First Department of Medicine, National and Kapodistrian University of Athens School of Medicine, Athens, Greece.
Division of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
Cancer Treat Rev. 2023 Feb;113:102499. doi: 10.1016/j.ctrv.2022.102499. Epub 2022 Dec 13.
Marching into the second decade after the approval of ipilimumab, it is clear that immune checkpoint inhibitors (ICIs) have dramatically improved the prognosis of melanoma. Although the current edge is already high, with a 4-year OS% of 77.9% for adjuvant nivolumab and a 6.5-year OS% of 49% for nivolumab/ipilimumab combination in the metastatic setting, a high proportion of patients with advanced melanoma have no benefit from immunotherapy, or experience an early disease relapse/progression in the first few months of treatment, surviving much less. Reasonably, the primary and acquired resistance to ICIs has entered into the focus of clinical research with positive (e.g., nivolumab and relatlimab combination) and negative feedbacks (e.g., nivolumab with pegylated-IL2, pembrolizumab with T-VEC, nivolumab with epacadostat, and combinatorial triplets of BRAF/MEK inhibitors with immunotherapy). Many intrinsic (intracellular or intra-tumoral) but also extrinsic (systematic) events are considered to be involved in the development of this resistance to ICIs: i) melanoma cell immunogenicity (e.g., tumor mutational burden, antigen-processing machinery and immunogenic cell death, neoantigen affinity and heterogeneity, genomic instability, melanoma dedifferentiation and phenotypic plasticity), ii) immune cell trafficking, T-cell priming, and cell death evasion, iii) melanoma neovascularization, cellular TME components(e.g., T, CAFs) and extracellular matrix modulation, iv) metabolic antagonism in the TME(highly glycolytic status, upregulated CD39/CD73/adenosine pathway, iDO-dependent tryptophan catabolism), v) T-cell exhaustion and negative immune checkpoints, and vi) gut microbiota. In the present overview, we discuss how these parameters compromise the efficacy of ICIs, with an emphasis on the lessons learned by the latest melanoma studies; and in parallel, we describe the main ongoing approaches to overcome the resistance to immunotherapy. Summarizing this information will improve the understanding of how these complicated dynamics contribute to immune escape and will help to develop more effective strategies on how anti-tumor immunity can surpass existing barriers of ICI-refractory melanoma.
在伊匹单抗获批后的第二个十年,免疫检查点抑制剂(ICIs)显著改善了黑色素瘤的预后,这一点已经很明确。尽管目前的疗效已经很高,辅助nivolumab 的 4 年 OS%为 77.9%,转移性nivolumab/ipilimumab 联合治疗的 6.5 年 OS%为 49%,但仍有相当一部分晚期黑色素瘤患者无法从免疫治疗中获益,或在治疗的头几个月内出现疾病早期复发/进展,生存时间大大缩短。合理地说,ICI 的原发性和获得性耐药已经成为临床研究的焦点,既有积极的反馈(如 nivolumab 和 relatlimab 联合治疗),也有消极的反馈(如 nivolumab 联合聚乙二醇化-IL2、pembrolizumab 联合 T-VEC、nivolumab 联合 epacadostat,以及 BRAF/MEK 抑制剂联合免疫治疗的三联组合)。许多内在(细胞内或肿瘤内)和外在(系统性)事件被认为参与了这种对 ICI 的耐药性的发展:i)黑色素瘤细胞免疫原性(例如肿瘤突变负担、抗原加工机制和免疫原性细胞死亡、新抗原亲和力和异质性、基因组不稳定性、黑色素瘤去分化和表型可塑性),ii)免疫细胞迁移、T 细胞启动和细胞死亡逃逸,iii)黑色素瘤新生血管形成、细胞 TME 成分(如 T 细胞、CAFs)和细胞外基质调节,iv)TME 中的代谢拮抗作用(高度糖酵解状态、上调的 CD39/CD73/腺苷途径、IDO 依赖性色氨酸分解代谢),v)T 细胞衰竭和负性免疫检查点,以及 vi)肠道微生物群。在本综述中,我们讨论了这些参数如何影响 ICI 的疗效,并强调了最新黑色素瘤研究中得到的经验教训;同时,我们描述了克服免疫治疗耐药性的主要方法。总结这些信息将有助于更好地理解这些复杂的动态如何导致免疫逃逸,并有助于制定更有效的策略,以克服对免疫治疗有抵抗的黑色素瘤现有的障碍。
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