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Ibarra, C., Karlsson, M., Codeluppi, S., Varas-Godoy, M., Zhang, S., Louhivuori, L., . . . Uhlen, P. (2019). BCG-induced cytokine release in bladder cancer cells is regulated by Ca2+ signaling. Molecular Oncology, 13(2), 202-211
Öppna denna publikation i ny flik eller fönster >>BCG-induced cytokine release in bladder cancer cells is regulated by Ca2+ signaling
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2019 (Engelska)Ingår i: Molecular Oncology, ISSN 1574-7891, E-ISSN 1878-0261, Vol. 13, nr 2, s. 202-211Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Bacillus Calmette-Guerin (BCG) is widely used in the clinic to effectively treat superficial urinary bladder cancer. However, a significant proportion of patients who fail to respond to BCG risk cystectomy or death. Though more than 3 million cancer treatments with BCG occur annually, surprisingly little is known about the initial signaling cascades activated by BCG. Here, we report that BCG induces a rapid intracellular Ca2+ (calcium ion) signal in bladder cancer cells that is essential for activating the transcription factor nuclear factor kappa-light-chain-enhancer of activated B cells (NF-kappa B) and for synthesizing and secreting proinflammatory cytokines, including interleukin 8 (IL-8). A similar Ca2+ response was observed when cells were exposed to the supernatant of BCG. Studying cellular molecular mechanisms involved in the BCG signaling event, we found pivotal roles for phospholipase C and the Toll-like receptor 4. Further assessment revealed that this signaling pathway induces synthesis of IL-8, whereas exocytosis appeared to be controlled by global Ca2+ signaling. These results shed new light on the molecular mechanisms underlying BCG treatment of bladder cancer, which can help in improving therapeutic efficacy and reducing adverse side effects.

Ort, förlag, år, upplaga, sidor
WILEY, 2019
Nyckelord
BCG, calcium signaling, TLR4, urinary bladder cancer
Nationell ämneskategori
Urologi och njurmedicin
Identifikatorer
urn:nbn:se:uu:diva-377672 (URN)10.1002/1878-0261.12397 (DOI)000457747900006 ()30358081 (PubMedID)
Forskningsfinansiär
Vetenskapsrådet, 20093364Vetenskapsrådet, 2013-3189Vetenskapsrådet, 2017-00815Knut och Alice Wallenbergs StiftelseStiftelsen för strategisk forskning (SSF)Cancerfonden, CAN 2013-802Cancerfonden, CAN 2016-801Åke Wibergs StiftelseMagnus Bergvalls StiftelseStiftelsen Olle Engkvist ByggmästareSvenska Sällskapet för Medicinsk Forskning (SSMF)
Tillgänglig från: 2019-02-25 Skapad: 2019-02-25 Senast uppdaterad: 2019-02-25Bibliografiskt granskad
Fletcher, E. A. K., Eltahir, M., Lindqvist, F., Rieth, J., Törnqvist, G., Leja-Jarblad, J. & Mangsbo, S. (2018). Extracorporeal human whole blood in motion, as a tool to predict first-infusion reactions and mechanism-of-action of immunotherapeutics. International Immunopharmacology, 54, 1-11
Öppna denna publikation i ny flik eller fönster >>Extracorporeal human whole blood in motion, as a tool to predict first-infusion reactions and mechanism-of-action of immunotherapeutics
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2018 (Engelska)Ingår i: International Immunopharmacology, ISSN 1567-5769, E-ISSN 1878-1705, Vol. 54, s. 1-11Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

First infusion reactions along with severe anaphylactic responses can occur as a result of systemic administration of therapeutic antibodies. The underlying mechanisms by which monoclonal antibodies induce cytokine release syndrome (CRS) can involve direct agonistic effects via the drug target, or a combination of target-engagement along with innate receptor interactions. Despite the wide variety of pathways and cells that can play a role in CRS, many currently used assays are devoid of one or more components that must be present for these responses to occur. One assay that has not been assessed for its capacity to predict CRS is the modified Chandler loop model. Herein we evaluate a plethora of commercially available monoclonal antibodies to evaluate the modified Chandler loop model's potential in CRS prediction. We demonstrate that in a 4-hour loop assay, both the superagonistic antibodies, anti-CD3 (OKT3) and anti-CD28 (ANC28.1), display a clear cytokine response with a mixed adaptive/innate cytokine source. OKT3 induce TNFα and IFN-γ release in 20 out of 23 donors tested, whereas ANC28.1 induce TNF-α, IL-2 and IFN-γ release in all donors tested (n = 18–22). On the other hand, non-agonistic antibodies associated with no or low infusion reactions in the clinic, namely cetuximab and natalizumab, neither induce cytokine release nor cause false positive responses. A TGN1412-like antibody also display a clear cytokine release with an adaptive cytokine profile (IFN-γ and IL-2) and all donors (n = 9) induce a distinct IL-2 response. Additionally, the value of an intact complement system in the assay is highlighted by the possibility to dissect out the mechanism-of-action of alemtuzumab and rituximab. The loop assay can either complement lymph node-like assays or stand-alone to investigate drug/blood interactions during preclinical development, or for individual safety screening prior to first-in-man clinical trial.

Nyckelord
Cytokine release syndrome, CRS, Immunotoxicity, Cytokine release assay, Anti-CD28, Alemtuzumab, OKT3
Nationell ämneskategori
Immunologi inom det medicinska området Farmakologi och toxikologi
Identifikatorer
urn:nbn:se:uu:diva-346359 (URN)10.1016/j.intimp.2017.10.021 (DOI)000423887900001 ()29100032 (PubMedID)
Forskningsfinansiär
Vetenskapsrådet, K2013-79X-22263-01-2Svenska Sällskapet för Medicinsk Forskning (SSMF)
Tillgänglig från: 2018-03-16 Skapad: 2018-03-16 Senast uppdaterad: 2018-03-16Bibliografiskt granskad
Fletcher, E., van Maren, W., Cordfunke, R., Dinkelaar, J., Codee, J. D. C., van der Marel, G., . . . Mangsbo, S. (2018). Formation of Immune Complexes with a Tetanus-Derived B Cell Epitope Boosts Human T Cell Responses to Covalently Linked Peptides in an Ex Vivo Blood Loop System. Journal of Immunology, 201(1), 87-97
Öppna denna publikation i ny flik eller fönster >>Formation of Immune Complexes with a Tetanus-Derived B Cell Epitope Boosts Human T Cell Responses to Covalently Linked Peptides in an Ex Vivo Blood Loop System
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2018 (Engelska)Ingår i: Journal of Immunology, ISSN 0022-1767, E-ISSN 1550-6606, Vol. 201, nr 1, s. 87-97Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Enhancing T cell responses against both viral and tumor Ags requires efficient costimulation and directed delivery of peptide Ags into APCs. Long peptide vaccines are considered favorable vaccine moieties from a clinical perspective, as they can harbor more than one immunogenic epitope enabling treatment of a broader target population. In addition, longer peptides are not extracellularly loaded on MHC class I; rather, they require intracellular processing and will thereby be presented to T cells mainly by professional APCs, thereby avoiding the risk of tolerance induction. The drawback of peptide vaccines regardless of peptide length is that naked peptides are not actively targeted to and taken up by APCs, and the standard nonconjugated adjuvant-peptide mixtures do not ensure cotargeting of the two to the same APC. We have identified a tetanus toxin-derived B cell epitope that can mediate the formation of immune complexes in the presence of circulating Abs. In this study, we show that these immune complexes improve both Ag uptake by APCs (blood monocytes and CD1c(+) dendritic cells) and consequently improve CD8(+) T cell recall responses in a human ex vivo blood loop system. The uptake of the peptide conjugate by blood monocytes is dependent on Abs and the complement component C1q. We envision that this strategy can be used to facilitate active uptake of Ags into APCs to improve T cell responses against pathogens or cancer.

Ort, förlag, år, upplaga, sidor
AMER ASSOC IMMUNOLOGISTS, 2018
Nationell ämneskategori
Immunologi inom det medicinska området
Identifikatorer
urn:nbn:se:uu:diva-364479 (URN)10.4049/jimmunol.1700911 (DOI)000442387100011 ()29752315 (PubMedID)
Forskningsfinansiär
VetenskapsrådetVINNOVASvenska Sällskapet för Medicinsk Forskning (SSMF)
Tillgänglig från: 2018-10-30 Skapad: 2018-10-30 Senast uppdaterad: 2018-10-30Bibliografiskt granskad
Mangsbo, S., Fletcher, E., van Maren, W., Redeker, A., Cordfunke, R., Dillmann, I., . . . Drijfhout, J. W. (2018). Linking T cell epitopes to a common linear B cell epitope: A targeting and adjuvant strategy to improve T cell responses. Molecular Immunology, 93, 115-124
Öppna denna publikation i ny flik eller fönster >>Linking T cell epitopes to a common linear B cell epitope: A targeting and adjuvant strategy to improve T cell responses
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2018 (Engelska)Ingår i: Molecular Immunology, ISSN 0161-5890, E-ISSN 1872-9142, Vol. 93, s. 115-124Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Immune complexes are potent mediators of cellular immunity and have been extensively studied for their disease mediating properties in humans and for their role in anti-cancer immunity. However, a viable approach to use antibody-complexed antigen as vehicle for specific immunotherapy has not yet reached clinical use. Since virtually all people have endogenous antibodies against tetanus toxoid (TTd), such commonly occurring antibodies are promising candidates to utilize for immune modulation. As an initial proof-of-concept we investigated if anti tetanus IgG could induce potent cross-presentation of a conjugate with SIINFEKL, a MHC class I presented epitope of ovalbumin (OVA), to TTd. This protein conjugate enhanced OVA-specific CD8 + T cell responses when administrated to seropositive mice. Since TTd is poorly defined, we next investigated whether a synthetic peptide peptide conjugate, with a chemically defined linear B cell epitope of tetanus toxin (TTx) origin, could improve cellular immune responses. Herein we identify one linear B cell epitope, here after named MTTE thru a screening of overlapping peptides from the alpha and beta region of TTx, and by assessment of the binding of pooled IgG, or individual human IgG from high-titer TTd vaccinated donors, to these peptides. Subsequently, we developed a chemical protocol to synthesize defined conjugates containing multiple copies of MITE covalently attached to one or more T cell epitopes of choice. To demonstrate the potential of the above approach we showed that immune complexes of anti-MITE antibodies with KM-containing conjugates are able to induce DC and T cell activation using model antigens.

Nyckelord
immune complex, FcgRs, dendritic cells, peptide conjugate
Nationell ämneskategori
Immunologi
Forskningsämne
Immunologi
Identifikatorer
urn:nbn:se:uu:diva-329037 (URN)10.1016/j.molimm.2017.11.004 (DOI)000424181000014 ()29175591 (PubMedID)
Forskningsfinansiär
Svenska Sällskapet för Medicinsk Forskning (SSMF)Göran Gustafssons stiftelse för naturvetenskaplig och medicinsk forskning (KVA)VINNOVA
Tillgänglig från: 2017-09-06 Skapad: 2017-09-06 Senast uppdaterad: 2018-04-03Bibliografiskt granskad
Eriksson, E., Moreno, R., Milenova, I. Y., Liljenfeldt, L., Dieterich, L. C., Christiansson, L., . . . Loskog, A. (2017). Activation of myeloid and endothelial cells by CD40L gene therapy supports T-cell expansion and migration into the tumor microenvironment. Gene Therapy, 24(2), 92-103
Öppna denna publikation i ny flik eller fönster >>Activation of myeloid and endothelial cells by CD40L gene therapy supports T-cell expansion and migration into the tumor microenvironment
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2017 (Engelska)Ingår i: Gene Therapy, ISSN 0969-7128, E-ISSN 1476-5462, Vol. 24, nr 2, s. 92-103Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

CD40 is an interesting target in cancer immunotherapy due to its ability to stimulate T-helper 1 immunity via maturation of dendritic cells and to drive M2 to M1 macrophage differentiation. Pancreatic cancer has a high M2 content that has shown responsive to anti-CD40 agonist therapy and CD40 may thus be a suitable target for immune activation in these patients. In this study, a novel oncolytic adenovirus armed with a trimerized membrane-bound extracellular CD40L (TMZ-CD40L) was evaluated as a treatment of pancreatic cancer. Further, the CD40L mechanisms of action were elucidated in cancer models. The results demonstrated that the virus transferring TMZ-CD40L had oncolytic capacity in pancreatic cancer cells and could control tumor progression. TMZ-CD40L was a potent stimulator of human myeloid cells and T-cell responses. Further, CD40L-mediated stimulation increased tumor-infiltrating T cells in vivo, which may be due to a direct activation of endothelial cells to upregulate receptors for lymphocyte attachment and transmigration. In conclusion, CD40L-mediated gene therapy is an interesting concept for the treatment of tumors with high levels of M2 macrophages, such as pancreatic cancer, and an oncolytic virus as carrier of CD40L may further boost tumor killing and immune activation.

Nationell ämneskategori
Annan medicinsk bioteknologi
Forskningsämne
Immunologi
Identifikatorer
urn:nbn:se:uu:diva-318170 (URN)10.1038/gt.2016.80 (DOI)000394682800006 ()27906162 (PubMedID)
Forskningsfinansiär
Cancerfonden
Tillgänglig från: 2017-03-23 Skapad: 2017-03-23 Senast uppdaterad: 2017-10-10Bibliografiskt granskad
Schiza, A., Wenthe, J., Mangsbo, S., Svensson, E., Nilsson, A., Tötterman, T., . . . Ullenhag, G. (2017). Adenovirus-mediated CD40L gene transfer increases Teffector/Tregulatory cell ratio and upregulates death receptors in metastatic melanoma patients. Journal of Translational Medicine, 15(79)
Öppna denna publikation i ny flik eller fönster >>Adenovirus-mediated CD40L gene transfer increases Teffector/Tregulatory cell ratio and upregulates death receptors in metastatic melanoma patients
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2017 (Engelska)Ingår i: Journal of Translational Medicine, ISSN 1479-5876, E-ISSN 1479-5876, Vol. 15, nr 79Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background and aims: Malignant melanoma is an aggressive tumor sensitive for immunotherapy such as checkpoint blockade antibodies. Still, most patients with late stage disease do not respond, and the side effects can be severe. Stimulation of the CD40 pathway to initiate anti-tumor immunity is a promising alternative. Herein, we demonstrate immune profiling data from melanoma patients treated with an adenovirus-based CD40 ligand gene therapy (AdCD40L). Methods: Peripheral blood mononuclear cells and plasma were collected from malignant melanoma patients (n = 15) enrolled in a phase I/IIa study investigating intratumoral delivery of AdCD40L with or without low dose cyclophosphamide. Cells were analyzed by flow cytometry while plasma samples were analyzed by a multi-array proteomics. Results: All patients had an increased Teffector/Tregulatory cell ratio post therapy. Simultaneously, the death receptors TNFR1 and TRAIL-R2 were significantly up-regulated post treatment. Stem cell factor (SCF), E-selectin, and CD6 correlated to enhanced overall survival while a high level of granulocytic myeloid-derived suppressor cells (gMDSCs), IL8, IL10, TGFb1, CCL4, PlGF and Fl3t ligand was highest in patients with short survival. Conclusions: AdCD40L intratumoral injection induced desirable systemic immune effects that correlated to prolonged survival. Further studies using CD40 stimulation in malignant melanoma are warranted.

Nyckelord
AdCD40L, Malignant melanoma, Immunotherapy, Proteomics, T regulatory cells, Myeloid-derived suppressor cells
Nationell ämneskategori
Immunologi inom det medicinska området
Identifikatorer
urn:nbn:se:uu:diva-322800 (URN)10.1186/s12967-017-1182-z (DOI)000399786900002 ()28427434 (PubMedID)
Tillgänglig från: 2017-06-20 Skapad: 2017-06-20 Senast uppdaterad: 2018-02-20Bibliografiskt granskad
Schiza, A., Wenthe, J., Mangsbo, S., Eriksson, E., Nilsson, A., Tötterman, T., . . . Ullenhag, G. (2017). Adenovirus-mediated CD40L gene transfer increases teffector/tregulatory cell ratio and upregulates death receptors in metastatic melanoma patients. Paper presented at 44th Annual Meeting of the Scandinavian-Society-for-Immunology (SSI), OCT 17-20, 2017, Stockholm, SWEDEN. Scandinavian Journal of Immunology, 86(4), 337-337
Öppna denna publikation i ny flik eller fönster >>Adenovirus-mediated CD40L gene transfer increases teffector/tregulatory cell ratio and upregulates death receptors in metastatic melanoma patients
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2017 (Engelska)Ingår i: Scandinavian Journal of Immunology, ISSN 0300-9475, E-ISSN 1365-3083, Vol. 86, nr 4, s. 337-337Artikel i tidskrift, Meeting abstract (Övrigt vetenskapligt) Published
Nationell ämneskategori
Immunologi inom det medicinska området
Identifikatorer
urn:nbn:se:uu:diva-346969 (URN)000411865200209 ()
Konferens
44th Annual Meeting of the Scandinavian-Society-for-Immunology (SSI), OCT 17-20, 2017, Stockholm, SWEDEN
Tillgänglig från: 2018-03-28 Skapad: 2018-03-28 Senast uppdaterad: 2018-03-28Bibliografiskt granskad
van Hooren, L., Sandin, L. C., Moskalev, I., Ellmark, P., Dimberg, A., Black, P., . . . Mangsbo, S. (2017). Local checkpoint inhibition of CTLA-4 as a monotherapy or in combination with anti-PD1 prevents the growth of murine bladder cancer. European Journal of Immunology, 47(2), 385-393
Öppna denna publikation i ny flik eller fönster >>Local checkpoint inhibition of CTLA-4 as a monotherapy or in combination with anti-PD1 prevents the growth of murine bladder cancer
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2017 (Engelska)Ingår i: European Journal of Immunology, ISSN 0014-2980, E-ISSN 1521-4141, Vol. 47, nr 2, s. 385-393Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Checkpoint blockade of CTLA-4 results in long-lasting survival benefits in metastatic cancer patients. However, patients treated with CTLA-4 blockade have suffered from immune-related adverse events, most likely due to the breadth of the induced T-cell activation. Here, we investigated the efficacy of a local low-dose anti-CTLA-4 administration for treatment of subcutaneous or orthotopic murine bladder 49 (MB49) bladder carcinoma in C57BL/6 mice. When MB49 tumors were grown s.c., peritumoral (p.t.) injection of anti-CTLA-4 treatment was equally effective as intravenous or s.c. (nontumor bearing flank) administration. Notably, p.t. injection was associated with lower circulating antibody levels and decreased IL-6 serum levels as compared to systemic treatment. Ultrasound-guided intratumoral anti-CTLA-4 antibody treatment of orthotopically growing MB49 tumors resulted in tumor regression, with more than tenfold reduction in systemic antibody levels as compared to i.v. or s.c. administration, in line with the compartmentally restrained nature of the bladder. Local anti-CTLA-4 therapy in combination with anti-PD-1 therapy resulted in complete responses, superior to each therapy alone. In addition, p.t. anti-CTLA-4 therapy was potentiated by depletion of regulatory T cells. Our results demonstrate that local anti-CTLA-4 antibody therapy is equally effective as systemic administration, but reduces systemic antibody levels and cytokine release, and enhances the response to anti-PD1 therapy.

Nyckelord
Bladder cancer, CTLA-4, Checkpoint inhibitors, Immunotherapy, Local low-dose, MB49, PD-1
Nationell ämneskategori
Medicinska och farmaceutiska grundvetenskaper Immunologi inom det medicinska området
Identifikatorer
urn:nbn:se:uu:diva-318999 (URN)10.1002/eji.201646583 (DOI)000394839800018 ()27873300 (PubMedID)
Forskningsfinansiär
EU, FP7, Sjunde ramprogrammet, MCA-ITN 317445CancerfondenVetenskapsrådetSvenska Sällskapet för Medicinsk Forskning (SSMF)Göran Gustafssons stiftelse för naturvetenskaplig och medicinsk forskning (KVA)
Tillgänglig från: 2017-03-30 Skapad: 2017-03-30 Senast uppdaterad: 2018-09-21Bibliografiskt granskad
Irenaeus, S., Schiza, A., Mangsbo, S. M., Wenthe, J., Svensson, E., Krause, J., . . . Ullenhag, G. (2017). Local irradiation does not enhance the effect of immunostimulatory AdCD40L gene therapy combined with low dose cyclophosphamide in melanoma patients. OncoTarget, 8(45), 78573-78587
Öppna denna publikation i ny flik eller fönster >>Local irradiation does not enhance the effect of immunostimulatory AdCD40L gene therapy combined with low dose cyclophosphamide in melanoma patients
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2017 (Engelska)Ingår i: OncoTarget, ISSN 1949-2553, E-ISSN 1949-2553, Vol. 8, nr 45, s. 78573-78587Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: AdCD40L is an immunostimulatory gene therapy under evaluation for advanced melanoma, including ocular melanoma. Herein, we present the final data of a Phase I/IIa trial using AdCD40L alone or in combination with low dose cyclophosphamide +/- radiation therapy.

Methods: AdCD40L is a replication-deficient adenovirus carrying the gene for CD40 ligand (CD40L). Twenty-four patients with advanced melanoma were enrolled and treated with AdCD40L monotherapy, or combined with cyclophosphamide +/- single fraction radiotherapy. The patients were monitored for 10 weeks using immunological and radiological evaluations and thereafter for survival.

Results: AdCD40L treatment was safe and well tolerated both alone and in combination with cyclophosphamide as well as local radiotherapy. Four out of twenty-four patients had >1 year survival. Addition of cyclophosphamide was beneficial but adding radiotherapy did not further extend survival. High initial plasma levels of IL12 and MIP3b correlated to overall survival, whereas IL8 responses post-treatment correlated negatively with survival. Interestingly, antibody reactions to the virus correlated negatively with post IL6 and pre IL1b levels in blood.

Conclusions: AdCD40L was safely administered to patients and effect was improved by cyclophosphamide but not by radiotherapy. Immune activation profile at baseline may predict responders better than shortly after treatment.

Nyckelord
AdCD40L, gene therapy, immunotherapy, irradiation, malignant melanoma
Nationell ämneskategori
Medicinsk bioteknologi (med inriktning mot cellbiologi (inklusive stamcellsbiologi), molekylärbiologi, mikrobiologi, biokemi eller biofarmaci)
Identifikatorer
urn:nbn:se:uu:diva-333305 (URN)10.18632/oncotarget.19750 (DOI)000412111300034 ()29108250 (PubMedID)
Tillgänglig från: 2017-11-10 Skapad: 2017-11-10 Senast uppdaterad: 2018-01-26Bibliografiskt granskad
Ellmark, P., Mangsbo, S. M., Furebring, C., Norlén, P. & Tötterman, T. (2017). Tumor-directed immunotherapy can generate tumor-specific T cell responses through localized co-stimulation. Cancer Immunology and Immunotherapy, 66(1), 1-7
Öppna denna publikation i ny flik eller fönster >>Tumor-directed immunotherapy can generate tumor-specific T cell responses through localized co-stimulation
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2017 (Engelska)Ingår i: Cancer Immunology and Immunotherapy, ISSN 0340-7004, E-ISSN 1432-0851, Vol. 66, nr 1, s. 1-7Artikel, forskningsöversikt (Refereegranskat) Published
Abstract [en]

The most important goals for the field of immuno-oncology are to improve the response rate and increase the number of tumor indications that respond to immunotherapy, without increasing adverse side effects. One approach to achieve these goals is to use tumor-directed immunotherapy, i.e., to focus the immune activation to the most relevant part of the immune system. This may improve anti-tumor efficacy as well as reduce immune-related adverse events. Tumor-directed immune activation can be achieved by local injections of immune modulators in the tumor area or by directing the immune modulator to the tumor using bispecific antibodies. In this review, we focus on therapies targeting checkpoint inhibitors and co-stimulatory receptors that can generate tumor-specific T cell responses through localized immune activation.

Nyckelord
Immunotherapy, Tumor-directed immunotherapy, Cancer, Intratumoral, Bispecific antibody, Immuno-oncology
Nationell ämneskategori
Cancer och onkologi
Identifikatorer
urn:nbn:se:uu:diva-318679 (URN)10.1007/s00262-016-1909-3 (DOI)000393598500001 ()27714433 (PubMedID)
Tillgänglig från: 2017-03-27 Skapad: 2017-03-27 Senast uppdaterad: 2017-11-29Bibliografiskt granskad
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