Oncogene (2008) 27, 158160

& 2008 Nature Publishing Group All rights reserved 0950-9232/08 $30.00
www.nature.com/onc

INTRODUCTION

Toll-like receptors in cancer

LAJ ONeill
School of Biochemistry and Immunology, Trinity College, Dublin, Ireland

Oncogene (2008) 27, 158160; doi:10.1038/sj.onc.1210903 This special issue comprises 10 reviews that discuss the potential of targeting a family of receptors termed the Toll-like receptors (TLRs) in cancer. With one drug already in the clinic for basal cell carcinoma (the TLR7 agonist imiquimod) and several clinical trials underway for other TLR-targeted drugs for various other malignancies, the clinical interest in TLRs continues to grow. Also of importance are fundamental studies on the role of TLRs in different types of cancer, notably in leukaemias, prostate cancer, ovarian cancer and gastrointestinal malignancies. These studies are revealing new mechanisms underlying tumorigenesis and also the capacity of the immune system to limit tumour development and growth. Agents that activate TLRs, either alone or possibly more importantly in combination with other approaches, including radiation therapy and chemotherapy, could have great potential as novel anticancer agents. Equally however, inhibiting certain TLRs in inammation-associated cancers might yield new therapies. Immunologists were rst alerted to the importance of TLRs in 1997, with a description of human Toll (subsequently named TLR4), a protein expressed on macrophages that when active was pro-inammatory (Medzhitov and Janeway, 1997). Toll had in fact rst been described in Drosophila as a protein important in development (Anderson et al., 1985). It was subsequently shown that Toll also plays a key role in antifungal defence in Drosophila (Lemaitre et al., 1996), opening the way for studies on TLRs in the innate immune system of other organisms. This led to an intensive and highly productive period of research, which revealed a great deal of complexity in the innate immune system and provided a key missing link in the events that occur during host defence that lead to both innate and adaptive immunity. TLRs also provided the mechanism, whereby inammatory cytokines are induced during infection and also in tissue injury, since they sense microbial products or products of inamed tissues, and trigger signalling pathways culminating in the activation of the key transcription factor NF-kB (Doyle and ONeill, 2006). There are 10 TLRs in humans that recognize various microbial products, and
Correspondence: Professor LAJ ONeill, School of Biochemistry and Immunology, Trinity College, Dublin, Ireland. E-mail: laoneill@tcd.ie

they signal via a specic set of adapter proteins termed MyD88, Mal, Trif and Tram (ONeill and Bowie, 2007). For obvious reasons, they have been mostly studied in the context of immunity to microbes and also during inammation, and have been implicated in such clinical conditions as septic shock, inammatory bowel disease, rheumatoid arthritis and systemic lupus erythematosis (ONeill, 2006). However, researchers interested in cancer, and most particularly, cancer associated with inammation, have also developed a strong interest in TLRs. This interest can in fact be dated back over 100 years, when William Coley demonstrated that crude microbial extracts (most probably, streptococci) when given repeatedly, could promote an antitumour response in several different types of cancer. It is highly likely that these extracts were in part acting via TLRs to promote an immune response to tumours. Another important nding prior to the discovery of TLRs was the observation that the BCG vaccine has efcacy in bladder cancer, and recently, it has been shown that this effect is likely to be due to the activation of TLR2 and -4 (Uehori et al., 2003). As is often the case in medical research therefore, others had already made clinical observations that are now explicable in molecular terms because of the advances made in molecular and cellular biology. Somewhat appropriately therefore, the rst review is by Art Kreig of Coley Pharmaceutical Group, the company at the forefront of developing agonists for TLRs in cancer. Krieg provides an excellent overview of TLR9-stimulating agents. Four different TLR9 ligands are currently in clinical developmentPF-3512676, ISS1018, IMO-2055 and CpG-28. Each of these show efcacy in animal models and are at various stages of development, either as monotherapies or in combination with other agents. The most advanced is Coleys own PF-3512676, which in a Phase II trial doubled the response rate to chemotherapy in non-small cell lung cancer. Disappointingly, this was not however repeated in a Phase III study. As Kreig argues, however, this could be due to the fact that patients in the trial were immunosuppressed, and in fact, this presents a major challenge for any trial in cancer involving immunotherapy. Patients are normally in a very immunosuppressed state, either because of previous therapy or because of the immunosuppressive effects of the tumours themselves. This lessens the chances of an immunotherapeutic agent working. However, as Kreig points out, the promise of using TLR9 agonists has to be viewed as substantial when given in combination with other

Toll-like receptors in cancer LAJ ONeill

159

agents, particularly those targeting angiogenesis, or with agents such as anti-CTLA4, which have immunopotentiating effects on cytotoxic T-cell responses. This theme is followed up in the next two reviews. Conroy et al. discuss the prospect of using TLR ligands to break tolerance to self-antigens and thereby promote an immune response to tumour antigens. However efcacy might be limited because TLRs can also generate immunosuppression in their own right in certain scenarios, possibly via effects on regulatory T cells. If this effect can be limited, again in the context of a combination approach (for example, using antiCTLA4 or anti-IL10) this might greatly enhance the efcacy of TLR ligands. Similarly, Wang and colleagues discuss the use of TLR8 activators. These might be particularly efcacious since they have been shown to reverse the suppressive function of regulatory T cells, which when combined with their activating effects on dendritic cells, results in a strong anti-tumour response. This might explain why imiquimod, which is an agonist to the related TLR7 is efcacious in basal cell carcinoma. A general overview of the use of TLR7 and -8 agonists in cancer is presented by Schon and Schon. They also raise the intriguing possibility that imiquimod might act in part by antagonizing adenosine receptors, which would relieve the inhibitory effect that these receptors have on pro-inammatory cytokine production. It therefore appears that in order for TLR agonists to be effective in cancer, there must also be an inhibition of immunosuppressive mechanisms, hence the need for combination therapies. One particularly interesting combination might be with radiation therapy. Roses et al. provides us with the intriguing information that instead of being immunosuppressive (as was always thought), radiation therapy might have specic immunostimulatory effects via TLRs. Radiation may in fact release endogenous ligands for TLRs, or possibly microbial products from commensal bacteria in the gut such as LPS, which activates TLRs and provokes an antitumour response. They also describe how a combination of radiotherapy with TLR9 stimulation is highly efcacious in a murine model of brosarcoma. There is also evidence that TLR9 activation might lead to radiosensitization in tumours, again pointing to combination therapy as a potentially fruitful approach. Sensitization is also discussed by Spaner and colleagues, who ask the question why have TLR agonists only been shown to be effective in cutaneous leukaemias and lymphomas but not in systemic disease? Could it be that TLRs act as sensitizers, making tumour cells sensitive to cytotoxic effector cells and antitumour drugs, and that in the tumour microenvironment this effect is limited, again by immunosuppressive cytokines, nucleosides or hypoxia? They suggest that concomitant use of agents to counter this intrinsic environment together with TLR agonists could prove highly effective. The remaining four reviews provide us with an opposite role for TLRs in cancer: promoting tumorigenesis via pro-inammatory effects. Huang et al. describe how TLR activation has been shown to have a positive effect on tumour cells and also promote

inammation that has been associated with tumorigenesis. They summarize a literature describing how TLR ligands cause tumour cell proliferation, resistance to apoptosis and metastasis, with TLRs being expressed on many tumour cell types, notably those in leukaemia. Perhaps in certain contexts, therefore, inhibiting TLRs might be useful. The two next reviews also discuss the importance of inammation in cancer development. Chen et al. give an excellent overview of inammation and cancer. They specically address their own work on TLR4 in ovarian cancer, where TLR4 activation generates a pro-inammatory environment that might lead to tumour formation and metastasis. A particularly interesting aspect here is the induction by TLRs of two microRNAsmiR155 and -146. Both of these miRNAs are highly expressed in various cancers and appear to be important for tumorigenesis. Perhaps, their induction is an important aspect of how inammation and TLRs might actually promote cancer. Fukata and Abreu provide us with a compelling overview on the role of TLRs in gastrointestinal malignancies. They remind us that the gastrointestinal tract has a higher incidence of cancer than any other system, and how chronic inammation drives malignancynotably in Barretts oesophagus, ulcerative colitis and in Helicobacter pyloriassociated gastric cancer, with the severity of inammation correlating with risk. Ligands for TLRs derived from commensals or pathogenic microbes might be the key drivers of inammation and malignancy in these diseases. Most interestingly, they point out how the APC model of colorectal cancer requires the TLR adapter protein MyD88. They also provide us with a possible mechanism, whereby TLR4 via MyD88 and NF-kB induces COX2 in intestinal epithelial cells, leading to proliferation and transformation. They further suggest that targeted inhibition of TLR pathways might provide an effective strategy in preventing gastrointestinal malignancies. Finally, El-Omar and Hold continue the theme of inammation and cancer by giving us a detailed account of polymorphisms in TLR genes and the risk of developing cancer. A TLR4 variant has been shown to associate with prostate cancer and also H. pylori-associated gastric cancer, and single nucleotide polymorphisms (SNPs) in TLR1, -4, -6 and -10 have been shown to associate with prostate cancer. Further analysis of SNPs in TLRs or signalling proteins in cancer may prove very fruitful, for prognosis, to help validate targets for therapy and to clarify the precise roles of TLRs in different cancers. These reviews therefore provide an excellent starting point for those interested in the role of TLRs in cancer. TLRs are primary drivers of innate immunity, and there is increasing evidence that innate cells such as macrophages and neutrophils have potent antitumour effects. This has most recently been seen in a study by Hicks et al. (2006), who have demonstrated that the basis for complete tumour resistance in the spontaneous regression/complete resistance mouse is due to innate cells whose antitumour effect can be adoptively transferred to recipient mice. Cancer researchers investigating antitumour immunity are colloquially referring to the
Oncogene

Toll-like receptors in cancer LAJ ONeill

160

donor mouse as the wonder mouse (J Obijeski, personal communication), and there is a strong likelihood that TLRs are involved in this process. The engagement of the innate system via TLRs, probably in combination with other anticancer agents, therefore
References Anderson KV, Jurgens G, Nusslein-Volhard C. (1985). Establishment of dorsalventral polarity in the Drosophila embryo: genetic studies on the role of the Toll gene product. Cell 42: 779789. Doyle SL, ONeill LAJ. (2006). Toll-like receptors: from the discovery of NFkappaB to new insights into transcriptional regulations in innate immunity. Biochem Pharmacol 72: 11021113. Hicks AM, Riedlinger G, Willingham MC, Alexander-Miller MA, Von Kap-Herr C, Pettenati MJ et al. (2006). Transferable anticancer innate immunity in spontaneous regression/ complete resistance mice. Proc Natl Acad Sci USA 103: 77537758. Lemaitre B, Nicolas E, Michaut L, Reichhart JM, Hoffmann JA. (1996). The dorsoventral regulatory gene cassette

provides us with the very exciting prospect of the development of new approaches to treat malignancies. Equally however, the inhibition of TLRs may be effective in certain inammation-associated cancers. Further studies are therefore eagerly awaited.

spatzle/Toll/cactus controls the potent antifungal response in Drosophila adults. Cell 86: 973983. Medzhitov R, Janeway Jr CA. (1997). A human homologue of the Drosophila Toll protein signals activation of adaptive immunity. Nature 388: 394397. ONeill LA. (2006). Targeting signal transduction as a strategy to treat inammatory diseases. Nat Rev Drug Discov 5: 549563. ONeill LA, Bowie AG. (2007). The family of ve: TIR domain containing adapters in TLR signalling. Nat Rev Immunol 7: 353364. Uehori J, Matsumoto M, Tsuji S, Akazawa T, Takeuchi O, Akira S et al. (2003). Simultaneous blocking of human Tolllike receptors 2 and 4 suppresses myeloid dendritic cell activation induced by Mycobacterium bovis bacillus Calmette-Guerin peptidoglycan. Infect Immun 71: 42384249.

Oncogene