54. ©2018 AACRSee related commentary by Khalil and O'Reilly, p. 4355.
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Affiliation(s)
| | - Silvia Cibin
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Inti Zlobec
- Institute of Pathology, University of Bern, Bern, Switzerland
| | - Erik Vassella
- Institute of Pathology, University of Bern, Bern, Switzerland
| | | | | | | | - Mathias Worni
- Department of Visceral Surgery, Insel University Hospital, University of Bern, Bern, Switzerland
| | - Beat Gloor
- Department of Visceral Surgery, Insel University Hospital, University of Bern, Bern, Switzerland
| | - Aurel Perren
- Institute of Pathology, University of Bern, Bern, Switzerland
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Birnbaum DJ, Bertucci F, Finetti P, Birnbaum D, Mamessier E. Molecular classification as prognostic factor and guide for treatment decision of pancreatic cancer. Biochim Biophys Acta Rev Cancer 2018; 1869:248-255. [PMID: 29499330 DOI: 10.1016/j.bbcan.2018.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 02/24/2018] [Accepted: 02/24/2018] [Indexed: 02/07/2023]
Abstract
Clinico-pathological factors fail to consistently predict the outcome after pancreatic resection for pancreatic ductal adenocarcinoma (PDAC). PDACs show a high level of inter- and intra- tumor genetic heterogeneity. A molecular classification should help sort patients into less heterogeneous and more appropriate groups regarding the metastatic risk and the therapeutic response, with the consequences of better predicting evolution and better orienting the treatment. PDAC can be classified based on mutational subtypes and 18gene alterations. Whole-genome sequencing identified mutational signatures, mutational burden and hyper-mutated tumors with specific DNA repair defects. Their overlap/similarities allow the definition of molecular subtypes. DNA and RNA classifications can be used in prognosis assessment. They are useful in therapeutic choice for they allow the design of approaches that can predict the respective drug sensitivity of each molecular subtype. This review provides a comprehensive analysis of available molecular classifications in PDAC and how this can help guide clinical decisions.
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Affiliation(s)
- David J Birnbaum
- Département d'Oncologie Moléculaire, Centre de Recherche en Cancérologie de Marseille, INSERM UMR1068, CNRS UMR7258, Aix-Marseille Université, Marseille, France; Faculté de Médecine, Aix-Marseille Université, Marseille, France; Département de Chirurgie Générale et Viscérale, AP-HM, Marseille, France.
| | - François Bertucci
- Département d'Oncologie Moléculaire, Centre de Recherche en Cancérologie de Marseille, INSERM UMR1068, CNRS UMR7258, Aix-Marseille Université, Marseille, France; Faculté de Médecine, Aix-Marseille Université, Marseille, France; Département d'Oncologie Médicale, Institut Paoli-Calmettes, Marseille, France
| | - Pascal Finetti
- Département d'Oncologie Moléculaire, Centre de Recherche en Cancérologie de Marseille, INSERM UMR1068, CNRS UMR7258, Aix-Marseille Université, Marseille, France; Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Daniel Birnbaum
- Département d'Oncologie Moléculaire, Centre de Recherche en Cancérologie de Marseille, INSERM UMR1068, CNRS UMR7258, Aix-Marseille Université, Marseille, France; Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Emilie Mamessier
- Département d'Oncologie Moléculaire, Centre de Recherche en Cancérologie de Marseille, INSERM UMR1068, CNRS UMR7258, Aix-Marseille Université, Marseille, France; Faculté de Médecine, Aix-Marseille Université, Marseille, France
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Harrington J, Carter L, Basu B, Cook N. Drug development and clinical trial design in pancreatico-biliary malignancies. Curr Probl Cancer 2018; 42:73-94. [PMID: 29402439 DOI: 10.1016/j.currproblcancer.2018.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 12/27/2017] [Accepted: 01/04/2018] [Indexed: 02/08/2023]
Abstract
Pancreatico-biliary (P-B) tumors arise from the pancreas, bile duct, and ampulla of Vater. Despite their close anatomical location, they have different etiology and biology. However, they uniformly share a poor prognosis, with no major improvements observed in overall survival over decades, even in the face of progress in diagnostic imaging and surgical techniques, and advances in systemic and loco-regional radiation therapies. To date, cytotoxic treatment has been associated with modest benefits in the advanced disease setting, and survival for patients with stage IV disease has not exceeded a year. Therefore, there is a pressing need to identify better treatments which may impact more significantly. Frequently, encouraging signals of potential efficacy for novel agents in early phase clinical trials have been followed by disappointing failures in larger phase III trials, raising the valid question of how drug development can be optimized for patients with pancreatic adenocarcinoma and biliary tract malignancies. In this article we summarize the current therapeutic options for these patients and their limitations. The biological context of these cancers is reviewed, highlighting features that may make them resistant to standard chemotherapeutics and could be potential therapeutic targets. We discuss the role of early phase clinical trials, defined as phase I and non-randomised phase II trials, within the clinical context and current therapeutic landscape of P-B tumors and postulate how translational studies and trial design may enable better realization of emerging targets together with a proposed model for future patient management. A detailed summary of current phase I clinical trials in P-B tumors is provided.
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Affiliation(s)
- Jennifer Harrington
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Louise Carter
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Bristi Basu
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK; Department of Oncology, University of Cambridge, Cambridge, UK
| | - Natalie Cook
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK; Division of Cancer Sciences, University of Manchester, Manchester, UK.
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Parente P, Parcesepe P, Covelli C, Olivieri N, Remo A, Pancione M, Latiano TP, Graziano P, Maiello E, Giordano G. Crosstalk between the Tumor Microenvironment and Immune System in Pancreatic Ductal Adenocarcinoma: Potential Targets for New Therapeutic Approaches. Gastroenterol Res Pract 2018; 2018:7530619. [PMID: 30662458 PMCID: PMC6312626 DOI: 10.1155/2018/7530619] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/04/2018] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma is a lethal disease for which radical surgery and chemotherapy represent the only curative options for a small proportion of patients. Recently, FOLFIRINOX and nab-paclitaxel plus gemcitabine have improved the survival of metastatic patients but prognosis remains poor. A pancreatic tumor microenvironment is a dynamic milieu of cellular and acellular elements, and it represents one of the major limitations to chemotherapy efficacy. The continued crosstalk between cancer cells and the surrounding microenvironment causes immunosuppression within pancreatic immune infiltrate increasing tumor aggressiveness. Several potential targets have been identified among tumor microenvironment components, and different therapeutic approaches are under investigation. In this article, we provide a qualitative literature review about the crosstalk between the tumor microenvironment components and immune system in pancreatic cancer. Finally, we discuss potential therapeutic strategies targeting the tumor microenvironment and we show the ongoing trials.
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Affiliation(s)
- Paola Parente
- 1Fondazione IRCCS Casa Sollievo della Sofferenza, UO di Anatomia Patologica, Viale Cappuccini 1, 71013 San Giovanni Rotondo, FG, Italy
| | - Pietro Parcesepe
- 2Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, P.le L.A. Scuro 10, 37134 Verona, Italy
| | - Claudia Covelli
- 1Fondazione IRCCS Casa Sollievo della Sofferenza, UO di Anatomia Patologica, Viale Cappuccini 1, 71013 San Giovanni Rotondo, FG, Italy
| | - Nunzio Olivieri
- 3Biology Department, University of Naples Federico II, Via Mezzocannone 8, 80134 Naples, Italy
| | - Andrea Remo
- 4“Mater Salutis” Hospital, ULSS 9, Via C. Gianella 1, 37045 Legnago, Verona, Italy
| | - Massimo Pancione
- 5Department of Sciences and Technologies, University of Sannio, Via Port'Arsa 11, 82100 Benevento, Italy
| | - Tiziana Pia Latiano
- 6Fondazione IRCCS Casa Sollievo della Sofferenza, UO di Oncologia Medica, Viale Cappuccini 1, 71013 San Giovanni Rotondo, FG, Italy
| | - Paolo Graziano
- 1Fondazione IRCCS Casa Sollievo della Sofferenza, UO di Anatomia Patologica, Viale Cappuccini 1, 71013 San Giovanni Rotondo, FG, Italy
| | - Evaristo Maiello
- 6Fondazione IRCCS Casa Sollievo della Sofferenza, UO di Oncologia Medica, Viale Cappuccini 1, 71013 San Giovanni Rotondo, FG, Italy
| | - Guido Giordano
- 6Fondazione IRCCS Casa Sollievo della Sofferenza, UO di Oncologia Medica, Viale Cappuccini 1, 71013 San Giovanni Rotondo, FG, Italy
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