Lung cancer vaccination from concept to reality: A critical review of clinical trials and latest advances

Lung cancer is a highly lethal malignancy that poses a significant burden on public health worldwide. There have been numerous therapeutic approaches, among which cancer vaccines have emerged as a promising approach to harnessing the patient's immune system to induce long-lasting anti-tumor immunity. The current study aims to provide an overview of cancer vaccination in the context of lung cancer to establish a clearer landscape for lung cancer treatment. To provide a comprehensive review, we not only gathered the published studies of lung cancer vaccination and discussed their effectiveness and safety profile but also analyzed all the relevant clinical trials registered on www.clinicaltrials.gov until March 2024. We demonstrated all utilized vaccine platforms along with having a glance at novel technologies such as mRNA vaccines. The present review discussed the challenges and shortcomings of lung cancer vaccination, as well as the way they could be managed to pave the way for reaching the most optimized vaccine formulation.

Improving the efficacy of peptide vaccines in cancer immunotherapy

Peptide vaccines have shown great potential in cancer immunotherapy by targeting tumor antigens and activating the patient's immune system to mount a specific response against cancer cells. However, the efficacy of peptide vaccines in inducing a sustained immune response and achieving clinical benefit remains a major challenge. In this review, we discuss the current status of peptide vaccines in cancer immunotherapy and strategies to improve their efficacy. We summarize the recent advancements in the development of peptide vaccines in pre-clinical and clinical settings, including the use of novel adjuvants, neoantigens, nano-delivery systems, and combination therapies. We also highlight the importance of personalized cancer vaccines, which consider the unique genetic and immunological profiles of individual patients. We also discuss the strategies to enhance the immunogenicity of peptide vaccines such as multivalent peptides, conjugated peptides, fusion proteins, and self-assembled peptides. Although, peptide vaccines alone are weak immunogens, combining peptide vaccines with other immunotherapeutic approaches and developing novel approaches such as personalized vaccines can be promising methods to significantly enhance their efficacy and improve the clinical outcomes for cancer patients.

Limitations and opportunities of technologies for the analysis of cell-free DNA in cancer diagnostics

Cell-free DNA (cfDNA) in the circulating blood plasma of patients with cancer contains tumour-derived DNA sequences that can serve as biomarkers for guiding therapy, for the monitoring of drug resistance, and for the early detection of cancers. However, the analysis of cfDNA for clinical diagnostic applications remains challenging because of the low concentrations of cfDNA, and because cfDNA is fragmented into short lengths and is susceptible to chemical damage. Barcodes of unique molecular identifiers have been implemented to overcome the intrinsic errors of next-generation sequencing, which is the prevailing method for highly multiplexed cfDNA analysis. However, a number of methodological and pre-analytical factors limit the clinical sensitivity of the cfDNA-based detection of cancers from liquid biopsies. In this Review, we describe the state-of-the-art technologies for cfDNA analysis, with emphasis on multiplexing strategies, and discuss outstanding biological and technical challenges that, if addressed, would substantially improve cancer diagnostics and patient care.

Immunotherapy in HER2-positive breast cancer: state of the art and future perspectives

Breast cancer (BC) is a complex disease with primary or acquired incurability characteristics in a significant part of patients. Immunotherapeutical agents represent an emerging option for breast cancer treatment, including the human epidermal growth factor 2 positive (HER2+) subtype. The immune system holds the ability to spontaneously implement a defensive response against HER2+ BC cells through complex mechanisms which can be exploited to modulate this response for obtaining a clinical benefit. Initial immune system modulating strategies consisted mostly in vaccine therapies, which are still being investigated and improved. However, the entrance of trastuzumab into the scenery of HER2+ BC treatment was the real game changing event, which embodied a dominant immune-mediated mechanism. More recently, the advent of the immune checkpoint inhibitors has caused a new paradigm shift for immuno-oncology, with promising initial results also for HER2+ BC. Breast cancer has been traditionally considered poorly immunogenic, being characterized by relatively low tumor mutation burden (TMB). Nevertheless, recent evidence has revealed high tumor infiltrating lymphocytes (TILs) and programmed cell death-ligand 1 (PD-L1) expression in a considerable proportion of HER2+ BC patients. This may translate into a higher potential to elicit anti-cancer response and, therefore, wider possibilities for the use and implementation of immunotherapy in this subset of BC patients. We are herein presenting and critically discussing the most representative evidence concerning immunotherapy in HER2+ BC cancer, both singularly and in combination with therapeutic agents acting throughout HER2-block, immune checkpoint inhibition and anti-cancer vaccines. The reader will be also provided with hints concerning potential future projection of the most promising immutherapeutic agents and approaches for the disease of interest.

PRODUCTION OF PURIFIED HUMAN RECOMBINANT ANTIGEN PRAME AND SPECIFIC MONOCLONAL ANTIBODIES

Tumor antigens recognized by CTLs have been identified several years ago and are major targets for creating anticancer vaccines. PRAME is an antigen which is highly expressed in various malignant tumors including melanomas and hematopoietic malignancies such as acute and chronic leukemias (AML, CML). Technology for producing recombinant antigen PRAME is based on creating a bacterial producer strain containing cDNA of human PRAME gene. We have obtained two producers of recombinant PRAME protein and its N-half, the synthesis of the target protein in the producers occurs in the inclusion bodies. The schemes of isolation and purification of soluble proteins have been developed. The protein purity was approximately 95-96%. The monoclonal antibodies raised against truncated recombinant PRAME were used for PRAME protein analysis by Western blot on the various tumor cells. Specific monoclonal antibodies recognized the native PRAME protein in tumor cell lines as well as in tumor samples from patients. Our findings support the suggestion that this recombinant antigen may be further used as a target for diagnostic and therapeutic approaches. The monoclonal antibodies can be used for immunoassays of tumor samples from patients with hematologic malignancies to reveal clinical features and to monitor tumor progression.

MAGE-A3: an immunogenic target used in clinical practice

Melanoma antigen family A, 3 (MAGE-A3) is a cancer-testis antigen whose expression has been demonstrated in a wide array of malignancies including melanoma, brain, breast, lung and ovarian cancer. In addition, its ability to elicit spontaneous humoral and cellular immune responses has been shown in cancer patients. As antigen-specific immune responses can be stimulated by immunization with MAGE-A3, several clinical trials have used MAGE-A3 vaccines to observe clinical responses. The frequent expressions of this antigen in various tumors and its immunogenicity in cancer patients have led to application of this antigen in cancer immunotherapy. However, the results of recent clinical trials indicate that there is a need for research in the vaccine design, adjuvant selection as well as patient selection criteria.

[Immunotherapy in non-small cell lung cancer: inhibition of PD1/PDL1 pathway]

Despite recent advances in targeted therapy of non-small cell lung cancer (NSCLC), many patients do not benefit from these therapies. Inhibition of PD1/PDL1 is an interesting therapeutic target which restores the immune system against tumor cells. PD1 is located on lymphocytes and PDL1 on the antigen presenting cells. PD1 and PDL1 are co-inhibition molecules and their interaction results in immune tolerance against tumor cells. Anti-PD1 and anti-PDL1 antibodies have been developed to restore immune system in solid cancer including NSCLC. In phase I, studies assessing nivolumab, an anti-PD1 antibody, objective responses were observed in 13 to 18% of NSCLC patients failing previous treatment. The data obtained with anti-PDL1 antibodies is similar with objective responses ranging from 6 to 22%. The encouraging results of phase I/II studies must be confirmed in ongoing phase III studies. Anti-PD1 and anti-PDL1 antibodies exposed to new adverse events including auto-immune diseases whose support is not codified. Questions about treatment duration and criteria evaluation are not resolved. These treatments pave the way for immunomodulation in NSCLC treatment.

Systemic and targeted therapies for early-stage lung cancer

BACKGROUND

Even with aggressive surgical treatment, relapse rates remain high for patients with resectable non-small-cell lung cancer (NSCLC). In an effort to improve survival in these patients, numerous clinical trials have evaluated neoadjuvant and adjuvant chemotherapy.

METHODS

The authors reviewed the results of the prospective randomized clinical trials that have established adjuvant chemotherapy as the standard of care for patients with surgically resected NSCLC. In addition, the authors summarize data on predictive and prognostic markers for patients with early-stage NSCLC and discuss novel therapies and clinical trials currently underway in early-stage NSCLC.

RESULTS

Three large randomized clinical trials and two meta-analyses have demonstrated a survival benefit for adjuvant cisplatin-based chemotherapy compared with surgery alone in patients with early-stage NSCLC. As a result, adjuvant cisplatin-based chemotherapy is recommended as the standard of care in these patients. Numerous promising biomarkers and agents have been developed in the metastatic setting and are currently being evaluated in the adjuvant setting.

CONCLUSIONS

While adjuvant chemotherapy has improved survival for patients with early-stage NSCLC, the prognosis for early-stage lung cancer remains poor. Incorporation of molecular markers and targeted therapies into the management of patients with advanced NSCLC has improved outcomes. Development of these strategies in the adjuvant setting offers the potential to increase cure rates in patients with early-stage NSCLC.

Therapeutic cancer vaccines: a long and winding road to success

Harnessing the immune system to achieve therapeutic efficacy in cancer has been a milestone in immuno-oncology. Tumor-induced suppression works as an obstacle for the effectiveness of immunotherapies. Advances in our understanding of the interrelationship between cancer immunoediting and immunotherapy led to successful manipulation of anticancer immunity; this provided the platform for combining cancer vaccines with chemotherapies counteracting, to some extent, tumor-induced suppressive entities and demonstrating clinical efficacy. Targeting co-inhibitory and co-stimulatory receptors with immunostimulatory antibodies has also shown clinical promise and its combined use with vaccines is a promising new approach of immunotherapy for cancer. Recent evidence supporting vaccine administration in patients with early and less aggressive disease should be additionally placed to select the appropriate patient population and to identify earlier markers of clinical benefit and immunological parameters that correlate with survival. This review focuses on promising vaccination platforms and essential perspectives in the treatment of cancer.

Efficient lysis of epithelial ovarian cancer cells by MAGE-A3-induced cytotoxic T lymphocytes using rAAV-6 capsid mutant vector

MAGE-A3 is highly expressed in epithelial ovarian cancer (EOC), making it a promising candidate for immunotherapy. We investigated whether dendritic cells (DCs) transduced with a rAAV-6 capsid mutant vector Y445F could elicit effective MAGE-A3-specific anti-tumor cytotoxic T lymphocyte (CTL) responses in vitro. MAGE-A3 was cloned and rAAV-6-MAGE-A3 purified, followed by proviral genome detection using real-time PCR. Immunofluorescence detection of rAAV-6-Y445F-MAGE-A3-transduced DCs demonstrated 60% transduction efficiency. Fluorescent in situ hybridization analysis confirmed chromosomal integration of rAAV vectors. Flow cytometric analysis of transduced DCs showed unaltered expression of critical monocyte-derived surface molecules with retention of allo-stimulatory activity. Co-culture of autologous T lymphocytes with MAGE-A3-expressing DCs produced CTLs that secreted IFN-γ, and efficiently killed MAGE-A3+ EOC cells. This form of rAAV-based DC immunotherapy, either alone or more likely in combination with other immune-enhancing protocols, may prove useful in the clinical setting for management of EOC.

New Approaches in Immunotherapy for the Treatment of Lung Cancer

Despite the several advances in the last few years into treatment of advanced lung cancer, the 5-year survival remains extremely low. New therapeutic strategies are currently under investigation, and immunotherapy seems to offer a promising treatment alternative. In the last decade, therapeutic cancer vaccines in lung cancer have been rather disappointing, mainly due to the lack of efficient predictive biomarkers. A better refinement of the patient population that might respond to treatment might finally lead to a success story. For the first time, the immune checkpoint inhibitors are demonstrating sustained antitumor response and improved survival and they may be the first immunotherapeutics available for patients with lung cancer.

Breathing new life into immunotherapy: review of melanoma, lung and kidney cancer

Previously, clinical approaches to using the immune system against cancer focused on vaccines that intended to specifically initiate or amplify a host response against evolving tumours. Although vaccine approaches have had some clinical success, most cancer vaccines fail to induce objective tumour shrinkage in patients. More-recent approaches have centred on a series of molecules known as immune checkpoints-whose natural function is to restrain or dampen a potentially over-exuberant response. Blocking immune checkpoint molecules with monoclonal antibodies has emerged as a viable clinical strategy that mediates tumour shrinkage in several cancer types. In addition to being part of the current treatment armamentarium for metastatic melanoma, immune checkpoint blockade is currently undergoing phase III testing in several cancer types.

New targets in non-small cell lung cancer

Lung cancer remains the most common cause of cancer-related death in the United States. At presentation, the majority of patients have regional or systemic metastases and therefore require systemic therapy. For years, chemotherapy was the only systemic therapy option. A major paradigm shift has occurred in recent years with the identification of driver genetic alterations in some non-small cell lung cancers (NSCLCs). It is part of current standard of care to assess epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK) translocations in tumors of patients with advanced NSCLC. Drugs targeting these mutations provide significant clinical benefit and are the preferred therapeutic option in these patients. Ongoing clinical trials are assessing the clinical benefit from targeting other driver genetic alterations. Further therapeutic targets have been identified through greater understanding of the variety of molecular processes that facilitate tumor formation and progression. Some of these new therapeutic targets are heat shock proteins and targets that can allow enhanced anti-tumor immune response. It is expected that these advances will allow personalized management of NSCLC patients and move us away from approaching all NSCLC patients with the same therapeutic tools.

Frequent T cell responses against immunogenic targets in lung cancer patients for targeted immunotherapy

To date, lung cancer is one of the leading causes of cancer mortality with short overall survival despite adequate therapy. New immunotherapeutic strategies using peptides derived from tumor-associated antigens (TAAs) can induce a specific cytotoxic T cell (CTL) response leading to a targeted tumor cell death. In the present study, we addressed whether there are further significant immunogenic candidate targets that may induce strong immune reactions with a high frequency in lung cancer patients eligible for cellular immunotherapeutic approaches, such as in a polyvalent vaccination approach. In this study, we investigated specific CTL responses of 14 HLA-A*0201-positive patients (of 33 screened patients) with non-small cell lung cancer (NSCLC; n=12) or small cell lung cancer (SCLC; n=2) against several known and novel TAA-derived peptides from lung cancer and/or other tumor entities, by measuring granzyme B (GrB) and/or interferon γ (IFNγ) secretion using enzyme-linked immunospot (ELISpot) analysis. Specific T cell responses could be detected for hTERT (4/13), two MAGE-A3-derived peptides (4/13 and 3/13, respectively), RHAMM (4/14), PRAME (8/14), G250 (7/12), survivin (3/13), HER2 (5/10) and WT1 (2/14), but also novel epitopes derived from Aurora kinase A (4/13) and B (5/13). Additionally, simultaneous CTL responses against the different peptides were examined and specific T cell responses against at least one of these TAAs could be detected in 13/14 (93%) patients. It could be shown that all patients with immune reactions against RHAMM and hTERT showed also immune responses against PRAME. Furthermore, patients with CTL responses against the Aurora kinase A peptide (Aura A1) also demonstrated a response against the Aurora kinase B peptide (Aura B1). Taken together, we showed that these TAA-derived peptides induce frequent specific T cell responses in patients with metastatic lung cancer and are, therefore, novel candidates for targeted immunotherapies and polyvalent approaches.

What lies within: novel strategies in immunotherapy for non-small cell lung cancer

Immunotherapy has become an increasingly important therapeutic strategy for those with cancer, with phase III studies demonstrating survival advantages in melanoma and castration-resistant prostate cancer. Non-small cell lung cancer (NSCLC) is a promising target for the next generation of immune-based strategies. In this article, we examine the current state of the art in lung cancer immunotherapy, including vaccines that specifically target lung tumor antigens and immune checkpoint antibodies such as antiprogrammed death 1 (anti-PD-1). Both approaches harness innate immunity against tumors by suppressing tumor-induced immune paresis. Methods. To identify relevant clinical trials of immunotherapy in NSCLC, PubMed and Medline databases were searched using the terms "immunotherapy" and "NSCLC," and several other therapy-specific search terms (e.g., PD-1, NSCLC). Additionally, abstracts presented at international lung cancer symposia, the American Society of Clinical Oncology annual meeting, and the European Society of Medical Oncology annual meeting between 2005 and 2013 were evaluated. Results. Large international phase III trials of NSCLC vaccines have completed accrual in both the adjuvant and metastatic disease settings. Results of the START study were disappointing, but results from other studies are still awaited. Immune checkpoint modulation has shown promise, with separate phase I studies of the anti-PD-1 antibody, nivolumab, and anti-PD-L1 antibody, MPDL3280A, demonstrating good tolerance and durable responses for certain patients with NSCLC who were heavily pretreated. Conclusions. Immune-based strategies have shown initial promise for early- and advanced-stage NSCLC. Validating these findings in randomized studies and discovering durable biomarkers of response represent the next challenges for investigation.

Adjuvant chemotherapy after pulmonary resection for lung cancer

Adjuvant chemotherapy using a cisplatin-based regimen is currently recommended for patients with stage II and III non-small cell lung cancer (NSCLC) after complete tumor resection and may be considered for patients with stage IB NSCLC. Although adjuvant chemotherapy after complete resection of localized NSCLC is associated with an absolute survival advantage of approximately 5% at 5 years, there is still a relatively high risk of relapse even for early-stage NSCLC. Efforts are ongoing to identify new treatments in the adjuvant setting and to select patients for individualized treatment based on biomarkers.

Current clinical immunotherapy targets in advanced nonsmall cell lung cancer (NSCLC)

NSCLC remains one of the most challenging malignancies to treat. Despite the introduction of innovative therapies over the last decade, the 5-year survival of NSCLC is still <20%. Clearly, novel, therapeutic approaches are required. Targeting the immune system to derive meaningful clinical benefit has proved successful in various malignancies in recent years. As a result, there is renewed focus on the use of immunotherapy in lung cancer. In this review, we provide an overview of current immune-modulatory approaches in the treatment of NSCLC.

Cancer testis antigens: a novel target in lung cancer

Lung cancer is the main cause of cancer mortality worldwide. This is mainly due to the fact that it is diagnosed in advanced stage patients, which are no more surgically curable. Consequently, searching for novel treatments and new modalities for early diagnosis offers great promise to improve the clinical outcome. Recently, a new group of antigens, the cancer testis antigens, have been described as possible early diagnostic tools and therapeutic targets in cancer therapy.This review will report emerging evidences of cancer testis antigens deregulation in lung cancer and explore the state of the art of their currently known role and potential as markers for early diagnosis and disease progression and targets of an immunotherapeutic approach aiming to improve the cure rate of this tumor.

Personalized therapy for non-small cell lung cancer: which drug for which patient?

The elucidation of the molecular alterations in non-small cell lung cancer (NSCLC) and the development of molecularly targeted agents have permanently shifted NSCLC therapy to a personalized approach. In the metastatic setting, the addition of the anti-vascular endothelial growth factor monoclonal antibody, bevacizumab, to chemotherapy improves overall survival. The oral epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors, gefitinib and erlotinib, prolong progression-free survival in patients selected for the presence of an EGFR activating mutation. The monoclonal antibody to EGFR, cetuximab, improves survival in patients with metastatic NSCLC, and the inhibitor of the echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase (EML4-ALK) fusion protein, crizotinib, has resulted in an unprecedented overall survival advantage in patients harboring the EML4-ALK translocation. In the adjuvant setting, gefitinib has not been shown to improve patient survival outcomes; however, there are several ongoing clinical trials in the adjuvant setting evaluating the role of erlotinib, bevacizumab, and the MAGE-A3 and MUC1 vaccines. The realm of personalized lung cancer therapy also includes the study of chemotherapy selected on the basis of the pharmacogenetic profile of a patient's tumor. Several ongoing clinical trials in both the metastatic and adjuvant settings are studying the excision repair cross-complementing group 1 (ERCC1) protein, the ribonucleotide reductase subunit 1 (RRM1) protein, thymidylate synthase, and BRCA1 as predictors of chemotherapy response. This review will outline the current state of the art of personalized NSCLC therapy.

Vaccines for melanoma and renal cell carcinoma

The inherent immunogenicity of melanoma and renal cell carcinoma (RCC) has made these tumors a focus of considerable research in vaccine development. Recent data from murine studies of immunosurveillance have highlighted the importance of both innate and adaptive immune responses in shaping a tumor's inherent susceptibility to immune surveillance and immunotherapy. Melanoma has been a useful model for the identification of tumor-associated antigens and a number of putative renal cell antigens have been described more recently. These antigens have been targeted using a variety of vaccine strategies, including protein- and peptide-based vaccines, recombinant antigen-expressing vectors, and whole cell vaccine approaches. While evidence for clinical benefit has been disappointing to date, several current phase III clinical trials are in progress based on promising results from phase II studies. Accumulating data suggest that the tumor microenvironment and mechanisms of immunological escape by established tumors are significant barriers that must be overcome before vaccine therapy can be fully realized. This review will discuss the basis for vaccine development, describe some of the more promising vaccine strategies in development, and mention some of the tumor escape mechanisms that block effective anti-tumor immunity for melanoma and RCC.

Cancer peptide vaccine therapy developed from oncoantigens identified through genome-wide expression profile analysis for bladder cancer

OBJECTIVE

The field of cancer vaccine therapy is currently expected to become the fourth option in the treatment of cancer after surgery, chemotherapy and radiation therapy. We developed a novel cancer peptide vaccine therapy for bladder cancer through a genome-wide expression profile analysis.

METHODS

Among a number of oncoproteins that are transactivated in cancer cells, we focused on M phase phosphoprotein 1 and DEP domain containing 1, both of which are cancer-testis antigens playing critical roles in the growth of bladder cancer cells, as candidate molecules for the development of drugs for bladder cancer. In an attempt to identify the peptide epitope from these oncoantigens, we conducted a clinical trial using these peptides for patients with advanced bladder cancer.

RESULTS

We identified HLA-A24-restricted peptide epitopes corresponding to parts of M phase phosphoprotein 1 and DEP domain containing 1 proteins, which could induce peptide-specific cytotoxic T lymphocytes. Using these peptides, we found that M phase phosphoprotein 1- and DEP domain containing 1-derived peptide vaccines could be well tolerated without any serious adverse events, and effectively induced peptide-specific cytotoxic T lymphocytes in vivo.

CONCLUSIONS

The novel approach adopted in the treatment with peptide vaccines is considered to be a promising therapy for bladder cancer.

Lung cancer vaccines

To date, in lung cancer, early attempts to modulate the immune system via vaccine-based therapeutics have been unsuccessful. An improved understanding of tumor immunology has facilitated the production of more sophisticated lung cancer vaccines. It is anticipated that it will likely require multiple epitopes of a diverse set of genes restricted to multiple haplotypes to generate a truly effective vaccine that is able to overcome the various immunologic escape mechanisms that tumors employ. Other issues to overcome include optimal patient selection, which adjuvant agent to use, and how to adequately monitor for an immunologic response. This review discusses the most promising vaccination strategies for non-small cell lung cancer including the allogeneic tumor cell vaccine belagenpumatucel-L, which is a mixture of 4 allogeneic non-small cell lung cancer cell lines genetically modified to secrete an antisense oligonucleotide to transforming growth factor β2 and 3 other target protein-specific vaccines designed to induce responses against melanoma-associated antigen A3, mucin 1, and epidermal growth factor.

Vaccines in non-small cell lung cancer: rationale, combination strategies and update on clinical trials

Non-small cell lung cancer (NSCLC) remains the leading cause of cancer related mortality worldwide and despite some advances in therapy the overall prognosis remains disappointing. New therapeutic approaches like vaccination have been proposed and several clinical trials are ongoing. Many tumor antigens have been identified so far and specific tumor vaccines targeting these antigens have been developed. Even if the ideal setting for vaccine therapy might be the adjuvant one, vaccines seem to be potentially beneficial also in advanced disease and combination therapy could be a promising treatment option. In the advanced setting anti-MUC-1 vaccine (belagenpumatucel) and anti-TGF-β(2) vaccine (BPL-25) have entered in phase III trials as maintenance therapy after first line chemotherapy. In the adjuvant setting the most relevant and promising vaccines are directed against MAGE-A3 and PRAME, respectively. We will review the key points for effective active immunotherapies and combination therapies, giving an update on the most promising vaccines developed in NSCLC.

Cancer immunotherapy comes of age

Activating the immune system for therapeutic benefit in cancer has long been a goal in immunology and oncology. After decades of disappointment, the tide has finally changed due to the success of recent proof-of-concept clinical trials. Most notable has been the ability of the anti-CTLA4 antibody, ipilimumab, to achieve a significant increase in survival for patients with metastatic melanoma, for which conventional therapies have failed. In the context of advances in the understanding of how tolerance, immunity and immunosuppression regulate antitumour immune responses together with the advent of targeted therapies, these successes suggest that active immunotherapy represents a path to obtain a durable and long-lasting response in cancer patients.

Pilot study of 1650-G: a simplified cellular vaccine for lung cancer

INTRODUCTION

Cancer immunotherapy is a conceptually attractive since it is highly specific and can deal with disseminated disease with minimal impact on normal tissues. Early phase clinical trials have well established the ability of a variety of immunotherapeutic approaches to induce antigen specific immune responses in lung cancer patients. Although no immunotherapy is likely to be a panacea, recent data from randomized phase IIB studies offer promise of therapeutic activity in both early and late stage lung cancer.

METHODS

This report describes early clinical experience with vaccine 1650-G, an allogeneic cellular vaccine using granulocyte macrophage colony stimulating factor as an adjuvant. This nonrandomized pilot study was conducted at four sites in the Commonwealth of Kentucky with primary objective of determining biological activity in a relevant patient population; the use of similar antigen source, immunization schedule, and immunological assessment facilitated comparison to DC vaccines previously tested by our group.

RESULTS

Data indicates 1650-G is safe and generated a robust and unequivocal immunological response in 6/11 of immunized patients. The relative frequency and kinetics of the response appears similar to that achieved with DC vaccines (1650+autologous DC). The fact that this vaccine could be transported and delivered to cancer patients in community cancer clinics also fulfills an important objective of our research.

CONCLUSIONS

These findings provide critical foundation for further testing of this simple, and comparatively inexpensive multivalent NSCLC vaccine.

[Molecular biology of lung cancer series]

INTRODUCTION

MAGE-A3 (Melanoma Associated Antigen-A3) is expressed in cancer cells but not in normal tissues except male germ line cells which are devoid of Major Histocompatibility Complex molecules and therefore do not present MAGE-A3 antigens.

BACKGROUND

MAGE-A3 is expressed in 30 to 60% of non-small cell lung cancers but its function is unknown. Its recognition by cytotoxic T lymphocytes implies its presentation on the cell surface by HLA type A1 molecules that are absent from germ cells.

VIEWPOINTS

MAGE-A3 represents a good target for active anticancer immunotherapy. Some trials, which used MAGE-A3 and an adjuvant showed a strong antigen-specific T-cell response with, perhaps, an improved survival.

CONCLUSION

This needs to be confirmed as an adjuvent therapy by current phase III randomized controlled trials.

Adjuvant therapy in non-small cell lung cancer: current and future directions

The cornerstone of treatment for early-stage non-small cell lung cancer (NSCLC) has long been surgical resection. Over the past few years, there has been a paradigm shift to provide adjuvant platinum-based chemotherapy for patients with completely resected stage II-IIIA NSCLC founded on large randomized clinical trials demonstrating longer overall survival with this treatment. Reassuringly, the National Cancer Institute of Canada Cancer Therapeutics Group JBR.10 trial recently reported a continued survival advantage for patients treated with adjuvant chemotherapy after >9 years of median follow-up. In contrast, the gains from using this approach for stage IB disease are less clear, although data from an unplanned subgroup analysis suggest benefit for patients with tumors > or = 4 cm. Herein, we review the evidence supporting adjuvant therapy in early-stage NSCLC patients before discussing key mitigating factors in providing treatment, such as stage of disease and the impact of the new seventh edition of the tumor-node-metastasis classification system. Criteria such as patient age and performance status, as well as the value of appropriate chemotherapy selection, are highlighted as measures to help guide management. The role of postoperative radiotherapy and the future landscape of early-stage NSCLC research are also explored; namely, therapeutic strategies exploiting pharmacogenomic and gene-expression profiling, in an attempt to personalize care, and the integration of novel targeted therapies into adjuvant clinical trials.

Molecularly defined vaccines for cancer immunotherapy, and protective T cell immunity

Malignant cells are frequently recognized and destroyed by T cells, hence the development of T cell vaccines against established tumors. The challenge is to induce protective type 1 immune responses, with efficient Th1 and CTL activation, and long-term immunological memory. These goals are similar as in many infectious diseases, where successful immune protection is ideally induced with live vaccines. However, large-scale development of live vaccines is prevented by their very limited availability and vector immunogenicity. Synthetic vaccines have multiple advantages. Each of their components (antigens, adjuvants, delivery systems) contributes specifically to induction and maintenance of T cell responses. Here we summarize current experience with vaccines based on proteins and peptide antigens, and discuss approaches for the molecular characterization of clonotypic T cell responses. With carefully designed step-by-step modifications of innovative vaccine formulations, T cell vaccination can be optimized towards the goal of inducing therapeutic immune responses in humans.

Immunotherapy in the landscape of new targeted treatments for non-small cell lung cancer

Non-small cell lung cancer (NSCLC) is the leading cause of cancer-related death worldwide. Active immunotherapies and molecules targeting tyrosine kinase receptors both offer new avenues for the treatment of NSCLC. Furthermore, their combinations or their administration along with standard treatments enlarges the potential for clinical benefit. Moreover, the discovery of biomarkers predicting the response to these new therapies should allow a better selection of patients susceptible to optimally benefit from these treatments. In this paper, we review the most promising active immunotherapies, antibodies and small molecules in the context of NSCLC management, focusing on compounds in phase III clinical development.

Expression of melanoma-antigen-A (MAGE-A) in disseminated tumor cells in regional lymph nodes of patients with operable non-small cell lung cancer

PURPOSE

Single disseminated tumor cells are detectable in regional lymph nodes of 30-50% patients with early-stage non-small cell lung cancer (NSCLC). This study investigated if these disseminated tumor cells express MAGE-A and thus might be targeted by adjuvant anti-MAGE-A immunotherapies.

EXPERIMENTAL DESIGN

Lymph nodes of 32 consecutive patients without neoadjuvant therapy were removed by systematic lymphadenectomy during resection of NSCLC. One-hundred of these lymph nodes were cut into two equal halves which were examined using either routine histo-pathology or quantitative reverse transcriptase PCR (qRT-PCR). qRT-PCR amplification of cytokeratin 19 transcripts was applied for the detection of disseminated tumor cells. Expression of MAGE-A was analyzed using one single primer pair amplifying subgroups MAGE-A1 to -A6 in one qRT-PCR reaction.

RESULTS

Ninety-four (94%) lymph nodes were tumor-free by histo-pathology. qRT-PCR detected disseminated tumor cells in 26 (28%) of these lymph nodes resulting in 19 (59%) patients with disseminated tumor cells. All of the remaining 6 lymph nodes that were judged by the pathologist to contain tumor cells exhibited CK19 transcripts. Fifteen (46%) lymph nodes with disseminated tumor cells contained MAGE-A transcripts resulting in 12 (37%) patients with disseminated tumor cells which expressed MAGE-A. There was no correlation between clinico-pathological parameters and the occurrence of disseminated tumor cells or their MAGE-A expression.

CONCLUSIONS

Since 37% of patients with operable NSCLC harbored disseminated tumor cells that expressed MAGE-A, only these patients might benefit from adjuvant immunotherapies directed against MAGE-A1 to -A6. This study may provide a basis for the preselection of patients to be included in such immunotherapy trials after resection of NSCLC.

Cancer vaccines: will we ever learn?

Scientists and clinicians engaged in developing therapeutic cancer vaccines cannot be anything other than troubled by the sheer number of Phase III clinical trial failures in the field. Are we inveterate optimists or do we have reason for continuing to plough our lonely furrow? In this perspective article, we answer why Phase III failures have been to the fore and highlight why the field should be optimistic given the knowledge gained from these pioneering studies and our improved understanding of how the immune system interacts with cancer.

Modified tumour antigen-encoding mRNA facilitates the analysis of naturally occurring and vaccine-induced CD4 and CD8 T cells in cancer patients

The development of effective anti-cancer vaccines requires precise assessment of vaccine-induced immunity. This is often hampered by low ex vivo frequencies of antigen-specific T cells and limited defined epitopes. This study investigates the applicability of modified, in vitro-transcribed mRNA encoding a therapeutically relevant tumour antigen to analyse T cell responses in cancer patients. In this study transfection of antigen presenting cells, by mRNA encoding the tumour antigen NY-ESO-1, was optimised and applied to address spontaneous and vaccine-induced T cell responses in cancer patients. Memory CD8+ T cells from lung cancer patients having detectable humoral immune responses directed towards NY-ESO-1 could be efficiently detected in peripheral blood. Specific T cells utilised a range of different T cell receptors, indicating a polyclonal response. Specific killing of a panel of NY-ESO-1 expressing tumour cell lines indicates recognition restricted to several HLA allelic variants, including a novel HLA-B49 epitope. Using a modified mRNA construct targeting the translated antigen to the secretory pathway, detection of NY-ESO-1-specific CD4+ T cells in patients could be enhanced, which allowed the in-depth characterisation of established T cell clones. Moreover, broad CD8+ and CD4+ T cell responses covering multiple epitopes were detected following mRNA stimulation of patients treated with a recombinant vaccinia/fowlpox NY-ESO-1 vaccine. This approach allows for a precise monitoring of responses to tumour antigens in a setting that addresses the breadth and magnitude of antigen-specific T cell responses, and that is not limited to a particular combination of known epitopes and HLA-restrictions.