presentación de powerpoint · cómo seleccionar inmuno vs no inmuno en 2º linea? checkmate 057 :...
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Inmunoterapia de segunda línea: largos supervivientes. Biomarcadores y posibles
pautas de selección
Dr. Manuel Cobo, Hospital Regional Universitario de Málaga
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Versteven M, Van den Bergh JMJ, Marcq E, et al. Dendritic Cells and Programmed Death-1 Blockade: A Joint Venture to Combat Cancer. Front Immunol. 2018 Mar 1;9:394
Immunocheckpoints act far beyond the simple synapse Teffector- Tumor cell
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Clinical trials in patients previously treated: NIVOLUMAB
Nivolumab – CheckMate 017 (PIII)1
2nd Line, squamous, PD-L1 All-Comer
Nivolumab – CheckMate 057 (PIII)2
2nd Line, non-squamous, PD-L1 All-Comer
1. Borghaei H et al. Poster presentation at ASCO 2016. 9025. 2. Brahmer JR et al. Oral presentation at AACR 2017. CT077. 3. Herbst RS et al. Poster presentation at ASCO 2017. 9090. 4. Rittmeyer A et al. Lancet. 2017;389(10066):255-265.
Borghaei et al., 2016, ASCO.1Time (Months)
100
80
60
40
20
00 6 30
OS
(%)
1812 24 36
NivolumabDocetaxel
Checkmate 017 (SQ)1
Time (Months)
2-yr OS = 23%2-yr OS = 8%
NivolumabDocetaxel
100
80
60
40
20
00 6 30
OS
(%)
1812 24 36
Checkmate 057 (NSQ)1
2-yr OS = 29%2-yr OS = 16%
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5-Year Estimates of OSa
CA209-003 5-Year Update: Phase 1 Nivolumab in Advanced NSCLC
5
Median OS (95% CI), mo
Overall (N = 129) 9.9 (7.8, 12.4)
100
80
60
40
20
0
0 1 2 3 4 5 6 7 8
129 49 27 20 17 16 3 1 0
YearsNo. at Risk
OS
(%)
1 y OS, 42%
2 y OS, 24%
3 y OS, 18% 5 y OS, 16%
aThere were 3 deaths between 3 and 5 years, all due to disease progression; 1 surviving patient was censored for OS prior to 5 years (OS: 58.2+ months)
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Pembrolizumab - Keynote 010 (PII/III)3
2nd+ Line, PD-L1 TPS ≥1%
1. Borghaei H et al. Poster presentation at ASCO 2016. 9025. 2. Brahmer JR et al. Oral presentation at AACR 2017. CT077. 3. Herbst RS et al. Poster presentation at ASCO 2017. 9090. 4. Rittmeyer A et al. Lancet. 2017;389(10066):255-265.
Herbst et al., 2017, ASCO.3Time (Months)
100
80
60
40
20
00 5 10 15 20 25 30 35
OS
(%)
Pembro 2 mg/kgPembro 10 mg/kgDocetaxel
KEYNOTE-010 (≥1% PD-L1)3
30-mo OS = 29.5%30-mo OS = 22.1%30-mo OS = 12.3%
Clinical trials in patients previously treated: Pembrozilumab
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Phase III OAK study design
Atezolizumab 1200 mg IV q3w
PD or loss of clinical benefit
Docetaxel 75 mg/m2 q3w
Locally Advanced or Metastatic NSCLC
• 1–2 prior lines of chemo including at least 1 platinum based
• Any PD-L1 status
N = 1,225 enrolleda
PD
R
1:1
Stratification factors• PD-L1 expression
• Histology
• Prior chemotherapy regimens
Primary Endpoints (first 850 enrolled patients):
• OS in the ITT population
• OS in patients with PD-L1 expression on ≥ 1% TC or IC
Secondary Endpoints: ORR, PFS, DoR, Safety
aA prespecified analysis of the first 850 patients provided sufficient power to test the co-primary endpoints of OS in the ITT and TC1/2/3 or IC1/2/3 subgroup (≥ 1% PD-L1 expression). TC, tumor cells; IC, tumor-infiltrating immune cells.
• Barlesi et al, Atezolizumab Phase III OAK Study. http://tago.ca/9Hh
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Fehrenbacher L, et al. JTO 2018
En el total de los pacientes (1220 pts), Atezolizumab sigue beneficio en SG frente a docetaxel
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Slide 19
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•Landmark 2-year overall survival in OAK phase III trial.
Atezolizumab vs docetaxel
•LTS, long-term survivors.
•a 27 atezolizumab- and 49 docetaxel-arm patients were censored prior to 24 months and excluded from this analysis.
•Data cutoff: 23 January, 2017.•Satouchi, et al. IASLC Tokio 2017
Overall survival (OS) in ITT850• 1–2 prior lines of chemo including at least 1 platinum based
• Any histology
• PDL! Determinates with SP142
Atezolizumab tiene beneficio en SG a largo plazo, con 31 % de pts supervivientes a dos años
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• Long-term survival with atezolizumab is associated with extended treatment duration and
is not limited to radiographic responders
•Treatment duration and time to response/progression in
atezolizumab LTS
•Data cutoff: 23 January, 2017.
•Satouchi, et al. WCLC 2017
Be
st R
esp
on
se
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TBP in Atezolizumab Arm: By Type of Post-PD Treatment
Gandara DR et al. OAK: Atezolizumab treatment beyond disease progression.
Data cutoff: 7 July, 2016.
18-mo OS
37%
20%
9%
12.7 mo (9.3, 14.9)
8.8 mo (6.0, 12.1)
2.2 mo (1.9, 3.4)
mOS 95% CI
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Slide 36
Presented By Solange Peters at 2018 ASCO Annual Meeting
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IASLC 2016
Pero, y tras dos años??????
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5-Year Estimates of OS <br />Phase 1 nivolumab
Presented By Solange Peters at 2018 ASCO Annual Meeting
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Inmunoterapia ca pulmon avanzado Segunda línea para todos los
pacientes ??
Cómo seleccionar inmuno vs no inmuno en 2º linea?
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12-month OS
Nivo (n=292) Doc (n=290)
mPFS, months 2.3 4.2
1-year PFS rate, % 19 8HR (95%CI) 0.92 (0.77, 1.11)
p=0.39
CURVESCROSSED
DELAYEDSEPARATION
Borghoei H, et al. NEJM 2015.
CHECKMATE 057 Adenocarcinoma pts: PFS & OS
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OS by prespecified PD-L1 expression levels, ITT population (secondary endpoint) after additional follow-up
Secondary endpoint: OS by PD-L1 expression level
18• CI, confidence interval; HR, hazard ratio; ITT, intention-to-treat; OS, overall survival; PD-L1, programmed death-ligand 1.
• Borghaei H, et al. N Engl J Med 2015;373:1627–39.
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OAK. Atezolizumab vs docetaxel
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Inmunoterapia ca pulmon avanzado Segunda línea para todos los
pacientes ??
Mejores biomarcadores de selección?
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Carbone. IASLC 2015
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The next frontier: utilising immune profilingfor a patient-driven approach
Adapted from Chen and Mellman. Immunity 2013; Hegde, et al. Clin Cancer Res 2016; Kim and Chen. Ann Oncol 2016; Chen, Herbst et al Nature 2014, and Mellman. Nature 2017
Each immune phenotype requires a personalised immunotherapy approach
to initiate/re-initiate the antitumour immune response
IMMUNE DESERTIMMUNE EXCLUDEDINFLAMED
GENERATEactive, tumour-directed T cells
INFILTRATEtumour
KILLtumour
Essential T cell activity required
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Pt CD8+ Density, Invasive Margin Before Treatment
Predicted Probability of Response
Blinded Prediction Clinical Response (RECIST1.1)
1 58 0.35 Progression Progression
2 159 0.37 Progression Progression
3 329 0.40 Progression Progression
4 341 0.41 Progression Progression
5 2120 0.75 Response Stable
6 5466 0.98 Response Progression
7 2211 0.76 Response Response
8 3810 0.92 Response Response
9 4294 0.95 Response Response
10 4948 0.97 Response Response
11 5565 0.98 Response Response
12 6004 0.99 Response Response
13 5951 0.99 Response Complete response
14 7230 0.99 Response Complete response
15 6320 0.99 Response Complete response
Lo ideal:la densidad de infiltración de LT8 junto con expresión de PD-L1
P. C. Tumeh et al., Nature 2014; 515,:568 -71.
La densidad de LT CD8 en el margen de invasión del tumor fue mucho más predictiva de beneficio a Pembrolizumab
que PD-L1. .- Este dato sugiere que expresión de PD-L1 en el tumor es más poderoso como biomarcador cuando se
observa en el contexto de una respuesta de cel T activos.
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Slide 7
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Types of alterations<br />
Mark Burkard at 2018 ASCO
Tipos de alteraciones genéticas detectadas en NGS
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Slide 8
Xiaoliang Wu at ASCO 2018
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Slide 23
Chan et al. 2018 ASCO 2018
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Slide 31
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Novel Clinical Trials: A multi-disciplinary approach to understand response and resistance
Herbs RS. IASLC Tokio 2017
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Slide 11
Joshi at 2018 ASCO 2018
¿ Es ya hora de secuenciar Linfocitos y tomar decisiones según la hiperclonalidad de los TCR ??
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1 pixel = 0.5 µM
PD-1/PD-L1 INTERACTION SCORE
PD
-L1
PD
-1 C
K D
AP
I
Interaction Score: 4078
Interaction Score: 188
Quantitative Spatial Profiling of PD-1/PD-L1:La interacción PD1-PDL1 captada con esta tecnología y haciendo un “SCORE”Este sería sin duda el biomarcador ideal para una terapia anti Pd1-Pdl1
Vamsidhar Velcheti. IASLC Tokio 2017
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identify a module of co-inhibitory receptors that includes not only several known co-inhibitory receptors (PD-1, TIM-3, LAG-3 and TIGIT) but
also many new surface receptors. Two new co-inhibitory receptors, activated protein C receptor (PROCR) and
podoplanin (PDPN). co-expressed in both CD4+ and CD8+ T cells and is part of a larger co-inhibitory gene program that is
shared by non-responsive T cells in several physiological contexts and is driven by the immunoregulatory cytokine IL-27. Computational analysis identified the transcription factors PRDM1 and c-MAF as cooperative regulators of the co-inhibitory module.
Secuenciación Linfocitos usando expresión RNA y proteinas: co-inhibitory receptors
Chihara, et al. Nature. 2018 .Induction and transcriptional regulation of the co-inhibitory gene module in T cells
HAY más checkpoints inhibitoriosAparte de los ya conocios
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Inmunoterapia ca pulmon avanzado Segunda línea para todos los
pacientes ??
Cómo seleccionar inmuno vs no inmuno en 2º linea?
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CHECKMATE 057 : Risk of early death (EPAR)Kaplan-Meier Plot of Overall Survival
European Public Assessment Report , EMA/246304/2016, page 27
Nivolumab 20% early death % vs 15% Docetaxel % at 3 months
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CHECKMATE 057 : Waterfall Plots ORR
More and deeper responses with Nivolumab
BUT
Also more and stronger progressions
Borghoei H, et al. NEJM 2015 (Appendix pag. 41-42 )
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3-Month Landmark Analysis of OS CheckMate 057: Nivolumab vs Docetaxel in Previously Treated NSQ NSCLC
Nivo(n = 232)
Doc (n = 244)
Median OS, mo
17.4 11.3
Events, n 131 179
HR (95% CI) 0.59 (0.47, 0.74)
Alive at 3 Months − All Patients
ITT Population1
Nivo(n = 292)
Doc (n = 290)
Median OS, mo
12.2 9.4
Events, n 190 223
HR (96% CI) 0.73 (0.59, 0.89)
Based on a March 18, 2015 database lock1. Borghaei H, et al. N Engl J Med 2015;373:1627–1639.
Nivolumab
Docetaxel
OS
(%)
Months
100
90
80
70
60
50
40
30
10
0
20
27211815129630 24
Months
100
90
80
70
60
50
40
30
10
0
20
27211815129630 24
Nivo(n = 82)
Doc(n = 87)
Median OS, mo
14.7 11.4
Events, n 51 62
HR (95% CI) 0.66 (0.45, 0.97)
Alive at 3 Months –Patients With <1% PD-L1 Expression
Months
100
90
80
70
60
50
40
30
10
0
20
27211815129630 24
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Definitions & Frequencies
Hiperprogresion
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TAC 9-2016(basal)
TAC 11-2016
Aumento lesión +Nódulo satélite
1º evaluación
Aumento de dolor
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15-3-2017
TAC 11-2016
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PD-L1 local SP 263 < 1%. Se opta por ensayo clínico atezolizumab vs atezolizumab + daratumumab (antiCD38) ( le toca brazo brazo cominación)
27-7-2017
1º evaluación
Progresión recist 1.1
10-10-2017
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PD-L1 local SP 263 < 1%. Se opta por ensayo clínico atezolizumab vs atezolizumab + daratumumab (antiCD38) . Se opta por seguir mismo tratamiento y esperar próxima evaluación
2º evaluación
Remisión Parcial
10-10-2017
27-7-201729-11-2017
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Predicting hyperprogression
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En células Tumorales también hay PD1La conexión PD1-PDL1 inhibe la proliferación en el tumorUn Ac monoclonal antiPD1 podría acelerar el crecimiento del tumor al estimularLa proliferación mediada por la vía PI3K
Ludin, A. Nature 2017
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2018
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En el modelo in vitro, Aumento viabilidadCelular tras bloqueo con AC antiPD1Disminución crecimiento celular con PD-L1recombinante
En el modelo in vivo, Tumores “inflamados”, la célula tumoral no suele expresar PD1. La terapia inmune: eficaz. Tumores fríos que expresan PD1 en cel tumoral: la terapia inmune produce crecimiento del TUMOR
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Inmunoterapia en 2º línea CPNM avanzado con mutación de EGFR: menos eficacia respecto a docetaxel que pts sin mutación
*Data for the pembrolizumab doses were pooled.
CheckMate 057
KEYNOTE-010*
OAK
Nivolumab Docetaxel
Pembrolizumab Docetaxel
Atezolizumab Docetaxel
References in slidenotes.
Pts,
n
Unstratified HR
(95% CI)
82 1.18 (0.69-2.00)
340 0.66 (0.51-0.86)
160 0.74 (0.51-1.06)
Events/Pts, n/N
HR (95% CI)
46/860.88 (0.45-
1.70)
447/8750.66 (0.55-
0.80)
Pts, n (%)
HR (95% CI)
85 (10)1.24 (0.71-
2.18)628 (74)
0.69 (0.57-0.83)
Mutant
Not detected
Not reported
MutantWild type
MutantWild type
1.00.5 2.00.25 4.0
1.00.1 10
1.00.2 2
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PDL1 es un factor predictivo que actúa como variable continua: a mayor nivel
de expresión, mayor eficacia de terapias anti PD1 /PDL1
Pero en el intervalo entre PD-L1 1-49, es realmente tan impactante la
variabilidad ?
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OS hazard ratios by baseline PD-L1 expression level
51• CI, confidence interval; OS, overall survival; PD-L1, programmed death-ligand 1.
• Opdivo-H-C-3985-II-0002: EPAR – Assessment Report – Variation. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Assessment_Report_-_Variation/human/003985/WC500205973.pdf Accessed 30 January 2017.
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Kaplan-Meier Plot of Overall Survival by PD-L1 Expression (1 and 10%)
European Public Assessment Report , EMA/246304/2016, page 32
Nivel expresión PDL-1& riesgo muerte precoz
CHECKMATE 057 : Risk of early death (EPAR)
Con PDL1 <1% (negativo), a los 3 m de tto:10% mueren con dctx y 25% con nivolumab (aprox)
Con PDL1 <10%, a los 3 m de tto:12% mueren con dctx y 30% con nivolumab (aprox)
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KEYNOTE-001: Efficacy Results
≤1% 1-49% ≥50%
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OAK: OS by PD-L1 EXpression
In favor ofdocetaxel
Hazard Ratioa
In favor of atezolizumab
Subgroup
Median OS, moAtezolizumab Docetaxel
n = 425 n = 425
0.2 1 2
TC1/2/3 or IC1/2/3a
TC0 and IC0
ITTa
TC3 or IC3
TC2/3 or IC2/3
13.8 9.6
12.6 8.9
15.7 10.3
16.3 10.8
20.5 8.90.41
0.67
0.74
0.75
0.73
45%
On-study Prevalence
• Barlesi et al, Atezolizumab Phase III OAK Study. http://tago.ca/9Hh
16%
31%
55%
100%
TC3 or IC316%
TC2/3 or
IC2/331%
TC1/2/3 or
IC1/2/354%
TC0 and IC045%
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Respuesta al tratamiento de primera línea
Intervalo libre progresión del tratamiento 1º línea: tiempo desde inicio 1º línea hasta la necesidad de comenzar nueva línea terapéutica
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CHECKMATE 057: OS SUBGROUP ANALYSIS
Borghoei H, et al. NEJM 2015.
CheckMate 057
1st line therapy
Stop 1st lineTherapy
<3 mo, 3-6 mo and >6 mo
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Which Is More Important, Choosing Patients Who Will Respond or Identifying Those Who Will Die Early?
Ramos I et al. WCLC 2018 (poster 8300)
0
5
10
15
20
25
30
35
≤4cycles >4cycles
NumberofcyclesofNivolumab
NumberofcyclesofNivolumab
n=22
n=27
Table1-BaselineCharacteristics AllPatients:49 *Rapidsprogressors:22 NonRapids
Progressors:27p-value
Maleno.(%)Femaleno.(%)
36(73,5)13(26,5)
18(81,81)4(18,19) 18(66,66)9(33,3)
0,594
Age-yr(Median,range)Age>75years(%)
62,8(44-77)
8,16
60,9(44-77)
4,54
65,0(48-78)
11,1
0,685
ECOG(%)0-12
91,18,9
90,919,09
92,67,4
0,611
Smokingstatus%-Currentorformer
smokers-NeverSmoked
Cumulativetobaccoconsumption,≥40Tobacco
packs
87,8
10,2
46,9
901040
86,2
3,8
55,6
0,723
0,472
Co-morbidity(%)-Yes-No
40,859,2
38,0961,9
6337
0,407
Histology:-Adenocarcinoma
-Squamous-NSCLCNOS
32,753,112,2
355510
33,351,914,8
0,666
Metastaticlocalitation%-SNC
-Hepatic-Bone
20,416,320,4
19,0433,3342,86
22,211,114,8
0,481
No.ofpriorsystemicregimens(%):
-1-2
-3ormore
69,418,412,2
63,6323,809,5
74,114,811,1
0,959
Bestresponsetomostrecentpriorsystemic-%-Completeorparcial
respones-Stabledisease
-Progressivedisease-UnKnown
30,6
20,416,332,7
19,04
38,0942,854,5
40,7
14,833,311,1
0,059
Timefrompriorchemotherapy(Mean-
Median,days)
329,23-239,0
179,05–163,0
440,48–324,0
0,002
*Rapidprogressors:patientswhohavereceived4cyclesorless
StatisticalanalysesusingthePearson’schi-squaretest,Fisher’sexacttest,andstudent’st-testwereusedtoevaluatetheclinicalcharacteristicsassociatedwiththeefficacyofNivolumab.
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Which Is More Important, Choosing Patients Who Will Respond or Identifying Those Who Will Die Early?
Fig.1.Kaplan-Meier survival curveofPFSforpatients who received Nivolumabtreatment
Fig.2.Kaplan-Meier survival curveofOSforpatienss whoreceived Nivolumab treatment
Fig.3.Kaplan-Meier survival curveofPFSaccording to time from prior chemoherapy
(< 6 months vs ≥ 6 months)
Fig.4.Kaplan-Meier survival curveofPFSaccording to time from prior chemoherapy
(< 6 months vs ≥ 6 months)
Ramos I et al. WCLC 2018 (poster 8300)
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Further multivariate analyses related to risk of early death
European Public Assessment Report , EMA/246304/2016, page 40
Associations found with
1. PD-L1 expression level (e.g. <1%, <5%, <10%, <50%) and ECOG score (e.g. ECOG PS 1)
2. time since last treatment < 3 months
3. progressive disease as best response to last treatment
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Carga tumoral.
Crecimiento rápido: Tiempo duplicación
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Mc Farlane F, et al. Bull Math Biol. 4 March 2018
Modelo matemático ratio control proliferacón Cel Tumorales en consonancia con cel inmunitarias
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Walker R, et al. Sci Rep. 2018 Jun 21;8(1):9474. Immune interconnectivity of anatomically distant tumors as a potential mediator of systemic responses to local therapy.
El aumento de carga tumoral e incremento de nº de lesiones: menos beneficio de inmunoterapia.Debido a la hiperdiversificación en la distribución de linfocitos con diferentes TCR no compartidos.Y además depende del índice de reclutamiento linfocitario y la ratio de crecimiento de cada lesión
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Walker R, et al. Sci Rep. 2018 Jun 21;8(1):9474. Immune interconnectivity of anatomically distant tumors as a potential mediator of systemic responses to local therapy.
El aumento de carga tumoral e incremento de nº de lesiones: menos beneficio de inmunoterapia.Debido a la hiperdiversificación en la distribución de linfocitos con diferentes TCR no compartidos.Y además depende del índice de reclutamiento linfocitario y la ratio de crecimiento de cada lesión
Varias localizaciones con igual patrón de crecimiento: Si la localización B tiene mayor índice de reclutamiento de linfocitos que localización A, se evidenciará un incremento del crecimiento del tumor de localización A
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Walker R, et al. Sci Rep. 2018 Jun 21;8(1):9474. Immune interconnectivity of anatomically distant tumors as a potential mediator of systemic responses to local therapy.
Sin tratamiento sistémico. Al resecar una lesión tumoral, decrece el crecimiento de la lesión no resecada, y además aumenta el componente de infiltración de células inmunes
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PD-L1 < 1%
Expresión PD-L1
PD-L1 1-49% PD-L1 % > 49%
Progresión rápidaDurante 1º línea
Quimioterapia/Quimio-antiangiog Inmunoterapia
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PD-L1 < 1%
Expresión PD-L1
PD-L1 1-49%
Progresión rápidaDurante 1º línea
Quimioterapia óQuimio-antiangiog
Progresión antesDe 3 meses de ultimaDosis de platino
Progresión despuésDe 3 meses de ultimaDosis de platino
Alta cargaTumoral /Progresiónrápida
Baja cargatumoral
Inmunoterapia
PD-L1 1-10% PD-L1 >10%
Baja cargatumoral
Inmunoterapia /Quimio o quimio +antiangiogénicos
Alta cargaTumoral +Progresiónrápida
Quimioterapia óQuimio-antiangiog /Inmunoterapia
Alta cargaTumoral +Progresiónlenta
Inmunoterapia
Progresión rápidaDurante 1º línea
Quimioterapia óQuimio-antiangiog /inmunoterapia
Progresión antesDe 3 meses de ultimaDosis de platino
Progresión despuésDe 3 meses de ultimaDosis de platino
Alta cargaTumoral /Progresiónrápida
Baja cargatumoral
Inmunoterapia
Baja cargatumoral
Inmunoterapia
Alta cargaTumoral +Progresiónrápida
Inmunoterapia /Quimioterapia óQuimio-antiangiog
Alta cargaTumoral +Progresiónlenta
Inmunoterapia
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• The tumor microenvironment contains various immunosuppressive factors from different sources that tumors use as defense mechanisms against the immune system – selected examples are shown
Secreción de factores inmunosupresores
Factor Sourceb Effectb
Transforming growth factor-β Tumor cells, Tregs, and MDSC Suppressive effects on T cells, NK cells, and APCs
IL-10 Tumor cells, tumor-associated macrophages, and TregsDownregulates expression of some co-stimulatory molecules and MHC
VEGFTumor cells and other associated cells
Inhibits DC function
Prostaglandin E24 Tumor cells, tumor-associated macrophages and fibroblasts, other inflammatory cells
Promotes MDSC and Treg development and function; suppresses DC function and antitumor T and NK cell responses
Arginase6 MDSCs, tumor cellsMetabolizes and prevents T cell access to the amino acid arginine; this inhibits T-cell proliferation and global protein synthesis
IDO7 Tumor cells, DCs, fibroblastsMetabolizes tryptophan, inhibiting T-cell proliferation and function and expanding local Treg populations
Adenosine9 Hypoxic tumor cells T-cell suppression and Treg expansion, tumor growth and angiogenesis
iNOS MDSCs MDSC induction, tumor angiogenesis
aInclude enzymes that produce
immunosuppressive factors. bMain
source(s) and key immune effects are
indicated; many factors have multiple
sources and overlapping effects.
IDO = indoleamine 2,3-dioxygenase; iNOS
= inducible nitric oxide synthase; MDSC =
myeloid-derived suppressor cell; VEGF =
vascular endothelial growth factor.1.
Kim JM, Chen DS. Immune escape to PD-L1/PD-1 blockade: seven steps to success (or failure). Ann Oncol 2016;27(8):1492-504.
Palucka AK, Coussens LM. The Basis of Oncoimmunology. Cell 2016;164:1233-47.
Reguladores intrínsecos
Reguladores extrínsecos
Microambiente tumoral
Presentación antigénica
. La adenosina (que es generada por la conversión de ATP gracias a ecto-nucleotidasas CD39 y CD73), inh actividad y expansión de células T a través del receptor de adenosina A2A. Ac que inhiben CD73, aumenta la actividad de anti-PD1
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S. Aspeslagh. ANN ONCOL FEB 2018.
Epigenetic modifiers as new immunomodulatory therapies in solid tumours