Immunotherapy in Colorectal Cancer: Where Are We Now?

Interference with pathways activated by topoisomerase inhibition alters the surface expression of PD-L1 and MHC I in colon cancer cells

Topoisomerase inhibitors are clinically used to treat various cancer types, including colorectal cancer. These drugs also activate signaling pathways that modulate cell survival and immune cell functions. Immunotherapy is promising for certain tumors, including microsatellite instable colorectal cancer, but not for microsatellite stable colorectal cancer. The reasons for this lack of responsiveness are largely unknown. Understanding how colorectal cancer cell-surface proteins interact with tumor-resident immune cells may offer an opportunity to identify molecules that, if targeted, may render tumor cells visible to immune cells. The present study used flow cytometry, fluorescent staining and immunoblotting to examine if inhibition of pathways activated by topoisomerase-targeting drugs may modulate the outcomes of treatment through effects on cell cycle arrest and apoptosis, and by altering surface expression levels of programmed death-ligand 1 (PD-L1) or major histocompatibility complex protein I (MHC I). Inhibition of either NF-κB or DNA-damage response (DDR) potently enhanced cell death in combination with topoisomerase inhibition, while only NF-κB inhibition increased MHC I. PD-L1 upregulation was moderately affected by NF-κB or DDR inhibitors, while both topoisomerase inhibitors and DNA damaging agents may enhance the surface expression of MHC I molecules on colon cancer cells. Such enhanced expression of MHC I may be suppressed by inhibitors of ataxia-telangiectasia mutated or checkpoint kinase kinases. Additionally, adaptive tolerance to topoisomerase inhibition caused altered cell cycle response, and reduced the expression levels of both PD-L1 and MHC I on both microsatellite instable and stable colon cancer cell lines. Therefore, targeted modulation of DDR pathways, PD-L1, MHC I or other immune regulators in colon cancer cells may make them more visible to immune cells and enable rational combination of conventional therapy with immunotherapy.

GUCY2C as a biomarker to target precision therapies for patients with colorectal cancer

Introduction

Colorectal cancer (CRC) is one of the most-deadly malignancies worldwide. Current therapeutic regimens for CRC patients are relatively generic, based primarily on disease type and stage, with little variation. As the field of molecular oncology advances, so too must therapeutic management of CRC. Understanding molecular heterogeneity has led to a new-found promotion for precision therapy in CRC; underlining the diversity of molecularly targeted therapies based on individual tumor characteristics.

Areas covered

We review current approaches for the treatment of CRC and discuss the potential of precision therapy in advanced CRC. We highlight the utility of the intestinal protein guanylyl cyclase C (GUCY2C), as a multi-purpose biomarker and unique therapeutic target in CRC. Here, we summarize current GUCY2C-targeted approaches for treatment of CRC.

Expert opinion

The GUCY2C biomarker has multi-faceted utility in medicine. Developmental investment of GUCY2C as a diagnostic and therapeutic biomarker offers a variety of options taking the molecular characteristics of cancer into account. From GUCY2C-targeted therapies, namely cancer vaccines, CAR-T cells, and monoclonal antibodies, to GUCY2C agonists for chemoprevention in those who are at high risk for developing colorectal cancer, the utility of this protein provides many avenues for exploration with significance in the field of precision medicine.

TCR Retrogenic Mice as a Model To Map Self-Tolerance Mechanisms to the Cancer Mucosa Antigen GUCY2C

Characterizing self-tolerance mechanisms and their failure is critical to understand immune homeostasis, cancer immunity, and autoimmunity. However, examination of self-tolerance mechanisms has relied primarily on transgenic mice expressing TCRs targeting well-characterized, but nonphysiologic, model Ags, such as OVA and hemagglutinin. Identifying TCRs directed against bona fide self-antigens is made difficult by the extraordinary diversity of TCRs and the low prevalence of Ag-specific clones (<10-100 naive cells per organism), limiting dissection of tolerance mechanisms restricting immunity to self-proteins. In this study, we isolated and characterized TCRs recognizing the intestinal epithelial cell receptor and colorectal cancer Ag GUCY2C to establish a model to study self-antigen-specific tolerance mechanisms. GUCY2C-specific CD4+ effector T cells were isolated from immunized, nontolerant Gucy2c -/- mice. Next-generation sequencing identified GUCY2C-specific TCRs, which were engineered into CD4+ T cells in vitro to confirm TCR recognition of GUCY2C. Further, the generation of "retrogenic" mice by reconstitution with TCR-transduced hematopoietic stem cells resulted in normal CD4+ T cell development, responsiveness to immunization, and GUCY2C-induced tolerance in recipient mice, recapitulating observations in conventional models. This retrogenic model can be employed to define self-tolerance mechanisms restricting T and B cell responses to GUCY2C to optimize colorectal cancer immunotherapy without autoimmunity.

Immunotherapy: enhancing the efficacy of this promising therapeutic in multiple cancers

Cancer treatments often reach a refractory period leading to treatment failure and patients developing disease recurrence. This can be due to tumour cells escaping the immune response and creating an immunosuppressive microenvironment enhancing cancer progression. Immunotherapy has become a promising tool for cancer treatment as it restores the anti-tumour response of the patient's immune system. Immune checkpoint inhibitors are the most widely studied immunotherapies worldwide and are now approved for multiple cancers. However, chimeric antigen receptor (CAR)-T cell therapy has also shown promise by targeting T lymphocytes that are genetically modified ex vivo to express CARs and this is now approved to treat some haematological cancers. Although immunotherapy has shown successful treatment outcomes in multiple cancers, some patients do not respond to this treatment. Therefore, approaches to enhance the efficacy of immunotherapies are likely to be the key to improve their effectiveness. Therefore, combination therapies of checkpoint inhibitors +/- chemotherapy are at the forefront of current research. Furthermore, biomarkers that predict treatment response are now beginning to emerge. Additionally, utilising nanoparticles as a newly targeted drug delivery system to enhance CAR-T cell therapy may enhance the efficacy of the cells when re-infused within the patient. Even if efficacy is enhanced, severe immune-related adverse events (irAEs) occur that are life-threatening and could lead to therapy being stopped. Therefore, predictive biomarkers for toxicity are also needed to improve both the patient's quality of life and treatment outcomes. This review will look at the current immunotherapies in clinical trials and discuss how to enhance their efficacy.