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Chavanton A, Mialhe F, Abrey J, Baeza Garcia A, Garrido C. LAG-3 : recent developments in combinational therapies in cancer. Cancer Sci 2024. [PMID: 38702996 DOI: 10.1111/cas.16205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/11/2024] [Accepted: 04/17/2024] [Indexed: 05/06/2024] Open
Abstract
The study of anticancer immune responses and in particular the action of immune checkpoint inhibitors that overcome T cell inhibition has revolutionized metastatic patients' care. Unfortunately, many patients are resistant to these innovative immunotherapies. Over the last decade, several immune checkpoint inhibitors, currently available in the clinic, have been developed, such as anti-PD-1/PD-L1 or anti-CTLA-4. More recently, other immune checkpoints have been characterized, among them lymphocyte activation gene 3 (LAG-3). LAG-3 has been the subject of numerous therapeutic studies and may be involved in cancer-associated immune resistance phenomena. This review summarizes the latest knowledge on LAG-3 as an immunotherapeutic target, particularly in combination with standard or innovative therapies. Indeed, many studies are looking at combining LAG-3 inhibitors with chemotherapeutic, immunotherapeutic, radiotherapeutic treatments, or adoptive cell therapies to potentiate their antitumor effects and/or to overcome patients' resistance. We will particularly focus on the association therapies that are currently in phase III clinical trials and innovative combinations in preclinical phase. These new discoveries highlight the possibility of developing other types of therapeutic combinations currently unavailable in the clinic, which could broaden the therapeutic spectrum of personalized medicine.
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Affiliation(s)
- Aude Chavanton
- INSERM, UMR 1231, Laboratoire d'Excellence LipSTIC and « Equipe labellisée par la Ligue Nationale contre le Cancer », Dijon, France
- Faculty of Medicine, Université de Bourgogne, Dijon, France
| | - Flavie Mialhe
- INSERM, UMR 1231, Laboratoire d'Excellence LipSTIC and « Equipe labellisée par la Ligue Nationale contre le Cancer », Dijon, France
- Faculty of Medicine, Université de Bourgogne, Dijon, France
| | - Jimena Abrey
- INSERM, UMR 1231, Laboratoire d'Excellence LipSTIC and « Equipe labellisée par la Ligue Nationale contre le Cancer », Dijon, France
- Faculty of Medicine, Université de Bourgogne, Dijon, France
| | - Alvaro Baeza Garcia
- INSERM, UMR 1231, Laboratoire d'Excellence LipSTIC and « Equipe labellisée par la Ligue Nationale contre le Cancer », Dijon, France
- Faculty of Medicine, Université de Bourgogne, Dijon, France
| | - Carmen Garrido
- INSERM, UMR 1231, Laboratoire d'Excellence LipSTIC and « Equipe labellisée par la Ligue Nationale contre le Cancer », Dijon, France
- Faculty of Medicine, Université de Bourgogne, Dijon, France
- Center for Cancer Georges-François Leclerc, Dijon, France
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2
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Lu C, Tan Y. Promising immunotherapy targets: TIM3, LAG3, and TIGIT joined the party. MOLECULAR THERAPY. ONCOLOGY 2024; 32:200773. [PMID: 38596295 PMCID: PMC10905042 DOI: 10.1016/j.omton.2024.200773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Immune checkpoint inhibitors (ICIs) have shown great promise as immunotherapy for restoring T cell function and reactivating anti-tumor immunity. The US Food and Drug Administration (FDA) approved the first immune checkpoint inhibitor, ipilimumab, in 2011 for advanced melanoma patients, leading to significant improvements in survival rates. Subsequently, other immune checkpoint-targeting antibodies were tested. Currently, seven ICIs, namely ipilimumab (anti-cytotoxic T lymphocyte-associated protein 4 [CTLA4]), pembrolizumab, nivolumab (anti-programmed cell death protein 1 [PD-1]), atezolizumab, avelumab, durvalumab, and cemiplimab (anti-PD-L1), have been approved for various cancer types. However, the efficacy of antibodies targeting CTLA4 or PD-1/programmed death-ligand 1 (PD-L1) remains suboptimal. Consequently, ongoing studies are evaluating the next generation of ICIs, such as lymphocyte activation gene-3 (LAG3), T cell immunoglobulin and mucin-domain containing 3 (TIM3), and T cell immunoglobulin and ITIM domain (TIGIT). Our review provides a summary of clinical trials evaluating these novel immune checkpoints in cancer treatment.
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Affiliation(s)
- Chenyu Lu
- Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong SAR, China
- Department of Biomedical Sciences, City University of Hong Kong, Hong Kong SAR, China
| | - Yuanyan Tan
- Institute of Advanced Biotechnology and School of Medicine, Southern University of Science and Technology, Shenzhen 518055, Guangdong, China
- Shenzhen Key Laboratory of Microbial Genetic Engineering, Vascular Disease Research Center, College of Life Sciences and Oceanography, Guangdong Provincial Key Laboratory of Regional Immunity and Disease, Shenzhen University, Shenzhen 518061, Guangdong, China
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3
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Patwekar M, Sehar N, Patwekar F, Medikeri A, Ali S, Aldossri RM, Rehman MU. Novel immune checkpoint targets: A promising therapy for cancer treatments. Int Immunopharmacol 2024; 126:111186. [PMID: 37979454 DOI: 10.1016/j.intimp.2023.111186] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/20/2023]
Abstract
The immune system frequently comprises immunological checkpoints. They serve as a barrier to keep the immune system from overreacting and damaging cells that are robust. Immune checkpoint inhibitors (ICIs) are utilized in immunotherapy to prevent the synergy of partner proteins of checkpoint proteins with auxiliary proteins. Moreover, the T cells may target malignant cells since the "off" signal cannot be conveyed. ICIs, which are mostly composed of monoclonal antibodies (mAbs) against cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) and anti- programmed death-1/programmed ligand 1 (anti-PD-1/PD-L1), might transform the context of cancer therapy. Further, more patients continued to exhibit adaptive resistance, even though several ICIs demonstrated convincing therapeutic benefits in selective tumor types. Immune checkpoint therapy's overall effectiveness is still lacking at this time. A popular area of study involves investigating additional immune checkpoint molecules. Recent research has found a number of fresh immune checkpoint targets, including NKG2A ligands, TIGIT, B7-H6 ligands, Galectin 3, TIM3, and so on. These targets have been focus of the study, and recent investigational approaches have shown encouraging outcomes. In this review article, we covered the development and present level understanding of these recently identified immune checkpoint molecules, its effectiveness and limitations.
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Affiliation(s)
| | - Nouroz Sehar
- Centre for Translational and Clinical Research, School of Chemical and Life Sciences, Jamia Hamdard University, New Delhi, 110062, India
| | - Faheem Patwekar
- Luqman College of Pharmacy, Gulbarga, 585102, Karnataka, India
| | | | - Shafat Ali
- Cytogenetics and Molecular Biology Laboratory, Centre of Research for Development, University of Kashmir, Srinagar, 190006, Jammu and Kashmir, India.
| | - Rana M Aldossri
- Department of Pharmacology and Toxicology, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, 11942, Saudi Arabia
| | - Muneeb U Rehman
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, 11451, Saudi Arabia
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4
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Li Y, Ju M, Miao Y, Zhao L, Xing L, Wei M. Advancement of anti-LAG-3 in cancer therapy. FASEB J 2023; 37:e23236. [PMID: 37846808 DOI: 10.1096/fj.202301018r] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 08/25/2023] [Accepted: 09/20/2023] [Indexed: 10/18/2023]
Abstract
Immune checkpoint inhibitors have effectively transformed the treatment of many cancers, particularly those highly devastating malignancies. With their widespread popularity, the drawbacks of immune checkpoint inhibitors are also recognized, such as drug resistance and immune-related systematic side effects. Thus, it never stops investigating novel immune checkpoint inhibitors. Lymphocyte Activation Gene-3 (LAG-3) is a well-established co-inhibitory receptor that performs negative regulation on immune responses. Recently, a novel FDA-approved LAG-3 blocking agent, together with nivolumab as a new combinational immunotherapy for metastatic melanoma, brought LAG-3 back into focus. Clinical data suggests that anti-LAG-3 agents can amplify the therapeutic response of other immune checkpoint inhibitors with manageable side effects. In this review, we elucidate the intercellular and intracellular mechanisms of LAG-3, clarify the current understanding of LAG-3 in the tumor microenvironment, identify present LAG-3-associated therapeutic agents, discuss current LAG-3-involving clinical trials, and eventually address future prospects for LAG-3 inhibitors.
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Affiliation(s)
- Yunong Li
- Department of Pharmacology, School of Pharmacy, China Medical University, Shenyang, P.R. China
| | - Mingyi Ju
- Department of Pharmacology, School of Pharmacy, China Medical University, Shenyang, P.R. China
| | - Yuxi Miao
- Department of Pharmacology, School of Pharmacy, China Medical University, Shenyang, P.R. China
| | - Lin Zhao
- Department of Pharmacology, School of Pharmacy, China Medical University, Shenyang, P.R. China
| | - Lijuan Xing
- Precision Laboratory, Panjin Central Hospital, Panjin, P.R. China
| | - Minjie Wei
- Department of Pharmacology, School of Pharmacy, China Medical University, Shenyang, P.R. China
- Shenyang Kangwei Medical Laboratory Analysis Co. Ltd, Shenyang, P.R. China
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5
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Hiltbrunner S, Cords L, Kasser S, Freiberger SN, Kreutzer S, Toussaint NC, Grob L, Opitz I, Messerli M, Zoche M, Soltermann A, Rechsteiner M, van den Broek M, Bodenmiller B, Curioni-Fontecedro A. Acquired resistance to anti-PD1 therapy in patients with NSCLC associates with immunosuppressive T cell phenotype. Nat Commun 2023; 14:5154. [PMID: 37620318 PMCID: PMC10449840 DOI: 10.1038/s41467-023-40745-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/07/2023] [Indexed: 08/26/2023] Open
Abstract
Immune checkpoint inhibitor treatment has the potential to prolong survival in non-small cell lung cancer (NSCLC), however, some of the patients develop resistance following initial response. Here, we analyze the immune phenotype of matching tumor samples from a cohort of NSCLC patients showing good initial response to immune checkpoint inhibitors, followed by acquired resistance at later time points. By using imaging mass cytometry and whole exome and RNA sequencing, we detect two patterns of resistance¨: One group of patients is characterized by reduced numbers of tumor-infiltrating CD8+ T cells and reduced expression of PD-L1 after development of resistance, whereas the other group shows high CD8+ T cell infiltration and high expression of PD-L1 in addition to markedly elevated expression of other immune-inhibitory molecules. In two cases, we detect downregulation of type I and II IFN pathways following progression to resistance, which could lead to an impaired anti-tumor immune response. This study thus captures the development of immune checkpoint inhibitor resistance as it progresses and deepens our mechanistic understanding of immunotherapy response in NSCLC.
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Affiliation(s)
- Stefanie Hiltbrunner
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, 8091, Switzerland
- Comprehensive Cancer Center Zurich, University Hospital Zurich, Zurich, 8091, Switzerland
- University of Zurich, Zurich, Switzerland
- University of Fribourg, Faculty of Science and Medicine, Fribourg, 1700, Switzerland
| | - Lena Cords
- University of Zurich, Zurich, Switzerland
- Department of Quantitative Biomedicine, University of Zurich, Zurich, 8057, Switzerland
- Institute of Molecular Health Sciences, ETH Zurich, Zurich, 8049, Switzerland
- Life Science Zurich Graduate School, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Sabrina Kasser
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, 8091, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Sandra N Freiberger
- Department of Pathology and Molecular Pathology, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Susanne Kreutzer
- Functional Genomics Center Zurich, ETH and University of Zurich, Zurich, 8057, Switzerland
| | - Nora C Toussaint
- NEXUS Personalized Health Technologies, ETH Zurich, Zurich, 8952, Switzerland
- SIB Swiss Institute of Bioinformatics, Lausanne, 1015, Switzerland
| | - Linda Grob
- NEXUS Personalized Health Technologies, ETH Zurich, Zurich, 8952, Switzerland
- SIB Swiss Institute of Bioinformatics, Lausanne, 1015, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, 8091, Switzerland
| | - Michael Messerli
- University of Zurich, Zurich, Switzerland
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, 8091, Switzerland
| | - Martin Zoche
- Department of Pathology and Molecular Pathology, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Alex Soltermann
- Department of Pathology and Molecular Pathology, University Hospital Zurich, 8091, Zurich, Switzerland
- Pathologie Länggasse, Ittigen, 3063, Switzerland
| | - Markus Rechsteiner
- Department of Pathology and Molecular Pathology, University Hospital Zurich, 8091, Zurich, Switzerland
| | - Maries van den Broek
- University of Zurich, Zurich, Switzerland
- Institute of Experimental Immunology, University of Zurich, Zurich, 8057, Switzerland
| | - Bernd Bodenmiller
- University of Zurich, Zurich, Switzerland
- Department of Quantitative Biomedicine, University of Zurich, Zurich, 8057, Switzerland
- Institute of Molecular Health Sciences, ETH Zurich, Zurich, 8049, Switzerland
| | - Alessandra Curioni-Fontecedro
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, 8091, Switzerland.
- Comprehensive Cancer Center Zurich, University Hospital Zurich, Zurich, 8091, Switzerland.
- University of Zurich, Zurich, Switzerland.
- University of Fribourg, Faculty of Science and Medicine, Fribourg, 1700, Switzerland.
- Clinic of Oncology, Cantonal Hospital Fribourg, Fribourg, 1752, Switzerland.
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Ridgley LA, Falci Finardi N, Gengenbach BB, Opdensteinen P, Croxford Z, Ma JKC, Bodman-Smith M, Buyel JF, Teh AYH. Killer to cure: Expression and production costs calculation of tobacco plant-made cancer-immune checkpoint inhibitors. PLANT BIOTECHNOLOGY JOURNAL 2023; 21:1254-1269. [PMID: 36811226 DOI: 10.1111/pbi.14034] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 01/18/2023] [Accepted: 02/11/2023] [Indexed: 05/27/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have achieved huge clinical success. However, many still have limited response rates, and are prohibitively costly. There is a need for effective and affordable ICIs, as well as local manufacturing capacity to improve accessibility, especially to low-to-middle income countries (LMICs). Here, we have successfully expressed three key ICIs (anti-PD-1 Nivolumab, anti-NKG2A Monalizumab, and anti-LAG-3 Relatimab) transiently in Nicotiana benthamiana and Nicotiana tabacum plants. The ICIs were expressed with a combination of different Fc regions and glycosylation profiles. They were characterized in terms of protein accumulation levels, target cell binding, binding to human neonatal Fc receptors (hFcRn), human complement component C1q (hC1q) and various Fcγ receptors, as well as protein recovery during purification at 100 mg- and kg-scale. It was found that all ICIs bound to the expected target cells. Furthermore, the recovery during purification, as well as Fcγ receptor binding, can be altered depending on the Fc region used and the glycosylation profiles. This opens the possibility of using these two parameters to fine-tune the ICIs for desired effector functions. A scenario-based production cost model was also generated based on two production scenarios in hypothetical high- and low-income countries. We have shown that the product accumulation and recovery of plant production platforms were as competitive as mammalian cell-based platforms. This highlights the potential of plants to deliver ICIs that are more affordable and accessible to a widespread market, including LMICs.
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Affiliation(s)
- Laura A Ridgley
- Institute for Infection and Immunity, St. George's, University of London, London, UK
- Institute for Cancer Vaccines and Immunotherapy, London, UK
| | - Nicole Falci Finardi
- Institute for Infection and Immunity, St. George's, University of London, London, UK
| | | | - Patrick Opdensteinen
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Aachen, Germany
| | - Zack Croxford
- Institute for Infection and Immunity, St. George's, University of London, London, UK
| | - Julian K-C Ma
- Institute for Infection and Immunity, St. George's, University of London, London, UK
| | - Mark Bodman-Smith
- Institute for Infection and Immunity, St. George's, University of London, London, UK
- Institute for Cancer Vaccines and Immunotherapy, London, UK
| | - Johannes F Buyel
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Aachen, Germany
- Institute for Molecular Biotechnology, RWTH Aachen University, Aachen, Germany
- Department of Biotechnology (DBT), Institute of Bioprocess Science and Engineering (IBSE), University of Natural Resources and Life Sciences, Vienna (BOKU), Vienna, Austria
| | - Audrey Y-H Teh
- Institute for Infection and Immunity, St. George's, University of London, London, UK
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7
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Villaruz LC, Blumenschein GR, Otterson GA, Leal TA. Emerging therapeutic strategies for enhancing sensitivity and countering resistance to programmed cell death protein 1 or programmed death-ligand 1 inhibitors in non-small cell lung cancer. Cancer 2023; 129:1319-1350. [PMID: 36848319 DOI: 10.1002/cncr.34683] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 10/27/2022] [Accepted: 12/13/2022] [Indexed: 03/01/2023]
Abstract
The availability of agents targeting the programmed cell death protein 1 (PD-1)/programmed death-ligand 1 (PD-L1) immune checkpoint has transformed treatment of advanced and/or metastatic non-small cell lung cancer (NSCLC). However, a substantial proportion of patients treated with these agents do not respond or experience only a brief period of clinical benefit. Even among those whose disease responds, many subsequently experience disease progression. Consequently, novel approaches are needed that enhance antitumor immunity and counter resistance to PD-(L)1 inhibitors, thereby improving and/or prolonging responses and patient outcomes, in both PD-(L)1 inhibitor-sensitive and inhibitor-resistant NSCLC. Mechanisms contributing to sensitivity and/or resistance to PD-(L)1 inhibitors in NSCLC include upregulation of other immune checkpoints and/or the presence of an immunosuppressive tumor microenvironment, which represent potential targets for new therapies. This review explores novel therapeutic regimens under investigation for enhancing responses to PD-(L)1 inhibitors and countering resistance, and summarizes the latest clinical evidence in NSCLC.
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Affiliation(s)
- Liza C Villaruz
- Division of Hematology/Oncology, Department of Medicine, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - George R Blumenschein
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gregory A Otterson
- The Ohio State University-James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Ticiana A Leal
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
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8
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Perez-Santos M, Anaya-Ruiz M, Villafaña-Diaz L, Sánchez Esgua G. Approaches for development of LAG-3 inhibitors and the promise they hold as anticancer agents. Expert Opin Drug Discov 2022; 17:1341-1355. [PMID: 36399656 DOI: 10.1080/17460441.2022.2148652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION LAG-3 is considered to be the third point of immunological control in relation to clinical trials that address cancer treatment, only behind PD-1 and CTLA-4, due to its role as a suppressor of the immune response and enhancer of differentiation of Treg cells. AREAS COVERED The authors focus on emphasizing the strategy of development of LAG-3 inhibitors to develop anticancer therapeutics, especially from the perspective of designing new monoclonal and bispecific antibodies against LAG-3. This article also covers details of patents and clinical trials of LAG-3 inhibitors reported in the literature. In addition, we highlight as future research challenges the design and development of peptides and small molecules as inhibitors of LAG-3 function. EXPERT OPINION Three approaches have been used for the development of LAG-3 inhibitors, and they include inhibitory LAG-3 binding peptides and antagonist monoclonal and multispecific antibodies. These approaches include more than 100 clinical trials of 21 molecules that bind to LAG-3 and block its binding to MHC II. However, these approaches do not cover the design and development of peptides and small molecules that could inhibit the function of LAG-3, for which it is necessary to develop new alternatives that cover this gap.
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Affiliation(s)
- Martin Perez-Santos
- Dirección de Innovación y Transferencia de Conocimiento, Benemérita Universidad Autónoma de Puebla, Puebla CP, México
| | - Maricruz Anaya-Ruiz
- Laboratorio de Biología Celular, Centro de Investigación Biomédica de Oriente, Instituto Mexicano del Seguro Social, Metepec, Puebla CP, México
| | - Luis Villafaña-Diaz
- Centro de Investigación en Inteligencia de Negocios, Universidad Popular Autónoma del Estado de Puebla, Puebla, México
| | - Gabriela Sánchez Esgua
- Dirección de Innovación y Transferencia de Conocimiento, Benemérita Universidad Autónoma de Puebla, Puebla CP, México
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Chocarro L, Bocanegra A, Blanco E, Fernández-Rubio L, Arasanz H, Echaide M, Garnica M, Ramos P, Piñeiro-Hermida S, Vera R, Escors D, Kochan G. Cutting-Edge: Preclinical and Clinical Development of the First Approved Lag-3 Inhibitor. Cells 2022; 11:2351. [PMID: 35954196 PMCID: PMC9367598 DOI: 10.3390/cells11152351] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized medical practice in oncology since the FDA approval of the first ICI 11 years ago. In light of this, Lymphocyte-Activation Gene 3 (LAG-3) is one of the most important next-generation immune checkpoint molecules, playing a similar role as Programmed cell Death protein 1 (PD-1) and Cytotoxic T-Lymphocyte Antigen 4 (CTLA-4). 19 LAG-3 targeting molecules are being evaluated at 108 clinical trials which are demonstrating positive results, including promising bispecific molecules targeting LAG-3 simultaneously with other ICIs. Recently, a new dual anti-PD-1 (Nivolumab) and anti-LAG-3 (Relatimab) treatment developed by Bristol Myers Squibb (Opdualag), was approved by the Food and Drug Administration (FDA) as the first LAG-3 blocking antibody combination for unresectable or metastatic melanoma. This novel immunotherapy combination more than doubled median progression-free survival (PFS) when compared to nivolumab monotherapy (10.1 months versus 4.6 months). Here, we analyze the large clinical trial responsible for this historical approval (RELATIVITY-047), and discuss the preclinical and clinical developments that led to its jump into clinical practice. We will also summarize results achieved by other LAG-3 targeting molecules with promising anti-tumor activities currently under clinical development in phases I, I/II, II, and III. Opdualag will boost the entry of more LAG-3 targeting molecules into clinical practice, supporting the accumulating evidence highlighting the pivotal role of LAG-3 in cancer.
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Affiliation(s)
- Luisa Chocarro
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31001 Pamplona, Spain; (E.B.); (L.F.-R.); (H.A.); (M.E.); (M.G.); (P.R.); (S.P.-H.); (D.E.); (G.K.)
| | - Ana Bocanegra
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31001 Pamplona, Spain; (E.B.); (L.F.-R.); (H.A.); (M.E.); (M.G.); (P.R.); (S.P.-H.); (D.E.); (G.K.)
| | - Ester Blanco
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31001 Pamplona, Spain; (E.B.); (L.F.-R.); (H.A.); (M.E.); (M.G.); (P.R.); (S.P.-H.); (D.E.); (G.K.)
- Division of Gene Therapy and Regulation of Gene Expression, Cima Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdISNA), 31001 Pamplona, Spain
| | - Leticia Fernández-Rubio
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31001 Pamplona, Spain; (E.B.); (L.F.-R.); (H.A.); (M.E.); (M.G.); (P.R.); (S.P.-H.); (D.E.); (G.K.)
| | - Hugo Arasanz
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31001 Pamplona, Spain; (E.B.); (L.F.-R.); (H.A.); (M.E.); (M.G.); (P.R.); (S.P.-H.); (D.E.); (G.K.)
- Medical Oncology Unit, Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31001 Pamplona, Spain;
| | - Miriam Echaide
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31001 Pamplona, Spain; (E.B.); (L.F.-R.); (H.A.); (M.E.); (M.G.); (P.R.); (S.P.-H.); (D.E.); (G.K.)
| | - Maider Garnica
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31001 Pamplona, Spain; (E.B.); (L.F.-R.); (H.A.); (M.E.); (M.G.); (P.R.); (S.P.-H.); (D.E.); (G.K.)
| | - Pablo Ramos
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31001 Pamplona, Spain; (E.B.); (L.F.-R.); (H.A.); (M.E.); (M.G.); (P.R.); (S.P.-H.); (D.E.); (G.K.)
| | - Sergio Piñeiro-Hermida
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31001 Pamplona, Spain; (E.B.); (L.F.-R.); (H.A.); (M.E.); (M.G.); (P.R.); (S.P.-H.); (D.E.); (G.K.)
| | - Ruth Vera
- Medical Oncology Unit, Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31001 Pamplona, Spain;
| | - David Escors
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31001 Pamplona, Spain; (E.B.); (L.F.-R.); (H.A.); (M.E.); (M.G.); (P.R.); (S.P.-H.); (D.E.); (G.K.)
| | - Grazyna Kochan
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31001 Pamplona, Spain; (E.B.); (L.F.-R.); (H.A.); (M.E.); (M.G.); (P.R.); (S.P.-H.); (D.E.); (G.K.)
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10
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Chocarro L, Blanco E, Arasanz H, Fernández-Rubio L, Bocanegra A, Echaide M, Garnica M, Ramos P, Fernández-Hinojal G, Vera R, Kochan G, Escors D. Clinical landscape of LAG-3-targeted therapy. IMMUNO-ONCOLOGY TECHNOLOGY 2022; 14:100079. [PMID: 35755891 PMCID: PMC9216443 DOI: 10.1016/j.iotech.2022.100079] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Lymphocyte-activated gene 3 (LAG-3) is a cell surface inhibitory receptor and a key regulator of immune homeostasis with multiple biological activities related to T-cell functions. LAG-3 is considered a next-generation immune checkpoint of clinical importance, right next to programmed cell death protein 1 (PD-1) and cytotoxic T-cell lymphocyte antigen-4 (CTLA-4). Indeed, it is the third inhibitory receptor to be exploited in human anticancer immunotherapies. Several LAG-3-antagonistic immunotherapies are being evaluated at various stages of preclinical and clinical development. In addition, combination therapies blocking LAG-3 together with other immune checkpoints are also being evaluated at preclinical and clinical levels. Indeed, the co-blockade of LAG-3 with PD-1 is demonstrating encouraging results. A new generation of bispecific PD-1/LAG-3-blocking agents have also shown strong capacities to specifically target PD-1+ LAG-3+ highly dysfunctional T cells and enhance their proliferation and effector activities. Here we identify and classify preclinical and clinical trials conducted involving LAG-3 as a target through an extensive bibliographic research. The current understanding of LAG-3 clinical applications is summarized, and most of the publically available data up to date regarding LAG-3-targeted therapy preclinical and clinical research and development are reviewed and discussed. LAG-3 is a highly important next-generation immune checkpoint molecule. Ninety-seven clinical trials are evaluating at least 16 LAG-3-targeting molecules. Here we identify preclinical and clinical studies conducted involving LAG-3. Bispecific LAG-3 molecules are being developed, showing strong capacities. LAG-3/PD-1 co-blockade is demonstrating encouraging results.
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Affiliation(s)
- L Chocarro
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - E Blanco
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain.,Division of Gene Therapy and Regulation of Gene Expression, Cima Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdISNA), Pamplona, Spain
| | - H Arasanz
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain.,Medical Oncology Unit, Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - L Fernández-Rubio
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - A Bocanegra
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - M Echaide
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - M Garnica
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - P Ramos
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - G Fernández-Hinojal
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain.,Medical Oncology Department, Hospital Clínico San Carlos, Madrid, Spain
| | - R Vera
- Medical Oncology Unit, Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - G Kochan
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - D Escors
- Oncoimmunology Research Unit, Navarrabiomed-Fundación Miguel Servet, Universidad Pública de Navarra (UPNA), Hospital Universitario de Navarra (HUN), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
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11
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Assessing the Future of Solid Tumor Immunotherapy. Biomedicines 2022; 10:biomedicines10030655. [PMID: 35327456 PMCID: PMC8945484 DOI: 10.3390/biomedicines10030655] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/03/2022] [Accepted: 03/09/2022] [Indexed: 02/04/2023] Open
Abstract
With the advent of cancer immunotherapy, there has been a major improvement in patient’s quality of life and survival. The growth of cancer immunotherapy has dramatically changed our understanding of the basics of cancer biology and has altered the standards of care (surgery, radiotherapy, and chemotherapy) for patients. Cancer immunotherapy has generated significant excitement with the success of chimeric antigen receptor (CAR) T cell therapy in particular. Clinical results using CAR-T for hematological malignancies have led to the approval of four CD19-targeted and one B-cell maturation antigen (BCMA)-targeted cell therapy products by the US Food and Drug Administration (FDA). Also, immune checkpoint inhibitors such as antibodies against Programmed Cell Death-1 (PD-1), Programmed Cell Death Ligand-1 (PD-L1), and Cytotoxic T-Lymphocyte-Associated Antigen 4 (CTLA-4) have shown promising therapeutic outcomes and long-lasting clinical effect in several tumor types and patients who are refractory to other treatments. Despite these promising results, the success of cancer immunotherapy in solid tumors has been limited due to several barriers, which include immunosuppressive tumor microenvironment (TME), inefficient trafficking, and heterogeneity of tumor antigens. This is further compounded by the high intra-tumoral pressure of solid tumors, which presents an additional challenge to successfully delivering treatments to solid tumors. In this review, we will outline and propose specific approaches that may overcome these immunological and physical barriers to improve the outcomes in solid tumor patients receiving immunotherapies.
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12
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Xie Y, Xie F, Zhang L, Zhou X, Huang J, Wang F, Jin J, Zhang L, Zeng L, Zhou F. Targeted Anti-Tumor Immunotherapy Using Tumor Infiltrating Cells. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2021; 8:e2101672. [PMID: 34658167 PMCID: PMC8596143 DOI: 10.1002/advs.202101672] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/21/2021] [Indexed: 05/08/2023]
Abstract
In the tumor microenvironment, T cells, B cells, and many other cells play important and distinct roles in anti-tumor immunotherapy. Although the immune checkpoint blockade and adoptive cell transfer can elicit durable clinical responses, only a few patients benefit from these therapies. Increased understanding of tumor-infiltrating immune cells can provide novel therapies and drugs that induce a highly specific anti-tumor immune response to certain groups of patients. Herein, the recent research progress on tumor-infiltrating B cells and T cells, including CD8+ T cells, CD4+ T cells, and exhausted T cells and their role in anti-tumor immunity, is summarized. Moreover, several anti-tumor therapy approaches are discussed based on different immune cells and their prospects for future applications in cancer treatment.
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Affiliation(s)
- Yifan Xie
- School of MedicineZhejiang University City CollegeHangzhou310015China
- College of Life SciencesZhejiang UniversityHangzhou310058China
| | - Feng Xie
- Institutes of Biology and Medical ScienceSoochow UniversitySuzhou215123P. R. China
| | - Lei Zhang
- Department of Orthopaedic SurgeryThe Third Affiliated Hospital of Wenzhou Medical UniversityRui'an325200China
| | - Xiaoxue Zhou
- MOE Key Laboratory of Biosystems Homeostasis & Protection and Innovation Center for Cell Signaling NetworkLife Sciences InstituteZhejiang UniversityHangzhou310058China
| | - Jun Huang
- MOE Key Laboratory of Biosystems Homeostasis & Protection and Innovation Center for Cell Signaling NetworkLife Sciences InstituteZhejiang UniversityHangzhou310058China
| | - Fangwei Wang
- MOE Key Laboratory of Biosystems Homeostasis & Protection and Innovation Center for Cell Signaling NetworkLife Sciences InstituteZhejiang UniversityHangzhou310058China
| | - Jin Jin
- MOE Key Laboratory of Biosystems Homeostasis & Protection and Innovation Center for Cell Signaling NetworkLife Sciences InstituteZhejiang UniversityHangzhou310058China
| | - Long Zhang
- MOE Key Laboratory of Biosystems Homeostasis & Protection and Innovation Center for Cell Signaling NetworkLife Sciences InstituteZhejiang UniversityHangzhou310058China
| | - Linghui Zeng
- School of MedicineZhejiang University City CollegeHangzhou310015China
| | - Fangfang Zhou
- Institutes of Biology and Medical ScienceSoochow UniversitySuzhou215123P. R. China
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13
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Nie D, Xue Y, Fang Q, Cheng J, Li B, Wang D, Li C, Gui S, Zhang Y, Zhao P. Immune Checkpoints: Therapeutic Targets for Pituitary Tumors. DISEASE MARKERS 2021; 2021:5300381. [PMID: 34447484 PMCID: PMC8384513 DOI: 10.1155/2021/5300381] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/06/2021] [Indexed: 11/18/2022]
Abstract
Pituitary tumors are the third most common intracranial tumors in adults. Treatment of refractory pituitary tumors is known to be difficult due to limited treatment options. As a promising therapeutic method, tumor immunotherapy has been applied in the treatment of many tumors, including pituitary tumors. Immune checkpoint blocking is one of the effective strategies to activate antitumor immunity. Immune checkpoints prevent tissue damage by regulating the immune response of peripheral tissues and participate in the maintenance of a normal immune environment. In the presence of a tumor, inhibition of T cell activity by tumor cells binding to immune checkpoints and their ligands is an important mechanism for tumor cells to escape immune injury. In this review, we summarize the latest findings of immune checkpoints and their potential as immunotherapeutic targets for pituitary tumors.
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Affiliation(s)
- Ding Nie
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yimeng Xue
- Savaid Medical School, University of Chinese Academy of Sciences, Beijing, China
| | - Qiuyue Fang
- Beijing Neurosurgical Institute, Beijing, China
| | | | - Bin Li
- Beijing Neurosurgical Institute, Beijing, China
| | - Dawei Wang
- Beijing Neurosurgical Institute, Beijing, China
| | - Chuzhong Li
- Beijing Neurosurgical Institute, Beijing, China
| | - Songbai Gui
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | - Peng Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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14
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Prognostic and Clinicopathologic Associations of LAG-3 Expression in Triple-negative Breast Cancer. Appl Immunohistochem Mol Morphol 2021; 30:62-71. [PMID: 34081635 DOI: 10.1097/pai.0000000000000954] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/04/2021] [Indexed: 11/26/2022]
Abstract
The immune checkpoint molecule lymphocyte activation gene 3 (LAG-3) is currently being investigated as a possible target for immunotherapy in triple-negative breast cancer (TNBC), frequently as an addition to treatment with programmed cell death protein 1/programmed death ligand 1 (PD-L1) inhibition. However, expression of LAG-3, the frequency of coexpression with PD-L1, and the prognostic significance of this marker have not been studied extensively in TNBC. For this study, tissue microarrays (TMAs) were constructed from surgical specimens of 514 patients with TNBC. TMAs were stained immunohistochemically for LAG-3 and PD-L1 expression. Tumor-infiltrating lymphocytes (TILs) were evaluated on full glass slides. LAG-3 expression was significantly associated with improved overall survival and relapse-free survival. When adjusted for clinicopathologic factors, each increment of 10 LAG-3-positive intratumoral lymphocytes per TMA core was associated with improved overall survival (hazard ratio=0.93, 95% confidence interval: 0.89-0.97, P=0.002), and recurrence-free survival (hazard ratio=0.91, 95% confidence interval: 0.85-0.97, P=0.002). PD-L1 expression on immune cells and PD-L1 expression evaluated with the combined positive score and TILs were also associated with improved survival in both univariate and multivariate analyses. PD-L1 expression on tumor cells was only associated with improved survival in univariate analysis. LAG-3 expression was associated with both TILs and PD-L1 expression. Coexpression of LAG-3 and PD-L1 did not confer additional survival benefits. In conclusion, LAG-3 expression is associated with improved survival in TNBC. LAG-3 is often coexpressed with PD-L1, confirming that TNBC is likely a suitable candidate for cotreatment with LAG-3 and programmed cell death protein 1/PD-L1 inhibitors. However, coexpression does not confer additional survival benefits.
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15
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Lee JB, Ha SJ, Kim HR. Clinical Insights Into Novel Immune Checkpoint Inhibitors. Front Pharmacol 2021; 12:681320. [PMID: 34025438 PMCID: PMC8139127 DOI: 10.3389/fphar.2021.681320] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/22/2021] [Indexed: 12/17/2022] Open
Abstract
The success of immune checkpoint inhibitors (ICIs), notably anti-cytotoxic T lymphocyte associated antigen-4 (CTLA-4) as well as inhibitors of CTLA-4, programmed death 1 (PD-1), and programmed death ligand-1 (PD-L1), has revolutionized treatment options for solid tumors. However, the lack of response to treatment, in terms of de novo or acquired resistance, and immune related adverse events (IRAE) remain as hurdles. One mechanisms to overcome the limitations of ICIs is to target other immune checkpoints associated with tumor microenvironment. Immune checkpoints such as lymphocyte activation gene-3 (LAG-3), T cell immunoglobulin and ITIM domain (TIGIT), T cell immunoglobulin and mucin-domain containing-3 (TIM-3), V-domain immunoglobulin suppressor of T cell activation (VISTA), B7 homolog 3 protein (B7-H3), inducible T cell costimulatory (ICOS), and B and T lymphocyte attenuator (BTLA) are feasible and promising options for treating solid tumors, and clinical trials are currently under active investigation. This review aims to summarize the clinical aspects of the immune checkpoints and introduce novel agents targeting these checkpoints.
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Affiliation(s)
- Jii Bum Lee
- Division of Hemato-oncology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, South Korea.,Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Sang-Jun Ha
- Department of Biochemistry, College of Life Science & Biotechnology, Yonsei University, Seoul, South Korea
| | - Hye Ryun Kim
- Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
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