U.S. patent application number 17/011455 was filed with the patent office on 2021-02-25 for suppression of myeloid derived suppressor cells and immune checkpoint blockade.
The applicant listed for this patent is The Johns Hopkins University. Invention is credited to Kibem Kim, Kenneth W. Kinzler, Bert Vogelstein, Shibin Zhou.
Application Number | 20210052729 17/011455 |
Document ID | / |
Family ID | 1000005196841 |
Filed Date | 2021-02-25 |
United States Patent
Application |
20210052729 |
Kind Code |
A1 |
Zhou; Shibin ; et
al. |
February 25, 2021 |
SUPPRESSION OF MYELOID DERIVED SUPPRESSOR CELLS AND IMMUNE
CHECKPOINT BLOCKADE
Abstract
Impressive responses have been observed in patients treated with
checkpoint inhibitory anti-PD-1 or anti-CTLA-4 antibodies. However,
immunotherapy against poorly immunogenic cancers remains a
challenge. Treatment with both anti-PD-1 and anti-CTLA-4 antibodies
were unable to eradicate large, modestly immunogenic CT26 tumors or
metastatic 4T1 tumors. However, co-treatment with epigenetic
modulating drugs and checkpoint inhibitors markedly improved
treatment outcomes, curing more than 80% of them. Functional
studies revealed that the primary targets of the epigenetic
modulators were myeloid-derived suppressor cells (MDSCs). A
PI3K-inhibitor that reduced circulating MDSCs also cured 80% of
mice with metastatic 4T1 tumors when combined with immune
checkpoint inhibitors. Thus, cancers resistant to immune checkpoint
blockade can be cured by eliminating MDSCs.
Inventors: |
Zhou; Shibin; (Owings Mills,
MD) ; Vogelstein; Bert; (Baltimore, MD) ;
Kinzler; Kenneth W.; (Baltimore, MD) ; Kim;
Kibem; (Lutherville, MD) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
The Johns Hopkins University |
Baltimore |
MD |
US |
|
|
Family ID: |
1000005196841 |
Appl. No.: |
17/011455 |
Filed: |
September 3, 2020 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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15326186 |
Jan 13, 2017 |
10869926 |
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PCT/US2015/040107 |
Jul 13, 2015 |
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17011455 |
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62024731 |
Jul 15, 2014 |
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62069881 |
Oct 29, 2014 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61K 39/39558 20130101;
A61K 35/742 20130101; A61K 31/437 20130101; A61K 2039/505 20130101;
A61K 45/06 20130101; C07K 2317/92 20130101; A61K 31/4406 20130101;
A61K 39/3955 20130101; C07K 2317/34 20130101; A61K 31/706 20130101;
C07K 16/2818 20130101 |
International
Class: |
A61K 39/395 20060101
A61K039/395; A61K 31/706 20060101 A61K031/706; A61K 31/437 20060101
A61K031/437; A61K 31/4406 20060101 A61K031/4406; C07K 16/28
20060101 C07K016/28; A61K 45/06 20060101 A61K045/06; A61K 35/742
20060101 A61K035/742 |
Goverment Interests
STATEMENT OF FEDERALLY SPONSORED RESEARCH
[0001] This invention was made with government support under grants
CA043460 and CA062924 awarded by the National Institutes of Health.
The government has certain rights in the invention.
Claims
1-66. (canceled)
67. A method of treating a mammal with a bacterial or viral
infection, comprising: administering at least one agent which
suppresses myeloid derived suppressor cells (MDSCs), wherein the
agent is selected from the group consisting of a histone
deacetylase inhibitor, a DNA methyltransferase inhibitor, a
p110.alpha. subunit of phosphoinositol 3 kinase (PI3K) inhibitor,
and combinations thereof.
68. The method of claim 67, wherein the agent is a histone
deacetylase inhibitor and the histone deacetylase inhibitor is
entinostat.
69. The method of claim 67, wherein the agent is a DNA
methyltransferase inhibitor and the DNA methyltransferase inhibitor
is 5-azacytadine.
70. The method of claim 67, wherein the agent is a p110.alpha.
subunit of phosphoinositol 3 kinase (PI3K) inhibitor and the
p110.alpha. subunit of phosphoinositol 3 kinase (PI3K) inhibitor is
J32.
71. The method of claim 67, wherein the infection is a chronic
viral infection.
72. he method of claim 67, wherein the infection is bacterial with
associated sepsis.
Description
TECHNICAL FIELD OF THE INVENTION
[0002] This invention is related to the area of cancer treatment.
In particular, it relates to combination therapies to overcome
treatment refractory tumors.
BACKGROUND OF THE INVENTION
[0003] The mammalian immune system is delicately regulated,
allowing it to mount an effective attack against foreign invaders
such as bacteria and viruses with minimal bystander casualties.
This requires functionally redundant regulatory mechanisms to
ensure safety (1-3). Cancers appear able to hijack these mechanisms
to avoid immune destruction. Several of the regulatory mechanisms
exploited by cancer have been identified. These include regulatory
T cells (Tregs), circulating MDSCs, resident tumor-associated
macrophages and neutrophils, checkpoint inhibiting receptors on
T-cells, and immunosuppressive cytokines (4-8). Most recently, the
checkpoints guarded by the PD-1 and CTLA-4 receptors have been
under intense investigation because of the availability of
antibodies which can inhibit their function. Recent clinical trials
with anti-CTLA-4, anti-PD-1 and anti-PD-L1 monoclonal antibodies
(mAbs) showed remarkable therapeutic responses (9-12), underscoring
the idea that disruption of the immune checkpoints can be
therapeutically useful. Yet, the objective responses were observed
in a minority of the treated patients and tumor types, and the
reasons why certain tumors respond and others don't are mysterious.
CT26 and 4T1 are among the most popular syngeneic tumor models used
for assessing novel therapeutic approaches. CT26 was derived from
an undifferentiated colorectal carcinoma induced in a BALB/c mouse
by repeated intrarectal instillations of N-nitroso-N-methylurethan
and shown to be modestly immunogenic (13, 14), whereas 4T1
originated from a spontaneous mammary tumor in a BALB/c mouse (15).
4T1 is poorly immunogenic and highly metastatic, characteristics
shared with advanced human cancers (16). Despite the extensive use
of these tumor cell lines in cancer research, little genetic
characterization is available for either of them.
[0004] There is a continuing need in the art to overcome the
problem of treatment recalcitrant cancers so that remissions may be
longer lasting and more widely spread in the population
treated.
SUMMARY OF THE INVENTION
[0005] According to one aspect of the invention a method of
treating a tumor-bearing mammal is provided. At least one first
agent which suppresses myeloid derived suppressor cells (MDSCs) is
administered to the mammal. At least one second agent which blocks
an immune checkpoint is administered to the mammal. The tumor may
or may not be non-small cell lung cancer (NSLC).
[0006] According to another aspect of the invention a kit is
provided. The kit comprises a single package and contains at least
one first agent which suppresses myeloid derived suppressor cells
(MDSCs). It further contains at least two second agents which block
at least two immune checkpoints.
[0007] In yet another aspect of the invention a composition is
provided. The composition comprises at least one first agent which
suppresses myeloid derived suppressor cells (MDSCs) and at least
two second agents which block at least two immune checkpoints.
[0008] According to another aspect of the invention a method of
treating a tumor-bearing mammal is provided. At least one first
agent which suppresses myeloid derived suppressor cells (MDSCs) is
administered to the mammal. At least two second agents which block
at least two immune checkpoints are administered to the mammal.
[0009] In yet another aspect of the invention a method of treating
a mammal with a bacterial or viral infection is provided. At least
one agent which suppresses myeloid derived suppressor cells (MDSCs)
is administered. The agent is selected from the group consisting of
a histone deacetylase inhibitor, a DNA methyltransferase inhibitor,
a p110.alpha. subunit of phosphoinositol 3 kinase (PI3K) inhibitor,
and combinations thereof.
[0010] These and other embodiments which will be apparent to those
of skill in the art upon reading the specification provide the art
with therapeutic preparations and methods for treating hard to
treat tumors.
BRIEF DESCRIPTION OF THE DRAWINGS
[0011] FIGS. 1A to 1G. Therapeutic response of tumor-bearing mice.
BALB/c mice bearing different tumors were treated with various
therapeutic modalities as indicated. IgG, IgG control; P, anti-PD-1
antibody; C, anti-CTLA-4 antibody; AZA, 5-azacytidine; ENT,
entinostat. Tumor volumes (FIG. 1A, FIG. 1C, and FIG. 1E) and
animal survival (FIG. 1B, FIG. 1D, and FIG. 1F) were recorded.
(FIG. 1A and FIG. 1B) BALB/c mice with CT26 tumors of moderate
sizes. (FIG. 1C and FIG. 1D) BALB/c mice with large CT26 tumors.
(FIG. 1E and FIG. 1F) BALB/c mice with metastatic 4T1 tumors. (FIG.
1G) 4T1 tumor-bearing mice were treated as indicated and euthanized
six weeks after tumor implantation. Primary tumor from each mouse
was measured and metastatic lesions (mets) lesions in different
organs were counted. Means and standard deviations are shown.
Number (n) of animals used in each experimental arm and P-values
are also indicated. *P<0.05, **P<0.01, ***P<0.001, ns, not
significant.
[0012] FIGS. 2A-2H. Response of immune cells following immune
checkpoint blockade and epigenetic modulation. BALB/c mice bearing
metastatic 4T1 tumors were treated with indicated therapeutic
modalities, followed by FACS and immunohistofluorescent analyses to
assess tumor-infiltrating and circulating immune cells. Means and
standard deviations are shown, with P-values indicated. (FIG. 2A)
FACS result for tumor-infiltrating CD8.sup.+ T cells. (FIG. 2B)
Representative immunohistofluorescent staining of
tumor-infiltrating CD8.sup.+ T cells. Scale bar, 50 .mu.m. (FIG.
2C) FACS result for tumor-infiltrating
CD4.sup.+CD25.sup.+FoxP3.sup.+ Tregs. (FIG. 2D) Representative FACS
data showing percentages of FoxP3 and CD25 double positive cells in
CD45.sup.+CD3.sup.+CD4.sup.+ gated tumor-infiltrating cells. (FIG.
2E) FACS result for circulating G-MDSCs. (F) Representative FACS
data showing percentages of Ly6G.sup.+Ly6C.sup.lo cells in
CD45.sup.+CD11b.sup.+F4/80.sup.-MHC-II.sup.- gated circulating
cells. (FIG. 2G) FACS result for tumor-infiltrating G-MDSCs. (FIG.
211) Representative immunohistofluorescent staining of
tumor-infiltrating Ly6G.sup.+ cells. Scale bar, 50 .mu.m.
[0013] FIGS. 3A-3C. Myeloid-derived Ly6G.sup.+ cells are
responsible for resistance to immune checkpoint blockade. (FIG. 3A)
BALB/c mice bearing 4T1 tumors were treated with various antibodies
or antibody combinations as indicated and tumor volumes recorded
over time. .alpha.Ly6G, anti-Ly6G antibody; .alpha.CD25, anti-CD25
antibody. (FIG. 3B) FACS result for circulating G-MDSCs after
treatment with different antibodies or antibody combinations. (FIG.
3C) 4T1 tumor-bearing mice were treated with anti-PD-1/anti-CTLA-4
antibodies plus epigenetic modulators with or without adoptive
transfer of MDSCs isolated by affinity purification from the 4T1
tumor-bearing animals. Tumor volumes were recorded following the
treatments. Means and standard deviations are shown, with P-values
indicated.
[0014] FIGS. 4A-4D. Direct effects of epigenetic modulators on
cultured cells. (FIG. 4A and FIG. 4B) 4T1 cells, purified CD8.sup.+
T cells or G-MDSCs were treated with different concentrations of
entinostat (FIG. 4A) or AZA (FIG. 4B). Cell viability was assessed
using a metabolism-based colorimetric assay. (FIG. 4C) Conditioned
media from co-cultures of G-MDSCs and CD8.sup.+ T cells at
different ratios were analyzed for IFN-.gamma. concentration. (FIG.
4D) Conditioned media from co-cultures at a G-MDSC to CD8.sup.+ T
cell ratio of 1:1 were collected after treatment with entinostat at
increasing doses for 24 hours and analyzed for IFN-.gamma.
concentration. Means and standard deviations of data from at least
tripli cate wells are shown. P-values are indicated.
[0015] FIG. 5 (S1). Body weight measurements. BALB/c mice bearing
4T1 tumors were treated with indicated therapeutic modalities.
Their body weights were measured and recorded regularly after
treatments. Means and standard deviations of data are shown.
[0016] FIG. 6 (S2). Expression of genes involved in MHC-I
presentation. RNA was isolated from 4T1 and CT26 tumor cells
cultured in vitro after treatment with the epigenetic modulators.
The expression of different genes involved in MHC-I presentation
was assessed by RT-PCR. .beta.-actin was used as loading control.
Lane A, untreated, Lane B, AZA treated, Lane C, entinostat treated,
Lane D, AZA/entinostat treated.
[0017] FIGS. 7A-7B. (S3). Elevated G-MDSC levels induced by 4T1
tumor. (FIG. 7A) Peripheral blood was collected at indicated time
points after 4T1 tumor implantation and analyzed for the levels of
G-MDSCs by FACS. (FIG. 7B) Peripheral blood, spleen, and tumor were
harvested from healthy mice or from tumor-bearing mice on day 18
after 4T1 tumor implantation and analyzed for the levels of G-MDSCs
by FACS. Means and standard deviations of data are shown.
[0018] FIGS. 8A-8C (S4). PI3K inhibitor eradicates 4T1 tumor by
depleting G-MDSC when combined with immune checkpoint blockade.
(FIG. 8A) G-MDSCs, CD8.sup.+ T cells and 4T1 tumor cells were
treated in vitro with J32 at various concentrations. Cell viability
was assessed using a metabolism-based colorimetric assay. Means and
standard deviations of data from triplicate wells are shown. (FIG.
8B) BALB/c mice bearing 4T1 tumors were treated with indicated
therapeutic modalities. FACS analysis was performed to quantify
circulating G-MDSCs. (FIG. 8C) BALB/c mice bearing 4T1 tumors were
treated with J32, anti-PD-1/anti-CTLA-4 antibodies or the
combination and tumor volumes recorded. Means and standard
deviations are shown, with P-values indicated.
[0019] FIG. 9. Meier Kaplan curves for combination treatments. From
lowest to highest curves: C. novyi-NT alone; Anti-PD-1/anti-CTLA-4
alone; Anti-PD-1/anti-CTLA-4+C. novyi-NT;
Anti-PD-1/anti-CTLA-4+ENT/AZA; Anti-PD-1/anti-CTLA-4+ENT/AZA+C.
novyi-NT.
DETAILED DESCRIPTION OF THE INVENTION
[0020] The inventors have developed a therapeutic approach that
involves agents that act on host cells in the immune system such as
MDSCs to reduce and/or suppress them. Such agents may be epigenetic
modulators such as histone deacetylase inhibitors or DNA
methyltransferase inhibitors. When used in conjunction with immune
checkpoint blockade, the epigenetic modulators kill MDSCs at much
lower concentrations than required for killing tumor cells in
vitro. The epigenetic modulators have only a marginal effect at
best on tumor cells in vivo at the doses used; reduction of MDSCs
using antibodies directed against them has similar antitumor
effects to those observed with the epigenetic modulators. In
adoptive transfer experiments, MDSCs purified from non-treated
tumor-bearing mice can abolish the therapeutic effects of
epigenetic modulation. Inhibition of MDSCs with a completely
different class of agents (a PIK3 inhibitor) has similar effects to
those of epigenetic modulators.
[0021] Types of tumors which are amenable to treatment according to
the methods of the invention and/or using the kits and/or using the
compositions of the invention are both solid tumors and
hematological cancers. Exemplary tumors include Adrenal Cancer,
Anal Cancer, Bile Duct Cancer, Bladder Cancer, Bone Cancer,
Brain/CNS Tumors In Adults, Brain/CNS Tumors In Children, Breast
Cancer, Breast Cancer In Men, Cancer in Adolescents, Cancer in
Children, Cancer in Young Adults, Cancer of Unknown Primary,
Castleman Disease, Cervical Cancer, Colon/Rectum Cancer,
Endometrial Cancer, Esophagus Cancer, Ewing Family Of Tumors, Eye
Cancer, Gallbladder Cancer, Gastrointestinal Carcinoid Tumors,
Gastrointestinal Stromal Tumor (GIST), Gestational Trophoblastic
Disease, Hodgkin Disease, Kaposi Sarcoma, Kidney Cancer, Laryngeal
and Hypopharyngeal Cancer, Leukemia, Leukemia--Acute Lymphocytic
(ALL) in Adults, Leukemia--Acute Myeloid (AML), Leukemia--Chronic
Lymphocytic (CLL), Leukemia--Chronic Myeloid (CML),
Leukemia--Chronic Myelomonocytic (CMML), Leukemia in Children,
Liver Cancer, Lung Cancer, Lung Cancer--Non-Small Cell, Lung
Cancer--Small Cell, Lung Carcinoid Tumor, Lymphoma, Lymphoma of the
Skin, Malignant Mesothelioma, Multiple Myeloma, Myelodysplastic
Syndrome, Nasal Cavity and Paranasal Sinus Cancer, Nasopharyngeal
Cancer, Neuroblastoma, Non-Hodgkin Lymphoma, Non-Hodgkin Lymphoma
In Children, Oral Cavity and Oropharyngeal Cancer, Osteosarcoma,
Ovarian Cancer, Pancreatic Cancer, Penile Cancer, Pituitary Tumors,
Prostate Cancer, Retinoblastoma, Rhabdomyosarcoma, Salivary Gland
Cancer, Sarcoma--Adult Soft Tissue Cancer, Skin Cancer, Skin
Cancer--Basal and Squamous Cell, Skin Cancer--Melanoma, Skin
Cancer--Merkel Cell, Small Intestine Cancer, Stomach Cancer,
Testicular Cancer, Thymus Cancer, Thyroid Cancer, Uterine Sarcoma,
Vaginal Cancer, Vulvar Cancer, Waldenstrom Macroglobulinemia, and
Wilms Tumor.
[0022] Types of bacterial infections which can be treated according
to the methods of the invention include Bacillus anthraces,
Bordetella pertussis, Borrelia burgdorferi, Brucella abortus,
Brucella canis, Brucella melitensis, Brucella suis, Campylobacter
jejuni, Chlamydia pneumoniae, Chlamydia trachomatis, Chlamydophila
psittaci, Clostridium botulinum, Clostridium difficile, Clostridium
perfringens, Clostridium tetani, Corynebacterium diphtheriae,
Enterococcus faecalis and Enterococcus faecium, Escherichia coli
(generally), Enterotoxigenic Escherichia coli (ETEC),
Enteropathogenic E. coli, E. coli O157:H7, Francisella tularensis,
Haemophilus influenzae, Helicobacter pylori, Legionella
pneumophila, Leptospira interrogans, Listeria monocytogenes,
Mycobacterium leprae, Mycobacterium tuberculosis, Mycoplasma
pneumoniae, Neisseria gonorrhoeae, Neisseria meningitidis,
Pseudomonas aeruginosa, Rickettsia rickettsia, Salmonella typhi,
Salmonella typhimurium, Shigella sonnei, and Staphylococcus
aureus.
[0023] Types of viral infections which can be treated according to
the invention include both chronic and acute infections. Exemplary
infection include Respiratory Viruses, such as, Adenoviruses, Avian
influenza, Influenza virus type A, Influenza virus type B, Measles,
Parainfluenza virus, Respiratory syncytial virus (RSV),
Rhinoviruses, SARS-CoV, Gastro-enteric Viruses, such as, Coxsackie
viruses, Enteroviruses, Poliovirus, Rotavirus, Hepatitis Viruses,
such as, Hepatitis B virus, Hepatitis C virus, Bovine viral
diarrhea virus (surrogate), Herpes Viruses, such as, Herpes simplex
1, Herpes simplex 2, Human cytomegalovirus, Varicella zoster virus,
Retroviruses, such as, Human immunodeficiency virus 1 (HIV-1),
Human immunodeficiency virus 2 (HIV-2), Simian immunodeficiency
virus (SIV), Simian human immunodeficiency virus (SHIV), Viral
Select Agents/Emerging Viral Pathogens, such as, Avian influenza,
Dengue virus, Hantavirus, Hemorrhagic fever viruses, Lymphocytic
choromeningitis virus, Smallpox virus surrogates, Cowpox,
Monkeypox, Rabbitpox, Vaccinia virus, Venezuelan equine
encephalomyelitis virus (VEE), West Nile virus, Yellow fever
virus.
[0024] Types of antibodies which may be used to target immune
checkpoints or MSDCs may be of any isotype. They may be humanized
or chimeric or other mammal or animal. They may be conjugated to
other moieties such as toxins. They may be monoclonal or
polyclonal. They may be single chain antibodies, fragments, or
portions of antibodies.
[0025] Modes of administration for the therapeutic agents may be
those which are used in the art. Examples include oral, topical,
inhalation, and injection. Locations for administration include
epicutaneous or topical, nasal administration, intraarterial,
intraarticular, intracardiac, intramuscular, intradermal,
intralesional, intraosseous infusion, intraperitoneal, intrathecal,
intrauterine, intravaginal administration, intravenous,
Intravesical infusion, intravitreal, subcutaneous, transdermal,
transmucosal, avitreal, subcutaneous, transdermal, and
transmucosal.
[0026] Mammals which may be treated include any which are
susceptible to tumors, hematological cancers, bacterial infections
or viral infections. These include: Acouchi--Myoprocta acouchy
(formerly, pratti), Alpaca--Lama pacos, Anteater,
giant--Myrmecophaga tridactyla, Armadillo, southern (formerly La
Plata) three-banded Tolypeutes matacus, Banded mongoose--Mungos
mungo, Bear, sloth--Melursus ursinus, Bear, Andean or
spectacled--Tremarctos ornatus, Beaver, American--Castor
canadensis, Bison, American--Bison bison (SCBI Front Royal only),
Caracal--Caracal caracal, Cat, fishing--Prionailurus viverrinus,
Cavy, rock--Kerodon rupestris, Cheetah--Acinonyx jubatus, Clouded
leopard--Neofelis nebulosa, Coati--Nasua narica, Colobus,
black-and-white or guereza--Colobus guereza, Cow, Hereford--Bos
taurus taurus hereford, Cow, Holstein--Bos taurus taurus holstein,
Deer, Burmese brow-antlered (Eld's deer)--Cervus eldi thamin (SCBI
Front Royal only), Deer, tufted--Elaphodus cephalophus (SCBI Front
Royal only), Degu--Octodon degus, Donkey, miniature--Equus asinus
asinus miniature, Elephant, Asian--Elephas maximus, Elephant shrew,
short-eared--Macroscelides proboscideus, Ferret,
black-footed--Mustela nigripes, Gazelle, Dama--Gazella dama,
Gibbon, white-cheeked--Nomascus leucogenys, Goat, Nigerian
dwarf--Capra hircus hircus nigerian dwarf, Goat, Nubian--Capra
hircus hircus anglo nubian, Goat, San Clemente Island--Capra hircus
hircus san clemente, Gorilla, western lowland--Gorilla gorilla
gorilla, Hog, Ossabaw Island--Sus scrofa scrofa, Horse,
Przewalski's--Equus caballus przewalskii or Equus ferus
przewalskii, Hyrax, rock--Procavia capensis, Lemur,
ring-tailed--Lemur catta, Lemur, red-fronted (subspecies of brown
lemur)--Lemur fulvus rufus, Lemur, red-ruffed--Varecia variegata
rubra, Lion, African--Panthera leo leo, Macaque, Celebes crested
(formerly, Sulawesi)--Macaca nigra, Macaque, liontail--Macaca
silenus, Marmoset, Geoffroy's (White-fronted or tufted-eared
marmoset)--Callithrix geoffroyi, Meerkat--Suricata suricatta, Mole
rat, Damaraland--Cryptomys damarensis, Mole-rat,
Naked--Heterocephalus glaber, Monkey, black howler--Alouatta
caraya, Mongoose, dwarf--Helogale parvula, Onager, Persian--Equus
hemionus onager (SCBI Front Royal only), Orangutan, Bornean--Pongo
pygmaeus, Orangutan, Sumatran-Bornean--Pongo pygmaeus abelii, Oryx,
scimitar-horned--Oryx dammah, Otter, Asian small-clawed Aonyx
cinerea, Otter, North American river--Lontra (formerly, Lutra)
canadensis, Panda, giant--Ailuropoda melanoleuca, Panda,
red--Ailurus fulgens, Peccary, collared--Tayassu tajacu, Porcupine,
prehensile-tailed--Coendou prehensilis, Prairie dog,
black-tailed--Cynomys ludovicianus, Rabbit, silver fox--Oryctolagus
cuniculus, Saki, Guianan (Pale-headed saki)--Pithecia pithecia,
Seal, gray--Halichoerus grypus, Siamang--Hylobates syndactylus,
Sloth, two-toed--Choloepus didactylus, Squirrel,
Prevost's--Callosciurus prevosti, Tamarin, golden
lion--Leontopithecus rosalia, Tamarin, golden-headed
lion--Leontopithecus chrysomelas, Tenrec, greater
Madagascar--Setifer setosus, Tenrec, small Madagascar
hedgehog--Echinops telfairi, Tiger, Sumatran--Panthera tigris
sumatrae, Titi, dusky (Orabussu titi)--Callicebus moloch, Tree
shrew, northern--Tupaia belangeri, Wolf, maned--Chrysocyon
brachyurus, and Zebra, Grevy's--Equus grevyi, pets, farm animals,
and wild animals may be treated as well as humans.
[0027] Kits are typically a divided or undivided container that
packages or contains multiple components. The components may be
separated or mixed. They may agents and/or delivery devices and/or
instructions. They may include mixing vessels or devices.
[0028] Spores of anaerobic Clostridium novyi may also be used in
combination with the other agents described here. The addition of
Clostridium spores achieves any even higher level of survival in a
tumor-bearing individual, even though alone it is less effective
than the other treatments. Amount of spores administered can be,
for example, from 10.sup.5 to 10.sup.9, from 10.sup.6 to 10.sup.8,
or from 1.times.10.sup.7 to 10.sup.8 per mouse. In one embodiment
the amount of spores is 5.0.times.10.sup.7 per mouse. Balb/c mice
average about 20-30 g. The amount of spores can be scaled according
to body weight of the recipient.
[0029] While the precise mechanism of action of the spores is not
yet known, it is known that C. novyi-NT infection can elicit a CD8+
T cell-mediated adaptive immune response specifically against the
tumors C. novyi-NT has infected. Moreover, it is known that
CD8.sup.+ T cells from C. novyi-NT-cured mice can confer adoptive
immunity in a tumor-specific fashion. Thus CD8.sup.+ T cells are
involved in the beneficial effect. See Agrawal et al., Proc Natl
Acad Sci USA. 2004 Oct. 19; 101(42): 15172-15177. One hypothesis is
that a robust inflammatory response induced by bacterial infection
enhances the adaptive immune response in general (against both
bacteria and tumor cells).
[0030] While applicants do not wish to be bound by any theory
regarding the mechanism of action, it is reasonable to postulate
that in order to generate a potent anti-tumor immune response, two
important components should be in place: (a) strong tumor antigens
or a robust inflammatory response to enhance the adaptive
anti-tumor immune response if strong tumor antigens are not present
(as can be provided by C. novyi-NT infection); and (b) cytotoxic T
cells that are not inactivated by the immune checkpoints (as can be
provided by anti-PD-1/anti-CTLA/4 antibody treatment) or MDSC (as
can be provided by entinostat/5-azacitidine).
[0031] A recent clinical study demonstrated that epigenetic
modulation exerted major therapeutic effects on a small fraction of
patients with non-small cell lung cancer (NSCLC) (36). Other
studies have suggested that 5-azacitidine up-regulates genes and
pathways related to both innate and adaptive immunity and genes
related to immune evasion in NSCLC lines (35). These important
studies as well as the recent clinical trials with immune check
point blockade have led to the initiation of a clinical trial
combining PD-1 antibody, 5-azacitidine and entinostat in NSCLC
patients
(http://clinicaltrialsgov/ct2/show/NCTO1928576?term=entinostat+p-
d-1&rank=1). It will be interesting to determine the importance
of both changes in gene expression in the tumor cells and changes
in the number and function of MDSCs in this trial. Our observations
raised a number of questions. For example, what are the mechanisms
underlying the selective suppression of MDSCs by epigenetic and
PI3K inhibitors? Would other approaches (e.g. myelosuppressive
agents) targeting immune suppressor cells synergize with immune
checkpoint blockade for complete eradication of solid tumors and
their metastases? Would priming with epigenetic inhibitors prior to
immune checkpoint blockade work as well as concomitant
administration of the two as done in the current study? Experiments
addressing these questions may lead to the development of more
effective therapies harnessing the power of immunity.
[0032] The above disclosure generally describes the present
invention. All references disclosed herein are expressly
incorporated by reference. A more complete understanding can be
obtained by reference to the following specific examples which are
provided herein for purposes of illustration only, and are not
intended to limit the scope of the invention.
Example 1
Materials and Methods
[0033] Reagents. HyClone RPMI 1640 with L-Glutamine and McCoy's 5A
were purchased from Invitrogen Life Technologies. HyClone Fetal
Bovine Serum (FBS) was purchased from Thermo Scientific.
Collagenase from Clostridium histolyticum, Type IV was purchased
from Sigma-Aldrich. The following antibodies and reagents were used
for animal experiments: mCD152 (mCTLA-4) monoclonal antibody (9H10,
BioXCell), mPD-1 monoclonal antibody (RMP1-14, BioXCell), mCD25
monoclonal antibody (PC61.5.3, BioXCell), mLy6G monoclonal antibody
(RB6-8C5, BioXCell), Polyclonal Hampster IgG (BioXCell), entinostat
(BPS Bioscience), 5-azacytidine (Invivogen).
[0034] Cell Lines. 4T1 (CRL-2539, murine breast tumor cells) and
CT26 (CRL-2638, murine colorectal adenocarcinoma) were purchased
from ATCC. Both tumor cell lines were grown in McCoy's 5A
supplemented with 10% Fetal Bovine Serum at 37.degree. C., 5%
CO2.
[0035] Preparation of Illumina Genomic DNA Libraries. Genomic DNA
libraries were prepared following Illumina's (Illumina) suggested
protocol with the following modifications. 2-3 .mu.g of genomic DNA
were diluted with TE to a final volume of 100 .mu.l and sheared in
a Covaris sonicator (Covaris) to an average size of 200 bp. DNA was
then purified with a Nucleospin kit (Macherey-Nagel), and eluted
with 50 .mu.l of elution buffer. All reagents used for the
following steps were from New England Biolabs (NEB) unless
otherwise noted. 45 .mu.l of purified DNA was then mixed with 40
.mu.l of ddH2O, 10 .mu.l of End Repair buffer and 5 .mu.l of End
Repair enzyme. The mixture was incubated at 20.degree. C. for 30
min, purified by a Qiagen PCR purification kit (Qiagen) and eluted
with 42 .mu.l of elution buffer (EB) warmed to 70.degree. C. The
end repair reaction was then A-tailed using 42 .mu.l of
end-repaired DNA, 5 .mu.l of 10.times.dA Tailing Reaction buffer
and 5 .mu.l of Klenow Fragment (3' to 5' exo-) and incubated at
37.degree. C. for 30 min then purified with a MinElute PCR
purification kit (Qiagen). Purified DNA was eluted with 27 .mu.l of
65oC EB. Adaptor ligation was performed with 25 .mu.l of A-tailed
DNA, 10 .mu.l of PE-adaptor (Illumina), 10 .mu.l of 5.times.
Ligation buffer and 5 .mu.l of Quick T4 Ligase. The ligation
mixture was incubated at 20.degree. C. for 15 min. Purification was
done using by mixing 50 .mu.l of the ligation mixture with 200
.mu.l of NT buffer from NucleoSpin Extract II kit (Clontech) and
loaded into a NucleoSpin column. The column was centrifuged at
14,000 g in a desktop centrifuge for 1 min, washed once with 600
.mu.l of wash buffer (NT3 from Clontech), and centrifuged again for
2 min to dry completely. DNA was eluted in 50 .mu.l elution buffer
included in the kit. Purified ligated DNA was PCR amplified under
the following conditions. Around 10 reactions were set up
consisting of 32.5 .mu.l of H2O, 2.5 .mu.l (DMSO), 10 .mu.l of
5.times. Phusion HF buffer, 1.0 .mu.l of a dNTP mix containing 10
mM of each dNTP, 0.5 .mu.l of Illumina PE primer #1, 0.5 .mu.l of
Illumina PE primer #2, 0.5 .mu.l of Hotstart Phusion polymerase,
and 5 .mu.l of ligated DNA. The PCR program used was: 98.degree. C.
1 minute; 10 to 16 cycles of 98.degree. C. for 20 seconds,
65.degree. C. for 30 seconds, 72.degree. C. for 30 seconds; and
72.degree. C. for 5 min. The reactions were then pooled and
purified with a 1:2 mixture of PCR product and NT buffer from a
NucleoSpin Extract II kit and purified via the protocol contained
within the kit. Library DNA was eluted with 70.degree. C. elution
the DNA concentration was estimated by absorption at 260 nm with a
nanodrop and then the samples proceeded to Sureselect exome
isolation.
[0036] Exome Capture. The mouse exome was captured following a
protocol from Agilent's SureSelect Paired-End Mouse Exome Kit
(Agilent) with the following modifications. (1) A hybridization
mixture was prepared containing 25 .mu.l of SureSelect Hyb #1, 1
.mu.l of SureSelect Hyb #2, 10 .mu.l of SureSelect Hyb #3, and 13
.mu.l of SureSelect Hyb #4. (2) 3.4 .mu.l (0.5 .mu.g) of the
PE-library DNA described above, 2.5 .mu.l of SureSelect Block #1,
2.5 .mu.l of SureSelect Block #2 and 0.6 .mu.l of Block #3; was
loaded into one well in a 384-well Diamond PCR plate (cat #AB-1111,
Thermo-Scientific), sealed with 2 layers of microAmp clear adhesive
film (cat #4306311; ABI) and placed in GeneAmp PCR system 9700
thermocycler (Life Sciences Inc.) for 5 min at 95.degree. C., then
held at 65.degree. C. (with the heated lid on). (3) 25 .mu.l of
hybridization buffer from step (1) was heated for at least 5 min at
65.degree. C. in another sealed plate with heated lid on. (4) 5
.mu.l of SureSelect Oligo Capture Library, 1 .mu.l of nuclease-free
water, and 1 .mu.l of diluted RNase Block (A 1:1 RNase Block,
nuclease-free water mix) were mixed and heated at 65.degree. C. for
2 min in another sealed 384-well plate. (5) While keeping all
reactions at 65.degree. C., 13 .mu.l of Hybridization Buffer from
Step (3) was quickly added to the 7 .mu.l of the SureSelect Capture
Library Mix from Step (4) and then the entire contents (9 .mu.l) of
the library from Step (2). The mixture was pipetted up and down 10
times. (6) The 384-well plate was sealed tightly and the
hybridization mixture was incubated for 24 hours at 65.degree. C.
with a heated lid. After hybridization, five steps were performed
to recover and amplify the captured DNA library: (1) 50 .mu.l of
Dynal MyOne Streptavidin Cl magnetic beads (Cat #650.02, Invitrogen
Dynal) was placed in a 1.5 ml microfuge tube and vigorously
resuspended on a vortex mixer. Beads were washed three times by
adding 200 .mu.l of SureSelect Binding buffer, mixing on a vortexer
for five seconds and then placing the tubes in a Dynal magnetic
separator prior to removing the supernatant after. After the third
wash, beads were resuspended in 200 .mu.l of SureSelect Binding
buffer. (2) To bind captured DNA, the entire hybridization mixture
described above (29 .mu.l) was transferred directly from the
thermocycler to the bead solution and immediately inverted a 4
times to mix; the hybridization mix/bead solution was then
incubated in an Eppendorf thermomixer at 850 rpm for 30 min at room
temperature. (3) To wash the beads, the supernatant was removed
from beads after applying a Dynal magnetic separator and the beads
were resuspended in 500 .mu.l SureSelect Wash Buffer #1 by mixing
on vortex mixer for 4 seconds and incubated for 15 min at room
temperature. Wash Buffer #1 was then removed from beads after
magnetic separation. The beads were further washed three times,
each with 500 .mu.l pre-warmed SureSelect Wash Buffer #2 after
incubation at 65.degree. C. for 10 min. After the final wash,
SureSelect Wash Buffer #2 was completely removed. (4) To elute
captured DNA, the beads were suspended in 50 .mu.l SureSelect
Elution Buffer, vortex-mixed and incubated for 10 min at room
temperature. The supernatant was removed after magnetic separation,
collected in a new 1.5 ml microcentrifuge tube, and mixed with 50
.mu.l of SureSelect Neutralization Buffer. DNA was purified with a
Qiagen MinElute column and eluted in 17 .mu.l of 65.degree. C.
buffer EB to obtain 15 .mu.l of captured DNA library. (5) The
captured DNA library was amplified in the following way:
Approximately 15 PCR reactions each containing 9.5 .mu.l of H2O, 3
.mu.l of 5.times.Phusion HF buffer, 0.3 .mu.l of 10 mM dNTP, 0.75
.mu.l of DMSO, 0.15 .mu.l of Illumina PE primer #1, 0.15 .mu.l of
Illumina PE primer #2, 0.15 .mu.l of Hotstart Phusion polymerase,
and 1 .mu.l of captured exome library were set up. The PCR program
used was: 98.degree. C. for 30 seconds; 14 cycles of 98.degree. C.
for 10 seconds, 65.degree. C. for 30 seconds, 72.degree. C. for 30
seconds; and 72.degree. C. for 5 min. To purify PCR products, 225
.mu.l of PCR mixture (from 15 PCR reactions) was mixed with 450
.mu.l of NT buffer from NucleoSpin Extract II kit and purified as
described above. The final library DNA was eluted with 30 .mu.l of
65.degree. C. elution buffer and DNA concentration was estimated by
OD.sub.260 measurement.
[0037] Preparation of cDNA for Sequencing Analysis. mRNA was
prepared from 5-10 .mu.g total RNA using two rounds of poly-A
selection using Dynal oligo-dT magnetic beads following the
manufacturers protocol (Life Technologies) and eluted the second
time with 13 .mu.l of elution buffer. Double-stranded (ds) cDNA was
prepared using the SuperScript ds-cDNA kit (Invitrogen) with the
following modifications. 12 .mu.l of the isolated mRNA was added to
2 .mu.l of 50 ng/.mu.l random hexamers and incubated at 70.degree.
C. for 10 minutes then placed on ice. 4.4 .mu.l of 5.times. First
Strand Buffer, 2.2 .mu.l of 0.1 M DTT and 1.1 .mu.l of a 10 mM dNTP
mixture were added to the tube and incubated at 45.degree. C. for 2
minutes upon which 1.5 .mu.l of SSII enzyme was added and the
entire mixture incubated for an additional 1 hour and then placed
on ice. Second Strand cDNA was made by adding to the first strand
reaction 90 .mu.l of ddH.sub.2O, 30 .mu.l of 5.times. Second Strand
Buffer, 3 .mu.l of 10 mM dNTPs, 4 .mu.l of DNA Pol I, 1 .mu.l of
RNaseH and 1 .mu.l of E. coli DNA ligase. The mixture was then
incubated at 16.degree. C. for 2 hours upon which 2 .mu.l of T4
ligase was added and incubated for an additional 5 minutes. The
resulting cDNA was then purified using a Qiagen PCR purification
kit following the manufacturer's instructions and eluted twice with
50 .mu.l of 70.degree. C. elution buffer each time. The 100 .mu.l
of cDNA was used for the construction of illumina libraries
following the genomic DNA library protocol with the cDNA in place
of genomic DNA.
[0038] Somatic Mutation Identification. Libraries were sequenced on
Illumina GAIIx or HiSeq Genome Analyzer. Sequencing reads were
analyzed and aligned to mouse genome mm9 with CASAVA (Illumina). A
mismatched base was identified as a mutation only when (i) it was
identified by four or more distinct pairs containing at least 2
reads in the forward and 2 in the reverse orientation; (ii) the
number of distinct tags containing a particular mismatched base was
at least 30% of the total distinct tags.
[0039] Identification of Putative Expressed H2-(d) Epitopes.
Identified somatic mutations were cross-referenced against the
RNAseq data to determine which mutations were expressed. The amino
acid change corresponding to the positive mutations were then used
for mutant epitope identification by isolating 8 amino acids up-
and down-stream of the mutant residue. This seventeen amino acid
sequence was than processed using the netMHC epitope identification
algorithm (netMHC v3.4) for potential 9 amino acid binders to
H2-k(d), H2-L(d) and H2-D(d). The cutoff used was 500 nM affinity
or higher which corresponds to moderate to high affinity binders.
Genes were determined to be expressed if the normalized counts
(normalized to length per million reads) of RNAseq data were
greater than 0.5.
[0040] Animal Models. Animal research was approved and overseen by
Johns Hopkins University Institutional Animal Care and Use
Committee. Six to eight weeks old female BALB/C mice (Harlan
Laboratories) were used for all animal experiments.
5.times.10.sup.6 4 T1 tumor cells or 5.times.10.sup.6 CT26 tumor
cells were inoculated subcutaneously into the right flank of each
mouse. Tumors were allowed to grow for 11 days prior to
randomization and treatment. CT26 bearing mice were given 10 mg/kg
of anti-PD-1 and/or anti-CTLA-4 antibodies intraperitoneally on day
11, 13, 15, 17, 20, 23 and 26 post-tumor implantations and 4T1
bearing mice were given 10 mg/kg anti-PD-1 and/or anti-CTLA-4
antibodies intraperitoneally on day 11, 13, 15, and 17 post-tumor
implantations. 4T1 tumor bearing mice were given a single dose of
10 mg/kg anti-CD25 antibody or 10 mg/kg anti-Ly6G antibody
intraperitoneally on day 12 post-tumor implantation for cell
depletion studies. All antibodies were diluted to appropriate
concentrations in 100 .mu.l sterile PBS, pH 7.4 (Invitrogen Life
Technologies). Entinostat and 5-azacytidine treatments were started
on day 12 post-tumor implantation at a dose of 20 mg/kg and 0.8
mg/kg, respectively. 4T1 bearing mice were injected
intraperitoneally on day 12, 14, 16, and 18. J32 was given at 22
mg/kg by intraperitoneal injections on day 12, 14, 16, and 18 of
4T1 tumor implantation. Tumors were measured for 30 days from the
start of the treatment at indicated intervals in the results
section. Tumor volume was calculated as
length.times.width.sup.2.times.0.5.
[0041] Metastasis Analysis. On day 46 post-tumor implantations, 4T1
tumor bearing mice were euthanized according to the IACUC
guidelines. Lungs, livers and spleens were harvested and fixed in
10% Neutral Buffered Formalin Solution (Sigma-Aldrich) and
metastatic nodules were counted from at least three mice per
group.
[0042] Flow Cytometry. The following antibodies and reagents were
used for flow cytometry: CD16/32 (BD Biosciences), CD3e Alexa Fluor
488 (14-C11; BD Biosciences), CD4 Brilliant Violet 421 (GK1.5, BD
Biosciences), CD8a PerCP-Cy5.5 (53-6.7, BD Biosciences), CD25 PE
(PC61, BD Biosciences), Foxp3 Alexa Fluor 647 (MF23, BD
Biosciences), CD11b Alexa Fluor 700 (M1/70, BD Biosciences),
I-A/I-E Alexa Fluor 488 (M5/114.15.2, BD Biosciences), Ly-6C
PerCP-Cy5.5 (AL-21, BD Biosciences), CD11c PE (HL3, BD
Biosciences), F4/80 APC (BM8, Biolegend), Ly-6G Pacific Blue (1A8,
Biolegend), CD45 Pacific Orange (30-F11, Invitrogen Life
Technologies), and Live/Dead Fixable Near IR Dead Cell Stain
(Invitrogen Life Technologies). Flow cytometry was performed with
LSR II (BD Biosciences) and the data was analyzed with FACS Diva
software (BD Biosciences). To assess the level of circulating
G-MDSC population, blood samples were collected from the mice 7
days after the initiation of the anti-PD-1/anti-CTLA-4 antibody
treatments with or without 5-AZA/Entinostat. 150 .mu.l of blood was
collected into K.sub.2EDTA BD Microtainer (BD Biosciences) from
either right or left facial vein. RBCs from anti-coagulated blood
samples were immediately lysed using 2 ml of 1.times.BD FACS Lyse
(BD Biosciences) for 3 minutes and the samples were washed twice in
ice-cold BD FACS Buffer (BD Biosciences). After 5-minute incubation
with Live/Dead Fixable Near IR Dead Cell Stain and two washes with
ice-cold BD FACS Buffer, the samples were stained with appropriate
antibodies. For analysis, we used previously established phenotypic
criteria of these cells as
CD45.sup.+CD11b.sup.+Ly6G.sup.+Ly6C.sup.lo F4/80.sup.-MHCII.sup.-
cells and total CD45 positive cells were used as a common
denominator. To assess the level of intratumoral CD8.sup.+ and
regulatory T cell populations, lymphocytes were first purified from
tumor samples excised from mice 7 days after the initiation of the
anti-PD-1/anti-CTLA-4 antibody treatments with or without
5-AZA/Entinostat. Briefly, primary tumor tissues were harvested,
weighed, and minced to fine fragments. Collagenase IV
(Sigma-Aldrich) at 1 mg/ml in HBSS (Invitrogen Life Technologies)
was added to each sample at a ratio of 1 ml per 200 mg of tumor
tissue. Samples were incubated on an end-over-end shaker for 30
minutes at 37.degree. C. The resulting tissue homogenates were 0.4
.mu.m filtered, washed three times in ice-cold BD FACS Buffer (BD
Biosciences), and 5.times.10.sup.6 cells per sample were used for
antibody labelling. CD8.sup.+ T cell level was assessed using
previously established phenotypic criteria of
CD45.sup.+CD3.sup.+CD8.sup.+ and total CD45.sup.+CD3.sup.+ cells
was used as a common denominator. Treg cell level was assessed
using previously established phenotypic criteria of
CD45.sup.+CD3.sup.+CD4.sup.+CD25.sup.+FoxP3.sup.+ and total
CD45.sup.+CD3.sup.+CD4.sup.+ cells were used as a common
denominator.
[0043] Cell Isolation. MDSCs from 4T1 tumor-bearing animals were
isolated from spleens using Myeloid-Derived Suppressor Cell
Isolation Kit, mouse (Miltenyi Biotec) and BD FACS Aria III cell
sorter (BD Biosciences). CD8.sup.+ cells were isolated from spleens
of 4T1-bearing animals treated with anti-PD-1 and anti-CTLA-4
antibodies using CD8a.sup.+ T Cell Isolation Kit II, mouse
(Miltenyi Biotec) and BD FACS Aria III cell sorter (BD
Biosciences). MDSC, Tregs, and CD8.sup.+ T cells were isolated and
cultured by following the manufacturer's protocols and published
protocols (38, 39). The purity of G-MDSCs
(CD11b.sup.+Ly6G.sup.+Ly6C.sup.lo F4/80.sup.-MHC-II.sup.-) and
CD8.sup.+ (CD3.sup.+CD8.sup.+) populations were greater than 95% as
determined by flow cytometry, and the viability was greater than
95% for these populations as determined by trypan blue
staining.
[0044] In Vitro Survival Assay. MDSCs and CD8.sup.+ T cells were
plated on 96-well plate at 2.times.10.sup.6 cells/ml in RPMI1640
medium supplemented with 10% FBS. CD8.sup.+ T cell cultures were
supplemented with recombinant interleukin-2 (Invitrogen Life
Technologies) at 2000 U/ml. 4T1 cells in McCoy 5A supplemented with
10% FBS were plated on 96-well plate and cultured until they
reached >70% confluency. Cells were cultured with entinostat,
5-azacytidine, or J32 at concentrations ranging from 0 .mu.M to 50
.mu.M for 24 hours at 37.degree. C., 5% CO2. The proportion of
viable cells was assessed by incubating the cells with 10% (v/v)
Cell Proliferation Reagent WST-1 (Roche Applied Science) for 3
hours at 37.degree. C. and measuring OD.sub.450 absorbance of the
resulting formazan products.
[0045] IFN-.gamma. Assay. Freshly isolated MDSCs and CD8.sup.+ T
cells from 4T1 tumor-bearing animals were cultured at MDSC to
CD8.sup.+ T cell ratios of 5:1, 2:1, 1:1, 1:2, and 1:5 in presence
of recombinant IL-2 (Invitrogen Life Technologies) at 2000 U/mL and
CD3/CD28 antibody coated beads (Miltenyi). MDSC and CD8.sup.+ T
cells were cultured at 1:1 ratio with entinostat at concentrations
ranging from 0 .mu.M to 0.25 .mu.M. Cell-free supernatants were
collected after 24-hour incubation at 37.degree. C. and IFN-.gamma.
levels were assayed using Mouse IFN-.gamma. DuoSet Elisa
Development Kit (R&D Systems) according to the manufacturer's
instruction.
[0046] MDSC Depletion and Adoptive Transfer. For in-vivo depletion
of MDSC, 4T1 tumor-bearing mice were treated with a single bolus of
mLy6G monoclonal antibody at 10 mg/kg administered
intraperitoneally on day 11 post-tumor implantation. For adoptive
transfer of MDSC, spleens from 4T1-bearing mice were collected and
MDSCs were purified with Myeloid-Derived Suppressor Cell Isolation
Kit, mouse (Miltenyi Biotec). After two sequential column
purifications, cells were washed twice in ice-cold 1.times.PBS
(Invitrogen Life Technologies) and cell concentration was adjusted
to 1.times.10.sup.8 cells/ml. Cell viability was greater than 95%
as verified with trypan blue staining and cell purity was greater
than 90% as determined by flow cytometry. Immediately following the
isolation, 100 .mu.l of MDSCs at 1.times.10.sup.8 cell/ml were
administered via tail vein injection on day 11, 13, and 15 post 4T1
tumor implantation.
[0047] Immunofluorescence. Mice were euthanized according to the
JHU IUCAC guidelines and primary tumors from 4T1 tumor-bearing mice
were excised using sterile disposable surgical scalpels
(Bard-Parker). Excised tissues were placed in base molds filled
with Tissue-Tek CRYO-OCT (Andwin Scientific) and stored at
-80.degree. C. until use. Frozen tissues were sectioned using Leica
CM3050 S Cryostat (Leica Biosystems) and tissues were fixed with 4%
Paraformaldehyde (Alfa Aesar), 0.3% Triton X-100 (Sigma-Aldrich) in
1.times.PBS (Invitrogen Life Technologies) for 10 minutes. Slides
were washed three times with 0.05% Tween-20 (Sigma-Aldrich) in
1.times.PBS followed by three 5-minute washes with 0.05% Tween-20
in 1.times.PBS. Tissues were blocked with 3% BSA (Sigma-Aldrich),
0.05% Tween-20 in 1.times.PBS for 30 minutes, followed by an
additional 30-minute block with 10% normal goat serum (Invitrogen
Life Technologies). Blocked tissues were incubated overnight in
anti-CD8 (YTS 169.4, Abcam) or anti-Ly6G (RB6-8C5, Abcam) at
concentrations 1:50, 1:100, and 1:200 at 4.degree. C. Following the
overnight staining with primary antibodies, the slides were washed
three times with 0.05% Tween-20 in 1.times.PBS and incubated with
1:500 goat anti-rat AF488 (Invitrogen Life Technologies) or goat
anti-rat AF594 (Invitrogen Life Technologies) secondary antibodies
for 1 hour at 20.degree. C. Slides were washed five times with
0.05% Tween-20 in 1.times.PBS, one drop of Gold/DAPI (Invitrogen
Life Technologies) was added to the tissue samples prior to placing
a cover slip, and the slides were stored at 4.degree. C. in dark.
For imaging, Nikon Cl Laser Scanning Confocal System, which
includes ECLIPSE TE2000-E microscope and EZ-LIMO for Nikon Cl
Confocal v. 2.30 was used.
[0048] Reverse-transcription PCR (RT-PCR). 5.times.10.sup.6 CT26 or
4T1 cells were resuspended in 0.75 ml Trizol LS Reagent (Invitrogen
Life Technologies) and 0.25 ml chloroform (Sigma-Aldrich). Samples
were vortexed for 15 seconds and incubated for 10 minutes at
20.degree. C. After a 15-minute 12000 g centrifugation at 4.degree.
C., upper aqueous phase was collected and 0.5 ml of 100%
isopropanol (Sigma-Aldrich) was added. Samples were centrifuged at
12000 g for 10 minutes at 4.degree. C. after 10 minute incubation
at 20.degree. C. The resulting pellets were air dried for less than
10 minutes and were resuspended with RNAse-free water (Invitrogen
Life Technologies) for a final concentration of 500 ng/.mu.l. PCR
was performed using SuperScript III One-Step RT-PCR System with
Platinum Taq DNA Polymerase (Invitrogen Life Technologies).
Annealing temperature was set at 55.degree. C. for H-2D(d), (32m
and TAP1, and set at 60.degree. C. for .beta.-actin. Samples were
analyzed on 1% agarose gel. The following primers were used for
RT-PCR: H-2D(d) Forward 5'-agggcaatgagcagagtttc-3' (SEQ ID NO: 1),
H-2D(d) Reverse 5'-CCACGTTTTCAGGTCTTCGT-3' (SEQ ID NO: 2), .beta.2m
Forward 5'-ATTCACCCCCACTGAGACTG-3' (SEQ ID NO: 3), .beta.2m Reverse
5'-GCTATTTCTTTCTGCGTGCAT-3' (SEQ ID NO: 4), TAP1 Forward
5'-GAGACATGCTGTGTCGGATG-3' (SEQ ID NO: 5), TAP1 Reverse
5'-TGGTGAGAATGGACATGAGC-3' (SEQ ID NO: 6), .beta.-actin Forward
5'-TTCTTTGCAGCTCCTTCGTTGCCG-3' (SEQ ID NO: 7), .beta.-actin Reverse
5'-TGGATGGCTACGTACATGGCTGGG-3' (SEQ ID NO: 8).
[0049] Statistics. All statistics analyses were performed with
Prism 5.0 (GraphPad Software, Inc). Primary tumor growth curves
were first analyzed with two-way ANOVA and individual groups were
compared with two tailed Wilcoxon rank-sum test. Kaplan-Meier
survival curves were analyzed with log-rank test. Statistical
significance of metastatic lesions, flow cytometric analyses, and
in-vitro assays were assessed with two tailed Wilcoxon rank-sum
test.
Example 2
[0050] Genetic analysis. We first sequenced the exomes (24,306
genes) of both CT26 and 4T1 cells. Eight and 3.5 gigabases of
generated sequence were mapped to the genome for CT26 and 4T1,
respectively. 83.5% (CT26) and 72.3% (4T1) of bases in the targeted
regions were covered by at least 10 unique reads in tumor DNA.
Sequencing of the exomes revealed 683 and 47 somatic mutations in
CT26 and 4T1, respectively (Dataset S1).
[0051] It has been shown that .about.10% of the mutant amino acids
created by somatic mutations in human colorectal and breast cancers
give rise to epitopes that are predicted to be recognized by the
patient's MHC-I alleles (17). To determine whether this was true
for the murine colorectal (CT26) and breast (4T1) tumors, we mapped
the somatically mutated epitopes to BALB/c MHC-I using established
algorithms. As such predictions are meaningful only if the mutant
genes are expressed, we determined the transcriptomes of the two
cell lines using RNA-Seq. Three hundred and fourteen of the 683
mutations detected in CT26 occurred in expressed genes, with 28
mutated epitopes predicted to bind with at least moderate affinity
to H2-(d) MHC-I alleles found in BALB/c mice (Dataset S1 and Table
1). The 4T1 cells harbored 27 mutations in expressed genes with
only one predicted to bind to H2-(d) MHC-I alleles. These data are
consistent with the suggestion that CT26 is more immunogenic than
4T1 because the former has more mutant epitopes. It is also
consistent with the observation that human tumors associated with
environmental mutagens (such as UV light and cigarette smoke) have
more mutations than other tumors (18).
TABLE-US-00001 TABLE 1 Mutant MHC-I Epitopes predicted from genome
and transcriptome analyses Affinity Name Epitope (nM) H-2 Allele
CT26 Tumor Cell SEQ ID NO. 9 AE2f8 SGPSYATYL 362 H-2Dd SEQ ID NO.
10 Haus6 SYETLKKSL 21 H-2Kd SEQ ID NO. 11 Slc20a1 SYTSYIMAI 28
H-2Kd SEQ ID NO. 12 Sel11 RYWTGIGVL 46 H-2Kd SEQ ID NO. 13 Glud1
AYVNAIEKI 49 H-2Kd SEQ ID NO. 14 Noc3l SYIKKLKEL 58 H-2Kd SEQ ID
NO. 15 Eml5 HYLNDGDAI 66 H-2Kd SEQ ID NO. 16 Gnas KVLAGKSTI 74
H-2Kd SEQ ID NO. 17 Mtor HHTMMVQAI 126 H-2Kd SEQ ID NO. 18 Map3k5
AYALNRRNL 131 H-2Kd SEQ ID NO. 19 Slc20a1 SYIMAICGM 146 H-2Kd SEQ
ID NO. 20 Dhx35 YYMRDVIAI 211 H-2Kd SEQ ID NO. 21 Pigo LFLKSPTAL
265 H-2Kd SEQ ID NO. 22 Ptpn13 PYFRLEHYL 311 H-2Kd SEQ ID NO. 23
Qsox1 SYLRRLPGL 316 H-2Kd SEQ ID NO. 24 Tars12 TYWKGNPEM 332 H-2Kd
SEQ ID NO. 25 Anks6 GYEAVVRLL 338 H-2Kd SEQ ID NO. 26 Slc41a2
PYLTALDDL 365 H-2Kd SEQ ID NO. 27 Pdgfra LFVTVLEVI 404 H-2Kd SEQ ID
NO. 28 Rwdd2b VYFTINVNL 432 H-2Kd SEQ ID NO. 29 Vps26b SYTEQNVKL
460 H-2Kd SEQ ID NO. 30 Qsox1 FYTSYLRRL 496 H-2Kd SEQ ID NO. 31
Phf3 FPPQNMFEF 5 H-2Ld SEQ ID NO. 32 Trim26 SPEAQLFAV 112 H-2Ld SEQ
ID NO. 33 Zfp449 EPQIAMDDM 115 H-2Ld SEQ ID NO. 34 Csnk2b IPDEAMVKL
184 H-2Ld SEQ ID NO. 35 Zeb1 EPQVEPLDF 272 H-2Ld SEQ ID NO. 36
Ttc15 DPFATPLSM 485 H-2Ld 4T1 Tumor Cell SEQ ID NO. 37 Qars
FPPDAINNF 27 H-2Dd
Example 3
[0052] Effects of immune checkpoint blockade. We then tested the
effects of immune checkpoint blocking antibodies on tumors derived
from these cells in mice. BALB/c mice bearing subcutaneous CT26
tumors of moderate sizes (.about.400 mm.sup.3) were used for the
initial experiments. While repeated treatment with anti-CTLA-4 or
anti-PD-1 antibodies as single agents retarded tumor growth, tumor
eradication was not observed (FIGS. 1A and B). Combination therapy
with both antibodies resulted in eradication of tumors in vast
majority of the mice. Conversely, tumors larger than 600 mm.sup.3
did not respond to the combined anti-PD-1/anti-CTLA4 treatment as
well (FIG. 1C), with only 4 out of 11 animals showing long-term
survival (FIG. 1D).
[0053] Next, BALB/c mice with well-established 4T1 tumors
(.about.400 mm.sup.3) were evaluated; these tumors spontaneously
metastasize to the lungs and other organs. The 4T1 tumor model is
highly recalcitrant to most therapeutic agents, including
immunotherapy (16). The animals generally succumb to metastatic
disease, even when the primary tumor is surgically removed (19).
Small number of the primary tumors showed durable response to
antibody treatment. Similar to the mice with large CT26 tumors,
only 3 out of 10 animals showed complete regression of their
primary tumors when treated with both anti-PD-1 and anti-CTLA-4
antibodies, and these were the only long-term survivors (FIGS. 1 E
and F).
Example 4
[0054] Epigenetic modulation. We hypothesized that the tumors in
the animals that had not been cured might have down-regulated the
expression of MHC-I-related genes through epigenetic silencing in
tumor cells. Indeed, this hypothesis forms the basis for therapies
involving epigenetic modulation (20), using inhibitors of either
DNA methyltransferase or histone deacetylase (HDAC). To evaluate
this possibility, we treated animals bearing large CT26 tumors
(>600 mm.sup.3) as described above with anti-PD-1/anti-CTLA-4
antibodies as well as 5-azacytidine (AZA, a DNA methyltransferase
inhibitor) and entinostat (ENT, a class I HDAC inhibitor). The
tumors responded to this regimen remarkably well, with eradication
of primary tumors in 10 out of 11 mice and 100% survival 60 days
after tumor implantation (FIG. 1D). Similarly, in response to the
anti-PD-1/anti-CTLA-4 plus AZA/ENT treatment, mice with 4T1 tumors
(.about.400 mm.sup.3) showed complete regression of all primary
tumors three weeks after treatment initiation and 80% survival 100
days after tumor implantation (FIGS. 1 E and F). Temporary
self-limiting toxicity, as indicated by body weight changes, was
observed when entinostat was used (FIG. 37). However, the addition
of anti-PD-1/anti-CTLA-4 antibodies did not add to the
toxicity.
[0055] In parallel experiments, we treated 4T1 tumor-bearing mice
as described above but sacrificed them six weeks after tumor
implantation. We then examined their primary tumors as well as
lungs and other organs for metastasis. The primary tumors were
eradicated in all five mice treated with anti-PD-1/anti-CTLA-4
antibodies plus AZA/entinostat and none of them showed any
metastases (FIG. 1G and Table 2). In contrast, all five mice with
anti-PD-1/anti-CTLA-4 treatment alone still had large primary
tumors and an average of 11 lung metastases. We also treated the
tumor-bearing mice with anti-PD-1/anti-CTLA-4 antibodies plus
either entinostat or AZA. No primary tumors or metastases were
found in any of the mice treated with anti-PD-1/anti-CTLA-4
antibodies plus entinostat, suggesting that when combined with
PD-1/CTLA-4 double blockade, class I HDAC inhibitors alone (without
DNA methylation inhibitors) were sufficient to eradicate both
primary tumors and metastasis (FIG. 1G and Table 2). In the mice
treated with anti-PD-1/anti-CTLA-4 antibodies plus AZA, the primary
tumors were not eradicated, though no metastases were observed.
Without PD-1/CTLA-4 inhibition, entinostat, AZA, alone or in
combination, were unable to eradicate either primary tumor or
metastasis (FIG. 1G and Table 2). When PD-1/CTLA-4 inhibition was
not applied, metastatic lesions were observed in multiple organs in
addition to those in the lungs.
TABLE-US-00002 TABLE 2 4T1 Primary Tumors and Metastatic Lesions
Treatment Primary Tumor Lung Liver Spleen Group Mouse No Vol
(mm.sup.3) Mets Mets Mets P + C 1 0 0 0 0 AZA + ENT 2 0 0 0 0 3 0 0
0 0 4 0 0 0 0 5 0 0 0 0 AVERAGE 0 0 0 0 STDEV 0 0 0 0 P + C 1 0 0 0
0 ENT 2 0 0 0 0 3 0 0 0 0 4 0 0 0 0 5 0 0 0 0 AVERAGE 0 0 0 0 STDEV
0 0 0 0 P + C 1 435 0 0 0 AZA 2 595 0 0 0 3 1069 0 0 0 4 754 0 0 0
AVERAGE 713 0 0 0 STDEV 271 0 0 0 P + C 1 2221 12 0 0 2 1768 14 0 0
3 2456 21 0 0 4 577 0 0 0 5 1874 9 0 0 AVERAGE 1779 11 0 0 STDEV
726 8 0 0 AZA + ENT 1 2891 34 10 0 2 2855 14 0 0 3 3613 22 49 2 4
2726 25 0 0 5 3597 22 7 1 AVERAGE 3137 23 13 1 STDEV 432 7 20 1 ENT
1 3005 25 10 1 2 5038 20 3 0 3 2275 0 0 0 4 3063 22 6 3 5 4032 20 0
0 AVERAGE 3483 17 4 1 STDEV 1070 10 4 1 AZA 1 2345 20 0 0 2 2454 16
43 3 3 2477 20 0 1 4 4358 17 16 0 5 2117 14 0 0 AVERAGE 2750 17 12
1 STDEV 910 3 19 1 Untreated 1 4359 32 3 2 2 3432 28 0 2 3 3185 18
28 0 AVERAGE 3659 26 10 1 STDEV 619 7 15 1
Example 5
[0056] Mechanistic studies. As noted above, we expected that the
epigenetic modulators were increasing the expression of
MHC-I-related genes, thereby making the cancer cells more
susceptible to killing by T cells. To test this expectation, we
analyzed the expression of genes involved in MHC-I presentation by
reverse transcription-polymerase chain reaction (RT-PCR) in CT26
and 4T1 cells treated with AZA, entinostat, or the combination of
the two. Expression of the MHC-I, .beta.-2 microglobulin (B2M), and
transporter associated with antigen processing 1 (TAP1) genes were
detected in both tumor cell lines in the absence of treatment.
However, exposure to epigenetic modulators did not significantly
increase the expression (FIG. S2).
[0057] We then determined whether the epigenetic modulators
affected T cell accumulation within the tumors. As assessed by flow
cytometry, tumor-infiltrating CD8.sup.+ T cells increased by
approximately four-fold after PD-1/CTLA-4 inhibition (FIGS. 2 A and
B). The addition of AZA and entinostat did not increase
tumor-infiltrating CD8.sup.+ T cells further. However, inclusion of
AZA and entinostat in the treatment regimen resulted in a
significant decrease in tumor-infiltrating FoxP3.sup.+ Tregs
compared to either untreated tumors or tumors treated with
anti-PD-1/CTLA-4 antibodies (FIGS. 2 C and D).
[0058] We next analyzed MDSCs by flow cytometry, as these
myeloid-derived immature cells are often elevated in tumor-bearing
hosts and have potent immunosuppressive activities (21, 22). We
found that 4T1 tumor-bearing mice had a five to seven-fold increase
in circulating Granulocytic MDSCs (G-MDSCs, defined as
CD11b.sup.+Ly6G.sup.+Ly6C.sup.lo MHC-II.sup.-) compared to
non-tumor-bearing animals (FIG. 2E, FIGS. S3 A and B). Large
numbers of G-MDSCs were also observed in the spleen and tumor (FIG.
S3B). Addition of entinostat or AZA/entinostat to PD-1/CTLA-4
inhibition resulted in a striking reduction in the number of
circulating G-MDSCs, bringing them down to a level similar to that
observed in non-tumor-bearing mice (FIGS. 2 E and F).
Interestingly, the epigenetic modulators alone or AZA plus
anti-PD-1/anti-CTLA-4 antibodies failed to abate the G-MDSCs. The
epigenetic modulators substantially reduced the number of
tumor-infiltrating G-MDSCs as well when combined with immune
checkpoint blockade (FIGS. 2 G and H).
[0059] These data are consistent with the hypothesis that immune
checkpoint blockade leads to expansion of cytotoxic effector T
cells (Teffs), but the Teffs are not fully functional unless immune
suppressor cells are reduced by treatment with epigenetic
modulators. To further test this hypothesis, we used neutralizing
antibodies against CD25 or Ly6G to deplete Tregs or G-MDSCs,
respectively, in mice bearing 4T1 tumors (23-25). We found that
anti-Ly6G, when used in combination with anti-PD-1/anti-CTLA-4
antibodies, were as effective as the epigenetic modulators (FIG.
3A). Flow cytometry showed a substantial reduction in G-MDSC levels
after anti-Ly6G treatment (FIG. 3B). In contrast, anti-CD25
treatment only showed marginal improvement in efficacy when
combined with immune checkpoint blockade (FIG. 3A). However, it
should be noted that the anti-CD25 treatment may also affect
activated Teffs, which can transiently express CD25. As expected,
without immune checkpoint blockade, both anti-CD25 and anti-Ly6G
were ineffective (FIG. 3A).
[0060] To evaluate directly the ability of the tumor-induced
G-MDSCs to interfere with the effects of immune checkpoint
blockade, we isolated them from 4T1 tumor-bearing mice by affinity
purification. We then injected the purified G-MDSCs into 4T1
tumor-bearing mice treated with anti-PD-1/anti-CTLA-4 antibodies
plus AZA/entinostat. The adoptive transfer of G-MDSCs significantly
attenuated the response to the combination therapy (FIG. 3C). Based
on above results, we concluded that the effects of epigenetic
modulation were more likely the result of depletion of G-MDSCs than
of direct depletion of Tregs.
[0061] To investigate whether epigenetic modulation directly
affected G-MDSCs, we purified these cells from 4T1 tumor-bearing
mice as described above and treated them with entinostat or AZA in
vitro. G-MDSCs showed markedly reduced viability after entinostat
treatment in a dose-dependent fashion (FIG. 4A). Conversely, AZA
had no effect at comparable concentrations (FIG. 4B). We also
treated 4T1 tumor cells with the same concentrations of entinostat
or AZA and found them unresponsive (FIGS. 4 A and B). Importantly,
entinostat had only modest effects on CD8.sup.+ T cells (FIG. 4A),
creating a large therapeutic window in which G-MDSCs can be
depleted while sparing CD8.sup.+ T cells. Finally, we co-cultured
CD8.sup.+ T cells with G-MDSCs and analyzed the concentration of
interferon-y (IFN-.gamma.) in culture medium by enzyme-linked
immunosorbent assay (ELISA) following T cell activation with CD3
and CD28 antibodies. G-MDSCs inhibited IFN-.gamma. secretion (FIG.
4C), whereas inclusion of entinostat in the culture medium reversed
the inhibition in a dose-dependent manner (FIG. 4D). These data
supported the notion that G-MDSCs directly inhibit the function of
CD8.sup.+ T cells and entinostat alleviates the inhibition by
directly suppressing G-MDSCs.
[0062] To further confirm this conclusion, as well as to provide
additional therapeutic approaches to achieve the same goal, we
searched for other therapeutic agents that might suppress G-MDSC
function. Phosphatidylinositide 3-kinases (PI3Ks) are known to play
important roles in hematopoietic cell biology and can activate
Gr1.sup.+/CD11b.sup.+ myeloid cells (26). We had previously
developed a diverse array of PI3K inhibitors and chose to test one
(J32) with high cellular potency (27-29). J32 proved to be
cytotoxic to G-MDSCs at nanomolar concentrations (EC.sub.50 of 14.3
nM) and much less toxic to CD8.sup.+ T cells (EC.sub.50 of 94.6 nM)
(FIG. S4A). Treatment of 4T1 tumor-bearing mice with a relatively
low dose of J32 (22 mg/kg) in combination with
anti-PD-1/anti-CTLA-4 antibodies resulted in a marked reduction in
circulating G-MDSCs (FIG. S4B) and eradication of 4T1 tumors in 80%
of the animals (FIG. S4C). Alone, J32 had no appreciable effect on
the 4T1 tumor growth.
Example 5
[0063] 4T1 tumor cells were subcutaneously injected into BALB/c
mice. On day 10, 12, 14 and 16 after the tumor cell injection,
anti-PD-1 (10 mg/kg) and anti-CTLA-4 (10 mg/kg) antibodies were
injected intraperitoneally into the mice in groups 2, 3, 4 and 5.
On day 11, 13, 15 and 17, entinostat (ENT, 20 mg/kg) and
5-azacytidine (AZA, 0.8 mg/kg) were injected intraperitoneally into
the mice in groups 4 and 5. On day 13 and 15, C. novyi-NT spores
(50 million per mouse) were injected directly into the subcutaneous
4T1 tumors on mice in groups 1, 3 and 5. Mouse survival was then
followed closely until day 100 after tumor cell injection. Survival
curves are shown in FIG. 9. The dead mice dissected for
pathological assessment invariably had extensive lung
metastases.
[0064] The efficacy for checkpoint blockade (anti-PD-1/anti-CTLA-4)
plus epigenetic inhibition (ENT/AZA) shown in this experiment (50%
cure rate) was somewhat lower than that shown in the prior examples
(80% cure rate). However, the efficacy for anti-PD-1/anti-CTLA-4
alone in this experiment was lower as well (10% cure rate here
versus 30% in the prior examples). The efficacy enhancement
observed in the combination therapy has not been diminished. The
variation in efficacy is likely due to the quality of the
antibodies from different manufacturing lots.
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Sequence CWU 1
1
37120DNAArtificial SequencePCR primer 1agggcaatga gcagagtttc
20220DNAArtificial SequencePCR primer 2ccacgttttc aggtcttcgt
20320DNAArtificial SequencePCR primer 3attcaccccc actgagactg
20421DNAArtificial SequencePCR primer 4gctatttctt tctgcgtgca t
21520DNAArtificial SequencePCR primer 5gagacatgct gtgtcggatg
20620DNAArtificial SequencePCR primer 6tggtgagaat ggacatgagc
20724DNAArtificial SequencePCR primer 7ttctttgcag ctccttcgtt gccg
24824DNAArtificial SequencePCR primer 8tggatggcta cgtacatggc tggg
2499PRTHomo sapiens 9Ser Gly Pro Ser Tyr Ala Thr Tyr Leu1
5109PRTHomo sapiens 10Ser Tyr Glu Thr Leu Lys Lys Ser Leu1
5119PRTHomo sapiens 11Ser Tyr Thr Ser Tyr Ile Met Ala Ile1
5129PRTHomo sapiens 12Arg Tyr Trp Thr Gly Ile Gly Val Leu1
5139PRTHomo sapiens 13Ala Tyr Val Asn Ala Ile Glu Lys Ile1
5149PRTHomo sapiens 14Ser Tyr Ile Lys Lys Leu Lys Glu Leu1
5159PRTHomo sapiens 15His Tyr Leu Asn Asp Gly Asp Ala Ile1
5169PRTHomo sapiens 16Lys Val Leu Ala Gly Lys Ser Thr Ile1
5179PRTHomo sapiens 17His His Thr Met Met Val Gln Ala Ile1
5189PRTHomo sapiens 18Ala Tyr Ala Leu Asn Arg Arg Asn Leu1
5199PRTHomo sapiens 19Ser Tyr Ile Met Ala Ile Cys Gly Met1
5209PRTHomo sapiens 20Tyr Tyr Met Arg Asp Val Ile Ala Ile1
5219PRTHomo sapiens 21Leu Phe Leu Lys Ser Pro Thr Ala Leu1
5229PRTHomo sapiens 22Pro Tyr Phe Arg Leu Glu His Tyr Leu1
5239PRTHomo sapiens 23Ser Tyr Leu Arg Arg Leu Pro Gly Leu1
5249PRTHomo sapiens 24Thr Tyr Trp Lys Gly Asn Pro Glu Met1
5259PRTHomo sapiens 25Gly Tyr Glu Ala Val Val Arg Leu Leu1
5269PRTHomo sapiens 26Pro Tyr Leu Thr Ala Leu Asp Asp Leu1
5279PRTHomo sapiens 27Leu Phe Val Thr Val Leu Glu Val Ile1
5289PRTHomo sapiens 28Val Tyr Phe Thr Ile Asn Val Asn Leu1
5299PRTHomo sapiens 29Ser Tyr Thr Glu Gln Asn Val Lys Leu1
5309PRTHomo sapiens 30Phe Tyr Thr Ser Tyr Leu Arg Arg Leu1
5319PRTHomo sapiens 31Phe Pro Pro Gln Asn Met Phe Glu Phe1
5329PRTHomo sapiens 32Ser Pro Glu Ala Gln Leu Phe Ala Val1
5339PRTHomo sapiens 33Glu Pro Gln Ile Ala Met Asp Asp Met1
5349PRTHomo sapiens 34Ile Pro Asp Glu Ala Met Val Lys Leu1
5359PRTHomo sapiens 35Glu Pro Gln Val Glu Pro Leu Asp Phe1
5369PRTHomo sapiens 36Asp Pro Phe Ala Thr Pro Leu Ser Met1
5379PRTHomo sapiens 37Phe Pro Pro Asp Ala Ile Asn Asn Phe1 5
* * * * *
References