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Principles of cancer immunotherapy

Authors: Alexander N Shoushtari, MD, Matthew Hellmann, MD
Section Editor: Michael B Atkins, MD
Deputy Editor: Sonali Shah, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Feb 2021. | This topic last updated: Mar 05, 2021.

INTRODUCTION

The fields of immunology and oncology have been linked since the late 19th century, when the surgeon William Coley reported
that an injection of killed bacteria into sites of sarcoma could lead to tumor shrinkage [1]. Since that time, exponential advances
in the understanding of the intersection between immune surveillance and tumor growth and development have led to broad
therapeutic advances that are now being studied in all cancer types.

The basic immunology and the various approaches to immunotherapy for tumors are discussed here. The details of
immunology's role in specific malignancies are discussed in the relevant tumor-oriented topics, and the toxicity of checkpoint
inhibitor immunotherapy is discussed separately. (See "Toxicities associated with checkpoint inhibitor immunotherapy".)

TUMOR IMMUNOLOGY

Cell types involved in tumor recognition and rejection — An efficient and specific cytotoxic immune response against a
tumor requires a complex, rapidly evolving interaction between various immune cell types in the adaptive and innate immune
system.

● CD8+ lymphocytes and Th1/Th2 subclasses of CD4+ T lymphocytes, traditionally referred to as cytotoxic T cells and helper T
cells. CD8+ and CD4+ lymphocytes initiate the distinction between self and non-self-antigens, through recognition at the
"immune synapse." (See 'The "immune synapse"' below.)

● Natural killer (NK) cells do not require antigen presentation by the major histocompatibility complex (MHC) for cytotoxic
activity. In fact, NK cells target cells with low MHC class 1 expression for destruction. Like T cells, NK cells express numerous
inhibitory molecules as well, most notably various killer immunoglobulin-like receptor (KIR) subtypes [2].

● Additional cell types, such as FoxP3+ CD25+ CD4+ T regulatory (Treg) and myeloid derived suppressor cells (MDSCs) largely
inhibit cytotoxic T lymphocyte activity [3,4]. Th17 cells, subsets of CD4+ T cells that secrete interleukin (IL)-17, are implicated
in autoimmunity and cancer [5].

● Macrophages differentiate into at least two different phenotypes: M1 macrophages, which release interferon (IFN) gamma
and are responsible for phagocytosis, and M2 macrophages, which release cytokines such as IL-4, IL-10, transforming
growth factor beta (TGF-beta), and dampen inflammatory responses and foster tolerance [6].

The "immune synapse" — The most widely studied phenomenon in immunologic surveillance is the ability of T lymphocytes to
distinguish self- versus non-self-antigens, which are presented by antigen-presenting cells (APCs) such as dendritic cells.
Overall, the cytotoxic activity of a CD8+ T cell is regulated by the presence and spatial orientation of a set of stimulatory and
inhibitory receptors whose expression is regulated by a myriad of cytokines. Together, this configuration is often referred to as
the "immune synapse" ( figure 1):
The T cell receptor (TCR) complex consists of three major components: the TCR itself, the CD4 or CD8 receptor, and the CD3
molecule:

● CD4 or CD8 receptor – The CD4 or CD8 receptor binds to the MHC. The CD4/CD8 protein in most T cells consists of a highly
variable alpha subunit linked to a beta subunit (ab). These variable regions of the CD4/CD8 molecule resemble the variable
fragment (Fab) of an antibody and are responsible for the specificity of a specific T cell for a particular antigen.

● CD3 molecule – The CD3 molecule encodes a nonvariable transmembrane protein complex with an intracellular tyrosine-
based activation component that relays surface signals to intracellular downstream effectors [7].

The TCR binds specific short stretches of amino acids presented by MHC molecules [8]. MHC class 1 is expressed by all
nucleated cells and is recognized by CD8+ T cells, while MHC class 2 molecules are constitutively expressed by APCs and are
recognized by CD4+ T cells.

For efficient activation of a naïve CD8+ T cell, its TCR must bind to a peptide presented by the MHC in the presence of a second
set of costimulatory signals ( figure 1). This interaction leads to CD3 intracellular signaling that causes secretion of pro-
inflammatory cytokines such as IL-12 and IFN gamma. In the absence of a costimulatory signal, a state of peripheral tolerance
to the antigen ("anergy") develops ( figure 2) [9].

The most important costimulatory signal in naïve T cells is CD28, which binds to B7-1 and B7-2 (CD80/86) on the APC ( figure 1
). This costimulatory process is tightly regulated by both "agonist" molecules (eg, GITR, OX40, ICOS) and inhibitory signals on
both the APC and T cells, often collectively referred to as "immune checkpoint" molecules. Examples of co-inhibitory or
"immune checkpoint" molecules include cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), programmed cell death-1 (PD-1),
TIM3, and LAG3. Chronic recognition of an antigen (such as that present in a malignant clone or in a chronic viral infection) may
lead to feedback inhibition of effector T cell function, resulting in a phenotype termed "exhaustion" [10].

Tumor evasion of immune surveillance — The prevailing theory of the immune system's influence on neoplastic progression
is termed "cancer immunoediting," which proceeds in three phases ( figure 3) [11]:

● The elimination phase consists of innate and adaptive immune responses to specific tumor-associated antigens and is
characterized by T, B, and NK cell effector function, which is mediated by cytokines such as IFN alpha, IFN gamma, and IL-12
[12,13].

● The equilibrium phase is a balance between immune-mediated destruction by the adaptive immune system (eg, activated
CD4+ and CD8+ T cells) and persistence of rare malignant clones.

● Immunologic escape describes the phase where malignant clones have acquired the ability to evade the adaptive immune
system.

There are several posited mechanisms for escape from immune surveillance [14]. Established mechanisms include:

● Loss or alteration of specific antigens or antigenic machinery [15,16]. Tumors can lose major MHC class 1 expression or the
intracellular machinery required to transport tumor antigens to the tumor surface for T cell recognition [17-20].

● Tumors can promote an immune-tolerant microenvironment by manipulation of cytokines (increased secretion of IL-6, IL-
10, and TGF-beta; consumption of IL-2) that encourage infiltration of Treg cells, myeloid derived suppressor cells (MDSCs),
and other cell types that inhibit cytotoxic T cell function [19,21,22]. These cells can then actively suppress proliferation of
CD4+ and CD8+ T lymphocytes that would otherwise recognize tumor antigens.

● Tumors can upregulate the expression of immune checkpoint molecules such as programmed cell death ligand 1 (PD-L1)
that promote peripheral T cell exhaustion [23].

● Many oncogenic cell signaling pathways that were originally viewed as pure accelerators of cell division and growth are
now understood to be mediators of immunologic escape. For example, constitutive KIT signaling in gastrointestinal stromal
 tumors leads to overexpression of indoleamine-2,3-dioxygenase (IDO), which enhances Treg infiltration that promotes
tumor growth; this can be reversed in a CD8 T cell-dependent fashion with the KIT inhibitor, imatinib [24]. Melanomas with
beta-catenin/Wnt signaling inhibit dendritic-cell mediated antigen presentation and exclude CD8+ T cell infiltration [25].

Understanding these mechanisms of immunologic escape can suggest mechanisms for immune-based therapies that may be
broadly applicable across cancer types.

THERAPEUTIC APPROACHES

A number of therapeutic approaches are being studied to unleash the immune system and control malignancy. These
approaches include cytokines, T cells (checkpoint inhibitors, agonism of costimulatory receptors), manipulation of T cells,
oncolytic viruses, therapies directed at other cell types, and vaccines.

Cytokines — Initial approaches to immunotherapy harnessed the numerous downstream effects of cytokines and other
substances that influence immune cell activity. Examples include:

● Interleukin (IL)-2 was initially discovered as T cell growth factor. IL-2 has pleiotropic effects on both cytotoxic T cell function
as well as T regulatory (Treg) cell maintenance. The effects partially depend upon the dose and timing of IL-2 administration
[26]. At higher doses, IL-2 promotes CD8+ effector T cell and natural killer (NK) cytolytic activity and promotes
differentiation of CD4+ cells into T helper (Th)1 and Th2 subclasses [27]. At lower doses, IL-2 appears to preferentially
expand Treg populations, probably due to the higher affinity of the trimeric IL-2 receptor (IL-2R, also known as CD25) on
those cells, and inhibits the formation of Th17 cells implicated in autoimmunity [28-30].

Although IL-2 use has been largely supplanted by the use of checkpoint inhibitors, bolus, high-dose IL-2 achieved durable
objective responses in a minority of patients with melanoma and renal cell carcinoma (RCC), serving as proof of principle
that the immune system could eliminate cancer cells [31,32]. (See "Interleukin 2 and experimental immunotherapy
approaches for advanced melanoma", section on 'Interleukin 2' and "Systemic therapy of advanced clear cell renal
carcinoma", section on 'Interleukin 2 and other interleukins'.)

● Lenalidomide and pomalidomide are immunomodulatory agents that have prolonged survival in multiple myeloma. These
agents mediate their antitumor effects largely via the cereblon-mediated destruction of Ikaros family proteins that inhibit
IL-2 secretion [33-35].

● Interferon (IFN) alfa-2b promotes Th1-mediated effector cell responses such as IL-12 secretion via STAT-1 and STAT-2-
mediated downstream signaling events [36,37]. IFN alfa has been used as adjuvant treatment of high-risk melanoma,
although its long-term impact on overall survival is controversial. Subsequent data have established the role of immune
checkpoint blockade as preferred adjuvant treatment [38,39]. (See "Adjuvant and neoadjuvant therapy for cutaneous
melanoma".)

● Bacillus Calmette-Guerin (BCG), derived from attenuated mycobacterium bovis, induces a robust inflammatory response
when injected in the bladder and is used for the treatment and secondary prevention of superficial bladder cancer [40].
(See "Treatment of primary non-muscle invasive urothelial bladder cancer".)

Checkpoint inhibitor immunotherapy

PD-1 and PD ligand 1/2 — Programmed cell death 1 (PD-1) is a transmembrane protein expressed on T cells, B cells, and NK
cells ( figure 4). It is an inhibitory molecule that binds to the programmed cell death ligand 1 (PD-L1; also known as B7-H1)
and PD-L2 (B7-H2). PD-L1 is expressed on the surface of multiple tissue types, including many tumor cells, as well as
hematopoietic cells; PD-L2 is more restricted to hematopoietic cells. The PD-1:PD-L1/2 interaction directly inhibits apoptosis of
the tumor cell, promotes peripheral T effector cell exhaustion, and promotes conversion of T effector cells to Treg cells [41,42].
Additional cells such as NK cells, monocytes, and dendritic cells also express PD-1 and/or PD-L1.
In general, PD-1 and PD-L1/L2 are upregulated in the context of pro-effector cytokines such as IL-12 and IFN gamma,
highlighting their role as a physiologic brake on unrestrained cytotoxic T effector function [43,44]. There are additional binding
partners outside of the PD-1:PD-L1 axis; for example, PD-L1 has also been shown to inhibit CD80 [45], suggesting layers of
interaction between cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), PD-1, and other pathways; these require further
research to elucidate the context-dependent roles of each pathway in regulating T effector cell function.

Based upon prolonged overall survival in phase III trials and durable responses in phase II studies, antibodies inhibiting PD-1
(pembrolizumab, nivolumab) and PD-L1 (atezolizumab, avelumab, durvalumab) have been approved for a number of clinical
indications and are being evaluated in multiple other malignancies; these are discussed in specific disease-related topics.

CTLA-4 — CTLA-4 was discovered in 1987 and implicated as a negative regulator of T cell activation in the mid-1990s [46-48].
CTLA-4 exerts its effect when it is present on the cell surface of CD4+ and CD8+ T lymphocytes, where it has higher affinity for
the costimulatory receptors CD80 and CD86 (B7-1 and B7-2) on antigen-presenting cells (APCs) than the T cell costimulatory
receptor CD28 ( figure 5) [49]. The expression of CTLA-4 is upregulated by the degree of T cell receptor (TCR) activation and
cytokines such as IL-12 and IFN gamma, forming a feedback inhibition loop on activated T effector cells. As a result, CTLA-4 can
be broadly considered a physiologic "brake" on the CD4+ and CD8+ T cell activation that is triggered by APCs.

CTLA-4 was initially implicated in immune surveillance of cancer when inhibition of CTLA-4 in mouse models of sarcoma and
colon adenocarcinoma led to tumor shrinkage [50]. The anti-CTLA-4 antibody ipilimumab was the first immune checkpoint
inhibitor to be approved based upon its ability to prolong survival in patients with metastatic melanoma [51]. Ipilimumab has
also been approved as adjuvant therapy for high-risk melanoma as an alternative to IFN. (See "Immunotherapy of advanced
melanoma with immune checkpoint inhibition", section on 'CTLA-4 inhibition (ipilimumab)'.)

Other potential targets — Increased understanding of the underlying immunologic mechanisms is leading to the
identification of several additional potential targets for checkpoint inhibition. Examples of these include the following, although
all are in early stage clinical development:

● BTLA – B and T cell lymphocyte attenuator (BTLA) is a ligand of herpes virus entry mediator (HVEM) whose interaction leads
to decreased production of cytokines and cell proliferation by CD4+ T cells [52,53]. It is expressed on B, T and NK cells as
well as APCs. BTLA is induced during T cell activation, with persistent expression in TH1 but not TH2 cells [52]. Blockade of
BTLA has been shown to enhance NY-ESO-1 specific CD8+ T cell function and add to anti-PD-1 efficacy [54].

● VISTA – V-domain Ig suppressor of T cell activation (VISTA), as connoted by its name, shares homology with PD-L1 and is a
negative checkpoint ligand [55-57]. It is found in hematopoietic tissues and T cell-infiltrated structures, including tumors
[55]. VISTA blockade has been shown to increase T cell infiltration and function in tumors, thereby reducing tumor growth
[57].

● TIM-3 – T cell immunoglobulin and mucin domain 3 (TIM-3) is expressed by dendritic cells, monocytes, CD8 T cells, and T-
helper-1 (Th1) cells [58,59]. When TIM-3 binds galectin-9, its ligand that is often found on tumors, this causes TH1 cell
death; conversely, TIM-3 blockade causes TH1 cell hyperproliferation and cytokine release [60,61]. In combination with anti-
CTLA4 or anti-PD-1, TIM-3 blockade led to tumor shrinkage in a mouse model [62].

● LAG3 – Lymphocyte activation gene 3 (LAG3) is expressed by B cells, some T cells, NK cells, and tumor infiltrating
lymphocytes (TIL) [63]. The LAG3 protein enhances Treg activity by binding major histocompatibility complex (MHC) class II
and hampering T cell differentiation and proliferation [64]. Dual LAG3 and PD-1 blockade shows preclinical efficacy [65].
Preliminary data from a study combining an antibody targeting LAG3 and nivolumab found initial evidence of clinical
activity in patients with advanced melanoma who had progressed on previous therapy with an antibody targeting PD-1 [66].

● CD47 – The antigen CD47 may be expressed on tumor cells, protecting them from phagocytosis by macrophages, and is
therefore a potential target for anticancer therapy. In a phase Ib study of 22 heavily pretreated patients with relapsed or
refractory non-Hodgkin lymphoma (NHL; 15 with diffuse large B cell lymphoma and 7 with follicular lymphoma), Hu5F9-G4
(a humanized anti-CD47 monoclonal antibody) in combination with rituximab was associated with objective responses in
 half, including complete response in more than one-third [67]. Adverse events were generally mild. This study suggests that
targeting CD47 may enhance the activity of tumor-directed antibodies in patients with NHL.

Agonism of costimulatory receptors — Multiple costimulatory receptors are involved in the immune response to tumors, and
hence are potential targets for cancer immunotherapy. The following are either being studied in preclinical animal models or
are in early phases of clinical development as noted:

● 4-1BB (CD137) – 4-1BB is expressed on activated T cells, activated NK and NKT cells, as well as being expressed
constitutively on some dendritic and Treg populations. When stimulated by 4-1BBL, its natural ligand, or agonist antibodies,
this promotes activity of T cells, dendritic cells, monocytes, and neutrophils [68-70]. Preclinical data show tumor control
with agonist anti-4-1BB antibodies alone [71,72] and in combination with other modalities [73-75].

A 4-1BB agonist antibody urelumab (BMS-663513) was originally developed as monotherapy, but development was
suspended due to fatal liver toxicity when given at higher doses [76]. Urelumab is now being studied at lower doses both as
monotherapy and in development with other agents. Another 4-1BB agonist antibody, PF-05082566, has also shown clinical
activity in a phase I trial without toxicity at lower dose levels [77].

● OX40 (CD134) – OX40 is expressed on activated CD4+ T cells one to two days after activation, as well as on CD8+ T cells,
dendritic cells, neutrophils, and Tregs [78,79]. OX40 is stimulated by the OX40 ligand (OX40L) found on APCs and activated T
cells. Interaction with an agonist antibody can also reverse regulatory T cells' suppressive function [79-82]. In preclinical
models, OX40 agonism has antitumor activity on its own [83] and in combination with various other chemo- and
immunotherapies [84-87]. Studies of anti-OX40 and anti-OX40L antibodies are ongoing.

● GITR (CD357) – Glucocorticoid-induced tumor necrosis factor (TNF)-like receptor (GITR) expression increases on CD4+ and
CD8+ T cells one to three days after stimulation and is then sustained. T cell proliferation and effector function, as well as
prevention of activation-induced cell death (AICD), results from GITR stimulation [88,89]. GITR may also play a role in
leukocyte adhesion and transmigration [90]. Furthermore, GITR can reverse suppression by Tregs [91,92], as well as induce
memory, contributing to protection from tumor rechallenge in mouse models [93]. Administration of the murine anti-GITR
antibody DTA-1 impairs Treg function and improves antitumor activity of CTLs [94,95].

● ICOS – Inducible T cell co-stimulator (ICOS) is expressed on activated T cells and has multiple functions, including a role in
isotype switching, germinal center formation, and effector and regulatory CD4+ T cell responses [96]. ICOS ligand
engagement of ICOS in combination with CTLA-4 blockade enhanced efficacy of the latter [97].

● CD40 – CD40 is a costimulatory molecule present on APC and necessary for dendritic cell activation that binds its ligand,
CD40L, expressed on T helper cells [98]. Two agents, dacetuzumab and lucatumumab, have been studied in hematologic
malignancies.

● CD28 – CD28 is constitutively expressed on T cells and is a costimulatory receptor for CD80 (B7.1) and CD86 (B7.2). In a
phase I trial in which CD28 was targeted by a monoclonal antibody, TGN1412, the six treated patients all suffered organ
damage and critical illness secondary to cytokine release [99]. CD28 is used as a stimulator of T cells ex vivo, but targeted
antibodies are no longer under development due to toxicity.

Combination immune checkpoint blockade strategies — Checkpoint inhibitor immunotherapy agents have regulatory
approval for multiple clinical indications. Concurrent PD-1 and CTLA-4 blockade (eg, nivolumab plus ipilimumab) is furthest
along in standard clinical use. As examples:

● Metastatic melanoma – In patients with metastatic melanoma, the combination of nivolumab plus ipilimumab ( figure 6
) improved overall survival compared with ipilimumab monotherapy in metastatic melanoma. Further details are discussed
separately. (See "Immunotherapy of advanced melanoma with immune checkpoint inhibition", section on 'Nivolumab plus
ipilimumab'.)
 ● Renal cell carcinoma – Similarly, in patients with treatment-naïve RCC, the combination of nivolumab plus ipilimumab
improved overall survival compared with sunitinib. Further details of this study are discussed separately. (See "Systemic
therapy of advanced clear cell renal carcinoma", section on 'Nivolumab plus ipilimumab'.)

● Non-small cell lung cancer – In patients with advanced non-small cell lung cancer (NSCLC), nivolumab plus ipilimumab
also improved overall survival compared with chemotherapy. Further details are discussed separately. (See "Management
of advanced non-small cell lung cancer lacking a driver mutation: Immunotherapy", section on 'Nivolumab plus ipilimumab
(without or with chemotherapy)'.)

● Other malignancies – Nivolumab plus ipilimumab also has clinical efficacy in hepatocellular carcinoma and microsatellite
instability-high (MSI-H) or mismatch repair deficient (dMMR) colorectal cancer. (See "Systemic treatment for advanced
hepatocellular carcinoma", section on 'Nivolumab plus ipilimumab' and "Tissue-agnostic cancer therapy: DNA mismatch
repair deficiency, tumor mutational burden, and response to immune checkpoint blockade in solid tumors", section on
'Nivolumab with or without ipilimumab'.)

Based on these data, the combination of nivolumab plus ipilimumab has been approved by the US Food and Drug
Administration (FDA) for melanoma, RCC, and NSCLC, among other malignancies. Of note, the rate of grade ≥3 adverse events
was higher with combined nivolumab plus ipilimumab versus nivolumab or ipilimumab monotherapy. (See "Toxicities
associated with checkpoint inhibitor immunotherapy".)

Clinical trials combining multiple other immunotherapy targets are being investigated in multiple cancers.

Manipulating T cells — Adoptive T cell transfer broadly refers to the practice of manipulating patient-specific T cells ex vivo to
make them more reactive to specific antigens.

Chimeric antigen receptors — Chimeric antigen receptor (CAR) T cells are genetically modified T cells, where a patient's
own (autologous) T cells are manipulated ex vivo to express the antigen-binding domain from a B cell receptor that is fused to
the intracellular domain of a CD3 TCR (CD3-zeta). As a result, recognition of a specific cell surface antigen activates T cell
response independently of MHC recognition. Various modifications can enhance CAR effector function, such as co-expression of
intracellular costimulatory domains such as CD28 or 4-1BB (CD137) or pro-effector cytokines such as IL-12 [100,101].

CAR T cells have been studied most extensively in hematologic malignancies. Clinical trials targeting CD19, the pan-B cell
antigen, have shown remarkable success in B cell acute lymphoblastic leukemia (B-ALL) [102] and pre-B-cell ALL [103]. Side
effects are substantial in certain patients and include signs of the cytokine release syndrome such as fever, hypotension, altered
mental status, and seizures, with some patients requiring intensive care. Trials in patients with chronic lymphocytic leukemia
(CLL) have also shown promising results [104,105].

Numerous trials in hematologic malignancies are ongoing, with early development in some solid tumors targeting shared
antigens such as CEA, mesothelin, and HER2.

Ex vivo expansion of tumor-infiltrating lymphocytes — Tumor-infiltrating lymphocytes (TILs) represent an immune cell

population that recognizes tumor antigen but may have developed an exhausted phenotype due to the tumor
microenvironment.

Ex vivo expansion of TILs utilizes freshly resected tumor tissue to extract TILs and co-culture with IL-2 to stimulate in vitro TIL
expansion. Prior to reinfusion of expanded TILs, the patient receives nonmyeloablative chemotherapy regimens such as
cyclophosphamide or total body irradiation, which functions to deplete inhibitory Treg cells and other lymphocytes in the
patient to improve the rate of in vivo expansion of the stimulated TILs [106]. The in-vitro-stimulated TILs, largely comprised of
CD8+ and to a lesser extent CD4+ T lymphocytes, are then reintroduced into patients at high doses, together with HD IL-2,
where they can recognize specific tumor antigens in a microenvironment that is now less prone to induce tolerance [107].

In a series of highly selected patients with advanced melanoma prior to the era of checkpoint inhibition, 56 percent of those
who received the T cell infusion had an objective response [108]. The major limitations of this approach are that it requires fresh
tissue, the expansion process that takes several weeks, and not all TILs are guaranteed to expand in vitro. (See "Interleukin 2
and experimental immunotherapy approaches for advanced melanoma".)

Adoptive cell therapy with the TIL product lifleucel (LN-144) has demonstrated clinical efficacy in patients with melanoma
refractory to prior PD-1 inhibitor therapy and, in some cases, BRAF plus MEK inhibitor therapy. (See "Systemic treatment of
metastatic melanoma with BRAF and other molecular alterations", section on 'Adoptive cell therapy'.)

Lifleucel is also being investigated in clinical trials for several other diseases, including cervical carcinoma, and in combination
with PD-1 blockade.

CD3-directed therapies

Bispecific T cell engagers — Conceptually, bispecific T cell engager antibodies (BiTEs) function as linkers between T cells
and specific target antigens in an MHC-subtype independent manner. They consist of a protein fragment containing two
separate single-chain variable regions. One end recognizes CD3, which is expressed on all T cells, and one end recognizes the
target antigen. BiTEs thus aim to induce cytotoxic T cell-mediated tumor eradication.

Because BiTEs are not MHC-specific, they can be administered to all patients regardless of human leukocyte antigen (HLA) type
and do not require patient-specific processing. One consequence of this more broadly applicable approach is its relative lack of
specificity in T cell recruitment when compared with the more labor-intensive method of adoptive T cell transfer. Because many
different T cell subtypes express CD3, BiTEs recruit polyclonal cytotoxic T cells, Th1 and Th2 CD4+ cells, and Tregs.

The most well-developed BiTE is blinatumomab, which has specificity for CD19 antigen found on many B cell malignancies and
the Fc region of the CD3 receptor found on T lymphocytes. Blinatumomab was given accelerated approval by the US FDA for
Philadelphia-chromosome negative B-ALL. (See "Treatment of relapsed or refractory acute lymphoblastic leukemia in adults",
section on 'Blinatumomab'.)

Immune-mobilizing monoclonal TCRs against cancer — Immune-mobilizing monoclonal TCRs against cancer

(ImmTACs) are similar to BiTEs in the sense that they aim to link T cells and specific target antigens. Unlike BiTEs, however, they
utilize an HLA-A specific engineered MHC class 1 molecule on one end and a single-chain variable region on the other end. This
can theoretically target both intracellular and extracellular expressed proteins like monoclonal TCRs. (See 'Monoclonal TCRs'
below.)

The most clinically advanced example is tebentafusp, an HLA-A 02:01 restricted agent targeting the melanocytic antigen gp100
with a CD3 variable chain fragment. This agent has demonstrated efficacy in clinical trials of patients with metastatic uveal
melanomas. Further details are discussed separately. (See "Management of metastatic uveal melanoma".)

Clinical trials are ongoing investigating the use of ImmTACs for additional targets across various cancer types.

Monoclonal TCRs — Another approach to increasing effector T cell function against a particular antigen is engineering a
soluble TCR (CD8) to recognize a particular antigen target and fusing this to the variable fragment that recognizes an effector
target, such as CD3 [109]. The ability to engineer a TCR rather than an antibody fragment can lead to higher affinity for a given
peptide chain and allow for targeting of intracellular peptide fragments [110]. This approach must be engineered using a
specific MHC class 1 molecule, and complications have occurred through TCR cross-recognition of other antigens [111]. MHC
A*02-restricted TCRs are furthest along in clinical development because these are the most common alleles (50 percent) in
people of Western European descent. See the figure for a simplified schematic representation of the key differences in the
above four T cell-directed therapies ( figure 7).

Oncolytic viruses — Oncolytic viruses mediate antitumor effects in several ways. Viruses can be engineered to efficiently infect
cancer cells preferentially over normal cells, to promote presentation of tumor-associated antigens, to activate "danger signals"
that promote a less immune-tolerant tumor microenvironment, and to serve as transduction vehicles for expression of immune
modulatory cytokines [112]. (See "Overview of gene therapy, gene editing, and gene silencing", section on 'Cancer therapy'.)
Talimogene laherparepvec (T-VEC) utilizes an attenuated herpes simplex virus 1 virus to overexpress granulocyte macrophage
colony-stimulating factor (GM-CSF), which promotes dendritic cell mediated antigen presentation. T-VEC improved durable
response rates compared with intratumoral GM-CSF alone in patients with unresectable, injectable advanced melanoma. This
agent is approved by the US FDA for unresectable or advanced melanoma with an injectable skin or lymph node metastasis with
limited visceral disease. Further data on the clinical efficacy of T-VEC in this patient population are discussed separately. (See
"Cutaneous melanoma: Management of local recurrence", section on 'Talimogene laherparepvec'.)

Numerous other virus backbones are under clinical or preclinical investigation, including adenovirus [113-116], reovirus [117],
Newcastle disease virus [118], and others.

Oncolytic virus plus checkpoint inhibition — Injection of oncolytic viruses may synergize with checkpoint inhibitors by
increasing CD8+ T cell infiltration and IFN gamma signaling as well as upregulating PD-L1 in the microenvironment [119]. In a
randomized trial of ipilimumab with or without T-VEC, the combination had a higher response rate than ipilimumab alone (39
versus 18 percent) [120]. A phase 1 trial of T-VEC plus pembrolizumab in patients with melanoma suggested that responses
were independent of baseline immune infiltration [119].

Therapies directed at other cell types in tumor microenvironment — In tumor immunology, cell types other than tumor-
specific and circulating T cells contribute to an effective versus a suppressed immune response, and thus represent additional
targets for immunotherapy beyond T cells.

Natural killer cells — The biology of natural killer (NK) cells is complex [121]. NK cell infiltrates in solid tumors, and
metastases have been associated with an improved prognosis [122-124], although the use of CD56 or CD57 markers also
expressed on T cell subsets (eg, CD8+ T cells) and some tumors may somewhat confound these findings. The killer
immunoglobulin-like receptor (KIR) genes are expressed by NK cells and bind to HLA molecules on normal host cells. Cancer
cells, which often lose HLA expression, are recognized by NK cells as missing their HLA molecules and are consequently
destroyed by the NK cells [121].

Anti-KIR antibodies have shown preclinical efficacy in lymphoma [125], multiple myeloma [126], and acute myelogenous
leukemia (AML) [127]. In clinical trials, a phase I study of IPH2101 was safe in patients with AML in first remission [128]. There
were no objective responses as a single agent in patients with relapsed/refractory multiple myeloma [129], but results were
more promising when administered in conjunction with lenalidomide in this population [130]. Lirilumab (BMS986015) is the
other anti-KIR antibody undergoing early stage trials alone and in combination in hematologic malignancies and solid tumors.

Macrophages — The presence of intratumoral macrophages can portend a poor prognosis. Although an oversimplification,
the general categorization of macrophages into classically activated phenotype (M1) and alternatively activated (M2) suggests
that in the context of malignancy, M2 macrophages play a pro-tumoral role due to their involvement in immunosuppression,
angiogenesis, and tumor cell activation [131].

Intratumoral macrophages are largely recruited by C-C chemokine ligand 2 (CCL2) or colony-stimulating factor 1 (CSF-1), and
pre-clinical and clinical data have focused on targeting the CSF-1/CSF-1 receptor axis. The antitumor impact of CSF-1 receptor
(CSF-1R) inhibition in pre-clinical models varies [132], but there are promising data in combination with other modalities such as
chemotherapy [133,134], radiation therapy [135], angiogenic inhibitors [136], adoptive cell transfer [137], as well as when used
in conjunction with CTLA-4 and PD-1 blockade in the challenging setting of pancreatic ductal adenocarcinoma [138].

Examples of CSF-1R inhibitors with clinical activity include emactuzumab (RG7155) and pexidartinib (PLX3397) [139-141].
Pexidartinib has regulatory approval for the treatment of unresectable tenosynovial giant cell tumor, a locally aggressive
neoplasm that overexpresses CSF-1. (See "Treatment for tenosynovial giant cell tumor and other benign neoplasms affecting
soft tissue and bone", section on 'Pexidartinib (CSF1R inhibitor)'.)

IDO — Indoleamine 2,3-dioxigenase 1 (IDO1) catalyzes the rate-limiting step in the conversion from the essential amino acid
L-tryptophan (Trp) into L-kynurenine (Kyn). IDO1 expression by tumors can promote evasion of immune surveillance by
suppressing T cell function [142] and impairing immune surveillance [143].
Although potentially promising activity was seen in early phase trials [144], a randomized phase 3 study of pembrolizumab with
or without epacadostat did not show benefit compared with the combination [145]. This negative result has resulted in
diminished interest in clinical development of IDO inhibitors.

Vaccines — There is a long history of attempting to harness the adaptive immune recognition of a cancer-related antigen to
effect antitumor responses. Vaccine methods range widely, and a full review is outside the scope of this article.

A simplistic way to view vaccine development method is that varying types of antigens, administration schedules, and
accompanying immune adjuvants can influence an adaptive immune response. Antigen choices range from simple peptides,
which are easy to administer but affect a narrow antigen spectrum and are often restricted by specific HLA class 1 molecule
expression that allows efficient antigen presentation, to whole cell preparations that offer a broader range of antigens but are
more costly and time-consuming to prepare [146].

The only approved vaccine-based therapy for advanced cancer is sipuleucel-T, which is an autologous dendritic-cell preparation
engineered to target prostatic acid phosphatase (PAP) that demonstrated an overall survival benefit in men with castrate-
resistant prostate adenocarcinoma [147]. Patient blood undergoes leukapheresis and is exposed ex vivo to PAP fused to GM-
CSF. Theoretically, GM-CSF fosters maturation of dendritic cells and other APCs to present PAP to the patient's T cells, which
then recognize the PAP. However, the degree of PAP-specific T cell proliferation at week 6 did not correlate with survival in the
study, suggesting that additional immunologic mechanisms may explain this survival benefit. (See "Immunotherapy for
castration-resistant prostate cancer", section on 'Sipuleucel-T'.)

Single-peptide vaccines continue to be tested extensively, especially in "immunogenic" cancers such as melanoma. They have
largely shown disappointing efficacy in preventing recurrence or prolonging survival [146]. As an example, in a randomized
phase III trial of 185 patients, those who received the combination of IL-2 plus the HLA-A*0201- MHC-specific vaccine against
the surface glycoprotein gp100 had a higher response than those who received IL-2 alone (22 versus 10 percent), and there was
a nonsignificant trend toward improved survival (17 versus 11 months) [148]. However, in the randomized clinical trial that
demonstrated a survival benefit for ipilimumab with or without this gp100 vaccine, the vaccine did not improve survival over
ipilimumab alone [149]. (See "Immunotherapy of advanced melanoma with immune checkpoint inhibition", section on
'Efficacy'.)

Given the increasing understanding of the importance of immune recognition of multiple patient-specific, tumor-specific
antigens, efforts to develop therapeutic vaccines against cancer are beginning to explore the use of individualized pooled
antigens. This suggests that patient-specific vaccination approaches may be feasible, particularly in immunogenic tumors such
as melanoma, non-small cell lung cancer, mismatch-repair deficient colorectal carcinoma, and bladder carcinoma [150,151].

IMMUNOTHERAPY RESPONSE CRITERIA

Patterns of response — Evaluation of the effectiveness of immune checkpoint inhibitors and other forms of immunotherapy
requires an understanding of the potentially different patterns of response seen with these classes of agents [152]. The
patterns of response to treatment with these immunotherapy agents can differ from those with molecularly targeted agents or
cytotoxic chemotherapy in several important respects [153]:

● Patients may have a transient worsening of disease, manifested either by progression of known lesions or the appearance
of new lesions, before the disease stabilizes or tumor regresses ( image 1). Therefore, some caution should be taken in
abandoning therapy early. However, these delayed responses are generally not observed in patients with symptomatic
deterioration [154], so continuing therapy beyond progression is not recommended in these patients.

● Responses can take longer to become apparent compared with cytotoxic therapy.

● Some patients who do not meet criteria for objective response can have prolonged periods of stable disease that are
clinically significant.
Response criteria — Immune-related response criteria (irRC) have been proposed to properly recognize the nontraditional
patterns of response occasionally seen with checkpoint inhibitors and some other immunotherapies [153].

● Immune-related complete response – Complete resolution of all measurable and nonmeasurable lesions, with no new
lesions. A complete response must be confirmed by a second, consecutive assessment at least four weeks later.

● Immune-related partial response – A decrease in the total tumor burden of 50 percent or more compared with baseline,
which must be confirmed by a second, consecutive assessment at least four weeks later. This category allows for the
inclusion of progression of some lesions or the appearance of new lesions as long as the total tumor burden meets the
response criterion.

● Immune-related stable disease – Not meeting the criteria for either a partial or complete response or for progressive
disease.

● Immune-related progressive disease – An increase in tumor burden of 25 percent or more relative to the minimum
recorded tumor burden. This must be confirmed by a second, consecutive assessment no fewer than four weeks after the
initial documentation of an increase in tumor.

Use of these immune-related response criteria is important because the application of traditional Response Evaluation Criteria
In Solid Tumors (RECIST) criteria in patients treated with checkpoint inhibitors may lead to premature discontinuation of
treatment in a patient who will eventually respond to treatment or have prolonged disease.

Consensus-based criteria for response to immunotherapy (iRECIST) have been developed for use in trials testing
immunotherapy ( table 1) [155]. They may also be applicable to patients receiving immunotherapy in a non-trial setting.

These criteria are based upon RECIST 1.1, with some modifications, and are prefixed with an "i" (immune). These iRECIST criteria
build upon the previously described response criteria (irRC), which were also based upon RECIST and World Health Organization
(WHO) guidelines for response assessment in patients treated with chemotherapy [153]. The major modifications are:

● The definitions of measurable and nonmeasurable disease; numbers and sites of target disease are the same as for RECIST
1.1.

● The biggest difference from RECIST 1.1 (and similar to the irRC) is that the development of new lesions during therapy is
classified as immune unconfirmed progressive disease (iUPD); immune confirmed progressive disease (iCPD) is only
assigned if at the next assessment, additional new lesions appear or there is an increase in the size of the new lesions (≥5
mm for the sum of the new lesion targets or any increase in a new lesion nontarget); the appearance of new lesions when
none have previously been recorded can also confirm iCPD.

● The response assignment categories are immune complete response (iCR), immune partial response (iPR), iUPD, iCPD, and
immune stable disease (iSD).

● Time point responses are defined according to whether or not there was a prior iUPD in any category ( table 2).

Immune-modified Response Evaluation Criteria In Solid Tumors (imRECIST) have also been developed to utilize a
unidimensional measurement system based upon the RECIST 1.1 system ( table 3) [156]. The imRECIST may offer advantages
compared with RECIST by recognizing the potential benefits from treatment in patients who have a transient progression after
initiation of immunotherapy.

In clinical practice, patients receiving any immune-based therapy and whose tumors show initial growth should be assessed
carefully for signs and symptoms of clinical benefit or progression; the majority of patients will have true progressive disease
[157]. In the absence of symptomatic progression, however, a short-term repeat scan is reasonable prior to considering
immune-based therapy a failure.
PREDICTORS OF RESPONSE TO IMMUNE-BASED THERAPY

As immune checkpoint blockade and other immune-based therapy approaches lead to broad treatment advances among
patients with advanced cancer, an important consideration is how to best select patients whose tumors will respond to these
therapies.

Programmed cell death ligand 1 (PD-L1) — Programmed cell death ligand 1 (PD-L1) is the candidate biomarker that has been
studied most extensively in trials utilizing programmed cell death-1 (PD-1) blockade. PD-L1 and PD-1 expression are dynamic
markers that change in relation to local cytokines and other factors, and the thresholds that separate "positive" and "negative"
PD-L1 expression remain under debate.

Still, most trials with either retrospective or prospective assessments of PD-L1 status have shown trends for increased response
rates to PD-1 blockade in PD-L1 "positive" tumors [158-161] (see 'PD-1 and PD ligand 1/2' above). Most notably, in randomized
trials comparing pembrolizumab to chemotherapy in patients with newly diagnosed advanced non-small cell lung cancers
(NSCLCs) with ≥50 percent PD-L1 expression, pembrolizumab improved overall survival [162]. On the basis of this trial, PD-L1
expression is a routine diagnostic marker for patients with newly diagnosed NSCLC.

PD-L1 is also now being used as a diagnostic marker in breast cancer [163-165], head and neck cancer [166], gastric cancer
[167], cervical cancer [168], and bladder cancer [169], although the specific assay, cell expression quantification, and threshold
for use in each tumor type can vary. (See "ER/PR negative, HER2-negative (triple-negative) breast cancer" and "Treatment of
metastatic and recurrent head and neck cancer" and "Progressive, locally advanced unresectable, and metastatic esophageal
and gastric cancer: Approach to later lines of systemic therapy" and "Management of recurrent or metastatic cervical cancer"
and "Treatment of metastatic urothelial cancer of the bladder and urinary tract".)

Tumor mutational burden — Tumor mutational burden is another predictive biomarker. Tumors with high levels of TMB (eg,
sun-exposed cutaneous melanoma, NSCLC, bladder cancer, and microsatellite-unstable colorectal carcinomas) can benefit from
immunotherapy such as pembrolizumab, among other agents. This approach is discussed in more detail separately. (See
"Tissue-agnostic cancer therapy: DNA mismatch repair deficiency, tumor mutational burden, and response to immune
checkpoint blockade in solid tumors".)

Additional gene-expression-based signatures for immune response are also under active investigation [170].

SUMMARY

● The pace of discovery in the fields of immunology and cancer biology is rapidly accelerating. Continued progress in the
treatment of malignancy is likely as our understanding evolves regarding the role of the immune system in tumor initiation,
progression, and metastasis. (See 'Tumor immunology' above.)

● Checkpoint inhibitor immunotherapy has become a primary treatment modality for patients with a broad diversity of
cancers, and prolongs survival in some malignancies. Clinical trials exploring a wide variety of immunotherapy
combinations in other malignancies are in progress. (See 'Therapeutic approaches' above.)

ACKNOWLEDGMENTS

The editorial staff at UpToDate would like to acknowledge Michael Postow, MD, Alexandra Snyder Charen, MD, and Jedd
Wolchok, MD, PhD, who contributed to earlier versions of this topic review.

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1. Coley WB. The treatment of malignant tumors by repeated inoculations of erysipelas: with a report of ten original cases.
Am J Med Sci 1893; 105:487.
2. Gras Navarro A, Björklund AT, Chekenya M. Therapeutic potential and challenges of natural killer cells in treatment of solid
tumors. Front Immunol 2015; 6:202.

3. Savage PA, Leventhal DS, Malchow S. Shaping the repertoire of tumor-infiltrating effector and regulatory T cells. Immunol
Rev 2014; 259:245.

4. Marvel D, Gabrilovich DI. Myeloid-derived suppressor cells in the tumor microenvironment: expect the unexpected. J Clin
Invest 2015; 125:3356.

5. Bailey SR, Nelson MH, Himes RA, et al. Th17 cells in cancer: the ultimate identity crisis. Front Immunol 2014; 5:276.

6. Laoui D, Van Overmeire E, De Baetselier P, et al. Functional Relationship between Tumor-Associated Macrophages and
Macrophage Colony-Stimulating Factor as Contributors to Cancer Progression. Front Immunol 2014; 5:489.

7. van der Merwe PA, Dushek O. Mechanisms for T cell receptor triggering. Nat Rev Immunol 2011; 11:47.
8. Hennecke J, Wiley DC. T cell receptor-MHC interactions up close. Cell 2001; 104:1.

9. Schwartz RH. A cell culture model for T lymphocyte clonal anergy. Science 1990; 248:1349.

10. Wherry EJ. T cell exhaustion. Nat Immunol 2011; 12:492.

11. Schreiber RD, Old LJ, Smyth MJ. Cancer immunoediting: integrating immunity's roles in cancer suppression and promotion.
Science 2011; 331:1565.

12. Tran E, Turcotte S, Gros A, et al. Cancer immunotherapy based on mutation-specific CD4+ T cells in a patient with epithelial
cancer. Science 2014; 344:641.

13. Matsushita H, Vesely MD, Koboldt DC, et al. Cancer exome analysis reveals a T-cell-dependent mechanism of cancer
immunoediting. Nature 2012; 482:400.
14. Vinay DS, Ryan EP, Pawelec G, et al. Immune evasion in cancer: Mechanistic basis and therapeutic strategies. Semin Cancer
Biol 2015; 35 Suppl:S185.

15. Johnsen AK, Templeton DJ, Sy M, Harding CV. Deficiency of transporter for antigen presentation (TAP) in tumor cells allows
evasion of immune surveillance and increases tumorigenesis. J Immunol 1999; 163:4224.

16. Donia M, Andersen R, Kjeldsen JW, et al. Aberrant Expression of MHC Class II in Melanoma Attracts Inflammatory Tumor-
Specific CD4+ T- Cells, Which Dampen CD8+ T-cell Antitumor Reactivity. Cancer Res 2015; 75:3747.

17. Rooney MS, Shukla SA, Wu CJ, et al. Molecular and genetic properties of tumors associated with local immune cytolytic
activity. Cell 2015; 160:48.

18. Catalán E, Charni S, Jaime P, et al. MHC-I modulation due to changes in tumor cell metabolism regulates tumor sensitivity
to CTL and NK cells. Oncoimmunology 2015; 4:e985924.

19. Reichel J, Chadburn A, Rubinstein PG, et al. Flow sorting and exome sequencing reveal the oncogenome of primary
Hodgkin and Reed-Sternberg cells. Blood 2015; 125:1061.

20. 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; 375:819.
21. Amend SR, Pienta KJ. Ecology meets cancer biology: the cancer swamp promotes the lethal cancer phenotype. Oncotarget
2015; 6:9669.

22. Guo F, Wang Y, Liu J, et al. CXCL12/CXCR4: a symbiotic bridge linking cancer cells and their stromal neighbors in oncogenic
communication networks. Oncogene 2016; 35:816.
23. Tumeh PC, Harview CL, Yearley JH, et al. PD-1 blockade induces responses by inhibiting adaptive immune resistance. Nature
2014; 515:568.
24. Balachandran VP, Cavnar MJ, Zeng S, et al. Imatinib potentiates antitumor T cell responses in gastrointestinal stromal
tumor through the inhibition of Ido. Nat Med 2011; 17:1094.

25. Spranger S, Bao R, Gajewski TF. Melanoma-intrinsic β-catenin signalling prevents anti-tumour immunity. Nature 2015;
523:231.

26. Boyman O, Sprent J. The role of interleukin-2 during homeostasis and activation of the immune system. Nat Rev Immunol
2012; 12:180.

27. Krieg C, Létourneau S, Pantaleo G, Boyman O. Improved IL-2 immunotherapy by selective stimulation of IL-2 receptors on
lymphocytes and endothelial cells. Proc Natl Acad Sci U S A 2010; 107:11906.

28. Zeiser R, Nguyen VH, Beilhack A, et al. Inhibition of CD4+CD25+ regulatory T-cell function by calcineurin-dependent
interleukin-2 production. Blood 2006; 108:390.

29. Laurence A, Tato CM, Davidson TS, et al. Interleukin-2 signaling via STAT5 constrains T helper 17 cell generation. Immunity
2007; 26:371.

30. Kryczek I, Wei S, Zou L, et al. Cutting edge: Th17 and regulatory T cell dynamics and the regulation by IL-2 in the tumor
microenvironment. J Immunol 2007; 178:6730.
31. Rosenberg SA, Yang JC, Topalian SL, et al. Treatment of 283 consecutive patients with metastatic melanoma or renal cell
cancer using high-dose bolus interleukin 2. JAMA 1994; 271:907.

32. Atkins MB, Lotze MT, Dutcher JP, et al. High-dose recombinant interleukin 2 therapy for patients with metastatic melanoma:
analysis of 270 patients treated between 1985 and 1993. J Clin Oncol 1999; 17:2105.

33. Lu G, Middleton RE, Sun H, et al. The myeloma drug lenalidomide promotes the cereblon-dependent destruction of Ikaros
proteins. Science 2014; 343:305.

34. Avitahl N, Winandy S, Friedrich C, et al. Ikaros sets thresholds for T cell activation and regulates chromosome propagation.
Immunity 1999; 10:333.

35. Quintana FJ, Jin H, Burns EJ, et al. Aiolos promotes TH17 differentiation by directly silencing Il2 expression. Nat Immunol
2012; 13:770.

36. Lesinski GB, Anghelina M, Zimmerer J, et al. The antitumor effects of IFN-alpha are abrogated in a STAT1-deficient mouse. J
Clin Invest 2003; 112:170.

37. Carson WE. Interferon-alpha-induced activation of signal transducer and activator of transcription proteins in malignant
melanoma. Clin Cancer Res 1998; 4:2219.
38. Weber J, Mandala M, Del Vecchio M, et al. Adjuvant Nivolumab versus Ipilimumab in Resected Stage III or IV Melanoma. N
Engl J Med 2017; 377:1824.

39. Eggermont AM, Chiarion-Sileni V, Grob JJ, et al. Prolonged Survival in Stage III Melanoma with Ipilimumab Adjuvant
Therapy. N Engl J Med 2016; 375:1845.
40. Redelman-Sidi G, Glickman MS, Bochner BH. The mechanism of action of BCG therapy for bladder cancer--a current
perspective. Nat Rev Urol 2014; 11:153.

41. Francisco LM, Salinas VH, Brown KE, et al. PD-L1 regulates the development, maintenance, and function of induced
regulatory T cells. J Exp Med 2009; 206:3015.

42. Amarnath S, Mangus CW, Wang JC, et al. The PDL1-PD1 axis converts human TH1 cells into regulatory T cells. Sci Transl Med
2011; 3:111ra120.

43. Spranger S, Spaapen RM, Zha Y, et al. Up-regulation of PD-L1, IDO, and T(regs) in the melanoma tumor microenvironment
is driven by CD8(+) T cells. Sci Transl Med 2013; 5:200ra116.

44. Kinter AL, Godbout EJ, McNally JP, et al. The common gamma-chain cytokines IL-2, IL-7, IL-15, and IL-21 induce the
expression of programmed death-1 and its ligands. J Immunol 2008; 181:6738.
45. Yang J, Riella LV, Chock S, et al. The novel costimulatory programmed death ligand 1/B7.1 pathway is functional in inhibiting
alloimmune responses in vivo. J Immunol 2011; 187:1113.

46. Chambers CA, Sullivan TJ, Allison JP. Lymphoproliferation in CTLA-4-deficient mice is mediated by costimulation-dependent
activation of CD4+ T cells. Immunity 1997; 7:885.

47. Tivol EA, Borriello F, Schweitzer AN, et al. Loss of CTLA-4 leads to massive lymphoproliferation and fatal multiorgan tissue
destruction, revealing a critical negative regulatory role of CTLA-4. Immunity 1995; 3:541.

48. Waterhouse P, Penninger JM, Timms E, et al. Lymphoproliferative disorders with early lethality in mice deficient in Ctla-4.
Science 1995; 270:985.
49. Walker LS, Sansom DM. The emerging role of CTLA4 as a cell-extrinsic regulator of T cell responses. Nat Rev Immunol 2011;
11:852.

50. Leach DR, Krummel MF, Allison JP. Enhancement of antitumor immunity by CTLA-4 blockade. Science 1996; 271:1734.

51. Schadendorf D, Hodi FS, Robert C, et al. Pooled Analysis of Long-Term Survival Data From Phase II and Phase III Trials of
Ipilimumab in Unresectable or Metastatic Melanoma. J Clin Oncol 2015; 33:1889.
52. Watanabe N, Gavrieli M, Sedy JR, et al. BTLA is a lymphocyte inhibitory receptor with similarities to CTLA-4 and PD-1. Nat
Immunol 2003; 4:670.

53. Murphy KM, Nelson CA, Sedý JR. Balancing co-stimulation and inhibition with BTLA and HVEM. Nat Rev Immunol 2006;
6:671.
54. Fourcade J, Sun Z, Pagliano O, et al. CD8(+) T cells specific for tumor antigens can be rendered dysfunctional by the tumor
microenvironment through upregulation of the inhibitory receptors BTLA and PD-1. Cancer Res 2012; 72:887.

55. Lines JL, Pantazi E, Mak J, et al. VISTA is an immune checkpoint molecule for human T cells. Cancer Res 2014; 74:1924.

56. Wang L, Rubinstein R, Lines JL, et al. VISTA, a novel mouse Ig superfamily ligand that negatively regulates T cell responses. J
Exp Med 2011; 208:577.
57. Le Mercier I, Chen W, Lines JL, et al. VISTA Regulates the Development of Protective Antitumor Immunity. Cancer Res 2014;
74:1933.

58. Monney L, Sabatos CA, Gaglia JL, et al. Th1-specific cell surface protein Tim-3 regulates macrophage activation and severity
of an autoimmune disease. Nature 2002; 415:536.
59. Anderson AC, Anderson DE, Bregoli L, et al. Promotion of tissue inflammation by the immune receptor Tim-3 expressed on
innate immune cells. Science 2007; 318:1141.

60. Zhu C, Anderson AC, Schubart A, et al. The Tim-3 ligand galectin-9 negatively regulates T helper type 1 immunity. Nat
Immunol 2005; 6:1245.

61. Sabatos CA, Chakravarti S, Cha E, et al. Interaction of Tim-3 and Tim-3 ligand regulates T helper type 1 responses and
induction of peripheral tolerance. Nat Immunol 2003; 4:1102.

62. Ngiow SF, von Scheidt B, Akiba H, et al. Anti-TIM3 antibody promotes T cell IFN-γ-mediated antitumor immunity and
suppresses established tumors. Cancer Res 2011; 71:3540.

63. Kisielow M, Kisielow J, Capoferri-Sollami G, Karjalainen K. Expression of lymphocyte activation gene 3 (LAG-3) on B cells is
induced by T cells. Eur J Immunol 2005; 35:2081.

64. Grosso JF, Goldberg MV, Getnet D, et al. Functionally distinct LAG-3 and PD-1 subsets on activated and chronically
stimulated CD8 T cells. J Immunol 2009; 182:6659.

65. Woo SR, Turnis ME, Goldberg MV, et al. Immune inhibitory molecules LAG-3 and PD-1 synergistically regulate T-cell function
to promote tumoral immune escape. Cancer Res 2012; 72:917.
66. Ascierto PA, Melero I, Bhaia S, et al. Initial efficacy of anti-lymphocyte activation gene-3 (anti–LAG-3; BMS-986016) in combin
ation with nivolumab (nivo) in pts with melanoma (MEL) previously treated with anti–PD-1/PD-L1 therapy (abstract 9520). 20
17 American Society of Clinical Oncology annual meeting.
67. Advani R, Flinn I, Popplewell L, et al. CD47 Blockade by Hu5F9-G4 and Rituximab in Non-Hodgkin's Lymphoma. N Engl J Med
2018; 379:1711.
68. Wilcox RA, Chapoval AI, Gorski KS, et al. Cutting edge: Expression of functional CD137 receptor by dendritic cells. J Immunol
2002; 168:4262.

69. McHugh RS, Whitters MJ, Piccirillo CA, et al. CD4(+)CD25(+) immunoregulatory T cells: gene expression analysis reveals a
functional role for the glucocorticoid-induced TNF receptor. Immunity 2002; 16:311.

70. Vinay DS, Kwon BS. 4-1BB signaling beyond T cells. Cell Mol Immunol 2011; 8:281.
71. Hernandez-Chacon JA, Li Y, Wu RC, et al. Costimulation through the CD137/4-1BB pathway protects human melanoma
tumor-infiltrating lymphocytes from activation-induced cell death and enhances antitumor effector function. J Immunother
2011; 34:236.

72. Melero I, Shuford WW, Newby SA, et al. Monoclonal antibodies against the 4-1BB T-cell activation molecule eradicate
established tumors. Nat Med 1997; 3:682.

73. Uno T, Takeda K, Kojima Y, et al. Eradication of established tumors in mice by a combination antibody-based therapy. Nat
Med 2006; 12:693.

74. Takeda K, Kojima Y, Uno T, et al. Combination therapy of established tumors by antibodies targeting immune activating and
suppressing molecules. J Immunol 2010; 184:5493.
75. Youlin K, Jianwei Z, Xin G, et al. 4-1BB protects dendritic cells from prostate cancer-induced apoptosis. Pathol Oncol Res
2013; 19:177.

76. Sznol M, Hodi FS, Margolin K, et al. Phase I study of BMS-663513, a fully human anti-CD137 agonist monoclonal antibody in
patients with advanced cancer (abstract 3007). 2008 American Society of Clinical Oncology meeting.
77. Segal NH, He AR, Doi T, et al. Phase I Study of Single-Agent Utomilumab (PF-05082566), a 4-1BB/CD137 Agonist, in Patients
with Advanced Cancer. Clin Cancer Res 2018; 24:1816.

78. Weinberg AD, Morris NP, Kovacsovics-Bankowski M, et al. Science gone translational: the OX40 agonist story. Immunol Rev
2011; 244:218.

79. Takeda I, Ine S, Killeen N, et al. Distinct roles for the OX40-OX40 ligand interaction in regulatory and nonregulatory T cells. J
Immunol 2004; 172:3580.

80. Griseri T, Asquith M, Thompson C, Powrie F. OX40 is required for regulatory T cell-mediated control of colitis. J Exp Med
2010; 207:699.

81. Valzasina B, Guiducci C, Dislich H, et al. Triggering of OX40 (CD134) on CD4(+)CD25+ T cells blocks their inhibitory activity: a
novel regulatory role for OX40 and its comparison with GITR. Blood 2005; 105:2845.

82. Croft M. Control of immunity by the TNFR-related molecule OX40 (CD134). Annu Rev Immunol 2010; 28:57.

83. Weinberg AD, Rivera MM, Prell R, et al. Engagement of the OX-40 receptor in vivo enhances antitumor immunity. J Immunol
2000; 164:2160.

84. Gough MJ, Crittenden MR, Sarff M, et al. Adjuvant therapy with agonistic antibodies to CD134 (OX40) increases local control
after surgical or radiation therapy of cancer in mice. J Immunother 2010; 33:798.

85. Pan PY, Zang Y, Weber K, et al. OX40 ligation enhances primary and memory cytotoxic T lymphocyte responses in an
immunotherapy for hepatic colon metastases. Mol Ther 2002; 6:528.

86. Watanabe A, Hara M, Chosa E, et al. Combination of adoptive cell transfer and antibody injection can eradicate established
tumors in mice--an in vivo study using anti-OX40mAb, anti-CD25mAb and anti-CTLA4mAb-. Immunopharmacol
Immunotoxicol 2010; 32:238.

87. Hirschhorn-Cymerman D, Rizzuto GA, Merghoub T, et al. OX40 engagement and chemotherapy combination provides
potent antitumor immunity with concomitant regulatory T cell apoptosis. J Exp Med 2009; 206:1103.
 88. Nocentini G, Ronchetti S, Petrillo MG, Riccardi C. Pharmacological modulation of GITRL/GITR system: therapeutic
perspectives. Br J Pharmacol 2012; 165:2089.

89. Schaer DA, Murphy JT, Wolchok JD. Modulation of GITR for cancer immunotherapy. Curr Opin Immunol 2012; 24:217.

90. Lacal PM, Petrillo MG, Ruffini F, et al. Glucocorticoid-induced tumor necrosis factor receptor family-related ligand triggering
upregulates vascular cell adhesion molecule-1 and intercellular adhesion molecule-1 and promotes leukocyte adhesion. J
Pharmacol Exp Ther 2013; 347:164.

91. Shimizu J, Yamazaki S, Takahashi T, et al. Stimulation of CD25(+)CD4(+) regulatory T cells through GITR breaks
immunological self-tolerance. Nat Immunol 2002; 3:135.

92. Stephens GL, McHugh RS, Whitters MJ, et al. Engagement of glucocorticoid-induced TNFR family-related receptor on
effector T cells by its ligand mediates resistance to suppression by CD4+CD25+ T cells. J Immunol 2004; 173:5008.
93. Ko K, Yamazaki S, Nakamura K, et al. Treatment of advanced tumors with agonistic anti-GITR mAb and its effects on tumor-
infiltrating Foxp3+CD25+CD4+ regulatory T cells. J Exp Med 2005; 202:885.

94. Schaer DA, Cohen AD, Wolchok JD. Anti-GITR antibodies--potential clinical applications for tumor immunotherapy. Curr
Opin Investig Drugs 2010; 11:1378.
95. Cohen AD, Schaer DA, Liu C, et al. Agonist anti-GITR monoclonal antibody induces melanoma tumor immunity in mice by
altering regulatory T cell stability and intra-tumor accumulation. PLoS One 2010; 5:e10436.

96. Simpson TR, Quezada SA, Allison JP. Regulation of CD4 T cell activation and effector function by inducible costimulator
(ICOS). Curr Opin Immunol 2010; 22:326.

97. Fan X, Quezada SA, Sepulveda MA, et al. Engagement of the ICOS pathway markedly enhances efficacy of CTLA-4 blockade
in cancer immunotherapy. J Exp Med 2014; 211:715.

98. Hassan SB, Sørensen JF, Olsen BN, Pedersen AE. Anti-CD40-mediated cancer immunotherapy: an update of recent and
ongoing clinical trials. Immunopharmacol Immunotoxicol 2014; 36:96.

99. Suntharalingam G, Perry MR, Ward S, et al. Cytokine storm in a phase 1 trial of the anti-CD28 monoclonal antibody
TGN1412. N Engl J Med 2006; 355:1018.

100. Davila ML, Brentjens R, Wang X, et al. How do CARs work?: Early insights from recent clinical studies targeting CD19.
Oncoimmunology 2012; 1:1577.

101. Sadelain M, Brentjens R, Rivière I. The basic principles of chimeric antigen receptor design. Cancer Discov 2013; 3:388.

102. Brentjens RJ, Davila ML, Riviere I, et al. CD19-targeted T cells rapidly induce molecular remissions in adults with
chemotherapy-refractory acute lymphoblastic leukemia. Sci Transl Med 2013; 5:177ra38.

103. Grupp SA, Kalos M, Barrett D, et al. Chimeric antigen receptor-modified T cells for acute lymphoid leukemia. N Engl J Med
2013; 368:1509.

104. Porter DL, Hwang WT, Frey NV, et al. Chimeric antigen receptor T cells persist and induce sustained remissions in relapsed
refractory chronic lymphocytic leukemia. Sci Transl Med 2015; 7:303ra139.

105. Geyer MB, Rivière I, Sénéchal B, et al. Safety and tolerability of conditioning chemotherapy followed by CD19-targeted CAR
T cells for relapsed/refractory CLL. JCI Insight 2019; 5.

106. Rosenberg SA, Restifo NP. Adoptive cell transfer as personalized immunotherapy for human cancer. Science 2015; 348:62.

107. Lu YC, Yao X, Crystal JS, et al. Efficient identification of mutated cancer antigens recognized by T cells associated with
durable tumor regressions. Clin Cancer Res 2014; 20:3401.

108. Rosenberg SA, Yang JC, Sherry RM, et al. Durable complete responses in heavily pretreated patients with metastatic
melanoma using T-cell transfer immunotherapy. Clin Cancer Res 2011; 17:4550.

109. Liddy N, Bossi G, Adams KJ, et al. Monoclonal TCR-redirected tumor cell killing. Nat Med 2012; 18:980.

110. Oates J, Hassan NJ, Jakobsen BK. ImmTACs for targeted cancer therapy: Why, what, how, and which. Mol Immunol 2015;
67:67.
111. Cameron BJ, Gerry AB, Dukes J, et al. Identification of a Titin-derived HLA-A1-presented peptide as a cross-reactive target
for engineered MAGE A3-directed T cells. Sci Transl Med 2013; 5:197ra103.

112. de Gruijl TD, Janssen AB, van Beusechem VW. Arming oncolytic viruses to leverage antitumor immunity. Expert Opin Biol
Ther 2015; 15:959.

113. Westphal M, Ylä-Herttuala S, Martin J, et al. Adenovirus-mediated gene therapy with sitimagene ceradenovec followed by
intravenous ganciclovir for patients with operable high-grade glioma (ASPECT): a randomised, open-label, phase 3 trial.
Lancet Oncol 2013; 14:823.

114. Freytag SO, Stricker H, Lu M, et al. Prospective randomized phase 2 trial of intensity modulated radiation therapy with or
without oncolytic adenovirus-mediated cytotoxic gene therapy in intermediate-risk prostate cancer. Int J Radiat Oncol Biol
Phys 2014; 89:268.

115. Dreno B, Urosevic-Maiwald M, Kim Y, et al. TG1042 (Adenovirus-interferon-γ) in primary cutaneous B-cell lymphomas: a
phase II clinical trial. PLoS One 2014; 9:e83670.

116. Dong J, Li W, Dong A, et al. Gene therapy for unresectable hepatocellular carcinoma using recombinant human adenovirus
type 5. Med Oncol 2014; 31:95.

117. Kicielinski KP, Chiocca EA, Yu JS, et al. Phase 1 clinical trial of intratumoral reovirus infusion for the treatment of recurrent
malignant gliomas in adults. Mol Ther 2014; 22:1056.

118. Zamarin D, Holmgaard RB, Subudhi SK, et al. Localized oncolytic virotherapy overcomes systemic tumor resistance to
immune checkpoint blockade immunotherapy. Sci Transl Med 2014; 6:226ra32.

119. Ribas A, Dummer R, Puzanov I, et al. Oncolytic Virotherapy Promotes Intratumoral T Cell Infiltration and Improves Anti-PD-1
Immunotherapy. Cell 2017; 170:1109.

120. Chesney J, Puzanov I, Collichio F, et al. 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; 36:1658.

121. Shifrin N, Raulet DH, Ardolino M. NK cell self tolerance, responsiveness and missing self recognition. Semin Immunol 2014;
26:138.

122. Kmiecik J, Zimmer J, Chekenya M. Natural killer cells in intracranial neoplasms: presence and therapeutic efficacy against
brain tumours. J Neurooncol 2014; 116:1.

123. Ishigami S, Natsugoe S, Tokuda K, et al. Prognostic value of intratumoral natural killer cells in gastric carcinoma. Cancer
2000; 88:577.

124. Villegas FR, Coca S, Villarrubia VG, et al. Prognostic significance of tumor infiltrating natural killer cells subset CD57 in
patients with squamous cell lung cancer. Lung Cancer 2002; 35:23.
125. Kohrt HE, Thielens A, Marabelle A, et al. Anti-KIR antibody enhancement of anti-lymphoma activity of natural killer cells as
monotherapy and in combination with anti-CD20 antibodies. Blood 2014; 123:678.

126. Nijhof IS, Lammerts van Bueren JJ, van Kessel B, et al. Daratumumab-mediated lysis of primary multiple myeloma cells is
enhanced in combination with the human anti-KIR antibody IPH2102 and lenalidomide. Haematologica 2015; 100:263.
127. Romagné F, André P, Spee P, et al. Preclinical characterization of 1-7F9, a novel human anti-KIR receptor therapeutic
antibody that augments natural killer-mediated killing of tumor cells. Blood 2009; 114:2667.

128. Vey N, Bourhis JH, Boissel N, et al. A phase 1 trial of the anti-inhibitory KIR mAb IPH2101 for AML in complete remission.
Blood 2012; 120:4317.

129. Benson DM Jr, Hofmeister CC, Padmanabhan S, et al. A phase 1 trial of the anti-KIR antibody IPH2101 in patients with
relapsed/refractory multiple myeloma. Blood 2012; 120:4324.

130. Benson DM Jr, Cohen AD, Jagannath S, et al. A Phase I Trial of the Anti-KIR Antibody IPH2101 and Lenalidomide in Patients
with Relapsed/Refractory Multiple Myeloma. Clin Cancer Res 2015; 21:4055.
131. Komohara Y, Jinushi M, Takeya M. Clinical significance of macrophage heterogeneity in human malignant tumors. Cancer
Sci 2014; 105:1.
132. Ruffell B, Coussens LM. Macrophages and therapeutic resistance in cancer. Cancer Cell 2015; 27:462.

133. DeNardo DG, Brennan DJ, Rexhepaj E, et al. Leukocyte complexity predicts breast cancer survival and functionally regulates
response to chemotherapy. Cancer Discov 2011; 1:54.

134. Ruffell B, Chang-Strachan D, Chan V, et al. Macrophage IL-10 blocks CD8+ T cell-dependent responses to chemotherapy by
suppressing IL-12 expression in intratumoral dendritic cells. Cancer Cell 2014; 26:623.
135. Shiao SL, Ruffell B, DeNardo DG, et al. TH2-Polarized CD4(+) T Cells and Macrophages Limit Efficacy of Radiotherapy. Cancer
Immunol Res 2015; 3:518.

136. Priceman SJ, Sung JL, Shaposhnik Z, et al. Targeting distinct tumor-infiltrating myeloid cells by inhibiting CSF-1 receptor:
combating tumor evasion of antiangiogenic therapy. Blood 2010; 115:1461.
137. Mok S, Koya RC, Tsui C, et al. Inhibition of CSF-1 receptor improves the antitumor efficacy of adoptive cell transfer
immunotherapy. Cancer Res 2014; 74:153.

138. Zhu Y, Knolhoff BL, Meyer MA, et al. CSF1/CSF1R blockade reprograms tumor-infiltrating macrophages and improves
response to T-cell checkpoint immunotherapy in pancreatic cancer models. Cancer Res 2014; 74:5057.

139. Cassier PA, Italiano A, Gomez-Roca CA, et al. CSF1R inhibition with emactuzumab in locally advanced diffuse-type
tenosynovial giant cell tumours of the soft tissue: a dose-escalation and dose-expansion phase 1 study. Lancet Oncol 2015;
16:949.

140. Tap WD, Wainberg ZA, Anthony SP, et al. Structure-Guided Blockade of CSF1R Kinase in Tenosynovial Giant-Cell Tumor. N
Engl J Med 2015; 373:428.
141. Tap WD, Gelderblom H, Palmerini E, et al. Pexidartinib versus placebo for advanced tenosynovial giant cell tumour
(ENLIVEN): a randomised phase 3 trial. Lancet 2019; 394:478.

142. Hwu P, Du MX, Lapointe R, et al. Indoleamine 2,3-dioxygenase production by human dendritic cells results in the inhibition
of T cell proliferation. J Immunol 2000; 164:3596.

143. Katz JB, Muller AJ, Prendergast GC. Indoleamine 2,3-dioxygenase in T-cell tolerance and tumoral immune escape. Immunol
Rev 2008; 222:206.

144. Hamid O, Gajewski TF, Frankel AE, et al. Epacadostat Plus Pembrolizumab in Patients With Advanced Melanoma: Phase 1 an
d 2 Efficacy and Safety Results From ECHO-202/KEYNOTE-037 (abstract 1214O). European Society for Medical Oncology ann
ual meeting, 2017.
145. Long GV, Dummer R, Hamid O, et al. Epacadostat plus pembrolizumab versus placebo plus pembrolizumab in patients with
unresectable or metastatic melanoma (ECHO-301/KEYNOTE-252): a phase 3, randomised, double-blind study. Lancet Oncol
2019; 20:1083.

146. Ozao-Choy J, Lee DJ, Faries MB. Melanoma vaccines: mixed past, promising future. Surg Clin North Am 2014; 94:1017.

147. Kantoff PW, Higano CS, Shore ND, et al. Sipuleucel-T immunotherapy for castration-resistant prostate cancer. N Engl J Med
2010; 363:411.

148. Schwartzentruber DJ, Lawson DH, Richards JM, et al. gp100 peptide vaccine and interleukin-2 in patients with advanced
melanoma. N Engl J Med 2011; 364:2119.

149. Hodi FS, O'Day SJ, McDermott DF, et al. Improved survival with ipilimumab in patients with metastatic melanoma. N Engl J
Med 2010; 363:711.

150. Sahin U, Derhovanessian E, Miller M, et al. Personalized RNA mutanome vaccines mobilize poly-specific therapeutic
immunity against cancer. Nature 2017; 547:222.

151. Ott PA, Hu Z, Keskin DB, et al. An immunogenic personal neoantigen vaccine for patients with melanoma. Nature 2017;
547:217.
152. Osorio JC, Arbour KC, Le DT, et al. Lesion-Level Response Dynamics to Programmed Cell Death Protein (PD-1) Blockade. J
Clin Oncol 2019; 37:3546.

153. Wolchok JD, Hoos A, O'Day S, et al. Guidelines for the evaluation of immune therapy activity in solid tumors: immune-
related response criteria. Clin Cancer Res 2009; 15:7412.

154. Vrankar M, Unk M. Immune RECIST criteria and symptomatic pseudoprogression in non-small cell lung cancer patients
treated with immunotherapy. Radiol Oncol 2018; 52:365.

155. Seymour L, Bogaerts J, Perrone A, et al. iRECIST: guidelines for response criteria for use in trials testing
immunotherapeutics. Lancet Oncol 2017; 18:e143.

156. Hodi FS, Ballinger M, Lyons B, et al. Immune-Modified Response Evaluation Criteria In Solid Tumors (imRECIST): Refining
Guidelines to Assess the Clinical Benefit of Cancer Immunotherapy. J Clin Oncol 2018; 36:850.
157. Hodi FS, Hwu WJ, Kefford R, et al. Evaluation of Immune-Related Response Criteria and RECIST v1.1 in Patients With
Advanced Melanoma Treated With Pembrolizumab. J Clin Oncol 2016; 34:1510.

158. Robert C, Long GV, Brady B, et al. Nivolumab in previously untreated melanoma without BRAF mutation. N Engl J Med 2015;
372:320.
159. Weber JS, D'Angelo SP, Minor D, et al. Nivolumab versus chemotherapy in patients with advanced melanoma who
progressed after anti-CTLA-4 treatment (CheckMate 037): a randomised, controlled, open-label, phase 3 trial. Lancet Oncol
2015; 16:375.

160. Larkin J, Chiarion-Sileni V, Gonzalez R, et al. Combined Nivolumab and Ipilimumab or Monotherapy in Untreated Melanoma.
N Engl J Med 2015; 373:23.
161. Weber JS, Kudchadkar RR, Yu B, et al. Safety, efficacy, and biomarkers of nivolumab with vaccine in ipilimumab-refractory or
-naive melanoma. J Clin Oncol 2013; 31:4311.

162. Reck M, Rodríguez-Abreu D, Robinson AG, et al. Pembrolizumab versus Chemotherapy for PD-L1-Positive Non-Small-Cell
Lung Cancer. N Engl J Med 2016; 375:1823.
163. Schmid P, Adams S, Rugo HS, et al. Atezolizumab and Nab-Paclitaxel in Advanced Triple-Negative Breast Cancer. N Engl J
Med 2018; 379:2108.

164. Cortes J, Cescon DW, Rugo HS, et al. Pembrolizumab plus chemotherapy versus placebo plus chemotherapy for previously
untreated locally recurrent inoperable or metastatic triple-negative breast cancer (KEYNOTE-355): a randomised, placebo-
controlled, double-blind, phase 3 clinical trial. Lancet 2020; 396:1817.
165. Cortes J, Cescon DW, Rugo HS, et al. KEYNOTE-355: Randomized, double-blind, phase III study of pembrolizumab plus
chemotherapy versus placebo plus chemotherapy for previously untreated locally recurrent inoperable or metastatic triple-
negative breast cancer. J Clin Oncol 2020; 38S: ASCO #1000.

166. Burtness B, Harrington KJ, Greil R, et al. Pembrolizumab alone or with chemotherapy versus cetuximab with chemotherapy
for recurrent or metastatic squamous cell carcinoma of the head and neck (KEYNOTE-048): a randomised, open-label,
phase 3 study. Lancet 2019; 394:1915.

167. Fuchs CS, Doi T, Jang RW, et al. Safety and Efficacy of Pembrolizumab Monotherapy in Patients With Previously Treated
Advanced Gastric and Gastroesophageal Junction Cancer: Phase 2 Clinical KEYNOTE-059 Trial. JAMA Oncol 2018; 4:e180013.

168. Chung HC, Ros W, Delord JP, et al. Efficacy and Safety of Pembrolizumab in Previously Treated Advanced Cervical Cancer:
Results From the Phase II KEYNOTE-158 Study. J Clin Oncol 2019; 37:1470.

169. Balar AV, Castellano D, O'Donnell PH, et al. First-line pembrolizumab in cisplatin-ineligible patients with locally advanced
and unresectable or metastatic urothelial cancer (KEYNOTE-052): a multicentre, single-arm, phase 2 study. Lancet Oncol
2017; 18:1483.
170. Lu S, Stein JE, Rimm DL, et al. Comparison of Biomarker Modalities for Predicting Response to PD-1/PD-L1 Checkpoint
Blockade: A Systematic Review and Meta-analysis. JAMA Oncol 2019.
Topic 99637 Version 27.0
GRAPHICS

Simplified immune synapse in a naïve (CD4 or) CD8 T cell and for an activated CD8+ T cell

Initially, CD8a/b chains recognize the MHC class 1 of a peptide presented by an antigen presented cell, and CD28 binds to CD80/86 to lead to
downstream activation (bottom), which releases IL-12, IFN-gamma, and meanwhile leads to feedback production of CTLA-4 in cytoplasm, which is
rapidly brought to the surface (red). Additional costimulatory receptors (not pictured) on activated T cell/APC synapses include OX40/OX40-ligand, CD40-
L/CD40, glucocorticoid-induced tumor necrosis factor (GITR)/GITR-L.

IL: interleukin; IFNg: interferon gamma; CTLA-4: cytotoxic T-lymphocyte-associated protein 4; CD: cluster of differentiation; APC: antigen-presenting cells; MHC:
major histocompatibility complex.

Graphic 103095 Version 1.0

Simplified immune synapse for an anergic CD8 T cell

In the absence of the "second signal," which in the naïve T cell is CD28 but in activated T cells can be OX40, CD137, etc, T cells can become anergic
and do not mount a response to antigen.

CD: cluster of differentiation; APC: antigen-presenting cells; MHC: major histocompatibility complex.

Graphic 103339 Version 1.0

Cancer immunoediting

Cancer immunoediting is an extrinsic tumor suppressor mechanism that engages only after cellular transformation has occurred
and intrinsic tumor suppressor mechanisms have failed. In its most complex form, cancer immunoediting consists of three
sequential phases: elimination, equilibrium, and escape. In the elimination phase, innate and adaptive immunity work together to
destroy developing tumors long before they become clinically apparent. Many of the immune molecules and cells that participate in
the elimination phase have been identified, but more work is needed to determine their exact sequence of action. If this phase
goes to completion, then the host remains free of cancer, and elimination thus represents the full extent of the process. If, however,
a rare cancer cell variant is not destroyed in the elimination phase, it may then enter the equilibrium phase, in which its outgrowth
is prevented by immunologic mechanisms. T cells, IL-12, and IFN-γ are required to maintain tumor cells in a state of functional
dormancy, whereas NK cells and molecules that participate in the recognition or effector function of cells of innate immunity are
not required; this indicates that equilibrium is a function of adaptive immunity only. Editing of tumor immunogenicity occurs in the
equilibrium phase. Equilibrium may also represent an end stage of the cancer immunoediting process and may restrain outgrowth
of occult cancers for the lifetime of the host. However, as a consequence of constant immune selection pressure placed on
genetically unstable tumor cells held in equilibrium, tumor cell variants may emerge that (i) are no longer recognized by adaptive
immunity (antigen loss variants or tumors cells that develop defects in antigen processing or presentation), (ii) become insensitive
to immune effector mechanisms, or (iii) induce an immunosuppressive state within the tumor microenvironment. These tumor cells
may then enter the escape phase, in which their outgrowth is no longer blocked by immunity. These tumor cells emerge to cause
clinically apparent disease.

Modified with permission from the Annual Review of Immunology. Vesely MD, Kershaw MH, Schreiber RD, Smyth MJ. Natural Innate and Adaptive
Immunity to Cancer. 2011; 29:235. Copyright © 2011 Annual Reviews, http://www.annualreviews.org.

Graphic 103342 Version 1.0

PD-1-PD-L1 binding leads to peripheral CD8+ T cell "exhaustion" phenotype

In a state of chronic antigen presentation, such as malignancy, the chronic presence of antigen or pro-inflammatory cytokines (IL-12, IFNgamma, etc) can
upregulate PD-1 expression on the T cell; tumor clones can also select for PD-L1 expression. With PD-1-PD-L1 binding, even in the presence of the
costimulatory molecule, "peripheral exhaustion" can occur.

PD-L1: programmed death-ligand 1; CD: cluster of differentiation; PD-1: programmed cell death-1; APC: antigen-presenting cells; MHC: major histocompatibility
complex; IL: interleukin; IFNgamma: interferon gamma.

Graphic 103341 Version 2.0

CTLA-4 acting as physiologic "brake" on costimulation of CD8+ T cell

CTLA4 outcompetes CD28 for CD80 and CD86, and the costimulatory signal ceases as the target is eliminated, reducing the release of pro-effector
cytokines such as IL-12 and cytotoxic enzymes such as perforin and granzyme B. Homeostasis is restored.

CD: cluster of differentiation; CTLA-4: cytotoxic T-lymphocyte-associated protein 4; APC: antigen-presenting cells; MHC: major histocompatibility complex; IL:
interleukin.

Graphic 103340 Version 1.0

Immune activation and checkpoint inhibition

PD1: programmed cell death receptor 1; PDL1: programmed cell death ligand 1; INFγ: interferon gamma; TCR: T cell receptor; CD28: cluster of differentiation 28; MHC: major
histocompatibility complex; CTLA4: cytotoxic T-lymphocyte-associated protein 4.

Reproduced with permission from: Scott Gettinger, MD.

Graphic 90346 Version 4.0

A simplified view of co-stimulatory and co-inhibitory ligand-receptor pairs that
regulate T cell activity

Note that some binding partners involving some molecules, such as VISTA, are still being explored. Many
additional co-stimulatory and co-inhibitory molecules (not shown) are involved in T cell activity and in the
tumor microenvironment.

Original figure modified for this publication. Callahan MK, Postow MA, Wolchok JD. Immunomodulatory therapy for
melanoma: ipilimumab and beyond. Clin Dermatol 2013; 31:191. Illustration used with the permission of Elsevier Inc. All
rights reserved.

Graphic 112935 Version 1.0

Delayed response to ipilimumab therapy

This patient with metastatic melanoma had no discernible disease in the liver at baseline. After four doses of ipilimumab,
numerous lesions were apparent, classically considered progression. However, two months later, without drug, these
lesions regressed. After four additional doses of ipilimumab, the patient had a complete response.

Reproduced with permission from: Saenger YM, Wolchok JD. The heterogeneity of the kinetics of response to ipilimumab in metastatic
melanoma: patient cases. Cancer Immun 2008; 8:1. Copyright © 2008 Jedd D. Wolchok.

Graphic 103343 Version 2.0

Consensus-based guideline for assessing response to immunotherapy in cancer (iRECIST): Comparison with standard RECIST 1.1

  RECIST 1.1 iRECIST

Definitions of measurable and Measurable lesions are ≥10 mm in diameter (≥15 mm for nodal No change from RECIST 1.1; however, new lesions are assessed as
non-measurable disease; lesions); maximum of five lesions (two per organ); all other disease is per RECIST 1.1 but are recorded separately on the case report form
numbers and site of target considered non-target (must be ≥10 mm in short axis for nodal (but not included in the sum of lesions for target lesions identified at
disease disease) baseline)

Complete response, partial Cannot have met criteria for progression before complete response, Can have had iUPD (one or more instances), but not iCPD, before iCR,
response, or stable disease partial response, or stable disease iPR, or iSD

Confirmation of complete Only required for non-randomised trials As per RECIST 1.1
response or partial response

Confirmation of stable disease Not required As per RECIST 1.1

New lesions Result in progression; recorded but not measured Results in iUPD but iCPD is only assigned on the basis of this
category if at next assessment additional new lesions appear or an
increase in size of new lesions is seen (≥5 mm for sum of new lesion
target or any increase in new lesion non-target); the appearance of
new lesions when none have previously been recorded, can also
confirm iCPD

Independent blinded review and Recommended in some circumstances (eg, in some trials with Collection of scans (but not independent review) recommended for
central collection of scans progression-based endpoints planned for marketing approval) all trials

Confirmation of progression Not required (unless equivocal) Required

Consideration of clinical status Not included in assessment Clinical stability is considered when deciding whether treatment is
continued after iUPD

"i" indicates immune responses assigned using iRECIST.

RECIST: Response Evaluation Criteria in Solid Tumours; iUPD: unconfirmed progression; iCPD: confirmed progression; iCR: complete response; iPR: partial response; iSD: stable disease.

Reproduced from: Seymour L, Bogaerts J, Perrone A, et al. iRECIST: guidelines for response criteria for use in trials testing immunotherapeutics. Lancet Oncol 2017; 18:e143. Table used with the
permission of Elsevier Inc. All rights reserved.

Graphic 115573 Version 1.0

Immune response criteria for immunotherapy (iRECIST): Assignment of timepoint response

Timepoint response with

  no previous iUPD in any Timepoint response with previous iUPD in any category*
category

Target lesions: iCR; non-target lesions: iCR; new iCR iCR

lesions: no

Target lesions: iCR; non-target lesions: non- iPR iPR

iCR/non-iUPD; new lesions: no

Target lesions: iPR; non-target lesions: non- iPR iPR

iCR/non-iUPD; new lesions: no

Target lesions: iSD; non-target lesions: non- iSD iSD

iCR/non-iUPD; new lesions: no

Target lesions: iUPD with no change, or with a Not applicable New lesions confirm iCPD if new lesions were previously identified and they have
decrease from last timepoint; non-target lesions: increased in size (≥5 mm in sum of measures for new lesion target or any increase for
iUPD with no change, or decrease from last new lesion non-target) or number; if no change is seen in new lesions (size or number)
timepoint; new lesions: yes from last timepoint, assignment remains iUPD

Target lesions: iSD, iPR, iCR; non-target lesions: iUPD Remains iUPD unless iCPD is confirmed on the basis of a further increase in the size of
iUPD; new lesions: no non-target disease (does not need to meet RECIST 1.1 criteria for unequivocal
progression)

Target lesions: iUPD; non-target lesions: non- iUPD Remains iUPD unless iCPD is confirmed on the basis of a further increase in sum of
iCR/non-iUPD, or iCR; new lesions: no measures ≥5 mm; otherwise, assignment remains iUPD

Target lesions: iUPD; non-target lesions: iUPD; new iUPD Remains iUPD unless iCPD is confirmed based on a further increase in previously
lesions: no identified target lesion iUPD in sum of measures ≥5 mm or non-target lesion iUPD
(previous assessment need not have shown unequivocal progression)

Target lesions: iUPD; non-target lesions: iUPD; new iUPD Remains iUPD unless iCPD is confirmed on the basis of a further increase in previously
lesions: yes identified target lesion iUPD sum of measures ≥5 mm, previously identified non-target
lesion iUPD (does not need to be unequivocal), or an increase in the size or number of
new lesions previously identified

Target lesions: non-iUPD or progression; non- iUPD Remains iUPD unless iCPD is confirmed on the basis of an increase in the size or
target lesions: non-iUPD or progression; new number of new lesions previously identified
lesions: yes

Target lesions, non-target lesions, and new lesions defined according to RECIST 1.1 principles; if no pseudoprogression occurs, RECIST 1.1 and iRECIST categories for
complete response, partial response, and stable disease would be the same.

iUPD: unconfirmed progression; iCR: complete response; non-iCR/non-iUPD: criteria for neither CR nor PD have been met; iPR: partial response; iSD: stable disease; iCPD: confirmed
progression; RECIST: Response Evaluation Criteria in Solid Tumours.
* Previously identified in assessment immediately before this timepoint. "i" indicates immune responses assigned using iRECIST.

Reproduced from: Seymour L, Bogaerts J, Perrone A, et al. iRECIST: guidelines for response criteria for use in trials testing immunotherapeutics. Lancet Oncol 2017; 18:e143. Table used with the
permission of Elsevier Inc. All rights reserved.

Graphic 115574 Version 1.0

Comparison of imRECIST with RECIST v1.1 and irRC

Criterion RECIST v1.1 irRC imRECIST

Tumor burden Unidimensional Bidimensional per WHO Unidimensional, with other target lesion
criteria (number, measurability) per RECIST
Up to five target lesions or two per organ Up to 10 target lesions or five per organ v1.1

New lesions Always represent PD New lesions do not categorically define PD New lesions do not categorically define PD

  Measurable new lesions incorporated into Measurable new lesions incorporated into
the total tumor burden the total tumor burden

  Nonmeasurable new lesions preclude CR Nonmeasurable new lesions preclude CR

Nontarget lesions Can contribute to defining CR or PD Nontarget progression does not define PD Nontarget progression does not define PD
(unequivocal progression)
Can only contribute to defining CR (complete Can only contribute to defining CR (complete
disappearance required) disappearance required)

PD ≥20% increase in the SLD (RECIST) and ≥5 Determined only on the basis of measurable Determined only on the basis of measurable
mm increase compared with nadir, disease disease
unequivocal progression in nontarget
lesions, and/or appearance of new lesions

  Negated by subsequent non-PD assessment Negated by subsequent non-PD assessment

≥4 weeks from the date first documented ≥4 weeks from the date first documented
(lack of confirmation) (lack of confirmation)

  ≥25% increase in the SLD compared with ≥20% increase in SLD (RECIST) compared with
baseline/nadir baseline/nadir

Confirmation of PD not required Best response may occur before confirmed Best response may occur after any number
PD of PD assessments

imRECIST: immune-modified Response Evaluation Criteria In Solid Tumors; RECIST: Response Evaluation Criteria In Solid Tumors; irRC: immune-related response criteria; WHO: World
Health Organization; PD: progressive disease; CR: complete response; SLD: sum of longest diameters.

From: Hodi FS, Ballinger M, Lyons B, et al. Immune-Modified Response Evaluation Criteria In Solid Tumors (imRECIST): Refining Guidelines to Assess the Clinical Benefit of Cancer Immunotherapy. J
Clin Oncol 2018. Reprinted with permission © 2018 American Society of Clinical Oncology.

Graphic 116649 Version 2.0

Contributor Disclosures
Alexander N Shoushtari, MD Grant/Research/Clinical Trial Support: Bristol-Myers Squibb; Immunocore; Novartis [Immunotherapy]; Xcovery
[Targeted therapy]; Polaris; Pfizer [Immunotherapy]. Consultant/Advisory Boards: Castle Biosciences; Immunocore; Bristol-Myers Squibb
[Immunotherapy]. Matthew Hellmann, MD Equity Ownership/Stock Options: Shattuck Labs; Immunai [Immunotherapy]. Patent Holder: MSK
Pharma [Tumor mutation burden to predict response to immunotherapy (PCT/US2015/062208)]. Grant/Research Support: Bristol-Myers
Squibb; Genentech; Merck; AstraZeneca [Immunotherapy]. Consultant/Advisory Boards: Bristol-Myers Squibb; Genentech; Merck;
AstraZeneca; Nektar Therapeutics; Mirati Therapeutics; Syndax Pharmaceuticals; Shattuck Labs; Immunai; Blueprint
[Immunotherapy]. Michael B Atkins, MD Equity Ownership/Stock Options: Werewolf Therapeutics; Pyxis [Immunotherapy].
Grant/Research/Clinical Trial Support: Bristol Myers Squibb [Melanoma and RCC]; Merck [Melanoma and RCC]; AstraZeneca [RCC].
Consultant/Advisory Boards: Bristol Myers Squibb; Merck; Novartis; Pfizer; Roche; Exelixis; Eisai; Adagene; Agenus; Asher Bio; Apexigen;
AstraZeneca; Aveo; Idera; ImmunoCore; Iovance; Surface; Pneuma; Leads; Arrowhead; Fathom; SeaGen; Symphogen; PACT; Neoleukin
[Melanoma, RCC, immunotherapy]. Sonali Shah, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a
multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content
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