Challengings - Current challenges in designing GBM trials for immunotherapy

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EDITORS’INVITEDMANUSCRIPTCurrentchallengesindesigningGBMtrialsforimmunotherapyShiao-PeiWeathers•MarkR.Gilbert

Received:5November2014/Accepted:31December2014/Publishedonline:11January2015ÓSpringerScience+BusinessMediaNewYork2015

AbstractImmunesystemmodulationisevolvingintoapromisingtreatmentmodalityinglioblastoma.Ourgrow-ingunderstandingofgliomaimmunobiologyhasfueledeffortstodevelopimmunotherapeuticstrategiestocombatthislethalprimarybraintumor.Autologousstimulatedlymphocytes,immunotherapywithcytokinesanddendriticcells,immunecheckpointinhibitors,virotherapy,andtumororpeptidebasedvaccinesareimmunotherapyapproachesunderactiveinvestigation.Anumberofchal-lengesareevidentinthedesignofimmunotherapyclinicaltrialsinglioblastomaincludingpatientselection,immuneandimagingresponsemonitoring,andevaluationofclin-icaloutcome.

KeywordsGlioblastomaÁImmunotherapyÁVaccinesÁImmunecheckpointinhibitorsÁVirotherapy

OverviewIntroductionGlioblastomaisthemostcommonmalignantprimarybraintumorinadults.Despiteoptimalmultimodalitytreatment

thattypicallyincludessurgery,radiation,andchemother-apy,glioblastomaremainsadevastatingdiagnosiswithamediansurvivalofonly14–16monthswitha26–33%2yearsurvivalratereportedinclinicaltrials[1,2].Thismodestimprovementinprogressionandoverallsurvivalhasunderscoredtheneedforthedevelopmentofnoveltherapiesinglioblastoma,andattentionhasbeenincreas-inglypaidtoimmunotherapeuticstrategiesasapotentialtreatmentapproach.Thegrowingunderstandingofimmunemechanismsinvolvingthecentralnervoussystem(CNS)andgliomaimmunobiologyhasacceleratedeffortstodevelopinnovativeimmunotherapeuticstrategieswhichhavefosteredasenseofrenewedoptimisminthetreatmentofglioblastoma.

CNSimmuneprivilegeTheCNShaslongbeenconsideredanimmunologicallyprivilegedsitebasedontheobservationthattissuesengraftedintothebrainsofexperimentalanimalswerenotedtoberejectedmoreslowlythantissuestransplantedtoothersites[3].TheCNSisbetterdescribedasimmu-nologicallydistinctstemmingfromseveralobservationsincludingthelackofprofessionalantigenpresentingcells(APC)withinthebrain,thelowlevelsofmajorhisto-compatibilitycomplex(MHC)moleculeexpression,theconstitutiveexpressionofimmunosuppressivecytokinesincludingInterleukin-10(IL-10)andtransforminggrowthfactor(TGFb),andthepresenceoftheblood–brainbarrier(BBB)[4,5].ImmuneprivilegeisnotprimarilysustainedbythepassiverestrictionofimmunecellsenteringtheCNSthoughthetightBBBbutisinsteadanactiveprocessofsuppressingunwantedimmuneresponsesviaadiversenumberofcellularandsolublefactors[6].Cumulativeexperimentalandclinicalevidencehavedemonstratedthat

S.-P.Weathers(&)DepartmentofNeuro-Oncology,UniversityofTexasMDAndersonCancerCenter,1515HolcombeBlvd.,Unit431,Houston,TX77030,USAe-mail:sweathers@mdanderson.org

M.R.GilbertNeuro-OncologyBranch,NationalCancerInstitute,NationalInstitutesofHealth,BlochBldg.82,Rm.235,9030OldGeorgetownRoad,Bethesda,MD20892,USAe-mail:mark.gilbert@nih.gov

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JNeurooncol(2015)123:331–337DOI10.1007/s11060-015-1716-2TcellsandantibodieshaveaccesstoantigenswithintheCNS,andTcellsenteringthebraincanmountaresponsetogliomacells[7–10].Thesefindingshavecontributedtothegrowingunderstandingthattheimmuneprivilegedstatusofthebrainisrelativeandnotabsolute.

ChallengesTherecentsuccessofimmunotherapeuticapproachesinothersolidtumorshasgeneratedincreasinginterestinwhethersimilarimmunotherapystrategiescouldbeemployedinthetreatmentofglioblastoma.Tworecentimmunotherapeuticstrategiestoimpactclinicalmain-streamincludetheapprovalofthefirstantigen-specificagent,sipuleucel-T,forcastrateresistantprostatecancerin2010[11]andtheFDAapprovalofipilimumab,amono-clonalantibodydirectedagainsttheimmunecheckpointCTLA-4,formetastaticmelanomain2011[12].Histori-cally,immunotherapyinglioblastomahasnotproducedcomparableclinicalresultsasthoseseeninmelanoma,prostatecancer,orrenalcellcarcinoma.Thedisappointingresultsareattributabletoseveralfactors.ThelocationofmalignantgliomaswithintheimmunologicallyprivilegedbrainandtheBBBmayposeamajorlimitationincon-sideringimmunotherapyforthesecancers.Inadditiontotheinherentlimitedbrainfunctionandmanymechanismsoftumor-inducedimmunosuppression,glioblastomaexpressesfewknowntumor-restrictedantigensandisconsiderednon-immunogenic[13]incontrasttoprostatecancerwhichexpresseswell-characterizedtumor-restrictedantigensandmelanomawhichisdefinitelyimmunogenic.Theuniquetumorenvironmentposesadditionalchal-lengesforthedevelopmentofimmunotherapeuticstrate-giesinglioblastoma.Thebraincannottolerateeventheslightestlevelofautoimmunityunlikeotherorganssuchastheskinorprostate.Thefixedcompartmentfromtherigidskullalsoprovidesforanedema-intolerantenvironment.Immunotherapyinglioblastomaimposesanintrinsicriskofdamagetonormalstructuresandneurologicfunctioninthesettingofinflammation.Thegliomamicroenvironmentisahostileenvironmentforthegenerationofaneffectiveantitumorimmuneresponse.Tcellfunctionisparalyzedbyglioma-derivedfactorsincludingprostaglandinE2,IL-10,vascularendothelialgrowthfactor(VEGF),TGFb,andcatabolitesoftheessentialaminoacidtryptophan[14,15].Thesefactorssecretedbygliomasarecapableofsup-pressingcytotoxicresponsesofTcellsagainsttumortar-getswhichdown-regulatesMHCexpressiontherebysuppressingTcellproliferationandinhibitingthematura-tionofdendriticcells(DCs)[16–18].Incontrasttothenormalbrainmicroenvironment,thegliomamicroenvi-ronmentischaracterizedbyaleakyBBB,hypoxia,aci-dosis,andtheaccumulationofsolublemediatorsandthe