DOI: 10.1002/JLB.

5BT0420-585RR

REVIEW

Breakthrough concepts in immune-oncology: Cancer vaccines

at the bedside

Sohini Roy1 Tarsheen K. Sethi2 David Taylor1 Young J. Kim1

Douglas B. Johnson2

1 Department of Otolaryngology – Head & Neck

Surgery, Vanderbilt University Medical Center, Abstract

Nashville, Tennessee, USA
2 Department of Medicine, Vanderbilt University
Medical Center, Nashville, Tennessee, USA
Correspondence
Young Kim and Douglas Johnson, 777 PRB,
2220 Pierce Ave, Nashville, TN 37232, USA.
Email: y2.kim@vumc.org;
douglas.b.johnson@vumc.org
Clinical approval of the immune checkpoint blockade (ICB) agents for multiple cancer types
has reinvigorated the long-standing work on cancer vaccines. In the pre-ICB era, clinical efforts
focused on the Ag, the adjuvants, the formulation, and the mode of delivery. These translational
efforts on therapeutic vaccines range from cell-based (e.g., dendritic cells vaccine Sipuleucel-T)
to DNA/RNA-based platforms with various formulations (liposome), vectors (Listeria monocyto-
genes), or modes of delivery (intratumoral, gene gun, etc.). Despite promising preclinical results,
cancer vaccine trials without ICB have historically shown little clinical activity. With the anticipa-
tion and expansion of combinatorial immunotherapeutic trials with ICB, the cancer vaccine field
has entered the personalized medicine arena with recent advances in immunogenic neoantigen-
based vaccines. In this article, we review the literature to organize the different cancer vaccines
in the clinical space, and we will discuss their advantages, limits, and recent progress to overcome
their challenges. Furthermore, we will also discuss recent preclinical advances and clinical strate-
gies to combine vaccines with checkpoint blockade to improve therapeutic outcome and present
a translational perspective on future directions.

KEYWORDS
cancer, DNA, neoantigen, nucleotide, peptide, RNA, vaccine

1 CLINICAL LANDSCAPE
OF CANCER VACCINES
Since James Coley’s first attempt to generate therapeutic immunity
against inoperable sarcoma with inoculated heat-inactivated bacteria
(“Coley’s toxins”), cancer vaccine development has lagged significantly
behind the success of infectious disease vaccines (Fig. 1). This can
partly be attributed to the immunosuppressive context of cancer
vaccine utilization (age, high disease burden (metastasis), cancer-
induced and cancer-therapy induced immunosuppression etc.). FDA
approved prophylactic cancer vaccines are operationally infectious
disease vaccines that target oncogenic microbes (human papilloma
and hepatitis B viruses) prior to the transformation into neoplastic
cells. These vaccines have achieved a great deal of success in prevent-
ing these viral-associated cancers and are outside the scope of this
review. Therapeutic cancer vaccines, in contrast, have yielded limited
clinical benefits. For example, an earlier report on meta-analysis of
440 patients enrolled between 1995 and 2004 at the National Cancer
Institute presented with metastatic disease and treated with different
vaccines showed a lowly objective response rate of 2.6%.1 Early strate-
gies on therapeutic cancer vaccines focused on tumor-associated Ags
(TAA), which include overexpressed Ags (e.g., Her2/neu), cancer testis
(CT) Ags, developmentally regulated Ags (e.g., oncofetal proteins), or
mutated neoantigens that are not found in normal cells.2,3 Failure of
these trials has been attributed to generation of tolerance to TAA, low
affinity/avidity tumor-specific T cells, and the homeostatic response
to check hyper-responsive adaptive effectors cells.4 Other hurdles
include suboptimal dose, mode of delivery, and improper or limited
adjuvant selections. However, the FDA approval of immune checkpoint
inhibitors has led to a renewed enthusiasm for therapeutic cancer
vaccines. In this review, we provide an overview of the emerging field
of “Cancer Vaccine 2.0”, the challenges that remain and the factors that
need to be taken into consideration for maximizing the chances of suc-
cess of this mode of combinatorial immunotherapy. We will also discuss

Received: 4 November 2019 Revised: 15 April 2020 Accepted: 18 April 2020

J Leukoc Biol. 2020;1–35. www.jleukbio.org ○
c 2020 Society for Leukocyte Biology 1
2 ROY ET AL .
FIGURE 1 A timeline of vaccine development
novel vaccine platforms (oncolytic virus vaccine, induced pluripotent
stem cell (iPSC) vaccine, personalized neoantigen vaccine) and their
combinatorial clinical trials with immune checkpoint blockade (ICB).
2 VACCINES IN CLINICAL DEVELOPMENT
2.1 FDA approved cancer vaccines
While the clinical efficacy of therapeutic vaccines for cancer as a
monotherapy is low, the following examples of approved cancer vac-
cines illustrate the critical elements required for successful translation
and some of the hurdles/problems that need to be addressed. The ear-
liest post-Coley “tumor vaccine” to be approved was Bacille Calmette-
Guerin (BCG) in 1977. This intravesically delivered, live, attenuated
mycobacterial extract vaccine was approved for use in prophylaxis of
early stage bladder cancer and the treatment of urothelial carcinoma
in situ. The approval was based on a phase III trial that showed a 5-year
disease free survival (DFS) of 45% with BCG.5 The FDA approval of
Sipuleucel-T (Provenge) for the treatment of metastatic castration-
resistant prostate cancer (mCRPC) in 2010 was another advance in
cancer immunotherapy. It is an autologous dendritic cell (DC)-based
immunotherapy containing at least 50 million autologous CD54+ cells
activated with a recombinant fusion protein (PA2024) consisting of
prostatic acid phosphatase (PAP) fused with GM-CSF (PAP-GMCSF).
The approval was based on a placebo-controlled phase III trial
with 512 patients randomized in a 2:1 ratio to receive Sipuleucel-T
(341 patients) or placebo (171 patients).6 More recently, talimogene
laherparepvec (T-VEC), an oncolytic virus-based vaccine was approved
for the treatment of advanced stage melanoma in 2015. T-VEC is an
oncolytic live attenuated herpes simplex virus-1 (HSV-1) genetically
modified to replicate within the tumor and produce GM-CSF. The
approval followed a phase III study that met its primary endpoint of
superior durable response rate (defined as objective response lasting
> 6 months) compared with GM-CSF, 16.3% versus 2.1%, respectively
(OR 8.9; P < 0.001).7 All these 3 examples underscore the importance
of adjuvants and the activation of the innate immunity for clinical effi-
cacy. While it is assumed that BCG and T-VEC-mediated induction of
cytolytic action on the tumor cells can release endogenous TAA, both
do not have specific TAA formulated in the vaccine. Both BCG and T-
VEC contain a rich source of Myeloid differentiation primary response
protein (MyD88) activating adjuvants—BCG contains TLR4 agonist
activity and T-VEC contains viral products and GM-CSF that can elicit
multiple adjuvant activity. Sipuleucel-T is a dendritic cell therapy that
bypasses the endogenous TAA capture. Another salient feature is the
clinical context of BCG’s success—the vaccine was used for early stage
and in situ disease, suggesting that cancer vaccine’s effectiveness
may occur primarily in the context of low tumor burden. The primary
concern with all these trials is the lack of biomarker development and
its associated mechanism of action in cancer patients.
2.2 Vaccine trials
Many other vaccines have been tested in phase I/II/III trials, but the
results have been less impressive. Owing to the exhaustive list of clini-
cal trials using different vaccine platforms, we have attempted to high-
light the completed clinical trials from the last 5 years in Table 1. Many
of these vaccines have adopted TAA and microbial vectors that fared
well in preclinical studies, though this success did not translate into
the clinic. With the approval of ICB, the most recent iteration of tri-
als has focused on combining vaccines with ICB and other therapeutic
modalities. The mechanisms and current evidence in support of these
combinations have been described in detail elsewhere8,9 and also
briefly later in this review. Leveraging the targeted generation of tumor
specific T-cell response from cancer vaccines and sustaining these
responses in the tumor microenvironment (TME) with ICB is an attrac-
tive prospect and has led to the testing of these combinations. Mech-
anistically, vaccination alone has been shown to increase the adaptive
immune resistance mechanism whereby IFN-𝛾 from tumor infiltrating
T cells can increase programmed death-ligand 1 (PD-L1) expression on
tumor cells.10,11 Preclinical studies have provided evidence for a syn-
ergistic effect combining vaccines and checkpoint inhibitors including
cytotoxic T-lymphocyte associated protein 4 (CTLA-4) inhibitors and
PD-1/PD-L1 inhibitors.12-18
Early phase studies evaluating the combination of vaccines and
immune checkpoint inhibitors have been completed or are ongoing.
We have separately highlighted selected completed combination trials
in the last 5 years in Table 2. A phase Ib study of Ipilimumab (CTLA-4
inhibitor) and GVAX in pancreatic adenocarcinoma showed improve-
ment in OS over Ipilimumab alone.19 The combination of MART-1
peptide-pulsed DC and Tremelimumab showed evidence of activity in
a phase I trial with advanced melanoma patients.20 Patients with pre-
treated advanced melanoma showed some responses to autologous
TA B L E 1 Selected list of completed vaccine trials in the last 5 years
ROY ET AL .

Trial
Vaccine Type Disease Trial combination NCT ID Phase Results References
1
GVAX GVAX Pancreatic cancer Cyclophosphamide NCT02243371 II NA
CRS 207
Nivolumab
GVAX Pancreatic cancer Cyclophosphamide NCT02004262 IIb Study did not meet primary 2

CRS 207 efficacy endpoint with no

chemotherapy improvement in OS in
Cy/GVAX + CRS-207
compared to chemotherapy
alone
Colon gvax mismatch repair–proficient Cyclophosphamide NCT02981524 II Gvax can modulate immune 3

(MMR-p) advanced pembrolizumab response compared to

colorectal cancer pembrolizumab alone
Dendritic cell Peritoneal Surface Celecoxib NCT02151448 I/II NA NA
Malignancies Interferon-alfa-2b
rintatolimod
NY-ESO-1(157-165) Locally Advanced Solid Aldesleukin NCT02775292 I NA NA
Peptide-pulsed Tumors Expressing Cyclophosphamide
Autologous Dendritic Cell NY-ESO-1 Fludarabine Phosphate
Vaccine Nivolumab
NY-ESO-1 Reactive TCR
Retroviral Vector
Transduced Autologous
PBL
DLK1, EPHA2, HBB, NRP1, Metastatic melanoma Dasatinib NCT01876212 II NA NA
RGS5, TEM1 peptide
Pulsed with Cancer stem cell Ovarian cancer NCT02178670 I/II NA NA
Pulsed with Cancer stem cell Lung cancer NCT02084823 I/II NA NA
Pulsed with Cancer stem cell Nasopharyngeal cancer NCT02115958 I/II NA NA
Pulsed with Cancer stem cell Pancreatic cancer NCT02074046 I/II NA NA
Pulsed with Cancer stem cell Colorectal cancer NCT02176746 I/II NA NA
Pulsed with Cancer stem cell Hepatocellular carcinoma NCT02089919 I/II NA NA
Sipuleucel-T Metastatic Tasquinimod NCT02159950 II NA NA
hormone-resistant
prostate cancer
Allogeneic DC Metastatic Renal Cell Sunitinib NCT02432846 II Complete response induced Onclive, 2019
(INTUVAX) Carcinoma by vaccine; details results
NA
INTUVAX Gastrointestinal cancer NCT02686944 I NA NA
Glioma stem cell pulsed Recurrent glioblastoma NCT02820584 I NA NA
(Continues)
3
 4

TA B L E 1 (Continued)

Trial
Vaccine Type Disease Trial combination NCT ID Phase Results References
Dendritic cell, Pulsed with tumor cell lysate NCT03114631 I/II NA NA
Tumor lysate or MUC-1/WT-1 peptide
DC vaccine, RNA CEA RNA Metastatic adenocarcinoma NCT00004604 I NA NA
as antigen
CEA RNA Metatstatic colon cancer NCT00003433 I/II NA NA
4
MART-1, tyrosinase, gp100, Metastatic melanoma siRNA to target NCT00672542 I In combination arm, immune
and MAGE-3 RNA immuneproteasome response remained
antigen prossessing elevated, circulating cancer
cells reduced and lytic T
cells activity was induced.
5
cytomegalovirus (CMV) Glioblastoma Multiforme Basiliximab,temozolomide, NCT00626483 I/II No significant clinical
pp65-lysosomal- radiation therapy benefit
associated membrane
protein (LAMP) mRNA and
GMCSF
6
cytomegalovirus (CMV) Glioblastoma temozolomide NCT00639639) I long-term PFS and OS in
pp65-lysosomal- vaccinated arm
associated membrane
protein (LAMP) mRNA and
GMCSF
TLR7/8-matured DCs AML in CR NCT01734304 I/II T cell responses observed. 7

electroporated with mRNA Long-term disease control and

encoding WT1, PRAME, immunological responses
and CMVpp65 are studied in the ongoing
phase II trial.
MAGE-A3, MelanA and Cutaneous melanoma KLH NCT00074230 I/II NA NA
Survivin RNA
(Continues)
ROY ET AL .
 (Continued)
ROY ET AL .

TA B L E 1

Trial
Vaccine Type Disease Trial combination NCT ID Phase Results References
CMV pp65 RNA glioblastoma Autologous T cells NCT00693095 I NA John Sampson
activated in vitro with DUMC. Evaluation
CMV pp65 pulsed DC of Recovery From
Drug-Induced
Lymphopenia Using
Cytomegalovirus-
specific T-cell
Adoptive Transfer.
In:
ClinicalTrials.gov
[Internet].
Bethesda (MD):
National Library of
Medicine (US);
2000. Available
from: http://clinical
trials.gov/show/
NCT00693095_
NLM_Identifier:
NCT00693095.
Amplified autologous tumor Metastatic prostate cancer NCT00108264 I NA NA
cell RNA
8
CEA peptide or CEA RNA Metastatic Colorectal cancer KLH NCT00228189 I/II RNA pulsed DC vaccination
failed to show improved
response
9
gp100 and tyrosinase mRNA Metastatic melanoma KLH NCT00243529 I/II broad repertoire of IFN𝛾
producing TAA-specific
CD8+ and CD4+ T cell
responses in stage III
patients mainly
Amplified autologous tumor Metastatic renal cell NCT00087984 I/II NA NA
cell RNA carcinoma
10
amplified tumor RNA plus metastatic clear cell renal cell sunitinib NCT00678119 II Doubling of expected survival,
synthetic CD40L RNA carcinoma encouraging long-term and
5-year overall survival in
intermediate risk group
Autologous tumor stem cell Recurrent glioblastoma Radiation, bevacizumab NCT00890032 I Immune analysis not yet 11

amplified RNA published

Tumor RNA Advanced kidney cancer NCT00005816 I NA NA
PSA RNA Prostate cancer NCT00004211 I/II NA NA
(Continues)
5
 6

TA B L E 1 (Continued)

Trial
Vaccine Type Disease Trial combination NCT ID Phase Results References
DC vaccine, DNA Autologous DC pulsed with Metastatic breast cancer NCT00197522 I NA NA
antigen Adenovirus Expressing
Her-2
Personalized Neoantigen mRNA Metastatic melanoma, NCT03480152 I/II Presence of neoepitope 12

neoantigen epithelial cancers. specific T cell responses

Neoantigen long peptides Melanoma TLR3 agonist poly-ICLC NCT01970358 I Elicited neoepitope specific T 13

Hiltonol R , anti-PD-1 cell responses, positive

after recurrence effect on recurrence
prevention; 2 patients with
metastatic disease who
relapsed benefited from
anti PD-1
14
DC loaded with neoantigen Cutaneous melanoma gp100 peptide; for first NCT00683-670, I Neoepitope specific T cell
peptide dose, influenza virus BB-IND responses found
vaccine was included as 13590
recall response
RNA based poly-neo epitope Melanoma Melanoma specific peptide Neoepitope specific 15

vaccine before polyfunctional T cell

neoantigen vaccine responses and autologous
injection; anti PD-1 if tumor cell killing found;
relapsed prevented recurrence and
regression in metastatic
lesions.
Oncolytic virus OncoVex-GMCSF Pancreatic cancer NCT00402025 I n/a n/a
T-VEC Melanoma NCT02014441 II Vaccine can be administered 16

to patients without
shedding by transmission
17,18,19,20,21
T-VEC Melanoma Compared with GMCSF NCT00769704 III T-VEC achieved higher DRR
and median OS compared
to GMCSF
22
T-VEC Melanoma NCT00289016 II Response rate 26%, abscopal
effects observed; survival
benefits recorded
T-VEC Melanoma Pembrolizumab NCT02263508 Ib Improved anti-PD-1 efficacy; 23

responders to combination
therapy had higher CD8+
and IFN-𝛾 signature
24
T-VEC Melanoma Ipilimumab NCT01740297 II ORR higher in combination
therapy with enhanced
anti-tumor activity,
abscopal effects observed
recombinant nonpathogenic Glioma NCT01491893 NA NA
polio-rhinovirus chimera
(PVSRIPO)
(Continues)
ROY ET AL .
 ROY ET AL .

TA B L E 1 (Continued)

Trial
Vaccine Type Disease Trial combination NCT ID Phase Results References
Oncolytic adenovirus BCG unresponsive non NCT02365818 II Strong response and limited 25

expressing GMCSF muscle invasive Bladder progression in patients with

cancer carcinoma in situ
TBI-1401(HF10) HSV1 virus Solid tumors with NCT02428036 I Stabilized disease Annals of Oncology
superficial lesions (2017) 28
(suppl_10): x113-
x116https://doi.org/
10.1093/annonc/
mdx667
26
human-derived adenovirus. Glioblastoma and IFN-gamma NCT02197169 Ib IFN-gamma did not improve
DNX-2401 gliosarcoma survival
CAVATAK Uveal melanoma metastatic ipilimumab NCT03408587 Ib NA NA
to liver
VCN-01 Pancreatic cancer Gemcitabine NCT02045589 I NA NA
AbraxaneR

27
HF10 Metastatic melanoma ipilimumab NCT02272855 II Combination showed
favorable profile and
antitumor activity
reolysin Pancreatic cancer Gemcitabine NCT02620423 II Antitumor response in 28

Irinotecan previously treated patients

Leucovorin observed. In depth immune
5-fluorouracil analysis planned and not
pembrolizumab yet published
29
Bacterial vaccine VXM01 Recurrent glioblastoma who NCT02718443 I Induced immune
(live attenuated bacteria have failed atleast response.Increased
modified to target radiochemotherapy with CD8+/Treg ratio
VEGFR2) temozolomide Intratumoral PDL-1
decreased in 1 patient
ADU-623 Astrocytic Tumors NCT01967758 I NA NA
(live-attenuated Listeria Glioblastoma Multiforme
Monocytogenes Strain Anaplastic Astrocytoma
expressing the Brain Tumor
EGFRvIII-NY-ESO-1
vaccine)
30
JNJ-64041809 NCT02625857 I Observed immune response
(Live Attenuated did not translate to clinical
Double-deleted Listeria) response
(Continues)
7
 8

TA B L E 1 (Continued)

Trial
Vaccine Type Disease Trial combination NCT ID Phase Results References
Peptide vaccine APVAC1 (off the shelf TAA glioblastoma Chemotherapy NCT02149225 I APVAC1-induced sustained 31

peptide) Poly-ICLC CD8 responses with

APVAC2 (personalized GMCSF memory phenotype
mutated peptide) APVAC2 induced CD4
responses of favorable TH1
type
GRN-1201 Resected melanoma GMCSF NCT02696356 I NA NA
((HLA)-A2-restricted
peptides)
IDO peptide Melagnant melanoma Ipilimumab NCT02077114 I NA NA
Vemurafenib
IDH1 Peptide emulsified in glioma Radiation NCT02454634 I Met its endpoint; 32,33,34

incomplete Freund’s chemotherapy immunogenicity observed

adjuvant
RV001V (RhoC peptide) Metastatic prostate NCT03199872 I/II Sustained immune response Rhovac press release
emulsified in the cancer at 3 and 6m reported.
immunoadjuvant Further analyses pending
montanide ISA-51
DNA vaccine MVA-brachyury-TRICOM Lung, breast, prostate, NCT02179515 I Induced T cell response in 35,36

vaccine ovarian vaccinated patients.

Most striking clinical outcome
observed in metastatic
EGFR-mutated lung cancer
who were on erlotinib
PROSTVAC Prostate cancer NCT02153918 II Increased CD8+/CD4+ 37

(PSA, TRICOM) peritumoral infioltrate

Immune response observed
TAA immune response in 50%
patients in peripheral blood
Increase in suppressive
markers post vaccination
observed

PROSTVAC Prostate cancer GMCSF or placebo NCT01322490 III No improvement in overall J Clin Oncol 36, 2018
(PSA, TRICOM) survival (suppl; abstr 5006)
modified vaccinia virus Recurrent Ovarian gemcitabine NCT02275039 I Combination feasible and did 38

ankara vaccine Epithelial Cancer not induce autoimmunity

expressing p53
(Continues)
ROY ET AL .
TA B L E 1 (Continued)
ROY ET AL .

Trial
Vaccine Type Disease Trial combination NCT ID Phase Results References
Whole cell HS110 Non-Small Cell Lung Cancer Cyclophosphamide NCT02117024 II Combination in first cohort 39

vaccine (viagenpumatucel-L: Or physician’s choice of Increased PD-1, Tim-3 and

irradiated tumor cells and chemotherapy alone Ki67 was observed on
modified to overexpress CD8+ T cells isolated from
gp96-Ig) peripheral blood indicating
CD8+ response to vaccine
HS110 Lung cancer nivolumab NCT02439450 Ib/II Immune response observed in ImmunoOncology
reduced tumor cases News
60% patients in cold tumor
cohort had tumot reduction
Mixed vaccine Kidney cancer NCT03357289 I/II NA NA
Mixed vaccine Metastatic colorectal cancer NCT03357276 I/II NA NA
Mixed vaccine Metastatic sarcoma NCT03357315 I/II NA NA
VIGIL Advanced melanoma Pembrolizumab NCT02574533 I NA NA
(GMCSF and shRNA to
target furin, the
pro-protein convertase
activator for TGF-𝛽1 and
TGF-𝛽2
VIGIL high-grade papillary NCT02346747 II/III Recurrence free survival was 40

serous/clear cell/ improved in vigil arm

endometrioid ovarian,
fallopian tube, or primary
peritoneal cancer
Owing to the exhaustive list of clinical trials using different vaccine platforms, several trials could not be included in this list. Details of all such trials are readily accessible from the Clinicaltrials.gov website. For the
current review, we have included trials that were completed and met safety endpoints. We have excluded trials for HPV+ cancer types and, also, ones that were either prematurely withdrawn or terminated.
1 Le DT, Crocenzi TS, Uram JN, Lutz ER, Laheru DA, Sugar EA, Vonderheide RH, Fisher GA, Ko AH, Murphy A, McDougall K, Ferber S, Brockstedt DG, Jaffee EM. Randomized phase 2 study of the safety, efficacy,

and immune response of GVAX pancreas (with cyclophosphamide) and CRS-207 with or without nivolumab in patients with previously treated metastatic pancreatic adenocarcinoma (STELLAR). Journal of Clinical
Oncology. 2016;34(15_suppl):TPS4153-TPS. https://doi.org/10.1200/JCO.2016.34.15_suppl.TPS4153.
2
Le DT, Picozzi VJ, Ko AH, Wainberg ZA, Kindler H, Wang-Gillam A, Oberstein P, Morse MA, Zeh HJ, Weekes C, Reid T, Borazanci E, Crocenzi T, LoConte NK, Musher B, Laheru D, Murphy A, Whiting C, Nair
N, Enstrom A, Ferber S, Brockstedt DG, Jaffee EM. Results from a Phase IIb, Randomized, Multicenter Study of GVAX Pancreas and CRS-207 Compared with Chemotherapy in Adults with Previously Treated
Metastatic Pancreatic Adenocarcinoma (ECLIPSE Study). Clinical Cancer Research. 2019;25(18):5493-502. https://doi.org/10.1158/1078-0432.ccr-18-2992.
3
Yarchoan M, Ferguson AK, Durham JN, Rozich N, Rodriguez C, Huang C-Y, Browner IS, Jesus-Acosta AD, Le DT, Laheru D, Donehower RC, Jaffee EM, Zheng L, Azad NS. A phase II study of
GVAX colon vaccine with cyclophosphamide and pembrolizumab in patients with mismatch repair–proficient (MMR-p) advanced colorectal cancer. Journal of Clinical Oncology. 2019;37(4_suppl):563-.
https://doi.org/10.1200/JCO.2019.37.4_suppl.563.
4
Dannull J, Haley NR, Archer G, Nair S, Boczkowski D, Harper M, De Rosa N, Pickett N, Mosca PJ, Burchette J, Selim MA, Mitchell DA, Sampson J, Tyler DS, Pruitt SK. Melanoma immunotherapy using mature DCs
expressing the constitutive proteasome. J Clin Invest. 2013;123(7):3135-45. Epub 2013/08/13. https://doi.org/10.1172/JCI67544. PubMed PMID: 23934126; PMCID: PMC3696565.
5
Vlahovic G, Archer GE, Reap E, Desjardins A, Peters KB, Randazzo D, Healy P, Herndon JE, Friedman AH, Friedman HS, Bigner DD, Sampson JH. Phase I trial of combination of antitumor immunother-
apy targeted against cytomegalovirus (CMV) plus regulatory T-cell inhibition in patients with newly-diagnosed glioblastoma multiforme (GBM). Journal of Clinical Oncology. 2016;34(15_suppl):e13518-e.
https://doi.org/10.1200/JCO.2016.34.15_suppl.e13518.
6
Batich KA, Reap EA, Archer GE, Sanchez-Perez L, Nair SK, Schmittling RJ, Norberg P, Xie W, Herndon JE, 2nd, Healy P, McLendon RE, Friedman AH, Friedman HS, Bigner D, Vlahovic G, Mitchell DA, Sampson
JH. Long-term Survival in Glioblastoma with Cytomegalovirus pp65-Targeted Vaccination. Clin Cancer Res. 2017;23(8):1898-909. Epub 2017/04/16. https://doi.org/10.1158/1078-0432.CCR-16-2057. PubMed
PMID: 28411277; PMCID: PMC5559300.
9
 10

TA B L E 1 Continued

7
Deiser K, Lichtenegger FS, Schnorfeil F, Koehnke T, Altmann T, Buecklein V, Moosmann A, Brueggemann M, Wagner B, Hiddemann W, Bigalke I, Kvalheim G, Subklewe MS. Next-Generation Dendritic Cell Vaccina-
tion in Postremission Therapy of AML: Results of a Clinical Phase I Trial. Blood. 2015;126(23):3805-. https://doi.org/10.1182/blood.V126.23.3805.3805.
8
Lesterhuis WJ, De Vries IJ, Schreibelt G, Schuurhuis DH, Aarntzen EH, De Boer A, Scharenborg NM, Van De Rakt M, Hesselink EJ, Figdor CG, Adema GJ, Punt CJ. Immunogenicity of dendritic cells pulsed with CEA
peptide or transfected with CEA mRNA for vaccination of colorectal cancer patients. Anticancer Res. 2010;30(12):5091-7. Epub 2010/12/29. PubMed PMID: 21187495.
9
Aarntzen EH, Schreibelt G, Bol K, Lesterhuis WJ, Croockewit AJ, de Wilt JH, van Rossum MM, Blokx WA, Jacobs JF, Duiveman-de Boer T, Schuurhuis DH, Mus R, Thielemans K, de Vries IJ, Figdor CG, Punt CJ, Adema
GJ. Vaccination with mRNA-electroporated dendritic cells induces robust tumor antigen-specific CD4+ and CD8+ T cells responses in stage III and IV melanoma patients. Clin Cancer Res. 2012;18(19):5460-70.
Epub 2012/08/17. https://doi.org/10.1158/1078-0432.CCR-11-3368. PubMed PMID: 22896657.
10 Amin A, Dudek AZ, Logan TF, Lance RS, Holzbeierlein JM, Knox JJ, Master VA, Pal SK, Miller WH, Jr., Karsh LI, Tcherepanova IY, DeBenedette MA, Williams WL, Plessinger DC, Nicolette CA, Figlin RA. Survival

with AGS-003, an autologous dendritic cell-based immunotherapy, in combination with sunitinib in unfavorable risk patients with advanced renal cell carcinoma (RCC): Phase 2 study results. J Immunother Cancer.
2015;3:14. Epub 2015/04/23. https://doi.org/10.1186/s40425-015-0055-3. PubMed PMID: 25901286; PMCID: PMC4404644.
11 Dunn-Pirio A, Peters K, DesJardins A, Randazzo D, Friedman H, Healy P, Herndon J, Reap E, Archer G, Li Q-J, Sampson J, Vlahovic G. Tumor stem cell RNA-loaded dendritic cell vaccine for recurrent glioblastoma:

a phase 1 trial (S41.004). Neurology. 2017;88(16 Supplement):S41.004.

12 Cafri G, Gartner JJ, Hopson K, Meehan RS, Zaks TZ, Robbins P, Rosenberg SA. Immunogenicity and tolerability of personalized mRNA vaccine mRNA-4650 encoding defined neoantigens expressed by the

autologous cancer. Journal of Clinical Oncology. 2019;37(15_suppl):2643-. https://doi.org/10.1200/JCO.2019.37.15_suppl.2643.

13 Ott PA, Hu Z, Keskin DB, Shukla SA, Sun J, Bozym DJ, Zhang W, Luoma A, Giobbie-Hurder A, Peter L, Chen C, Olive O, Carter TA, Li S, Lieb DJ, Eisenhaure T, Gjini E, Stevens J, Lane WJ, Javeri I, Nellaiappan

K, Salazar AM, Daley H, Seaman M, Buchbinder EI, Yoon CH, Harden M, Lennon N, Gabriel S, Rodig SJ, Barouch DH, Aster JC, Getz G, Wucherpfennig K, Neuberg D, Ritz J, Lander ES, Fritsch EF, Hacohen N,
Wu CJ. An immunogenic personal neoantigen vaccine for patients with melanoma. Nature. 2017;547(7662):217-21. Epub 2017/07/06. https://doi.org/10.1038/nature22991. PubMed PMID: 28678778; PMCID:
PMC5577644.
14
Carreno BM, Magrini V, Becker-Hapak M, Kaabinejadian S, Hundal J, Petti AA, Ly A, Lie WR, Hildebrand WH, Mardis ER, Linette GP. Cancer immunotherapy. A dendritic cell vaccine increases the breadth and
diversity of melanoma neoantigen-specific T cells. Science. 2015;348(6236):803-8. Epub 2015/04/04. https://doi.org/10.1126/science.aaa3828. PubMed PMID: 25837513; PMCID: PMC4549796.
15
Sahin U, Derhovanessian E, Miller M, Kloke BP, Simon P, Lower M, Bukur V, Tadmor AD, Luxemburger U, Schrors B, Omokoko T, Vormehr M, Albrecht C, Paruzynski A, Kuhn AN, Buck J, Heesch S, Schreeb KH,
Muller F, Ortseifer I, Vogler I, Godehardt E, Attig S, Rae R, Breitkreuz A, Tolliver C, Suchan M, Martic G, Hohberger A, Sorn P, Diekmann J, Ciesla J, Waksmann O, Bruck AK, Witt M, Zillgen M, Rothermel A, Kasemann
B, Langer D, Bolte S, Diken M, Kreiter S, Nemecek R, Gebhardt C, Grabbe S, Holler C, Utikal J, Huber C, Loquai C, Tureci O. Personalized RNA mutanome vaccines mobilize poly-specific therapeutic immunity against
cancer. Nature. 2017;547(7662):222-6. Epub 2017/07/06. https://doi.org/10.1038/nature23003. PubMed PMID: 28678784.
16
Andtbacka RHI, Amatruda T, Nemunaitis J, Zager JS, Walker J, Chesney JA, Liu K, Hsu CP, Pickett CA, Mehnert JM. Biodistribution, shedding, and transmissibility of the oncolytic virus talimogene laherparepvec
in patients with melanoma. EBioMedicine. 2019;47:89-97. Epub 2019/08/15. https://doi.org/10.1016/j.ebiom.2019.07.066. PubMed PMID: 31409575.
17
Andtbacka RH, Kaufman HL, Collichio F, Amatruda T, Senzer N, Chesney J, Delman KA, Spitler LE, Puzanov I, Agarwala SS, Milhem M, Cranmer L, Curti B, Lewis K, Ross M, Guthrie T, Linette GP, Daniels GA,
Harrington K, Middleton MR, Miller WH, Jr., Zager JS, Ye Y, Yao B, Li A, Doleman S, VanderWalde A, Gansert J, Coffin RS. Talimogene Laherparepvec Improves Durable Response Rate in Patients With Advanced
Melanoma. J Clin Oncol. 2015;33(25):2780-8. Epub 2015/05/28. https://doi.org/10.1200/JCO.2014.58.3377. PubMed PMID: 26014293.
18
Harrington KJ, Andtbacka RH, Collichio F, Downey G, Chen L, Szabo Z, Kaufman HL. Efficacy and safety of talimogene laherparepvec versus granulocyte-macrophage colony-stimulating factor in patients with
stage IIIB/C and IVM1a melanoma: subanalysis of the Phase III OPTiM trial. Onco Targets Ther. 2016;9:7081-93. Epub 2016/11/30. https://doi.org/10.2147/OTT.S115245. PubMed PMID: 27895500; PMCID:
PMC5119624.
19 Kaufman HL, Andtbacka RHI, Collichio FA, Amatruda T, Senzer NN, Chesney J, Delman KA, Spitler LE, Puzanov I, Ye Y, Li A, Gansert JL, Coffin R, Ross MI. Primary overall survival (OS) from OPTiM, a randomized

phase III trial of talimogene laherparepvec (T-VEC) versus subcutaneous (SC) granulocyte-macrophage colony-stimulating factor (GM-CSF) for the treatment (tx) of unresected stage IIIB/C and IV melanoma.
Journal of Clinical Oncology. 2014;32(15_suppl):9008a-a. https://doi.org/10.1200/jco.2014.32.15_suppl.9008a.
20 Kaufman HL, Bines SD. OPTIM trial: a Phase III trial of an oncolytic herpes virus encoding GM-CSF for unresectable stage III or IV melanoma. Future Oncol. 2010;6(6):941-9. Epub 2010/06/10.

https://doi.org/10.2217/fon.10.66. PubMed PMID: 20528232.

21 Kaufman HL, Kim DW, DeRaffele G, Mitcham J, Coffin RS, Kim-Schulze S. Local and distant immunity induced by intralesional vaccination with an oncolytic herpes virus encoding GM-CSF in patients with stage

IIIc and IV melanoma. Ann Surg Oncol. 2010;17(3):718-30. Epub 2009/11/17. https://doi.org/10.1245/s10434-009-0809-6. PubMed PMID: 19915919.
22 Senzer NN, Kaufman HL, Amatruda T, Nemunaitis M, Reid T, Daniels G, Gonzalez R, Glaspy J, Whitman E, Harrington K, Goldsweig H, Marshall T, Love C, Coffin R, Nemunaitis JJ. Phase II clinical trial of a

granulocyte-macrophage colony-stimulating factor-encoding, second-generation oncolytic herpesvirus in patients with unresectable metastatic melanoma. J Clin Oncol. 2009;27(34):5763-71. Epub 2009/11/04.
https://doi.org/10.1200/JCO.2009.24.3675. PubMed PMID: 19884534.
23
Ribas A, Dummer R, Puzanov I, VanderWalde A, Andtbacka RHI, Michielin O, Olszanski AJ, Malvehy J, Cebon J, Fernandez E, Kirkwood JM, Gajewski TF, Chen L, Gorski KS, Anderson AA, Diede SJ,
Lassman ME, Gansert J, Hodi FS, Long GV. Oncolytic Virotherapy Promotes Intratumoral T Cell Infiltration and Improves Anti-PD-1 Immunotherapy. Cell. 2017;170(6):1109-19 e10. Epub 2017/09/09.
https://doi.org/10.1016/j.cell.2017.08.027. PubMed PMID: 28886381.
24
Chesney J, Puzanov I, Collichio F, Singh P, Milhem MM, Glaspy J, Hamid O, Ross M, Friedlander P, Garbe C, Logan TF, Hauschild A, Lebbe C, Chen L, Kim JJ, Gansert J, Andtbacka RHI, Kaufman HL. Randomized,
Open-Label Phase II Study Evaluating the Efficacy and Safety of Talimogene Laherparepvec in Combination With Ipilimumab Versus Ipilimumab Alone in Patients With Advanced, Unresectable Melanoma. J Clin
Oncol. 2018;36(17):1658-67. Epub 2017/10/06. https://doi.org/10.1200/JCO.2017.73.7379. PubMed PMID: 28981385; PMCID: PMC6075852.
ROY ET AL .
TA B L E 1 Continued
ROY ET AL .

25
Packiam VT, Lamm DL, Barocas DA, Trainer A, Fand B, Davis RL, 3rd, Clark W, Kroeger M, Dumbadze I, Chamie K, Kader AK, Curran D, Gutheil J, Kuan A, Yeung AW, Steinberg GD. An open label, single-arm, phase
II multicenter study of the safety and efficacy of CG0070 oncolytic vector regimen in patients with BCG-unresponsive non-muscle-invasive bladder cancer: Interim results. Urol Oncol. 2018;36(10):440-7. Epub
2017/08/02. https://doi.org/10.1016/j.urolonc.2017.07.005. PubMed PMID: 28755959.
26 Lang FF, Tran ND, Puduvalli VK, Elder JB, Fink KL, Conrad CA, Yung WKA, Penas-Prado M, Gomez-Manzano C, Peterkin J, Fueyo J. Phase 1b open-label randomized study of the oncolytic adenovirus DNX-2401

administered with or without interferon gamma for recurrent glioblastoma. Journal of Clinical Oncology. 2017;35(15_suppl):2002-. https://doi.org/10.1200/JCO.2017.35.15_suppl.2002.
27 Andtbacka RHI, Ross MI, Agarwala SS, Taylor MH, Vetto JT, Neves RI, Daud A, Khong HT, Ungerleider RS, Tanaka M, Grossmann KF. Final results of a phase II multicenter trial of HF10, a replication-

competent HSV-1 oncolytic virus, and ipilimumab combination treatment in patients with stage IIIB-IV unresectable or metastatic melanoma. Journal of Clinical Oncology. 2017;35(15_suppl):9510-.
https://doi.org/10.1200/JCO.2017.35.15_suppl.9510.
28 Mahalingam D, Fountzilas C, Moseley JL, Noronha N, Cheetham K, Dzugalo A, Nuovo G, Gutierrez A, Arora SP. A study of REOLYSIN in combination with pembrolizumab and chemotherapy in patients (pts) with

relapsed metastatic adenocarcinoma of the pancreas (MAP). Journal of Clinical Oncology. 2017;35(15_suppl):e15753-e. https://doi.org/10.1200/JCO.2017.35.15_suppl.e15753.
29 Wick W, Wick A, Sahm F, Riehl D, Deimling Av, Bendszus M, Kickingereder P, Beckhove P, Schmitz-Winnenthal FH, Jungk C, Wieckowski S, Podola L, Herold-Mende C, Unterberg A, Platten M. VXM01 phase I

study in patients with progressive glioblastoma: Final results. Journal of Clinical Oncology. 2018;36(15_suppl):2017-. https://doi.org/10.1200/JCO.2018.36.15_suppl.2017.
30 Drake CG, Pachynski RK, Subudhi SK, McNeel DG, Antonarakis ES, Bauer TM, Patricia D, Wade M, Zudaire E, Mason G, Knoblauch RE, Stone NL, Infante JR, Gottardis M, Fong L. Safety and preliminary

immunogenicity of JNJ-64041809, a live attenuated, double-deleted Listeria monocytogenes-based immunotherapy, in metastatic castration-resistant prostate cancer (mCRPC). Journal of Clinical Oncology.
2019;37(15_suppl):e16509-e. https://doi.org/10.1200/JCO.2019.37.15_suppl.e16509.
31
Wick W, Dietrich P-Y, Kuttruff S, Hilf N, Frenzel K, Admon A, Burg SHvd, Deimling Av, Gouttefangeas C, Kroep JR, Martinez-Ricarte F, Okada H, Ottensmeier CHH, Ponsati B, Poulsen HS, Stevanovic S, Tabatabai
G, Rammensee H-G, Sahin U, Singh H, Consortium G. GAPVAC-101: First-in-human trial of a highly personalized peptide vaccination approach for patients with newly diagnosed glioblastoma. Journal of Clinical
Oncology. 2018;36(15_suppl):2000-. https://doi.org/10.1200/JCO.2018.36.15_suppl.2000.
32
Platten M, Schilling D, Bunse T, Sahm F, Hueckelhoven A, Schenkel I, Stevanovic S, Schmitt A, Laumann M, Steinbach JP, Misch M, Tabatabai G, Weyerbrock A, Schnell O, Krex D, Hense J, Bendszus M, Deim-
ling Av, Schmitt M, Wick W. A mutation-specific peptide vaccine targeting IDH1R132H in patients with newly diagnosed malignant astrocytomas: A first-in-man multicenter phase I clinical trial of the German
Neurooncology Working Group (NOA-16). Journal of Clinical Oncology. 2016;34(15_suppl):TPS2082-TPS. https://doi.org/10.1200/JCO.2016.34.15_suppl.TPS2082.
33
Platten M, Schilling D, Bunse L, Wick A, Bunse T, Riehl D, Karapanagiotou-Schenkel I, Harting I, Sahm F, Schmitt A, Steinbach JP, Weyerbrock A, Hense J, Misch M, Krex D, Stevanovic S, Tabatabai G, Deim-
ling Av, Schmitt M, Wick W. A mutation-specific peptide vaccine targeting IDH1R132H in patients with newly diagnosed malignant astrocytomas: A first-in-man multicenter phase I clinical trial of the German
Neurooncology Working Group (NOA-16). Journal of Clinical Oncology. 2018;36(15_suppl):2001-. https://doi.org/10.1200/JCO.2018.36.15_suppl.2001.
34
Platten M, Schilling D, Bunse L, Wick A, Bunse T, Riehl D, Green E, Sanghvi K, Karapanagiotou-Schenkel I, Harting I, Sahm F, Steinbach J, Weyerbrock A, Hense J, Misch M, Krex D, Stevanovic S,
Tabatabai G, von Deimling A, Schmitt M, Wick W. ATIM-33. NOA-16: A FIRST-IN-MAN MULTICENTER PHASE I CLINICAL TRIAL OF THE GERMAN NEUROONCOLOGY WORKING GROUP EVAL-
UATING A MUTATION-SPECIFIC PEPTIDE VACCINE TARGETING IDH1R132H IN PATIENTS WITH NEWLY DIAGNOSED MALIGNANT ASTROCYTOMAS. Neuro-Oncology. 2018;20(suppl_6):vi8-vi9.
https://doi.org/10.1093/neuonc/noy148.028.
35 Heery CR, Donahue R, Lepone L, Grenga I, Richards J, Metenou S, Fernando RI, Dirmeier U, Singh H, Madan R, Gulley JL, Schlom J. Phase I, dose-escalation, clinical trial of MVA-Brachyury-TRICOM vaccine

demonstrating safety and brachyury-specific T cell responses. Journal for Immunotherapy of Cancer. 2015;3(Suppl 2):P132-P. https://doi.org/10.1186/2051-1426-3-S2-P132. PubMed PMID: PMC4645490.
36 eery CR, Palena C, McMahon S, Donahue RN, Lepone LM, Grenga I, Dirmeier U, Cordes L, Marte J, Dahut W, Singh H, Madan RA, Fernando RI, Hamilton DH, Schlom J, Gulley JL. Phase I Study of a Poxviral TRICOM-

Based Vaccine Directed Against the Transcription Factor Brachyury. Clin Cancer Res. 2017;23(22):6833-45. Epub 2017/09/01. https://doi.org/10.1158/1078-0432.CCR-17-1087. PubMed PMID: 28855356;
PMCID: PMC5690815.
37 Gulley JL, Sater HA, Marte J, Donahue RN, Rodriguez BW, Heery CR, Stern M, Thompson D, Cordes LM, Chun G, Karzai F, Bilusic M, Schlom J, Dahut WL, Madan RA, Pinto PA. Effect of rilimogene gal-

vacirepvec/rilimogene glafolivec on intra/peritumoral immune infiltrate in patients with localized prostate cancer undergoing radical prostatectomy. Journal of Clinical Oncology. 2018;36(15_suppl):5083-.
https://doi.org/10.1200/JCO.2018.36.15_suppl.5083.
38 Cristea MC, Hardwick N, Frankel PH, Morgan R, Leong LA, Diamond DJ. A phase I study of a p53MVA vaccine in combination with gemcitabine (GEM) in recurrent ovarian cancer (OC). Journal of Clinical Oncology.

2016;34(15_suppl):e17040-e. https://doi.org/10.1200/JCO.2016.34.15_suppl.e17040.
39 Cohen RB, Morgensztern D, Walsh WV, Bazhenova L, Melnyk AM, Beck JT, Nemunaitis JJ, Schreiber TH, Price ML. First interim exploratory analysis of immune response in patients with advanced

non-small cell lung cancer receiving viagenpumatucel-l (HS-110) in combination with low-dose cyclophosphamide in an ongoing phase II trial. Journal of Clinical Oncology. 2015;33(15_suppl):3077-.
https://doi.org/10.1200/jco.2015.33.15_suppl.3077.
40
Oh J, Barve M, Matthews CM, Koon EC, Heffernan TP, Fine B, Grosen E, Bergman MK, Fleming EL, DeMars LR, West L, Spitz DL, Goodman H, Hancock KC, Wallraven G, Kumar P, Bognar E, Manning L, Pap-
pen BO, Adams N, Senzer N, Nemunaitis J. Phase II study of Vigil(R) DNA engineered immunotherapy as maintenance in advanced stage ovarian cancer. Gynecol Oncol. 2016;143(3):504-10. Epub 2016/09/30.
https://doi.org/10.1016/j.ygyno.2016.09.018. PubMed PMID: 27678295.
11
12
monocyte-derived mRNA electroporated dendritic cells (trimixdc-
mel) plus Ipilimumab in a phase II trial.21 PROSTVAC (a viral based
vaccine directed against the prostate specific Ag, PSA) was found to
be safe in combination with ICB in a phase I study22 and its efficacy
is currently being studied in mCRPC patients in several phase II trials
(NCT02506114, NCT02933255). A phase II study evaluated the
combination of an HPV E6/E7 peptide vaccine, ISA101 and Nivolumab
and showed promising OS and overall response rates (ORR) compared
with retrospective data with Nivolumab in advanced HPV-16 positive
cancer (22 out of 24 reported patients had oropharyngeal cancer).23 A
few additional phase I studies have reported safety of anti PD-1 combi-
nations including p53MVA combined with Pembrolizumab (advanced
solid cancers) and peptide vaccine with Nivolumab (melanoma).24-26
Several ongoing studies are testing similar combinations and have
recently been well described by Curran et al.27
2.3 Personalized cancer vaccines—the next
generation of vaccines
Recent years have seen major advances in next generation sequenc-
ing (NGS) providing the opportunity for successful crosstalk between
our ever-expanding knowledge base of oncologic mutations and tumor
immunology. Targeting tumor-specific Ags (TSA or neoantigens) based
on unique tumor somatic mutations (neoantigens) has been one strat-
egy toward vaccines “personalized” to the tumor.28-30 This approach
has the theoretical advantage of inherently escaping central toler-
ance to generate high affinity T cell engagement. Recognition of the
tumor mutanome led to the next challenge of identifying which muta-
tions to target in the individual tumor. Leveraging bioinformatics tools,
one proposed framework used an RNA-based approach against mul-
tiple neo-epitopes and this method showed promise in a pilot cohort
of melanoma patients.31 Combination trials of neoantigen based vac-
cines with immune modulators including checkpoint inhibitors are in
progress (NCT02287528, NCT03199040, NCT03380871). We have
provided a list of selected ongoing trials in personalized vaccine plat-
form in Table 3.
2.3.1 Immune checkpoint blockade and immunoscore
Despite significant improvements in the therapeutic cancer vaccine
platforms, they have still failed to provide meaningful clinical benefit
as monotherapy. This can be attributed to the TME intrinsic resis-
tance mechanisms discussed later in this review. Several studies have
highlighted that even in vaccinated patients, T and NK cells are less
functional in the tumor.32-35 This can partly arise from increased
expression of multiple inhibitory checkpoint molecules such as CTLA-
4, IDO (Indoleamine 2,3-dioxygenase), KIR (Killer Ig-like receptors),
LAG-3 (Lymphocyte activation protein 3), TIM-3 (T cell immunoglob-
ulin and mucin domain containing protein 3), SIGLEC-7 (Sialic acid
binding immunoglobulin like lectin-7), PD-1 (programmed cell death
1), PD-L1 (/programmed death-ligand 1), and NKG2A resulting in
T cell exhaustion, NK cell impairment, and/or recruitment of Tregs
in the tumor. Currently, there are two FDA approved pathways for
targeting multiple inhibitors of checkpoint blockade (ICB): Ipilimumab
ROY ET AL .
(trade name Yervoy) against CTLA-4 and 6 different agents against
PD-1 (Nivolumab and Pembrolizumab) and PD-L1 (Atezolizumab,
Avelumab, Durvalumab, and Cemiplimab), respectively. CTLA-4 binds
CD28 on DC and limits T cell functionality whereas PD-1 binding to
PD-L1 disrupts the co-stimulatory signaling downstream of CD28.
Clinical administration of monoclonal antibodies against CTLA-4 and
PD-1/PD-L1 axis has shown transformative benefits in a minority of
patients with >15 cancers.36-48 These drugs are thought to remove
the inhibitory brakes induced by the tumor cells within the TME to
prevent cell killing potential of activated T cells. Modest benefits
from these combinations were also noted in other cancers including
non-small cell lung carcinoma,49-52 small cell lung cancer,53 prostate,54
esophagogastric cancer,55 and Hodgkin’s lymphoma.56 Trials studying
other checkpoint blockade molecules in addition to anti PD-1/PD-L1
and anti-CTLA-4 are currently ongoing. For example, Monalizumab, a
blocking anti-human NKG2A mAb has already been tested in combina-
tion with cetuximab57 and metastatic microsatellite-stable colorectal
cancer (MSS-CRC).58 LAG-3 (NCT04140500) and TIM-359 as well
as co-stimulatory molecules like OX4060 are also currently being
evaluated in clinical trials. It is still unclear whether combination ICB
can alter the existing TCR repertoire to foster the expansion of new
tumor Ag specific T cell clones.61,62
Another mechanism of resistance is the global immunosuppressive
TME. Unfortunately, despite the success stories observing durable
responses in a subset of patients, even in the immunologically “hot”
tumors characterized by high level of inflammation and high T cell
infiltration with elevated expression of PD-1/PD-L1 that benefit
from ICB, the percentage of responders is far from optimal due to
acquired resistance or co-expression of other inhibitory molecules.
Non-immunogenic “cold” cancers like pancreatic, ovarian, breast,
and glioblastoma that have poor immune infiltration are mostly
non-responsive to ICB.63 Proposed mechanism of action for this resis-
tance is the enrichment of immunosuppressive cells (myeloid derived
suppressor cells (MDSC) and regulatory T cells (Tregs) as well as the
dynamic temporo-spatial architecture of the TME that allows the
tumor cells to outgrow the immune response generated against the
tumor. Cancer classification system relying on tumor characteristics,
such as size of the primary tumor (T), spread to regional lymph nodes
(N), and distant metastases (M) (TNM staging) and other markers
(e.g., tumor cell of origin, tumor gene signatures, etc.) fails to provide
complete prognostic information about the immune fitness of the
tumor and therefore may not correctly predict or stratify patients
who will respond to a certain therapy. Currently, patient stratification
based on Immunoscore and immune contexture that indicate the
type, density, and spatial distribution of the two types of immune
cells (cytolytic T-cells versus immunosuppressive Tregs and myeloid
cells) in the pre-existing tumor are investigated to potentially help
predict which patients are more likely to benefit from ICB and direct
therapeutic intervention.64 This immune based classification system
identifies four types of tumors: (i) hot (high immune cells infiltration
with high expression of PD-1/PD-L1), (ii) excluded (T cells at margin,
indicating the system could potentially mount an anti-tumor response
but fails to do so due to the presence of tumor-imposed physical
ROY ET AL . 13

TA B L E 2 Selected ongoing trials evaluating vaccine combinations

Vaccine name and type Trial combination NCT number Disease Trialphase
Intravesical BCG Durvalumab +EBRT NCT03317158 Bladder 1/2
(Bacterial cancer vaccine)
DPX-Survivac Pembrolizumab + NCT03029403 Ovarian, Peritoneal, 2
(peptide vaccine) Cyclophosphamide or fallopian tube
cancer
CDX-1401 Atezolizumab + NCT03206047 Ovarian cancer 2
(protein vaccine) Guadecitabine
EGFRvIII, EphA2, Bevacizumab NCT02754362 Glioblastoma 2
Her2/neu peptide
(peptide vaccine)
ISA101b Utomilumab NCT03258008 HPV16+ 2
(HPV16 E6/E7 peptide vaccine) (4–1BB agonist) oropharyn
xcancer
Intuva Sunitinib NCT02432846 RCC 2
x(allogenic cell-based therapy)
GVAX (GM-CSF-secreting tumor cells) Nivolumab+ NCT02451982 Pancreatic cancer 1/2
Cyclophosphamide
GVAX Nivolumab + ipilimumab+ NCT03190265 Pancreatic cancer 2
CRS-207 +
Cyclophosphamide
GVAX Neoadjuvant NCT03161379 Pancreatic cancer 2
cyclophosphamide +
SBRT + Nivolumab
GVAX Adjuvant NCT02648282 Pancreatic cancer 2
Cyclophosphamide +
SBRT + Pembrolizumab
GVAX Epaccadostat + NCT03006302 Pancreatic cancer 2
Pembrolizumab +
CRS-207 ± GVAX
Dendritic cell-based p53 vaccine Nivolumab + NCT03406715 Small cell lung cancer 2
ipilimumab
PROSTVAC (poxviral vector expressing Nivolumab NCT02933255 Prostate cancer 1/2
PSA)
PROSTVAC Ipilimumab NCT02506114 Prostate cancer 2
MVA-HPV16E6/E7-IL2 vaccine TG4001 Avelumab NCT03260023 HPV16+ 1/2
(vaccinia virus vector) oropharyn
xcancer
MEDI0457 Durvalumab NCT03162224 p16 or 1/2
(DNA vaccine) HPV16/18+
HNSCC
HPV E6/E7 GX-188E pembrolizumab NCT03444376 HPV16/18 1/2
(DNA vaccine) cervical cancer

pTVG-HP Pembrolizumab NCT02499835 Prostate cancer 1/2

(DNA Vaccine)
EBRT, external beam radiation therapy; SBRT, stereotactic body radiation therapy; RCC, renal cell cancer; HNSCC, head and neck squamous cell carcinoma.

barrier like aberrant vasculature and dense stroma), (iii) immunosup-
pressed (few T cell infiltrate inside tumor, suggesting the absence
of physical barrier but presence of immunosuppressive factors), and
(iv) cold (no T cell inside or at margin, low mutation burden, absence
of PD-1, PD-L1, and poor expression of Ag presentation machinery
like MHCI).64-78
Understandably, the “cold” tumors with low immunoscore present
most challenges to effective immunotherapy. In order to overcome the
absence of pre-existing immune responses in these tumors, patients
would likely require a priming strategy, for example, vaccine therapy,
radiation, or chemotherapy. This would reverse this immunosup-
pressive TME by inducing immunogenic cell death (ICD) to expand
the Ag repertoire through epitope spreading and increase the pro-
inflammatory TME. Radiation and specific chemotherapy induced cell
death can release DNA or damage- associated molecular patterns
(DAMPs) from dying cells that can trigger the STING mediated Type
I IFNs pathway and increase intratumoral infiltration of DC and
cytotoxic T cells. Several preclinical studies across multiple tumor
types have highlighted that multifactorial approach of combining ICB
with vaccination therapies and/or radiation and chemotherapy can
14 ROY ET AL .

TA B L E 3 Ongoing trials evaluating personalized vaccines

Vaccine Name and Type Trial Combination NCT Number Disease TrialPhase
Personalized Temozolomide+ RT+ NCT02287428 Glioblastoma 1
Neoantigen Peptide pembrolizumab
vaccine (NeoVax)
NeoVax Ipilimumab NCT02950766 Clear cell RCC 1
Personalized peptide-based vaccine CD40 agonist antibody NCT03597282 Melanoma 1
(NEO-PV-01) (APX005M) or ipilimumab
with nivolumab
NEO-PV-01 Pembrolizumab NCT03380871 NSCLC 1
NEO-PV-01 Nivolumab NCT02897765 Melanoma, lung cancer or 1
bladder cancer
NEO-PV-01 TLR-3 agonist poly-ICLC NCT01970358 Melanoma 1
Personalized Peptide Vaccine Pembrolizumab NCT02600949 Pancreatic carcinoma or 1
colorectal cancer
Personalized peptide-based Bevacizumab NCT01814813 Glioblastoma 2
Vaccine
(HSPPC-96)
Neoantigen DNA vaccine With or without durvalumab NCT03199040 TNBC 1
Personalized RNA mutanome vaccine Atezolizumab NCT03289962 Melanoma, NSCLC, TNBC, 1
(RO7198457) HNSCC, colorectal cancer,
and RCC
Personalized RNA mutanome vaccine Pembrolizumab NCT03815058 Melanoma 2
(RO7198457)
RT, radiation therapy; RCC, renal cell cancer; NSCLC, non-small cell lung cancer; TNBC, triple-negative breast cancer, HNSCC, head and neck squamous cell
carcinoma; HSPPC-96, heat shock protein peptide complex-96.

reinforce the therapeutic margin of one another and are currently
being evaluated in clinical trials.13,16,17,79–85 Another attractive thera-
peutic approach would be to combine vaccines with adoptive chimeric
Ag receptor (CAR) T cell therapy. Although its success is mainly limited
to hematological malignancies, a recent work by Ma et al. showed that
combination of vaccine and CAR-T cells eradicated 60% of solid tumors
in mice through robust activation of the latter in lymph nodes.86
Another recent study reported robust CAR T cell activation in murine
tumors by combination with a nanoparticulate RNA vaccine,87 which
opens the intriguing prospective of exploiting a combined approach of
therapeutic cancer vaccines and CAR T therapy against solid tumors in
the future. These strategies along with supporting preclinical data have
been exhaustively discussed elsewhere and is beyond the scope of
this review.63,88,89
Based on the immunome, the altered “excluded” or “immunosup-
pressed” tumors that present T cells at the borders or poor infiltration
could benefit from targeted therapies to increase chemokines
or cytokines or soluble factor inhibitors to either enhance T cell
mobilization and trafficking inside the tumor or deplete MDSC
and/or Tregs. Another important factor that contributes to poor
T cell infiltration is the presence of a “physical barrier” by either
aberrant vasculature or dense stroma, as in pancreatic cancer and
could be targeted by either anti-angiogenic therapies or by agents
disrupting the dense matrix barrier. A multitude of these agents
(anti-angiogenic, stromal targeting agents) are either in preclinical
stage or are being evaluated as monotherapy or as part of a multi-
pronged treatment approach. These have been discussed in more
detail elsewhere.88,90
However, one must appreciate that the above discussed type of
tumor stratification into “hot” or “cold” phenotypes is clearly an over-
simplification of the complex events occurring in the TME. It is possible
that even a tumor that appears “hot” may actually have an extremely
immunosuppressed microenvironment due to co-existence of multi-
ple parallel oncogenic mechanisms and may thus not respond to the
approaches tailored for “hot” tumors. Also, tumors evolve their resis-
tance mechanisms over time, adding an extra level of complexity.
Hence, exploitation of a combined evaluation of the spatiotemporal
interplay of immune cell types (immune contexture and immunoscore)
and other parameters (morphology, chromosomal instability, tumor
cell of origin, oncogenic driver genes signature, etc.) can help improve
prediction of clinical outcomes and stratify patients for successful ther-
apeutic intervention.
3 CANCER VACCINE PLATFORMS
With this 30,000-feet aerial view of the clinical landscape of cancer
vaccines from its infancy to latest generation of neoantigen-based
platforms, we will survey some of the major classes of vaccines,
particularly those that have formidably crossed over the chiasmic
divide into the clinical phase. Vaccine platforms are vast, and there
are many excellent reviews that highlight their basic components with
their advantages or limitations27,91,92 (Fig. 2). In the following sections,
we will highlight the recent developments, challenges, and future
prospect for some of the major classes of vaccines. The companion
review will focus on novel developments on formulation.
ROY ET AL . 15

F I G U R E 2 (A) Next generation cancer vaccine platforms. The essential components of an effective therapeutic cancer vaccine are illustrated
here: (i) source of tumor Ag: this can be either tumor associated or neoantigens. Ags can be derived from either whole cell lysate, peptides, over-
expressed protein, tissue differentiation, cancer testis, oncofetal proteins, and/or DNA or RNA. (ii) Formulation: vaccines can be cell based (whole
cell or loaded into DC), protein or peptide based, nucleic acid based, or microbial organism based. (iii) Adjuvants and/or cytokines used: different
types of adjuvants and/or cytokines like TLR ligands, STING agonists, Type I IFNs, IL-12, GM-CSF are used to improve vaccine efficacy and adap-
tive immunity activation. (iv) Delivery vehicles: vaccines are bioengineered and formulated into emulsions, liposomes, virosomes, or nanodiscs and
other biological scaffolds to improve bioavailability and targeting to the desired site. (B) Mechanism of T cell priming and cancer cell killing. Depend-
ing on the vaccine platform and Ag source used, the APCs are primed and/or activated. This is followed by specific binding of a TCR on T cells in the
tumor draining lymph nodes to its cognate peptide-major histocompatibility (MHC) complex displayed on an APC, like, M𝜙 or dendritic cell. This,
in combination with co-stimulatory signals and inflammatory cytokine release from activated APC can successfully transform resting naïve T cells
(CD4+ , CD8+ ) to activated effector cancer cell killing T cells and result in tumor regression. Co-stimulation may be improved by using adjuvants
that activate the pattern recognition receptors on APC and upregulate the co-stimulatory ligands, as well as by agonist antibodies that can engage
with the co-stimulatory molecules on the T cells and trigger an activation signaling cascade. Within the tumor, T cells up-regulate the expression
of checkpoint inhibitory molecules including CTLA-4 and PD-1 and this can dampen the vaccine efficacy. Combining vaccine therapy with immune
checkpoint blockade has therefore emerged as a potential treatment modality in wide variety of cancers, unfortunately with limited efficacy so far
16 ROY ET AL .

3.1 Cellular vaccines TGF-𝛽, IL-10, VEGF, Arg-1, IDO interfere with DC maturation and
arrest them in a dysfunctional state. Additional factors like expression
The cellular vaccine comes in two variants: whole tumor cell based and
of high level of coinhibitory molecules like TIM3, PDL-1, PD-1 on DCs,
autologous dendritic cell based, pulsed with either tumor cell derived
metabolic stress as well as Ag masking and faulty Ag presentation
lysates, proteins, peptides, patient specific neoantigens, viruses, or
facilitate the switch from inflammatory to tolerogenic phenotype.
nucleic acids.
Hence, over the past decade, much effort was invested to understand
the complex interplay and biology of DCs with other immune cells in
3.2 Whole cell vaccines the tumor microenvironment and modulate them for activation of T
cells against the tumor.
Whole tumor cell vaccines are essentially prepared from whole tumor
Since DC can activate Ag specific T cells, the goal of DC vac-
cells or tumor cell lysates generated by irradiation or repeated freeze
cine is to repair the immune suppression by administering “trained”
thaw cycles, derived from either autologous patient tumor tissues or
DCs and activate the adaptive immune responses in the patient. Typ-
heterologous tumor cell lines. These are often genetically modified to
ically, monocytes are isolated from patients via leukapheresis and
produce different cytokines/chemokines (GM-CSF) that can augment
then differentiated using GM-CSF and IL-4 in vitro to yield imma-
adjuvant function (recruit DCs and facilitate Ag uptake, cross priming
ture DC. These are then loaded with either (i) whole tumor prepa-
and presentation to CD8+ T cells). Irradiated tumor cells can release
ration, (ii) DC-tumor cell fusion, (iii) virus, (iv) defined, shared tumor
DAMP molecules such as HMGB1, pentraxin-3 (PTX3), heat shock pro-
associated Ags (peptides, nucleic acid), or (v) unique neoantigens from
teins (HSP 70/90), and uric acid that can stimulate DC maturation and
the tumor cells. The Ag-loaded DCs are then further matured using
T cell responses against the tumor.93 One advantage of using whole
a cytokine mixture that essentially makes them competent for pro-
cell vaccine is that the cells would serve as an unbiased source of a
cesses like lymph node homing, Ag cross presentation and activation
broad spectrum of tumor Ags, thereby eliminating the requirement of
of T cells as well as production of pro-inflammatory cytokines.128-130
identifying an immunogenic Ag or potential concerns of Ag loss.93-95
These ex vivo matured DCs are then infused back to the patient.120,131
As mentioned earlier, tumor cell vaccines are often genetically mod-
To date, DC vaccines have been applied to a variety of malignan-
ified to express different cytokines or chemokines or co-stimulatory
cies (over 240 completed clinical trials) including melanoma, prostate,
molecules to stimulate more robust immune response to the vac-
renal cell carcinoma, glioblastoma, and pancreatic cancer.117,123,129
cine. Of different cytokines tested, a superior response was observed
In the earliest trials, the first-generation DC vaccines from blood
with irradiated melanoma cells transduced with GM-CSF. This vac-
monocytes that were only loaded with synthetic TAA peptides or
cine (GVAX) showed promising results in early preclinical studies96-103
tumor cell lysates was found to be safe and immunogenic and were
that laid the groundwork for numerous clinical trials targeting a vari-
tested in a variety of cancers,132-142 but only 3.3% patients experi-
ety of cancers including prostate, melanoma, NSCLC, and pancreatic
enced tumor regression.123,128,129,135,143,144 In many studies, it was
cancer.104,105 However, in most of the clinical trials, it failed to live up to
reported that Treg-mediated immunosuppression hindered the effi-
its expectations.106-110 Despite these disappointing results, clinicians
cacy of DC vaccines.143 Subsequently, the DCs were matured using
continue to test the efficacy of GVAX in combination with different
a defined cocktail of cytokines and these second-generation vaccines
treatment strategies, especially ICB molecules.
performed better with an overall objective response rate (ORR) in the
There are other whole cell tumor vaccines: Oncovax (colon can-
range of 8–15%. There is also an interesting strategy to use DC and
cer; Vaccinogen),111-113 and Reniale (renal cancer; Liponova)114,115 to
tumor cell hybrid, and these improved immune response in patients
name a few. Of these, Oncovax, prepared by irradiating patient tumor
(NCT01096602).145,146
cells and administered with BCG bacteria as adjuvant, significantly
Despite some modest clinical efficacy for DC vaccines, the early tri-
reduced the chances of recurrence post-surgery in several early phase
als raised some questions and challenges. One concern is that the spe-
trials in colon cancer patients.111-113 Based on these promising results,
cific details of DC vaccine manufacturing vary considerably and cover
a randomized, multicenter Phase IIIb clinical trial (NCT02448173)
various aspects like the source and starting cell population, culture
is ongoing to test if Oncovax improves disease free survival post-
condition, maturation cocktail used, choice of Ag and Ag loading tech-
surgery. Unfortunately, the main disadvantage of an autologous whole
nique, as well as time and route of administration. The DC subtypes are
cell vaccine approach is its inherent logistic hurdle—it is time con-
transcriptionally and functionally distinct in their developmental ori-
suming, expensive, and variable.96,100,116 Alternatively, allogeneic cells
gin, and localization.147,148 A recent single cell RNA sequencing study
derived from different tumors could be used with the likelihood that
identified 6 different classes of circulating DC in peripheral blood.149
the patient’s tumor will share Ags with that of the vaccine.
Some researchers argue in favor of using peripheral blood derived DC
to better retain their physiological functionality following transfusion
3.3 DC vaccines to patients. Indeed, studies report transcriptional and phenotypic
Dendritic cells (DC) are the most potent APCs, and depending on differences in monocyte derived (moDC) and conventional DCs (cDC)
the context, DC also provide either co-stimulatory or co-inhibitory that translate to poor migratory capacity of moDC to lymph nodes
signals to T cells for activation or suppression.117-127 In the tumor and T cell priming.150,151 Heterogeneity of human DC population is
microenvironment, immunosuppressive molecules and cytokines like further highlighted by studies showing potent Ag presentation by
ROY ET AL .
moDC152,153 whereas some studies indicated potent Ag presentation
by BDCA1/CD1c+ moDCs and BDCA3/CD141+ moDCs.123,154 The
use of cDC harvested from circulation is limited owing to their poor
availability in the peripheral blood of cancer patients and the potential
need for repeated dosing in a therapeutic setting as well as their
compromised capacity to present Ags and secrete pro-inflammatory
cytokines.155 Still in its infancy, cDC vaccines are being tested as pilot
trials in the European study, “Professional cross-priming for ovarian
and prostate cancer” (PROCROP). A recent trial, however, used autol-
ogous naturally circulating DC loaded with HLA-A2.1 restricted tumor
Ag for stage IV melanoma patients (NCT01690377). Four out of 14
patients showed long-term progression-free survival that correlated
with the development of cytolytic, multifunctional effector T cells.156
Scientists have also attempted to use plasmacytoid DC as vaccines.157
Another important variable that dictates DC vaccine efficacy is the
combination of cytokines used to mature the DC. Scientists have differ-
entiated DC from CD34+ stem cells or cord blood by adding molecules
like FLT3L, Stem Cell Factor (SCF), GM-CSF, Thrombopoietin, IL-7,
Notch ligand Delta Like-1 (DL1), and IL-4, at the same time attempt-
ing to recapitulate physiological DC phenotype ex vivo by culturing the
cells for different time periods (1 or 3 week).151,158–162 Unfortunately,
there is no consensus for optimal DC maturation protocols and the
maturation cocktail used. Earlier, the gold standard was to use a cock-
tail containing TNF-𝛼, IL-1𝛽, and IL-6 in combination with PGE2.163
However, PGE2 has been shown to induce Tregs, increase the expres-
sion of IDO and reduce the secretion of IL-12.164,165 Scientists and clin-
icians have explored alternative maturation cocktails. These include
triggering of co-stimulatory pathways (e.g., CD40-CD40L), activation
of TLR by using agonists like poly IC (TLR3), resiquimod (TLR7/8)
pathway, and 3-O-deacylated monophosphoryl lipid A (MPLA) either
as single agents or in combination.166-168 For instance, DC trans-
fected on the TriMix platform with mRNA encoding constitutively
active TLR4, CD40L, and CD70 has been clinically tested in melanoma
patients.21,169 However, combination of different agonists in varying
doses and varying maturation time may potentially alter the expres-
sion of inflammatory genes and chemokines that will translate to the
efficacy of the DC vaccine in vivo.170 Recently, a novel method of trans-
fecting DC with a mRNA cocktail encoding co-stimulatory molecules
(CD40L, CD70, and a constitutively active TLR4) has shown promising
result in melanoma patients (NCT00074230, NCT01066390).21,171
Another possible reason for DC vaccines to have shown limited effi-
cacy is that many of the clinical trials were done with patients having
late stage disease where dominant immunosuppressive mechanisms
can dampen responses to DC vaccines and T cell activation. This is
reflected in earlier studies that noted T cell activation in higher fraction
of patients receiving adjuvant DC vaccines compared to those with
metastatic disease. This indicates that DC vaccines may perform better
in adjuvant settings.145,146,172 Another potential for improvement is
DC mobilization. Intradermal injection allows ≤5% of DCs to migrate to
lymph nodes whereas intravenous route distributes DC to non-specific
locations like spleen, lungs, liver, and bone marrow. Attempts have
been made to manipulate DC by viral vectors to overexpress molecules
to improve their trafficking to the tumor in vivo.173 Other factors that
17
significantly affect the DC vaccine efficacy are the choice and method
of Ag loading. While a broad range of Ags have been explored includ-
ing defined peptides, whole tumor cell lysate, nucleic acids, irradiated
tumor cells, neoantigenic peptides, and viruses, how to generate the
best immunogenic Ag and its loading technique to ensure maximum
clinical response remains an open question. Oxidizing whole tumor
lysate with hypochlorous acid or infecting the tumor cell with New-
Castle Disease virus significantly improved DC vaccination outcome
in the preclinical setting.174-176 Combining chemotherapeutic drugs or
oncolytic viruses that induce immunogenic cell death of tumor cells is
another way to improve DC vaccine outcome. Lastly, the cost of pro-
duction and the complexity associated with its manufacture has hin-
dered its wide-spread clinical application.
Despite these challenges, there are several novel and state of the art
DC-based vaccines that are currently being tested in different phases
of clinical trials. For example, a placebo-controlled phase III trial is test-
ing an autologous DC vaccine loaded with tumor lysate (DCVax-L) in
glioblastoma patients in combination with radiation and chemotherapy
(NCT00045968). The initial reports show DC vaccination improved
overall survival to 23 months compared to 15–17 months in case of
patients who received standard of care therapy in earlier studies.177
Other phase III studies include investigating the efficacy of autologous
RNA loaded DC vaccine as an adjuvant to standard of care in uveal
melanoma (NCT01983748) and that of BDCA3+ naturally circulating
DC in stage 3 melanoma patients (NCT02993315). The patients will be
assessed for 2-year recurrence free survival. Other trials are testing
the efficacy of DC vaccines in combination with radiation, chemother-
apy, targeted therapies, depletion of myeloid cells, and Tregs. In
addition, the emergence of neoantigens has initiated the development
and use of personalized neoantigen DC vaccines.178 A recent meta-
analysis reported that the objective response rate to DC vaccines in
melanoma and glioblastoma was 8.5% and 15.6%, respectively.129
Hence, strategies to incorporate neoantigens into DC vaccines are
already ongoing179 (NCT03300843). Lastly, in the light of current
understanding, like many other vaccine platforms, DC vaccines have
been combined with ICB,20 including in combination with different PD-
1 or CTLA-4 inhibitors in several cancers including glioblastoma (and
other brain tumors), colorectal cancer, and melanoma. DC vaccines can
also be combined with other ICB like Abs targeting Tim-3, Lag-3, and
NKG2A that are currently in different stages of clinical development.
3.4 Peptide vaccines in cancer
Peptide-based vaccines that initially targeted tumor enriched
Ags,180,181 can be classified into two distinct categories:
tumor-associated Ags (TAA) and neoantigens (tumor specific Ags,
TSA). TAAs are enriched on cancerous cells but also expressed
on some normal cells and are further subcategorized to (a) aber-
rantly overexpressed Ags (e.g., Her2/neu182 and survivin183 ), (b)
lineage-restricted Ags (e.g., gp100184 , prostate-specific Ag,185 and
tyrosinase186 ), (c) cancer-testis (CT) Ags (e.g., MAGE family187 and
NY-ESO-1188 ), (d) oncofetal Ags (e.g., Carcinoembryonic Ag189-191 ),
and (e) oncogenic viral Ags (HPV E6/E7). Neoantigens, on the other
18
hand, are developed from somatic mutations (e.g., insertions, deletions,
translocations)192 in the tumor triggered by DNA-damage events,
resulting in specific expression in the tumor.
Early clinical trials utilized TAA-based vaccines alone, such as
the MAGEA3 vaccine,193 to treat established cancers and gener-
ally resulted in good safety profiles but lacked objective clinical
responses.194 Various forms of adjuvants (Montanide, TLR agonists,
incomplete Freund’s adjuvant, etc.) are an essential component
of these vaccines,195-197 and some early studies showed modest
signs of clinical benefits for recurrence and disease-free survival
compared to non-vaccinated patients.198 However, even with
the added anticancer benefits from immunostimulants or deliv-
ery vehicles, no peptide-based vaccine has been FDA approved
to treat cancer. One biological reason may be the low immuno-
genicity of the TAAs, which is why it may be more beneficial to
target neoantigens for peptide vaccines. An illustrative exam-
ple of this is the Kras-based neoantigen vaccine that showed no
clinical benefit.199-201
To address immunosuppression from advanced tumor burden,
combination strategies have been adopted to increase immunogenic
cancer cell death, for example, by using approved chemotherapeutic
agents like gemcitabine, cyclophosphamide, fluorouracil (5-FU), or
folfirinox among others. These treatments were also reported to sup-
press the tumor promoting functions of Tregs and MDSCs.202-211 For
instance, gemcitabine was shown to specifically reduce the number of
Gr1+ MDSC in spleens of tumor bearing mice. This decrease in splenic
MDSCs was accompanied by an increase in the antitumor activity of
CD8+ T cells and NK cells.202 Similarly, 5-FU significantly contracted
the number of MDSC in spleen and tumor bed and concomitantly
increased IFN-𝛾 production by CD8+ T cells and promoted T cell
dependent antitumor activity.206 The effect of chemotherapy on Tregs
is also appreciated. Chemotherapy can selectively reduce the number
of Tregs in the tumor bed, tumor draining lymph nodes as well as
peripheral blood.204,212,213 Cyclophosphamide may also reduce the
number Tregs by inducing apoptosis and inhibiting proliferation.204
Based on these encouraging results, multiple trials have employed this
combinatorial strategy but have failed to show any significant clinical
effect. For example, a phase II clinical study for patients with resected
pancreatic cancer determined that gemcitabine plus OCV-C02, a
3-peptide cocktail, had no significant effect on DFS compared to
gemcitabine alone.214 Another strategy explored is the combination of
peptide vaccines and ICB because of ICB’s ability to intensify immuno-
genic responses. This combination strategy is still in its infancy, and
these clinical trials are still ongoing.
3.5 Nucleic acid vaccines
Nucleic acids have been well recognized as potent adjuvants,215,216
and these also come in multiple flavors.217,218 Both RNA and DNA
have been used as adjuvants, but these also offer the ability to code
for TAA. For RNA vaccine, RNA is transcribed in vitro (IVT) by a DNA
template encoding the Ag and bacteriophage RNA polymerase.219
Pertinent biological factors for these platforms have been discussed
ROY ET AL .
elsewhere.217,220 While there are examples of naked RNA vaccine
that codes for carcinoembryonic Ag (CEA) exhibiting strong immune
responses when challenged with CEA overexpressing cancer cells,221
stability of RNA has been an issue. Some of this work has been adopted
by the bioengineers as a delivery problem and various forms of alter-
native vaccine delivery method (“gene gun,” protamine condensation,
encapsulation) have been used.222-225 An example of this is CV9103
comprising of mRNA encoding four prostate cancer associated Ags
that was condensed with protamine for castration resistant prostate
cancer. The vaccine was well tolerated and showed Ag specific T cell
responses in 36 patients with metastatic prostate cancer, and the
vaccine showed a median overall survival of 30 months compared to
predicted 16.5 months (EudraCT number: 2011-006314-14).181,226
A similar approach for lung cancer patients is ongoing.227-229 To
improve RNA half-life and delivery in vivo, naked RNA IVT is often
encapsulated in nanoparticles and cationic lipid complexes for deliv-
ery for patients230 (NCT03313778). Details about similar studies
can be found on the ClinicalTrials.gov website (NCT03289962,
NCT03815058).
The RNA and DC platform can be combined, whereby DCs can be
pulsed with either total tumor RNA, TAA RNA, or neoantigen RNA.
There are currently over 24 ongoing clinical trials investigating RNA
loaded DC vaccines. The advantage (or the disadvantage) with using
whole tumor RNA for DC priming is it presents the entire constellation
of Ags without the requirement of identification of immunogenic
epitopes. Most of these early studies have shown little toxicity and
potential to elicit antitumor immune response.231-235 In a more
recent Phase II trial with Rocapuldencel-T or AGS-003, moDC was
co-electroporated with whole tumor RNA plus RNA encoding a cos-
timulatory gene CD40L and administered to treatment naïve patients
with clear cell renal cell carcinoma and evaluated in combination with
sunitinib. The combination was well tolerated and yielded supportive
immunologic responses and significant increase in OS.236 Alterna-
tively, DCs can also be loaded with single or multiple TAA encoding
IVT mRNAs and infused back into the patients. With this method, the
Ag must be immunogenic enough to activate the T cells, and these TAA
pulsed DCs have been tested in multiple clinical trials.237-241 DCs have
also been stimulated with mRNA encoding melanoma Ags (MAGEA3,
melanoma-associated Ag C2 (MAGEC2), tyrosinase and melanocyte
lineage-specific Ag GP100, and other mRNAs encoding immune
co-stimulatory genes like CD40 ligand (CD40L), a constitutively active
mutant form of TLR4 and CD70 (NCT01066390).21,169,242,243 Trimix
vaccine is currently being tested in a placebo controlled clinical trial in
breast cancer patients (NCT03788083).
DNA based vaccine is the other flavor of nucleic acid vaccines, and
much like RNA, their clinical development is focused around delivery
and combination with ICB. Biological basis of DNA based vaccines are
reviewed elsewhere.216,244 The commonly used techniques to deliver
the vaccine are electroporation, sonoporation, gene gun, or DNA
tattooing. For gene gun mediated intradermal injection, Langerhans
cells, the APCs residing in skin directly engulf the plasmids and express
the Ag, which is then presented by MHCI to prime naïve T cells in
the lymphoid tissues. For intramuscular route, myocytes take up the
ROY ET AL .
plasmids. However, they are not potent inducers of immune activation.
Instead, they recruit DCs that phagocytose the infected cells and then
mount T cell response and memory. These techniques have been com-
prehensively reviewed elsewhere.245 Unfortunately, DNA vaccines
as a monotherapy have often showed limited success in the clinic.244
Several clinical trials are testing the potential of DNA vaccines in
combination with ICB in a variety of tumors (Clinicaltrials.gov).
3.6 Microbial vector vaccines—oncolytic
and bacterial
Oncolytic viruses (OV) have recently emerged as one of the most
promising treatment options in cancer therapy. In brief, oncolytic
viruses infect and replicate within tumor cells causing cell death and
release of Ags and viral debris.245,246 Phenotypic “hallmarks of can-
cer” including the high metabolic activity within tumor cells and driver
mutations have been shown to increase the replication of viruses inside
the cancer cells. The major advantage of oncolytic viruses is that they
can specifically target and lyse neoplastic tissue while sparing healthy
cells, thus having limited systemic toxicity theoretically. Also, in con-
trast to drug pharmacokinetics that decreases with time, the viral dose
in tumor increases due to in situ replication. Viral receptors can be
overexpressed by tumor cells, and recombinant viruses can be modi-
fied to target tumor-specific receptors and to overexpress cancer spe-
cific genes (e.g., apoptosis inducing or immune stimulating), to amplify
the antitumor effects. OV can be either DNA or RNA virus and either
single stranded or double stranded. They establish lytic cycle in can-
cer cells by either replicating preferentially in cancer cells by using
activated oncogenic pathways, or have been genetically modified to
replicate selectively in malignant cells. Details of oncolytic viruses have
been exhaustively reviewed in depth elsewhere.246-251
In brief, immune stimulatory properties of OV stem from their abil-
ity to induce immunogenic cell death like programmed necrosis or
necroptosis252-256 to activate immune cells against the infected malig-
nant cells as well as prime de novo T cell response against tumor associ-
ated as well as neoantigens that were not exposed earlier. OV-induced
lysis of cancer cells releases endogenous nuclear and cellular contents
including pathogen-associated molecular patterns (PAMPs), DAMPs,
viral proteins, and nucleic acids, tumor associated Ags, immunogenic
neoepitopes,248,257,258 and activate antitumor immune response cas-
cades. PAMPs, DAMPs, tumor Ags thus released can be phagocytosed
by M𝜙s or DCs and fuel the release of inflammatory and immune acti-
vating cytokines. These then can activate immune cells against the
infected malignant cells as well as prime de novo T cell response against
tumor associated as well as neoantigens that were not exposed ear-
lier. Type I IFNs and DAMPs can also directly activate NK cells that will
now effectively kill cancer cells that have down-regulated their expres-
sion of MHC I, a common occurrence in most cancers. OV can also
be genetically modified to express anti angiogenic molecules to target
tumor angiogenesis.259 OVs have also been reported to produce absco-
pal effect—the regression or delayed progression of metastatic sites
distant from the site of inoculation.259
19
Currently, there are numerous OV that are being tested in clinical
trials for the treatment of different types of cancer.260 To date,
FDA has approved the HSV-1 based oncolytic virus, talimogene
laherparepvec, or T-VEC (ImlygicTM ) for the treatment of metastatic
melanoma that are surgically nonresectable. TVEC is composed of
genetically modified HSV-1 made to overexpress GM-CSF.20,261–263
There are 28 trials that are active and testing TVEC in a variety of
cancers including pancreatic cancer, sarcoma, breast cancer, and
melanoma among others, either alone or in combination with radia-
tion, chemotherapy, or immune therapy. Another example of oncolytic
virus therapy that has shown promising results in early phase trials is
a genetically modified poliovirus: rhinovirus chimera, PVSRIPO. The
virus elicited effective antitumor immune responses in patients with
recurrent glioblastoma.264,265 A phase II trial is currently under way
testing the efficacy of PVSRIPO with or without the chemotherapy
drug Iomustine (Gleostine
R
) in glioblastoma patients. Based on the
promising results, PVSRIPO was granted “breakthrough” status by
the FDA. Other examples of OV are the human Orthoreovirus that
can cross the blood–brain barrier to activate cytotoxic T cell response
against brain tumors,266 and Maraba virus isolated from a variety of
sandfly in Brazil to treat triple negative breast cancer (TNBC).267
With the expansion of OV in clinical trials, there is now an urgent
need for biomarker discovery, optimal dosing, and combinatorial
pathways268,269 to identify patients that may benefit more from the
virus therapy either as stand-alone drug or in combination with other
immunomodulating agents. With the wealth of well characterized
microbial agents, several other viral vectors are currently being inves-
tigated in preclinical phases for translation.
The other microbial vector is the bacterium, and other reviews
are available that discuss this platform in detail.270-275 Commonly
used strains include Clostridium, Salmonella, and Listeria. A mod-
ified Salmonella vaccine was tested for dose, safety, tolerability,
and immune response in patients with refractory solid tumors
(NCT00006254, NCT00004216). Salmonella modified to express IL-
2 has been orally administered to patients with refractory hepatic
metastases from solid tumors in a phase I study (NCT01099631).
One ongoing phase I trial will test the safety and dosage of orally
administered live Salmonella vaccine modified to produce survivin
in patients with multiple myeloma and induce survivin Ag-specific
T cell response (NCT03762291). In a phase I clinical trial with 1
patient presenting retroperitoneal leiomyosarcoma, Clostridium vac-
cine showed extensive tumor necrosis and improved quality of life
(NCT01924689).273 Clostridium vaccine is currently being tested in
combination with pembrolizumab in solid tumors (NCT03435952).
Lastly, Listeria strains modified to express the tumor Ag mesothelin
(CRS207) have also been tested in mesothelioma, lung, pancreatic, or
ovarian cancers in early phase trials. Both the vaccines were well toler-
ated in patients and induced tumor specific T and NK cell responses.276
CRS207 was next investigated in a phase II trial in combination with
GVAX and cyclophosphamide (NCT02004262) in previously treated
pancreatic metastatic patients. A phase I clinical trial is ongoing to
test the safety, dose, and immune response of a live Listeria vac-
cine (ADU623) expressing EGFRvIII and NY-ESO-1 to treat patients
20
with astrocytic tumors (NCT01967758). Ongoing trials are focusing on
combining Listeria vaccines with other conventional treatment options
or immunotherapies (Clinicaltrials.gov). For example, Listeria vaccine is
currently being tested in combination with anti-PD-1 (NCT03847519)
or as an adjuvant after chemotherapy (NCT01675765) in non-small
cell lung carcinoma and malignant mesothelioma, respectively. Worth
mentioning is another study by Aduro Biotech Inc. that is aimed to
test the efficacy of a personalized live attenuated Listeria vaccine in
metastatic colorectal cancer patients (NCT03189030).
3.7 iPSC-based vaccine
The concept of embryonic tissue being used for vaccination dated
back to 1906, when Georg Schöne reported that mice immunized with
fetal tissue rejected transplanted tumors.277,278 Published reports
now indicate that embryonic cells and tumor cells share transcriptome
profile and Ag repertoire.279,280 Induced pluripotent cell-based vac-
cines circumvent the ethical roadblock and are the newest addition in
the family of cancer vaccine. Reports now show that iPSCs share nearly
identical gene expression profiles with that of embryonic stem cells
and cancer cells and have immunogenic properties as well.281-287 The
concept has recently been tested by Kooreman et al. In their elegant
study, the authors have developed an autologous vaccine from irradi-
ated mouse pluripotent stem cells (to arrest their proliferation in vivo
and prevent the formation of teratoma). Used prophylactically, the vac-
cine was effective in preventing tumor formation in syngeneic models
of breast cancer, mesothelioma, and melanoma and showed clear indi-
cations of humoral and cellular immune responses. The vaccine culmi-
nated in mature APCs in the draining lymph nodes (dLN) and increase
in the local and systemic helper and cytotoxic T cells. In an adjuvant
setting, it reduced metastatic tumor burden and potentially altered
immune responses characterized by fewer Th17 cells and increased
infiltration of Gr1+ CD11b+ myeloid cells into the tumors. Interest-
ingly, when the authors adoptively transferred T cells from vaccinated
tumor bearing mice, it elicited an Ag-specific antitumor response in
unvaccinated recipients.288
One major advantage of autologous iPSC vaccine is that it circum-
vents the challenge of patient specific tumor Ag selection. Also, it will
be readily available from the patient skin or blood. However, there are a
few safety concerns that need to be noted. iPSCs are immature progen-
itor cells that do not have growth restraint and therefore may give rise
to teratomas once injected. Genetic modifications with suicide gene ex
vivo are potentially feasible options in the near future. Another issue
is the labor-intensive process of reprogramming iPSCs ex vivo that
introduces concerns for cost and time required to prepare the vaccine.
Although iPSC-based vaccines showed encouraging results in preclini-
cal settings, its translation in patients is pending.
3.8 Personalized cancer vaccine
As mentioned earlier, TAAs are often expressed in low level in normal
tissue and hinder immune responses to vaccine therapy through cen-
tral and peripheral tolerance or autoimmunity. Thus, the lack of enough
ROY ET AL .
“foreignness” may have been the reason for failure of many vaccine
studies in the past. As the cancer evolves, it accumulates mutations
that alter the amino acid sequences in proteins. The most common
types of mutations are single nucleotide variation (SNV), insertion,
deletion, and fusion or duplications. These mutations can either result
in single amino acid mutation or change the open reading frame
yielding mutated peptides/proteins called neoepitopes. These can vary
within different regions of the same tumor and are truly tumor specific
Ags. There are reports of shared neoantigens, but most are not shared
across tumor types and are specific for the patient.289 Personalized
vaccines targeting the unique set of neoantigens in an individual’s
tumor have been developed; the challenges facing this platform is
primarily that of immunogenicity and heterogeneity. Early examples in
murine Lewis Lung carcinoma models in 1994 of mutated connexin 37
showed the biological basis of these neoantigen based platforms, but
their translational potential was spurred by advancements in the fields
of next generation sequencing and bioinformatics.290-295 The typical
workflow for the development of personalized neoantigen vaccine
involves whole exome and RNA sequencing of tumor and matched nor-
mal tissue, followed by bioinformatics platforms to analyze the clonal
ancestry for determining the neoantigen clonality in the tumor and
intratumor heterogeneity. Potential vaccine neoepitopes are next pre-
dicted based on their binding affinity to the HLA subtype determined
in the patient. NetMHC and IEDB consensus are 2 such platforms.
Finally, the validated epitopes are selected for vaccine formulation
and administered to the patients. In some settings, immunogenicity
can be determined with ELISPOT using synthetic peptides. In one such
study, 3 melanoma patients were treated with autologous DCs that
were loaded with 7 HLA-A2 restricted synthetic 7-mer peptides that
represented the individual antigenic mutations in the patients.179
In addition to the neoepitope vaccine, they also received melanoma
gp100-derived peptides G209-2M and G280-9V (as positive controls
for vaccination). The treatment was well tolerated in the patients who
developed neoantigen specific T cell responses.
To date, multiple combinatorial approaches have been exploited
to deliver different neoantigen-based vaccines.294,296–304 Examples
range from direct injection of unformulated Ags to DC pulsed with
immunogenic neoantigens179 or bioengineered neoantigen delivery
formulations.305-307 It is noteworthy that based on the recent devel-
opments, multiple personalized vaccines trials are now ongoing or in
the pipeline, awaiting their evaluation in clinical settings. RNA based
personalized vaccine RO7198457 (Genentech) is currently in a Phase
Ia/Ib dose escalation study either as a single agent or in combina-
tion with Atezolizumab (MPDL3280A, an engineered anti-PD-L1 Ab).
Neovax (formulated with poly-ICLC) will be combined with Ipilimumab
in a cohort of 18–20 patients diagnosed with stage III/IV clear cell
renal cell carcinoma (ccRCC; NCT02950766). NEO-PV-01, a person-
alized cancer vaccine containing up to 20 neoantigens individually
selected for each patient diagnosed with advanced melanoma, blad-
der cancer, or non-small cell lung cancer (NSCLC) is also ongoing
(NCT01970358). A second Phase II study is currently ongoing to eval-
uate the efficacy, safety, pharmacokinetics, and patient-reported out-
comes (PROs) of RO7198457 plus Pembrolizumab (PD-1 blocking
ROY ET AL .
agent) compared with Pembrolizumab alone in patients with previ-
ously untreated advanced melanoma.
The design and development of neoantigen based personalized
cancer vaccines involve the rapid and accurate identification of
patient’s mutanome and thus heavily rely on the robustness of in silico
modeling and derivation of neoantigens- working with patient sample
to sequencing and bioinformatics analysis. This is especially imperative
for tumors with lower mutation load. There are still significant gaps in
HLA presentation prediction based solely on Kd versus actual immuno-
genicity that is not accounted for in the sequencing-based methods
to generate these personalized vaccines. Current bioinformatics algo-
rithms face significant challenges in accurately assessing MHC binding
affinity and specificity partly due to limited knowledge available about
several HLA alleles. Recent studies showed that CD8+ T cell response
against predicted high affinity binders were low as 29%, warranting
improvements of the algorithms currently used.31 Researchers are
currently exploiting other methods including mass spectrometry to
identify actual neoantigens presented on HLA molecules. For example,
mass spectrometric analysis of peptide-HLA complexes revealed
the HLA ligandome derived from human tumors.308-312 Collectively,
this entire process of identification of patient tumor neoantigen,
validating their presentation on HLA molecules, and demonstrating
their immunogenicity may take up to several weeks or months, which
may not be a feasible option if the patient is diagnosed with large
tumor burden or an advanced stage of cancer. Last but not the least,
the platform also introduces the concern for affordability by majority
of the patients.
4 HURDLES FACING SUCCESS OF CANCER
VACCINE THERAPY
Challenges still remain as each platform has its own limitations as
noted above. Additionally, several tumor intrinsic factors also pose a
significant hurdle to the success of any type of treatment employed.
There are multiple reviews that delineate some of these tumor-
intrinsic problems (Refs below), and we would like to summarize some
of these salient features.
4.1 Development of tumor cell intrinsic resistance
mechanisms
The heterogeneity of cancer cells in a tumor results in the develop-
ment of resistance mechanisms, and clinical persistence or recurrence
of disease to immunotherapy are the manifestation of this important
mechanism. For example, epigenetic modifications often trigger alter-
nate signaling pathways in cancer cells.313 Also, genetic mutations in
genes following therapeutic intervention (“immuno-editing”) can ren-
der immune therapy ineffective. One study investigated the genetic
mutations in patients that were responsible for acquired resistance to
Pembrolizumab. Surprisingly, 2 patients were found to have mutations
in JAK1 or JAK2 genes that interfered with IFN-𝛾 signaling. A third
patient had a mutation in B2M gene that was important for the recog-
21
nition and elimination of cancer cells.314 These tumor intrinsic resis-
tance mechanisms have been extensively discussed elsewhere.315
4.2 T cell exclusion from solid tumors
Excluding T cells from the TME (concept of immunologic ignorance)
is a common mechanism of immune evasion by tumors. Leaky tumor
vasculature and hypoxic regions resulting in spatial differences in
metabolites are important factors that influence T cell extravasation,
survival, and function in the TME.315 Also, the endothelium of tumor
blood vessels often downregulate the expression of leucocyte adhe-
sion molecules like intercellular adhesion molecule-1 (ICAM-1) and
vascular cell adhesion molecule-1 (VCAM-1) or increase the level of
Endothelin B receptor in the tumor microvasculature that dampen
T cell entry. TAMs and MDSC also secrete chemokines that support
Tregs trafficking but prevent cytotoxic T cells. Tumor cells and TAMs
also express Fas ligand (FasL) to induce apoptosis in infiltrating T
cells.315 Such molecular mechanisms may explain robust desmoplastic
reaction in pancreatic cancer that can trap T cells in the stroma to
prevent their migration to the tumor cell rich areas.
4.3 Freeing immune cells from co-inhibitory
checkpoints and exhaustion
Immune checkpoint molecules are essential for maintaining immune
homeostasis and autoimmunity. They regulate the breadth and mag-
nitude of T cell response by balancing co-stimulatory and co-inhibitory
signals for T cell activation. However, cancer cells, as a mechanism to
escape immune killing often hijack these molecules to suppress T cell
activation. Further, due to chronic Ag stimulation, tumor infiltrating T
cells become exhausted, that is, attain a hyporesponsive state charac-
terized by progressive loss of effector functions.316,317 In this context,
combinatorial ICB involving CTLA-4, PD-1 and its ligands PDL-1/PDL-
2, and LAG3 have become attractive targets in cancer immune therapy.
Immune checkpoint mechanisms have been extensively reviewed else-
where and is beyond the scope of this article.318-321 In brief, CTLA-4
competes with CD28 for binding with CD80 and CD86 and provides a
co-inhibitory signal to prevent T cell activation by APCs. PD-1 on T cells
can bind to PDL-1 or PDL-2 expressed by cancer cells or TAMs and this
can arrest T cells in a non-activated state. For example, in a clinical trial
using TG4010 Muc-1 vaccine in lung cancer, patients with lower PDL-
1 expression showed higher progression free survival.322 Abs target-
ing immune checkpoints are now widely used in clinical trials as single
agent or combination therapy for boosting immune response.323 The
best clinical responses have been demonstrated in melanoma where
PD-1 and CTLA4 blocking antibodies (response rates of 45–60%) are
now standard of care. Combining cancer vaccines with checkpoint
blockade may yield superior immune responses in patients. This was
observed in a phase II clinical trial with DC vaccine and Ipilimumab.
Patients who received combination therapy showed better response
compared to those who received monotherapy.21
22
In addition to checkpoint blockade, several co-stimulatory agonists
like OX40 and 4-1BB have shown synergistic effects in preclinical
studies324,325 and are now being tested in the clinics.323
4.4 Immunosuppressive cells in the TME
The solid TME is a highly complex structure and is often heavily infil-
trated by endothelial cells, cancer-associated fibroblasts (CAF), TAMs,
tolerogenic DC, MDSCs, suppressive regulatory B cells, 𝛾𝛿 T cells, and
Tregs. They engage in a complex cross-talk to collectively establish
an environment of immune suppression315,326–332 and aid in cancer
cell survival, growth, and metastases. For instance, TAMs and MDSC
secrete suppressive cytokines like IL-10, TGF-𝛽, and IL-4 to dampen
T cell function, induce T cell apoptosis and favor Tregs formation.
A similar suppressive activity has been reported for regulatory B
and 𝛾𝛿 T cells.333–338 Additionally, TAMs up-regulate expression of
co-inhibitory molecules like PDL-1 to drive T cells to suppression.
They are also important for pre metastatic niche formation. Each of
these TME members are well known contributors to therapy failure.
Another emerging mechanism in the human TME is the immunosup-
pressive process of efferocytosis. It has recently been reported that
phagocytosis of apoptotic debris in the TME drives M𝜙s toward an
immunosuppressive phenotype.252,339,340 This is one of the factors
that contributes to the relapse of the disease in more aggressive form.
In addition, often circulating MDSCs increase in patients undergoing
therapy.341 A variety of strategies are being tested to target TAMs or
MDSCs in clinics and are discussed elsewhere.323 For example, STING
agonists can reprogram suppressive MDSCs to an activated inflamma-
tory type.342 In a clinical trial with NY-ESO1-ISCOMATRIX vaccine in
melanoma, poor response to the vaccine correlated with higher Tregs
number in metastatic patients compared to early stage patients.343
Ab-mediated Tregs depletion or by adding low-dose CpG-ODN to
the ISCOM formulation restored efficacy of the vaccine in preclinical
models.344 However, selective depletion of Tregs in patients is chal-
lenging. Using cyclophosphamide has shown some success, achieved
by metronomic scheduling.345 As said in one review, “there is no partic-
ular hierarchy in immunosuppression in solid tumors and the dynamic
nature and the potential redundancy of suppressive mechanisms”315
continue to remain one of the biggest hurdles for vaccine therapy.
4.5 Immunosuppressive metabolic barrier
Another important consideration is the metabolic demands of the
tumor immune cells and the limited metabolic milieu of the TME
that can affect their metabolic requirements and therefore, functional
polarization.346-352 For an effective vaccine, naïve T cells need to
mature into multifunctional effector cells for which they heavily rely
on aerobic glycolysis. However, inside the TME, factors like hypoxia,
areas of necrosis as well as rapid proliferation of tumor cells create
nutrient constriction. In general, the metabolic landscape is hostile and
does not support effector T cell activation. The glycolytic cancer cells
outcompete the T cells for glucose consumption.353–355 This directly
reduce TCR signaling, proliferation, and production of tumor cell killing
ROY ET AL .
cytokines.356-361 Further, lactate produced by glycolysis is detrimental
to T cell proliferation and IFN-𝛾 release.362 Glucose restriction on the
other hand does not affect Tregs that depend on oxidative phospho-
rylation for their function.363 In addition to glucose, glutamine addic-
tion is common for many cancer types. For example, ovarian cancer
cells metabolize glutamine to glutamate. This is taken up by CAFs that
convert it back to glutamine and thus fosters a vicious feed forward
loop with cancer cells. Unfortunately, glutamine is also important for T
cell proliferation. Hence, glutamine deprivation faced by T cells in TME
affects their antitumor activity.315
An example of amino acid dependent mechanism of immunosup-
pression in the TME is IDO. This enzyme converts tryptophan to
kynurenines and is highly expressed on tumor cells, DC, and sup-
pressive myeloid population. Tryptophan is important for T cell acti-
vation, and its depletion restricts tumoricidal effector function of T
cells. Additionally, IDO can directly recruit myeloid cells and Tregs and
blunt NK cell function.315 High level of Arginase-1 in myeloid cells is
another contributor to T cell dysfunction in TME. Although Arginase-1
inhibitors are in clinical development, we are not aware of any clinical
trial using Arginase-1 inhibitor in combination with vaccines to date.
4.6 Hypoxic environment of the tumor
As a tumor grows, large areas within can become hypoxic. The
tumor compensates by producing more angiogenic factors like vas-
cular endothelial growth factor (VEGF), but most often the neoan-
giogenic and lymphangiogenic blood vessels fail to induce normoxia.
Also, in highly desmoplastic tumors like pancreatic adenocarcinoma,
blood vessels collapse and further contribute to hypoxic TME. The lack
of oxygen within the tumor has profound effect on several aspects
of tumor growth, metastases, metabolism and associated immune
response. Hypoxia induces the expression of Hypoxia Inducible Factor
1 𝛼 (HIF1𝛼), a key mediator of hypoxia signaling, which drives angiogen-
esis, procurement of epithelial to mesenchymal (EMT) phenotype, gly-
colysis in cancer cells and immune suppression. Hypoxia also induces
the expression of targetable CD47 in tumor cells that relays “do not eat
me” signal to M𝜙s or DCs. It can also induce the expression of HLA-G,
an important negative immune modulator that dampens the function-
ality of macrophages, NK cells, T cells, and B cells by binding to cognate
receptors expressed by these cells.
Hypoxia also affects immune cells within the tumor. For example,
hypoxia increases the expression of PDL-1 in M𝜙s, MDSCs, and DCs
to promote immune suppression of T cells. One of the hallmarks of
cancer is aerobic glycolysis where glucose is converted to lactate
instead of being shuttled to oxidative phosphorylation. This way,
the intermediates from glycolysis can be used for biosynthesis of
other macromolecules. HIF-1𝛼 up-regulates the expression of several
glucose transporters and glycolytic genes such as glucose transporters
1 and 3 (GLUT1 and GLUT3), pyruvate dehydrogenase, lactate dehy-
drogenase A (LDHA), phosphoglycerate kinase 1, and hexokinase 1
(HK1). This restricts glucose availability to effector T cells that rely
on glycolysis to mature to multifunctional T cells. Also, the lactate
produced from glycolysis dampens the activity of T cells and NK
ROY ET AL .
cells. All this collectively pose a significant hurdle to rewiring vaccine
mediated anti-tumor immunity. Currently, a variety of metabolic
modulators are being studied or in clinical developmental stage.
Combing them carefully with existing cancer vaccines may improve
patient responses.315
4.7 Suboptimal Ag selection
Since the discovery of the first tumor Ag MAGE-1 in 1911, extensive
efforts have been undertaken to design and develop efficient vaccines
to eradicate tumor. For reliable activation of immune responses, selec-
tion of appropriate immunogenic Ag is essential. TAAs like EGFR or
gp100 that are overexpressed on cancer cells and often shared across
multiple cancer types have been targeted for vaccine development.
However, they are also expressed in low levels in non-cancerous tis-
sues resulting in a weaker immune response due to central and periph-
eral tolerance.91 Thus, more recent approaches have focused on Ags
that are mutated in individual tumors. These neoantigens or tumor-
specific Ags are identified through next generation sequencing and are
unique to the tumor and patient. As discussed above, their expression
levels can vary within different tumor clones in the same individual.
Also, among the identified neoepitopes, not all will be immunogenic
enough to stimulate T cell responses. Therefore, the current person-
alized vaccines are designed to target multiple neoepitopes, usually up
to 20.91,364,365
4.8 Selection of patients, vaccine platform, time,
dose, and route of delivery
It is now appreciated that there co-exist distinct genetic and pheno-
typic populations within the same tumor, between tumors in the same
patient and in tumors of a particular type in different patients. Even
for a tumor of the same histological type, patient specific factors such
as germline genetic and somatic mutation profile (point mutations,
single nucleotide variation, insertion, deletion, copy number variation,
allelic loss, karyotype aberrations) either present before/at the time
of treatment or acquired at progression (temporal heterogeneity),
epigenetic changes, and environmental factors contribute to the
development of intratumor and inter-patient heterogeneity. Germline
genetic polymorphism analysis across multiple cancer types has been
shown to influence lymphoid and myeloid cell infiltration into the
tumor, which would affect clinical response since inflamed tumors are
more likely to respond to checkpoint therapies like antiPD-1 or anti
PDL-1.366 Another example comes from the loss of heterozygosity at
the HLA (HLA-C*08:02) locus in the resistant clones during treatment
with T cell clones engineered to recognize KRASG12D . Since this
allele was necessary to present KRASG12D neoantigenic epitope,
its loss enabled immune escape.367 In a recent study, rapid autopsy
performed on breast cancer patients with metastases harboring
activating PIK3CA mutations (phosphatidylinositol-4,5-bisphosphate
3-kinase, catalytic subunit alpha, PI(3)K𝛼) revealed intertumoral
variations where some patients lost the original PIK3CA mutation,
whereas some developed bi-allelic loss of PTEN (phosphatase and
23
tensin homolog) with disease progression and treatment.368 Similarly,
analysis of non-small-cell lung cancers (NSCLCs) patients showed a
complete loss of Retinoblastoma (RB) gene in course of treatment
in cases where the disease transformed to small-cell lung cancer
(SCLC) in a subset of patients, also acquiring elevated expression
of neuroendrocrine markers.369 An extensive genomic characteri-
zation carried out in glioblastoma patients identified differences in
mutations in responders versus non-responders to immune check-
point inhibitors.370 These tumor heterogeneity issues have been
extensively discussed elsewhere371–379 and highlighted in several
recent research articles366,380–383 and are beyond the scope of this
review. Unless carefully detected and characterized, these factors can
have detrimental effects by misdirecting treatment decisions. Collec-
tively, these form the basis for precision medicine targeting specific
genetic alterations present in a tumor instead of a “one size fits all”
treatment strategy.
Therefore, one of the most important factors that affects the
efficacy of vaccine or immune therapy is the selection of patient
population who are most likely to respond to a treatment modality.
For example, in a recent study, the peripheral blood TCR repertoire
was sequenced from pancreatic cancer patient cohorts: in one cohort
patients received checkpoint blockade molecule Ipilimumab with or
without GVAX; in the other cohort, patients were given GVAX and
a bacterial cancer vaccine with or without Nivolumab. Higher TCR
clonality in the GVAX plus Ipilimumab arm correlated with long-term
survival.384 Cancers like melanoma, NSCLC, bladder cancer, gastric
cancer, and squamous cell carcinoma of the head and neck (SCCHN)
that carry heavier mutational load and more inflamed TME compared
to “cold” cancers like pancreatic adenocarcinoma or prostate cancer,
may be better targets for vaccine development.385,386 Another recent
study showed that patients with maximal heterozygosity of HLA class
I locus (HLA-A, B, and C) showed greater survival following treatment
with either anti PD-1 or anti CTLA-4.383
Other factors include the type of vaccine administered for a type
of cancer, the combination therapy employed, dose, and timing of
therapy. For many cancers, the standard of care is either radiation
or chemotherapy. Chemotherapeutic agents have profound effect on
non-malignant cells as well. It is possible when the patient receives a
vaccine or any type of immune therapy after radiation or chemother-
apy, the immune cells are already in a compromised state and too
weak to mount a robust response. Similarly, when using vaccines and
checkpoint blockade as combinatorial therapy, timing could play a very
important role. For example, CTLA-4 and PD-1 blockade had bet-
ter efficacy in preclinical models when administered after GVAX or
TG4010 (Muc-1-targeted MVA vaccine) treatment, respectively,18,387
whereas a PSA-targeted DNA vaccine worked better when used con-
currently with PD-1 blockade.388
Another concern is selection of route of delivery of the drug. Follow-
ing parenteral administration, vaccines quickly spread in circulation
and very small amounts home to lymph nodes for T cell activation.
Hence, researchers are now focusing their efforts to develop other
effective methods of vaccine delivery, like nanoparticles, bioscaffolds,
and so on.
24
F I G U R E 3 Integrating next generation cancer vaccine platforms with combinatorial standard of care therapies, biomarker-based patient
selection and ICB to maximize clinical response and vaccine efficacy
4.9 Effect of microbiome
In recent times, there is a renewed interest in the >100 trillion
microbes in each person. Emerging evidences suggest host micro-
biome can not only increase one’s susceptibility to developing a
particular type of cancer but also affect response to therapy by reg-
ulating the immune system. Gut microbes have been shown to affect
therapeutic efficacy in preclinical models and patient cohorts.389
For example, patients who respond to anti-PD-1 based therapy have
a higher diversity of gut bacteria and differences in composition
that correlated with prolonged progression-free survival.390,391 The
mechanisms for these correlative findings are still early and their use
as a clinical biomarker is yet to be validated.
5 CONCLUSIONS AND
FUTURE PERSPECTIVE
Cancer remains the second leading cause of death worldwide. The
ability of the host immune system to recognize and attack trans-
formed cells, and their ability to generate durable clinical responses
to immunotherapy has revolutionized oncology and cancer research.
However, heterogeneity of the tumor cells and tumor-associated
immune suppression produce substantial barriers. Fortunately,
extensive research in the last decade has dramatically increased our
understanding of tumor-immune cell interactions. This has resulted
in breakthroughs in cancer immune therapy treatment modalities.
Cancer therapeutic vaccines have emerged as an attractive treatment
strategy, mainly because of their ability to elicit long lasting memory
against cancer Ags. Successful cancer vaccines rely on careful identi-
fication and selection of immunogenic Ags and appropriate delivery
vectors that can act in synergy and trigger effector and memory T cell
responses against transformed cells. Unfortunately, most vaccines
ROY ET AL .
have yielded unsatisfactory results in clinical setting. The past few
years have seen an enormous advancement in the field of immune
therapy, like immune checkpoint blockade and adoptive cell therapy,
both of which have shown clinical benefits in a fraction of patients.
However, many patients do not respond to immune therapies alone
and often relapse with more aggressive form of the disease. Ideally, a
“hot,” “altered,” or “cold” tumor characterization based on parameters
like tumor foreignness, immunome status, presence or absence of
inhibitory metabolites, checkpoint expression, and soluble inhibitors
needs to be performed on the resected tumor (primary as well as
metastatic) to best direct the course of treatment. Unfortunately, the
genetic and immunologic composition of the tumor may vary within a
tumor, between different tumors, and over time, even within the same
patient. Enormous efforts are being exhausted to develop alternative
strategies like liquid biopsies that capture circulating tumor cells and
immuno-positron-emission tomography (PET) imaging to visualize
T cells in the tumor. The numerous hurdles in the TME indicate the
requirement for multi-pronged approach based on patient history
as well as cancer type, stage, and grade and most importantly, pre-
existing immune landscape. Lessons learnt from failed attempts are
now driving researchers to look for more immunogenic TAAs as well
as tumor-specific neoantigens, improved vaccine platforms, optimum
dose, and route of delivery to patients. Although combination with
checkpoint blockade or CAR T cell therapy has shown promising
results in a handful of clinical trials, we are still a long way from estab-
lishing the perfect treatment regime and dose that will be optimum
to elicit clinically relevant immune response. Finally, with the advent
of tumor specific neoantigen personalized vaccines, cancer vaccine
therapy has come of age. With the advancement in the field of high
throughput sequencing and bioinformatics (like CIBERSORT, xCELL,
and TIMER that can deconvolute bulk sequencing data from tumor
and reveal the presence of enriched immune cell types in the TME),
we can now identify the elusive immunogenic unique Ag epitopes with
ROY ET AL .
the potential to unleash the full power of the immune system against
the tumor. Additionally, integrating multiple platforms including tumor
genomics, immunoscore assay, multiplex immunohistochemistry,
immune gene signature analysis, single cell sequencing, or bar code
sequencing could now help reveal multiple prognostic and predictive
biomarkers and direct the best possible combination treatment
modality for an individual patient.
In summary, armed with improved understanding and advanced
technological resources, the future looks promising for therapeutic
cancer vaccines. One cannot deny that there are still pending questions
to be addressed. However, with combinatorial therapy of checkpoint
blockade or CAR T cell adoptive transfer and neoantigen personalized
vaccine (Fig. 3), it is plausible that substantial progress may await in the
near future.
DISCLOSURES
D.B.J. serves on advisory boards for Array Biopharma, BMS, Incyte,
Merck, and Novartis, and receives research funding from BMS and
Incyte, and travel support from Genentech. Y.J.K. serves on advisory
boards for Dracen, Aduro, Novartis, Sanofi, and Takeda.
ORCID
Douglas B. Johnson https://orcid.org/0000-0002-6390-773X
REFERENCES
1. Rosenberg SA, Yang JC, Restifo NP. Cancer immunotherapy: moving
beyond current vaccines. Nat Med. 2004;10(9):909-915.
2. Guo C, Manjili MH, Subjeck JR, Sarkar D, Fisher PB, Wang XY. Ther-
apeutic cancer vaccines: past, present, and future. Adv Cancer Res.
2013;119:421-475.
3. Pan RY, Chung WH, Chu MT, Chen SJ, Chen HC, Zheng L, Hung SI.
Recent development and clinical application of cancer vaccine: tar-
geting neoantigens. J Immunol Res. 2018;2018:4325874.
4. Melero I, Gaudernack G, Gerritsen W, et al. Therapeutic vac-
cines for cancer: an overview of clinical trials. Nat Rev Clin Oncol.
2014;11(9):509-524.
5. Sylvester Richard J, van der Meijden APM, Lamm DL. Intravesical
bacillus calmette-guerin reduces the risk of progression in patients
with superficial bladder cancer: A meta-analysis of the published
results of randomized clinical trials. J Urol. 2002;168(5):1964-1970.
6. Kantoff PW, Higano CS, Shore ND, et al. Sipuleucel-T immunother-
apy for castration-resistant prostate cancer. N Engl J Med.
2010;363(5):411-422
7. Andtbacka RHI, Collichio FA, Amatruda T, et al. OPTiM: A random-
ized phase III trial of talimogene laherparepvec (T-VEC) versus sub-
cutaneous (SC) granulocyte-macrophage colony-stimulating factor
(GM-CSF) for the treatment (tx) of unresected stage IIIB/C and IV
melanoma. J Clin Oncol. 2013;31(18_suppl):LBA9008-LBA.
8. DeMaria PJ, Bilusic M. Cancer vaccines. Hematol Oncol Clin North Am.
2019;33(2):199-214.
9. Mougel A, Terme M, Tanchot C. Therapeutic cancer vaccine and
combinations with antiangiogenic therapies and immune checkpoint
blockade. Front Immunol. 2019;10:467.
10. Fu J, Kanne DB, Leong M, et al. STING agonist formulated cancer
vaccines can cure established tumors resistant to PD-1 blockade. Sci
Transl Med. 2015;7(283):283ra52.
25
11. Spranger S, Spaapen RM, Zha Y, Williams J, Meng Y, Ha TT, Gajew-
ski TF. Up-regulation of PD-L1, IDO, and T(regs) in the melanoma
tumor microenvironment is driven by CD8(+) T cells. Sci Transl Med.
2013;5(200):200ra116.
12. Badoual C, Hans S, Merillon N, et al. PD-1-expressing tumor-
infiltrating T cells are a favorable prognostic biomarker in HPV-
associated head and neck cancer. Cancer Res. 2013;73(1):128-138.
13. Duraiswamy J, Kaluza KM, Freeman GJ, Coukos G. Dual block-
ade of PD-1 and CTLA-4 combined with tumor vaccine effectively
restores T-cell rejection function in tumors. Cancer Res. 2013;73(12):
3591-603.
14. Hurwitz AA, Foster BA, Kwon ED, et al. Combination immunotherapy
of primary prostate cancer in a transgenic mouse model using CTLA-
4 blockade. Cancer Res. 2000;60(9):2444-2448.
15. Rice AE, Latchman YE, Balint JP, Lee JH, Gabitzsch ES, Jones FR. An
HPV-E6/E7 immunotherapy plus PD-1 checkpoint inhibition results
in tumor regression and reduction in PD-L1 expression. Cancer Gene
Ther. 2015;22(9):454-62.
16. Soares KC, Rucki AA, Wu AA, et al. PD-1/PD-L1 blockade together
with vaccine therapy facilitates effector T-cell infiltration into pan-
creatic tumors. J Immunother. 2015;38(1):1-11.
17. van Elsas A, Hurwitz AA, Allison JP. Combination immunotherapy of
B16 melanoma using anti-cytotoxic T lymphocyte-associated antigen
4 (CTLA-4) and granulocyte/macrophage colony-stimulating factor
(GM-CSF)-producing vaccines induces rejection of subcutaneous and
metastatic tumors accompanied by autoimmune depigmentation.
J Exp Med. 1999;190(3):355-66.
18. 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.
19. Le DT, Lutz E, Uram JN, et al. Evaluation of ipilimumab in com-
bination with allogeneic pancreatic tumor cells transfected with a
GM-CSF gene in previously treated pancreatic cancer. J Immunother.
2013;36(7):382-389.
20. Ribas A, Comin-Anduix B, Chmielowski B, et al. Dendritic cell vacci-
nation combined with CTLA4 blockade in patients with metastatic
melanoma. Clin Cancer Res. 2009;15(19):6267-6276.
21. Wilgenhof S, Corthals J, Heirman C, et al. Phase II study of autol-
ogous monocyte-derived mRNA electroporated dendritic cells
(TriMixDC-MEL) plus ipilimumab in patients with pretreated
advanced melanoma. J Clin Oncol. 2016;34(12):1330-1338.
22. 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(5):501-518.
23. Massarelli E, William W, Johnson F, et al. Combining immune check-
point blockade and tumor-specific vaccine for patients with incur-
able human papillomavirus 16-related cancer: a phase 2 clinical trial.
JAMA Oncol. 2019;5(1):67-73.
24. Chung V, Kos FJ, Hardwick N, et al. Evaluation of safety and efficacy
of p53MVA vaccine combined with pembrolizumab in patients with
advanced solid cancers. Clin Transl Oncol. 2019;21(3):363-372.
25. Gibney GT, Kudchadkar RR, DeConti RC, et al. Safety, correlative
markers, and clinical results of adjuvant nivolumab in combination
with vaccine in resected high-risk metastatic melanoma. Clin Cancer
Res. 2015;21(4):712-720.
26. Weber JS, Kudchadkar RR, Yu B, et al. Safety, efficacy, and biomark-
ers of nivolumab with vaccine in ipilimumab-refractory or -naive
melanoma. J Clin Oncol. 2013;31(34):4311-4318.
27. Curran MA, Glisson BS. New hope for therapeutic cancer vac-
cines in the era of immune checkpoint modulation. Annu Rev Med.
2019;70:409-424.
28. Tureci O, Vormehr M, Diken M, Kreiter S, Huber C, Sahin U. Targeting
the heterogeneity of cancer with individualized neoepitope vaccines.
Clin Cancer Res. 2016;22(8):1885-1896.
26
29. Yarchoan M, Johnson BA, Lutz ER 3rd, Laheru DA, Jaffee EM. Tar-
geting neoantigens to augment antitumour immunity. Nat Rev Cancer.
2017;17(4):209-222.
30. Hu Z, Ott PA, Wu CJ. Towards personalized, tumour-specific, thera-
peutic vaccines for cancer. Nat Rev Immunol. 2018;18(3):168-182.
31. Sahin U, Derhovanessian E, Miller M, et al. Personalized RNA
mutanome vaccines mobilize poly-specific therapeutic immunity
against cancer. Nature. 2017;547(7662):222-226.
32. Ahmadzadeh M, Johnson LA, Heemskerk B, et al. Tumor antigen-
specific CD8 T cells infiltrating the tumor express high levels of PD-1
and are functionally impaired. Blood. 2009;114(8):1537-1544.
33. Appay V, Jandus C, Voelter V, et al. New generation vaccine induces
effective melanoma-specific CD8+ T cells in the circulation but not in
the tumor site. J Immunol. 2006;177(3):1670-1678.
34. Baitsch L, Baumgaertner P, Devevre E, et al. Exhaustion of tumor-
specific CD8(+) T cells in metastases from melanoma patients. J Clin
Invest. 2011;121(6):2350-2360.
35. Zippelius A, Batard P, Rubio-Godoy V, et al. Effector function of
human tumor-specific CD8 T cells in melanoma lesions: a state of
local functional tolerance. Cancer Res. 2004;64(8):2865-2873.
36. Wolchok JD, Kluger H, Callahan MK, et al. Nivolumab plus ipilimumab
in advanced melanoma. N Engl J Med. 2013;369(2):122-133.
37. Postow MA, Chesney J, Pavlick AC, et al. Nivolumab and ipili-
mumab versus ipilimumab in untreated melanoma. N Engl J Med.
2015;372(21):2006-2017.
38. Larkin J, Chiarion-Sileni V, Gonzalez R, et al. Combined nivolumab
and ipilimumab or monotherapy in untreated melanoma. N Engl J Med.
2015;373(1):23-34.
39. Larkin J, Hodi FS, Wolchok JD. Combined nivolumab and ipili-
mumab or monotherapy in untreated melanoma. N Engl J Med.
2015;373(13):1270-1271.
40. Wolchok JD, Chiarion-Sileni V, Gonzalez R, et al. Overall survival with
combined nivolumab and ipilimumab in advanced melanoma. N Engl J
Med. 2017;377(14):1345-1356.
41. Hodi FS, Chiarion-Sileni V, Gonzalez R,et al. Nivolumab plus ipil-
imumab or nivolumab alone versus ipilimumab alone in advanced
melanoma (CheckMate 067): 4-year outcomes of a multicentre, ran-
domised, phase 3 trial. Lancet Oncol. 2018;19(11):1480-1492.
42. Long GV, Atkinson V, Cebon JS, et al. Standard-dose pembrolizumab
in combination with reduced-dose ipilimumab for patients with
advanced melanoma (KEYNOTE-029): an open-label, phase 1b trial.
Lancet Oncol. 2017;18(9):1202-1210.
43. Tawbi HA, Chung C, Margolin K. Nivolumab and ipilimumab
in melanoma metastatic to the brain. N Engl J Med. 2018;379
(22):2178.
44. Tawbi HA, Forsyth PA, Algazi A, et al. Combined nivolumab and
ipilimumab in melanoma metastatic to the brain. N Engl J Med.
2018;379(8):722-730.
45. Weber JS, Gibney G, Sullivan RJ, et al. Sequential administration of
nivolumab and ipilimumab with a planned switch in patients with
advanced melanoma (CheckMate 064): an open-label, randomised,
phase 2 trial. Lancet Oncol. 2016;17(7):943-955.
46. Hodi FS, Chesney J, Pavlick AC, et al. Combined nivolumab and
ipilimumab versus ipilimumab alone in patients with advanced
melanoma: 2-year overall survival outcomes in a multicentre,
randomised, controlled, phase 2 trial. Lancet Oncol. 2016;17(11):
1558-1568.
47. Meerveld-Eggink A, Rozeman EA, Lalezari F, van Thienen JV, Haanen
J, Blank CU. Short-term CTLA-4 blockade directly followed by PD-1
blockade in advanced melanoma patients: a single-center experience.
Ann Oncol. 2017;28(4):862-867.
48. Kirchberger MC, Hauschild A, Schuler G, Heinzerling L. Com-
bined low-dose ipilimumab and pembrolizumab after sequential ipil-
imumab and pembrolizumab failure in advanced melanoma. Eur
J Cancer. 2016;65:182-184.
ROY ET AL .
49. Hellmann MD, Rizvi NA, Goldman JW, et al. Nivolumab plus ipili-
mumab as first-line treatment for advanced non-small-cell lung can-
cer (CheckMate 012): results of an open-label, phase 1, multicohort
study. Lancet Oncol. 2017;18(1):31-41.
50. Hellmann MD, Ciuleanu TE, Pluzanski A, et al. Nivolumab plus ipili-
mumab in lung cancer with a high tumor mutational burden. N Engl J
Med. 2018;378(22):2093-2104.
51. Hellmann MD, Paz-Ares L. Lung cancer with a high tumor mutational
burden. N Engl J Med. 2018;379(11):1093-1094.
52. Ready N, Hellmann MD, Awad MM, et al. First-line nivolumab plus
ipilimumab in advanced non-small-cell lung cancer (CheckMate 568):
outcomes by programmed death ligand 1 and tumor mutational bur-
den as biomarkers. J Clin Oncol. 2019;37(12):992-1000.
53. Antonia SJ, Lopez-Martin JA, Bendell J, et al. Nivolumab alone
and nivolumab plus ipilimumab in recurrent small-cell lung cancer
(CheckMate 032): a multicentre, open-label, phase 1/2 trial. Lancet
Oncol. 2016;17(7):883-895.
54. Boudadi K, Suzman DL, Anagnostou V, et al. Ipilimumab plus
nivolumab and DNA-repair defects in AR-V7-expressing metastatic
prostate cancer. Oncotarget. 2018;9(47):28561-28571.
55. Janjigian YY, Bendell J, Calvo E, et al. CheckMate-032 study:
efficacy and safety of nivolumab and nivolumab plus ipilimumab
in patients with metastatic esophagogastric cancer. J Clin Oncol.
2018;36(28):2836-2844.
56. Carbone A, Gloghini A. Checkpoint blockade therapy resistance in
Hodgkin’s lymphoma. Lancet. 2018;392(10154):1194-1196.
57. Andre P, Denis C, Soulas C, et al. Anti-NKG2A mAb Is a checkpoint
inhibitor that promotes anti-tumor immunity by unleashing both T
and NK cells. Cell. 2018;175(7):1731-1743 e13.
58. Fayette J, Lefebvre G, Posner MR, et al. Results of a phase II study
evaluating monalizumab in combination with cetuximab in previously
treated recurrent or metastatic squamous cell carcinoma of the head
and neck (R/M SCCHN). Ann Oncol. 2018;29(Suppl 8):viii374.
59. Harding JJ, Patnaik A, Moreno V, et al. A phase Ia/Ib study of
an anti-TIM-3 antibody (LY3321367) monotherapy or in combina-
tion with an anti-PD-L1 antibody (LY3300054): Interim safety, effi-
cacy, and pharmacokinetic findings in advanced cancers. J Clin Oncol.
2019;37(8_suppl):12.
60. Glisson B, Leidner R, Ferris RL, et al. Safety and clinical activity
of MEDI0562, a humanized OX40 agonist monoclonal antibody, in
adult patients with advanced solid tumors. Ann Oncol. 2018;29(Suppl
8):viii410.
61. Simon S, Vignard V, Varey E, et al. Emergence of high-avidity melan-A-
specific clonotypes as a reflection of anti-PD-1 clinical efficacy. Can-
cer Res. 2017;77(24):7083-7093.
62. Wieland A, Kamphorst AO, Adsay NV, et al. T cell receptor
sequencing of activated CD8 T cells in the blood identifies tumor-
infiltrating clones that expand after PD-1 therapy and radiation
in a melanoma patient. Cancer Immunol Immunother. 2018;67(11):
1767-1776.
63. Bonaventura P, Shekarian T, Alcazer V, et al. Cold tumors: a therapeu-
tic challenge for immunotherapy. Front Immunol. 2019;10:168.
64. Pages F, Mlecnik B, Marliot F, et al. International validation of
the consensus immunoscore for the classification of colon can-
cer: a prognostic and accuracy study. Lancet. 2018;391(10135):
2128-2139.
65. Galon J, Costes A, Sanchez-Cabo F, et al. Type, density, and location
of immune cells within human colorectal tumors predict clinical out-
come. Science. 2006;313(5795):1960-1964.
66. Mlecnik B, Tosolini M, Kirilovsky A, et al. Histopathologic-based prog-
nostic factors of colorectal cancers are associated with the state of
the local immune reaction. J Clin Oncol. 2011;29(6):610-618.
67. Galon J, Angell HK, Bedognetti D, Marincola FM. The continuum of
cancer immunosurveillance: prognostic, predictive, and mechanistic
signatures. Immunity. 2013;39(1):11-26.
ROY ET AL .
68. Angell H, Galon J. From the immune contexture to the Immunoscore:
the role of prognostic and predictive immune markers in cancer. Curr
Opin Immunol. 2013;25(2):261-267.
69. Galon J, Fridman WH, Pages F. The adaptive immunologic microen-
vironment in colorectal cancer: a novel perspective. Cancer Res.
2007;67(5):1883-1886.
70. Pages F, Kirilovsky A, Mlecnik B, et al. In situ cytotoxic and memory T
cells predict outcome in patients with early-stage colorectal cancer.
J Clin Oncol. 2009;27(35):5944-5951.
71. Galon J, Mlecnik B, Bindea G, et al. Towards the introduction
of the ‘Immunoscore’ in the classification of malignant tumours.
J Pathol. 2014;232(2):199-209.
72. Camus M, Tosolini M, Mlecnik B, et al. Coordination of intratumoral
immune reaction and human colorectal cancer recurrence. Cancer
Res. 2009;69(6):2685-2693.
73. Mlecnik B, Bindea G, Angell HK, et al. Integrative analyses of colorec-
tal cancer show immunoscore is a stronger predictor of patient sur-
vival than microsatellite instability. Immunity. 2016;44(3):698-711.
74. Mlecnik B, Bindea G, Angell HK, et al. Functional network pipeline
reveals genetic determinants associated with in situ lympho-
cyte proliferation and survival of cancer patients. Sci Transl Med.
2014;6(228):228ra37.
75. Chew V, Chen J, Lee D, et al. Chemokine-driven lymphocyte
infiltration: an early intratumoural event determining long-term
survival in resectable hepatocellular carcinoma. Gut. 2012;61(3):
427-438.
76. Tahkola K, Mecklin JP, Wirta EV, Ahtiainen M, Helminen O, Bohm J,
Kellokumpu I. High immune cell score predicts improved survival in
pancreatic cancer. Virchows Arch. 2018;472(4):653-665.
77. Bosmuller HC, Wagner P, Peper JK, et al. Combined immunoscore of
CD103 and CD3 identifies long-term survivors in high-grade serous
ovarian cancer. Int J Gynecol Cancer. 2016;26(4):671-679.
78. Hao D, Liu J, Chen M, et al. Immunogenomic analyses of advanced
serous ovarian cancer reveal immune score is a strong prognos-
tic factor and an indicator of chemosensitivity. Clin Cancer Res.
2018;24(15):3560-3571.
79. Li B, VanRoey M, Wang C, Chen TH, Korman A, Jooss K. Anti-
programmed death-1 synergizes with granulocyte macrophage
colony-stimulating factor–secreting tumor cell immunotherapy pro-
viding therapeutic benefit to mice with established tumors. Clin Can-
cer Res. 2009;15(5):1623-1634.
80. Duraiswamy J, Freeman GJ, Coukos G. Therapeutic PD-1 pathway
blockade augments with other modalities of immunotherapy T-cell
function to prevent immune decline in ovarian cancer. Cancer Res.
2013;73(23):6900-6912.
81. Duraiswamy J, Freeman GJ, Coukos G. Dual blockade of PD-1
and CTLA-4 combined with tumor vaccine effectively restores T-
cell rejection function in tumors–response. Cancer Res. 2014;74(2):
633-634.
82. Curran MA, Montalvo W, Yagita H, Allison JP. PD-1 and CTLA-4 com-
bination blockade expands infiltrating T cells and reduces regulatory
T and myeloid cells within B16 melanoma tumors. Proc Natl Acad Sci
USA. 2010;107(9):4275-4280.
83. Deng L, Liang H, Xu M, et al. STING-dependent cytosolic DNA sensing
promotes radiation-induced type I interferon-dependent antitumor
immunity in immunogenic tumors. Immunity. 2014;41(5):843-852.
84. Woo SR, Fuertes MB, Corrales L, et al. STING-dependent cytosolic
DNA sensing mediates innate immune recognition of immunogenic
tumors. Immunity. 2014;41(5):830-842.
85. Zheng W, Skowron KB, Namm JP, et al. Combination of radiotherapy
and vaccination overcomes checkpoint blockade resistance. Oncotar-
get. 2016;7(28):43039-43051.
86. Ma L, Dichwalkar T, Chang JYH, et al. Enhanced CAR-T cell activity
against solid tumors by vaccine boosting through the chimeric recep-
tor. Science. 2019;365(6449):162-168.
27
87. Reinhard K, Rengstl B, Oehm P, et al. An RNA vaccine drives expan-
sion and efficacy of claudin-CAR-T cells against solid tumors. Science.
2020;367(6476):446-453.
88. Galon J, Bruni D. Approaches to treat immune hot, altered and cold
tumours with combination immunotherapies. Nat Rev Drug Discov.
2019;18(3):197-218.
89. Zhao J, Chen Y, Ding ZY, Liu JY. Safety and efficacy of therapeu-
tic cancer vaccines alone or in combination with immune checkpoint
inhibitors in cancer treatment. Front Pharmacol. 2019;10:1184.
90. Foley KC, Nishimura MI, Moore TV. Combination immunotherapies
implementing adoptive T-cell transfer for advanced-stage melanoma.
Melanoma Res. 2018;28(3):171-184.
91. Fennemann FL, de Vries IJM, Figdor CG, Verdoes M. Attacking
tumors from all sides: personalized multiplex vaccines to tackle intra-
tumor heterogeneity. Front Immunol. 2019;10:824.
92. Banchereau J, Palucka K. Immunotherapy: cancer vaccines on the
move. Nat Rev Clin Oncol. 2018;15(1):9-10.
93. Chiang CL, Coukos G, Kandalaft LE. Whole tumor antigen vaccines:
where are we? Vaccines. 2015;3(2):344-372.
94. Chiang CL, Benencia F, Coukos G. Whole tumor antigen vaccines.
Semin Immunol. 2010;22(3):132-143.
95. Buckwalter MR, Srivastava PK. “It is the antigen(s), stupid” and other
lessons from over a decade of vaccitherapy of human cancer. Semin
Immunol. 2008;20(5):296-300.
96. Dranoff G, Jaffee E, Lazenby A, et al. Vaccination with irradiated
tumor cells engineered to secrete murine granulocyte-macrophage
colony-stimulating factor stimulates potent, specific, and long-
lasting anti-tumor immunity. Proc Natl Acad Sci USA. 1993;90(8):
3539-3543.
97. Armstrong CA, Botella R, Galloway TH, et al. Antitumor effects
of granulocyte-macrophage colony-stimulating factor production by
melanoma cells. Cancer Res. 1996;56(9):2191-2198.
98. Sanda MG, Ayyagari SR, Jaffee EM, et al. Demonstration of a
rational strategy for human prostate cancer gene therapy. J Urol.
1994;151(3):622-628.
99. Dunussi-Joannopoulos K, Dranoff G, Weinstein HJ, Ferrara JL,
Bierer BE, Croop JM. Gene immunotherapy in murine acute myeloid
leukemia: granulocyte-macrophage colony-stimulating factor tumor
cell vaccines elicit more potent antitumor immunity compared
with B7 family and other cytokine vaccines. Blood. 1998;91(1):
222-230.
100. Dranoff G. GM-CSF-based cancer vaccines. Immunol Rev.
2002;188:147-154.
101. Soiffer R, Hodi FS, Haluska F, et al. Vaccination with irradiated,
autologous melanoma cells engineered to secrete granulocyte-
macrophage colony-stimulating factor by adenoviral-mediated gene
transfer augments antitumor immunity in patients with metastatic
melanoma. J Clin Oncol. 2003;21(17):3343-3350.
102. Soiffer R, Lynch T, Mihm M, et al. Vaccination with irradiated autol-
ogous melanoma cells engineered to secrete human granulocyte-
macrophage colony-stimulating factor generates potent antitumor
immunity in patients with metastatic melanoma. Proc Natl Acad Sci
USA. 1998;95(22):13141-13146.
103. Thomas AM, Santarsiero LM, Lutz ER, et al. Mesothelin-specific
CD8(+) T cell responses provide evidence of in vivo cross-priming
by antigen-presenting cells in vaccinated pancreatic cancer patients.
J Exp Med. 2004;200(3):297-306.
104. Eager R, Nemunaitis J. GM-CSF gene-transduced tumor vaccines. Mol
Ther. 2005;12(1):18-27.
105. Hege KM, Jooss K, Pardoll D. GM-CSF gene-modifed cancer cell
immunotherapies: of mice and men. Int Rev Immunol. 2006;25(5-
6):321-352.
106. Laheru D, Lutz E, Burke J, et al. Allogeneic granulocyte macrophage
colony-stimulating factor-secreting tumor immunotherapy alone or
in sequence with cyclophosphamide for metastatic pancreatic can-
28
cer: a pilot study of safety, feasibility, and immune activation. Clin Can-
cer Res. 2008;14(5):1455-1463.
107. Lipson EJ, Sharfman WH, Chen S, et al. Safety and immunologic corre-
lates of Melanoma GVAX, a GM-CSF secreting allogeneic melanoma
cell vaccine administered in the adjuvant setting. J Transl Med.
2015;13:214.
108. Small EJ, Sacks N, Nemunaitis J, et al. Granulocyte macrophage
colony-stimulating factor–secreting allogeneic cellular immunother-
apy for hormone-refractory prostate cancer. Clin Cancer Res.
2007;13(13):3883-3891.
109. Salgia R, Lynch T, Skarin A, et al. Vaccination with irradiated autol-
ogous tumor cells engineered to secrete granulocyte-macrophage
colony-stimulating factor augments antitumor immunity in some
patients with metastatic non-small-cell lung carcinoma. J Clin Oncol.
2003;21(4):624-630.
110. Le DT, Picozzi VJ, Ko AH, et al. Results from a phase IIb,
randomized, multicenter study of GVAX pancreas and CRS-207
compared with chemotherapy in adults with previously treated
metastatic pancreatic adenocarcinoma (ECLIPSE Study). Clin Cancer
Res. 2019;25(18):5493-5502.
111. Hoover HC, Jr., Surdyke MG, Dangel RB, Peters LC, Hanna
MG, Jr. Prospectively randomized trial of adjuvant active-
specific immunotherapy for human colorectal cancer. Cancer.
1985;55(6):1236-1243.
112. Hoover HC, Jr., Brandhorst JS, Peters LC, et al. Adjuvant active spe-
cific immunotherapy for human colorectal cancer: 6.5-year median
follow-up of a phase III prospectively randomized trial. J Clin Oncol.
1993;11(3):390-399.
113. Vermorken JB, Claessen AM, van Tinteren H, et al. Active specific
immunotherapy for stage II and stage III human colon cancer: a ran-
domised trial. Lancet. 1999;353(9150):345-350.
114. Van Poppel H, Joniau S, Van Gool SW. Vaccine therapy in patients
with renal cell carcinoma. Eur Urol. 2009;55(6):1333-1342.
115. May M, Kendel F, Hoschke B, et al. [Adjuvant autologous tumour
cell vaccination in patients with renal cell carcinoma. Overall survival
analysis with a follow-up period in excess of more than 10 years]. Urol
A. 2009;48(9):1075-1083.
116. Simons JW, Jaffee EM, Weber CE, et al. Bioactivity of autolo-
gous irradiated renal cell carcinoma vaccines generated by ex vivo
granulocyte-macrophage colony-stimulating factor gene transfer.
Cancer Res. 1997;57(8):1537-1546.
117. Bol KF, Schreibelt G, Gerritsen WR, de Vries IJ, Figdor CG. Dendritic
cell-based immunotherapy: state of the art and beyond. Clin Cancer
Res. 2016;22(8):1897-1906.
118. van Willigen WW, Bloemendal M, Gerritsen WR, Schreibelt G, de
Vries IJM, Bol KF. Dendritic cell cancer therapy: vaccinating the right
patient at the right time. Front Immunol. 2018;9:2265.
119. Santos PM, Butterfield LH. Dendritic cell-based cancer vaccines.
J Immunol. 2018;200(2):443-449.
120. Mastelic-Gavillet B, Balint K, Boudousquie C, Gannon PO, Kandalaft
LE. Personalized dendritic cell vaccines-recent breakthroughs and
encouraging clinical results. Front Immunol. 2019;10:766.
121. Huber A, Dammeijer F, Aerts J, Vroman H. Current state of dendritic
cell-based immunotherapy: opportunities for in vitro antigen loading
of different DC subsets? Front Immunol. 2018;9:2804.
122. Saxena M, Bhardwaj N. Re-emergence of dendritic cell vaccines for
cancer treatment. Trends Cancer. 2018;4(2):119-137.
123. Ahmed MS, Bae YS. Dendritic cell-based therapeutic cancer vaccines:
past, present and future. Clin Exp Vaccine Res. 2014;3(2):113-116.
124. Dzionek A, Fuchs A, Schmidt P, et al. BDCA-2, BDCA-3, and BDCA-4:
three markers for distinct subsets of dendritic cells in human periph-
eral blood. J Immunol. 2000;165(11):6037-6046.
125. Lande R, Gregorio J, Facchinetti V, et al. Plasmacytoid dendritic
cells sense self-DNA coupled with antimicrobial peptide. Nature.
2007;449(7162):564-569.
ROY ET AL .
126. Nizzoli G, Krietsch J, Weick A, et al. Human CD1c+ dendritic cells
secrete high levels of IL-12 and potently prime cytotoxic T-cell
responses. Blood. 2013;122(6):932-942.
127. Perussia B, Fanning V, Trinchieri G. A leukocyte subset bearing HLA-
DR antigens is responsible for in vitro alpha interferon produc-
tion in response to viruses. Nat Immun Cell Growth Regul. 1985;4(3):
120-137.
128. Anguille S, Smits EL, Bryant C, et al. Dendritic cells as pharmaco-
logical tools for cancer immunotherapy. Pharmacol Rev. 2015;67(4):
731-753.
129. Anguille S, Smits EL, Lion E, van Tendeloo VF, Berneman ZN.
Clinical use of dendritic cells for cancer therapy. Lancet Oncol.
2014;15(7):e257-e267.
130. Koski GK, Cohen PA, Roses RE, Xu S, Czerniecki BJ. Reengi-
neering dendritic cell-based anti-cancer vaccines. Immunol Rev.
2008;222:256-276.
131. Garg AD, Coulie PG, Van den Eynde BJ, Agostinis P. Integrat-
ing next-generation dendritic cell vaccines into the current cancer
immunotherapy landscape. Trends Immunol. 2017;38(8):577-593.
132. Inaba K, Inaba M, Romani N, et al. Generation of large numbers
of dendritic cells from mouse bone marrow cultures supplemented
with granulocyte/macrophage colony-stimulating factor. J Exp Med.
1992;176(6):1693-1702.
133. Inaba K, Pack M, Inaba M, Sakuta H, Isdell F, Steinman RM. High
levels of a major histocompatibility complex II-self peptide complex
on dendritic cells from the T cell areas of lymph nodes. J Exp Med.
1997;186(5):665-672.
134. Inaba K, Steinman RM, Pack MW, et al. Identification of pro-
liferating dendritic cell precursors in mouse blood. J Exp Med.
1992;175(5):1157-1167.
135. Butterfield LH. Dendritic cells in cancer immunotherapy clinical tri-
als: are we making progress? Front Immunol. 2013;4:454.
136. Butterfield LH, Ribas A, Dissette VB, et al. Determinant spreading
associated with clinical response in dendritic cell-based immunother-
apy for malignant melanoma. Clin Cancer Res. 2003;9(3):998-1008.
137. Hsu FJ, Benike C, Fagnoni F, et al. Vaccination of patients with B-cell
lymphoma using autologous antigen-pulsed dendritic cells. Nat Med.
1996;2(1):52-58.
138. Markowicz S, Engleman EG. Granulocyte-macrophage colony-
stimulating factor promotes differentiation and survival of human
peripheral blood dendritic cells in vitro. J Clin Invest. 1990;85(3):
955-961.
139. Mukherji B, Chakraborty NG, Yamasaki S, et al. Induction of antigen-
specific cytolytic T cells in situ in human melanoma by immunization
with synthetic peptide-pulsed autologous antigen presenting cells.
Proc Natl Acad Sci USA. 1995;92(17):8078-8082.
140. Nestle FO, Alijagic S, Gilliet M, et al. Vaccination of melanoma
patients with peptide- or tumor lysate-pulsed dendritic cells. Nat
Med. 1998;4(3):328-332.
141. Romani N, Gruner S, Brang D, et al. Proliferating dendritic cell pro-
genitors in human blood. J Exp Med. 1994;180(1):83-93.
142. Van Tendeloo VF, Van de Velde A, Van Driessche A, et al. Induction
of complete and molecular remissions in acute myeloid leukemia by
Wilms’ tumor 1 antigen-targeted dendritic cell vaccination. Proc Natl
Acad Sci USA. 2010;107(31):13824-13829.
143. Lim DS, Kim JH, Lee DS, Yoon CH, Bae YS. DC immunother-
apy is highly effective for the inhibition of tumor metastasis or
recurrence, although it is not efficient for the eradication of
established solid tumors. Cancer Immunol Immunother. 2007;56(11):
1817-1829.
144. Germeau C, Ma W, Schiavetti F, et al. High frequency of antitumor T
cells in the blood of melanoma patients before and after vaccination
with tumor antigens. J Exp Med. 2005;201(2):241-248.
145. Akasaki Y, Kikuchi T, Homma S, et al. Phase I/II trial of combination
of temozolomide chemotherapy and immunotherapy with fusions
ROY ET AL .
of dendritic and glioma cells in patients with glioblastoma. Cancer
Immunol Immunother. 2016;65(12):1499-1509.
146. Rosenblatt J, Stone RM, Uhl L, Neuberg D, et al. Individualized vac-
cination of AML patients in remission is associated with induction
of antileukemia immunity and prolonged remissions. Sci Transl Med.
2016;8(368):368ra171.
147. Crozat K, Guiton R, Guilliams M, et al. Comparative genomics as a tool
to reveal functional equivalences between human and mouse den-
dritic cell subsets. Immunol Rev. 2010;234(1):177-198.
148. Osugi Y, Vuckovic S, Hart DN. Myeloid blood CD11c(+) dendritic cells
and monocyte-derived dendritic cells differ in their ability to stimu-
late T lymphocytes. Blood. 2002;100(8):2858-2866.
149. Villani AC, Satija R, Reynolds G, et al. Single-cell RNA-seq reveals new
types of human blood dendritic cells, monocytes, and progenitors. Sci-
ence. 2017;356(6335):eaah4573.
150. Helft J, Bottcher J, Chakravarty P, et al. GM-CSF mouse bone
marrow cultures comprise a heterogeneous population of
CD11c(+)MHCII(+) macrophages and dendritic cells. Immunity.
2015;42(6):1197-1211.
151. Balan S, Ollion V, Colletti N, et al. Human XCR1+ dendritic
cells derived in vitro from CD34+ progenitors closely resemble
blood dendritic cells, including their adjuvant responsiveness, con-
trary to monocyte-derived dendritic cells. J Immunol. 2014;193(4):
1622-1635.
152. Collin M, McGovern N, Haniffa M. Human dendritic cell subsets.
Immunology. 2013;140(1):22-30.
153. Lundberg K, Albrekt AS, Nelissen I, et al. Transcriptional profiling of
human dendritic cell populations and models—unique profiles of in
vitro dendritic cells and implications on functionality and applicabil-
ity. PLoS One. 2013;8(1):e52875.
154. Jongbloed SL, Kassianos AJ, McDonald KJ, et al. Human CD141+
(BDCA-3)+ dendritic cells (DCs) represent a unique myeloid DC
subset that cross-presents necrotic cell antigens. J Exp Med.
2010;207(6):1247-1260.
155. Orsini E, Guarini A, Chiaretti S, Mauro FR, Foa R. The circulat-
ing dendritic cell compartment in patients with chronic lymphocytic
leukemia is severely defective and unable to stimulate an effective T-
cell response. Cancer Res. 2003;63(15):4497-4506.
156. Schreibelt G, Bol KF, Westdorp H, et al. Effective clinical responses
in metastatic melanoma patients after vaccination with primary
myeloid dendritic cells. Clin Cancer Res. 2016;22(9):2155-2166.
157. Tel J, Aarntzen EH, Baba T, et al. Natural human plasmacytoid den-
dritic cells induce antigen-specific T-cell responses in melanoma
patients. Cancer Res. 2013;73(3):1063-1075.
158. Di Nicola M, Carlo-Stella C, Mortarini R, et al. Boosting T cell-
mediated immunity to tyrosinase by vaccinia virus-transduced,
CD34(+)-derived dendritic cell vaccination: a phase I trial in
metastatic melanoma. Clin Cancer Res. 2004;10(16):5381-5390.
159. Mackensen A, Herbst B, Chen JL, et al. Phase I study in melanoma
patients of a vaccine with peptide-pulsed dendritic cells generated
in vitro from CD34(+) hematopoietic progenitor cells. Int J Cancer.
2000;86(3):385-392.
160. Balan S, Arnold-Schrauf C, Abbas A, et al. Large-scale human den-
dritic cell differentiation revealing notch-dependent lineage bifurca-
tion and heterogeneity. Cell Rep. 2018;24(7):1902-1915 e6.
161. Kirkling ME, Cytlak U, Lau CM, et al. Notch signaling facilitates in
vitro generation of cross-presenting classical dendritic cells. Cell Rep.
2018;23(12):3658-3672 e6.
162. Proietto AI, Mittag D, Roberts AW, Sprigg N, Wu L. The equivalents
of human blood and spleen dendritic cell subtypes can be gener-
ated in vitro from human CD34(+) stem cells in the presence of fms-
like tyrosine kinase 3 ligand and thrombopoietin. Cell Mol Immunol.
2012;9(6):446-454.
163. Lee AW, Truong T, Bickham K, et al. A clinical grade cocktail
of cytokines and PGE2 results in uniform maturation of human
29
monocyte-derived dendritic cells: implications for immunotherapy.
Vaccine. 2002;20:(Suppl 4):A8-A22.
164. Jongmans W, Tiemessen DM, van Vlodrop IJ, Mulders PF, Oosterwijk
E. Th1-polarizing capacity of clinical-grade dendritic cells is triggered
by Ribomunyl but is compromised by PGE2: the importance of matu-
ration cocktails. J Immunother. 2005;28(5):480-487.
165. Krause P, Singer E, Darley PI, Klebensberger J, Groettrup M, Legler
DF. Prostaglandin E2 is a key factor for monocyte-derived dendritic
cell maturation: enhanced T cell stimulatory capacity despite IDO.
J Leukoc Biol. 2007;82(5):1106-1114.
166. Carreno BM, Becker-Hapak M, Huang A, et al. IL-12p70-producing
patient DC vaccine elicits Tc1-polarized immunity. J Clin Invest.
2013;123(8):3383-3394.
167. Kolanowski ST, Sritharan L, Lissenberg-Thunnissen SN, Van Schijndel
GM, Van Ham SM, ten Brinke A. Comparison of media and serum
supplementation for generation of monophosphoryl lipid
A/interferon-gamma-matured type I dendritic cells for immunother-
apy. Cytotherapy. 2014;16(6):826-834.
168. Mailliard RB, Wankowicz-Kalinska A, Cai Q, et al. alpha-type-1 polar-
ized dendritic cells: a novel immunization tool with optimized CTL-
inducing activity. Cancer Res. 2004;64(17):5934-5937.
169. Wilgenhof S, Van Nuffel AM, Benteyn D, et al. A phase IB
study on intravenous synthetic mRNA electroporated dendritic cell
immunotherapy in pretreated advanced melanoma patients. Ann
Oncol. 2013;24(10):2686-2693.
170. Massa C, Thomas C, Wang E, Marincola F, Seliger B. Different matura-
tion cocktails provide dendritic cells with different chemoattractive
properties. J Transl Med. 2015;13:175.
171. Van Nuffel AM, Benteyn D, Wilgenhof S, et al. Intravenous and
intradermal TriMix-dendritic cell therapy results in a broad T-
cell response and durable tumor response in a chemorefrac-
tory stage IV-M1c melanoma patient. Cancer Immunol Immunother.
2012;61(7):1033-1043.
172. Koido S. Dendritic-tumor fusion cell-based cancer vaccines. Int J Mol
Sci. 2016;17(6)828.
173. Lee JM, Lee MH, Garon E, et al. Phase I trial of intratumoral injection
of CCL21 gene-modified dendritic cells in lung cancer elicits tumor-
specific immune responses and CD8(+) T-cell infiltration. Clin Cancer
Res. 2017;23(16):4556-4568.
174. Chiang CL, Kandalaft LE, Tanyi J, et al. A dendritic cell vaccine pulsed
with autologous hypochlorous acid-oxidized ovarian cancer lysate
primes effective broad antitumor immunity: from bench to bedside.
Clin Cancer Res. 2013;19(17):4801-4815.
175. Zhao L, Niu C, Shi X, et al. Dendritic cells loaded with the lysate
of tumor cells infected with Newcastle Disease Virus trigger potent
anti-tumor immunity by promoting the secretion of IFN-gamma and
IL-2 from T cells. Oncol Lett. 2018;16(1):1180-1188.
176. Tanyi JL, Bobisse S, Ophir E, et al. Personalized cancer vaccine effec-
tively mobilizes antitumor T cell immunity in ovarian cancer. Sci Transl
Med. 2018;10(436):eaao5931.
177. Liau LM, Ashkan K, Tran DD, et al. First results on survival from
a large phase 3 clinical trial of an autologous dendritic cell vac-
cine in newly diagnosed glioblastoma. J Transl Med. 2018;16(1):
142.
178. Overwijk WW, Wang E, Marincola FM, Rammensee HG, Restifo NP.
Mining the mutanome: developing highly personalized Immunother-
apies based on mutational analysis of tumors. J Immunother Cancer.
2013;1:11.
179. Carreno BM, Magrini V, Becker-Hapak M, et al. Cancer immunother-
apy. a dendritic cell vaccine increases the breadth and diversity
of melanoma neoantigen-specific T cells. Science. 2015;348(6236):
803-808.
180. Bruggen P, Traversari C, Chomez P, et al. A gene encoding an anti-
gen recognized by cytolytic T lymphocytes on a human melanoma.
Science. 1991;254(5038):1643-1647.
30
181. Kallen K-J, Gnad-Vogt U, Scheel B, Rippin G, Stenzl A. A phase I/IIa
study of the mRNA based cancer vaccine CV9103 prepared with the
RNActive technology results in distinctly longer survival than pre-
dicted by the Halabi Nomogram which correlates with the induc-
tion of antigen-specific immune responses. J Immunother Cancer.
2013;1(1):P219.
182. Shariat S, Badiee A, Jalali SA, et al. P5 HER2/neu-derived pep-
tide conjugated to liposomes containing MPL adjuvant as an effec-
tive prophylactic vaccine formulation for breast cancer. Cancer Lett.
2014;355(1):54-60.
183. Schmidt SM, Schag K, Müller MR, et al. Survivin is a shared tumor-
associated antigen expressed in a broad variety of malignancies and
recognized by specific cytotoxic T cells. Blood. 2003;102(2):571-576.
184. Bakker AB, Schreurs MW, de Boer AJ, et al. Melanocyte lineage-
specific antigen gp100 is recognized by melanoma-derived tumor-
infiltrating lymphocytes. J Exp Med. 1994;179(3):1005-1009.
185. Mikolajczyk SD, Rittenhouse HG. Tumor-associated forms of
prostate specific antigen improve the discrimination of prostate
cancer from benign disease. Rinsho Byori. 2004;52(3):223-230.
186. Chi DD, Merchant RE, Rand R, et al. Molecular detection of tumor-
associated antigens shared by human cutaneous melanomas and
gliomas. Am J Pathol. 1997;150(6):2143-2152.
187. Jungbluth AA, Busam KJ, Kolb D, et al. Expression of MAGE-antigens
in normal tissues and cancer. Int J Cancer. 2000;85(4):460-465.
188. Schultz-Thater E, Noppen C, Gudat F, et al. NY-ESO-1 tumour asso-
ciated antigen is a cytoplasmic protein detectable by specific mon-
oclonal antibodies in cell lines and clinical specimens. Br J Cancer.
2000;83(2):204-208.
189. Williams RR, McIntire KR, Waldmann TA, et al. Tumor-associated
antigen levels (carcinoembryonic antigen, human chorionic
gonadotropin, and alpha-fetoprotein) antedating the diagno-
sis of cancer in the Framingham Study 1. J Natl Cancer Inst.
1977;58(6):1547-1551.
190. Kelderman S, Heemskerk B, Fanchi L, et al. Antigen-specific TIL
therapy for melanoma: a flexible platform for personalized cancer
immunotherapy. Eur J Immunol. 2016;46(6):1351-1360.
191. Kelderman S, Kvistborg P. Tumor antigens in human cancer control.
Biochim Biophys Acta. 2016;1865(1):83-89.
192. Pleasance ED, Cheetham RK, Stephens PJ, et al. A comprehensive cat-
alogue of somatic mutations from a human cancer genome. Nature.
2010;463(7278):191-196.
193. Marchand M, Weynants P, Rankin E, et al. Tumor regression
responses in melanoma patients treated with a peptide encoded by
gene MAGES-3. Int J Cancer. 1995;63(6):883-885.
194. Parmiani G, Russo V, Maccalli C, Parolini D, Rizzo N, Maio M.
Peptide-based vaccines for cancer therapy. Hum Vaccin Immunother.
2014;10(11):3175-3178.
195. Habjanec L, Halassy B, Tomašić J. Immunomodulatory activity
of novel adjuvant formulations based on Montanide ISA oil-
based adjuvants and peptidoglycan monomer. Int Immunopharmacol.
2008;8(5):717-424.
196. Sabbatini P, Tsuji T, Ferran L, et al. Phase I trial of overlapping long
peptides from a tumor self-antigen and poly-ICLC shows rapid induc-
tion of integrated immune response in ovarian cancer patients. Clin
Cancer Res. 2012;18(23):6497-6508.
197. Tsuji T, Sabbatini P, Jungbluth AA, et al. Effect of Montanide and poly-
ICLC adjuvant on human self/tumor antigen-specific CD4+ T cells in
phase I overlapping long peptide vaccine trial. Cancer Immunol Res.
2013;1(5):340-350.
198. Chamani R, Ranji P, Hadji M, Nahvijou A, Esmati E, Alizadeh AM.
Application of E75 peptide vaccine in breast cancer patients: a sys-
tematic review and meta-analysis. Eur J Pharmacol. 2018;831:87-93.
199. Khleif SN, Abrams SI, Hamilton JM, et al. A phase I vaccine trial
with peptides reflecting ras oncogene mutations of solid tumors.
J Immunother. 1999;22(2):155-165.
ROY ET AL .
200. Rahma OE, Hamilton JM, Wojtowicz M, et al. The immunological and
clinical effects of mutated ras peptide vaccine in combination with
IL-2, GM-CSF, or both in patients with solid tumors. J Transl Med.
2014;12(1):55.
201. Toubaji A, Achtar M, Provenzano M, et al. Pilot study of mutant ras
peptide-based vaccine as an adjuvant treatment in pancreatic and
colorectal cancers. Cancer Immunol Immunother. 2008;57(9):1413-
1420.
202. Suzuki E, Kapoor V, Jassar AS, Kaiser LR, Albelda SM. Gemcitabine
selectively eliminates splenic Gr-1+/CD11b+ myeloid suppressor
cells in tumor-bearing animals and enhances antitumor immune
activity. Clin Cancer Res. 2005;11(18):6713-6721.
203. Wang Z, Till B, Gao Q. Chemotherapeutic agent-mediated elim-
ination of myeloid-derived suppressor cells. Oncoimmunology.
2017;6(7):e1331807.
204. Lutsiak ME, Semnani RT, De Pascalis R, Kashmiri SV, Schlom J, Sabze-
vari H. Inhibition of CD4(+)25+ T regulatory cell function implicated
in enhanced immune response by low-dose cyclophosphamide. Blood.
2005;105(7):2862-2868.
205. Le HK, Graham L, Cha E, Morales JK, Manjili MH, Bear HD. Gemc-
itabine directly inhibits myeloid derived suppressor cells in BALB/c
mice bearing 4T1 mammary carcinoma and augments expansion of
T cells from tumor-bearing mice. Int Immunopharmacol. 2009;9(7-
8):900-909.
206. Vincent J, Mignot G, Chalmin F, et al. 5-Fluorouracil selectively
kills tumor-associated myeloid-derived suppressor cells resulting
in enhanced T cell-dependent antitumor immunity. Cancer Res.
2010;70(8):3052-3061.
207. Qu X, Felder MA, Perez Horta Z, Sondel PM, Rakhmilevich AL. Antitu-
mor effects of anti-CD40/CpG immunotherapy combined with gemc-
itabine or 5-fluorouracil chemotherapy in the B16 melanoma model.
Int Immunopharmacol. 2013;17(4):1141-1147.
208. Sawant A, Schafer CC, Jin TH, et al. Enhancement of antitumor immu-
nity in lung cancer by targeting myeloid-derived suppressor cell path-
ways. Cancer Res. 2013;73(22):6609-6620.
209. Otsubo D, Yamashita K, Fujita M, et al. Early-phase treatment
by low-dose 5-fluorouracil or primary tumor resection inhibits
MDSC-mediated lung metastasis formation. Anticancer Res.
2015;35(8):4425-4431.
210. Annels NE, Shaw VE, Gabitass RF, et al. The effects of gemc-
itabine and capecitabine combination chemotherapy and of low-
dose adjuvant GM-CSF on the levels of myeloid-derived suppressor
cells in patients with advanced pancreatic cancer. Cancer Immunol
Immunother. 2014;63(2):175-183.
211. Chaudhary B, Elkord E. Regulatory T cells in the tumor microenvi-
ronment and cancer progression: role and therapeutic targeting. Vac-
cines. 2016;4(3):28.
212. Ghiringhelli F, Larmonier N, Schmitt E, et al. CD4+CD25+ regula-
tory T cells suppress tumor immunity but are sensitive to cyclophos-
phamide which allows immunotherapy of established tumors to be
curative. Eur J Immunol. 2004;34(2):336-344.
213. Li JY, Duan XF, Wang LP, et al. Selective depletion of regulatory T cell
subsets by docetaxel treatment in patients with nonsmall cell lung
cancer. J Immunol Res. 2014;2014:286170.
214. Taniguchi H, Iwasa S, Yamazaki K, et al. Phase 1 study of OCV-C02,
a peptide vaccine consisting of two peptide epitopes for refractory
metastatic colorectal cancer. Cancer Sci. 2017;108(5):1013-1021.
215. Restifo NP, Ying H, Hwang L, Leitner WW. The promise of nucleic acid
vaccines. Gene Ther. 2000;7(2):89-92.
216. Hobernik D, Bros M. DNA vaccines-how far from clinical use? Int J Mol
Sci. 2018;19(11):3605.
217. Pastor F, Berraondo P, Etxeberria I, et al. An RNA toolbox for cancer
immunotherapy. Nat Rev Drug Discov. 2018;17(10):751-767.
218. Rodriguez-Ruiz ME, Perez-Gracia JL, Rodriguez I, et al. Combined
immunotherapy encompassing intratumoral poly-ICLC, dendritic-cell
ROY ET AL .
vaccination and radiotherapy in advanced cancer patients. Ann Oncol.
2018;29(5):1312-1319.
219. Pardi N, Muramatsu H, Weissman D, Kariko K. In vitro transcrip-
tion of long RNA containing modified nucleosides. Methods Mol Biol.
2013;969:29-42.
220. Pardi N, Hogan MJ, Porter FW, Weissman D. mRNA vaccines - a new
era in vaccinology. Nat Rev Drug Discov. 2018;17(4):261-279.
221. Conry RM, LoBuglio AF, Wright M, et al. Characterization of
a messenger RNA polynucleotide vaccine vector. Cancer Res.
1995;55(7):1397-1400.
222. Dileo J, Miller TE, Jr., Chesnoy S, Huang L. Gene transfer to subdermal
tissues via a new gene gun design. Hum Gene Ther. 2003;14(1):79-87.
223. Qiu P, Ziegelhoffer P, Sun J, Yang NS. Gene gun delivery of mRNA in
situ results in efficient transgene expression and genetic immuniza-
tion. Gene Ther. 1996;3(3):262-268.
224. Steitz J, Britten CM, Wolfel T, Tuting T. Effective induction of anti-
melanoma immunity following genetic vaccination with synthetic
mRNA coding for the fusion protein EGFP.TRP2. Cancer Immunol
Immunother. 2006;55(3):246-253.
225. Weide B, Pascolo S, Scheel B, et al. Direct injection of protamine-
protected mRNA: results of a phase 1/2 vaccination trial in metastatic
melanoma patients. J Immunother. 2009;32(5):498-507.
226. Stenzl A, Feyerabend S, Syndikus I, et al. 1149PResults of the
randomized, placebo-controlled phase I/IIB trial of CV9104, an
mRNA based cancer immunotherapy, in patients with metastatic
castration-resistant prostate cancer (mCRPC). Ann Oncol.
2017;28(suppl_5):v403-v407.
227. Sebastian M, Schroder A, Scheel B, et al. A phase I/IIa study of
the mRNA-based cancer immunotherapy CV9201 in patients with
stage IIIB/IV non-small cell lung cancer. Cancer Immunol Immunother.
2019;68(5):799-812.
228. Hong HS, Koch SD, Scheel B, et al. Distinct transcriptional changes
in non-small cell lung cancer patients associated with multi-
antigenic RNActive(R) CV9201 immunotherapy. Oncoimmunology.
2016;5(12):e1249560.
229. Papachristofilou A, Hipp MM, Klinkhardt U, et al. Phase Ib evaluation
of a self-adjuvanted protamine formulated mRNA-based active can-
cer immunotherapy, BI1361849 (CV9202), combined with local radi-
ation treatment in patients with stage IV non-small cell lung cancer.
J Immunother Cancer. 2019;7(1):38.
230. Burris HA, Patel MR, Cho DC, et al. A phase I multicenter study to
assess the safety, tolerability, and immunogenicity of mRNA-4157
alone in patients with resected solid tumors and in combination with
pembrolizumab in patients with unresectable solid tumors. J Clin
Oncol. 2019;37(15_suppl):2523.
231. Bonehill A, Van Nuffel AM, Corthals J, et al. Single-step antigen load-
ing and activation of dendritic cells by mRNA electroporation for the
purpose of therapeutic vaccination in melanoma patients. Clin Cancer
Res. 2009;15(10):3366-3375.
232. Kyte JA, Kvalheim G, Aamdal S, Saeboe-Larssen S, Gaudernack G.
Preclinical full-scale evaluation of dendritic cells transfected with
autologous tumor-mRNA for melanoma vaccination. Cancer Gene
Ther. 2005;12(6):579-591.
233. McNamara MA, Nair SK, Holl EK. RNA-based vaccines in cancer
immunotherapy. J Immunol Res. 2015;2015:794528.
234. Nair SK, Morse M, Boczkowski D, et al. Induction of tumor-specific
cytotoxic T lymphocytes in cancer patients by autologous tumor
RNA-transfected dendritic cells. Ann Surg. 2002;235(4):540-549.
235. Su Z, Dannull J, Heiser A, et al. Immunological and clinical
responses in metastatic renal cancer patients vaccinated with
tumor RNA-transfected dendritic cells. Cancer Res. 2003;63(9):
2127-2133.
236. Amin A, Dudek AZ, Logan TF, et al. Survival with AGS-003, an
autologous dendritic cell-based immunotherapy, in combination with
sunitinib in unfavorable risk patients with advanced renal cell car-
31
cinoma (RCC): phase 2 study results. J Immunother Cancer. 2015;
3:14.
237. Dorfel D, Appel S, Grunebach F, et al. Processing and presentation of
HLA class I and II epitopes by dendritic cells after transfection with in
vitro-transcribed MUC1 RNA. Blood. 2005;105(8):3199-3205.
238. Grunebach F, Kayser K, Weck MM, Muller MR, Appel S, Brossart P.
Cotransfection of dendritic cells with RNA coding for HER-2/neu and
4-1BBL increases the induction of tumor antigen specific cytotoxic T
lymphocytes. Cancer Gene Ther. 2005;12(9):749-756.
239. Heiser A, Coleman D, Dannull J, et al. Autologous dendritic
cells transfected with prostate-specific antigen RNA stimulate
CTL responses against metastatic prostate tumors. J Clin Invest.
2002;109(3):409-417.
240. Morse MA, Nair SK, Boczkowski D, et al. The feasibility and safety of
immunotherapy with dendritic cells loaded with CEA mRNA follow-
ing neoadjuvant chemoradiotherapy and resection of pancreatic can-
cer. Int J Gastrointest Cancer. 2002;32(1):1-6.
241. Morse MA, Nair SK, Mosca PJ, et al. Immunotherapy with autolo-
gous, human dendritic cells transfected with carcinoembryonic anti-
gen mRNA. Cancer Invest. 2003;21(3):341-349.
242. Van Lint S, Wilgenhof S, Heirman C, et al. Optimized dendritic cell-
based immunotherapy for melanoma: the TriMix-formula. Cancer
Immunol Immunother. 2014;63(9):959-967.
243. Wilgenhof S, Corthals J, Van Nuffel AM, et al. Long-term clini-
cal outcome of melanoma patients treated with messenger RNA-
electroporated dendritic cell therapy following complete resection of
metastases. Cancer Immunol Immunother. 2015;64(3):381-388.
244. Lopes A, Vandermeulen G, Preat V. Cancer DNA vaccines: current
preclinical and clinical developments and future perspectives. J Exp
Clin Cancer Res. 2019;38(1):146.
245. Tiptiri-Kourpeti A, Spyridopoulou K, Pappa A, Chlichlia K. DNA vac-
cines to attack cancer: strategies for improving immunogenicity and
efficacy. Pharmacol Ther. 2016;165:32-49.
246. Aghi M, Visted T, Depinho RA, Chiocca EA. Oncolytic herpes
virus with defective ICP6 specifically replicates in quiescent cells
with homozygous genetic mutations in p16. Oncogene. 2008;27(30):
4249-4254.
247. Howells A, Marelli G, Lemoine NR, Wang Y. Oncolytic viruses-
interaction of virus and tumor cells in the battle to eliminate cancer.
Front Oncol. 2017;7:195.
248. Russell SJ, Barber GN. Oncolytic viruses as antigen-agnostic cancer
vaccines. Cancer Cell. 2018;33(4):599-605.
249. Twumasi-Boateng K, Pettigrew JL, Kwok YYE, Bell JC, Nelson
BH. Oncolytic viruses as engineering platforms for combination
immunotherapy. Nat Rev Cancer. 2018;18(7):419-432.
250. Bommareddy PK, Shettigar M, Kaufman HL. Integrating oncolytic
viruses in combination cancer immunotherapy. Nat Rev Immunol.
2018;18(8):498-513.
251. Coffey MC, Strong JE, Forsyth PA, Lee PW. Reovirus therapy
of tumors with activated Ras pathway. Science. 1998;282(5392):
1332-1334.
252. Roy S, Bag AK, Dutta S, et al. Macrophage-derived neuropilin-
2 exhibits novel tumor-promoting functions. Cancer Res.
2018;78(19):5600-5617.
253. Barber GN. Cytoplasmic DNA innate immune pathways. Immunol Rev.
2011;243(1):99-108.
254. Barber GN. Innate immune DNA sensing pathways: STING, AIMII and
the regulation of interferon production and inflammatory responses.
Curr Opin Immunol. 2011;23(1):10-20.
255. Franz KM, Kagan JC. Innate immune receptors as competitive deter-
minants of cell fate. Mol Cell. 2017;66(6):750-760.
256. Takeuchi O, Akira S. Innate immunity to virus infection. Immunol Rev.
2009;227(1):75-86.
257. Kaminskyy V, Zhivotovsky B. To kill or be killed: how viruses interact
with the cell death machinery. J Intern Med. 2010;267(5):473-482.
32
258. Schock SN, Chandra NV, Sun Y, et al. Induction of necroptotic cell
death by viral activation of the RIG-I or STING pathway. Cell Death
Differ. 2017;24(4):615-625.
259. Raja J, Ludwig JM, Gettinger SN, Schalper KA, Kim HS. Oncolytic virus
immunotherapy: future prospects for oncology. J Immunother Cancer.
2018;6(1):140.
260. Lundstrom K. New frontiers in oncolytic viruses: optimizing
and selecting for virus strains with improved efficacy. Biologics.
2018;12:43-60.
261. Andtbacka RH, Kaufman HL, Collichio F, et al. Talimogene laher-
parepvec improves durable response rate in patients with advanced
melanoma. J Clin Oncol. 2015;33(25):2780-2788.
262. Chesney J, Puzanov I, Collichio F, et al. Randomized, open-label
phase II study evaluating the efficacy and safety of talimogene laher-
parepvec in combination with ipilimumab versus ipilimumab alone
in patients with advanced, unresectable melanoma. J Clin Oncol.
2018;36(17):1658-1667.
263. Ribas A, Dummer R, Puzanov I, et al. Oncolytic virotherapy promotes
intratumoral T cell infiltration and improves anti-PD-1 immunother-
apy. Cell. 2017;170(6):1109-1119 e10.
264. Desjardins A, Gromeier M, Herndon JE, et al. Recurrent glioblastoma
treated with recombinant poliovirus. N Engl J Med. 2018;379(2):150-
161.
265. Brown MC, Holl EK, Boczkowski D, et al. Cancer immunother-
apy with recombinant poliovirus induces IFN-dominant activation
of dendritic cells and tumor antigen-specific CTLs. Sci Transl Med.
2017;9(408):eaan4220.
266. Samson A, Scott KJ, Taggart D, et al. Intravenous delivery of oncolytic
reovirus to brain tumor patients immunologically primes for subse-
quent checkpoint blockade. Sci Transl Med. 2018;10(422):eaam7577.
267. Bourgeois-Daigneault MC, Roy DG, Aitken AS, et al. Neoadju-
vant oncolytic virotherapy before surgery sensitizes triple-negative
breast cancer to immune checkpoint therapy. Sci Transl Med.
2018;10(422):eaao1641.
268. Lawler SE, Speranza MC, Cho CF, Chiocca EA. Oncolytic viruses in
cancer treatment: a review. JAMA Oncol. 2017;3(6):841-849.
269. Pol J, Bloy N, Obrist F, et al. Trial watch: oncolytic viruses for cancer
therapy. Oncoimmunology. 2014;3:e28694.
270. Hoption Cann SA, van Netten JP, van Netten C. Dr William Coley and
tumour regression: a place in history or in the future. Postgrad Med J.
2003;79(938):672-680.
271. Richardson MA, Ramirez T, Russell NC, Moye LA. Coley toxins
immunotherapy: a retrospective review. Altern Ther Health Med.
1999;5(3):42-47.
272. Felgner S, Pawar V, Kocijancic D, Erhardt M, Weiss S. Tumour-
targeting bacteria-based cancer therapies for increased specificity
and improved outcome. Microb Biotechnol. 2017;10(5):1074-1078.
273. Theys J, Lambin P. Clostridium to treat cancer: dream or reality? Ann
Transl Med. 2015;3(Suppl 1):S21.
274. Zhang YL, Lu R, Chang ZS, et al. Clostridium sporogenes deliv-
ers interleukin-12 to hypoxic tumours, producing antitumour activ-
ity without significant toxicity. Lett Appl Microbiol. 2014;59(6):
580-586.
275. Chowdhury S, Castro S, Coker C, Hinchliffe TE, Arpaia N, Danino
T. Programmable bacteria induce durable tumor regression and sys-
temic antitumor immunity. Nat Med. 2019;25(7):1057-1063.
276. Le DT, Brockstedt DG, Nir-Paz R, et al. A live-attenuated Listeria
vaccine (ANZ-100) and a live-attenuated Listeria vaccine expressing
mesothelin (CRS-207) for advanced cancers: phase I studies of safety
and immune induction. Clin Cancer Res. 2012;18(3):858-868.
277. Goyvaerts C, Breckpot K. Towards a personalized iPSC-based vac-
cine. Nat Biomed Eng. 2018;2(5):277-278.
278. Brewer BG, Mitchell RA, Harandi A, Eaton JW. Embryonic vaccines
against cancer: an early history. Exp Mol Pathol. 2009;86(3):192-197.
ROY ET AL .
279. Ben-Porath I, Thomson MW, Carey VJ, et al. An embryonic stem cell-
like gene expression signature in poorly differentiated aggressive
human tumors. Nat Genet. 2008;40(5):499-507.
280. Ghosh Z, Huang M, Hu S, Wilson KD, Dey D, Wu JC. Dissecting
the oncogenic and tumorigenic potential of differentiated human
induced pluripotent stem cells and human embryonic stem cells. Can-
cer Res. 2011;71(14):5030-5039.
281. de Almeida PE, Meyer EH, Kooreman NG, et al. Transplanted ter-
minally differentiated induced pluripotent stem cells are accepted
by immune mechanisms similar to self-tolerance. Nat Commun.
2014;5:3903.
282. Cao J, Li X, Lu X, Zhang C, Yu H, Zhao T. Cells derived from iPSC can
be immunogenic - yes or no? Protein Cell. 2014;5(1):1-3.
283. Zhao T, Zhang ZN, Rong Z, Xu Y. Immunogenicity of induced pluripo-
tent stem cells. Nature. 2011;474(7350):212-215.
284. Bock C, Kiskinis E, Verstappen G, et al. Reference Maps of human
ES and iPS cell variation enable high-throughput characterization of
pluripotent cell lines. Cell. 2011;144(3):439-52.
285. Mallon BS, Chenoweth JG, Johnson KR, et al. StemCellDB: the human
pluripotent stem cell database at the National Institutes of Health.
Stem Cell Res. 2013;10(1):57-66.
286. Mallon BS, Hamilton RS, Kozhich OA, et al. Comparison of the molec-
ular profiles of human embryonic and induced pluripotent stem cells
of isogenic origin. Stem Cell Res. 2014;12(2):376-386.
287. Soldner F, Hockemeyer D, Beard C, et al. Parkinson’s disease patient-
derived induced pluripotent stem cells free of viral reprogramming
factors. Cell. 2009;136(5):964-977.
288. Kooreman NG, Kim Y, de Almeida PE, et al. Autologous iPSC-
based vaccines elicit anti-tumor responses in vivo. Cell Stem Cell.
2018;22(4):501-513 e7.
289. Klebanoff CA, Wolchok JD. Shared cancer neoantigens: making pri-
vate matters public. J Exp Med. 2018;215(1):5-7.
290. Castle JC, Kreiter S, Diekmann J, et al. Exploiting the mutanome for
tumor vaccination. Cancer Res. 2012;72(5):1081-1091.
291. Kreiter S, Vormehr M, van de Roemer N, et al. Mutant MHC class
II epitopes drive therapeutic immune responses to cancer. Nature.
2015;520(7549):692-696.
292. Matsushita H, Vesely MD, Koboldt DC, et al. Cancer exome analy-
sis reveals a T-cell-dependent mechanism of cancer immunoediting.
Nature. 2012;482(7385):400-404.
293. Gubin MM, Zhang X, Schuster H, et al. Checkpoint blockade can-
cer immunotherapy targets tumour-specific mutant antigens. Nature.
2014;515(7528):577-581.
294. Yadav M, Jhunjhunwala S, Phung QT, et al. Predicting immuno-
genic tumour mutations by combining mass spectrometry and exome
sequencing. Nature. 2014;515(7528):572-576.
295. Duan F, Duitama J, Al Seesi S, et al. Genomic and bioinformatic profil-
ing of mutational neoepitopes reveals new rules to predict anticancer
immunogenicity. J Exp Med. 2014;211(11):2231-2248.
296. Li L, Goedegebuure SP, Gillanders WE. Preclinical and clinical
development of neoantigen vaccines. Ann Oncol. 2017;28(suppl_12):
xii11-xii7.
297. Tran E, Robbins PF, Rosenberg SA. ‘Final common pathway’ of human
cancer immunotherapy: targeting random somatic mutations. Nat
Immunol. 2017;18(3):255-262.
298. van der Burg SH, Arens R, Ossendorp F, van Hall T, Melief CJ. Vac-
cines for established cancer: overcoming the challenges posed by
immune evasion. Nat Rev Cancer. 2016;16(4):219-233.
299. Fifis T, Gamvrellis A, Crimeen-Irwin B, et al. Size-dependent immuno-
genicity: therapeutic and protective properties of nano-vaccines
against tumors. J Immunol. 2004;173(5):3148-3154.
300. Liu H, Moynihan KD, Zheng Y, et al. Structure-based program-
ming of lymph-node targeting in molecular vaccines. Nature.
2014;507(7493):519-522.
ROY ET AL .
301. Manolova V, Flace A, Bauer M, Schwarz K, Saudan P, Bachmann MF.
Nanoparticles target distinct dendritic cell populations according to
their size. Eur J Immunol. 2008;38(5):1404-1413.
302. Hanson MC, Crespo MP, Abraham W, et al. Nanoparticulate STING
agonists are potent lymph node-targeted vaccine adjuvants. J Clin
Invest. 2015;125(6):2532-2546.
303. Nuhn L, Vanparijs N, De Beuckelaer A, et al. pH-degradable
imidazoquinoline-ligated nanogels for lymph node-focused immune
activation. Proc Natl Acad Sci USA. 2016;113(29):8098-8103.
304. Ott PA, Hu Z, Keskin DB, et al. An immunogenic personal neoanti-
gen vaccine for patients with melanoma. Nature. 2017;547(7662):
217-221.
305. Guo Y, Lei K, Tang L. Neoantigen vaccine delivery for personalized
anticancer immunotherapy. Front Immunol. 2018;9:1499.
306. Luo M, Wang H, Wang Z, et al. A STING-activating nanovaccine for
cancer immunotherapy. Nat Nanotechnol. 2017;12(7):648-654.
307. Li AW, Sobral MC, Badrinath S, et al. A facile approach to enhance
antigen response for personalized cancer vaccination. Nat Mater.
2018;17(6):528-534.
308. Rammensee HG, Singh-Jasuja H. HLA ligandome tumor antigen
discovery for personalized vaccine approach. Expert Rev Vaccines.
2013;12(10):1211-1217.
309. Singh-Jasuja H, Emmerich NP, Rammensee HG. The Tubingen
approach: identification, selection, and validation of tumor-
associated HLA peptides for cancer therapy. Cancer Immunol
Immunother. 2004;53(3):187-195.
310. Walter S, Weinschenk T, Stenzl A, et al. Multipeptide immune
response to cancer vaccine IMA901 after single-dose cyclophos-
phamide associates with longer patient survival. Nat Med.
2012;18(8):1254-1261.
311. Bentzen AK, Marquard AM, Lyngaa R, et al. Large-scale detection of
antigen-specific T cells using peptide-MHC-I multimers labeled with
DNA barcodes. Nat Biotechnol. 2016;34(10):1037-1045.
312. Bentzen AK, Such L, Jensen KK, et al. T cell receptor finger-
printing enables in-depth characterization of the interactions gov-
erning recognition of peptide-MHC complexes. Nat Biotechnol.
2018;36:1191-1196.
313. Zugazagoitia J, Guedes C, Ponce S, Ferrer I, Molina-Pinelo S,
Paz-Ares L. Current challenges in cancer treatment. Clin Ther.
2016;38(7):1551-1566.
314. Zaretsky JM, Garcia-Diaz A, Shin DS, et al. Mutations associated with
acquired resistance to PD-1 blockade in melanoma. N Engl J Med.
2016;375(9):819-829.
315. Anderson KG, Stromnes IM, Greenberg PD. Obstacles posed by the
tumor microenvironment to T cell activity: a case for synergistic ther-
apies. Cancer Cell. 2017;31(3):311-325.
316. Blank CU, Haining WN, Held W, et al. Defining ‘T cell exhaustion’. Nat
Rev Immunol. 2019;19(11):665-674.
317. Philip M, Schietinger A. Heterogeneity and fate choice: T cell exhaus-
tion in cancer and chronic infections. Curr Opin Immunol. 2019;58:
98-103.
318. Wei SC, Duffy CR, Allison JP. Fundamental mechanisms of
immune checkpoint blockade therapy. Cancer Discov. 2018;8(9):
1069-1086.
319. He QF, Xu Y, Li J, Huang ZM, Li XH, Wang X. CD8+ T-cell exhaustion
in cancer: mechanisms and new area for cancer immunotherapy. Brief
Funct Genomics. 2019;18(2):99-106.
320. Jiang Y, Li Y, Zhu B. T-cell exhaustion in the tumor microenvironment.
Cell Death Dis. 2015;6:e1792.
321. Wang JC, Xu Y, Huang ZM, Lu XJ. T cell exhaustion in cancer:
mechanisms and clinical implications. J Cell Biochem. 2018;119(6):
4279-4286.
322. Quoix E, Lena H, Losonczy G, et al. TG4010 immunotherapy and
first-line chemotherapy for advanced non-small-cell lung cancer
(TIME): results from the phase 2b part of a randomised, double-blind,
33
placebo-controlled, phase 2b/3 trial. Lancet Oncol. 2016;17(2):212-
223.
323. Vermaelen K. Vaccine strategies to improve anti-cancer cellular
immune responses. Front Immunol. 2019;10:8.
324. Cuadros C, Dominguez AL, Lollini PL, et al. Vaccination with den-
dritic cells pulsed with apoptotic tumors in combination with anti-
OX40 and anti-4-1BB monoclonal antibodies induces T cell-mediated
protective immunity in Her-2/neu transgenic mice. Int J Cancer.
2005;116(6):934-943.
325. Ito F, Li Q, Shreiner AB, et al. Anti-CD137 monoclonal antibody
administration augments the antitumor efficacy of dendritic cell-
based vaccines. Cancer Res. 2004;64(22):8411-8419.
326. Becker JC, Andersen MH, Schrama D, Thor Straten P. Immune-
suppressive properties of the tumor microenvironment. Cancer
Immunol Immunother. 2013;62(7):1137-1148.
327. Hanahan D, Coussens LM. Accessories to the crime: functions
of cells recruited to the tumor microenvironment. Cancer Cell.
2012;21(3):309-322.
328. Kumar V, Patel S, Tcyganov E, Gabrilovich DI. The nature of myeloid-
derived suppressor cells in the tumor microenvironment. Trends
Immunol. 2016;37(3):208-220.
329. Stromnes IM, Brockenbrough JS, Izeradjene K, et al. Targeted deple-
tion of an MDSC subset unmasks pancreatic ductal adenocarcinoma
to adaptive immunity. Gut. 2014;63(11):1769-1781.
330. Stromnes IM, DelGiorno KE, Greenberg PD, Hingorani SR. Stro-
mal reengineering to treat pancreas cancer. Carcinogenesis.
2014;35(7):1451-1460.
331. Stromnes IM, Greenberg PD, Hingorani SR. Molecular path-
ways: myeloid complicity in cancer. Clin Cancer Res. 2014;20(20):
5157-5170.
332. Whiteside TL. The tumor microenvironment and its role in promoting
tumor growth. Oncogene. 2008;27(45):5904-5912.
333. Gunderson AJ, Kaneda MM, Tsujikawa T, et al. Bruton tyrosine
kinase-dependent immune cell cross-talk drives pancreas cancer.
Cancer Discov. 2016;6(3):270-285.
334. Lee KE, Spata M, Bayne LJ, et al. Hif1a deletion reveals pro-
neoplastic function of B cells in pancreatic neoplasia. Cancer Discov.
2016;6(3):256-269.
335. Schwartz M, Zhang Y, Rosenblatt JD. B cell regulation of the anti-
tumor response and role in carcinogenesis. J Immunother Cancer.
2016;4:40.
336. Pylayeva-Gupta Y, Das S, Handler JS, et al. IL35-producing B cells
promote the development of pancreatic neoplasia. Cancer Discov.
2016;6(3):247-255.
337. Oberg HH, Kellner C, Peipp M, et al. Monitoring circulating gam-
madelta T cells in cancer patients to optimize gammadelta T cell-
based immunotherapy. Front Immunol. 2014;5:643
338. Wesch D, Peters C, Siegers GM. Human gamma delta T regulatory
cells in cancer: fact or fiction? Front Immunol. 2014;5:598.
339. Stanford JC, Young C, Hicks D, et al. Efferocytosis produces a
prometastatic landscape during postpartum mammary gland involu-
tion. J Clin Invest. 2014;124(11):4737-1452.
340. Vaught DB, Cook RS. Clearance of dying cells accelerates malignancy.
Oncotarget. 2015;6(28):24590-24591.
341. Wesolowski R, Duggan MC, Stiff A, et al. Circulating myeloid-derived
suppressor cells increase in patients undergoing neo-adjuvant
chemotherapy for breast cancer. Cancer Immunol Immunother.
2017;66(11):1437-1447.
342. Chandra D, Quispe-Tintaya W, Jahangir A, et al. STING ligand c-di-
GMP improves cancer vaccination against metastatic breast cancer.
Cancer Immunol Res. 2014;2(9):901-910.
343. Nicholaou T, Ebert LM, Davis ID, et al. Regulatory T-cell-mediated
attenuation of T-cell responses to the NY-ESO-1 ISCOMATRIX vac-
cine in patients with advanced malignant melanoma. Clin Cancer Res.
2009;15(6):2166-2173.
34
344. Jacobs C, Duewell P, Heckelsmiller K, et al. An ISCOM vaccine com-
bined with a TLR9 agonist breaks immune evasion mediated by reg-
ulatory T cells in an orthotopic model of pancreatic carcinoma. Int J
Cancer. 2011;128(4):897-907.
345. Ghiringhelli F, Menard C, Puig PE, et al. Metronomic cyclophos-
phamide regimen selectively depletes CD4+CD25+ regulatory T
cells and restores T and NK effector functions in end stage cancer
patients. Cancer Immunol Immunother. 2007;56(5):641-648.
346. O’Sullivan D, Sanin DE, Pearce EJ, Pearce EL. Metabolic interventions
in the immune response to cancer. Nat Rev Immunol. 2019;19(5):324-
335.
347. Porporato PE, Filigheddu N, Pedro JMB, Kroemer G, Galluzzi L. Mito-
chondrial metabolism and cancer. Cell Res. 2018;28(3):265-280.
348. Gardiner CM. NK cell metabolism. J Leukoc Biol. 2019;105(6):
1235-1242.
349. Terren I, Orrantia A, Vitalle J, Zenarruzabeitia O, Borrego F.
NK cell metabolism and tumor microenvironment. Front Immunol.
2019;10:2278.
350. Gabrilovich DI. Myeloid-derived suppressor cells. Cancer Immunol
Res. 2017;5(1):3-8.
351. Kishton RJ, Sukumar M, Restifo NP. Metabolic regulation of T
cell longevity and function in tumor immunotherapy. Cell Metab.
2017;26(1):94-109.
352. O’Neill LA, Pearce EJ. Immunometabolism governs dendritic cell and
macrophage function. J Exp Med. 2016;213(1):15-23.
353. Hanahan D, Weinberg RA. Hallmarks of cancer: the next generation.
Cell. 2011;144(5):646-674.
354. Cascone T, McKenzie JA, Mbofung RM, et al. Increased tumor glycol-
ysis characterizes immune resistance to adoptive T cell therapy. Cell
Metab. 2018;27(5):977-87 e4.
355. Cao Y, Rathmell JC, Macintyre AN. Metabolic reprogramming
towards aerobic glycolysis correlates with greater proliferative abil-
ity and resistance to metabolic inhibition in CD8 versus CD4 T cells.
PLoS One. 2014;9(8):e104104.
356. Chang CH, Pearce EL. Emerging concepts of T cell metabolism as a
target of immunotherapy. Nat Immunol. 2016;17(4):364-368.
357. Chang CH, Qiu J, O’Sullivan D, et al. Metabolic competition in the
tumor microenvironment is a driver of cancer progression. Cell.
2015;162(6):1229-1241.
358. Ho PC, Bihuniak JD, Macintyre AN, et al. Phosphoenolpyruvate
is a metabolic checkpoint of anti-tumor T cell responses. Cell.
2015;162(6):1217-1228.
359. Jacobs SR, Herman CE, Maciver NJ, et al. Glucose uptake is limiting
in T cell activation and requires CD28-mediated Akt-dependent and
independent pathways. J Immunol. 2008;180(7):4476-4486.
360. Renner K, Geiselhoringer AL, Fante M, et al. Metabolic plasticity of
human T cells: preserved cytokine production under glucose depriva-
tion or mitochondrial restriction, but 2-deoxy-glucose affects effec-
tor functions. Eur J Immunol. 2015;45(9):2504-2516.
361. Ota Y, Ishihara S, Otani K, et al. Effect of nutrient starvation on prolif-
eration and cytokine secretion of peripheral blood lymphocytes. Mol
Clin Oncol. 2016;4(4):607-310.
362. Scharping NE, Delgoffe GM. Tumor microenvironment metabolism:
a new checkpoint for anti-tumor immunity. Vaccines. 2016;4
(4):46.
363. Pearce EL, Walsh MC, Cejas PJ, et al. Enhancing CD8 T-cell mem-
ory by modulating fatty acid metabolism. Nature. 2009;460(7251):
103-137.
364. Heemskerk B, Kvistborg P, Schumacher TN. The cancer antigenome.
EMBO J. 2013;32(2):194-203.
365. Yarchoan M, Johnson BA, 3rd, Lutz ER, Laheru DA, Jaffee EM. Tar-
geting neoantigens to augment antitumour immunity. Nat Rev Cancer.
2017;17(9):569
ROY ET AL .
366. Lim YW, Chen-Harris H, Mayba O, et al. Germline genetic polymor-
phisms influence tumor gene expression and immune cell infiltration.
Proc Natl Acad Sci USA. 2018;115(50):E11701-E11710.
367. Tran E, Robbins PF, Lu YC, et al. T-cell transfer therapy targeting
mutant KRAS in cancer. N Engl J Med. 2016;375(23):2255-2262.
368. Juric D, Castel P, Griffith M, et al. Convergent loss of PTEN
leads to clinical resistance to a PI(3)Kalpha inhibitor. Nature.
2015;518(7538):240-244.
369. Niederst MJ, Sequist LV, Poirier JT, et al. RB loss in resistant EGFR
mutant lung adenocarcinomas that transform to small-cell lung can-
cer. Nat Commun. 2015;6:6377.
370. Zhao J, Chen AX, Gartrell RD, et al. Immune and genomic correlates
of response to anti-PD-1 immunotherapy in glioblastoma. Nat Med.
2019;25(3):462-469.
371. Stanta G, Bonin S. Overview on clinical relevance of intra-tumor het-
erogeneity. Front Med. 2018;5:85.
372. Meacham CE, Morrison SJ. Tumour heterogeneity and cancer cell
plasticity. Nature. 2013;501(7467):328-337.
373. Reiter JG, Baretti M, Gerold JM, et al. An analysis of genetic hetero-
geneity in untreated cancers. Nat Rev Cancer. 2019;19(11):639-650.
374. Jamal-Hanjani M, Quezada SA, Larkin J, Swanton C. Trans-
lational implications of tumor heterogeneity. Clin Cancer Res.
2015;21(6):1258-1266.
375. Cusnir M, Cavalcante L. Inter-tumor heterogeneity. Hum Vaccin
Immunother. 2012;8(8):1143-1145.
376. de Sousa VML, Carvalho L. Heterogeneity in Lung Cancer. Pathobiol-
ogy. 2018;85(1-2):96-107.
377. Liu J, Dang H, Wang XW. The significance of intertumor and intratu-
mor heterogeneity in liver cancer. Exp Mol Med. 2018;50(1):e416.
378. Finotello F, Eduati F. Multi-omics profiling of the tumor microenvi-
ronment: paving the way to precision immuno-oncology. Front Oncol.
2018;8:430.
379. Janiszewska M. The microcosmos of intratumor heterogeneity: the
space-time of cancer evolution. Oncogene. 2019;39:2031-2039.
380. Losic B, Craig AJ, Villacorta-Martin C, et al. Intratumoral heterogene-
ity and clonal evolution in liver cancer. Nat Commun. 2020;11(1):291.
381. Kemper K, Krijgsman O, Cornelissen-Steijger P, et al. Intra- and inter-
tumor heterogeneity in a vemurafenib-resistant melanoma patient
and derived xenografts. EMBO Mol Med. 2015;7(9):1104-1118.
382. Charoentong P, Finotello F, Angelova M, et al. Pan-cancer
immunogenomic analyses reveal genotype-immunophenotype
relationships and predictors of response to checkpoint blockade. Cell
Rep. 2017;18(1):248-262.
383. Chowell D, Morris LGT, Grigg CM, et al. Patient HLA class I genotype
influences cancer response to checkpoint blockade immunotherapy.
Science. 2018;359(6375):582-587.
384. Hopkins AC, Yarchoan M, Durham JN, et al. T cell receptor repertoire
features associated with survival in immunotherapy-treated pancre-
atic ductal adenocarcinoma. JCI Insight. 2018;3(13):e122092.
385. Thorsson V, Gibbs DL, Brown SD, et al. The immune landscape of can-
cer. Immunity. 2018;48(4):812-30 e14.
386. Wellenstein MD, de Visser KE. Cancer-cell-intrinsic mechanisms
shaping the tumor immune landscape. Immunity. 2018;48(3):
399-416.
387. Remy-Ziller C, Thioudellet C, Hortelano J, et al. Sequential adminis-
tration of MVA-based vaccines and PD-1/PD-L1-blocking antibodies
confers measurable benefits on tumor growth and survival: Preclini-
cal studies with MVA-betaGal and MVA-MUC1 (TG4010) in a murine
tumor model. Hum Vaccin Immunother. 2018;14(1):140-145.
388. McNeel DG, Eickhoff JC, Wargowski E, et al. Concurrent, but not
sequential, PD-1 blockade with a DNA vaccine elicits anti-tumor
responses in patients with metastatic, castration-resistant prostate
cancer. Oncotarget. 2018;9(39):25586-25596.
ROY ET AL . 35

389. Helmink BA, Khan MAW, Hermann A, Gopalakrishnan V, Wargo

JA. The microbiome, cancer, and cancer therapy. Nat Med. How to cite this article: Roy S, Sethi TK, Taylor D, Kim YJ,
2019;25(3):377-388.
Johnson DB. Breakthrough concepts in immune-oncology: Can-
390. Gopalakrishnan V, Spencer CN, Nezi L, et al. Gut microbiome mod-
ulates response to anti-PD-1 immunotherapy in melanoma patients.
cer vaccines at the bedside. J Leukoc Biol. 2020;1–35. https://
Science. 2018;359(6371):97-103. doi.org/10.1002/JLB.5BT0420-585RR
391. Routy B, Le Chatelier E, Derosa L, et al. Gut microbiome influences
efficacy of PD-1-based immunotherapy against epithelial tumors. Sci-
ence. 2018;359(6371):91-97.