Kan Uchiyama

Current Immunotherapeutic Approaches in Pancreatic Cancer

Pancreatic cancer is a highly aggressive and notoriously difficult to treat. As the vast majority of patients are diagnosed at advanced stage of the disease, only a small population is curative by surgical resection. Although gemcitabine-based chemotherapy is typically offered as standard of care, most patients do not survive longer than 6 months. Thus, new therapeutic approaches are needed. Pancreatic cancer cells that develop gemcitabine resistance would still be suitable targets for immunotherapy. Therefore, one promising treatment approach may be immunotherapy that is designed to target pancreatic-cancer-associated antigens. In this paper, we detail recent work in immunotherapy and the advances in concept of combination therapy of immunotherapy and chemotherapy. We offer our perspective on how to increase the clinical efficacy of immunotherapies for pancreatic cancer.

Immunotherapy for colorectal cancer

The incidence of colorectal cancer (CRC) is on the rise, and the prognosis for patients with recurrent or metastatic disease is extremely poor. Although chemotherapy and radiation therapy can improve survival rates, it is imperative to integrate alternative strategies such as immunotherapy to improve outcomes for patients with advanced CRC. In this review, we will discuss the effect of immunotherapy for inducing cytotoxic T lymphocytes and the major immunotherapeutic approaches for CRC that are currently in clinical trials, including peptide vaccines, dendritic cell-based cancer vaccines, whole tumor cell vaccines, viral vector-based cancer vaccines, adoptive cell transfer therapy, antibody-based cancer immunotherapy, and cytokine therapy. The possibility of combination therapies will also be discussed along with the challenges presented by tumor escape mechanisms.

N‐3 polyunsaturated fatty acid diet therapy for patients with inflammatory bowel disease

Background: N‐3 polyunsaturated fatty acids (PUFA) are considered important pharmaconutrients for modulating mucosal immunity and therapeutic responses in patients with inflammatory bowel disease (IBD). We investigated the influence of diet therapy involving the use of an “n‐3 PUFA food exchange table” (n‐3DP) on the fatty acid composition of the erythrocyte membranes of IBD patients and its remission‐maintaining effects. Methods: We analyzed the fatty acid composition of the erythrocyte membrane before and after n‐3DP intervention in 20 initial‐onset IBD patients who had not undergone any dietary intervention. We then analyzed it again and evaluated disease activity after 12–18 months intervention in 230 IBD patients (168 ulcerative colitis, 62 Crohns disease; follow‐up group) in whom n‐3DP was introduced after remission had been achieved. The follow‐up group was divided into remission and relapse groups. Results: In the 20 initial‐onset patients, the mean n‐3/n‐6 ratio significantly increased after intervention (0.41 ± 0.16 versus 0.70 ± 0.20; P < 0.001). In the follow‐up group the ratio in the remission group (n = 145) was significantly higher than that in the relapse group (n = 85) (0.65 ± 0.28 versus 0.53 ± 0.18; P < 0.001). The ratio significantly decreased in those who suffered a relapse after the beginning of treatment (P < 0.01). Conclusions: N‐3DP significantly increased the erythrocyte membrane n‐3/n‐6 ratio in IBD patients, and this ratio was significantly higher in the remission group, suggesting that n‐3DP alters the fatty acid composition of the cell membrane and influences clinical activity in IBD patients. (Inflamm Bowel Dis 2010)

Thiopurine S-methyltransferase and inosine triphosphate pyrophosphohydrolase genes in Japanese patients with inflammatory bowel disease in whom adverse drug reactions were induced by azathioprine/6-mercaptopurine treatment

BackgroundThe main cause of azathioprine (AZA)/6-mercaptopurine (6MP)-induced adverse reactions is a reduction in the activities of the metabolizing enzymes thiopurine S-methyltransferase (TPMT) and inosine triphosphate pyrophosphohydrolase (ITPA). Adverse reactions develop at a high frequency in Japanese patients at half the dose required for European and American patients; however, the association with TPMT and ITPA gene polymorphisms in Japanese has not been fully investigated.MethodsGene mutations of TPMT and ITPA, the major AZA/6-MP -metabolizing enzymes, were investigated retrospectively in 16 Japanese patients with inflammatory bowel disease (IBD) in whom AZA/6MP treatment induced adverse reactions.ResultsThe TPMT gene was found to have a wild-type sequence in all patients, but in the ITPA gene a mutation, 94C>A, was detected at a rate of 50% (8/16), with 83.3% (5/6) occurring in patients with acute bone marrow suppression and 75% (3/4) in those with agranulocytosis. The 94C>A allele frequency was 10 of 32 (0.313; 95% CI, 0.180–0.486). Adverse reactions developed earlier in patients with the 94C>A mutation. However, in half the patients, no gene polymorphism was noted.ConclusionsIt is suggested that the ITPA gene mutation is closely related to the adverse reactions of AZA/6-MP in Japanese patients, and screening for the mutant allele is useful for predicting the most serious adverse reactions, agranulocytosis and acute bone marrow suppression.

Fusions between dendritic cells and whole tumor cells as anticancer vaccines

Various strategies have been developed to deliver tumor-associated antigens (TAAs) to dendritic cells (DCs). Among these, the fusion of DCs and whole cancer cells can process a broad array of TAAs, including hitherto unidentified molecules, and present them in complex with MHC Class I and II molecules and in the context of co-stimulatory signals. DC-cancer cell fusions have been shown to stimulate potent antitumor immune responses in animal models. In early clinical trials, however, the antitumor effects of DC-cancer cell fusions are not as vigorous as in preclinical settings. This mini-review summarizes recent advances in anticancer vaccines based on DC-cancer cell fusions.

Dendritic/pancreatic carcinoma fusions for clinical use: Comparative functional analysis of healthy- versus patient-derived fusions.

Fetal calf serum (FCS)-independent pancreatic cancer cells were established in plasma protein fraction (PPF)-supplemented medium that is an agent of good manufacturing practice (GMP) grade. Dendritic cells (DCs) were activated with the Toll-like receptor agonist, penicillin-inactivated Streptococcus pyogenes (OK-432) that is also a GMP grade agent. Therefore, sufficient amounts of FCS-independent fusions were successfully generated with decreased potential hazards of FCS. The FCS-independent fusions expressed tumor-associated antigens, HLA-DR, costimulatory molecules, IL-12, and IL-10. Stimulation of T cells with fusions from healthy donors resulted in proliferation of T cells with high expression levels of perforin/granzyme B and IFN-gamma and efficient induction of antigen-specific cytotoxic T lymphocytes (CTLs). Selection and expansion of T-cell clones were confirmed by TCR Vbeta analysis. However, fusions from patients with metastatic pancreatic cancer induced increased expression levels of TGF-beta1 in CD4+ CD25high T cells and low levels of CTLs with decreased IFN-gamma production.

Combined TLR2/4-Activated Dendritic/Tumor Cell Fusions Induce Augmented Cytotoxic T Lymphocytes

Induction of antitumor immunity by dendritic cell (DC)-tumor fusion cells (DC/tumor) can be modulated by their activation status. In this study, to address optimal status of DC/tumor to induce efficient antigen-specific cytotoxic T lymphocytes (CTLs), we have created various types of DC/tumor: 1) un-activated DC/tumor; 2) penicillin-killed Streptococcus pyogenes (OK-432; TLR4 agonist)-activated DC/tumor; 3) protein-bound polysaccharides isolated from Coriolus versicolor (PSK; TLR2 agonist)-activated DC/tumor; and 4) Combined OK-432- and PSK-activated DC/tumor. Moreover, we assessed the effects of TGF-β1 derived from DC/tumor on the induction of MUC1-specific CTLs. Combined TLR2- and TLR4-activated DC/tumor overcame immune-suppressive effect of TGF-β1 in comparison to those single activated or un-activated DC/tumor as demonstrated by: 1) up-regulation of MHC class II and CD86 expression on DC/tumor; 2) increased fusion efficiency; 3) increased production of fusions derived IL-12p70; 4) activation of CD4+ and CD8+ T cells that produce high levels of IFN-γ; 5) augmented induction of CTL activity specific for MUC1; and 6) superior efficacy in inhibiting CD4+CD25+Foxp3+ T cell generation. However, DC/tumor-derived TGF-β1 reduced the efficacy of DC/tumor vaccine in vitro. Incorporating combined TLRs-activation and TGF-β1-blockade of DC/tumor may enhance the effectiveness of DC/tumor-based cancer vaccines and have the potential applicability to the field of adoptive immunotherapy.

Long-Term Alteration of Intestinal Microbiota in Patients with Ulcerative Colitis by Antibiotic Combination Therapy

Previous work has demonstrated that intestinal bacteria, such as Fusobacterium varium (F. varium), contribute to the clinical activity in ulcerative colitis (UC); thus, an antibiotic combination therapy (amoxicillin, tetracycline, and metronidazole (ATM)) against F. varium can induce and maintain UC remission. Therefore, we investigated whether ATM therapy induces a long-term alteration of intestinal microbiota in patients with UC. Patients with UC were enrolled in a multicenter, randomized, double-blind, placebo-controlled study. Biopsy samples at the beginning of the trial and again at 3 months after treatment completion were randomly obtained from 20 patients. The terminal restriction fragment length polymorphism (T-RFLP) in mucosa-associated bacterial components was examined to assess the alteration of the intestinal microbiota. Profile changes of T-RFLP in mucosa-associated bacterial components were found in 10 of 12 patients in the treatment group and in none of 8 in the placebo group. Dice similarity coefficients using the unweighted pair group method with arithmetic averages (Dice-UPGMA) confirmed that the similarity of mucosal microbiota from the descending colon was significantly decreased after the ATM therapy, and this change was maintained for at least 3 months. Moreover, at 3 months after treatment completion, the F. varium/β-actin ratio, examined by real-time PCR using nested PCR products from biopsy samples, was reduced less than 40% in 8 of 12 treated patients, which was higher, but not significantly, than in 4 of 8 patients in the placebo group. Together, these results suggest that ATM therapy induces long-term alterations in the intestinal microbiota of patients with UC, which may be associated, at least in part, with clinical effects of the therapy.

Factors associated with incomplete colonoscopy at a Japanese academic hospital

AIM To evaluate significant risk factors for incomplete colonoscopy at a Japanese academic hospital. METHODS A total of 11812 consecutive Japanese people were identified who underwent a colonoscopy at an academic hospital. A multiple logistic regression model was used to evaluate retrospectively the significant risk factors for incomplete colonoscopy. RESULTS The cecal intubation rate was 95.0%. By univariate analysis, age, female sex, poor bowel cleansing, and a history of abdominal or pelvic surgery were significant risk factors for incomplete colonoscopy (P < 0.001). Moreover, age- and sex-adjusted analysis showed that significant risk factors for incomplete colonoscopy were female sex (OR = 1.38, 95%CI: 1.17-1.64, P = 0.0002), age ≥ 60 years old (OR = 1.44, 95%CI: 1.22-1.71, P < 0.0001), a history of prior abdominal or pelvic surgery (OR = 1.55, 95%CI: 1.28-1.86, P < 0.0001), poor bowel cleansing (OR = 4.64, 95%CI: 3.69-5.84, P < 0.0001), and inflammatory bowel disease (IBD) (OR = 1.48, 95%CI: 1.13-1.95, P = 0.0048). In Japanese men, by age-adjusted analysis, IBD (OR = 1.69, 95%CI: 1.18-2.43, P = 0.005) was an independent risk factor for incomplete colonoscopy. CONCLUSION Several characteristics in the Japanese population were identified that could predict technical difficulty with colonoscopy.

Immunotherapy synergizes with chemotherapy targeting pancreatic cancer

Pancreatic adenocarcinoma is a devastating disease and has an extremely poor prognosis. Despite aggressive treatment approaches, including surgery, chemotherapy and radiation, the overall 5‐year survival rate is less than 5%. Therefore, the development of therapeutic strategies for advanced pancreatic cancer has traditionally been considered particularly challenging to improve clinical outcomes. Although immunotherapy that is designed to target tumor-associated antigens (TAAs) is a promising treatment approach, immunotherapy alone is limited by the number of cytotoxic T lymphocytes (CTLs) able to penetrate the large established pancreatic tumor. Even if large numbers of antigen-specific polyclonal CTLs were generated in vitro and injected into the patients, CTLs cannot penetrate into tumor sites because of stroma cells such as cancer-associated fibroblasts, tolerogenic dendritic cells (DCs), myeloid-derived suppressor cells (MDSCs), immunosuppressive tumor-associated macrophages and Tregs. Moreover, these cells produce immunosuppressive cytokines such as IL-10 and TGF-β; thus, clinical responses by immunotherapy alone cannot induce efficient antitumor immunity in patients with advanced pancreatic cancer. On the other hand, cytotoxic chemotherapy is well known to blunt immune responses, because of its toxicity for dividing cells including peripheral lymphoid tissue as well as the bone marrow. However, increasing evidence has been mounting to suggest that immunotherapy has the possibility of achieving better success when used in combination with chemotherapy [1]. For example, necrotic or apoptotic tumor cells induced by chemotherapy can be phagocytosed by DCs that are potent antigen-presenting cells, processed and presented to immune lymphocytes, followed by induction of antitumor immune responses. Different chemotherapeutic agents may kill tumor cells through an apparently homogeneous apoptotic pathway. Of note, treatment of pancreatic cancer cells with a standard cytotoxic agent for pancreatic cancer, gemcitabine, results in enhanced cross-presentation of TAAs by DCs and CTL induction [2]. Moreover, gemcitabine can also inhibit Tregs, B cells and MDSCs [2,3], but induce the proliferation of DCs [4]. These phenomena suggest that gemcitabine induces efficient CTL responses, improves the penetration of CTLs into the tumor parenchyma, and enhances tumor cell sensitivity to lyze antigen-specific CTLs. Thus, immunotherapy may mediate a potent antitumor effect when c ombined with chemotherapy.