EUROPEAN UROLOGY 68 (2015) 267–279

available at www.sciencedirect.com
journal homepage: www.europeanurology.com

Platinum Priority – Review – Bladder Cancer

Editorial by Tom Powles on pp. 280–282 of this issue

A Systematic Review of Immunotherapy in Urologic Cancer:

Evolving Roles for Targeting of CTLA-4, PD-1/PD-L1, and HLA-G

Edgardo D. Carosella a,b,*, Guillaume Ploussard c, Joel LeMaoult a,b, Francois Desgrandchamps a,b,c
a
CEA, Institute of Emerging Diseases and Innovative Therapies (iMETI), Research Division in Hematology and Immunology (SRHI), Saint-Louis Hospital, Paris,
b c
France; University Paris Diderot, Sorbonne Paris Cité, UMR E_5 Institut Universitaire d’Hematologie, Saint-Louis Hospital, Paris, France; Urology
Department, Saint-Louis Hospital, Paris, France

Article info Abstract

Article history: Context: Overexpression of immune checkpoint molecules affects tumor-specific T-cell
Accepted February 25, 2015 immunity in the cancer microenvironment, and can reshape tumor progression and
metastasis. Antibodies targeting checkpoints could restore antitumor immunity by
blocking the inhibitory receptor-ligand interaction.
Keywords: Objective: To analyze data and current trends in immune checkpoint targeting therapy
Cancer immunotherapy for urologic cancers.
Monoclonal antibodies Evidence acquisition: Systematic literature search for clinical trials in the PubMed and
Cochrane databases up to August 2014 according to Preferred Reporting Items for
Checkpoint
Systematic Reviews and Meta-analyses guidelines. Endpoints included oncologic
CTLA-4 results, tumor response rates, safety, and tolerability.
PD-1 Evidence synthesis: Anti-CTLA-4 monotherapy has demonstrated biochemical responses
HLA-G in prostate cancer. One phase 3 trial assessing ipilimumab efficacy in castration-resistant
disease was negative overall. Nevertheless, ipilimumab may significantly improve overall
survival compared with placebo in subgroups of patients with favorable prognostic
features. In renal cancer, phase 1 trials showed interesting stabilization or long-lasting
objective response rates approaching 50% using anti-PD-1/PD-L1 drugs in heavily pre-
treated metastatic patients. In bladder cancer, one phase 2 trial indicated a good safety
profile for ipilimumab as a neoadjuvant drug before radical cystectomy. Overall, immune-
Please visit related effects such as colitis and dermatitis were common and well tolerated.
www.eu-acme.org/ Conclusions: Our systematic review shows that antibodies blocking immune check-
points offer interesting and long-lasting response rates in heavily pretreated patients
europeanurology to read and
with advanced urologic cancers. More promising results are currently provided by anti-
answer questions on-line. CTLA-4 antibodies in prostate cancer and by PD-1/PD-L1 inhibitors in renal cancer. These
The EU-ACME credits will should encourage new clinical trials of immune therapy combinations and immuno-
then be attributed therapy monotherapy combined with conventional anticancer drugs. In bladder cancer,
the use of targeted immunotherapy still remains underevaluated; however, preliminary
automatically.
results reported at recent conferences seem encouraging.
Patient summary: Data from studies support the activity and safety of immune check-
point inhibitors in urologic cancers, alone or in combination with conventional cancer
therapies. Encouraging data in other oncologic fields could translate into interesting
responses in urological cancers.
# 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author. CEA, Institute of Emerging Diseases and Innovative Therapies (iMETI),
Research Division in Hematology and Immunology (SRHI), Saint-Louis Hospital, 1 Avenue Claude
Vellefaux, 75475 Paris Cedex 10, France. Tel. +33 1 57276778; Fax: +33 1 47276780.
E-mail address: edgardo.carosella@cea.fr (E.D. Carosella).
http://dx.doi.org/10.1016/j.eururo.2015.02.032
0302-2838/# 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.
268 EUROPEAN UROLOGY 68 (2015) 267–279

1. Introduction association for immune checkpoints and/or its functional

To survive and proliferate, tumors adopt active immune
escape strategies that protect them from antitumor
immunity. To restore antitumor immune efficiency, im-
mune escape mechanisms must be bypassed, overridden, or
cancelled. Current cancer immunotherapy strategies mostly
aim at restoring T-cell–mediated antitumor immunity. T-
cell–mediated immunity includes multiple sequential
steps: clonal selection of antigen-specific cells, activation,
proliferation, trafficking, and execution of direct effector
function. Each step is regulated by a balance between
stimulatory and inhibitory signals. Immune checkpoints are
the inhibitory pathways that physiologically counterbal-
ance the co-stimulatory pathways to fine-tune the immune
responses. In other words, immune checkpoints are normal
immune signals capable of stopping an immune response.
They involve inhibitory receptors and their ligands (Fig. 1
and Fig. 2): one is expressed by a putative target cell and the
other is expressed by effector cells, in particular T cells.
Under normal physiological conditions, immune check-
point pathways are crucial for self-tolerance maintenance,
modulation of the duration and strength of normal
physiological immune responses, and minimization of
collateral damage to healthy tissues. Thus, overexpression
of immune checkpoint molecules by tumor cells profoundly
affects tumor-specific T-cell immunity in the cancer
microenvironment. This effectively marks tumor cells as
not for elimination, and can therefore reshape tumor
progression and metastasis. Since most tumor immune
escape mechanisms that use immune checkpoints block
effector cell functions, antitumor immunity may be restored
by antibodies that block the inhibitory receptor-ligand
interaction and thus inactivate the immune checkpoints.
On the basis of these immunology data, monoclonal
antibodies capable of disrupting the ligand-receptor
consequences were developed. In animal models, such
antibodies were successful at restoring antitumor immuni-
ty when tumor escape depended on the particular immune
checkpoint considered. Thus, immunotherapeutic clinical
trials were initiated, some of which are currently ongoing.
To date, antibodies blocking immune checkpoints have
exhibited oncologic efficacy, including prolongation of
overall survival (OS), in various malignancies, mainly breast
cancer and melanomas. Here we review immune check-
points related to urologic cancers with a focus on CTLA-4/B7,
PD-1/PD-L1, and HLA-G/ILT-2/4 because of their specific
relevance to immunotherapy and clinical trials to modulate
them have been conducted.
2. Evidence acquisition
A systematic literature search in the PubMed and Cochrane
databases was performed to identify clinical and random-
ized controlled trials (RCTs) published up to August
2014. Various algorithms including the following terms
were used: bladder cancer, prostate cancer, renal cancer,
immunotherapy, CTLA-4, PD-1, PD-L1, MHC-II, B7-H1, B7-H3,
B7-H4, TIM3, HLA-G, and each molecule under development
(Table 1). Given that targeted immunotherapy is a fast-
moving field, we also searched abstracts from the major
oncology conferences during 2012–2014. Inclusion criteria
used were published full articles, clinical trials, retrospec-
tive series, meta-analyses, and English language. Our
systematic review focused on published clinical trials
according to Preferred Reporting Items for Systematic
Reviews and Meta-analyses (PRISMA) guidelines. Primary
outcomes included oncologic results and tumor response
rates. Secondary outcomes included safety and tolerability.
The flow diagram for article selection is shown in
Figure 3. Each identified article was analyzed and classified.

[(Fig._1)TD$IG]
T cell ac!va!on
Prolifera!on
IFNG secre!on
Res!ng Cytotoxic func!on Ac!vated
T cell T cell

PD1

+ + BTLA

TCR CD28
TCR CD28 TIM-3
B7-H1/PDL1
LILRB1/ILT2

CTLA4/CD152
LAG-3/CD223

LILRB1/ILT2

APC/tumor cell MHC-I / II B7-1, B7-2

Fig. 1 – Upregulation of immune checkpoint receptors on T cell activation. With the exception of ILT2, most immune checkpoint receptors are absent
from the resting T-cell surface. T cell activation is initiated by combined signals from TCR:MHC and BD28:B7 engagement. This leads to proliferation,
upregulation of proinflammatory cytokine expression, acquisition of effector cell function, which is cytotoxicity in the case of CD8+ cells, and
provision of help for CD4+ T cells. Activated T cells are effector T cells. They express immune checkpoint receptors, and have therefore become
sensitive to inhibition by ligands expressed by tumor cells or within the microenvironment. APC = antigen-presenting cell; IFNG = interferon-
gamma.
 EUROPEAN UROLOGY 68 (2015) 267–279 269

Fig. 2 – Schematic representation of possible engagement of checkpoint proteins leading to T cell inhibition. On engagement of immune checkpoint
protein receptors (expressed by activated T cells) by immune checkpoint ligands (expressed by APC or tumor cells), the activated T-cell functions
(proliferation, IFNG secretion, and cytotoxic function shown here) are inhibited. Furthermore, immune checkpoint signaling may induce T cell anergy
and the differentiation of regulatory T cells whose functions contribute to further inhibition of antitumor immunity. APC = antigen-presenting cell;
IFNG = interferon-gamma.

3. Evidence synthesis
3.1. Antitumor activity
3.1.1. CTLA-4
Cytotoxic T-lymphocyte–associated antigen 4 (CTLA-4; also
known as CD152) is expressed exclusively on T cells. CTLA-4
primarily regulates the amplitude of early-stage T-cell
activation. One of its mechanisms of action involves
antagonism of B7-CD28–mediated co-stimulatory signals,
which occurs because CTLA-4 has a much higher affinity
for B7 than CD28 does: binding of CTLA-4 to CD80/86 is
500–2500 times greater than that of CD28. Signaling
through CD28 promotes mRNA expression of the cytokine
IL-2 and entry into the cell cycle, T-cell survival, T-helper-cell
differentiation, and immunoglobulin isotype switching. Thus,
signaling through CTLA-4 inhibits IL-2 mRNA production
and inhibits cell cycle progression. This mechanism only
depends on the extracellular domain of CTLA-4 [1,2]. A second
mechanism by which CTLA-4 can inactivate T cells involves
delivery of a negative signal. This mechanism requires the
cytoplasmic tail of CTLA-4 and occurs at low levels of surface
expression [3]. In most cases, the inhibitory actions of CTLA-4
occur via its association with the tyrosine phosphatases SHP1,
SHP2, and PP2A.
CTLA-4 is expressed by activated CD8+ effector T cells.
However, its major physiological role seems to be through
distinct effects on CD4+ T cells, including downregulation of
helper T (TH) cell activity and enhancement of regulatory
T cell (TReg) immunosuppressive activity [4,5]. CTLA-4
blockade results in broad enhancement of the immune
responses that depend on TH cells.
3.1.1.1. Prostate cancer. Preclinical studies have supported the
potential role of an anti–CTLA-4 antibody (ipilimumab) as
an antitumor agent in prostate cancer [6–8]. However, only
six phase 1/2 trials and one phase 3 trial have been
published to date. Outcome data are listed in Table 2.
In phase 1/2 trials, anti–CTLA-4 blockade monotherapy
led to biochemical responses (prostate-specific antigen
decline >50%) in approximately 15% of cases [9,10]. A
combination of ipilimumab with granulocyte-macrophage
colony-stimulating factor or vaccines seemed to improve the
biochemical tumor response rate by up to 25–50% [11–15].
Use of a vaccine that enhances co-stimulation of the immune
system did not seem to exacerbate the immune-related
270 EUROPEAN UROLOGY 68 (2015) 267–279

Table 1 – Immune checkpoint targets in cancer immunotherapy

Target Function Antibody or Ig Description Indication Clinical Company

fusion protein development

CTL-4 Inhibitory Ipilimumab Fully human IgG1 mAb Unresectable metastatic melanoma FDA approval Bristol Myers
receptor Squibb
Urothelial carcinoma Phase 2
Metastatic CRPC Phase 2
RCC Phase 1b and 2
Tremelimumab Fully human IgG2 mAb Advanced melanoma Phase 3 Pfizer
PSA-recurrent prostate cancer and RCC Phase 1
PD-1 Inhibitory Nivolumab Fully human IgG4 mAb Metastatic melanoma Approval for treatment Bristol-Myers
receptor (BMS-936558; NSCLC Phase 3 Squibb
ONO-4538; RCC Phase 3
MDX-1106) CRPC Phase 1
Lambrolizumab Humanized IgG4 mAb NSCLC, RCC, melanoma Phase 3 Merck
(MK-3475) Triple-negative breast cancer, Phase 1
metastatic bladder cancer, and head
and neck cancer
Pidilizumab Humanized IgG1 mAb DLBCL, colon cancer, multiple Phase 2 CureTech
(CT-011) myeloma, acute leukemia, pancreatic
and bladder cancers
AMP-224 PD-L2 (B7-DC) human Solid tumors, cutaneous T-cell Phase 1 GlaxoSmithKline/
IgG1 fusion protein lymphoma Amplimmune
PD-L1 Ligand for BMS-936559 Fully human IgG4 mAb NSCLC, melanoma, RCC, pancreatic, Phase 1 Bristol Myers
PD-1 (MDX-1105) gastric, and breast cancers Squibb
RG7446/ Fully human IgG1 mAb Bladder cancer Phase 1 Roche/Genentech
MPDL3280 (engineered Fc NSCLC Phase 3
domain optimized)
MEDI4736 Fully human IgG1 mAb NSCLC Phase 3 Medimmune
(B7-H1 a)
b
MHCII Enhancing ImmuFact Soluble LAG-3 Ig Breast cancer Phase 3 Immutep
TReg cell IMP321 fusion protein Metastatic RCC Phase 1/2a
B7-H3 Inhibitory MGA271 Fully human IgG1 mAb Solid tumors in multiple cancers Phase 1 MacroGenics
(CD276) ligand (engineered Fc domain
optimized)
B7-H4 Inhibitory Fully human IgG mAb Preclinical
ligand development
TIM3 Inhibitory Mouse mAb Preclinical
receptor development
HLA-G Inhibitory Mouse mAb Preclinical
ligand development

CRPC = castration-resistant prostate cancer; DLBCL = diffuse large B-cell lymphoma; FDA = US Food and Drug Administration; Ig = immunoglobulin; LAG-
3 = lymphocyte activation gene 3; mAb = monoclonal antibody; NSCLC = non-small-cell lung carcinoma; PSA = prostate-specific antigen; RCC = renal cell
carcinoma; TIM3 = T-cell membrane protein 3.
a
B7 homology 1, PD-L1.
b
LAG-3 (CD223) ligand of MHCII antigen-presenting cell activation.

[(Fig._3)TD$IG] adverse events associated with ipilimumab. Most patients

included in these trials had very advanced castration-
Prostate cancer Kidney cancer Bladder cancer resistant prostate cancer (CRPC) that was refractory to
various therapies including chemotherapy. Moreover, when
Ar!cle selec!on obtained, objective responses tended to have a sustainable
120 142 29
n
effect over time.
One phase 3 RCT has been recently reported (Table 2)
Editorials 13 11 2 [16]. This trial assessed the efficacy of ipilimumab at the
Reviews 40 34 6
Other cancers 38 31 5 dose of 10 mg/kg every 3 wk for up to four cycles in
Case report 1 1 0
Preclinical 14 47 13
comparison with placebo in metastatic CRPC (mCRPC).
Language 3 7 1 After a mid-term follow-up of less than 12 mo, this study
was negative overall (median survival 11.2 vs 10.0 mo;
Eligible studies
p = 0.053). However, subgroup analyses suggested that
11 7 1
n ipilimumab might provide an OS benefit for patients with
favorable prognostic features and who do not have a heavy
Fig. 3 – Flow chart for article selection. Clinical trials reporting oncologic
metastatic burden. For the subgroup of patients with
results, tumor response rates, safety, and tolerability for use of antibodies
blocking immune checkpoints in prostate, kidney, and bladder cancer. favorable prognostic features, ipilimumab significantly
Table 2 – Outcome data from clinical trials of immune checkpoint inhibitors in urologic cancers

Clinical trial Phase Treatment Patients Population Endpoints Follow-up OS Factors favoring drug Conclusion
(mo) (mo) (subgroup analysis)

Prostate cancer
CTLA-4
Ipilimumab [16] 3 10 mg/kg vs 799 mCRPC (i) OS 9.6 11.2 vs 10.0 Race (white) (i) NS (p = 0.053)
placebo (1:1) Post-CT ECOG score 0 OS 0–5 mo: HR 1.46 (1.1–1.9)
(ii) PFS ALP <1.5 times the upper OS 5–12 mo: HR 0.65 (0.5–0.8)
Bone-directed RT limit of normal (ULN) OS >12 mo: HR 0.60 (0.4–0.9)
8 Gy before inclusion Gleason score>7
Normal LDH level (ii) S (p<0.0001)
No visceral metastases b
Hemoglobin >110 g/L
Not North America region
Low pain score
c
Ipilimumab [9] 1/2 10 mg/kg 50 mCRPC Safety 15.7 17.4 N/A PSA decline >50%: 16%
!RT (n = 34) PSA response RECIST criteria:

EUROPEAN UROLOGY 68 (2015) 267–279

RECIST Complete (3.6%)
Partial (7.1%)
Stable (21.4%)
Ipilimumab [10] 1 3 mg/kg 14 mCRPC (i) Safety N/A N/A N/A PSA decline >50%: 14.3%
(ii) PSA response
d
Ipilimumab + GM-CSF [11] 1 Ipilimumab 3 mg/kg 6 mCRPC (i) Safety N/A N/A N/A PSA decline >50%: 50%
+ GM-CSF (ii) PSA response RECIST criteria:
(ii) RECIST Complete (0)
Partial (16.7%)
Ipilimumab + vaccines [12,13] 1 1, 3, 5, 10 mg/kg 30 mCRPC (i) Safety N/A 34.4 No previous CT PSA decline>50%: 50%
+ PROSTVAC (ii) PSA response Immune biomarkers
(PD1+CD4+, CTLA-4/TReg)
e
Ipilimumab + vaccines [14,15] 1 3 mg/kg 16 mCRPC (i) Safety N/A 29.2 PSMA antibody response PSA decline >50%: 25%
+ GVAX (ii) PSA response Immune biomarkers (including e)
(T-cell regulation, low TReg
levels, CD4+/CTLA-4+)
Tremelimumab [17] 1 3–6 mg/kg 11 Rising PSA after (i) Safety N/A N/A N/A No significant increase
+ bicalutamide local treatment (ii) PSA kinetics in PSA doubling time
150 mg 6 mo
PD-1
Nivolumab [29,35] 1 10 mg/kg 17 CRPC (i) Safety N/A N/A N/A No objective response
(ii) RECIST
Bladder cancer
CTLA-4
Ipilimumab [22] 2 3–10 mg/kg 12 Neoadjuvant (i) Safety 7-33 N/A N/A Correlation between OS
precystectomy (ii) Immune and increase in CD4+ICOS+ T cells
monitoring
Kidney cancer
CTLA-4
a
Ipilimumab [18] 2 3 then 1 mg/kg 61 mRCC (i) Safety N/A N/A Severity of immune-related Response rate 12.5%
3 then 3 mg/kg (ii) RECIST adverse effects
No previous IL-2 therapy
Tremelimumab [20] 1 6, 10, 15 mg/kg 28 mRCC (i) Safety Partial response 42%
+ sunitinib (ii) RECIST

271
272 EUROPEAN UROLOGY 68 (2015) 267–279

improved OS compared with placebo (hazard ration

ALP = alkaline phosphatase; CT = chemotherapy; ECOG = Eastern Cooperative Oncology Group; GM-CSF = granulocyte/macrophage colony-stimulating factor; HR = hazard ratio; LDH = lactate dehydrogenase; mCRPC = metastatic
castration-resistant prostate cancer; mRCC = metastatic renal cell carcinoma; NA = not applicable (or not reported); NS = not significant; OS = overall survival; PFS = progression-free survival; RECIST = Response Evaluation Criteria
[HR] 0.64; p = 0.0038). Treatment with ipilimumab also
significantly improved progression-free survival com-

Objective response 11.8%

Objective response: 27%

Conclusion

pared with placebo in the overall cohort (4.0 vs 3.1 mo;

No objective response
Stabilization 34.5%
p < 0.001).

Stabilization: 27%
Stabilization 41%
Another key point was the delayed benefit reported in
patients receiving ipilimumab. Whereas short-term OS did
not differ between the ipilimumab and placebo arms,
survival curves began to diverge after 5 mo. The 2-yr OS rate
was 26.2% in the ipilimumab group and only 15.0% in the
placebo group. Continuing survival follow-up is warranted
Factors favoring drug
(subgroup analysis)

to draw strong conclusions and address whether blocking of

PD-L1-positive tumors

this immune checkpoint provides a survival advantage in

(response rate 36%
vs 0%; p = 0.0006)

mCRPC patients. Studies in advanced melanoma patients

Dose >6 mg

have suggested that the length of follow-up is fundamental

when assessing the sustainability of survival benefit of
ipilimumab treatment. In chemotherapy-naı̈ve prostate
NA

cancer and neoadjuvant settings, numerous clinical studies

assessing ipilimumab at an early stage are also under way
(NCT01194271, NCT01057810).
(mo)
OS

Another anti-CTLA4 antibody, tremelimumab, was eval-

NA

NA

NA

uated in a phase 1 trial [17]. Only 11 patients treated for

biochemical recurrence after local therapy were included.
Follow-up

Although the safety profile was good, no oncologic data are

(mo)

NA

NA

NA

yet available.

3.1.1.2. Kidney cancer. Immune-based therapy using IL-2 has

(i) Pharmacokinetics
(ii) Safety, RECIST

an objective response rate of 20% in renal cancer. Despite

Endpoints

this relatively low rate, a minority of patients have been

(ii) RECIST

(ii) RECIST

cured by this therapy and the majority of tumor regression

(i) Safety

(i) Safety

was long-lasting, leading to continued interest in immuno-

therapy for renal cancer management.
To date, three clinical trials have tested ipilimumab or
tremelimumab as antitumor agents in patients with
Population

metastatic renal cancer [18–20].

The first phase 1 trial of ipilimumab only reported the
mRCC

mRCC

mRCC

incidence of autoimmune hypophisitis in a mixed cohort of

Prior dose-escalation phase involving 12 patients (drug doses 0.3, 1. and 3 mg/kg).
Prior dose-escalation phase involving 18 patients (drug doses 0.5 and 1.5 mg/kg).

patients treated for melanoma (n = 113) or renal cancer

Prior dose-escalation phase involving 21 patients (drug doses 3 and 5 mg/kg).
Patients

(n = 50) [19]. A more mature phase 2 trial investigated the

17

34

21

safety of ipilimumab and the response rate in 61 patients

with metastatic renal cell carcinoma (RCC) [18]. The
objective partial response rate according to Response
0.3, 1, 3, 10 mg/kg

Evaluation Criteria in Solid Tumors (RECIST) was 12.5%.

Treatment

No complete response was noted. The duration of the

0.05–30 mg

response ranged from 7 to 21 mo. The absence of a

10 mg/kg

In the 40 patients receiving 3 mg/kg at each dose.

previous IL-2 regimen and the severity of immune-related

in Solid Tumors; RT = radiotherapy; S = significant.

toxicity were associated with tumor regression and its

sustainability.
Phase

A phase 1 dose-escalation trial investigated the combi-

1

Significant in multivariate analysis.

nation of sunitinib and tremelimumab in 28 patients with

metastatic RCC [20]. Three doses of tremelimumab (6, 10,
and 15 mg/kg) were investigated in combination with
sunitinib. Twenty-one patients were evaluable for tumor
Table 2 (Continued )

response, of whom nine (43%) showed objective partial

Nivolumab [29,36]
BMS-936559 [35]

responses. A median response duration was not achieved.

Clinical trial

IMP321 [69]

Nevertheless, from comparisons with data available from

phase 3 trials of sunitinib alone, the authors concluded that
MHC II
PD-L1

PD-1

the objective response rate did not differ obviously with the
d
b
a

addition of tremelimumab.
c
 EUROPEAN UROLOGY 68 (2015) 267–279
3.1.1.3. Bladder cancer. Few preclinical studies have investi-
gated the role of CTLA-4 in bladder cancer carcinogenesis or
aggressiveness. A recent report highlighted a significant
association between CTLA-4 polymorphism and bladder
cancer risk in a case-control study [21].
Given the ongoing trials assessing ipilimumab in other
urologic malignancies, one phase 2 trial investigated the
safety and efficacy of ipilimumab as a neoadjuvant drug
before radical cystectomy in muscle-invasive bladder
cancers (Table 2) [22]. Twelve patients receiving ipilimumab
at a dose of 3–10 mg/kg for two cycles were included. In this
presurgical setting, the safety profile was acceptable and
measurable immunologic effects were noted. Further trials
are warranted to assess the oncologic and pathologic impact
of such effects.
3.1.2. PD-1/PD-L1
Programmed death 1 (PD-1) is more broadly expressed than
CTLA-4: it is induced on other activated non–T-lymphocyte
subsets, including B cells and natural killer (NK) cells, in
which it limits lytic activity. Therefore, PD-1 blockade,
which enhances the activity of effector T cells, should also
enhance NK cell activity in tumors and tissues, and antibody
production. PD-1 ligand 1 (PD-L1; also known as B7-H1 or
CD274) and PD-1 ligand 2 (PD-L2; also known as B7-DC or
CD273) are the two ligands of PD-1 [23,24].
In contrast to CTLA-4, which regulates T-cell activation,
the major role of PD-1 [25] is to limit the activity of T cells in
peripheral tissues at the time of an inflammatory response
to infection, and to limit autoimmunity [26]. This translates
into a major immune resistance mechanism within the
tumor microenvironment [27]. PD-1 expression is induced
when T cells are activated (Fig. 1) [25]. Engagement of PD-1
by a ligand during antigen recognition induces cross-
linkage of the antigen-receptor complex with PD-1. This
results in phosphorylation of the tyrosine residue in the
immunoreceptor tyrosine-based switch motif of PD-1 and
recruits the tyrosine phosphatase SHP-2, which depho-
sphorylates and inactivates proximal effector molecules
such as Syk in B cells and Zap70 in T cells. The immediate
outcome of stimulation via PD-1 is inhibition of cell growth
and cytokine secretion [28].
PD-1 is highly expressed on TReg cells, where it may
enhance their proliferation in the presence of a ligand. Thus,
because many tumors are infiltrated with TReg cells,
blockade of the PD-1 pathway may also enhance antitumor
immune responses by diminishing the number and/or
suppressive activity of intratumoral TReg cells.
3.1.2.1. Prostate cancer. A recent multicenter phase 1 trial
assessed the efficacy and safety profile of nivolumab, a fully
human anti–PD-1 antibody, in a cohort of 296 patients with
advanced cancer (Table 2) [29]. Only 17 CRPC patients were
enrolled and treated with nivolumab. Whereas antitumor
activity was seen in melanoma, lung cancer, and RCC
patients, no objective response was reported for CRPC.
Immunostaining for PD-L1 expression has been suggested
to explain these discrepancies in antitumor activity.
Prostate cancer shows low levels of PD-L1 expression,
273
although T cells surrounding the prostate are positive for
PD-1 [30]. All CRPC cases stained for PD-L1 expression in the
study by Topalian et al [29] were negative, in accordance
with previous immunohistochemistry cohorts [31]. Phase
1b/2 trials are investigating the use of these PD-1/PD-L1
agents in prostate cancer (NCT01420965, NCT00730639).
3.1.2.2. Kidney cancer. PD-1 expression in RCC, blood, tumors,
and tumor-infiltrating lymphocytes has been independent-
ly associated with an increased risk of overall and cancer-
specific mortality [32–34].
In kidney cancer, drugs targeting the PD-1/PD-L1 pathway
have been tested in the metastatic setting [29,35,36].
Tumor response to an anti–PD-L1 antibody was assessed
as a secondary endpoint in a phase 1 trial in 17 patients with
metastatic RCC [36]. A total of 207 patients with advanced
cancers (melanoma, lung, colorectal, ovarian, pancreatic)
were included to test anti–PD-L1 drug safety. Before
inclusion, 94%, 82%, and 41% of RCC patients had been
treated using nephrectomy, antiangiogenic therapy, and
immunotherapy, respectively. An objective response
according to RECIST criteria was observed in two patients
(12%) with a durable response lasting 4 and 17 mo. Stable
disease lasting at least 24 wk was observed in seven
additional patients (41%). No survival data were available.
In a phase 1 trial assessing nivolumab (anti–PD-1), an
objective response rate of 27% was estimated in 34 RCC
patients [29,35]. At a dose of 10 mg/kg, the response
duration ranged from 8 to 22 mo. In line with the anti–PD-
L1 antibody trial, patients were heavily pretreated. Inter-
estingly, objective responses were observed in various
metastasis sites. Disease stabilization was also noted in 27%
of patients, suggesting that more than half of tumors
responded to nivolumab with prolonged disease control.
The 6-mo progression-free survival rate was 56%.
The superiority of one agent over the other should be
evaluated in a dedicated direct comparison trial.
It has been noted in other malignancies that anti-PD-1/
PD-L1 therapy may induce transient worsening of disease
progression and that tumor responses may be delayed.
Nevertheless, the objective response rate and the prolonged
disease stabilization, even after discontinuation of immune
therapy, encouraged further clinical trials. Several phase 1/2
trials are studying the use of anti–PD-1 and anti–PD-L1 agents
in renal cell cancers, and updated analyses from already
published trials confirmed durable clinical activity and
interesting response rates (NCT01472081, NCT01668784,
NCT01354431, NCT01441765, NCT01984242). Preliminary
results from NCT01375842 assessing the PD-L1 antibody
MPDL3280a have been presented, revealing 6-mo progres-
sion-free survival of 50% [37]. Results from a randomized
dose-ranging trial of nivolumab for metastatic renal cancer
were presented at the 2014 European Society for Medical
Oncology (ESMO) conference [38]. Overall, more than half of
patients had objective responses lasting for >1 yr. Combina-
tions of nivolimab with pazopanib or sunitinb are also being
tested and show comparable 50% objective response rates
[39]. Further clinical investigations should also focus on
theranostic factors. Preliminary data demonstrated that
274 EUROPEAN UROLOGY 68 (2015) 267–279
PD-L1 expression might be an interesting predictive bio-
marker for response to PD-1 and PD-L1 inhibitors [40,41]. In
the nivolumab trial, an objective response rate of 36% was
observed for PD-L1-positive tumors, in contrast to none for
PD-L1-negative tumors.
3.1.2.3. Bladder cancer. PD-L1 immunohistochemistry in
urothelial cancer has suggested that PD-L1 expression is
associated with tumor aggressiveness [42,43]. PD-1 and
PD-L1 were altered in a large proportion of urothelial
cancers and, more importantly, PD-L1 expression predicted
overall mortality after cystectomy for patients with organ-
confined tumors, suggesting that PD-L1 manipulation may
be a beneficial immunotherapy target in muscle-invasive
bladder cancers [44,45].
At least one phase 1 trial is under way to assess the safety
of a fully human anti–PD-L1 antibody, as well as two phase
1/2 trials of anti–PD-1 drugs (lambrolizumab, pidilizumab).
Preliminary results from the phase 1b KEYNOTE-012
(NCT01848834) study were presented at the last ESMO
conference [46]. Thirty-three heavily pretreated (at least
two prior therapies) patients with advanced urothelial
cancer were enrolled. A response rate of 24% was reported.
Inhibition of PD-L1 also showed encouraging results, with a
43% response rate for PD-L1 positivity on tumor biopsy
[47]. In a recent phase 1 expansion study with an adaptive
design that allowed for biomarker-positive enriched
cohorts, tumors expressing PD-L1–positive tumor-infiltrat-
ing immune cells had particularly high response rates [48].
3.1.3. HLA-G
HLA-G is a nonclassical HLA class I molecule whose primary
function is to protect the fetus from destruction by the
mother’s immune system, playing a role in maternal-fetal
tolerance [49–52]. Thus, HLA-G is one of the few proteins
whose physiological immune checkpoint function is
exerted primarily towards foreign tissues. Under normal
physiological conditions, HLA-G is hardly expressed by
adult tissues. By contrast, most tumors neoexpress HLA-G at
different stages of their evolution, either on their cell
surface or released as soluble forms. In vitro and in vivo
studies of the function of HLA-G revealed a broad
immunoregulating function that affects both innate and
adaptive immune responses. Through its receptors LILRB1,
LILRB2 (also known as ILT2/CD85j and ILT4/CD85d), and
KIR2DL4, which are differentially expressed by immune cells,
HLA-G inhibits the cytolytic function of uterine and
peripheral blood NK cells, the antigen-specific cytolytic
function of cytotoxic T lymphocytes (CTLs) and g/dT cells, the
alloproliferative response of CD4+ T cells, the proliferation of
T cells and peripheral blood NK cells, and the maturation and
function of dendritic cells (DCs). HLA-G also induces TReg cells
and myeloid suppressive cells. Thus, HLA-G is capable of
inhibiting all actors in antitumor responses and, in contrast to
both CTLA-4 and PD-1, of blocking all stages of such an
antitumor response, from APC activation and effector
priming, to the function of fully activated CTLs or NK cells.
In cancer, HLA-G is expressed on tumor cells and tumor-
infiltrating cells. HLA-G expression is associated with higher
tumor grade and worse prognosis [52]. Animal models have
demonstrated that anti–HLA-G blocking antibodies restore
antitumor immunity against HLA-G–expressing tumor cells
in vivo. Furthermore, HLA-G expression was associated with
tumor metastasis and poor survival in a humanized mouse
model of ovarian cancer [53].
HLA-G plays a key role in the induction of immune
tolerance and constitutes a novel immune escape mechanism
of tumor cells. Tissue HLA-G and soluble HLA-G were
upregulated in RCC [54,55]. However, the therapeutic role
of HLA-G peptide-based immunotherapy requires further
investigation. HLA-G is also expressed in bladder cancer
[56,57], and therapeutic anti–HLA-G antibodies are currently
in preclinical development for non–muscle-invasive bladder
cancer.
3.1.4. Other immune checkpoint molecules
The molecules described above are those that have been
studied the most and, in the case of CTLA-4 and PD-1, for
which clinical developments are the most advanced.
Nevertheless, other immune checkpoint proteins have been
identified in basic studies, some of which are under clinical
evaluation. We briefly describe B7-H3, B7-H4, LAG3, and
TIM3.
B7-H3 protein (also known as CD276 [58]) is physiologi-
cally expressed by activated monocytes, T cells, B cells, and
NK cells. The receptors for B7-H3 have not been identified
and it has been reported that B7-H3 has both stimulatory and
inhibitory functions. Thus, B7-H3 is thought to have several
ligands that can trigger several, even antagonist functions.
B7-H3 expression has been reported for tumor cell lines
and/or patient specimens including prostate cancer. It often
correlated with increased tumor size. B7-H3 expression is
also associated with decreased numbers of tumor-infiltrating
lymphocytes and suppression of antitumor T-cell responses.
B7-H4 [59] is a ligand of the B7 family whose receptor is
still unknown. Its engagement decreases T-cell proliferation
and IL-2 production, as well as expansion of neutrophil
progenitors. Besides its immunoinhibitory function, B7-H4
may also directly promote the growth of cancer cells. B7-H4
overexpression has been identified in multiple solid
malignancies, including renal cancer. It has been consis-
tently correlated with increasing tumor burden, neovascu-
larization, and poor patient outcomes [60–62].
LAG3 (lymphocyte-activation gene 3, also known as
CD223 [63]) is an inhibitory receptor that binds HLA class
II molecules. It may be upregulated on tumor cells, and it is
expressed at high levels by tumor-infiltrating antigen-
presenting cells and macrophages. LAG3 has a dual function:
it inhibits T cell functions, in particular those of CD8+ T cells,
and enhances the immunoinhibitory functions of TReg cells. A
synergic tumor escape function of PD-1 and LAG3 was
recently shown in mice.
TIM3 [64] is a receptor for galectin 9, which is upregulated
in various types of cancer. TIM3 inhibits TH1 cell responses
and is coexpressed with PD-1 on tumor-specific CD8+ T cells.
In animal models, blockade of both PD-1 and TIM3 enhanced
antitumor immune responses and tumor rejection to a
greater extent than blockade of each individual molecule.
 EUROPEAN UROLOGY 68 (2015) 267–279 275

3.1.4.1. Prostate cancer. Molecules targeting other immune
checkpoints are underevaluated in prostate cancer. Howev-
er, preclinical and prognostic studies may lead to the
promotion of new clinical trials. A high level of B7-H3
expression in prostate cancer has been correlated with tumor
progression, proliferation markers, and poor oncologic out-
comes, suggesting it is a promising therapeutic target
[65–68].
3.1.4.2. Kidney cancer. A recombinant soluble LAG-3 fusion
protein, IMP 321, which agonizes MHC class II–driven
dendritic cell activation, was safe and stabilized advanced
renal cancer in a phase 1 trial [69]. Disease stabilization was
observed in a third of patients, and this rate reached 87%
when the IMP 321 dose was >6 mg/injection. However, the
primary endpoints of this study were evaluations of
pharmacokinetics and pharmacodynamics, and further
clinical investigation is warranted.
To date, no clinical trial evaluating other drugs targeting
immune checkpoints has been published. Several molecules
are in development and preclinical data support their
potential role in renal cancer therapy.
B7-H3 expression is approximately 15% in RCC but
reaches 95% in blood vessels surrounding such tumors
[70,71]. This vascular expression has been associated with
adverse clinicopathologic features and with metastatic
status. In particular, tumor vasculature B7-H3 expression
was significantly associated with an increased risk of death
from renal cancer [71]. Similar findings have been
suggested for B7-H4 expression [34].
3.1.4.3. Bladder cancer. No clinical trial investigating the
usefulness of other immune blockades in bladder cancer
has been published. A target of interest might be B7-H3,
whose expression is largely altered in bladder tumors.
The aim of the ongoing NCT01391143 phase 1 trial is to
assess the safety of the inhibitory ligand MGA271 in various
malignancies, including prostate, kidney, and bladder
cancers.
3.2. Safety
Safety was the primary endpoint in most phase 1/2 trials
assessing targeted immune therapy in urologic cancers.
Overall, immune therapy was relatively well tolerated.
However, drug-related adverse events, including immune-
related effects, were frequent. The frequency and severity of
drug-related adverse events are listed in Table 3.
The toxicity reported for CTLA-4 blockade includes
immune-related adverse effects such as colitis, mostly

Table 3 – Toxicity of checkpoint inhibitors used in urologic cancers

Clinical trial Cancer Patients ECOG Grade 3/4 Discontinuation Most frequent immune-related adverse
score rate (%) effects

CTLA-4
Ipilimumab 10 mg/kg [16] Prostate 400 0: 42% Grade 3: 59% (vs 41%) 35 Diarrhea (39%), pruritus (20%), rash (17%),
1: 55% Grade 4: 17% (vs 11%) colitis (7%)
2: 1%
Ipilimumab 10 mg/kg [9] Prostate 50 0: 38% 46% 16 Diarrhea (54%), pruritus (20%), rash (32%),
1: 56% colitis (22%)
2: 0%
Ipilimumab 10 mg/kg [12] Prostate 15 0–1 18% 43.3 Diarrhea/colitis (26.7%), rash (53.3%),
pan-hypopituitarism (13.3%)
Ipilimumab 10 mg/kg [22] Urothelial 12 NA 33.3% 8.3 Diarrhea/colitis (58.3%), pruritus (25%),
rash (58.3%), uveitis (8.3%)
Ipilimumab 3 mg/kg [11] Prostate 6 0–1 50% N/A G3 diarrhea (16.7%), G3
pan-hypopituitarism (16.7%),
G3 temporal arteritis (16.7%)
Ipilimumab 3 mg/kg [10] Prostate 14 0: 71% Grade 3: 21% N/A Diarrhea (21.4%), rash (14.3%),
1: 28% Grade 4: 0 pruritus (7.1%)
Ipilimumab 3 mg/kg [14] Prostate 16 0: 94% Grade 3: 29% 19 Colitis (19%), hypophysitis (13%),
1: 6% Grade 4: 4% hepatitis (6%)
Ipilimumab 3 mg/kg [18] RCC 61 0: 61% Grade 3: 27.9% N/A Colonic perforation (5%), diarrhea/ colitis
1: 40% Grade 4: 3.3% (27.8%), hypopituitarism (3.3%),
Grade 5: 1.6% adrenal insufficiency (1.6%)
Tremelimumab [17] Prostate 11 0: 91% Grade 3: 27.3% 9.1 Diarrhea (27.3%), pruritus (27.3%),
1: 9% Grade 4: 0 rash (36.4%), colitis (9.1%)
Tremelimumab + mRCC 28 0: 64% 61% Colitis
sunitinib [20] 1: 36%
PD-1
Nivolumab 10 mg/kg [29] Prostate 17 0-2 14% N/A Diarrhea (9%), rash (8%), pruritus (7%),
RCC 34 dysthyroidism (3%)
Other cancers 245
PD-L1
BMS-936559 [35] RCC 17 0-2 9% 11 Diarrhea/colitis (9%), pruritus (6%),
Other cancers 190 rash (7%), dysthyroidism (4%)
MHC II
IMP 321 [69] RCC 21 0-1 0 0 Infusion reaction (10%)

ECOG = Eastern Cooperative Oncology Group; mRCC = metastatic renal cell carcinoma; NA = not applicable.
276 EUROPEAN UROLOGY 68 (2015) 267–279

Table 4 – Ongoing clinical trials

Clinical trial Drug Phase Cancer Estimated Population Primary endpoint Arms Estimated completion
enrollment date

CTLA-4
NCT01057810 Ipilimumab 3 Prostate 600 CT-naı̈ve mCRPC OS Versus placebo February 2016
NCT01530984 Ipilimumab 2 Prostate 54 CT-naı̈ve mCRPC PSA decline Versus ipilimumab + December 2018
GM-CSF
NCT01688492 Ipilimumab 1/2 Prostate 25 CT-naı̈ve mCRPC PSA decline With abiraterone September 2015
NCT01498978 Ipilimumab 2 Prostate 30 mCRPC PSA decline April 2018
NCT01194271 Ipilimumab 2a Prostate 20 Localized Immune response Neoadjuvant September 2015
NCT01804465 Ipilimumab 2 Prostate 66 CT-naı̈ve mCRPC Immune response With sipuleucel-T December 2016
NCT02231749 Ipilimumab 3 RCC 1070 mRCC OS, PFS With nivolumab October 2019
versus sunitinib
NCT01524991 Ipilimumab 2 Bladder 36 M OS With GC June 2016
PD-1
NCT01354431 Nivolumab 2 RCC 150 mRCC RECIST April 2015
NCT01668784 Nivolumab 3 RCC 822 mRCC RECIST Versus everolimus September 2016
NCT01441765 Pidilizumab 2 RCC 44 mRCC RECIST ! dendritic cell vaccine November 2015
NCT01420965 Pidilizumab 2 Prostate 57 mCRPC Immune response With sipuleucel ! December 2018
cyclophosphamide
NCT02210117 Nivolumab 2 RCC 45 mCRPC Safety ! sunitinib versus ! January 2019
ipilimumab
NCT01928394 Nivolumab 1/2 Bladder 410 M Response rate ! ipilimumab March 2017
PD-L1
NCT01984242 MPDL3280A 2 RCC 150 mRCC RECIST ! sunitinib versus January 2016
bevacizumab
NCT02108652 MPDL3280A 2 Bladder 330 M Response rate March 2016
B7-H3
NCT01391143 MGA271 1 Prostate 151 M Safety February 2016
Bladder
RCC

CRPC = castration-resistant prostate cancer; RCC = renal cell carcinoma; m = metastatic; GM-CSF = granulocyte/macrophage colony-stimulating factor;
OS = overall survival; PSA = prostate-specific antigen; PFS = progression-free survival; CT = chemotherapy; RECIST = Response Evaluation Criteria in Solid
Tumors; GC = gemcitabine and cisplatin.

manifested as diarrhea, dermatitis (pruritus, rash), uveitis,
and hypophysitis. Arthritis, hepatitis, iritis, and vitiligo were
also seen. Manifestations of immune toxicity are generally
treated with systemic steroids. Table 3 shows the rate of
grade 3/4 events and the most frequent immune-related
adverse effects. Rash and diarrhea are frequent, occurring in
approximately 30–40% of patients. The overall rate of grade
3/4 toxicity ranged from 20% to >50% among studies. Grade
5 adverse effects have also been noted, with a significant
rate of colonic perforation due to severe colitis in renal
cancer patients [18,20].
It has been suggested that the immune-related adverse
effects of anti–CTLA-4 antibodies and their severity are
correlated with objective tumor responses [18,72].
The type of immune-related adverse events for anti–PD-1/
PD-L1 agents was similar to that seen with ipilimumab
[73]. Dermatological adverse events, diarrhea, and fatigue
occurred in approximately 20%, 20%, and 30% of cases,
respectively. Severe colitis was infrequent. Pneumonitis has
also been observed after the use anti-PD-1 agents [35].
Although anti–CTLA-4 and anti–PD-1/PD-L1 antibodies have
not been directly compared, immune-related effects associ-
ated with anti–CTLA-4 drugs were more common and of
higher grade. Thus, approximately 10% of patients experi-
enced grade 3/4 adverse effects after using anti–PD-1/PD-L1
antibodies, compared with 20–50% after using CTLA-4
inhibitors. Infusion reactions were more frequently observed
with anti–PD-L1 therapy (10%). It has been suggested that the
level of PD-L1 expression in tumor tissue is correlated with
the severity of toxicity.
Toxicity induced by agents targeted at other immune
checkpoints is expected to be quite similar to that reported
for anti–CTLA-4 and anti–PD-1/PD-L1 antibodies. However,
the lack of published reports for phase 1/2 trials currently
precludes strong conclusions for urologic cancer patients.
4. Conclusions
An improved understanding of the molecular mechanisms
that govern interactions between a tumor and the host
immune response has led to major advances in targeted
immunotherapy and cancer treatments. Our systematic
review demonstrates that immune checkpoint inhibitors
offer interesting and long-lasting response rates in heavily
pretreated patients with advanced urologic cancers.
In prostate cancer, a growing body of data supports the
oncologic role of anti–CTLA-4 antibodies, alone or in
combination with other immune therapies. A recent phase
3 trial assessing ipilimumab in castration-resistant prostate
cancer is negative; nevertheless, interesting response rates
in cancers with favorable features encourage further
investigations and longer follow-up. Despite better tolera-
bility, PD-1/PD-L1 inhibitors have not yet shown satisfac-
tory oncologic outcomes in prostate cancer.
 EUROPEAN UROLOGY 68 (2015) 267–279
In renal cancer, the most encouraging findings have
been observed for PD-1/PD-L1 inhibitors given their safety
and antitumor activity. Recent presentations at 2014 on-
cology conferences highlighted interesting and long-
lasting tumor response rates ("50%). Final publications
for these trials are awaited. The superiority of one agent
over the other should be evaluated in a dedicated head-to-
head comparison trial. In bladder cancer, the use of
targeted immunotherapy remains underevaluated and
further trials are awaited.
The field of immunotherapy in urologic cancer treatment
is evolving. Oncologic efficacy, including prolongation of
overall survival, has already been observed for immune
checkpoint inhibitors in various malignancies, mainly in
breast cancer and melanomas. Several ongoing trials are
studying immune therapy combinations and immune
monotherapy combined with conventional anticancer
drugs (Table 4). An anti–CTLA-4 antibody and vaccine
combination has already been tested with interesting
outcomes. Preclinical studies also support the synergistic
role of CTLA-4 and PD-1 blockade [74,75].
The continual development of new drugs highlights the
need to improve the prediction of response to immune
therapies and to optimize sequential therapeutic modali-
ties. Identification of activity and marker correlates should
be included in newly opened clinical trials to guide
treatment decision-making. In this light, the preliminary
data suggest that PD-L1 expression in tumor tissue might be
a predictive marker of tumor response to anti-PD-1
antibodies and might guide treatment choice.
Author contributions: Edgardo D. Carosella had full access to all the data
in the study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Carosella, Ploussard, LeMaoult, Desgrand-
champs.
Acquisition of data: Carosella, Ploussard, LeMaoult, Desgrandchamps.
Analysis and interpretation of data: Carosella, Ploussard, LeMaoult,
Desgrandchamps.
Drafting of the manuscript: Carosella, Ploussard, LeMaoult, Desgrand-
champs.
Critical revision of the manuscript for important intellectual content:
Carosella, Desgrandchamps.
Statistical analysis: None.
Obtaining funding: None.
Administrative, technical, or material support: None.
Supervision: Carosella.
Other: None.
Financial disclosures: Edgardo D. Carosella certifies that all conflicts of
interest, including specific financial interests and relationships and
affiliations relevant to the subject matter or materials discussed in the
manuscript (eg, employment/affiliation, grants or funding, consul-
tancies, honoraria, stock ownership or options, expert testimony,
royalties, or patents filed, received, or pending), are the following:
None.
Funding/Support and role of the sponsor: None.
Acknowledgments: We thank Dr. Adrien Riviere, Urology Department,
APHP, Saint-Louis Hospital, for his help with the data collection for this
review.
277
References
[1] Collins AV, Brodie DW, Gilbert RJC, et al. The interaction properties
of costimulatory molecules revisited. Immunity 2002;17:201–10.
[2] Rudd CE, Taylor A, Schneider H. CD28 and CTLA-4 coreceptor
expression and signal transduction. Immunol Rev 2009;229:12–26.
[3] Teft WA, Kirchhof MG, Madrenas J. A molecular perspective of
CTLA-4 function. Annu Rev Immunol 2006;24:65–97.
[4] Lenschow DJ, Walunas TL, Bluestone JA. CD28/B7 system of T cell
costimulation. Annu Rev Immunol 1996;14:233–58.
[5] Wing K, Onishi Y, Prieto-Martin P, et al. CTLA-4 control over Foxp3+
regulatory T cell function. Science 2008;322:271–5.
[6] Hurwitz AA, Foster BA, Kwon ED, et al. Combination immunother-
apy of primary prostate cancer in a transgenic mouse model using
CTLA-4 blockade. Cancer Res 2000;60:2444–8.
[7] Demaria S, Kawashima N, Yang AM, et al. Immune-mediated inhi-
bition of metastases after treatment with local radiation and CTLA-
4 blockade in a mouse model of breast cancer. Clin Cancer Res
2005;11:728–34.
[8] Wada S, Jackson CM, Yoshimura K, et al. Sequencing CTLA-4 block-
ade with cell-based immunotherapy for prostate cancer. J Transl
Med 2013;11:89.
[9] Slovin SF, Higano CS, Hamid O, et al. Ipilimumab alone or in
combination with radiotherapy in metastatic castration-resistant
prostate cancer: results from an open-label, multicenter phase I/II
study. Ann Oncol 2013;24:1813–21.
[10] Small EJ, Tchekmedyian NS, Rini BI, Fong L, Lowy I, Allison JP. A pilot
trial of CTLA-4 blockade with human anti-CTLA-4 in patients with
hormone-refractory prostate cancer. Clin Cancer Res 2007;13:
1810–5.
[11] Fong L, Kwek SS, O’Brien S, et al. Potentiating endogenous antitu-
mor immunity to prostate cancer through combination immuno-
therapy with CTLA4 blockade and GM-CSF. Cancer Res 2009;69:
609–15.
[12] Madan RA, Mohebtash M, Arlen PM, et al. Ipilimumab and a
poxviral vaccine targeting prostate-specific antigen in metastatic
castration-resistant prostate cancer: a phase 1 dose-escalation
trial. Lancet Oncol 2012;13:501–8.
[13] Jochems C, Tucker JA, Tsang KY, et al. A combination trial of vaccine
plus ipilimumab in metastatic castration-resistant prostate cancer
patients: immune correlates. Cancer Immunol Immunother 2014;63:
407–18.
[14] van den Eertwegh AJM, Versluis J, van den Berg HP, et al. Combined
immunotherapy with granulocyte-macrophage colony-stimulating
factor-transduced allogeneic prostate cancer cells and ipilimumab
in patients with metastatic castration-resistant prostate cancer: a
phase 1 dose-escalation trial. Lancet Oncol 2012;13:509–17.
[15] Santegoets SAM, Stam AM, Lougheed S, et al. T cell profiling reveals
high CD4+CTLA-4+ T cell frequency as dominant predictor for
survival after prostate GVAX/ipilimumab treatment. Cancer Immu-
nol Immunother 2013;62:245–56.
[16] Kwon ED, Drake CG, Scher HI, et al. Ipilimumab versus placebo after
radiotherapy in patients with metastatic castration-resistant pros-
tate cancer that had progressed after docetaxel chemotherapy
(CA184-043): a multicentre, randomised, double-blind, phase 3 tri-
al. Lancet Oncol 2014;15:700–12.
[17] McNeel DG, Smith HA, Eickhoff JC, et al. Phase I trial of tremeli-
mumab in combination with short-term androgen deprivation in
patients with PSA-recurrent prostate cancer. Cancer Immunol
Immunother 2012;61:1137–47.
[18] Yang JC, Hughes M, Kammula U, et al. Ipilimumab (anti-CTLA4
antibody) causes regression of metastatic renal cell cancer asso-
ciated with enteritis and hypophysitis. J Immunother 2007;30:
825–30.
278 EUROPEAN UROLOGY 68 (2015) 267–279
[19] Blansfield JA, Beck KE, Tran K, et al. Cytotoxic T-lymphocyte-asso-
ciated antigen-4 blockage can induce autoimmune hypophysitis in
patients with metastatic melanoma and renal cancer. J Immun-
other 2005;28:593–8.
[20] Rini BI, Stein M, Shannon P, et al. Phase 1 dose-escalation trial of
tremelimumab plus sunitinib in patients with metastatic renal cell
carcinoma. Cancer 2011;117:758–67.
[21] Wang L, Su G, Zhao X, et al. Association between the cytotoxic T-
lymphocyte antigen 4 +49A/G polymorphism and bladder cancer
risk. Tumour Biol 2014;35:1139–42.
[22] Carthon BC, Wolchok JD, Yuan J, et al. Preoperative CTLA-4 block-
ade: tolerability and immune monitoring in the setting of a pre-
surgical clinical trial. Clin Cancer Res 2010;16:2861–71.
[23] Freeman GJ, Long AJ, Iwai Y, et al. Engagement of the PD-1 immu-
noinhibitory receptor by a novel B7 family member leads to negative
regulation of lymphocyte activation. J Exp Med 2000;192:1027–34.
[24] Tseng S-Y, Otsuji M, Gorski K, et al. B7-Dc, a New dendritic cell
molecule with potent costimulatory properties for T cells. J Exp
Med 2001;193:839–46.
[25] Ishida Y, Agata Y, Shibahara K, Honjo T. Induced expression of PD-1,
a novel member of the immunoglobulin gene superfamily, upon
programmed cell death. EMBO J 1992;11:3887–95.
[26] Keir ME, Butte MJ, Freeman GJ, Sharpe AH. PD-1 and its ligands in
tolerance and immunity. Annu Rev Immunol 2008;26:677–704.
[27] Dong H, Strome SE, Salomao DR, et al. Tumor-associated B7-H1
promotes T-cell apoptosis: a potential mechanism of immune
evasion. Nat Med 2002;8:793–800.
[28] Okazaki T, Chikuma S, Iwai Y, Fagarasan S, Honjo T. A rheostat for
immune responses: the unique properties of PD-1 and their advan-
tages for clinical application. Nat Immunol 2013;14:1212–8.
[29] Topalian SL, Hodi FS, Brahmer JR, et al. Safety, activity, and immune
correlates of anti-PD-1 antibody in cancer. N Engl J Med 2012;366:
2443–54.
[30] Sfanos KS, Bruno TC, Meeker AK, De Marzo AM, Isaacs WB, Drake
CG. Human prostate-infiltrating CD8+ T lymphocytes are oligoclo-
nal and PD-1+. Prostate 2009;69:1694–703.
[31] Roth I, Corry DB, Locksley RM, Abrams JS, Litton MJ, Fisher SJ.
Human placental cytotrophoblasts produce the immunosuppres-
sive cytokine interleukin 10. J Exp Med 1996;184:539–48.
[32] Tang PA, Heng DY. Programmed death 1 pathway inhibition in
metastatic renal cell cancer and prostate cancer. Curr Oncol Rep
2013;15:98–104.
[33] Thompson RH, Dong H, Kwon ED. Implications of B7-H1 expression
in clear cell carcinoma of the kidney for prognostication and
therapy. Clin Cancer Res 2007;13, 709s–15s.
[34] Krambeck AE, Dong H, Thompson RH, et al. Survivin and B7-H1 are
collaborative predictors of survival and represent potential thera-
peutic targets for patients with renal cell carcinoma. Clin Cancer
Res 2007;13:1749–56.
[35] Brahmer JR, Drake CG, Wollner I, et al. Phase I study of single-agent
anti-programmed death-1 (MDX-1106) in refractory solid tumors:
safety, clinical activity, pharmacodynamics, and immunologic cor-
relates. J Clin Oncol 2010;28:3167–75.
[36] Brahmer JR, Tykodi SS, Chow LQ, et al. Safety and activity of anti-
PD-L1 antibody in patients with advanced cancer. N Engl J Med
2012;366:2455–65.
[37] Cho DC, Sosman JA, Sznol M, et al. Clinical activity, safety, and
biomarkers of MPDL3280A, an engineered PD-L1 antibody in
patients with metastatic renal cell carcinoma (mRCC). ASCO Meet-
ing Abstr 2013;31:4505.
[38] Motzer RJ, Rini BI, McDermott DF, et al. Randomized, dose-ranging
phase II trial of nivolumab for metastatic renal cell carcinoma. Ann
Oncol 2014;25(Suppl 4):iv281.
[39] Amin A, Plimack ER, Infante JR, et al. Nivolumab in combination
with sunitinib or pazopanib in patients with metastatic renal cell
carcinoma. Ann Oncol 2014;25(Suppl 4), iv362–3.
[40] Choueiri TK, Figueroa DJ, Fay AP, et al. Correlation of PD-L1 tumor
expression and treatment outcomes in patients with renal cell
carcinoma receiving sunitinib or pazopanib: results from COM-
PARZ, a randomized controlled trial. Clin Cancer Res 2015;21:
1071–7.
[41] Herbst RS, Soria J-C, Kowanetz M, et al. Predictive correlates of
response to the anti-PD-L1 antibody MPDL3280A in cancer
patients. Nature 2014;515:563–7.
[42] Nakanishi J, Wada Y, Matsumoto K, Azuma M, Kikuchi K, Ueda S.
Overexpression of B7-H1 (PD-L1) significantly associates with
tumor grade and postoperative prognosis in human urothelial
cancers. Cancer Immunol Immunother 2007;56:1173–82.
[43] Inman BA, Sebo TJ, Frigola X, et al. PD-L1 (B7-H1) expression by
urothelial carcinoma of the bladder and BCG-induced granulomata:
associations with localized stage progression. Cancer 2007;109:
1499–505.
[44] Xylinas E, Robinson BD, Kluth LA, et al. Association of T-cell co-
regulatory protein expression with clinical outcomes following
radical cystectomy for urothelial carcinoma of the bladder. Eur J
Surg Oncol 2014;40:121–7.
[45] Boorjian SA, Sheinin Y, Crispen PL, et al. T-cell coregulatory mole-
cule expression in urothelial cell carcinoma: clinicopathologic
correlations and association with survival. Clin Cancer Res
2008;14:4800–8.
[46] Plimack ER, Gupta S, Bellmunt J, et al. A phase Ib study of pem-
brolizumab in patients with advanced urothelial tract cancer. Ann
Oncol 2014;25(Suppl 4):mdu438.24.
[47] Bellmunt J, Petrylak DP, Powles T, et al. Inhibition of PD-L1
by MPDL3208a leads to clinical activity in patients with meta-
static urothelial bladder cancer. Ann Oncol 2014;25(Suppl
4):iv280.
[48] Powles T, Eder JP, Fine GD, et al. MPDL3280A (anti-PD-L1) treat-
ment leads to clinical activity in metastatic bladder cancer. Nature
2014;515:558–62.
[49] Carosella ED, Favier B, Rouas-Freiss N, Moreau P, Lemaoult J.
Beyond the increasing complexity of the immunomodulatory
HLA-G molecule. Blood 2008;111:4862–70.
[50] Carosella ED, Gregori S, LeMaoult J. The tolerogenic interplay(s)
among HLA-G, myeloid APCs, and regulatory cells. Blood 2011;118:
6499–505.
[51] Carosella ED, Moreau P, Lemaoult J, Rouas-Freiss N. HLA-G: from
biology to clinical benefits. Trends Immunol 2008;29:125–32.
[52] Rouas-Freiss N, Moreau P, LeMaoult J, Carosella ED. The dual role of
HLA-G in cancer. J Immunol Res 2014:359748.
[53] Lin A, Zhang X, Xu HH, Xu DP, Ruan YY, Yan WH. HLA-G expression
is associated with metastasis and poor survival in the Balb/c nu/nu
murine tumor model with ovarian cancer. Int J Cancer 2012;131:
150–7.
[54] Li BL, Lin A, Zhang XJ, et al. Characterization of HLA-G expression in
renal cell carcinoma. Tissue Antigens 2009;74:213–21.
[55] Bukur J, Rebmann V, Grosse-Wilde H, et al. Functional role of
human leukocyte antigen-G up-regulation in renal cell carcinoma.
Cancer Res 2003;63:4107–11.
[56] El-Chennawi FA, Auf FA, El-Diasty AM, et al. Expression of HLA-G in
cancer bladder. Egypt J Immunol 2005;12:57–64.
[57] Gan LH, Huang LF, Zhang X, et al. Tumor-specific upregulation of
human leukocyte antigen-G expression in bladder transitional cell
carcinoma. Hum Immunol 2010;71:899–904.
[58] Wang L, Kang F-B, Shan B-E. B7-H3-mediated tumor immunology:
friend or foe? Int J Cancer 2014;134:2764–71.
 EUROPEAN UROLOGY 68 (2015) 267–279
[59] Ceeraz S, Nowak EC, Noelle RJ. B7 family checkpoint regulators
in immune regulation and disease. Trends Immunol 2013;34:
556–63.
[60] Jiang J, Zhu Y, Wu C, et al. Tumor expression of B7-H4 predicts poor
survival of patients suffering from gastric cancer. Cancer Immunol
Immunother 2010;59:1707–14.
[61] Krambeck AE, Thompson RH, Dong H, et al. B7-H4 expression in
renal cell carcinoma and tumor vasculature: associations with
cancer progression and survival. Proc Natl Acad Sci U S A
2006;103:10391–6.
[62] Tringler B, Zhuo S, Pilkington G, et al. B7-H4 is highly expressed
in ductal and lobular breast cancer. Clin Cancer Res 2005;11:
1842–8.
[63] Norde WJ, Hobo W, van der Voort R, Dolstra H. Coinhibitory
molecules in hematologic malignancies: targets for therapeutic
intervention. Blood 2012;120:728–36.
[64] Ngiow SF, Teng MWL, Smyth MJ. Prospects for TIM3-targeted
antitumor immunotherapy. Cancer Res 2011;71:6567–71.
[65] Liu Y, Vlatkovic L, Saeter T, et al. Is the clinical malignant phenotype
of prostate cancer a result of a highly proliferative immune-evasive
B7-H3-expressing cell population? Int J Urol 2012;19:749–56.
[66] Yuan H, Wei X, Zhang G, Li C, Zhang X, Hou J. B7-H3 over expression
in prostate cancer promotes tumor cell progression. J Urol
2011;186:1093–9.
[67] Parker AS, Heckman MG, Sheinin Y, et al. Evaluation of B7-H3
expression as a biomarker of biochemical recurrence after salvage
279
radiation therapy for recurrent prostate cancer. Int J Radiat Oncol
Biol Phys 2011;79:1343–9.
[68] Roth TJ, Sheinin Y, Lohse CM, et al. B7-H3 ligand expression by
prostate cancer: a novel marker of prognosis and potential target
for therapy. Cancer Res 2007;67:7893–900.
[69] Brignone C, Escudier B, Grygar C, Marcu M, Triebel F. A phase I
pharmacokinetic and biological correlative study of IMP321, a
novel MHC class II agonist, in patients with advanced renal cell
carcinoma. Clin Cancer Res 2009;15:6225–31.
[70] Qin X, Zhang H, Ye D, Dai B, Zhu Y, Shi G. B7-H3 is a new cancer-
specific endothelial marker in clear cell renal cell carcinoma. Onco
Targets Ther 2013;6:1667–73.
[71] Crispen PL, Sheinin Y, Roth TJ, et al. Tumor cell and tumor vascu-
lature expression of B7-H3 predict survival in clear cell renal cell
carcinoma. Clin Cancer Res 2008;14:5150–7.
[72] Beck KE, Blansfield JA, Tran KQ, et al. Enterocolitis in patients with
cancer after antibody blockade of cytotoxic T-lymphocyte-associ-
ated antigen 4. J Clin Oncol 2006;24:2283–9.
[73] Dolan DE, Gupta S. PD-1 pathway inhibitors: changing the land-
scape of cancer immunotherapy. Cancer Control 2014;21:231–7.
[74] Wolchok JD, Kluger H, Callahan MK, et al. Nivolumab plus ipilimu-
mab in advanced melanoma. N Engl J Med 2013;369:122–33.
[75] Curran MA, Montalvo W, Yagita H, Allison JP. PD-1 and CTLA-4
combination blockade expands infiltrating T cells and reduces
regulatory T and myeloid cells within B16 melanoma tumors. Proc
Natl Acad Sci U S A 2010;107:4275–80.