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Nanajian A, Scott M, Burcus NI, Ruedlinger BL, Oshin EA, Beebe SJ, Guo S. Nano-Pulse Treatment Overcomes the Immunosuppressive Tumor Microenvironment to Elicit In Situ Vaccination Protection against Breast Cancer. Vaccines (Basel) 2024; 12:633. [PMID: 38932362 PMCID: PMC11209453 DOI: 10.3390/vaccines12060633] [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: 04/29/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024] Open
Abstract
We previously reported that nano-pulse treatment (NPT), a pulsed power technology, resulted in 4T1-luc mammary tumor elimination and a strong in situ vaccination, thereby completely protecting tumor-free animals against a second live tumor challenge. The mechanism whereby NPT mounts effective antitumor immune responses in the 4T1 breast cancer predominantly immunosuppressive tumor microenvironment (TME) remains unanswered. In this study, orthotopic 4T1 mouse breast tumors were treated with NPT (100 ns, 50 kV/cm, 1000 pulses, 3 Hz). Blood, spleen, draining lymph nodes, and tumors were harvested at 4-h, 8-h, 1-day, 3-day, 7-day, and 3-month post-treatment intervals for the analysis of frequencies, death, and functional markers of various immune cells in addition to the suppressor function of regulatory T cells (Tregs). NPT was verified to elicit strong in situ vaccination (ISV) against breast cancer and promote both acute and long-term T cell memory. NPT abolished immunosuppressive dominance systemically and in the TME by substantially reducing Tregs, myeloid-derived suppressor cells (MDSCs), and tumor-associated macrophages (TAMs). NPT induced apoptosis in Tregs and TAMs. It also functionally diminished the Treg suppression capacity, explained by the downregulation of activation markers, particularly 4-1BB and TGFβ, and a phenotypic shift from predominantly activated (CD44+CD62L-) to naïve (CD44-CD62L+) Tregs. Importantly, NPT selectively induced apoptosis in activated Tregs and spared effector CD4+ and CD8+ T cells. These changes were followed by a concomitant rise in CD8+CD103+ tissue-resident memory T cells and TAM M1 polarization. These findings indicate that NPT effectively switches the TME and secondary lymphatic systems from an immunosuppressive to an immunostimulatory state, allowing cytotoxic T cell function and immune memory formation to eliminate cancer cells and account for the NPT in situ vaccination.
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Affiliation(s)
- Anthony Nanajian
- Frank Reidy Research Center for Bioelectrics, Old Dominion University, Norfolk, VA 23508, USA; (A.N.); (M.S.); (N.I.B.); (B.L.R.); (E.A.O.); (S.J.B.)
- Department of Biological Sciences, Old Dominion University, Norfolk, VA 23529, USA
| | - Megan Scott
- Frank Reidy Research Center for Bioelectrics, Old Dominion University, Norfolk, VA 23508, USA; (A.N.); (M.S.); (N.I.B.); (B.L.R.); (E.A.O.); (S.J.B.)
| | - Niculina I. Burcus
- Frank Reidy Research Center for Bioelectrics, Old Dominion University, Norfolk, VA 23508, USA; (A.N.); (M.S.); (N.I.B.); (B.L.R.); (E.A.O.); (S.J.B.)
| | - Brittney L. Ruedlinger
- Frank Reidy Research Center for Bioelectrics, Old Dominion University, Norfolk, VA 23508, USA; (A.N.); (M.S.); (N.I.B.); (B.L.R.); (E.A.O.); (S.J.B.)
| | - Edwin A. Oshin
- Frank Reidy Research Center for Bioelectrics, Old Dominion University, Norfolk, VA 23508, USA; (A.N.); (M.S.); (N.I.B.); (B.L.R.); (E.A.O.); (S.J.B.)
- Department of Electrical & Computer Engineering, Old Dominion University, Norfolk, VA 23529, USA
| | - Stephen J. Beebe
- Frank Reidy Research Center for Bioelectrics, Old Dominion University, Norfolk, VA 23508, USA; (A.N.); (M.S.); (N.I.B.); (B.L.R.); (E.A.O.); (S.J.B.)
| | - Siqi Guo
- Frank Reidy Research Center for Bioelectrics, Old Dominion University, Norfolk, VA 23508, USA; (A.N.); (M.S.); (N.I.B.); (B.L.R.); (E.A.O.); (S.J.B.)
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2
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Aldahlawi A, Basingab F, Alrahimi J, Zaher K, Pushparaj PN, Hassan MA, Al-Sakkaf K. Herpesvirus entry mediator as a potential biomarker in breast cancer compared with conventional cytotoxic T‑lymphocyte‑associated antigen 4. Biomed Rep 2023; 19:56. [PMID: 37560313 PMCID: PMC10407466 DOI: 10.3892/br.2023.1638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 03/17/2023] [Indexed: 08/11/2023] Open
Abstract
Breast cancer (BC) is the most common cancer in women worldwide, with 2.3 million cases recorded in 2020. Despite improvements in cancer treatment, patients with BC still succumb to the disease, due to regional and distant metastases when diagnosed at later stages. Several immune checkpoint inhibitors have been approved for BC treatment, based on their expression and role in maintaining immunosurveillance against tumors. The present study aimed to evaluate the expression of 12 immune checkpoints in patients with BC, and assess their role as diagnostic and therapeutic markers. Expression levels were measured using reverse transcription-quantitative polymerase chain reaction. Among the 12 immune markers, herpesvirus entry mediator (HVEM) was found to be significantly upregulated in patients with malignant BC compared to non-malignant controls, with a relative fold change (FC) of 1.46 and P=0.012. A similar finding was observed for cytotoxic T-lymphocyte-associated antigen 4 (CTLA4; FC=1.47 and P=0.035). In addition, receiver operating characteristic curve analysis revealed that HVEM expression allowed significant differentiation between groups, with an area under the curve of 0.74 (P=0.013). Upregulation in both HVEM and CTLA4 was revealed to be significantly associated with the human epidermal growth factor receptor-2 (HER2)-enriched phenotype (FC=3.53, P=0.009 and FC=5.98, P=0.002, respectively), while only HVEM was significantly associated with the triple-negative phenotype (FC=2.07, P=0.016). Furthermore, HVEM was significantly higher in patients with grade III tumors (FC=1.88, P=0.025) and negative vascular invasion (FC=1.67, P=0.046) compared with non-malignant controls. Serum protein levels were assessed by multiplex immunoassay, and a significant increase in HVEM was detected in patients with malignant BC compared with that in non-malignant controls (P=0.035). These data indicated that HVEM may serve as a potential biomarker and target for immunotherapy, especially for certain types of BC.
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Affiliation(s)
- Alia Aldahlawi
- Department of Biological Sciences, Faculty of Sciences, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Immunology Unit, King Fahad for Medical Research, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Fatemah Basingab
- Department of Biological Sciences, Faculty of Sciences, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Immunology Unit, King Fahad for Medical Research, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Jehan Alrahimi
- Department of Biological Sciences, Faculty of Sciences, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Immunology Unit, King Fahad for Medical Research, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Kawther Zaher
- Immunology Unit, King Fahad for Medical Research, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Peter Natesan Pushparaj
- Center of Excellence in Genomic Medicine Research, King Fahad for Medical Research, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Center for Transdisciplinary Research, Department of Pharmacology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Chennai, India
| | - Mohammed A. Hassan
- Department of Medical Basic Sciences, College of Medicine and Health Sciences, Hadhramout University, Mukalla 50511, Republic of Yemen
- Department of Biochemistry, Faculty of Science, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Kaltoom Al-Sakkaf
- Immunology Unit, King Fahad for Medical Research, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah 21589, Saudi Arabia
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Alharbi B, Qanash H, Binsaleh NK, Alharthi S, Elasbali AM, Gharekhan CH, Mahmoud M, Lioudakis E, O'Leary JJ, Doherty DG, Mohamed BM, Gray SG. Proof of concept nanotechnological approach to in vitro targeting of malignant melanoma for enhanced immune checkpoint inhibition. Sci Rep 2023; 13:7462. [PMID: 37156818 PMCID: PMC10167246 DOI: 10.1038/s41598-023-34638-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/04/2023] [Indexed: 05/10/2023] Open
Abstract
Immunotherapies, including immune checkpoint inhibitors, have limitations in their effective treatment of malignancies. The immunosuppressive environment associated with the tumor microenvironment may prevent the achievement of optimal outcomes for immune checkpoint inhibitors alone, and nanotechnology-based platforms for delivery of immunotherapeutic agents are increasingly being investigated for their potential to improve the efficacy of immune checkpoint blockade therapy. In this manuscript, nanoparticles were designed with appropriate size and surface characteristics to enhance their retention of payload so that they can transmit their loaded drugs to the tumor. We aimed to enhance immune cell stimulation by a small molecule inhibitor of PD-1/PD-L1 (BMS202) using nanodiamonds (ND). Melanoma cells with different disease stages were exposed to bare NDs, BMS202-NDs or BMS202 alone for 6 h. Following this, melanoma cells were co-cultured with freshly isolated human peripheral blood mononuclear cells (hPBMCs). The effects of this treatment combination on melanoma cells were examined on several biological parameters including cell viability, cell membrane damage, lysosomal mass/pH changes and expression of γHA2X, and caspase 3. Exposing melanoma cells to BMS202-NDs led to a stronger than normal interaction between the hPBMCs and the melanoma cells, with significant anti-proliferative effects. We therefore conclude that melanoma therapy has the potential to be enhanced by non-classical T-cell Immune responses via immune checkpoint inhibitors delivered by nanodiamonds-based nanoparticles.
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Affiliation(s)
- Bandar Alharbi
- Department of Medical Laboratory Science, College of Applied Medical Sciences, University of Ha'il, Hail, 55476, Saudi Arabia
| | - Husam Qanash
- Department of Medical Laboratory Science, College of Applied Medical Sciences, University of Ha'il, Hail, 55476, Saudi Arabia.
| | - Naif K Binsaleh
- Department of Medical Laboratory Science, College of Applied Medical Sciences, University of Ha'il, Hail, 55476, Saudi Arabia
| | - Salem Alharthi
- Department of Biological Science, College of Arts and Science, Najran University, Najran, 55461, Saudi Arabia
| | - Abdulbaset M Elasbali
- Clinical Laboratory Science, College of Applied Medical Sciences-Qurayyat, Jouf University, Sakaka, 42421, Saudi Arabia
| | - Chandranil H Gharekhan
- Amrita Center for Nanosciences and Molecular Medicine, Amrita Vishwa Vidyapeetham, Cochin, India
| | | | - Emmanouil Lioudakis
- Department of Pharmacology and Therapeutics, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - John J O'Leary
- Department of Histopathology, Trinity College Dublin, Emer Casey Molecular Pathology Research Laboratory, Coombe Women and Infants University Hospital, Dublin, Ireland
- Trinity St James's Cancer Institute, Dublin, Ireland
- Department of Obstetrics and Gynaecology, Trinity College Dublin, Dublin, Ireland
| | - Derek G Doherty
- Trinity St James's Cancer Institute, Dublin, Ireland
- Department of Immunology, Trinity College Dublin, Dublin, Ireland
| | - Bashir M Mohamed
- Trinity St James's Cancer Institute, Dublin, Ireland.
- Department of Obstetrics and Gynaecology, Trinity College Dublin, Dublin, Ireland.
- Department of Immunology, Trinity College Dublin, Dublin, Ireland.
| | - Steven G Gray
- Trinity St James's Cancer Institute, Dublin, Ireland
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
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Cao C, Lu X, Guo X, Zhao H, Gao Y. Patient-derived models: Promising tools for accelerating the clinical translation of breast cancer research findings. Exp Cell Res 2023; 425:113538. [PMID: 36871856 DOI: 10.1016/j.yexcr.2023.113538] [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: 12/12/2022] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/06/2023]
Abstract
Breast cancer has become the highest incidence of cancer in women. It was extensively and deeply studied by biologists and medical workers worldwide. However, the meaningful results in lab researches cannot be realized in clinical, and a part of new drugs in clinical experiments do not obtain as good results as the preclinical researches. It is urgently that promote a kind of breast cancer research models that can get study results closer to the physiological condition of the human body. Patient-derived models (PDMs) originating from clinical tumor, contain primary elements of tumor and maintain key clinical features of tumor. So they are promising research models to facilitate laboratory researches translate to clinical application, and predict the treatment outcome of patients. In this review, we summarize the establishment of PDMs of breast cancer, reviewed the application of PDMs in clinical translational researches and personalized precision medicine with breast cancer as an example, to improve the understanding of PDMs among researchers and clinician, facilitate them to use PDMs on a large scale of breast cancer researches and promote the clinical translation of laboratory research and new drug development.
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Affiliation(s)
- Changqing Cao
- Department of General Surgery, The Second Affiliated Hospital of Air Force Medical University, China; State Key Laboratory of Cancer Biology, Biotechnology Center, School of Pharmacy, The Fourth Military Medical University, China
| | - Xiyan Lu
- Department of Outpatient, The Second Affiliated Hospital of Air Force Medical University, China
| | - Xinyan Guo
- State Key Laboratory of Cancer Biology, Biotechnology Center, School of Pharmacy, The Fourth Military Medical University, China
| | - Huadong Zhao
- Department of General Surgery, The Second Affiliated Hospital of Air Force Medical University, China.
| | - Yuan Gao
- State Key Laboratory of Cancer Biology, Biotechnology Center, School of Pharmacy, The Fourth Military Medical University, China.
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Barnestein R, Galland L, Kalfeist L, Ghiringhelli F, Ladoire S, Limagne E. Immunosuppressive tumor microenvironment modulation by chemotherapies and targeted therapies to enhance immunotherapy effectiveness. Oncoimmunology 2022; 11:2120676. [PMID: 36117524 PMCID: PMC9481153 DOI: 10.1080/2162402x.2022.2120676] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
With the rapid clinical development of immune checkpoint inhibitors (ICIs), the standard of care in cancer management has evolved rapidly. However, immunotherapy is not currently beneficial for all patients. In addition to intrinsic tumor factors, other etiologies of resistance to ICIs arise from the complex interplay between cancer and its microenvironment. Recognition of the essential role of the tumor microenvironment (TME) in cancer progression has led to a shift from a tumor-cell-centered view of cancer development, to the concept of a complex tumor ecosystem that supports tumor growth and metastatic dissemination. The expansion of immunosuppressive cells represents a cardinal strategy deployed by tumor cells to escape detection and elimination by the immune system. Regulatory T lymphocytes (Treg), myeloid-derived suppressor cells (MDSCs), and type-2 tumor-associated macrophages (TAM2) are major components of these inhibitory cellular networks, with the ability to suppress innate and adaptive anticancer immunity. They therefore represent major impediments to anticancer therapies, particularly immune-based interventions. Recent work has provided evidence that, beyond their direct cytotoxic effects on cancer cells, several conventional chemotherapeutic (CT) drugs and agents used in targeted therapies (TT) can promote the elimination or inactivation of suppressive immune cells, resulting in enhanced antitumor immunity. In this review, we will analyze findings pertaining to this concept, discuss the possible molecular bases underlying the selective targeting of these immunosuppressive cells by antineoplastic agents (CT and/or TT), and consider current challenges and future prospects related to the integration of these molecules into more efficient anticancer strategies, in the era of immunotherapy.
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Affiliation(s)
- Robby Barnestein
- University of Burgundy, Dijon, France
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center, Dijon, France
| | - Loïck Galland
- University of Burgundy, Dijon, France
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center, Dijon, France
- Department of Medical Oncology, Georges François Leclerc Center, Dijon, France
| | - Laura Kalfeist
- University of Burgundy, Dijon, France
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center, Dijon, France
- Centre de Recherche INSERM LNC-UMR1231, Dijon, France
- Genomic and Immunotherapy Medical Institute, Dijon University Hospital, Dijon, France
| | - François Ghiringhelli
- University of Burgundy, Dijon, France
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center, Dijon, France
- Department of Medical Oncology, Georges François Leclerc Center, Dijon, France
- Centre de Recherche INSERM LNC-UMR1231, Dijon, France
- Genomic and Immunotherapy Medical Institute, Dijon University Hospital, Dijon, France
| | - Sylvain Ladoire
- University of Burgundy, Dijon, France
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center, Dijon, France
- Department of Medical Oncology, Georges François Leclerc Center, Dijon, France
- Centre de Recherche INSERM LNC-UMR1231, Dijon, France
- Genomic and Immunotherapy Medical Institute, Dijon University Hospital, Dijon, France
| | - Emeric Limagne
- University of Burgundy, Dijon, France
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer Center, Dijon, France
- Department of Medical Oncology, Georges François Leclerc Center, Dijon, France
- Centre de Recherche INSERM LNC-UMR1231, Dijon, France
- Genomic and Immunotherapy Medical Institute, Dijon University Hospital, Dijon, France
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Kaneko K, Acharya CR, Nagata H, Yang X, Hartman ZC, Hobeika A, Hughes PF, Haystead TAJ, Morse MA, Lyerly HK, Osada T. Combination of a novel heat shock protein 90-targeted photodynamic therapy with PD-1/PD-L1 blockade induces potent systemic antitumor efficacy and abscopal effect against breast cancers. J Immunother Cancer 2022; 10:jitc-2022-004793. [PMID: 36171008 PMCID: PMC9528636 DOI: 10.1136/jitc-2022-004793] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND We previously demonstrated potent antitumor activity against human breast cancer xenografts using photodynamic therapy (PDT) targeting a novel tumor-specific photosensitizer (HS201), which binds heat shock protein 90 (HS201-PDT). However, induction of systemic antitumor immunity by HS201-PDT alone or by the combination strategy with immune checkpoint blockade has yet to be determined. METHODS Using unilateral and bilateral implantation models of syngeneic breast tumors (E0771, MM3MG-HER2, and JC-HER3) in mice, we assessed whether HS201-PDT could induce local and systemic antitumor immunity. In an attempt to achieve a stronger abscopal effect for distant tumors, the combination strategy with anti-PD-L1 antibody was tested. Tumor-infiltrating leukocytes were analyzed by single cell RNA-sequencing and receptor-ligand interactome analysis to characterize in more detailed the mechanisms of action of the treatment and key signaling pathways involved. RESULTS HS201-PDT demonstrated greater tumor control and survival in immune competent mice than in immunocompromised mice, suggesting the role of induced antitumor immunity; however, survival was modest and an abscopal effect on distant implanted tumor was weak. A combination of HS201-PDT with anti-PD-L1 antibody demonstrated the greatest antigen-specific immune response, tumor growth suppression, prolonged mouse survival time and abscopal effect. The most significant increase of intratumoral, activated CD8+T cells and decrease of exhausted CD8+T cells occurred following combination treatment compared with HS201-PDT monotherapy. Receptor-ligand interactome analysis showed marked enhancement of several pathways, such as CXCL, GALECTIN, GITRL, PECAM1 and NOTCH, associated with CD8+T cell activation in the combination group. Notably, the expression of the CXCR3 gene signature was the highest in the combination group, possibly explaining the enhanced tumor infiltration by T cells. CONCLUSIONS The increased antitumor activity and upregulated CXCR3 gene signature induced by the combination of anti-PD-L1 antibody with HS201-PDT warrants the clinical testing of HS201-PDT combined with PD-1/PD-L1 blockade in patients with breast cancer, and the use of the CXCR3 gene signature as a biomarker.
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Affiliation(s)
- Kensuke Kaneko
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Chaitanya R Acharya
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Hiroshi Nagata
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Xiao Yang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Amy Hobeika
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Philip F Hughes
- Department of Pharmacology and Cancer Biology, Duke University, Durham, North Carolina, USA
| | - Timothy A J Haystead
- Department of Pharmacology and Cancer Biology, Duke University, Durham, North Carolina, USA
| | - Michael A Morse
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Herbert Kim Lyerly
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Takuya Osada
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Targeted Therapeutic Options and Future Perspectives for HER2-Positive Breast Cancer. Cancers (Basel) 2022; 14:cancers14143305. [PMID: 35884366 PMCID: PMC9320771 DOI: 10.3390/cancers14143305] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/01/2022] [Accepted: 07/03/2022] [Indexed: 02/07/2023] Open
Abstract
Simple Summary The development of several antiHuman Epidermal Growth Factor Receptor 2 (HER2) treatments over the last few years has improved the landscape of HER2-positive breast cancer. Despite this, relapse is still the main issue in HER2-positive breast cancer. The reasons for therapeutic failure lie in the heterogeneity of the disease itself, as well as in the drug resistance mechanisms. In this review, we intended to understand the milestones that have had an impact on this disease up to their implementation in clinical practice. In addition, understanding the underlying molecular biology of HER2-positive disease is essential for the optimization and personalization of the different treatment options. For this reason, we focused on two relevant aspects, which are triple-positive disease and the role that modulation of the immune response might play in treatment and prognosis. Abstract Despite the improvement achieved by the introduction of HER2-targeted therapy, up to 25% of early human epidermal growth factor receptor 2-positive (HER2+) breast cancer (BC) patients will relapse. Beyond trastuzumab, other agents approved for early HER2+ BC include the monoclonal antibody pertuzumab, the antibody-drug conjugate (ADC) trastuzumab-emtansine (T-DM1) and the reversible HER2 inhibitor lapatinib. New agents, such as trastuzumab-deruxtecan or tucatinib in combination with capecitabine and trastuzumab, have also shown a significant improvement in the metastatic setting. Other therapeutic strategies to overcome treatment resistance have been explored in HER2+ BC, mainly in HER2+ that also overexpress estrogen receptors (ER+). In ER+ HER2+ patients, target therapies such as phosphoinositide-3-kinase (PI3K) pathway inhibition or cyclin-dependent kinases 4/6 blocking may be effective in controlling downstream of HER2 and many of the cellular pathways associated with resistance to HER2-targeted therapies. Multiple trials have explored these strategies with some promising results, and probably, in the next years conclusive results will succeed. In addition, HER2+ BC is known to be more immunogenic than other BC subgroups, with high variability between tumors. Different immunotherapeutic agents such as HER-2 therapy plus checkpoint inhibitors, or new vaccines approaches have been investigated in this setting, with promising but controversial results obtained to date.
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