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Gitto SB, Whicker M, Davies G, Kumar S, Kinneer K, Xu H, Lewis A, Mamidi S, Medvedev S, Kim H, Anderton J, Tang EJ, Ferman B, Coats S, Wilkinson RW, Brown E, Powell DJ, Simpkins F. A B7-H4-Targeting Antibody-Drug Conjugate Shows Antitumor Activity in PARPi and Platinum-Resistant Cancers with B7-H4 Expression. Clin Cancer Res 2024; 30:1567-1581. [PMID: 37882675 PMCID: PMC11034955 DOI: 10.1158/1078-0432.ccr-23-1079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/21/2023] [Accepted: 10/24/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE Platinum and PARP inhibitors (PARPi) demonstrate activity in breast and ovarian cancers, but drug resistance ultimately emerges. Here, we examine B7-H4 expression in primary and recurrent high-grade serous ovarian carcinoma (HGSOC) and the activity of a B7-H4-directed antibody-drug conjugate (B7-H4-ADC), using a pyrrolobenzodiazepine-dimer payload, in PARPi- and platinum-resistant HGSOC patient-derived xenograft (PDX) models. EXPERIMENTAL DESIGN B7-H4 expression was quantified by flow cytometry and IHC. B7-H4-ADC efficacy was tested against multiple cell lines in vitro and PDX in vivo. The effect of B7-H4-ADC on cell cycle, DNA damage, and apoptosis was measured using flow cytometry. RESULTS B7-H4 is overexpressed in 92% of HGSOC tumors at diagnosis (n = 12), persisted in recurrent matched samples after platinum treatment, and was expressed at similar levels across metastatic sites after acquired multi-drug resistance (n = 4). Treatment with B7-H4-ADC resulted in target-specific growth inhibition of multiple ovarian and breast cancer cell lines. In platinum- or PARPi-resistant ovarian cancer cells, B7-H4-ADC significantly decreased viability and colony formation while increasing cell-cycle arrest and DNA damage, ultimately leading to apoptosis. Single-dose B7-H4-ADC led to tumor regression in 65.5% of breast and ovarian PDX models (n = 29), with reduced activity in B7-H4 low or negative models. In PARPi and platinum-resistant HGSOC PDX models, scheduled B7-H4-ADC dosing led to sustained tumor regression and increased survival. CONCLUSIONS These data support B7-H4 as an attractive ADC target for treatment of drug-resistant HGSOC and provide evidence for activity of an ADC with a DNA-damaging payload in this population. See related commentary by Veneziani et al., p. 1434.
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Affiliation(s)
- Sarah B. Gitto
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Margaret Whicker
- Penn Ovarian Cancer Research Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19104 USA
| | | | - Sushil Kumar
- Penn Ovarian Cancer Research Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19104 USA
| | | | - Haineng Xu
- Penn Ovarian Cancer Research Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19104 USA
| | | | | | - Sergey Medvedev
- Penn Ovarian Cancer Research Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Hyoung Kim
- Penn Ovarian Cancer Research Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19104 USA
| | | | - E. Jessica Tang
- Department of Cancer Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Benjamin Ferman
- Penn Ovarian Cancer Research Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19104 USA
| | | | | | - Eric Brown
- Department of Cancer Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Daniel J. Powell
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
- Penn Ovarian Cancer Research Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Fiona Simpkins
- Penn Ovarian Cancer Research Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19104 USA
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Gitto SB, Ihewulezi CJN, Powell DJ. Adoptive T cell therapy for ovarian cancer. Gynecol Oncol 2024; 186:77-84. [PMID: 38603955 DOI: 10.1016/j.ygyno.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/27/2024] [Accepted: 04/01/2024] [Indexed: 04/13/2024]
Abstract
Although ovarian cancer patients typically respond to standard of care therapies, including chemotherapy and DNA repair inhibitors, the majority of tumors recur highlighting the need for alternative therapies. Ovarian cancer is an immunogenic cancer in which the accumulation of tumor infiltrating lymphocytes (TILs), particularly T cells, is associated with better patient outcome. Thus, harnessing the immune system through passive administration of T cells, a process called adoptive cell therapy (ACT), is a promising therapeutic option for the treatment of ovarian cancer. There are multiple routes by which tumor-specific T cell products can be generated. Dendritic cell cancer vaccines can be administered to the patients to induce or bolster T cell responses against tumor antigens or be utilized ex vivo to prime T cells against tumor antigens; these T cells can then be prepared for infusion. ACT protocols can also utilize naturally-occurring tumor-reactive T cells isolated from a patient tumor, known as TILs, as these cells often are heterogeneous in composition and antigen specificity with patient-specific cancer recognition. Alternatively, T cells may be sourced from the peripheral blood, including those that are genetically modified to express a tumor antigen-specific T cell receptor (TCR) or chimeric antigen receptor (CAR) to redirect their specificity and promote their activity against tumor cells expressing the target tumor antigen. Here, we review current ACT strategies for ovarian cancer and provide insights into advancing ACT therapy strategies for the treatment of ovarian cancer.
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Affiliation(s)
- Sarah B Gitto
- Department of Pathology and Laboratory Medicine, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Chibuike J N Ihewulezi
- Department of Pathology and Laboratory Medicine, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Daniel J Powell
- Department of Pathology and Laboratory Medicine, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Ovarian Cancer Research Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Hung SI, Chu MT, Hou MM, Lee YS, Yang CK, Chu SY, Liu FY, Hsu HC, Pao SC, Teng YC, Chen CB, Chao A, Chung WH, Chang JWC, Lai CH. Personalized neoantigen-based T cell therapy triggers cytotoxic lymphocytes expressing polyclonal TCR against metastatic ovarian cancer. Biomed Pharmacother 2023; 169:115928. [PMID: 38011788 DOI: 10.1016/j.biopha.2023.115928] [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: 08/26/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 11/29/2023] Open
Abstract
Neoantigen-reactive cytotoxic T lymphocytes play a vital role in precise cancer cell elimination. In this study, we demonstrate the effectiveness of personalized neoantigen-based T cell therapy in inducing tumor regression in two patients suffering from heavily-burdened metastatic ovarian cancer. Our approach involved the development of a robust pipeline for ex vivo expansion of neoantigen-reactive T lymphocytes. Neoantigen peptides were designed and synthesized based on the somatic mutations of the tumors and their predicted HLA binding affinities. These peptides were then presented to T lymphocytes through co-culture with neoantigen-loaded dendritic cells for ex vivo expansion. Subsequent to cell therapy, both patients exhibited significant reductions in tumor marker levels and experienced substantial tumor regression. One patient achieved repeated cancer regression through infusions of T cell products generated from newly identified neoantigens. Transcriptomic analyses revealed a remarkable increase in neoantigen-reactive cytotoxic lymphocytes in the peripheral blood of the patients following cell therapy. These cytotoxic T lymphocytes expressed polyclonal T cell receptors (TCR) against neoantigens, along with abundant cytotoxic proteins and pro-inflammatory cytokines. The efficacy of neoantigen targeting was significantly associated with the immunogenicity and TCR polyclonality. Notably, the neoantigen-specific TCR clonotypes persisted in the peripheral blood after cell therapy. Our findings indicate that personalized neoantigen-based T cell therapy triggers cytotoxic lymphocytes expressing polyclonal TCR against ovarian cancer, suggesting its promising potential in cancer immunotherapy.
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Affiliation(s)
- Shuen-Iu Hung
- Cancer Vaccine & Immune Cell Therapy Core Lab, Department of Medical Research, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan; Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, No.155, Section 2, Linong Street, Taipei 112, Taiwan.
| | - Mu-Tzu Chu
- Cancer Vaccine & Immune Cell Therapy Core Lab, Department of Medical Research, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan.
| | - Ming-Mo Hou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan; College of Medicine, Chang Gung University, No. 5, De-Ming Road., Taoyuan 333, Taiwan.
| | - Yun-Shien Lee
- Genomic Medicine Research Core Laboratory, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Guishan, Taoyuan 333, Taiwan; Department of Biotechnology, Ming-Chuan University, Taoyuan 333, Taiwan.
| | - Chan-Keng Yang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan; College of Medicine, Chang Gung University, No. 5, De-Ming Road., Taoyuan 333, Taiwan.
| | - Sung-Yu Chu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan.
| | - Feng-Yuan Liu
- College of Medicine, Chang Gung University, No. 5, De-Ming Road., Taoyuan 333, Taiwan; Department of Nuclear Medicine and Molecular Imaging Center, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan; Gynecologic Cancer Research Center, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan; School of Medicine, National Tsing Hua University, No.101, Section 2, Kuang-Fu Road, Hsinchu 300, Taiwan.
| | - Hung-Chih Hsu
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan; College of Medicine, Chang Gung University, No. 5, De-Ming Road., Taoyuan 333, Taiwan.
| | - Shih-Cheng Pao
- Cancer Vaccine & Immune Cell Therapy Core Lab, Department of Medical Research, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan; Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, No.155, Section 2, Linong Street, Taipei 112, Taiwan.
| | - Yu-Chuan Teng
- Genomic Medicine Research Core Laboratory, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Guishan, Taoyuan 333, Taiwan.
| | - Chun-Bing Chen
- College of Medicine, Chang Gung University, No. 5, De-Ming Road., Taoyuan 333, Taiwan; Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan.
| | - Angel Chao
- College of Medicine, Chang Gung University, No. 5, De-Ming Road., Taoyuan 333, Taiwan; Gynecologic Cancer Research Center, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan; Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan.
| | - Wen-Hung Chung
- Cancer Vaccine & Immune Cell Therapy Core Lab, Department of Medical Research, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan; College of Medicine, Chang Gung University, No. 5, De-Ming Road., Taoyuan 333, Taiwan; Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan; Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung Branch, No. 222, Maijin Road., Keelung 204, Taiwan.
| | - John Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan; College of Medicine, Chang Gung University, No. 5, De-Ming Road., Taoyuan 333, Taiwan.
| | - Chyong-Huey Lai
- College of Medicine, Chang Gung University, No. 5, De-Ming Road., Taoyuan 333, Taiwan; Gynecologic Cancer Research Center, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan; Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Branch, No. 5. Fuxing Street, Taoyuan 333, Taiwan.
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4
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Ranoa DRE, Sharma P, Schane CP, Lewis AN, Valdez E, Marada VVVR, Hager MV, Montgomery W, Wolf SP, Schreiber K, Schreiber H, Bailey K, Fan TM, Hergenrother PJ, Roy EJ, Kranz DM. Single CAR-T cell treatment controls disseminated ovarian cancer in a syngeneic mouse model. J Immunother Cancer 2023; 11:e006509. [PMID: 37258040 PMCID: PMC10255004 DOI: 10.1136/jitc-2022-006509] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Treatment of some blood cancers with T cells that express a chimeric antigen receptor (CAR) against CD19 have shown remarkable results. In contrast, CAR-T cell efficacy against solid tumors has been difficult to achieve. METHODS To examine the potential of CAR-T cell treatments against ovarian cancers, we used the mouse ovarian cancer cell line ID8 in an intraperitoneal model that exhibits disseminated solid tumors in female C57BL/6J mice. The CAR contained a single-chain Fv from antibody 237 which recognizes a Tn-glycopeptide-antigen expressed by ID8 due to aberrant O-linked glycosylation in the absence of the transferase-dependent chaperone Cosmc. The efficacy of four Tn-dependent CARs with varying affinity to Tn antigen, and each containing CD28/CD3ζ cytoplasmic domains, were compared in vitro and in vivo in this study. RESULTS In line with many observations about the impact of aberrant O-linked glycosylation, the ID8Cosmc knock-out (ID8Cosmc-KO) exhibited more rapid tumor progression compared with wild-type ID8. Despite the enhanced tumor growth in vivo, 237 CAR and a mutant with 30-fold higher affinity, but not CARs with lower affinity, controlled advanced ID8Cosmc-KO tumors. Tumor regression could be achieved with a single intravenous dose of the CARs, but intraperitoneal administration was even more effective. The CAR-T cells persisted over a period of months, allowing CAR-treated mice to delay tumor growth in a re-challenge setting. The most effective CARs exhibited the highest affinity for antigen. Antitumor effects observed in vivo were associated with increased numbers of T cells and macrophages, and higher levels of cleaved caspase-3, in the tumor microenvironment. Notably, the least therapeutically effective CAR mediated tonic signaling leading to antigen-independent cytokine expression and it had higher levels of the immunosuppressive cytokine interleukin10. CONCLUSION The findings support the development of affinity-optimized CAR-T cells as a potential treatment for established ovarian cancer, with the most effective CARs mediating a distinct pattern of inflammatory cytokine release in vitro. Importantly, the most potent Tn-dependent CAR-T cells showed no evidence of toxicity in tumor-bearing mice in a syngeneic, immunocompetent system.
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Affiliation(s)
- Diana Rose E Ranoa
- Carl R. Woese Institute for Genomic Biology and Cancer Center at Illinois, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
- Department of Chemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Preeti Sharma
- Department of Biochemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Claire P Schane
- Department of Biochemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Amber N Lewis
- Department of Biochemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Edward Valdez
- Department of Biochemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Venkata V V R Marada
- Department of Biochemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Marlies V Hager
- Department of Biochemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
- Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Will Montgomery
- Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Steven P Wolf
- Department of Pathology and David and Etta Jonas Center for Cellular Therapy, The University of Chicago, Chicago, Illinois, USA
| | - Karin Schreiber
- Department of Pathology and David and Etta Jonas Center for Cellular Therapy, The University of Chicago, Chicago, Illinois, USA
| | - Hans Schreiber
- Department of Pathology and David and Etta Jonas Center for Cellular Therapy, The University of Chicago, Chicago, Illinois, USA
| | - Keith Bailey
- Charles River Laboratories Inc Mattawan, Mattawan, Michigan, USA
| | - Timothy M Fan
- Carl R. Woese Institute for Genomic Biology and Cancer Center at Illinois, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
- Department of Veterinary Clinical Medicine, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Paul J Hergenrother
- Carl R. Woese Institute for Genomic Biology and Cancer Center at Illinois, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
- Department of Chemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Edward J Roy
- Carl R. Woese Institute for Genomic Biology and Cancer Center at Illinois, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
- Department of Pathology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - David M Kranz
- Carl R. Woese Institute for Genomic Biology and Cancer Center at Illinois, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
- Department of Biochemistry, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
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5
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Millar DG, Yang SYC, Sayad A, Zhao Q, Nguyen LT, Warner K, Sangster AG, Nakatsugawa M, Murata K, Wang BX, Shaw P, Clarke B, Bernardini MQ, Pugh T, Thibault P, Hirano N, Perreault C, Ohashi PS. Identification of antigenic epitopes recognized by tumor infiltrating lymphocytes in high grade serous ovarian cancer by multi-omics profiling of the auto-antigen repertoire. Cancer Immunol Immunother 2023:10.1007/s00262-023-03413-7. [PMID: 36943460 DOI: 10.1007/s00262-023-03413-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/16/2023] [Indexed: 03/23/2023]
Abstract
Immunotherapeutic strategies aimed at enhancing tumor cell killing by tumor-specific T cells hold great potential for reducing tumor burden and prolonging survival of cancer patients. Although many potential tumor antigens have been described, identifying relevant targets when designing anti-cancer vaccines or targeted cell therapies remains a challenge. To identify novel, potentially immunogenic candidate tumor antigens, we performed integrated tumor transcriptomic, seromic, and proteomic analyses of high grade serous ovarian cancer (HGSC) patient tumor samples. We identified tumor neo-antigens and over-expressed antigens using whole exome and RNA sequencing and examined these in relation to patient-matched auto-antibody repertoires. Focusing on MHC class I epitopes recognized by CD8+ T cells, HLA-binding epitopes were identified or predicted from the highly expressed, mutated, or auto-antibody target antigen, or MHC-associated peptides (MAPs). Recognition of candidate antigenic peptides was assessed within the tumor-infiltrating T lymphocyte (TIL) population expanded from each patient. Known tumor-associated antigens (TAA) and cancer/testis antigens (CTA) were commonly found in the auto-antibody and MAP repertoires and CD8+ TILs recognizing epitopes from these antigens were detected, although neither expression level nor the presence of auto-antibodies correlated with TIL recognition. Auto-antibodies against tumor-mutated antigens were found in most patients, however, no TIL recognition of the highest predicted affinity neo-epitopes was detected. Using high expression level, auto-antibody recognition, and epitope prediction algorithms, we identified epitopes in 5 novel antigens (MOB1A, SOCS3, TUBB, PRKAR1A, CCDC6) recognized by HGSC patient TILs. Furthermore, selection of epitopes from the MAP repertoire identified 5 additional targets commonly recognized by multiple patient TILs. We find that the repertoire of TIL specificities includes recognition of highly expressed and immunogenic self-antigens that are processed and presented by tumors. These results indicate an ongoing autoimmune response against a range of self-antigens targeted by HGSC TILs.
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Affiliation(s)
- Douglas G Millar
- Tumor Immunotherapy Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - S Y Cindy Yang
- Tumor Immunotherapy Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Azin Sayad
- Tumor Immunotherapy Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Qingchuan Zhao
- Institute for Research in Immunology and Cancer, Université de Montréal, Montréal, Québec, Canada
| | - Linh T Nguyen
- Tumor Immunotherapy Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Kathrin Warner
- Tumor Immunotherapy Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Ami G Sangster
- Tumor Immunotherapy Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Munehide Nakatsugawa
- Tumor Immunotherapy Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Kenji Murata
- Tumor Immunotherapy Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Ben X Wang
- Tumor Immunotherapy Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Patricia Shaw
- Tumor Immunotherapy Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Blaise Clarke
- Tumor Immunotherapy Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Marcus Q Bernardini
- Division of Gynecologic Oncology, Cancer Clinical Research Unit (CCRU), Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Trevor Pugh
- Tumor Immunotherapy Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Pierre Thibault
- Institute for Research in Immunology and Cancer, Université de Montréal, Montréal, Québec, Canada
| | - Naoto Hirano
- Tumor Immunotherapy Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
- Department of Immunology, University of Toronto, Toronto, ON, Canada
| | - Claude Perreault
- Institute for Research in Immunology and Cancer, Université de Montréal, Montréal, Québec, Canada
| | - Pamela S Ohashi
- Tumor Immunotherapy Program, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada.
- Department of Immunology, University of Toronto, Toronto, ON, Canada.
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6
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Shen X, Gu X, Ma R, Li X, Wang J. Identification of the Immune Signatures for Ovarian Cancer Based on the Tumor Immune Microenvironment Genes. Front Cell Dev Biol 2022; 10:772701. [PMID: 35372348 PMCID: PMC8974491 DOI: 10.3389/fcell.2022.772701] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 03/02/2022] [Indexed: 11/21/2022] Open
Abstract
Ovarian cancer (OV) is a deadly gynecological cancer. The tumor immune microenvironment (TIME) plays a pivotal role in OV development. However, the TIME of OV is not fully known. Therefore, we aimed to provide a comprehensive network of the TIME in OV. Gene expression data and clinical information from OV patients were obtained from the Cancer Genome Atlas Program (TCGA) database. Non-negative Matrix Factorization, NMFConsensus, and nearest template prediction algorithms were used to perform molecular clustering. The biological functions of differentially expressed genes (DEGs) were identified using Metascape, gene set enrichment analysis (GSEA), gene ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis. The copy number variations (CNVs), single nucleotide polymorphisms (SNPs) and tumor mutation burden were analyzed using Gistic 2.0, R package maftools, and TCGA mutations, respectively. Estimation of STromal and Immune cells in MAlignant Tumor tissues using Expression data and CIBERSORT were utilized to elucidate the TIME. Moreover, external data from the International Cancer Genome Consortium (ICGC) and ArrayExpress databases were used to validate the signature. All 361 samples from the TCGA OV dataset were classified into Immune Class and non-Immune Class with immune signatures. By comparing the two classes, we identified 740 DEGs that accumulated in immune-related, cancer-related, inflammation-related biological functions and pathways. There were significant differences in the CNVs between the Immune and non-Immune Classes. The Immune Class was further divided into immune-activated and immune-suppressed subtypes. There was no significant difference in the top 20 genes in somatic SNPs among the three groups. In addition, the immune-activated subtype had significantly increased proportions of CD4 memory resting T cells, T cells, M1 macrophages, and M2 macrophages than the other two groups. The qRT-PCR results indicated that the mRNA expression levels of RYR2, FAT3, MDN1 and RYR1 were significantly down-regulated in OV compared with normal tissues. Moreover, the signatures of the TIME were validated using ICGC cohort and the ArrayExpress cohort. Our study clustered the OV patients into an immune-activated subtype, immune-suppressed subtype, and non-Immune Class and provided potential clues for further research on the molecular mechanisms and immunotherapy strategies of OV.
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Affiliation(s)
- Xiaoyan Shen
- Department of Gynecology, Peking University People’s Hospital, Beijing, China
| | - Xiao Gu
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ruiqiong Ma
- Department of Gynecology, Peking University People’s Hospital, Beijing, China
| | - Xiaoping Li
- Department of Gynecology, Peking University People’s Hospital, Beijing, China
| | - Jianliu Wang
- Department of Gynecology, Peking University People’s Hospital, Beijing, China
- *Correspondence: Jianliu Wang,
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7
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Zheng M, Hu Y, Gou R, Li S, Nie X, Li X, Lin B. Development of a seven-gene tumor immune microenvironment prognostic signature for high-risk grade III endometrial cancer. MOLECULAR THERAPY-ONCOLYTICS 2021; 22:294-306. [PMID: 34553020 PMCID: PMC8426172 DOI: 10.1016/j.omto.2021.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 07/02/2021] [Indexed: 02/06/2023]
Abstract
Uterine corpus endometrial carcinoma locally infiltrates numerous immune cells and other tumor immune microenvironment components. These cells are involved in malignant tumor growth and proliferation and the process of resistance toward immunotherapies. Here, we aimed to develop a tumor immune microenvironment-related prognostic signature for high-risk grade III endometrial carcinoma based on The Cancer Genome Atlas. The signature was systematically correlated with immune infiltration characteristics of the tumor microenvironment. The seven-gene Riskscore signature was robust and performed well in training, testing, and Gene Expression Omnibus-independent cohorts. A nomogram comprising the gene signature accurately predicted patient prognosis, with our model performing better than other endometrial cancer-related signatures. Analysis of the IMvigor210 immunotherapy cohort revealed that subgroups with a low Riskscore had a better prognosis than subgroups with a high Riskscore. Subgroups with a low Riskscore exhibited immune cell infiltration and inflammatory profiles, whereas subgroups with a high Riskscore experienced progressive disease. The receiver operating characteristic curve indicated that risk score, neoantigen, and tumor mutation burden models together accurately predicted treatment response. Taken together, we developed a tumor microenvironment-based seven-gene prognostic stratification system to predict the prognosis of patients with high-risk endometrial cancer and guide more effective immunotherapy strategies.
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Affiliation(s)
- Mingjun Zheng
- Department of Gynecology and Obstetrics, Shengjing Hospital of China Medical University, Liaoning 110004, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Key Laboratory of Obstetrics and Gynecology of Higher Education of Liaoning Province, China.,Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Maistrasse 11, 80337 Munich, Germany
| | - Yuexin Hu
- Department of Gynecology and Obstetrics, Shengjing Hospital of China Medical University, Liaoning 110004, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Key Laboratory of Obstetrics and Gynecology of Higher Education of Liaoning Province, China
| | - Rui Gou
- Department of Gynecology and Obstetrics, Shengjing Hospital of China Medical University, Liaoning 110004, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Key Laboratory of Obstetrics and Gynecology of Higher Education of Liaoning Province, China
| | - Siting Li
- Department of Gynecology and Obstetrics, Shengjing Hospital of China Medical University, Liaoning 110004, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Key Laboratory of Obstetrics and Gynecology of Higher Education of Liaoning Province, China
| | - Xin Nie
- Department of Gynecology and Obstetrics, Shengjing Hospital of China Medical University, Liaoning 110004, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Key Laboratory of Obstetrics and Gynecology of Higher Education of Liaoning Province, China
| | - Xiao Li
- Department of Gynecology and Obstetrics, Shengjing Hospital of China Medical University, Liaoning 110004, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Key Laboratory of Obstetrics and Gynecology of Higher Education of Liaoning Province, China
| | - Bei Lin
- Department of Gynecology and Obstetrics, Shengjing Hospital of China Medical University, Liaoning 110004, China.,Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Key Laboratory of Obstetrics and Gynecology of Higher Education of Liaoning Province, China
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8
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Banville AC, Wouters MCA, Oberg AL, Goergen KM, Maurer MJ, Milne K, Ashkani J, Field E, Ghesquiere C, Jones SJM, Block MS, Nelson BH. Co-expression patterns of chimeric antigen receptor (CAR)-T cell target antigens in primary and recurrent ovarian cancer. Gynecol Oncol 2020; 160:520-529. [PMID: 33342620 DOI: 10.1016/j.ygyno.2020.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/06/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Chimeric antigen receptor (CAR)-T cell strategies ideally target a surface antigen that is exclusively and uniformly expressed by tumors; however, no such antigen is known for high-grade serous ovarian carcinoma (HGSC). A potential solution involves combinatorial antigen targeting with AND or OR logic-gating. Therefore, we investigated co-expression of CA125, Mesothelin (MSLN) and Folate Receptor alpha (FOLRA) on individual tumor cells in HGSC. METHODS RNA expression of CA125, MSLN, and FOLR1 was assessed using TCGA (HGSC) and GTEx (healthy tissues) databases. Antigen expression profiles and CD3+, CD8+ and CD20+ tumor-infiltrating lymphocyte (TIL) patterns were assessed in primary and recurrent HGSC by multiplex immunofluorescence and immunohistochemistry. RESULTS At the transcriptional level, each antigen was overexpressed in >90% of cases; however, MSLN and FOLR1 showed substantial expression in healthy tissues. At the protein level, CA125 was expressed by the highest proportion of cases and tumor cells per case, followed by MSLN and FOLRA. The most promising pairwise combination was CA125 and/or MSLN (OR gate), with 51.9% of cases containing ≥90% of tumor cells expressing one or both antigens. In contrast, only 5.8% of cases contained ≥90% of tumor cells co-expressing CA125 and MSLN (AND gate). Antigen expression patterns showed modest correlations with TIL. Recurrent tumors retained expression of all three antigens and showed increased TIL densities. CONCLUSIONS An OR-gated CAR-T cell strategy against CA125 and MSLN would target the majority of tumor cells in most cases. Antigen expression and T-cell infiltration patterns are favorable for this strategy in primary and recurrent disease.
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Affiliation(s)
- Allyson C Banville
- Deeley Research Centre, BC Cancer, Victoria, BC V8R 6V5, Canada; Interdisciplinary Oncology Program, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | | | - Ann L Oberg
- Division of Biomedical Statistics & Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN 55905, USA
| | - Krista M Goergen
- Division of Biomedical Statistics & Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN 55905, USA
| | - Matthew J Maurer
- Division of Biomedical Statistics & Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN 55905, USA
| | - Katy Milne
- Deeley Research Centre, BC Cancer, Victoria, BC V8R 6V5, Canada
| | - Jahanshah Ashkani
- Genome Sciences Centre, BC Cancer Research Centre, Vancouver, BC V5Z 1L3, Canada
| | - Emma Field
- Deeley Research Centre, BC Cancer, Victoria, BC V8R 6V5, Canada
| | | | - Steven J M Jones
- Genome Sciences Centre, BC Cancer Research Centre, Vancouver, BC V5Z 1L3, Canada
| | - Matthew S Block
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Brad H Nelson
- Deeley Research Centre, BC Cancer, Victoria, BC V8R 6V5, Canada; Department of Biochemistry and Microbiology, University of Victoria, Victoria, BC V8P 3E6, Canada; Department of Medical Genetics, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada.
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9
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Th17-inducing autologous dendritic cell vaccination promotes antigen-specific cellular and humoral immunity in ovarian cancer patients. Nat Commun 2020; 11:5173. [PMID: 33057068 PMCID: PMC7560895 DOI: 10.1038/s41467-020-18962-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 09/21/2020] [Indexed: 01/13/2023] Open
Abstract
In ovarian cancer (OC), IL-17-producing T cells (Th17s) predict improved survival, whereas regulatory T cells predict poorer survival. We previously developed a vaccine whereby patient-derived dendritic cells (DCs) are programmed to induce Th17 responses to the OC antigen folate receptor alpha (FRα). Here we report the results of a single-arm open-label phase I clinical trial designed to determine vaccine safety and tolerability (primary outcomes) and recurrence-free survival (secondary outcome). Immunogenicity is also evaluated. Recruitment is complete with a total of 19 Stage IIIC-IV OC patients in first remission after conventional therapy. DCs are generated using our Th17-inducing protocol and are pulsed with HLA class II epitopes from FRα. Mature antigen-loaded DCs are injected intradermally. All patients have completed study-related interventions. No grade 3 or higher adverse events are seen. Vaccination results in the development of Th1, Th17, and antibody responses to FRα in the majority of patients. Th1 and antibody responses are associated with prolonged recurrence-free survival. Antibody-dependent cell-mediated cytotoxic activity against FRα is also associated with prolonged RFS. Of 18 patients evaluable for efficacy, 39% (7/18) remain recurrence-free at the time of data censoring, with a median follow-up of 49.2 months. Thus, vaccination with Th17-inducing FRα-loaded DCs is safe, induces antigen-specific immunity, and is associated with prolonged remission.
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10
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Macpherson AM, Barry SC, Ricciardelli C, Oehler MK. Epithelial Ovarian Cancer and the Immune System: Biology, Interactions, Challenges and Potential Advances for Immunotherapy. J Clin Med 2020; 9:E2967. [PMID: 32937961 PMCID: PMC7564553 DOI: 10.3390/jcm9092967] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/28/2020] [Accepted: 09/03/2020] [Indexed: 12/11/2022] Open
Abstract
Recent advances in the understanding of immune function and the interactions with tumour cells have led to the development of various cancer immunotherapies and strategies for specific cancer types. However, despite some stunning successes with some malignancies such as melanomas and lung cancer, most patients receive little or no benefit from immunotherapy, which has been attributed to the tumour microenvironment and immune evasion. Although the US Food and Drug Administration have approved immunotherapies for some cancers, to date, only the anti-angiogenic antibody bevacizumab is approved for the treatment of epithelial ovarian cancer. Immunotherapeutic strategies for ovarian cancer are still under development and being tested in numerous clinical trials. A detailed understanding of the interactions between cancer and the immune system is vital for optimisation of immunotherapies either alone or when combined with chemotherapy and other therapies. This article, in two main parts, provides an overview of: (1) components of the normal immune system and current knowledge regarding tumour immunology, biology and their interactions; (2) strategies, and targets, together with challenges and potential innovative approaches for cancer immunotherapy, with attention given to epithelial ovarian cancer.
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Affiliation(s)
- Anne M. Macpherson
- Discipline of Obstetrics and Gynaecology, Adelaide Medical School, Robinson Research Institute, University of Adelaide, Adelaide 5000, Australia; (A.M.M.); (C.R.)
| | - Simon C. Barry
- Molecular Immunology, Robinson Research Institute, University of Adelaide, Adelaide 5005, Australia;
| | - Carmela Ricciardelli
- Discipline of Obstetrics and Gynaecology, Adelaide Medical School, Robinson Research Institute, University of Adelaide, Adelaide 5000, Australia; (A.M.M.); (C.R.)
| | - Martin K. Oehler
- Discipline of Obstetrics and Gynaecology, Adelaide Medical School, Robinson Research Institute, University of Adelaide, Adelaide 5000, Australia; (A.M.M.); (C.R.)
- Department of Gynaecological Oncology, Royal Adelaide Hospital, Adelaide 5000, Australia
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11
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Liu J, Meng H, Nie S, Sun Y, Jiang P, Li S, Yang J, Sun R, Cheng W. Identification of a prognostic signature of epithelial ovarian cancer based on tumor immune microenvironment exploration. Genomics 2020; 112:4827-4841. [PMID: 32890701 DOI: 10.1016/j.ygeno.2020.08.027] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/24/2020] [Accepted: 08/21/2020] [Indexed: 12/22/2022]
Abstract
This study aims to develop an immune-related genes (IRGs) prognostic signature to stratify the epithelial ovarian cancer (EOC) patients. We identified 332 up- and 154 down-regulated EOC-specific IRGs. As a result, candidate IRGs were idendified to construct prognostic models respectivy for overall survial and progression-free survival. The risk score was validated as a risk factor for prognosis and was used to built a combined nomogram. According to the IRG-related prognostic model, EOC patients were divided into high- and low- risk group and were further explored their association with tumor immune microenvironment (TME). CIBERSORT algorithm showed higher macrophages M1 cell, T cells follicular helper cell and plasma cells infiltrating levels in the low-risk group. In addition, the low-risk group was found with higher immunophenoscore and distinct mutation signatures compared with the high-risk group. These findings may shed light on the development of novel immune biomarkers and target therapy of EOC.
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Affiliation(s)
- Jinhui Liu
- Department of Gynecology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu, China
| | - Huangyang Meng
- Department of Gynecology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu, China
| | - Sipei Nie
- Department of Gynecology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu, China
| | - Ying Sun
- Department of Gynecology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu, China
| | - Pinping Jiang
- Department of Gynecology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu, China
| | - Siyue Li
- Department of Gynecology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu, China
| | - Jing Yang
- Department of Gynecology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu, China
| | - Rui Sun
- Department of Gynecology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu, China
| | - Wenjun Cheng
- Department of Gynecology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, Jiangsu, China.
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12
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Zhao Q, Laverdure JP, Lanoix J, Durette C, Côté C, Bonneil É, Laumont CM, Gendron P, Vincent K, Courcelles M, Lemieux S, Millar DG, Ohashi PS, Thibault P, Perreault C. Proteogenomics Uncovers a Vast Repertoire of Shared Tumor-Specific Antigens in Ovarian Cancer. Cancer Immunol Res 2020; 8:544-555. [PMID: 32047025 DOI: 10.1158/2326-6066.cir-19-0541] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/03/2019] [Accepted: 02/07/2020] [Indexed: 11/16/2022]
Abstract
High-grade serous ovarian cancer (HGSC), the principal cause of death from gynecologic malignancies in the world, has not significantly benefited from advances in cancer immunotherapy. Although HGSC infiltration by lymphocytes correlates with superior survival, the nature of antigens that can elicit anti-HGSC immune responses is unknown. The goal of this study was to establish the global landscape of HGSC tumor-specific antigens (TSA) using a mass spectrometry pipeline that interrogated all reading frames of all genomic regions. In 23 HGSC tumors, we identified 103 TSAs. Classic TSA discovery approaches focusing only on mutated exonic sequences would have uncovered only three of these TSAs. Other mutated TSAs resulted from out-of-frame exonic translation (n = 2) or from noncoding sequences (n = 7). One group of TSAs (n = 91) derived from aberrantly expressed unmutated genomic sequences, which were not expressed in normal tissues. These aberrantly expressed TSAs (aeTSA) originated primarily from nonexonic sequences, in particular intronic (29%) and intergenic (22%) sequences. Their expression was regulated at the transcriptional level by variations in gene copy number and DNA methylation. Although mutated TSAs were unique to individual tumors, aeTSAs were shared by a large proportion of HGSCs. Taking into account the frequency of aeTSA expression and HLA allele frequencies, we calculated that, in Caucasians, the median number of aeTSAs per tumor would be five. We conclude that, in view of their number and the fact that they are shared by many tumors, aeTSAs may be the most attractive targets for HGSC immunotherapy.
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Affiliation(s)
- Qingchuan Zhao
- Institute for Research in Immunology and Cancer, Université de Montréal, Montreal, Quebec, Canada.,Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Jean-Philippe Laverdure
- Institute for Research in Immunology and Cancer, Université de Montréal, Montreal, Quebec, Canada
| | - Joël Lanoix
- Institute for Research in Immunology and Cancer, Université de Montréal, Montreal, Quebec, Canada
| | - Chantal Durette
- Institute for Research in Immunology and Cancer, Université de Montréal, Montreal, Quebec, Canada
| | - Caroline Côté
- Institute for Research in Immunology and Cancer, Université de Montréal, Montreal, Quebec, Canada
| | - Éric Bonneil
- Institute for Research in Immunology and Cancer, Université de Montréal, Montreal, Quebec, Canada
| | - Céline M Laumont
- Institute for Research in Immunology and Cancer, Université de Montréal, Montreal, Quebec, Canada.,Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Patrick Gendron
- Institute for Research in Immunology and Cancer, Université de Montréal, Montreal, Quebec, Canada
| | - Krystel Vincent
- Institute for Research in Immunology and Cancer, Université de Montréal, Montreal, Quebec, Canada
| | - Mathieu Courcelles
- Institute for Research in Immunology and Cancer, Université de Montréal, Montreal, Quebec, Canada
| | - Sébastien Lemieux
- Institute for Research in Immunology and Cancer, Université de Montréal, Montreal, Quebec, Canada.,Department of Computer Science and Operations Research, Université de Montréal, Montreal, Quebec, Canada
| | - Douglas G Millar
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Pamela S Ohashi
- Campbell Family Institute for Breast Cancer Research, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Department of Medical Biophysics and Immunology, University of Toronto, Toronto, Ontario, Canada
| | - Pierre Thibault
- Institute for Research in Immunology and Cancer, Université de Montréal, Montreal, Quebec, Canada. .,Department of Chemistry, Université de Montréal, Montreal, Quebec, Canada
| | - Claude Perreault
- Institute for Research in Immunology and Cancer, Université de Montréal, Montreal, Quebec, Canada. .,Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
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13
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CAR T Cells Targeting MISIIR for the Treatment of Ovarian Cancer and Other Gynecologic Malignancies. Mol Ther 2019; 28:548-560. [PMID: 31870622 DOI: 10.1016/j.ymthe.2019.11.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 11/22/2019] [Accepted: 11/29/2019] [Indexed: 01/20/2023] Open
Abstract
The prognosis of patients diagnosed with advanced ovarian or endometrial cancer remains poor, and effective therapeutic strategies are limited. The Müllerian inhibiting substance type 2 receptor (MISIIR) is a transforming growth factor β (TGF-β) receptor family member, overexpressed by most ovarian and endometrial cancers while absent in most normal tissues. Restricted tissue expression, coupled with an understanding that MISIIR ligation transmits apoptotic signals to cancer cells, makes MISIIR an attractive target for tumor-directed therapeutics. However, the development of clinical MISIIR-targeted agents has been challenging. Prompted by the responses achieved in patients with blood malignancies using chimeric antigen receptor (CAR) T cell therapy, we hypothesized that MISIIR targeting may be achieved using a CAR T cell approach. Herein, we describe the development and evaluation of a CAR that targets MISIIR. T cells expressing the MISIIR-specific CAR demonstrated antigen-specific reactivity in vitro and eliminated MISIIR-overexpressing tumors in vivo. MISIIR CAR T cells also recognized a panel of human ovarian and endometrial cancer cell lines, and they lysed a battery of patient-derived tumor specimens in vitro, without mediating cytotoxicity of a panel of normal primary human cells. In conclusion, these results indicate that MISIIR targeting for the treatment of ovarian cancer and other gynecologic malignancies is achievable using CAR technology.
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14
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Bast RC, Matulonis UA, Sood AK, Ahmed AA, Amobi AE, Balkwill FR, Wielgos-Bonvallet M, Bowtell DDL, Brenton JD, Brugge JS, Coleman RL, Draetta GF, Doberstein K, Drapkin RI, Eckert MA, Edwards RP, Elias KM, Ennis D, Futreal A, Gershenson DM, Greenberg RA, Huntsman DG, Ji JXY, Kohn EC, Iavarone C, Lengyel ER, Levine DA, Lord CJ, Lu Z, Mills GB, Modugno F, Nelson BH, Odunsi K, Pilsworth JA, Rottapel RK, Powell DJ, Shen L, Shih LM, Spriggs DR, Walton J, Zhang K, Zhang R, Zou L. Critical questions in ovarian cancer research and treatment: Report of an American Association for Cancer Research Special Conference. Cancer 2019; 125:1963-1972. [PMID: 30835824 PMCID: PMC6557260 DOI: 10.1002/cncr.32004] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 12/17/2018] [Accepted: 12/19/2018] [Indexed: 12/24/2022]
Abstract
Substantial progress has been made in understanding ovarian cancer at the molecular and cellular level. Significant improvement in 5-year survival has been achieved through cytoreductive surgery, combination platinum-based chemotherapy, and more effective treatment of recurrent cancer, and there are now more than 280,000 ovarian cancer survivors in the United States. Despite these advances, long-term survival in late-stage disease has improved little over the last 4 decades. Poor outcomes relate, in part, to late stage at initial diagnosis, intrinsic drug resistance, and the persistence of dormant drug-resistant cancer cells after primary surgery and chemotherapy. Our ability to accelerate progress in the clinic will depend on the ability to answer several critical questions regarding this disease. To assess current answers, an American Association for Cancer Research Special Conference on "Critical Questions in Ovarian Cancer Research and Treatment" was held in Pittsburgh, Pennsylvania, on October 1-3, 2017. Although clinical, translational, and basic investigators conducted much of the discussion, advocates participated in the meeting, and many presentations were directly relevant to patient care, including treatment with poly adenosine diphosphate ribose polymerase (PARP) inhibitors, attempts to improve immunotherapy by overcoming the immune suppressive effects of the microenvironment, and a better understanding of the heterogeneity of the disease.
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Affiliation(s)
- Robert C. Bast
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Anil K. Sood
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Andrew Futreal
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | | | | | | | | | - Zhen Lu
- University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Brad H. Nelson
- University of British Columbia, Canada
- BC Cancer Agency, Canada
| | | | | | | | | | - Li Shen
- Roswell Park Cancer Institute, Buffalo, NY
| | - le-Ming Shih
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | | | | | - Lee Zou
- Massachusetts General Hospital, Boston, MD
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15
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Ovarian Cancer Immunotherapy: Turning up the Heat. Int J Mol Sci 2019; 20:ijms20122927. [PMID: 31208030 PMCID: PMC6628106 DOI: 10.3390/ijms20122927] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 06/11/2019] [Accepted: 06/13/2019] [Indexed: 12/20/2022] Open
Abstract
Epithelial ovarian cancer (EOC) is the leading cause of death among gynecological malignancies. Despite surgery and chemotherapy, 5-years survival rates have improved only modestly over the past few decades remaining at 45% for advanced stages. Therefore, novel therapies are urgently needed. The presence of tumor-infiltrating lymphocytes (TILs) in OC tumor microenvironment (TME) has already proved to be correlated with overall survival (OS), while immune evasion mechanisms are associated with poor prognosis. Although these data indicate that immunotherapy has a strong rationale in OC, single agent immune-checkpoints inhibitors (ICIs) have shown only modest results in this malignancy. In this review, we will discuss immune-targeting combination therapies and adoptive cell therapy (ACT), highlighting the challenges represented by these strategies, which aim at disrupting the stroma-tumor barrier to boost immune system against ovarian cancer.
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16
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Ovarian Cancer Stem Cells with High ROR1 Expression Serve as a New Prophylactic Vaccine for Ovarian Cancer. J Immunol Res 2019; 2019:9394615. [PMID: 31008116 PMCID: PMC6441513 DOI: 10.1155/2019/9394615] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 11/25/2018] [Accepted: 01/20/2019] [Indexed: 01/16/2023] Open
Abstract
Tumor vaccines offer a number of advantages for cancer treatment. In the study, the vaccination with cancer stem cells (CSCs) with high expression of the type I receptor tyrosine kinase-like orphan receptor (ROR1) was evaluated in a murine model for the vaccine's immunogenicity and protective efficacy against epithelial ovarian carcinoma (EOC). CD117+CD44+ CSCs were isolated from human EOC HO8910 cell line using a magnetic-activated cell sorting system; murine ID8 EOC suspension sphere cells, which are collectively known as cancer stem-like cells, were acquired from serum-free suspension sphere-forming culture. Mice were subcutaneously immunized with the repeat cycles of freezing and thawing whole HO8910 CD117+CD44+ CSCs and ID8 cancer stem-like cells, respectively, followed by a challenge with HO8910 or ID8 cells at one week after final vaccination. The results showed that the CSC vaccination significantly induced immunity against EOC growth and markedly prolonged the survival of EOC-bearing mice in the prophylactic setting compared with non-CSC vaccination. Flow cytometry showed significantly increased immunocyte cytotoxicities and remarkably reduced CSC counts in the CSC-vaccinated mice. Moreover, the protective efficacy against EOC was decreased when the ROR1 expression was downregulated by shRNA in CSC vaccines. The findings from the study suggest that CSC vaccines with high ROR1 expression were highly effective in triggering immunity against EOC in vaccinated mice and may serve as an effective vaccine for EOC immunoprophylaxis.
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17
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Kim G, Bhattarai PY, Choi HS. Peptidyl-prolyl cis/trans isomerase NIMA-interacting 1 as a molecular target in breast cancer: a therapeutic perspective of gynecological cancer. Arch Pharm Res 2019; 42:128-139. [PMID: 30684192 DOI: 10.1007/s12272-019-01122-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Accepted: 01/16/2019] [Indexed: 12/11/2022]
Abstract
Peptidyl-prolyl cis/trans isomerase NIMA-interacting 1 (PIN1) induces conformational and functional changes to numerous key signaling molecules following proline-directed phosphorylation and its deregulation contributes to disease, particularly cancer. PIN1 is overexpressed in breast cancer, promoting cell proliferation and transformation in collaboration with several oncogenic signaling pathways, and is correlated with a poor clinical outcome. PIN1 level is also increased in certain gynecological cancers such as cervical, ovarian, and endometrial cancers. Although women with breast cancer are at risk of developing a second primary gynecological malignancy, particularly of the endometrium and ovary, the common oncogenic signaling pathway mediated by PIN1 has not been noted to date. This review discusses the roles of PIN1 in breast tumorigenesis and gynecological cancer progression, as well as the clinical effect of targeting this enzyme in breast and gynecological cancers.
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Affiliation(s)
- Garam Kim
- College of Pharmacy, Chosun University, 309 Philmundaero, Dong-gu, Gwangju, 61452, Republic of Korea
| | - Poshan Yugal Bhattarai
- College of Pharmacy, Chosun University, 309 Philmundaero, Dong-gu, Gwangju, 61452, Republic of Korea
| | - Hong Seok Choi
- College of Pharmacy, Chosun University, 309 Philmundaero, Dong-gu, Gwangju, 61452, Republic of Korea.
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18
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Fan CA, Reader J, Roque DM. Review of Immune Therapies Targeting Ovarian Cancer. Curr Treat Options Oncol 2018. [PMID: 30430276 DOI: 10.1007/s11864-018-0584-3]+[] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
OPINION STATEMENT The rise of immunotherapy is the greatest advance in oncology to occur over the last several years, but applications in gynecologic malignancies lag behind other tumors. The term "immunotherapy" envelops monoclonal antibodies as receptor mediators, including immune checkpoint inhibitors (ICPI), cancer vaccines, and adoptive immunotherapies alone or in combination with other therapeutic approaches. The purpose of this review is to summarize the status of immunotherapy trials in ovarian cancer and to specifically highlight data published in the last 1-2 years.
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Affiliation(s)
- Cong Ava Fan
- Division of Gynecologic Oncology, Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland-Baltimore, 22 S. Greene Street S3AX31, Baltimore, MD, 21201, USA
| | - Jocelyn Reader
- Division of Gynecologic Oncology, Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland-Baltimore, 22 S. Greene Street S3AX31, Baltimore, MD, 21201, USA
| | - Dana M Roque
- Division of Gynecologic Oncology, Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland-Baltimore, 22 S. Greene Street S3AX31, Baltimore, MD, 21201, USA.
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19
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Abstract
OPINION STATEMENT The rise of immunotherapy is the greatest advance in oncology to occur over the last several years, but applications in gynecologic malignancies lag behind other tumors. The term "immunotherapy" envelops monoclonal antibodies as receptor mediators, including immune checkpoint inhibitors (ICPI), cancer vaccines, and adoptive immunotherapies alone or in combination with other therapeutic approaches. The purpose of this review is to summarize the status of immunotherapy trials in ovarian cancer and to specifically highlight data published in the last 1-2 years.
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20
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Abstract
OPINION STATEMENT The rise of immunotherapy is the greatest advance in oncology to occur over the last several years, but applications in gynecologic malignancies lag behind other tumors. The term "immunotherapy" envelops monoclonal antibodies as receptor mediators, including immune checkpoint inhibitors (ICPI), cancer vaccines, and adoptive immunotherapies alone or in combination with other therapeutic approaches. The purpose of this review is to summarize the status of immunotherapy trials in ovarian cancer and to specifically highlight data published in the last 1-2 years.
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Nair D, Rådestad E, Khalkar P, Diaz-Argelich N, Schröder A, Klynning C, Ungerstedt J, Uhlin M, Fernandes AP. Methylseleninic Acid Sensitizes Ovarian Cancer Cells to T-Cell Mediated Killing by Decreasing PDL1 and VEGF Levels. Front Oncol 2018; 8:407. [PMID: 30324091 PMCID: PMC6172341 DOI: 10.3389/fonc.2018.00407] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 09/06/2018] [Indexed: 12/14/2022] Open
Abstract
Redox active selenium (Se) compounds at sub toxic doses act as pro-oxidants with cytotoxic effects on tumor cells and are promising future chemotherapeutic agents. However, little is known about how Se compounds affect immune cells in the tumor microenvironment. We demonstrate that the inorganic Se compound selenite and the organic methylseleninic acid (MSA) do not, despite their pro-oxidant function, influence the viability of immune cells, at doses that gives cytotoxic effects in ovarian cancer cell lines. Treatment of the ovarian cancer cell line A2780 with selenite and MSA increases NK cell mediated lysis, and enhances the cytolytic activity of T cells. Increased T cell function was observed after incubation of T cells in preconditioned media from tumor cells treated with MSA, an effect that was coupled to decreased levels of PDL1, HIF-1α, and VEGF. In conclusion, redox active selenium compounds do not kill or inactivate immune cells at doses required for anti-cancer treatment, and we demonstrate that MSA enhances T cell-mediated tumor cell killing via PDL1 and VEGF inhibition.
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Affiliation(s)
- Deepika Nair
- Department of Medicine Huddinge, Center for Hematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Sweden.,Division of Biochemistry, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Emelie Rådestad
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Prajakta Khalkar
- Division of Biochemistry, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Nuria Diaz-Argelich
- Division of Biochemistry, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden.,Department of Organic and Pharmaceutical Chemistry, University of Navarra, Pamplona, Spain
| | - Axel Schröder
- Division of Biochemistry, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Charlotte Klynning
- Department of Gynecological Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Johanna Ungerstedt
- Department of Medicine Huddinge, Center for Hematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Sweden.,Hematology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Uhlin
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Applied Physics, Royal Institute of Technology, Stockholm, Sweden.,Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Aristi P Fernandes
- Division of Biochemistry, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
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22
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Gao Q, Xiang SD, Wilson K, Madondo M, Stephens AN, Plebanski M. Sperm Protein 17 Expression by Murine Epithelial Ovarian Cancer Cells and Its Impact on Tumor Progression. Cancers (Basel) 2018; 10:cancers10080276. [PMID: 30127274 PMCID: PMC6115966 DOI: 10.3390/cancers10080276] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 12/12/2022] Open
Abstract
The cancer testis antigen sperm protein 17 (Sp17) is a promising antigenic target in epithelial ovarian cancer (EOC) vaccine development. However, its role in ovarian cancer is unclear. We isolated and expanded Sp17+ and Sp17− clones from the murine EOC cell line ID8, and compared their in-vitro cell growth characteristics and in-vivo tumorigenicity. We also examined the potential co-expression of molecules that may influence cancer cell survival and interaction with immune cells. These include stimulatory and immunosuppressive molecules, such as major histocompatibility class I molecules (MHC I), MHC II, cytotoxic T lymphocyte associated antigen-4 (CTLA-4), CD73, CD39, tumor necrosis factor receptor II (TNFRII), signal transducer and activator of transcription 3 (STAT3) and programmed death-ligand 1 (PD-L1). Whilst the presence of Sp17 was not correlated with the ID8 cell proliferation/growth capacity in vitro, it was critical to enable progressive tumor formation in vivo. Flow cytometry revealed that Sp17+ ID8 cells displayed higher expression of both STAT3 and PD-L1, whilst MHC II expression was lower. Moreover, Sp17high (PD-L1+MHCII−) cell populations showed significantly enhanced resistance to Paclitaxel-induced cell death in vitro compared to Sp17low (PD-L1−MHCII+) cells, which was associated in turn with increased STAT3 expression. Together, the data support Sp17 as a factor associated with in-vivo tumor progression and chemo-resistance, validating it as a suitable target for vaccine development.
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Affiliation(s)
- Qian Gao
- Department of Immunology and Pathology, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria 3004, Australia.
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha 410008, China.
| | - Sue D Xiang
- Department of Immunology and Pathology, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria 3004, Australia.
- Centre for Cancer Research, Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia.
- Department of Molecular and Translational Sciences, Monash University, Clayton, Victoria 3168, Australia.
| | - Kirsty Wilson
- Department of Immunology and Pathology, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria 3004, Australia.
| | - Mutsa Madondo
- Department of Immunology and Pathology, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria 3004, Australia.
| | - Andrew N Stephens
- Centre for Cancer Research, Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia.
- Department of Molecular and Translational Sciences, Monash University, Clayton, Victoria 3168, Australia.
| | - Magdalena Plebanski
- Department of Immunology and Pathology, Central Clinical School, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria 3004, Australia.
- School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria 3083, Australia.
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23
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Matsuda T, Leisegang M, Park JH, Ren L, Kato T, Ikeda Y, Harada M, Kiyotani K, Lengyel E, Fleming GF, Nakamura Y. Induction of Neoantigen-Specific Cytotoxic T Cells and Construction of T-cell Receptor–Engineered T Cells for Ovarian Cancer. Clin Cancer Res 2018; 24:5357-5367. [DOI: 10.1158/1078-0432.ccr-18-0142] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/31/2018] [Accepted: 04/30/2018] [Indexed: 01/26/2023]
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24
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Sensitive and frequent identification of high avidity neo-epitope specific CD8 + T cells in immunotherapy-naive ovarian cancer. Nat Commun 2018; 9:1092. [PMID: 29545564 PMCID: PMC5854609 DOI: 10.1038/s41467-018-03301-0] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 02/05/2018] [Indexed: 12/23/2022] Open
Abstract
Immunotherapy directed against private tumor neo-antigens derived from non-synonymous somatic mutations is a promising strategy of personalized cancer immunotherapy. However, feasibility in low mutational load tumor types remains unknown. Comprehensive and deep analysis of circulating and tumor-infiltrating lymphocytes (TILs) for neo-epitope specific CD8+ T cells has allowed prompt identification of oligoclonal and polyfunctional such cells from most immunotherapy-naive patients with advanced epithelial ovarian cancer studied. Neo-epitope recognition is discordant between circulating T cells and TILs, and is more likely to be found among TILs, which display higher functional avidity and unique TCRs with higher predicted affinity than their blood counterparts. Our results imply that identification of neo-epitope specific CD8+ T cells is achievable even in tumors with relatively low number of somatic mutations, and neo-epitope validation in TILs extends opportunities for mutanome-based personalized immunotherapies to such tumors.
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25
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Nelson BH, Jazaeri AA. Immunotherapy for gynecological cancers: opportunities abound. Gynecol Oncol 2017; 145:411-412. [DOI: 10.1016/j.ygyno.2017.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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