1

Immunity to tumor
 Outline Presentation

1. Overview of tumor immunity

2. Tumor antigens
3. Immune responses to tumors
4. Evasion of immune responses by tumors
5. Immunotherapy for tumors
 3

Overview
 Tumor stimulate specific adaptive immune responses that can
prevent or limit the growth and spread of the cancer

 Immune response frequently fail to prevent the growth

1. Specialized mechanism for subverting host immune response
2. Tumor cells lose the expression of antigens that may be
recognized by the host immune system
3. The rapid growth and spread of a tumor may overwhelm the
capacity of the immune system to effectively control the tumor.

 Ineffective adaptive immune responses to cancers can be

overcome by therapeutic that stimulate such responses, such
that antitumor T cells can be activated to effectively kill tumor
cells (ex. Tumor vaccine)
Lymphocytic inflammation
associated with tumors

Certain tumor have associated

to lymphocytic infiltrates
(A) Medullary breast carcinoma
(B) Malignant carcinoma
(C) The tumor cell appear blue
and the CD8+ T cells brown
(D) Increased CD3+ T cells
associated with longer
disease-free survival
Red arrow indicate malignant
cell.
Yellow arrow indicate
lymphocyte-rich inflammatory
infiltrates.
 TUMOR ANTIGENS
 The majority of tumor antigens that elicit protective immune
responses are neoantigens produced by mutated genes in
different tumor cell clones
 Neoantigens : antigens encoded by mutated genes
 The protein neoantigens of tumors are mostly the products
of randomly mutated genes (“passenger mutation”)
reflecting the genetic instability of cancer cells or, less
commonly, products of mutated oncogenes or tumor
suppressor genes that are involved in oncogenesis (“driver
mutation”)
 Antigens of oncogenic viruses
The product of oncogenic viruses function as tumor
antigens and elicit specific T cell responses that may serve
to eradicate virus-induced tumors.
Tumor Neoantigens

Tumor neoantigens produced

by somatic mutations may
change a self-protein that the
patient
(A)Tolerant to
(B)A peptide with new TCR
contact residue that is
recognized by T cells
(C)Tumors caused by
oncogenic viruses produce
viral proteins that stimulate
CD8+ T cells
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Cross-presentation of tumor antigens

 TUMOR ANTIGENS
 Overexpressed cellular proteins
Some tumor antigens are the product of genes that are
silenced in normal cells and derepressed in tumor cells, or
are proteins made by normal cells but produced in
excessive amounts by tumors.
 Cancer-testis antigens are proteins expressed in gametes
and trophoblasts and in many types of cancers but not in
normal somatic tissues
 Some proteins are expressed at abnormally high levels in
tumor cells because the genes encoding these proteins are
amplified.
 Differentiation antigens are found normally on tumor cells
and on the cells types of origin of the tumors but not on
cells from other tissues
Unmutated Tumor Antigens

Proteins that are not

mutated but are
expressed more
abundantly by tumors
than normal cells may
induce T cell response.
Many of these tumor
antigens include
proteins encoded by
genes that are
normally not
expressed all in most
cells of adults because
of epigenetic
suppresion, but are
depressed in tumor
cells.
 Other Antigens of Tumors

1. Oncofetal antigens
- High level in cancer cells and in fetal not adult
tissues
- Their expression in adults is not limited to tumors,
but it increased in tissue and circulation
- No evidence as inducers of antitumor immunity
- Usefulness as tumor markers, target of antibodies
or vaccine candidate is limited
- Examples : carcinoembryonic antigen (CEA) and
α-fetoprotein (AFP)
 Other Antigens of Tumors
2. Altered glycolipid and glicoprotein antigens
- Tumors express higher surface glycoproteins
and glycolipids (including gangliosides, blood
group antigens and mucins
- Tumors have disregulated expression of
enzymes that synthesize the carbohydrate
side chains od mucins, lead to the
appearance of tumor-specific epitopes on the
carbohydrate side chains or on the abnormally
exposed polypeptide core.
- Example : MUC-1
 Other Antigens of Tumors

2. Altered glycolipid and glicoprotein antigens

- Example : MUC-1
- MUC 1 : an integral membrane protein that is
normally expressed only on the apical surface
of breast ductal epithelium, a site that relatively
sequestered from the immune system
- In some carcinoma, MUC-1 is expressed in a
non polarized fashion and contain new, tumor-
specific carbohydrate and peptide epitopes
detectable by mouse monoclonal antibodies.
IMMUNE RESPONSES TO TUMORS

1. T lymphocytes
2. Antibodies
3. Natural killer cells
4. Macrophages
 IMMUNE RESPONSES TO TUMORS :
T-Lymphocytes

• The principal mechanism of immune protection

against tumors is killing of tumor cells by CD8+
CTLs
• CD8+ T cell responses specific for tumor antigens
may require cross-presentation of the tumor
antigens by dendritic cells
• CD4+ helper T cells contribute to antitumor
immune responses by several mechanism (Ex.
Th1 enhancing CD8+ T cells responses and
activating macrophages; granzyme B expression)
 IMMUNE RESPONSES TO TUMORS :
T-Lymphocytes

• The demonstration that the numbers of

different types of T cells within resected
tumor correlates with the likelihood of
metastatic disease has led to the practice
of determining an immune score for
cancers to assess prognosis and direct
treatment options.
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CTL response
against tumors

Tumor antigens are picked up

by host dendritic cells and
responses are initiated in
peripheral (secondary)
lymphoid organs. Tumor-
specific CTLs migrate back to
the tumor and kill tumor cells.
Other mechanisms of tumor
immunity are not shown.
 IMMUNE RESPONSES TO TUMORS :
Antibodies

• Tumor-bearing hosts often produce

antibodies against tumor antigens, but the
significance of these antibodies in
protecting against cancers is unknown.
• Antibodies may kill cancer cells by
activating complement or by antibody-
dependent cell-mediated cytotoxicity, in
which Fc receptor-bearing macrophages or
NK cells mediate the killing.
 IMMUNE RESPONSES TO TUMORS :
Natural Killer Cells

• NK cells are capable of killing many types

of tumor cells and may contribute to
immune surveillance against cancers.
• Tumor cells become susceptible to killing
by NK cells when they down-regulate
expression of class I MHC or they up-
regulate expression of ligands that bind
activating NK cell receptors.
 IMMUNE RESPONSES TO TUMORS :
Macrophages

• Macrophages are capable of both

inhibiting and promoting the growth and
spread of cancers, depending on their
activation state.
Classical and alternative macrophage activation
Promotion of tumor growth by the antiinflammatory tumor
macroenvironment
- Inflammation can promote malignant
transformation and the development
of cancer
- Established tumors often create a
microenvironment which suppresses
antitumor immunity and promotes
cancer cell growth.
- Tumor alter the phenotype of DCs in
ways that promote the differentiation
of antiinflammatory Treg and Th2
cells  promote differentiation and
accumulation of M2 macrophages
and myeloid-derived suppressor
cells.
- These cells block the action of
antitumor CTLS and Th1 cells and
provide growth factors for tumor
cells and tumor blood vessels.
EVASION OF IMMUNE RESPONSES
BY TUMORS
• Most evasion mechanisms can be
categorized as either active inhibition of
antitumor immune responses or loss of
antigens that drive these responses
1. Immune checkpoints : inhibition of
immune responses
2. Loss of tumor antigen expression
 EVASION OF IMMUNE RESPONSES BY TUMORS
Immune checkpoints : inhibition of immune responses

• Tumor evade antitumor T cell responses by

engaging inhibitory molecules that normally
function to prevent autoimmunity or regulate
immune responses to microbes (CTLA-4 and PD-1)
• Secreted products of tumor cells may suppress
antitumor immune responses (TGF-β  secreted
by many tumors and inhibits the proliferation and
effector functions of lymphocytes and
macrophages.
 EVASION OF IMMUNE RESPONSES BY TUMORS
Immune checkpoints : inhibition of immune responses

• Regulatory T cells may suppress T cell

responses to tumors.
• Myeloid-derived suppressor cells (MDSCs) are
immature myeloid precursors that accumulate
in bone marrow, lymphoid tissues, blood and
tumors of tumor-bearing animals and cancer
patients, and suppress innate and T cell-
mediated antitumor immune responses
 EVASION OF IMMUNE RESPONSES BY TUMORS
Loss of Tumor antigen Expression

• Immune responses to tumor cells impart

selective pressures that result in the
survival and outgrowth of variant tumor
cells with reduced immunogenicity
Mechanisms by wich tumors
escape immune defenses

 Antitumor immunity develops

when T cells recognize tumor
antigens and are activated.
 Tumor cells may evade
immune responses by losing
expression of antigens or
MHC molecules or by
producing ligands for T cell
inhibitory receptors and
immunosuppressive
cytokines
 Immunotherapy for Tumors
Reasons for immunologic treatments :
1. Most established therapies for cancer on drugs
(chemotherapy) or radiation that kill dividing
cells or block cell division and these treatments
have harmful effects on normal proliferating
cells.
2. Cytotoxic drugs have unsuccessful in achieving
durable benefits in most cancers that have
spread in the body beyond their site of origin.
 History of cancer immunotherapy

Some of the important discoveries in the field of

cancer chemotherapy
 Immunotherapy for Tumors
Checkpoint Blokade: Blocking T Cell
Inhibitory Pathways
 Blockade of T cell inhibitory molecules has
emerged as one of the most promising
methods for effectively enhancing patient’
immune responses to their tumors.
 These inhibitory mechanisms establish
checkpoints in immune responses, the
approach of stimulating immune responses
by a drug that inhibits the inhibitors is
called checkpoint blockade.
 Checkpoint blokade

Tumor patients often mount ineffective T cell responses to their tumors because
of the upregulation of inhibitory receptors such as CTLA-4 and PD-1 on the
tumor-specific T cells and expression of the ligand PDL-1 on the tumor cells. (A)
Blocking anti-CTLA-4 antibodies (B) blocking anti PD-1 or PD-L1 antibodies are
highly effective in treating several types of advanced tumors.
 Resistance of Checkpoint Blockade

More than 50% of patients treated with anti-CTLA-4 or anti

PD-1 do not respond to these drugs or develop resistance
after an initial response.
1. Unlikely to work in patients with tumors that have
relatively few somatic mutations encoding neo-antigens
because there will be few clones of tumor-specific T
cells that will respond
2. The nature of the cellular infiltrate around the tumor
predicts the response to checkpoint blockade
Abundant effector T cells, predict good response and
abundant Treg predict poor responses.
 Resistance of Checkpoint Blockade
3. Many tumors do not take advantage of PD-1 or PD-L1
pathway as a strategy to evade antitumor immunity
4. PD-L1 expressing tumors that initially respond to anti
PD-1 therapy may become resistant in the presence
of the strong immune response. The acquired
resistance could occur by selective growth of clones of
tumor cells that express molecules other then PD-L1
that inhibit T cell responses.
To increase the percentage of patients that response to
checkpoint blockade treatment : combination CTLA-4 and
PD-1  autoimmune reactions; combination of
checkpoint blockade with tumor vaccines.
 Vaccination With Tumor Antigens

 Vaccination of tumor-bearing individuals with tumor

antigens may result in enhanced immune responses
against the tumor.
 Clinical trial for vaccines : inconsistent and generally not
very successful  reflects the ability of cancers to evade
host immunity by inhibiting immune responses.
 Most tumor vaccines are therapeutic vaccines (given after
the host has developed the tumor) unlike preventive
vaccines for infections.
 The development of virus-induced tumors can be reduced
by preventive vaccination with viral antigens or attenuated
live viruses (Ex. HPV vaccines).
Detecting tumor neoantigens that elicit T cell
responses
1.Tumor DNA can be purified
2.Exome sequencing can detect
random mutations in the
genome of the cancer cells
3.Computer algorithm can be
used to determine which
mutation occur in amino acid
sequences that encoded
peptides that would bind to
the MHC alleles in that patient
4.The putative neoantigenic
peptides can be tested cell
response to these peptides in
vitro or by testing if MHC-
peptide multimeric complexes
can bind to the T cells
 Tumor Vaccination Strategies
Tumor vaccination strategies :
1. Proinflammatory molecules are used to enhance the number of
activated dendritic cells at the vaccination site (TLR ligand : CpG
DNA; mimics of dsRNA; cytokines: granulocyte-macrophage colony
stimulating factor (GM-CSF) and IL12.
2. Tumor antigens are delivered in the form of dendritic cell vaccines.
Dendritic cells are purified from patients, incubated with tumor
antigens and then injected back into the patients (Approved for
advanced prostate cancer. This vaccine is composed of a
preparation of a patient’s peripheral blood leukocytes that is
enriched for DC, which are exposed to a recombinant fusion protein
consisting of GM-CSF and the tumor associated antigen prostatic
acid phosphatase.GM-CSF promotes maturation of DC.
3. DNA vaccines and viral vectors encoding tumor antigens are being
tested in clinical trials.
 Dendritic cell vaccines

Dendritic cells generated in vitro from blood monocytes taken from a tumor
patient, can be pulsed with defined tumor antigens and infused back into
the patient where they will present the antigen to T cells specific for the
antigen and boost a tumor-specific immune response.
In other approaches, the dendritic cells are transfected with a gene
encoding the tumor antigen, and sometimes also a cytokine that promotes
immune responses, and these cells are used as vaccines
 Adoptive Cellular Therapy With
Antitumor T Cells
• Adoptive therapy using T cells expressing
Chimeric Antigen Receptors (CARs) has proven
successful in some hematologic maglinancies,
and this approach is in trials for other tumors.
• CARs are genetically engineered receptors with
tumor antigen-specific binding sites encoded by
recombinant immunoglobulin (Ig) variable genes
and cytoplasmic tails containing signaling
domains of both the TCR and costimulatory
receptors.
Chimeric T cell antigen receptor T cell Therapy
A.T cells isolated from the blood of a
patient are expanded by culture in
IL-2, anti-CD3 and anti-CD28,
genetically modified to express
recombinant chimeric antigen
receptors (CARs) and transfer red
back into the patient.
B.CARs are composed of an
extracellular Ig single chain variable
fragment specific for a tumor antigen
and cytoplasmic signaling domains
that activate T cells, such as TCR
complex ζ chain ITAMs and motifs in
the cytoplasmic domain of the
costimulatory receptors such as
CD28 and 4-1BB, which promote
robust T cell activation.
CAR-T cell therapy has been succesful
to treat certain leukemias and
lymphomas.
 Adoptive Cellular Therapy With
Antitumor T Cells

1. Chimeric Antigen Receptor T Cell Therapy

(CARs)

2. Adoptive Cellular Therapy With Tumor-

Specific T Cells
 Chimeric Antigen Receptor T cell
Therapy
• CARs using an Ig with a binding site specific for
the tumor antigen as the recognition receptor,
even though it has to function in T cells, is that to
avoids the problem of the MHC restriction of
TCRs, so the same CAR construct can be used in
any patient.
• Several variation of CARs contain TCR ζ chain
ITAM motifs and the cytoplasmic signaling motifs
of costimulatory receptors such as CD28 or 4-1BB
(a TNF receptor family member).
Protocol of Adoptive Cellular Therapy
With Antitumor T Cells
• A patient’s peripheral blood T cells are isolated, stimulated
with anti-CD3 and/or anti CD28 antibodies to expand all the
T cells and transfected with CAR-encoding retroviral or
lentiviral vectors.
• The expanded CAR-expressing T cells are then injected
back into patient.
• The transferred T cell undergo further robust proliferation in
the patient, in response to tumor antigen recognition by the
CAR
Patients with B cell maglinancies : CLL,ALL;have been
effective treated with CAR-expressing T cells specific for
CD19.
 Problems in the use of CAR-T cell therapy

1. The dangerous adverse reaction that frequently occurs soon after

adoptive transfer of the T cells into patients with high tumor burden.
• Many T cells activated in the same time  systemic inflammatory
response (cytokine release syndrome)  treating using anti IL-6
receptor antibody.
• Caution: cerebral edema, long term damage to the CNS especially in
children.
2. If the tumor is not completely eradicated, surviving cells may lose the
antigen being targeted by the CAR and the tumor may recur.
Problem solving : introduce two CARs  specific for 2 tumor antigens 
transfer to patient
3. In some patients, transferred CAR-T cells appear to become
unresponsive over time, and initially controlled tumors have recurred.
The CAR-T cells express markers of dysfunction (exhaustion)
Genome editing to eliminate the PD-1 gene in CAR-T cells before transfer.
Eliminating endogenous TCRs from CAR-T cells  avoid autoimmunity
 Adoptive Cellular Therapy With Tumor-
Specific T Cells

• T cells specific for tumor antigens can be harvested

from a patient’s tumor tissue or blood, expanded and
activated in vitro, and reinfused into cancer patients.
• Limited succes  isolated cells contain low frequency
of potent tumor specific T cells.
Passive Immunotherapy With Antibodies

The transfer of tumor-specific antibodies, which is

rapid and theoretically very specific (magic bullets),
but does not lead to long lived immunity.
1. Antitumor antibodies bind to cell surface
molecules on tumor cells and engage host
effector to kill tumor cells.
Mechanism : NK cell-mediated cytotoxicity;
complement-mediated lysis; complement- or Fc
receptor-mediated phagocytosis by macrophages.
Passive Immunotherapy With Antibodies

2. Other monoclonal antibodies bind to growth factor

receptors on cancer cells and interfere the signaling for
tumor growth and signaling. Ex. Anti HER2/Neu
3. Bispecific T cell engagers (BiTEs) facilitate host T cells to
attack tumor cells. These reagents are recombinant
antibodies engineered to express two different antigen
binding sites (one specific for a tumor antigen and
second specific for a T cell surface molecule, usually
CD3).
Antigen binding site is composed of a single chain variable
fragment containing Ig heavy and light variable domain
(=CARs).
Passive Immunotherapy With Antibodies

4. Immunotoxins or conjugated monoclonal

antibodies are antibodies specific for tumor
antigens that are linked to a chemotherapy drug
or to a radioisotope. Ex. HER2/neu and CD30
 Antitumor Monoclonal Antibodies Approved for Clinical Use (1)

Specificity of Drug Name Form of Antibody Clinical Use

antibody Used
HER2/Neu (EGFR) Transtuzumab Humanized Breast cancer
CD19 Blinatumomab CD19-/CD3- Acute lymphoblastic
bispecific antibody leukemia
CD20 Rituzumab Chimeric B cell lymphomas and
leukemias
Ofatumumab Human Chronic lymphocytic
leukemia
CD20 90Y-Ibritumomab Radioisotope Low grade or
tiuxetan conjugated mouse transformed B cell non
Hodgkin’s lymphoma
CD30 Brentuximab Drug-conjugated Hodgkin’s or systemic
vedotin chimeric anaplastic large cell
lymphoma
CD33 Gentuzumab Humanized Acute myelogenous
ozogamicin leukemia
 Antitumor Monoclonal Antibodies Approved for Clinical Use (2)

Specificity of Drug Name Form of Antibody Clinical Use

antibody Used
CD52 Alemtuzumab Humanized CLL,CTCL and T-cell
lymphoma
CTLA-4 Ipilimumab Human Metastatic melanoma
PD-1/PD-L1 Nivolumab Humanized Metastatic melanoma;
Pembrolizumab Humanized lung cancer
EGFR Cetuximab Chimeric Colorectal, breast and
lung cancer; other
tumor
Panitumumab Human Colorectal cancer
Nimotuzumab Humanized Head and neck cancer
VEGFA Bevacizumab Humanized Colorectal and lung
cancerCD254
CD 254 (RANK Denosumab Human Solid tumor bony
Ligand) metastases
 Other Approaches for Stimulating
Antitumor Immunity
1. Cytokine therapy
Cancer patients can be treated with cytokines that stimulate
proliferation and differentiation of T lymphocytes and NK
cells
2. Nonspecific inflammatory stimuli
Immune response to tumors may be stimulated by the local
administration of inflammatory substances or by systemic
treatment with agents that function as polyclonal activators
of lymphocytes.
3. Graft-Versus-Leukemia Effect
In leukemia patients, administration of T cells and NK cells
together with hematopoietic stem cells from an allogeneic
donor can contribute to eradication of the tumor.
Terima Kasih