Update on active specific immunotherapy with melanoma vaccines

Mechanism of action of immunotherapy

The immune system plays a vital role in regulating the growth of tumors. Some types of inflammatory responses can promote tumor growth, while a tumor-specific adaptive immune response can potentially control tumor growth. Malignancies have the ability to evade the immune system, and proliferate and metastasize. The goal of immunotherapy is to marshal the specificity and long-term memory of the adaptive immune response to achieve durable tumor regression and possible cure, although, to date, this has been achieved in only a small subset of patients. A variety of approaches to immunotherapy have been investigated. These include administration of exogenous cytokines or therapeutic vaccines to increase the frequency of tumor-specific T cells, adoptive transfer of tumor-specific immune effector cells, and, more recently, the application of a variety of immune checkpoint inhibitors and agonists of co-stimulatory receptors to overcome tumor-induced immune-suppressive mechanisms. Some approaches have been more successful than others for reasons that are now becoming apparent, and these observations have led to an exciting resurgence in clinical research to develop more effective immunotherapeutic strategies.

Specific immunotherapy of cancer in elderly patients

The concept of immunotherapy of cancer is more than a century old, but only recently have molecularly defined therapeutic approaches been developed. In this review, we focus on the most promising approach, active therapeutic vaccination. The identification of tumour antigens can now be accelerated by methods allowing the amplification of gene products selectively or preferentially transcribed in the tumour. However, determining the potential immunogenicity of such gene products remains a demanding task, since major histocompatibility complex (MHC) restriction of T cells implies that for any newly defined antigen, immunogenicity will have to be defined for any individual MHC haplotype. Tumour-derived peptides eluted from MHC molecules of tumour tissue are also a promising source of antigen. Tumour antigens are mostly of weak immunogenicity, because the vast majority are tumour-associated differentiation antigens already 'seen' by the patient's immune system. Effective therapeutic vaccination will thus require adjuvant support, possibly by new approaches to immunomodulation such as bispecific antibodies or antibody-cytokine fusion proteins. Tumour-specific antigens, which could be a more potent target for immunotherapy, mostly arise by point mutations and have the disadvantage of being not only tumour-specific, but also individual-specific. Therapeutic vaccination will probably focus on defined antigens offered as protein, peptide or nucleic acid. Irrespective of the form in which the antigen is applied, emphasis will be given to the activation of dendritic cells as professional antigen presenters. Dendritic cells may be loaded in vitro with antigen, or, alternatively, initiation of an immune response may be approached in vivo by vaccination with RNA or DNA, given as such or packed into attenuated bacteria. The importance of activation of T helper cells has only recently been taken into account in cancer vaccination. Activation of cytotoxic T cells is facilitated by the provision of T helper cell-derived cytokines. T helper cell-dependent recruitment of elements of non-adaptive defence, such as leucocytes, natural killer cells and monocytes, is of particular importance when the tumour has lost MHC class I expression. Barriers to successful therapeutic vaccination include: (i) the escape mechanisms developed by tumour cells in response to immune attack; (ii) tolerance or anergy of the evoked immune response; (iii) the theoretical possibility of provoking an autoimmune reaction by vaccination against tumour-associated antigens; and (iv) the advanced age of many patients, implying reduced responsiveness of the senescent immune system.

Host defense mechanisms in polyaromatic hydrocarbon carcinogenesis

Polyaromatic hydrocarbons (PAHs) are chemicals that are widely employed to examine the complex mechanisms by which chemicals cause cancer. While it is clear that the tumors that carcinogenic PAHs produce elicit an immune response, the interplay between host immune defense mechanisms and earlier stages in the cutaneous carcinogenesis pathway has received little attention. Studies from our laboratories have shown that topical application of several different PAHs to mice results in the development of an antigen-specific cell-mediated immune response to them. The response is genetically determined and is mediated by CD8+ T cells. Development of a cell-mediated immune response is associated with resistance to dimethylbenz(a)anthracene tumorigenesis. These findings are consistent with the hypothesis that host defense mechanisms against PAHs help to protect individuals from the carcinogenic actions of these agents. This may form the basis for novel immunopreventive strategies for individuals at high risk for development of tumors produced by PAHs.

Advances in specific immunotherapy of malignant melanoma

Management of malignant melanoma continues to present a challenge to dermatologists, particularly in advanced cases. In light of the steady increase in the worldwide incidence and mortality rates for melanoma, better understanding of the immune mechanisms regulating melanoma progression and interaction with the host's immune system seems eminently important. New studies on the role of immune mechanisms in the pathogenesis and clinical course of melanoma have recently been published. We review the immune mechanisms involved in tumor progression and ways in which these mechanisms may be applied toward immunotherapeutic management of malignant melanoma.

LEARNING OBJECTIVE

After the completion of this learning activity, participants should be familiar with (1) the immune mechanisms involved in host-tumor interaction and tumor rejection, (2) factors allowing the escape of melanoma cells from immune recognition, and (3) the current rationale for the different types of specific immunotherapy in melanoma. Better understanding of basic mechanisms in tumor immunology should raise awareness of future immunotherapeutic approaches in patients with melanoma, particularly in those who are at high risk of recurrence or who present with advanced disease.

Melanoma vaccines

Remarkable advances in tumor vaccination have been made since Coley first deliberately infected cancer patients with both live and heat-killed bacteria. Melanoma is the most immunogenic solid tumor and, as such, has served as the major model for tumor vaccine investigation in both the laboratory and the clinic. Many advances in the field of melanoma vaccination have been based on an improved understanding of the cellular interaction required to induce a specific antitumor immune response. As a result of this new knowledge, many clinical trials of melanoma vaccines are now under way, and vaccines for metastatic melanoma have shown evidence of clinical effectiveness. This paper outlines the current status of melanoma vaccination.

Cancer therapy: new concepts on active immunization

There is increasing evidence that tumors express putative target molecules for a therapeutic immune reaction. Yet, tumor cells lack the prerequisites for appropriate antigen presentation and--hence--the immune system does not respond. This difficulty can probably be circumvented when tumor antigens are processed by conventional antigen presenting cells. Thus, the identification of immunogenic tumor-associated antigens may allow new modes of vaccination with the hope of adding a fourth and hopefully powerful weapon to surgery, radiation and chemotherapy in the fight against cancer.

Comparison of melanoma antigens in whole tumor vaccine to those from IIB-MEL-J cells

Immunotherapy for melanoma shows promise. Our previous whole tumor (WT) vaccine was noted to have positive clinical effects. We have now developed a new, safer melanoma vaccine that is derived from IIB-MEL-J tissue culture (TC) cells. In this study, we compare by Western blot analyses the antigens in the WT vaccine to antigens in the TC vaccine. Sera from 12 WT vaccine recipients, 8 melanoma patients who received no immunotherapy, and 8 controls served as a source of antibodies to investigate potential antigens in the vaccines. Three major antigenic peptides with approximate molecular weighs of 46, 40, and 36 kDA were present in both vaccines, while two other antigenic peptides with approximate molecular weighs of 68 and 48 kDA were present only in the TC vaccine. The reaction was similar between the patients who received the WT vaccine and those who did not receive the vaccine. Some of the individuals who did not have melanoma showed some reaction, but not to the extent of the melanoma patients. The intensity of immunostaining was greater for the TC vaccine when compared to the WT vaccine, indicating that these proteins are in a higher concentration in the TC vaccine. This new vaccine from IIB-MEL-J tissue culture cells provides a higher yield and a much more consistent source of potentially clinically relevant antigens without risk of infection or contamination by other irrelevant materials.

Clinical implications of the new biology in the development of melanoma vaccines

There has been a resurgence in clinical research of vaccine therapies, particularly for the treatment of melanoma. The renewed interest in this field is attributable to an increased understanding regarding the immune response to tumors and the immunobiology of melanoma. Molecular biology techniques have enabled investigators to develop genetically engineered tumor vaccines that are intended to favor the type 1 immune response over the type 2 response. Melanoma-associated antigens have been characterized at the molecular level and are currently being investigated in clinical trials. Dendritic cell biology has also provided a potent method to present antigens to the host for immunization. Lastly, vaccines are being explored as a method to generate immune T-cells for adoptive immunotherapy. These new areas of clinical investigation will be reviewed in the context of the historical developments that have laid the foundations of this field.

Targeting melanoma with 211At/131I-methylene blue: preclinical and clinical experience

The increasing incidence of melanoma and a lack of effective therapy have stimulated a search for new methods of early detection and treatment of the disease. Melanin synthesized in melanoma cells presents a unique target to which the treatment can be selectively addressed, provided the pigment is recognized by a suitable drug. Methylene blue possesses a high affinity for melanin and, therefore, accumulates preferentially in melanoma cells. Since not directly toxic to the tumor, methylene blue serves as a carrier for radioisotopes and, once taken up by melanoma cells, acts as a selectively localized source of radiation. Hence, radioderivatives of the compound can be used for diagnosis and therapy of disseminated melanoma. 131I-methylene blue in conjunction with gamma camera imaging has already proved in clinical studies to be a useful tool for the detection of early melanoma dissemination. 211At-methylene blue exceptional efficacy in treating melanoma and preventing its metastatic spread without damaging normal structures when administered systemically to human melanoma-bearing mice led to the approval of this alpha-particle emitting methylene blue derivative for the Phase I clinical trial.

Susceptibility to the biological effects of polyaromatic hydrocarbons is influenced by genes of the major histocompatibility complex

Polyaromatic hydrocarbons are ubiquitous environmental chemicals that are important mutagens and carcinogens. The purpose of this study was to determine whether genes within the major histocompatibility complex (MHC) influence their biological activities. Cell-mediated immunity to dimethylbenz(a)anthracene (DMBA) was investigated in congenic strains of mice. On three different backgrounds, H-2(k) and H-2(a) haplotype mice developed significantly greater contact-hypersensitivity responses to DMBA than H-2(b), H-2(d), and H-2(s) mice. In B10.A(R1) mice, which are Kk and Id, a vigorous contact-hypersensitivity response was present, indicating that the response was governed by class I, rather than class II, MHC genes. C3H/HeN (H-2(k)) and C3H.SW (H-2(s)) strains were also compared for the development of skin tumors and the persistence of DMBA-DNA adducts. When subjected to a DMBA initiation, phorbol 12-tetradecanoate 13-acetate (TPA)-promotion skin-tumorigenesis protocol, C3H/HeN mice, (which develop cell-mediated immunity to DMBA) were found to have significantly fewer tumors than C3H.SW mice (a strain that failed to develop a cell-mediated immune response to DMBA). DMBA-DNA adducts were removed more rapidly in C3H/HeN than in C3H.SW mice. The results indicate that genes within the MHC play an important role in several of the biological activities of carcinogenic polyaromatic hydrocarbons. The observations are consistent with the hypothesis that cell-mediated immunity to chemical carcinogens serves to protect individuals by removing mutant cells before they can evolve into clinically apparent neoplasms.