Canadian Journal of Gastroenterology and Hepatology
Volume 2018 (2018), Article ID 6240467, 7 pages
https://doi.org/10.1155/2018/6240467

Review Article

Combination Immunotherapy Approaches for Pancreatic Cancer Treatment

Xianliang Cheng,¹ Gang Zhao,² and Yunqi Zhao¹

¹School of Pharmaceutical Sciences & Yunnan Provincial Key Laboratory of Pharmacology for Natural Products, Kunming Medical University, Kunming, Yunnan, China
²The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China

Correspondence should be addressed to Yunqi Zhao; chloe_zyq@163.com

Received 6 November 2017; Accepted 24 December 2017; Published 7 March 2018

Academic Editor: Qi Chen

Copyright © 2018 Xianliang Cheng et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Pancreatic ductal adenocarcinoma is a lethal malignant disease with a very low medium survival. Currently, metastatic pancreatic cancer poorly responds to conventional treatments and exhibits an acute resistance to most chemotherapy. Few approaches have been shown to be effective for metastatic pancreatic cancer treatment. Novel therapeutic approaches to treat patients with pancreatic adenocarcinoma are in great demand. Last decades, immunotherapies have been evaluated in clinical trials and received great success in many types of cancers. However, it has very limited success in treating pancreatic cancer. As pancreatic cancer poorly responds to many single immunotherapeutic agents, combination immunotherapy was introduced to improve efficacy. The combination therapies hold great promise for enhancing immune responses to achieve better therapeutic effects. This review summarizes the existing and potential combination immunotherapies for the treatment of pancreatic cancer.

1. Introduction

Pancreatic ductal adenocarcinoma (PDAC) is the most common form of pancreatic cancer (approximately 90%), and it is the third leading cause of cancer death with an overall 5-year survival rate of 5–10% [1, 2]. Since PDAC is normally diagnosed at a late stage, the majority of patients with PDAC do not survive a year after diagnosis. The standard chemotherapy for metastatic PDAC is FOLFIRINOX, a combination of oxaliplatin, irinotecan, fluorouracil, and leucovorin [3]. However, concerns for toxicity and adverse side effects quickly restricted patients to the treatment. Due to rising incidence of PDAC, there is a major unmet need to develop novel promising therapeutic strategies.

Immunotherapy opens a new era in cancer treatment. People achieve great success in cancer vaccines and immunomodulators, such as checkpoint blockade to induce endogenous host immune response. Nevertheless, PDAC has nonimmunogenic and immune-suppressive microenvironment, and immune checkpoint inhibitor monotherapy alone lacks efficacy in this disease. Tremendous efforts have been made to seek a new strategy to improve immunotherapy efficacy.

Innate immune cells express pattern-recognition receptors, such as dectin-1, on their surfaces. Dectin-1 was found highly expressed in human PDAC tumor and peritumoral inflammatory compartments. The dectin-1 signal transduction pathway opens a new area in the anticancer therapeutic application. It could be an attractive target for PDAC immunotherapy.

Adoptive immunotherapy utilizing chimeric antigen receptor-engineered T-cells is being exploited as a promising strategy to redirect patient’s T-cells against tumors and reduce tumor load. Several antigens, such as carcinoembryonic antigen and mesothelin, have been chosen as the target of the engineered T-cells. Researches indicate that this strategy showed encouraging results. However, serious adverse events were associated with the treatment [4, 5] such as cytokine release syndrome and neurological toxicity [6]. Other therapeutic approaches need to be done to solve the safety issue.

In this review, we summarized recent findings in the development of novel combination immunotherapies to improve treatment efficacy in PDAC.

2. Immune Checkpoint

Immune checkpoints are involved in regulation of antigen recognition of T-cell receptor by costimulatory or inhibitory signaling transduction in the immune system. Immune checkpoint blockade therapy achieves great success in treating many types of cancers [7]. It targets T-cell regulatory pathways to enhance anticancer immune response. Since the immune response has dynamic nature, research indicates that combination therapies may provide a better survival benefit for cancer patients [8].

2.1. Cytotoxic T-Lymphocyte-Associated Antigen-4 (CTLA-4)

T-cell exclusion is obviously evident in PDAC, in which effector T-cells are often scarce within tumor tissue and confined to peritumoral lymph nodes and lymphoid aggregates [9]. CTLA-4 is an immune checkpoint receptor expressed on regulatory T (Treg) cells and recently activated conventional T-cells [10]. It is a negative regulator of T-cell activation, and it is also known as CD152. CTLA-4 is homologous to CD28 and they share the same ligands. Both B7-1 (CD80) and B7-2 (CD86) ligands are expressed on antigen-presenting cells (APCs) and can render costimulatory signals to T-cells. Upon activation, T-cells express CTLA-4 on the cell surface. CTLA-4 engagement with B7 inhibits T-cell activation. CTLA-4 has higher affinity to B7 ligands compared to CD28. CTLA-4 ligation delivers an inhibitory signal to T-cells, whereas CD28 delivers a stimulatory signal [11, 12]. The anti-CTLA-4 antibody can blockade CTLA-4 interaction with B7 and prevents the inhibitory signal [13]. Targeting CTLA-4 with a human anti-CTLA-4 antibody has demonstrated therapeutic success in the treatment of melanoma [14]. Then blockade of CTLA-4 may be a promising new approach to cancer therapy and constitutes a novel approach to induce host responses against tumors. It could downregulate the immune system and produce durable anticancer responses [15]. However, there is no sufficient evidence showing that CTLA-4 is a potential therapeutic target for PDAC immunotherapy [16]. Little benefit has been achieved so far by applying CTLA-4 antibodies alone in PDAC treatment. This might be due to high tumor burden and the intrinsic nonimmunogenic nature of pancreatic cancer that cause immune quiescent, and the blockage of only one checkpoint is not enough for immunosuppressive reduction.

Ipilimumab (MDX-010) is a fully humanized IgG1 monoclonal antibody that works by blocking the ligand-receptor interaction of B7-1/B7-2 and CTLA-4. Thereby, ipilimumab has the potential to increase antigen-specific immune responses. In 2011, it is approved by US Food and Drug Administration (FDA) to treat metastatic melanoma [17], and the thread name is Yervoy. Ipilimumab, as a single agent, has been tested in PDAC patients. Despite the fact that ipilimumab at a dose of 3.0 mg/kg was minimally effective for the treatment of advanced pancreatic cancer, the delayed response case suggests that it deserves further investigation and complete assessment of immunotherapeutic approaches to pancreatic cancer [18]. Therefore, the concept of synergy between immune checkpoint blockade and cancer vaccines was brought up. It has shown encouraging results in PDAC in treatment combinations with granulocyte macrophage-colony stimulating factor (GM-CSF) cell-based vaccines (GVAX). In a phase I b trial study, ipilimumab 10 mg/kg + GVAX treatment group showed prolonged median overall survival and 1-year overall survival compared to ipilimumab 10 mg/kg treatment group. It indicates that checkpoint blockade in combination with GVAX has clinical benefit potential for PDAC patients [19].

Tremelimumab (CP 675206; CP-675; CP-675,206; CP-675206; Ticilimumab) is fully humanized IgG2 monoclonal antibody that antagonizes CTLA-4. It has been used for the treatment of various cancers, such as melanoma, colorectal cancer, prostate cancer, and pancreatic cancer [20]. A phase I study of tremelimumab combined with gemcitabine to treat pancreatic cancer was performed [21]. The study demonstrated a safe and tolerable profile and suggested that anti-CTLA-4 antibody in combination with standard chemotherapy might provide synergistic anticancer activity without increasing side effects.

2.2. Programmed Death 1 (PD-1)

PD-1 protein, known as another immune checkpoint, is expressed on the surface of activated T-cells and is associated with programmed cell death [22]. PD-1, together with one of its ligands, programmed death-ligand 1 (PD-L1; also called B7-H1 or CD274), a B-7 family ligand, can suppress the overstimulation of immune responses and commit to the maintenance of immune tolerance to self-antigens [23]. It is an immunosuppressive pathway that is upregulated in tumor cells. PD-L1 is expressed by immune cells and various cancer cells, including breast, cervical, colorectal, gastric, glioblastoma, melanoma, non-small-cell lung, ovarian, pancreatic, and urothelial cancer [24]. Binding of PD-1 to its ligands inhibits T-cell activity and restricts tumor cell killing [25–28], leading to detrimental immune responses and preventing autoimmunity [29]. Blocking the ligation between PD-1 and PD-L1 should, therefore, augment immune response in vitro and initiate antitumor activity in preclinical models [30–32]. Because of this, targeting PD-1/PD-L1, as immune checkpoint blockade, has been developing in oncologic therapy for various cancers as of late. For instance, pembrolizumab (trade name Keytruda, 2014), nivolumab (trade name Opdivo, 2014), atezolizumab (trade name Tecentriq, 2016), and Durvalumab (trade name Imfinzi, 2017) were approved by US FDA for the treatment of metastatic non-small cell lung cancer, squamous cell carcinoma of the head and neck, metastatic melanoma, and bladder cancer, respectively. However, in the treatment of pancreatic cancer, there tends to be no apparent therapeutic effects of a single antibody [33, 34].

Therefore, to overcome the resistance of anti-PD-1/PD-L1 monotherapy, combination therapy strategies have been suggested for PDAC treatment. The current study shows that 92% clinical efficacy rate can be achieved when pembrolizumab is combined with gemcitabine plus nab-paclitaxel [35]. Meanwhile, combining radiotherapy with PD-1/PD-L1 blockade therapy could increase radiosensitization and enhance the tumor cell immunogenicity [36]. Anti-PD-1/PD-L1 also can be combined with targeted therapies. Research indicates that the combination with poly (ADP-ribose) polymerase (PARP) inhibitors may be effective against pancreatic cancer with BRCA1/2 mutations [37]. Since many mechanisms are involved in immunosuppression of PDAC, two different immunotherapies also can be combined. When anti-PD-1 combined with GVAX, the murine survival rate was significantly improved compared to anti-PD-1 or GVAX monotherapy [38].

Therefore, as discussed above, the combination therapy of anti-PD-1/PD-L1 may overcome the immune resistance properties of PDAC and could improve the therapeutic efficacy of anti-PD-1/PD-L1 immunotherapy.

3. Dectin-1 and Innate Immune System

Dectin-1, also known as C-type lectin domain family 7 member A, is encoded by CLEC7A gene and is a pattern-recognition receptor expressed by myeloid-monocytic lineage cells [39]. Dectin-1 recognizes -glucans polysaccharides in fungal cell walls and is directly associated with the innate immune system [40]. Dectin-1 was found highly expressed in both mouse and human PDAC tumors and macrophages. Ligation of dectin-1 with galectin-9, a member of the -galactoside-binding family of lectins and a functional ligand for dectin-1, can accelerate the progression of PDAC in mice. The treatment by dectin-1 agonist could induce accelerated PDAC progression.

Galectin-9 is also overexpressed in both murine and human PDAC and upregulated in diverse PDAC-infiltrating myeloid cells and cancer cells. The blockade of galectin-9 could extend animal survival. Similarly, elevated galectin-9 expression associated with reduced survival in human PDAC [41]. The ligation of dectin-1 with galectin-9 in pancreatic cancer can cause mouse and human tolerogenic macrophages programming and adaptive immune suppression. The upregulated expression of either dectin-1 or galectin-9 plays a pivotal role in the ability of pancreatic tumor cells to evade the host’s immune system, causing immunotherapy failure. Due to animal survival experiments and the limitation of targeting dectin-1 or galectin-9, additional treatments are required for the immunotherapy [41]. Therefore, immunotherapy regimen targeting PD-1 has been suggested to combine with therapies targeting either dectin-1 or galectin-9. This strategy might offer synergistic efficacy for cancer treatment.

4. Chimeric Antigen Receptors (CARs) and Adoptive Immune System

The better understanding of T-cell biology and genetic engineering allows us to modify T-cells by associating a synthetic molecule and infusing them into tumor tissue to enhance the immune response against malignant lesion [42]. Genetically engineered T-cells can specifically target cancer cells to eradicate tumor burden through a T-cell receptor or chimeric antigen receptors (CARs). CARs, also known as chimeric immunoreceptors, are engineered recombinant receptors with an intracellular signaling domain consisting of T-cell receptor-CD3-ζ domain and an extracellular single-chain variable antibody fragment [43]. CARs can directly bind to tumor-associated antigens, carbohydrates or glycolipids.

In August 2017, US FDA has approved a CARs therapy (tisagenlecleucel, Kymriah, Novartis) that used adoptive cell transfer technique to treat acute lymphoblastic leukemia. Actually, the CARs therapy technology was first introduced in 1989. The first generation of CARs, the targeting moiety, is coupled to a CD3-ζ module, which initiates T-cell activation and enables T-cell to mediate cytotoxicity [44]. This generation was shown clinically ineffective in patients with diverse solid tumors [45]. The second generation of CARs incorporate an additional costimulatory domains (CD28 or CD137), which have enhanced T-cell proliferation as well as cytotoxic activity [46]. The costimulatory effect may be imparted by receptors, for example, 4-1BB [47], CD28 [48], or ICOS [49]. A complete response of 90% was achieved in lymphodepleted patients treated with the second-generation CAR T-cells [50]. The third generation of CAR comprises CD3-ζ and two additional costimulatory signaling domains, CD28 and 4-1BB, or CD28 and OX40 [51]. T-cell targeting by a TCR faces a challenge because it is restricted by human leukocyte antigen (HLA) while CARs help T-cells to target tumor cells directly and are not restricted by HLA [52]. Both second- and third-generation CARs have shown preclinical efficacy in mesothelioma and ovarian xenograft models [53]. However, there is still a lot to learn about which method will be the safest and best suited to treat solid tumors [54].

The antigens overexpressed on solid tumor cells but with limited or no expression on normal cells can be promising targets for CAR T-cell therapy. Pancreatic cancer exhibits a number of tumor-specific antigens, such as carcinoembryonic antigen, mesothelin, HER-2, and MUC1, which are promising applicants for testing CARs T-cell therapy [55, 56].

4.1. Carcinoembryonic Antigen (CEA)

CEA is a set of glycoproteins involved in cell adhesion, and the expression of CEA is low in healthy adults. The serum level of CEA can be elevated in some types of a cancer patient; for example, the antigen expressed in pancreatic adenocarcinomas is nearly 75% [57, 58]. CEA can be recognized by CARs T-cells, which makes it a valuable candidate target in CARs T-cell therapy for pancreatic cancer. In addition, the CEA level in serum can be a specific marker used routinely to monitor disease progression and tumor load. It was found that when patients received the highest dose of anti-CEA CARs T-cell, the levels of CEA declined [59]. In a clinically relevant model in murine, adoptive transfer of anti-CEA CAR-engineered T-cells was able to specifically and efficiently reduce the size of pancreatic tumors below the limit of detection in all mice and give continuing tumor eradication in 67% of mice [60]. This suggests the notion that CAR T-cells targeting CEA have the potential to treat pancreatic cancer.

4.2. Mesothelin (MSLN)

MSLN is a glycosyl-phosphatidylinositol- (GPI-) linked membrane glycoprotein, which is highly expressed in mesothelioma, pancreatic, lung, ovarian, and other cancers, but lowly expressed in normal tissue [61]. The aberrant expression of MSLN involves the aggressiveness and transformation of tumors through promoting cancer cell proliferation [62]. In a preclinical model, T-cells were engineered to express an affinity-enhanced TCR and were utilized to target MSLN antigen in a genetically engineered model of autochthonous PDAC. Engineered T-cells are known to accumulate in PDAC, inducing tumor death and stromal remodeling. Engineered human T-cells lyse PDAC cells in vitro, which further supports TCR-based strategy for the treatment of PDAC [63]. Other similar studies of CAR T-cells targeting MUC1 [64], CD24 [65], and HER2 [65] were tested, leading to tumor regression in mice. MORAb-009 is a chimeric antimesothelin monoclonal antibody that was utilized to target tumor-associated mesothelin overexpressed on pancreatic, ovarian, lung, and colorectal carcinoma. It was found that MORAb-009 reduced tumor growth in mesothelin-positive cancers and enhanced effectiveness of chemotherapy [66]. MORAb-009 was found to be safe in phase I clinical study of 24 mesothelin-positive patients, which included 7 pancreatic cancer patients [67].

4.3. Treatment Concerns

The treatment of pancreatic cancer through CARs T-cell therapy still remains challenging because of on-target and off-tumor effects. Identification of choosing an ideal tumor-restricted antigen is rare and rigorous. The CAR T-cell has toxicities to healthy tissue, causing trials cease, especially when the target tissue is expressed in central tissues, such as lungs, heart, or liver [6]. This has once again illustrated the importance of careful target antigen selection.

Cytokine release syndrome (CRS) and neurological toxicity are the most common severe side effects of CARs T-cell immunotherapy, and tocilizumab (IL-6 blocker) is used to treat patients with CRS. CRS correlates with disease burden [68] and is potentially due to the release of inflammatory cytokines produced by amounts of activated CARs T-cells [69].

Serious adverse events of CARs T-cells immunotherapy can be related to several factors. The current approaches of toxicity management have incorporated dual targeting strategies [70]. Suicide gene combined with cellular therapeutic products can eliminate the majority of CARs modified T-cells and prevent contiguous cells and/or tissues from collateral damage. This strategy has been advised to be combined together to reduce the side effects.

Another approach is to aim at coexpressing “inhibitory” CARs (iCARs) to avoid normal tissue targeting. iCARs can incorporate with CTLA-4 and PD-1 domain to transmit an inhibition signal instead of an activation signal [71]. Targeting multiple cancer-specific markers simultaneously could result in increased specificity and better therapeutic efficacy. “TanCAR” was introduced to avoid the off-target effect. TanCar mediates bispecific activation and targets to T-cells. This strategy could potentially offer a safer approach to minimize the severe adverse effects [72].

5. Summary

Pancreatic cancer remains a devastating lethal disease with poor prognosis. Immunotherapy uses the self-immune system to fight cancer and is emerging as the fourth pillar of cancer treatment, after surgery, chemotherapy, and radiation therapy. In the immune system, immune checkpoints are molecules involved in cell signaling transduction. By inhibiting T-cell signaling, many cancers can evade from the immune system elimination. Immune checkpoint therapy can target T-cells’ regulatory pathways and enhance antitumor immune responses. Immune checkpoint inhibitors, such as anti-CTLA-4, anti-PD-1, and anti-PD-L1, can enhance antitumor immunity and mediate cancer regressions in many types of cancers. These findings have established immune checkpoint blockade immunotherapy as a viable treatment option for patients with advanced cancers. However, due to pancreatic cancer’s unique characteristics, the treatment of single immune checkpoint inhibitor, anti-CTLA-4, anti-PD-1, or anti-PD-L1, has shown minimal clinical benefits in the treatment of advanced PDAC. Although some early success has been achieved with monotherapies blocking PD-1 pathways, the efficacy of an anti-PD-1/PD-L1 monotherapy may be ineffective when treating pancreatic cancer in an immune system suppressed by high tumor burden and intrinsic nonimmunogenic nature [73]. However, preclinical models have indicated that combinatorial approaches will provide some favorable clinical outcomes. Therefore, combination immune therapy that targets PDAC immune checkpoints is currently the subject of intense study.

Besides, antibody blockers of novel immune checkpoints, which may be effective if employed in treatment combinations, are under development. These include lymphocyte activation gene 3 (LAG-3), killer inhibitory receptors (KIRs), B7-H3 (CD276), T-cell immunoglobulin and mucin-3 (TIM-3), V-domain Ig-containing suppressor of T-cell activation (VISTA), T-cell immunoglobulin and immunotyrosine inhibitory motif (ITIM) domain (TIGIT), and indoleamine 2,3-dioxygenase (IDO) [7]. The blockade of these checkpoints can be combined with anti-PD-1 or anti-PD-L1 to enhance antitumor immunity. Both innate and adaptive immunity are cooperating to promote tumor progression in PDAC. Dectin-1 plays a role in the innate immune response. The ligation of dectin-1 with galectin-9 in PDAC results in tolerogenic macrophage programming and adaptive immune suppression. The development of the therapeutics that target dectin-1/galectin-9 axis in combination with other immunotherapies will potentially be an attractive strategy for immunotherapeutic for human PDAC.

Adoptive immunotherapy using CARs T-cells is emerging as a novel approach to pancreatic cancer immunotherapy. Despite the improvement of CAR T-cells therapy within the last decade, its application as a treatment still remains in its infancy for PDAC. There are many obstacles in the clinical development of CARs-based immunotherapy for PDAC, such as significant toxicity profile and high cost. To ensure safety, a combination of two targets has been applied and will be investigated in clinical trials. Therefore, the selection of suitable targets to increase the precision of tumor targeting is crucial in future CARs development.

Immunotherapy has been successfully applied in treating various types of cancers. It also has the potential to treat pancreatic cancer. Even though PDAC does not have a good response to many single immune therapeutic agents, such as immune checkpoint inhibitors, combination therapy opens new possibilities. Therefore, more preclinical and clinical studies are needed to further identify better combination immunotherapy for PDAC.

Conflicts of Interest

All authors declare that they have no conflicts of interest.

Acknowledgments

This work was supported by 2017 Yunnan Applied Basic Research Projects, Basic Research Kunming Medical University joint Project Special Funds, 2017FE468(-131) (PI: Yunqi Zhao).

References

D. Yadav and A. B. Lowenfels, “The epidemiology of pancreatitis and pancreatic cancer,” Gastroenterology, vol. 144, no. 6, pp. 1252–1261, 2013.

T. Kamisawa, L. D. Wood, T. Itoi, and K. Takaori, “Pancreatic cancer,” Lancet (London, England), vol. 388, no. 10039, pp. 73–85, 2016.

V. Vaccaro, I. Sperduti, and M. Milella, “FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer,” The New England Journal of Medicine, vol. 365, no. 8, pp. 768-769, 2011.

R. A. Morgan, J. C. Yang, M. Kitano, M. E. Dudley, C. M. Laurencot, and S. A. Rosenberg, “Case report of a serious adverse event following the administration of t cells transduced with a chimeric antigen receptor recognizing ERBB2,” Molecular Therapy, vol. 18, no. 4, pp. 843–851, 2010.

C. Berger, D. Sommermeyer, M. Hudecek et al., “Safety of targeting ROR1 in primates with chimeric antigen receptor-modified T cells,” Cancer Immunology Research, vol. 3, no. 2, pp. 206–216, 2015.

C. E. Brown and P. S. Adusumilli, “Next frontiers in CAR T-cell therapy,” Molecular Therapy - Oncolytics, vol. 3, Article ID 16028, 2016.

S. Topalian, C. Drake, and D. Pardoll, “Immune checkpoint blockade: a common denominator approach to cancer therapy,” Cancer Cell, vol. 27, no. 4, pp. 450–461, 2015.

P. Sharma and J. P. Allison, “The future of immune checkpoint therapy,” Science, vol. 348, no. 6230, pp. 56–61, 2015.

F. Bengsch, D. M. Knoblock, A. Liu, F. McAllister, and G. L. Beatty, “CTLA-4/CD80 pathway regulates T cell infiltration into pancreatic cancer,” Cancer Immunology, Immunotherapy, vol. 66, no. 12, pp. 1609–1617, 2017.

K. D. McCoy and G. Le Gros, “The role of CTLA-4 in the regulation of T cell immune responses,” Immunology & Cell Biology, vol. 77, no. 1, pp. 1–10, 1999.

R. R. Huang, J. Jalil, J. S. Economou et al., “CTLA4 blockade induces frequent tumor infiltration by activated lymphocytes regardless of clinical responses in humans,” Clinical Cancer Research, vol. 17, no. 12, pp. 4101–4109, 2011.

S. Ville, N. Poirier, G. Blancho, and B. Vanhove, “Costimulatory blockade of the CD28 / CD80-86 / CTLA-4 balance in transplantation: impact on memory T cells?” Frontiers in Immunology, vol. 6, article no. 411, 2015.

M. K. Callahan, J. D. Wolchok, and J. P. Allison, “AntiCTLA-4 antibody therapy: Immune monitoring during clinical development of a novel immunotherapy,” Seminars in Oncology, vol. 37, no. 5, pp. 473–484, 2010.

D. Schadendorf, F. S. Hodi, C. Robert et al., “Pooled analysis of long-term survival data from phase II and phase III trials of ipilimumab in unresectable or metastatic melanoma,” Journal of Clinical Oncology, vol. 33, no. 17, pp. 1889–1894, 2015.

G. Q. Phan, J. S. Weber, and V. K. Sondak, “CTLA-4 blockade with monoclonal antibodies in patients with metastatic cancer: Surgical issues,” Annals of Surgical Oncology, vol. 15, no. 11, pp. 3014–3021, 2008.

L. S. K. Walker and D. M. Sansom, “Confusing signals: recent progress in CTLA-4 biology,” Trends in Immunology, vol. 36, no. 2, pp. 63–70, 2015.

A. Ito, S. Kondo, K. Tada, and S. Kitano, “Clinical development of immune checkpoint inhibitors,” BioMed Research International, vol. 2015, Article ID 605478, 12 pages, 2015.

R. E. Royal, C. Levy, K. Turner et al., “Phase 2 trial of single agent ipilimumab (Anti-CTLA-4) for locally advanced or metastatic pancreatic adenocarcinoma,” Journal of Immunotherapy, vol. 33, no. 8, pp. 828–833, 2010.

D. T. Le, E. Lutz, J. N. Uram et al., “Evaluation of ipilimumab in combination with allogeneic pancreatic tumor cells transfected with a GM-CSF gene in previously treated pancreatic cancer,” Journal of Immunotherapy, vol. 36, no. 7, pp. 382–389, 2013.

“Tremelimumab,” Drugs in R&D, vol. 10, no. 2, pp. 123–132, 2010.

M. Aglietta, C. Barone, M. Muliello et al., “A phase I dose escalation trial of CP-675206 (tremelimumab) in combination with gemcitabine in patients with chemotherapy-naive metastatic pancreatic cancer,” Journal of Clinical Oncology, vol. 28, no. 15_suppl, pp. 4134–4134, 2010.

Y. Ishida, Y. Agata, K. Shibahara, and T. Honjo, “Induced expression of PD-1, a novel member of the immunoglobulin gene superfamily, upon programmed cell death,” EMBO Journal, vol. 11, no. 11, pp. 3887–3895, 1992.

B. H. Moreno and A. Ribas, “Anti-programmed cell death protein-1/ligand-1 therapy in different cancers,” British Journal of Cancer, vol. 112, no. 9, pp. 1421–1427, 2015.

W. Zou and L. Chen, “Inhibitory B7-family molecules in the tumour microenvironment,” Nature Reviews Immunology, vol. 8, no. 6, pp. 467–477, 2008.

J.-J. Park, R. Omiya, Y. Matsumura et al., “B7-H1/CD80 interaction is required for the induction and maintenance of peripheral T-cell tolerance,” Blood, vol. 116, no. 8, pp. 1291–1298, 2010.

J. Yang, L. V. Riella, S. Chock et al., “The novel costimulatory programmed death ligand 1/B7.1 pathway is functional in inhibiting alloimmune responses in vivo,” The Journal of Immunology, vol. 187, no. 3, pp. 1113–1119, 2011.

A. M. Paterson, K. E. Brown, M. E. Keir et al., “The programmed Death-1 ligand 1:B7-1 pathway restrains diabetogenic effector T cells in vivo,” The Journal of Immunology, vol. 187, no. 3, pp. 1097–1105, 2011.

M. J. Butte, M. E. Keir, T. B. Phamduy, A. H. Sharpe, and G. J. Freeman, “Programmed death-1 ligand 1 interacts specifically with the B7-1 costimulatory molecule to inhibit T cell responses,” Immunity, vol. 27, no. 1, pp. 111–122, 2007.

S. L. Topalian, C. G. Drake, and D. M. Pardoll, “Targeting the PD-1/B7-H1(PD-L1) pathway to activate anti-tumor immunity,” Current Opinion in Immunology, vol. 24, no. 2, pp. 207–212, 2012.

B. T. Fife, K. E. Pauken, T. N. Eagar et al., “Interactions between PD-1 and PD-L1 promote tolerance by blocking the TCR-induced stop signal.,” Nature Immunology, vol. 10, no. 11, pp. 1185–1192, 2009.

H. Dong, S. E. Strome, and D. R. Salomao, “Tumor-associated B7-H1 promotes T-cell apoptosis: a potential mechanism of immune evasion,” Nature Medicine, vol. 8, no. 8, pp. 793–800, 2002.

Y. Iwai, M. Ishida, Y. Tanaka, T. Okazaki, T. Honjo, and N. Minato, “Involvement of PD-L1 on tumor cells in the escape from host immune system and tumor immunotherapy by PD-L1 blockade,” in Proceedings of the National Academy of Sciences of the United States of America, vol. 99, pp. 12293–12297.

J. R. Brahmer et al., “Safety and activity of anti-PD-L1 antibody in patients with advanced cancer,” The New England Journal of Medicine, vol. 366, no. 26, pp. 2455–65, 2012.

R. S. Herbst, J. C. Soria, and M. Kowanetz, “Predictive correlates of response to the anti-PD-L1 antibody MPDL3280A in cancer patients,” Nature, vol. 515, no. 7528, pp. 563–567, 2014.

G. J. Weiss, J. Waypa, L. Blaydorn et al., “A phase Ib study of pembrolizumab plus chemotherapy in patients with advanced cancer (PembroPlus),” British Journal of Cancer, vol. 117, no. 1, pp. 33–40, 2017.

A. B. Sharabi, M. Lim, T. L. DeWeese, and C. G. Drake, “Radiation and checkpoint blockade immunotherapy: Radiosensitisation and potential mechanisms of synergy,” The Lancet Oncology, vol. 16, no. 13, pp. e498–e509, 2015.

B. Kaufman et al., “Olaparib monotherapy in patients with advanced cancer and a germline BRCA1/2 mutation,” Journal of Clinical Oncology, vol. 33, no. 3, pp. 244–50, 2015.

K. C. Soares, A. A. Rucki, A. A. Wu et al., “PD-1/PD-L1 blockade together with vaccine therapy facilitates effector T-cell infiltration into pancreatic tumors,” Journal of Immunotherapy, vol. 38, no. 1, pp. 1–11, 2015.

H. S. Goodridge, C. N. Reyes, C. A. Becker et al., “Activation of the innate immune receptor Dectin-1 upon formation of a ‘Phagocytic synapse’,” Nature, vol. 472, no. 7344, pp. 471–475, 2011.

P. R. Taylor, S. V. Tsoni, J. A. Willment et al., “Dectin-1 is required for β-glucan recognition and control of fungal infection,” Nature Immunology, vol. 8, no. 1, pp. 31–38, 2007.

D. Daley, V. R. Mani, N. Mohan et al., “Dectin 1 activation on macrophages by galectin 9 promotes pancreatic carcinoma and peritumoral immune tolerance,” Nature Medicine, vol. 23, no. 5, pp. 556–567, 2017.

T. J. Harris and C. G. Drake, “Primer on tumor immunology and cancer immunotherapy,” Journal for ImmunoTherapy of Cancer, vol. 1, article 12, 2013.

G. Gross, T. Waks, and Z. Eshhar, “Expression of immunoglobulin-T-cell receptor chimeric molecules as functional receptors with antibody-type specificity,” in Proceedings of the National Acadamy of Sciences of the United States of America, vol. 86, pp. 10024–10028, 1989.

E. Lanitis, M. Poussin, A. W. Klattenhoff et al., “Chimeric antigen receptor T cells with dissociated signaling domains exhibit focused antitumor activity with reduced potential for toxicity in vivo,” Cancer Immunology Research, vol. 1, no. 1, pp. 43–53, 2013.

M. H. Kershaw, J. A. Westwood, L. L. Parker et al., “A phase I study on adoptive immunotherapy using gene-modified T cells for ovarian cancer,” Clinical Cancer Research, vol. 12, no. 20, pp. 6106–6115, 2006.

J. Maher, R. J. Brentjens, G. Gunset, I. Rivière, and M. Sadelain, “Human T-lymphocyte cytotoxicity and proliferation directed by a single chimeric TCRζ/CD28 receptor,” Nature Biotechnology, vol. 20, no. 1, pp. 70–75, 2002.

M. J. Riese, L.-C. S. Wang, E. K. Moon et al., “Enhanced effector responses in activated CD8+ T cells deficient in diacylglycerol kinases,” Cancer Research, vol. 73, no. 12, pp. 3566–3577, 2013.

C. Carpenito, M. C. Milone, R. Hassan et al., “Control of large, established tumor xenografts with genetically retargeted human T cells containing CD28 and CD137 domains,” in Proceedings of the National Academy of Sciences of the United States of America, vol. 106, pp. 3360–3365, 2009.

S. Guedan, X. Chen, A. Madar et al., “ICOS-based chimeric antigen receptors program bipolar TH17/TH1 cells,” Blood, vol. 124, no. 7, pp. 1070–1080, 2014.

D. W. Lee, J. N. Kochenderfer, M. Stetler-Stevenson et al., “T cells expressing CD19 chimeric antigen receptors for acute lymphoblastic leukaemia in children and young adults: a phase 1 dose-escalation trial,” The Lancet, vol. 385, no. 9967, pp. 517–528, 2015.

X.-S. Zhong, M. Matsushita, J. Plotkin, I. Riviere, and M. Sadelain, “Chimeric antigen receptors combining 4-1BB and CD28 signaling domains augment PI₃ kinase/AKT/Bcl-XL activation and CD⁸⁺ T cell-mediated tumor eradication,” Molecular Therapy, vol. 18, no. 2, pp. 413–420, 2010.

M. H. Kershaw, “The use of chimeric human Fc(epsilon) receptor I to redirect cytotoxic T lymphocytes to tumors,” Journal of Leukocyte Biology, vol. 60, no. 6, p. 721, 1996.

P. S. Adusumilli, L. Cherkassky, J. Villena-Vargas et al., “Regional delivery of mesothelin-targeted CAR T cell therapy generates potent and long-lasting CD4-dependent tumor immunity,” Science Translational Medicine, vol. 6, no. 261, Article ID 261ra151, 2014.

I. M. Stromnes, T. M. Schmitt, A. G. Chapuis, S. R. Hingorani, and P. D. Greenberg, “Re-adapting T cells for cancer therapy: from mouse models to clinical trials,” Immunological Reviews, vol. 257, no. 1, pp. 145–164, 2014.

D. Alrifai, D. Sarker, and J. Maher, “Prospects for adoptive immunotherapy of pancreatic cancer using chimeric antigen receptor-engineered T-cells,” Immunopharmacology and Immunotoxicology, vol. 38, no. 1, pp. 50–60, 2016.

H. Almåsbak, T. Aarvak, and M. C. Vemuri, “CAR T cell therapy: a game changer in cancer treatment,” Journal of Immunology Research, vol. 2016, Article ID 5474602, 10 pages, 2016.

G. H. R. Albers, G. Fleuren, M. J. Escribano, and M. Nap, “Immunohistochemistry of CEA in the human pancreas during development, in the adult, chronic pancreatitis and pancreatic adenocarcinoma,” American Journal of Clinical Pathology, vol. 90, no. 1, pp. 17–22, 1988.

W. H. Allum, H. J. Stokes, F. MacDonald, and J. W. L. Fielding, “Demonstration of carcinoembryonic antigen (CEA) expression in normal, chronically inflamed, and malignant pancreatic tissue by immunohistochemistry,” Journal of Clinical Pathology, vol. 39, no. 6, pp. 610–614, 1986.

A. Holzinger and H. Abken, “CAR T cells targeting solid tumors: carcinoembryonic antigen (CEA) proves to be a safe target,” Cancer Immunology, Immunotherapy, vol. 66, no. 11, pp. 1505–1507, 2017.

M. Chmielewski, O. Hahn, G. Rappl et al., “T cells that target carcinoembryonic antigen eradicate orthotopic pancreatic carcinomas without inducing autoimmune colitis in mice,” Gastroenterology, vol. 143, no. 4, pp. 1095–e2, 2012.

A. Morello, M. Sadelain, and P. S. Adusumilli, “Mesothelin-targeted CARs: driving t cells to solid tumors,” Cancer Discovery, vol. 6, no. 2, pp. 133–146, 2016.

S. S. Kachala, “Mesothelin Overexpression Is a Marker of Tumor Aggressiveness and Is Associated with Reduced Recurrence-Free and Overall Survival in Early-Stage Lung Adenocarcinoma,” Clinical Cancer Research, vol. 20, no. 14, pp. 3896–3896, 2014.

I. M. Stromnes, T. M. Schmitt, A. Hulbert et al., “T cells engineered against a native antigen can surmount immunologic and physical barriers to treat pancreatic ductal adenocarcinoma,” Cancer Cell, vol. 28, no. 5, pp. 638–652, 2015.

A. D. Posey Jr., R. D. Schwab, A. C. Boesteanu et al., “Engineered CAR T cells targeting the cancer-associated Tn-glycoform of the membrane mucin MUC1 control adenocarcinoma,” Immunity, vol. 44, no. 6, pp. 1444–1454, 2016.

A. Maliar, C. Servais, T. Waks et al., “Redirected T cells that target pancreatic adenocarcinoma antigens eliminate tumors and metastases in mice,” Gastroenterology, vol. 143, no. 5, pp. 1375–e5, 2012.

R. Hassan et al., “Preclinical evaluation of MORAb-009, a chimeric antibody targeting tumor-associated mesothelin,” Cancer Immunity, vol. 7, p. 20, 2007.

R. Hassan, S. J. Cohen, M. Phillips et al., “Phase I clinical trial of the chimeric anti-mesothelin monoclonal antibody MORAb-009 in patients with mesothelin-expressing cancers,” Clinical Cancer Research, vol. 16, no. 24, pp. 6132–6138, 2010.

J. N. Kochenderfer, M. E. Dudley, S. A. Feldman et al., “B-cell depletion and remissions of malignancy along with cytokine-associated toxicity in a clinical trial of anti-CD19 chimeric-antigen-receptor-transduced T cells,” Blood, vol. 119, no. 12, pp. 2709–2720, 2012.

M. L. Davila et al., “Efficacy and toxicity management of 19-28z CAR T cell therapy in B cell acute lymphoblastic leukemia,” Science Translational Medicine, vol. 6, no. 224, pp. 224r–25, 2014.

K. Minagawa, X. Zhou, S. Mineishi, and A. Di Stasi, “Seatbelts in CAR therapy: how safe are CARS?” Pharmaceuticals, vol. 8, no. 2, pp. 230–249, 2015.

V. D. Fedorov, M. Themeli, and M. Sadelain, “PD-1– and CTLA-4–based inhibitory chimeric antigen receptors (iCARs) divert off-target immunotherapy responses,” Science Translational Medicine, vol. 5, no. 215, Article ID 215ra172, 2013.

Z. Grada, M. Hegde, T. Byrd et al., “TanCAR: a novel bispecific chimeric antigen receptor for cancer immunotherapy,” Molecular Therapy—Nucleic Acids, vol. 2, article e105, 2013.

Y. Pico de Coaña, A. Choudhury, and R. Kiessling, “Checkpoint blockade for cancer therapy: revitalizing a suppressed immune system,” Trends in Molecular Medicine, vol. 21, no. 8, pp. 482–491, 2015.