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Jiani W, Qin T, Jie M. Tumor neoantigens and tumor immunotherapies. Aging Med (Milton) 2024; 7:224-230. [PMID: 38725698 PMCID: PMC11077340 DOI: 10.1002/agm2.12295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/01/2024] [Accepted: 03/28/2024] [Indexed: 05/12/2024] Open
Abstract
As a high-risk group of patients with cancer, the elderly exhibit limited efficacy with traditional treatments. Immunotherapy emerges as a promising adjunctive therapeutic approach that holds potential in addressing the needs of geriatric patients with cancer. Neoantigens, a unique class of tumor-specific antigens generated by non-synonymous mutations, are garnering increasing attention as targets for immunotherapy in clinical applications. Newly developed technologies, such as second-generation gene sequencing and mass spectrometry, have provided powerful technical support for the identification and prediction of neoantigens. At present, neoantigen-based immunotherapy has been extensively applied in clinical trials and has demonstrated both safety and efficacy, marking the beginning of a new era for cancer immunotherapy. This article reviews the conception, classification, inducers, and screening process of tumor neoantigens, as well as the application prospects and combination therapy strategies of neoantigen-based cancer immunotherapy.
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Affiliation(s)
- Wang Jiani
- Department of Biotherapy Center, Beijing Hospital, National Center of GerontologyInstitute of Geriatric Medicine, Chinese Academy of Medical SciencesBeijingChina
| | - Tan Qin
- Department of Biotherapy Center, Beijing Hospital, National Center of GerontologyInstitute of Geriatric Medicine, Chinese Academy of Medical SciencesBeijingChina
| | - Ma Jie
- Department of Biotherapy Center, Beijing Hospital, National Center of GerontologyInstitute of Geriatric Medicine, Chinese Academy of Medical SciencesBeijingChina
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Linehan A, O’Reilly M, McDermott R, O’Kane GM. Targeting KRAS mutations in pancreatic cancer: opportunities for future strategies. Front Med (Lausanne) 2024; 11:1369136. [PMID: 38576709 PMCID: PMC10991798 DOI: 10.3389/fmed.2024.1369136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/22/2024] [Indexed: 04/06/2024] Open
Abstract
Targeting the RAS pathway remains the holy grail of precision oncology. In the case of pancreatic ductal adenocarcinomas (PDAC), 90-92% harbor mutations in the oncogene KRAS, triggering canonical MAPK signaling. The smooth structure of the altered KRAS protein without a binding pocket and its affinity for GTP have, in the past, hampered drug development. The emergence of KRASG12C covalent inhibitors has provided renewed enthusiasm for targeting KRAS. The numerous pathways implicated in RAS activation do, however, lead to the development of early resistance. In addition, the dense stromal niche and immunosuppressive microenvironment dictated by oncogenic KRAS can influence treatment responses, highlighting the need for a combination-based approach. Given that mutations in KRAS occur early in PDAC tumorigenesis, an understanding of its pleiotropic effects is key to progress in this disease. Herein, we review current perspectives on targeting KRAS with a focus on PDAC.
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Affiliation(s)
- Anna Linehan
- Department of Medical Oncology, St Vincent’s University Hospital, Dublin, Ireland
| | - Mary O’Reilly
- Department of Medical Oncology, St Vincent’s University Hospital, Dublin, Ireland
| | - Ray McDermott
- Department of Medical Oncology, St Vincent’s University Hospital, Dublin, Ireland
| | - Grainne M. O’Kane
- Department of Medical Oncology, St James’s Hospital, Dublin, Ireland
- Princess Margaret Cancer Centre, Toronto, ON, Canada
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Pant S, Wainberg ZA, Weekes CD, Furqan M, Kasi PM, Devoe CE, Leal AD, Chung V, Basturk O, VanWyk H, Tavares AM, Seenappa LM, Perry JR, Kheoh T, McNeil LK, Welkowsky E, DeMuth PC, Haqq CM, O'Reilly EM. Lymph-node-targeted, mKRAS-specific amphiphile vaccine in pancreatic and colorectal cancer: the phase 1 AMPLIFY-201 trial. Nat Med 2024; 30:531-542. [PMID: 38195752 PMCID: PMC10878978 DOI: 10.1038/s41591-023-02760-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/11/2023] [Indexed: 01/11/2024]
Abstract
Pancreatic and colorectal cancers are often KRAS mutated and are incurable when tumor DNA or protein persists or recurs after curative intent therapy. Cancer vaccine ELI-002 2P enhances lymph node delivery and immune response using amphiphile (Amph) modification of G12D and G12R mutant KRAS (mKRAS) peptides (Amph-Peptides-2P) together with CpG oligonucleotide adjuvant (Amph-CpG-7909). We treated 25 patients (20 pancreatic and five colorectal) who were positive for minimal residual mKRAS disease (ctDNA and/or serum tumor antigen) after locoregional treatment in a phase 1 study of fixed-dose Amph-Peptides-2P and ascending-dose Amph-CpG-7909; study enrollment is complete with patient follow-up ongoing. Primary endpoints included safety and recommended phase 2 dose (RP2D). The secondary endpoint was tumor biomarker response (longitudinal ctDNA or tumor antigen), with exploratory endpoints including immunogenicity and relapse-free survival (RFS). No dose-limiting toxicities were observed, and the RP2D was 10.0 mg of Amph-CpG-7909. Direct ex vivo mKRAS-specific T cell responses were observed in 21 of 25 patients (84%; 59% both CD4+ and CD8+); tumor biomarker responses were observed in 21 of 25 patients (84%); biomarker clearance was observed in six of 25 patients (24%; three pancreatic and three colorectal); and the median RFS was 16.33 months. Efficacy correlated with T cell responses above or below the median fold increase over baseline (12.75-fold): median tumor biomarker reduction was -76.0% versus -10.2% (P < 0.0014), and the median RFS was not reached versus 4.01 months (hazard ratio = 0.14; P = 0.0167). ELI-002 2P was safe and induced considerable T cell responses in patients with immunotherapy-recalcitrant KRAS-mutated tumors. ClinicalTrials.gov identifier: NCT04853017 .
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Affiliation(s)
- Shubham Pant
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Zev A Wainberg
- University of California, Los Angeles, Los Angeles, CA, USA
| | | | | | | | | | - Alexis D Leal
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Olca Basturk
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Zafar A, Khan MJ, Abu J, Naeem A. Revolutionizing cancer care strategies: immunotherapy, gene therapy, and molecular targeted therapy. Mol Biol Rep 2024; 51:219. [PMID: 38281269 PMCID: PMC10822809 DOI: 10.1007/s11033-023-09096-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/04/2023] [Indexed: 01/30/2024]
Abstract
Despite the availability of technological advances in traditional anti-cancer therapies, there is a need for more precise and targeted cancer treatment strategies. The wide-ranging shortfalls of conventional anticancer therapies such as systematic toxicity, compromised life quality, and limited to severe side effects are major areas of concern of conventional cancer treatment approaches. Owing to the expansion of knowledge and technological advancements in the field of cancer biology, more innovative and safe anti-cancerous approaches such as immune therapy, gene therapy and targeted therapy are rapidly evolving with the aim to address the limitations of conventional therapies. The concept of immunotherapy began with the capability of coley toxins to stimulate toll-like receptors of immune cells to provoke an immune response against cancers. With an in-depth understating of the molecular mechanisms of carcinogenesis and their relationship to disease prognosis, molecular targeted therapy approaches, that inhibit or stimulate specific cancer-promoting or cancer-inhibitory molecules respectively, have offered promising outcomes. In this review, we evaluate the achievement and challenges of these technically advanced therapies with the aim of presenting the overall progress and perspective of each approach.
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Affiliation(s)
- Aasma Zafar
- Department of Biosciences, COMSATS University, Islamabad, 45550, Pakistan
| | | | - Junaid Abu
- Hazm Mebaireek General Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | - Aisha Naeem
- Qatar University Health, Qatar University, P.O. Box 2713, Doha, Qatar.
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Liu Y, Xie B, Chen Q. RAS signaling and immune cells: a sinister crosstalk in the tumor microenvironment. J Transl Med 2023; 21:595. [PMID: 37670322 PMCID: PMC10481548 DOI: 10.1186/s12967-023-04486-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 08/30/2023] [Indexed: 09/07/2023] Open
Abstract
The rat sarcoma virus (RAS) gene is the most commonly mutated oncogene in cancer, with about 19% of cancer patients carrying RAS mutations. Studies on the interaction between RAS mutation and tumor immune microenvironment (TIM) have been flourishing in recent years. More and more evidence has proved that RAS signals regulate immune cells' recruitment, activation, and differentiation while assisting tumor cells to evade immune surveillance. This review concluded the direct and indirect treatment strategies for RAS mutations. In addition, we updated the underlying mechanisms by which RAS signaling modulated immune infiltration and immune escape. Finally, we discussed advances in RAS-targeted immunotherapies, including cancer vaccines and adoptive cell therapies, with a particular focus on combination strategies with personalized therapy and great potential to achieve lasting clinical benefits.
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Affiliation(s)
- Yongting Liu
- Department of Geriatrics, Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Bin Xie
- Department of Geriatrics, Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Qiong Chen
- Department of Geriatrics, Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, 410008, China.
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, China.
- Xiangya Lung Cancer Center, Xiangya Hospital, Central South University, Changsha, 410008, China.
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Wu X, Song W, Cheng C, Liu Z, Li X, Cui Y, Gao Y, Li D. Small molecular inhibitors for KRAS-mutant cancers. Front Immunol 2023; 14:1223433. [PMID: 37662925 PMCID: PMC10470052 DOI: 10.3389/fimmu.2023.1223433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Three rat sarcoma (RAS) gene isoforms, KRAS, NRAS, and HRAS, constitute the most mutated family of small GTPases in cancer. While the development of targeted immunotherapies has led to a substantial improvement in the overall survival of patients with non-KRAS-mutant cancer, patients with RAS-mutant cancers have an overall poorer prognosis owing to the high aggressiveness of RAS-mutant tumors. KRAS mutations are strongly implicated in lung, pancreatic, and colorectal cancers. However, RAS mutations exhibit diverse patterns of isoforms, substitutions, and positions in different types of cancers. Despite being considered "undruggable", recent advances in the use of allele-specific covalent inhibitors against the most common mutant form of RAS in non-small-cell lung cancer have led to the development of effective pharmacological interventions against RAS-mutant cancer. Sotorasib (AMG510) has been approved by the FDA as a second-line treatment for patients with KRAS-G12C mutant NSCLC who have received at least one prior systemic therapy. Other KRAS inhibitors are on the way to block KRAS-mutant cancers. In this review, we summarize the progress and promise of small-molecule inhibitors in clinical trials, including direct inhibitors of KRAS, pan-RAS inhibitors, inhibitors of RAS effector signaling, and immune checkpoint inhibitors or combinations with RAS inhibitors, to improve the prognosis of tumors with RAS mutations.
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Affiliation(s)
- Xuan Wu
- Department of Internal Medicine, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
| | - Wenping Song
- Department of Pharmacy, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
- Henan Engineering Research Center for Tumor Precision Medicine and Comprehensive Evaluation, Henan Cancer Hospital, Zhengzhou, China
- Henan Provincial Key Laboratory of Anticancer Drug Research, Henan Cancer Hospital, Zhengzhou, China
| | - Cheng Cheng
- Department of Internal Medicine, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Ziyang Liu
- Academy of Medical Science, Zhengzhou University, Zhengzhou, China
| | - Xiang Li
- Department of Internal Medicine, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Yu Cui
- Department of Internal Medicine, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Yao Gao
- Department of Internal Medicine, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Ding Li
- Department of Pharmacy, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
- Henan Engineering Research Center for Tumor Precision Medicine and Comprehensive Evaluation, Henan Cancer Hospital, Zhengzhou, China
- Henan Provincial Key Laboratory of Anticancer Drug Research, Henan Cancer Hospital, Zhengzhou, China
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Herpels M, Ishihara J, Sadanandam A. The clinical terrain of immunotherapies in heterogeneous pancreatic cancer: unravelling challenges and opportunities. J Pathol 2023; 260:533-550. [PMID: 37550956 DOI: 10.1002/path.6171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/20/2023] [Accepted: 06/22/2023] [Indexed: 08/09/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the most common and aggressive type of pancreatic cancer and has abysmal survival rates. In the past two decades, immunotherapeutic agents with success in other cancer types have gradually been trialled against PDACs at different stages of cancer progression, either as a monotherapy or in combination with chemotherapy. Unfortunately, to this day, chemotherapy still prolongs the survival rates the most and is prescribed in clinics despite the severe side effects in other cancer types. The low success rates of immunotherapy against PDAC have been attributed most frequently to its complex and multi-faceted tumour microenvironment (TME) and low mutational burden. In this review, we give a comprehensive overview of the immunotherapies tested in PDAC clinical trials thus far, their limitations, and potential explanations for their failure. We also discuss the existing classification of heterogenous PDACs into cancer, cancer-associated fibroblast, and immune subtypes and their potential opportunity in patient selection as a form of personalisation of PDAC immunotherapy. © 2023 The Pathological Society of Great Britain and Ireland.
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Affiliation(s)
- Melanie Herpels
- Division of Molecular Pathology, Institute of Cancer Research, London, UK
- Department of Bioengineering, Imperial College London, London, UK
| | - Jun Ishihara
- Department of Bioengineering, Imperial College London, London, UK
| | - Anguraj Sadanandam
- Division of Molecular Pathology, Institute of Cancer Research, London, UK
- Centre for Global Oncology, Division of Molecular Pathology, Institute of Cancer Research, London, UK
- Centre for Translational Immunotherapy, Division of Radiotherapy and Imaging, Institute of Cancer Research, London, UK
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Bteich F, Mohammadi M, Li T, Bhat MA, Sofianidi A, Wei N, Kuang C. Targeting KRAS in Colorectal Cancer: A Bench to Bedside Review. Int J Mol Sci 2023; 24:12030. [PMID: 37569406 PMCID: PMC10418782 DOI: 10.3390/ijms241512030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 07/21/2023] [Accepted: 07/23/2023] [Indexed: 08/13/2023] Open
Abstract
Colorectal cancer (CRC) is a heterogeneous disease with a myriad of alterations at the cellular and molecular levels. Kristen rat sarcoma (KRAS) mutations occur in up to 40% of CRCs and serve as both a prognostic and predictive biomarker. Oncogenic mutations in the KRAS protein affect cellular proliferation and survival, leading to tumorigenesis through RAS/MAPK pathways. Until recently, only indirect targeting of the pathway had been investigated. There are now several KRAS allele-specific inhibitors in late-phase clinical trials, and many newer agents and targeting strategies undergoing preclinical and early-phase clinical testing. The adequate treatment of KRAS-mutated CRC will inevitably involve combination therapies due to the existence of robust adaptive resistance mechanisms in these tumors. In this article, we review the most recent understanding and findings related to targeting KRAS mutations in CRC, mechanisms of resistance to KRAS inhibitors, as well as evolving treatment strategies for KRAS-mutated CRC patients.
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Affiliation(s)
- Fernand Bteich
- Department of Medical Oncology, Montefiore Medical Center, Bronx, NY 10467, USA;
- Department of Medical Oncology, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (M.M.); (T.L.); (M.A.B.); (N.W.)
| | - Mahshid Mohammadi
- Department of Medical Oncology, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (M.M.); (T.L.); (M.A.B.); (N.W.)
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Terence Li
- Department of Medical Oncology, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (M.M.); (T.L.); (M.A.B.); (N.W.)
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Muzaffer Ahmed Bhat
- Department of Medical Oncology, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (M.M.); (T.L.); (M.A.B.); (N.W.)
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Amalia Sofianidi
- Oncology Unit, Third Department of Internal Medicine, Sotiria General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Ning Wei
- Department of Medical Oncology, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (M.M.); (T.L.); (M.A.B.); (N.W.)
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Chaoyuan Kuang
- Department of Medical Oncology, Montefiore Medical Center, Bronx, NY 10467, USA;
- Department of Medical Oncology, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (M.M.); (T.L.); (M.A.B.); (N.W.)
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
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Ashok Kumar P, Serinelli S, Zaccarini DJ, Huang R, Danziger N, Janovitz T, Basnet A, Sivapiragasam A, Graziano S, Ross JS. Genomic landscape of clinically advanced KRAS wild-type pancreatic ductal adenocarcinoma. Front Oncol 2023; 13:1169586. [PMID: 37404765 PMCID: PMC10315669 DOI: 10.3389/fonc.2023.1169586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 06/07/2023] [Indexed: 07/06/2023] Open
Abstract
Introduction KRAS mutation is a common occurrence in Pancreatic Ductal Adenocarcinoma (PDA) and is a driver mutation for disease development and progression. KRAS wild-type PDA may constitute a distinct molecular and clinical subtype. We used the Foundation one data to analyze the difference in Genomic Alterations (GAs) that occur in KRAS mutated and wild-type PDA. Methods Comprehensive genomic profiling (CGP) data, tumor mutational burden (TMB), microsatellite instability (MSI) and PD-L1 by Immunohistochemistry (IHC) were analyzed. Results and discussion Our cohort had 9444 cases of advanced PDA. 8723 (92.37%) patients had KRAS mutation. 721 (7.63%) patients were KRAS wild-type. Among potentially targetable mutations, GAs more common in KRAS wild-type included ERBB2 (mutated vs wild-type: 1.7% vs 6.8%, p <0.0001), BRAF (mutated vs wild-type: 0.5% vs 17.9%, p <0.0001), PIK3CA (mutated vs wild-type: 2.3% vs 6.5%, p <0.001), FGFR2 (mutated vs wild-type: 0.1% vs 4.4%, p <0.0001), ATM (mutated vs wild-type: 3.6% vs 6.8%, p <0.0001). On analyzing untargetable GAs, the KRAS mutated group had a significantly higher percentage of TP53 (mutated vs wild-type: 80.2% vs 47.6%, p <0.0001), CDKN2A (mutated vs wild-type: 56.2% vs 34.4%, p <0.0001), CDKN2B (mutated vs wild-type: 28.9% vs 23%, p =0.007), SMAD4 (mutated vs wild-type: 26.8% vs 15.7%, p <0.0001) and MTAP (mutated vs wild-type: 21.7% vs 18%, p =0.02). ARID1A (mutated vs wild-type: 7.7% vs 13.6%, p <0.0001 and RB1(mutated vs wild-type: 2% vs 4%, p =0.01) were more prevalent in the wild-type subgroup. Mean TMB was higher in the KRAS wild-type subgroup (mutated vs wild-type: 2.3 vs 3.6, p <0.0001). High TMB, defined as TMB > 10 mut/mB (mutated vs wild-type: 1% vs 6.3%, p <0.0001) and very-high TMB, defined as TMB >20 mut/mB (mutated vs wild-type: 0.5% vs 2.4%, p <0.0001) favored the wild-type. PD-L1 high expression was similar between the 2 groups (mutated vs wild-type: 5.7% vs 6%,). GA associated with immune checkpoint inhibitors (ICPIs) response including PBRM1 (mutated vs wild-type: 0.7% vs 3.2%, p <0.0001) and MDM2 (mutated vs wild-type: 1.3% vs 4.4%, p <0.0001) were more likely to be seen in KRAS wild-type PDA.
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Affiliation(s)
| | - Serenella Serinelli
- Department of Pathology, Upstate Medical University, Syracuse, NY, United States
| | - Daniel J. Zaccarini
- Department of Pathology, Upstate Medical University, Syracuse, NY, United States
| | | | | | | | - Alina Basnet
- Upstate Cancer Center, Upstate Medical University, Syracuse, NY, United States
| | | | - Stephen Graziano
- Upstate Cancer Center, Upstate Medical University, Syracuse, NY, United States
| | - Jeffrey S. Ross
- Department of Pathology, Upstate Medical University, Syracuse, NY, United States
- Foundation Medicine, Cambridge, MA, United States
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Mehralizadeh H, Nazari A, Oruji F, Roostaie M, Hosseininozari G, Yazdani O, Esbati R, Roudini K. Cytokine sustained delivery for cancer therapy; special focus on stem cell- and biomaterial- based delivery methods. Pathol Res Pract 2023; 247:154528. [PMID: 37257247 DOI: 10.1016/j.prp.2023.154528] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/06/2023] [Accepted: 05/08/2023] [Indexed: 06/02/2023]
Abstract
As immune regulators, cytokines serve critical role as signaling molecules in response to danger, tissue damage, or injury. Importantly, due to their vital role in immunological surveillance, cytokine therapy has become a promising therapeutics for cancer therapy. Cytokines have, however, been used only in certain clinical settings. Two key characteristics of cytokines contribute to this clinical translational challenge: first, they are highly pleiotropic, and second, in healthy physiology, they are typically secreted and act very locally in tissues. Systemic administration of the cytokines can consequently result in serious side effects. Thus, scientists have sought various strategies to circumvent theses hurdles. Recent in vivo reports signify that cytokine delivery platforms can increase their safety and therapeutic efficacy in tumor xenografts. Meanwhile, cytokine delivery using multipotent stem cells, in particular mesenchymal stem/stromal cells (MSCs), and also a diversity of particles and biomaterials has demonstrated greater capability in this regards. Herein, we take a glimpse into the recent advances in cytokine sustained delivery using stem cells and also biomaterials to ease safe and effective treatments of a myriad of human tumors.
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Affiliation(s)
| | - Ahmad Nazari
- Tehran University of Medical Sciences, Tehran, Iran
| | - Farshid Oruji
- College of Medicine, Department of Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Minoo Roostaie
- School of Medicine, Islamic Azad University Tehran Medical Branch, Tehran, Iran
| | - Ghazaleh Hosseininozari
- Department of Cell and Molecular biology, Babol Branch, Islamic Azad University, Babol, Iran
| | - Omid Yazdani
- Department of Medicine, Shahid Beheshti University, Tehran, Iran
| | - Romina Esbati
- Department of Medicine, Shahid Beheshti University, Tehran, Iran.
| | - Kamran Roudini
- Department of Internal Medicine, Cancer Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Iran.
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Zhang X, Xu Z, Dai X, Zhang X, Wang X. Research progress of neoantigen-based dendritic cell vaccines in pancreatic cancer. Front Immunol 2023; 14:1104860. [PMID: 36761724 PMCID: PMC9905145 DOI: 10.3389/fimmu.2023.1104860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/04/2023] [Indexed: 01/26/2023] Open
Abstract
The mutation of the crucial genes such as tumor suppressors or oncogenes plays an important role in the initiation and development of tumors. The non-synonymous mutations in the tumor cell genome will produce non-autologous proteins (neoantigen) to activate the immune system by activating CD4+ and CD8+ T cells. Neoantigen-based peptide vaccines have exhibited exciting therapeutic effects in treating various cancers alone or in combination with other therapeutic strategies. Furthermore, antigen-loaded DC vaccines are more powerful in inducing stronger immune responses than vaccines generated by antigens and adjuvants. Therefore, neoantigen-based dendritic cell (DC) vaccines could achieve promising effects in combating some malignant tumors. In this review, we summarized and discussed the recent research progresses of the neoantigen, neoantigen-based vaccines, and DC-based vaccine in pancreatic cancers (PCs). The combination of the neoantigen and DC-based vaccine in PC was also highlighted. Therefore, our work will provide more detailed evidence and novel opinions to promote the development of a personalized neoantigen-based DC vaccine for PC.
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Affiliation(s)
- Xin Zhang
- Department of Pathology, China-Japan Union Hospital, Jilin University, Changchun, Jilin, China
| | - Zheng Xu
- Department of Pathology, China-Japan Union Hospital, Jilin University, Changchun, Jilin, China
| | - Xiangpeng Dai
- Key Laboratory of Organ Regeneration and Transplantation of Ministry of Education, First Hospital of Jilin University, Changchun, China,National-Local Joint Engineering Laboratory of Animal Models for Human Disease, First Hospital of Jilin University, Changchun, China
| | - Xiaoling Zhang
- Key Laboratory of Organ Regeneration and Transplantation of Ministry of Education, First Hospital of Jilin University, Changchun, China,National-Local Joint Engineering Laboratory of Animal Models for Human Disease, First Hospital of Jilin University, Changchun, China
| | - Xueju Wang
- Department of Pathology, China-Japan Union Hospital, Jilin University, Changchun, Jilin, China,*Correspondence: Xueju Wang,
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12
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Yang H, Zhou X, Fu D, Le C, Wang J, Zhou Q, Liu X, Yuan Y, Ding K, Xiao Q. Targeting RAS mutants in malignancies: successes, failures, and reasons for hope. Cancer Commun (Lond) 2023; 43:42-74. [PMID: 36316602 PMCID: PMC9859734 DOI: 10.1002/cac2.12377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/15/2022] [Accepted: 10/13/2022] [Indexed: 01/22/2023] Open
Abstract
RAS genes are the most frequently mutated oncogenes and play critical roles in the development and progression of malignancies. The mutation, isoform (KRAS, HRAS, and NRAS), position, and type of substitution vary depending on the tissue types. Despite decades of developing RAS-targeted therapies, only small subsets of these inhibitors are clinically effective, such as the allele-specific inhibitors against KRASG12C . Targeting the remaining RAS mutants would require further experimental elucidation of RAS signal transduction, RAS-altered metabolism, and the associated immune microenvironment. This study reviews the mechanisms and efficacy of novel targeted therapies for different RAS mutants, including KRAS allele-specific inhibitors, combination therapies, immunotherapies, and metabolism-associated therapies.
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Affiliation(s)
- Hang Yang
- Department of Colorectal Surgery and OncologyKey Laboratory of Cancer Prevention and InterventionMinistry of EducationThe Second Affiliated HospitalZhejiang University School of MedicineHangzhouZhejiang310009P. R. China
| | - Xinyi Zhou
- Department of Colorectal Surgery and OncologyKey Laboratory of Cancer Prevention and InterventionMinistry of EducationThe Second Affiliated HospitalZhejiang University School of MedicineHangzhouZhejiang310009P. R. China
| | - Dongliang Fu
- Department of Colorectal Surgery and OncologyKey Laboratory of Cancer Prevention and InterventionMinistry of EducationThe Second Affiliated HospitalZhejiang University School of MedicineHangzhouZhejiang310009P. R. China
| | - Chenqin Le
- Department of Colorectal Surgery and OncologyKey Laboratory of Cancer Prevention and InterventionMinistry of EducationThe Second Affiliated HospitalZhejiang University School of MedicineHangzhouZhejiang310009P. R. China
| | - Jiafeng Wang
- Department of Pharmacology and Department of Gastroenterology of the Second Affiliated HospitalZhejiang University School of MedicineHangzhouZhejiang310058P. R. China
| | - Quan Zhou
- Department of Cell BiologySchool of Basic Medical SciencesZhejiang UniversityHangzhouZhejiang310058P. R. China
| | - Xiangrui Liu
- Department of Pharmacology and Department of Gastroenterology of the Second Affiliated HospitalZhejiang University School of MedicineHangzhouZhejiang310058P. R. China
- Cancer CenterZhejiang UniversityHangzhouZhejiang310058P. R. China
| | - Ying Yuan
- Department of Medical Oncologythe Second Affiliated Hospital of Zhejiang University School of MedicineHangzhouZhejiang310058P. R. China
| | - Kefeng Ding
- Department of Colorectal Surgery and OncologyKey Laboratory of Cancer Prevention and InterventionMinistry of EducationThe Second Affiliated HospitalZhejiang University School of MedicineHangzhouZhejiang310009P. R. China
- Cancer CenterZhejiang UniversityHangzhouZhejiang310058P. R. China
| | - Qian Xiao
- Department of Colorectal Surgery and OncologyKey Laboratory of Cancer Prevention and InterventionMinistry of EducationThe Second Affiliated HospitalZhejiang University School of MedicineHangzhouZhejiang310009P. R. China
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13
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Bhatia R, Bhyravbhatla N, Kisling A, Li X, Batra SK, Kumar S. Cytokines chattering in pancreatic ductal adenocarcinoma tumor microenvironment. Semin Cancer Biol 2022; 86:499-510. [PMID: 35346801 PMCID: PMC9510605 DOI: 10.1016/j.semcancer.2022.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 12/11/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) tumor microenvironment (TME) consists of multiple cell types interspersed by dense fibrous stroma. These cells communicate through low molecular weight signaling molecules called cytokines. The cytokines, through their receptors, facilitate PDAC initiation, progression, metastasis, and distant colonization of malignant cells. These signaling mediators secreted from tumor-associated macrophages, and cancer-associated fibroblasts in conjunction with oncogenic Kras mutation initiate acinar to ductal metaplasia (ADM), resulting in the appearance of early preneoplastic lesions. Further, M1- and M2-polarized macrophages provide proinflammatory conditions and promote deposition of extracellular matrix, whereas myofibroblasts and T-lymphocytes, such as Th17 and T-regulatory cells, create a fibroinflammatory and immunosuppressive environment with a significantly reduced cytotoxic T-cell population. During PDAC progression, cytokines regulate the expression of various oncogenic regulators such as NFκB, c-myc, growth factor receptors, and mucins resulting in the formation of high-grade PanIN lesions, epithelial to mesenchymal transition, invasion, and extravasation of malignant cells, and metastasis. During metastasis, PDAC cells colonize at the premetastatic niche created in the liver, and lung, an organotropic function primarily executed by cytokines in circulation or loaded in the exosomes from the primary tumor cells. The indispensable contribution of these cytokines at every stage of PDAC tumorigenesis makes them exciting candidates in combination with immune-, chemo- and targeted radiation therapy.
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Affiliation(s)
- Rakesh Bhatia
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Namita Bhyravbhatla
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Andrew Kisling
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Xiaoqi Li
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Surinder K Batra
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Fred and Pamela Buffett Cancer Center, Omaha, NE, USA; Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Sushil Kumar
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Fred and Pamela Buffett Cancer Center, Omaha, NE, USA.
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14
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Abstract
Pancreatic adenocarcinoma remains one of the most lethal cancers globally, with a significant need for improved therapeutic options. While the recent breakthroughs of immunotherapy through checkpoint inhibitors have dramatically changed treatment paradigms in other malignancies based on considerable survival benefits, this is not so for pancreatic cancer. Chemotherapies with modest benefits are still the cornerstone of advanced pancreatic cancer treatment. Pancreatic cancers are inherently immune-cold tumors and have been largely refractory to immunotherapies in clinical trials. Understanding and overcoming the current failures of immunotherapy through elucidating resistance mechanisms and developing novel therapeutic approaches are essential to harnessing the potential durable benefits of immune-modulating therapy in pancreatic cancer patients.
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Affiliation(s)
- Reetu Mukherji
- The Ruesch Center for the Cure of Gastrointestinal Cancers, Georgetown Lombardi Comprehensive Cancer Center, Division of Hematology and Oncology, Medstar Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Dipanjan Debnath
- Department of Internal Medicine, Medstar Washington Hospital Center, 110 Irving Street NW, Washington, DC 20010, USA
| | - Marion L. Hartley
- The Ruesch Center for the Cure of Gastrointestinal Cancers, Georgetown Lombardi Comprehensive Cancer Center, Division of Hematology and Oncology, Medstar Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Marcus S. Noel
- The Ruesch Center for the Cure of Gastrointestinal Cancers, Georgetown Lombardi Comprehensive Cancer Center, Division of Hematology and Oncology, Medstar Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC 20007, USA
- Correspondence:
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15
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Yu G, He X, Li X, Wu Y. Driving neoantigen-based cancer vaccines for personalized immunotherapy into clinic: A burdensome journey to promising land. Biomed Pharmacother 2022; 153:113464. [DOI: 10.1016/j.biopha.2022.113464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/15/2022] [Accepted: 07/21/2022] [Indexed: 11/02/2022] Open
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16
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Smith C, Zheng W, Dong J, Wang Y, Lai J, Liu X, Yin F. Tumor microenvironment in pancreatic ductal adenocarcinoma: Implications in immunotherapy. World J Gastroenterol 2022; 28:3297-3313. [PMID: 36158269 PMCID: PMC9346457 DOI: 10.3748/wjg.v28.i27.3297] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/22/2022] [Accepted: 06/20/2022] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma is one of the most aggressive and lethal cancers. Surgical resection is the only curable treatment option, but it is available for only a small fraction of patients at the time of diagnosis. With current therapeutic regimens, the average 5-year survival rate is less than 10% in pancreatic cancer patients. Immunotherapy has emerged as one of the most promising treatment options for multiple solid tumors of advanced stage. However, its clinical efficacy is suboptimal in most clinical trials on pancreatic cancer. Current studies have suggested that the tumor microenvironment is likely the underlying barrier affecting immunotherapy drug efficacy in pancreatic cancer. In this review, we discuss the role of the tumor microenvironment in pancreatic cancer and the latest advances in immunotherapy on pancreatic cancer.
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Affiliation(s)
- Caitlyn Smith
- Department of Pathology and Anatomical Sciences, University of Missouri School of Medicine, Columbia, MO 65212, United States
| | - Wei Zheng
- Department of Pathology, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Jixin Dong
- Eppley Institute for Research in Cancer and Allied Diseases, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE 68198, United States
| | - Yaohong Wang
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, United States
| | - Jinping Lai
- Department of Pathology and Laboratory Medicine, Kaiser Permanente Sacramento Medical Center, Sacramento, CA 95825, United States
| | - Xiuli Liu
- Department of Pathology and Immunology, Washington University, St. Louis, MO 63110, United States
| | - Feng Yin
- Department of Pathology and Anatomical Sciences, University of Missouri, Columbia, MO 65212, United States
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17
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Lu C, Zhu Y, Cheng H, Kong W, Zhu L, Wang L, Tang M, Chen J, Li Q, He J, Li A, Qiu X, Chen D, Meng F, Qian X, Liu B, Qiu Y, Du J. Case Report: Pathologic Complete Response to Induction Therapy in a Patient With Potentially Resectable Pancreatic Cancer. Front Oncol 2022; 12:898119. [PMID: 35734594 PMCID: PMC9207502 DOI: 10.3389/fonc.2022.898119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 04/22/2022] [Indexed: 11/21/2022] Open
Abstract
Immune monotherapy does not appear to work in patients with pancreatic cancer so far. We are conducting a clinical trial that combines programmed cell death protein-1 (PD-1) inhibitor with chemotherapy and concurrent radiotherapy as induction therapy for patients with locally advanced pancreatic cancer (LAPC) and borderline resectable pancreatic cancer (BRPC). Here, we report a case with a pathologic complete response (pCR) and no postoperative complications after the induction therapy. The patient received four cycles of induction therapy and achieved a partial response (PR) with a significant decline of tumor marker carbohydrate antigen 19-9 (CA19-9). Also, peripheral blood samples were collected during the treatment to investigate serial circulating tumor DNA (ctDNA) dynamic changes in predicting the tumor response and outcomes in patients. Our result suggested that PD-1 blockade plus chemotherapy and concurrent radiotherapy is a promising mode as induction therapy for patients with potentially resectable pancreatic cancer. In this case, serial ctDNA alterations accurately provide a comprehensive outlook of the tumor status and monitor the response to the therapy, as validated by standard imaging.
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Affiliation(s)
- Changchang Lu
- The Comprehensive Cancer Center of Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.,Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
| | - Yahui Zhu
- The Comprehensive Cancer Center of Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Hao Cheng
- Department of Hepatopancreatobiliary Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Weiwei Kong
- The Comprehensive Cancer Center of Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Linxi Zhu
- Department of Hepatopancreatobiliary Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Lei Wang
- Digestive Department of Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Min Tang
- Imaging Department of Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jun Chen
- Pathology Department of Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Qi Li
- Pathology Department of Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jian He
- Nuclear Medicine Department of Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Aimei Li
- Nuclear Medicine Department of Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xin Qiu
- Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
| | - Dongsheng Chen
- The State Key Laboratory of Translational Medicine and Innovative Drug Development, Medical Department, Jiangsu Simcere Diagnostics Co., Ltd., Nanjing, China
| | - Fanyan Meng
- The Comprehensive Cancer Center of Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiaoping Qian
- The Comprehensive Cancer Center of Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Baorui Liu
- The Comprehensive Cancer Center of Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yudong Qiu
- Department of Hepatopancreatobiliary Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Juan Du
- The Comprehensive Cancer Center of Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
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18
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Yin C, Alqahtani A, Noel MS. The Next Frontier in Pancreatic Cancer: Targeting the Tumor Immune Milieu and Molecular Pathways. Cancers (Basel) 2022; 14:2619. [PMID: 35681599 PMCID: PMC9179513 DOI: 10.3390/cancers14112619] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/13/2022] [Accepted: 05/19/2022] [Indexed: 12/11/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive cancer with abysmal prognosis. It is currently the third most common cause of cancer-related mortality, despite being the 11th most common cancer. Chemotherapy is standard of care in all stages of pancreatic cancer, yet survival, particularly in the advanced stages, often remains under one year. We are turning to immunotherapies and targeted therapies in PDAC in order to directly attack the core features that make PDAC notoriously resistant to chemotherapy. While the initial studies of these agents in PDAC have generally been disappointing, we find optimism in recent preclinical and early clinical research. We find that despite the immunosuppressive effects of the PDAC tumor microenvironment, new strategies, such as combining immune checkpoint inhibitors with vaccine therapy or chemokine receptor antagonists, help elicit strong immune responses. We also expand on principles of DNA homologous recombination repair and highlight opportunities to use agents, such as PARP inhibitors, that exploit deficiencies in DNA repair pathways. Lastly, we describe advances in direct targeting of driver mutations and metabolic pathways and highlight some technological achievements such as novel KRAS inhibitors.
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Affiliation(s)
| | | | - Marcus S. Noel
- Ruesch Center for the Cure of Gastrointestinal Cancers, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC 20007, USA; (C.Y.); (A.A.)
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19
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Guiren Fritah H, Rovelli R, Lai-Lai Chiang C, Kandalaft LE. The current clinical landscape of personalized cancer vaccines. Cancer Treat Rev 2022; 106:102383. [DOI: 10.1016/j.ctrv.2022.102383] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 03/20/2022] [Indexed: 12/11/2022]
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20
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Wandmacher AM, Letsch A, Sebens S. Challenges and Future Perspectives of Immunotherapy in Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13164235. [PMID: 34439389 PMCID: PMC8391691 DOI: 10.3390/cancers13164235] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/19/2021] [Accepted: 08/20/2021] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Immunotherapeutic agents harness the patient’s immune system to fight cancer cells. Especially immune checkpoint inhibitors, a certain group of immunotherapeutic agents, have recently improved treatment options for many cancer types. Unfortunately, clinical trials testing of these agents in pancreatic cancer patients have not confirmed promising results from laboratory experiments. Several characteristics of pancreatic cancer biology, especially the profound tumour microenvironment that inhibits the successful identification and elimination of tumour cells by immune cells seems to be responsible for the lacking efficacy of immunotherapeutics in pancreatic cancer. We summarise recently published clinical trials investigating immunotherapeutic strategies in pancreatic cancer patients and available data on how these treatments influence pancreatic cancer biology. Moreover, we identify potential strategies to improve experimental and clinical studies in order to generate more conclusive data and improve patient outcomes in the future. Abstract To date, extensive efforts to harness immunotherapeutic strategies for the treatment of pancreatic ductal adenocarcinoma (PDAC) have yielded disappointing results in clinical trials. These strategies mainly focused on cancer vaccines and immune checkpoint inhibitors alone or in combination with chemotherapeutic or targeted agents. However, the growing preclinical and clinical data sets from these efforts have established valuable insights into the immunological characteristics of PDAC biology. Most notable are the immunosuppressive role of the tumour microenvironment (TME) and PDAC’s characteristically poor immunogenicity resulting from tumour intrinsic features. Moreover, PDAC tumour heterogeneity has been increasingly well characterized and may additionally limit a “one-fits-all” immunotherapeutic strategy. In this review, we first outline mechanisms of immunosuppression and immune evasion in PDAC. Secondly, we summarize recently published data on preclinical and clinical efforts to establish immunotherapeutic strategies for the treatment of PDAC including diverse combinatorial treatment approaches aiming at overcoming this resistance towards immunotherapeutic strategies. Particularly, these combinatorial treatment approaches seek to concomitantly increase PDAC antigenicity, boost PDAC directed T-cell responses, and impair the immunosuppressive character of the TME in order to allow immunotherapeutic agents to unleash their full potential. Eventually, the thorough understanding of the currently available data on immunotherapeutic treatment strategies of PDAC will enable researchers and clinicians to develop improved treatment regimens and to design innovative clinical trials to overcome the pronounced immunosuppression of PDAC.
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Affiliation(s)
- Anna Maxi Wandmacher
- Department of Internal Medicine II, University Medical Center Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany; (A.M.W.); (A.L.)
- Institute for Experimental Cancer Research, Kiel University and University Hospital Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany
| | - Anne Letsch
- Department of Internal Medicine II, University Medical Center Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany; (A.M.W.); (A.L.)
| | - Susanne Sebens
- Institute for Experimental Cancer Research, Kiel University and University Hospital Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany
- Correspondence:
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21
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Timmer FEF, Geboers B, Nieuwenhuizen S, Dijkstra M, Schouten EAC, Puijk RS, de Vries JJJ, van den Tol MP, Bruynzeel AME, Streppel MM, Wilmink JW, van der Vliet HJ, Meijerink MR, Scheffer HJ, de Gruijl TD. Pancreatic Cancer and Immunotherapy: A Clinical Overview. Cancers (Basel) 2021; 13:4138. [PMID: 34439292 DOI: 10.3390/cancers13164138] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/10/2021] [Accepted: 08/13/2021] [Indexed: 12/13/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive disease with high mortality. The vast majority of patients present with unresectable, advanced stage disease, for whom standard of care chemo(radio)therapy may improve survival by several months. Immunotherapy has led to a fundamental shift in the treatment of several advanced cancers. However, its efficacy in PDAC in terms of clinical benefit is limited, possibly owing to the immunosuppressive, inaccessible tumor microenvironment. Still, various immunotherapies have demonstrated the capacity to initiate local and systemic immune responses, suggesting an immune potentiating effect. In this review, we address PDAC's immunosuppressive tumor microenvironment and immune evasion methods and discuss a wide range of immunotherapies, including immunomodulators (i.e., immune checkpoint inhibitors, immune stimulatory agonists, cytokines and adjuvants), oncolytic viruses, adoptive cell therapies (i.e., T cells and natural killer cells) and cancer vaccines. We provide a general introduction to their working mechanism as well as evidence of their clinical efficacy and immune potentiating abilities in PDAC. The key to successful implementation of immunotherapy in this disease may rely on exploitation of synergistic effects between treatment combinations. Accordingly, future treatment approaches should aim to incorporate diverse and novel immunotherapeutic strategies coupled with cytotoxic drugs and/or local ablative treatment, targeting a wide array of tumor-induced immune escape mechanisms.
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22
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Abstract
Neoantigens, a type of tumor-specific antigens derived from non-synonymous mutations, have recently been characterized as attractive targets for cancer immunotherapy. Owing to the development of next-generation sequencing and utilization of machine-learning algorithms, it has become feasible to computationally predict neoantigens by depicting genetic alterations, aberrant post-transcriptional mRNA processing and abnormal mRNA translation events within tumor tissues. Consequently, neoantigen-based therapies such as cancer vaccines have been widely tested in clinical trials and have demonstrated promising safety and efficacy, opening a new era for cancer immunotherapy. We systematically summarize recent advances in the identification of both personalized and public neoantigens, neoantigen formulations and neoantigen-based clinical trials in this review. Moreover, we discuss future techniques and strategies for neoantigen-based cancer treatment either as a monotherapy or as a combination therapy with radiotherapy, chemotherapy or immune checkpoint inhibitors.
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Affiliation(s)
- Xuan Zhao
- Biotherapy Center & Cancer Center, The First Affiliated Hospital of Zhengzhou University, 450052, Zhengzhou, China.,State Key Laboratory of Esophageal Cancer Prevention & Treatment, Zhengzhou University, 450052, Zhengzhou, China
| | - Xiaoxin Pan
- Shenzhen NeoCura Biotechnology Corporation, 518055, Shenzhen, China
| | - Yi Wang
- Shenzhen NeoCura Biotechnology Corporation, 518055, Shenzhen, China
| | - Yi Zhang
- Biotherapy Center & Cancer Center, The First Affiliated Hospital of Zhengzhou University, 450052, Zhengzhou, China. .,State Key Laboratory of Esophageal Cancer Prevention & Treatment, Zhengzhou University, 450052, Zhengzhou, China. .,School of Life Sciences, Zhengzhou University, 450052, Zhengzhou, China. .,Henan Key Laboratory for Tumor Immunology and Biotherapy, 450052, Zhengzhou, China.
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23
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Abstract
The immunoprevention of cancer and cancer recurrence is an important area of concern for the scientific community and society as a whole. Researchers have been working for decades to develop vaccines with the potential to alleviate these health care and economic burdens. So far, vaccines have made more progress in preventing cancer than in eliminating already established cancer. In particular, vaccines targeting oncogenic viruses, such as the human papillomavirus and the hepatitis B virus, are exceptional examples of successful prevention of virus-associated cancers, such as cervical cancer and hepatocellular carcinoma. Cancer-preventive vaccines targeting nonviral antigens, such as tumor-associated antigens and neoantigens, are also being extensively tested. Here, we review the currently approved preventive cancer vaccines; discuss the challenges in this field by covering ongoing preclinical and clinical human trials in various cancers; and address various issues related to maximizing cancer vaccine benefit.
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Affiliation(s)
- Tomohiro Enokida
- Department of Medicine, Precision Immunology Institute, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alvaro Moreira
- Department of Medicine, Precision Immunology Institute, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- The Kimberly and Eric J. Waldman Department of Dermatology at Mount Sinai, New York, New York, USA
| | - Nina Bhardwaj
- Department of Medicine, Precision Immunology Institute, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- The Kimberly and Eric J. Waldman Department of Dermatology at Mount Sinai, New York, New York, USA
- Extramural member of the Parker Institute for Cancer Immunotherapy, San Francisco, California, USA
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24
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Miyazawa M, Katsuda M, Kawai M, Hirono S, Okada KI, Kitahata Y, Yamaue H. Advances in immunotherapy for pancreatic ductal adenocarcinoma. J Hepatobiliary Pancreat Sci 2021; 28:419-430. [PMID: 33742512 DOI: 10.1002/jhbp.944] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 12/14/2022]
Abstract
Advances in immunotherapy against advanced cancers can be considered stunning and epoch-making. Meanwhile, efficacy of immune-based therapies, especially immune checkpoint inhibitors, remains insufficient in pancreatic ductal adenocarcinoma, differing from other immunogenic cancers. To date, neither immunotherapies targeting immune system acceleration nor release of immunologic brakes have been able to overcome the robust immune barrier in the pancreatic tumor microenvironment, which is characterized by rich fibrotic stroma and accumulation of immunosuppressive myeloid cells. However, by receiving an immune checkpoint blockade, patients with abundant tumor-infiltrating lymphocytes in pancreatic ductal adenocarcinoma clearly have better prognosis, and patients with mismatch repair deficiency have achieved better outcomes, albeit in a small population of pancreatic ductal adenocarcinoma. We overview recent preclinical and clinical studies that have been concerned with immune-based therapies including cancer vaccine and immune checkpoint inhibitors. By providing a deep insight into the immunosuppressive tumor microenvironment, we suggest the possibility of comprehensive immune intensification that could reverse the tumor microenvironment, making it conducive to cytotoxic T lymphocyte activity for overcoming pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Motoki Miyazawa
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masahiro Katsuda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Manabu Kawai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Seiko Hirono
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Ken-Ichi Okada
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yuji Kitahata
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
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25
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Chen F, Yao C, Feng Y, Yu Y, Guo H, Yan J, Chen J. The identification of neutrophils-mediated mechanisms and potential therapeutic targets for the management of sepsis-induced acute immunosuppression using bioinformatics. Medicine (Baltimore) 2021; 100:e24669. [PMID: 33761636 PMCID: PMC9282053 DOI: 10.1097/md.0000000000024669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 01/18/2021] [Indexed: 01/05/2023] Open
Abstract
Neutrophils have crucial roles in defensing against infection and adaptive immune responses. This study aimed to investigate the genetic mechanism in neutrophils in response to sepsis-induced immunosuppression.The GSE64457 dataset was downloaded from the Gene Expression Omnibus database and the neutrophil samples (D3-4 and D6-8 post sepsis shock) were assigned into two groups. The differentially expressed genes (DEGs) were identified. The Short Time-series Expression Miner (STEM) clustering analysis was conducted to select the consistently changed DEGs post sepsis shock. The overlapping genes between the DEGs and the deposited genes associated with immune, sepsis, and immunosuppression in the AmiGO2 and Comparative Toxicogenomics Database were screened out and used for the construction of the protein-protein interaction (PPI) network. The expression of several hub genes in sepsis patients was validated using the PCR analysis. The drugs targeting the hub genes and the therapy strategies for sepsis or immunosuppression were reviewed and used to construct the drug-gene-therapy-cell network to illustrate the potential therapeutic roles of the hub genes.A total of 357 overlapping DEGs between the two groups were identified and were used for the STEM clustering analysis, which generated four significant profiles with 195 upregulated (including annexin A1, ANXA1; matrix metallopeptidase 9, MMP9; and interleukin 15, IL-15) and 151 downregulated DEGs (including, AKT1, IFN-related genes, and HLA antigen genes). Then, a total of 34 of the 151 downregulated DEGs and 39 of the 195 upregulated DEGs were shared between the databases and above DEGs, respectively. The PPI network analysis identified a downregulated module including IFN-related genes. The deregulation of DEGs including AKT1 (down), IFN-inducible protein 6 (IFI6, down), IL-15 (up), and ANXA1 (up) was verified in the neutrophils from patients with sepsis-induced immunosuppression as compared with controls. Literature review focusing on the therapy showed that the upregulation of IL-15, IFN, and HLA antigens are the management targets. Besides, the AKT1 gene was targeted by gemcitabine.These findings provided additional clues for understanding the mechanisms of sepsis-induced immunosuppression. The drugs targeting AKT1 might provide now clues for the management strategy of immunosuppression with the intention to prevent neutrophil infiltration.
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Affiliation(s)
- Fang Chen
- Nursing Department, Zhejiang Hospital
| | - Chunyan Yao
- Institute of Health Food, Zhejiang Academy of Medical Sciences
| | - Yue Feng
- Radiology Department, Zhejiang Hospital
| | - Ying Yu
- Institute of Health Food, Zhejiang Academy of Medical Sciences
| | - Honggang Guo
- Zhejiang Experimental Animal Center, Zhejiang Academy of Medical Sciences
| | - Jing Yan
- Intensive Care Unit, Zhejiang Hospital
| | - Jin Chen
- General Practice Department, Zhejiang Hospital, Hangzhou, Zhejiang, China
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26
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Luchini C, Paolino G, Mattiolo P, Piredda ML, Cavaliere A, Gaule M, Melisi D, Salvia R, Malleo G, Shin JI, Cargnin S, Terrazzino S, Lawlor RT, Milella M, Scarpa A. KRAS wild-type pancreatic ductal adenocarcinoma: molecular pathology and therapeutic opportunities. J Exp Clin Cancer Res 2020; 39:227. [PMID: 33115526 PMCID: PMC7594413 DOI: 10.1186/s13046-020-01732-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/13/2020] [Indexed: 12/24/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a deadly disease, whose main molecular trait is the MAPK pathway activation due to KRAS mutation, which is present in 90% of cases.The genetic landscape of KRAS wild type PDAC can be divided into three categories. The first is represented by tumors with an activated MAPK pathway due to BRAF mutation that occur in up to 4% of cases. The second includes tumors with microsatellite instability (MSI) due to defective DNA mismatch repair (dMMR), which occurs in about 2% of cases, also featuring a high tumor mutational burden. The third category is represented by tumors with kinase fusion genes, which marks about 4% of cases. While therapeutic molecular targeting of KRAS is an unresolved challenge, KRAS-wild type PDACs have potential options for tailored treatments, including BRAF antagonists and MAPK inhibitors for the first group, immunotherapy with anti-PD-1/PD-L1 agents for the MSI/dMMR group, and kinase inhibitors for the third group.This calls for a complementation of the histological diagnosis of PDAC with a routine determination of KRAS followed by a comprehensive molecular profiling of KRAS-negative cases.
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Affiliation(s)
- Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, 37134, Verona, Italy
| | - Gaetano Paolino
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, 37134, Verona, Italy
| | - Paola Mattiolo
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, 37134, Verona, Italy
| | - Maria L Piredda
- ARC-Net Research Center, University and Hospital Trust of Verona, 37134, Verona, Italy
| | - Alessandro Cavaliere
- Section of Oncology, Department of Medicine, University and Hospital Trust of Verona, Piazzale L.A. Scuro 10, 37134, Verona, VR, Italy
| | - Marina Gaule
- Section of Oncology, Department of Medicine, University and Hospital Trust of Verona, Piazzale L.A. Scuro 10, 37134, Verona, VR, Italy
| | - Davide Melisi
- Section of Oncology, Department of Medicine, University and Hospital Trust of Verona, Piazzale L.A. Scuro 10, 37134, Verona, VR, Italy
| | - Roberto Salvia
- Department of Surgery, University of Verona, 37134, Verona, Italy
| | - Giuseppe Malleo
- Department of Surgery, University of Verona, 37134, Verona, Italy
| | - Jae Il Shin
- Yonsei University College of Medicine, 03722, Seoul, Republic of Korea
| | - Sarah Cargnin
- Department of Pharmaceutical Sciences and Interdepartmental Research Center of Pharmacogenetics and Pharmacogenomics (CRIFF), University of Piemonte Orientale, 28100, Novara, Italy
| | - Salvatore Terrazzino
- Department of Pharmaceutical Sciences and Interdepartmental Research Center of Pharmacogenetics and Pharmacogenomics (CRIFF), University of Piemonte Orientale, 28100, Novara, Italy
| | - Rita T Lawlor
- ARC-Net Research Center, University and Hospital Trust of Verona, 37134, Verona, Italy
| | - Michele Milella
- Section of Oncology, Department of Medicine, University and Hospital Trust of Verona, Piazzale L.A. Scuro 10, 37134, Verona, VR, Italy.
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, 37134, Verona, Italy
- ARC-Net Research Center, University and Hospital Trust of Verona, 37134, Verona, Italy
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27
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Mejia I, Bodapati S, Chen KT, Díaz B. Pancreatic Adenocarcinoma Invasiveness and the Tumor Microenvironment: From Biology to Clinical Trials. Biomedicines 2020; 8:E401. [PMID: 33050151 PMCID: PMC7601142 DOI: 10.3390/biomedicines8100401] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/28/2020] [Accepted: 10/03/2020] [Indexed: 12/18/2022] Open
Abstract
Pancreatic adenocarcinoma (PDAC) originates in the glandular compartment of the exocrine pancreas. Histologically, PDAC tumors are characterized by a parenchyma that is embedded in a particularly prominent stromal component or desmoplastic stroma. The unique characteristics of the desmoplastic stroma shape the microenvironment of PDAC and modulate the reciprocal interactions between cancer and stromal cells in ways that have profound effects in the pathophysiology and treatment of this disease. Here, we review some of the most recent findings regarding the regulation of PDAC cell invasion by the unique microenvironment of this tumor, and how new knowledge is being translated into novel therapeutic approaches.
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Affiliation(s)
- Isabel Mejia
- Department of Medicine, Division of Medical Hematology Oncology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA 90502, USA;
| | - Sandhya Bodapati
- College of Osteopathic Medicine, Pacific Western University of Health Sciences, Pomona, CA 91766, USA;
| | - Kathryn T. Chen
- Department of Surgery, Division of Surgical Oncology, Harbor-UCLA Medical Center, Torrance, CA 90502, USA;
| | - Begoña Díaz
- Department of Medicine, Division of Medical Hematology Oncology, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA 90502, USA;
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA 90095, USA
- Jonsson Comprehensive Cancer Center, University of California at Los Angeles, Los Angeles, CA 90095, USA
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28
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Nsingwane Z, Candy G, Devar J, Omoshoro-Jones J, Smith M, Nweke E. Immunotherapeutic strategies in pancreatic ductal adenocarcinoma (PDAC): current perspectives and future prospects. Mol Biol Rep 2020; 47:6269-6280. [PMID: 32661873 DOI: 10.1007/s11033-020-05648-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 07/08/2020] [Indexed: 01/08/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is among the deadliest human malignancies with a dismal prognosis. During PDAC progression, the immune response is affected as cancer cells evade detection and elimination. Recently, there have been advances in the treatment of PDAC using immunotherapy, although a lot more work is yet to be done. In this review, we discuss these advances, challenges and potentials. We focus on existing and potential immune targets for PDAC, drugs used to target them, and some clinical trials conducted so far with them. Finally, novel targets in the tumour microenvironment such as stromal cells and other potential future areas to explore including bacterial therapy and the use of neoantigens in immunotherapy are highlighted.
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Affiliation(s)
- Zanele Nsingwane
- Department of Surgery, Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa.
| | - Geoffrey Candy
- Department of Surgery, Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
| | - John Devar
- Department of Surgery, Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
| | - Jones Omoshoro-Jones
- Department of Surgery, Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
| | - Martin Smith
- Department of Surgery, Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
| | - Ekene Nweke
- Department of Surgery, Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
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