A very Happy Father's Day from a stage IV Melanoma Survivor..Jim Breitfeller

I want to thank all the people that has made this day a very special Day.


As a stage IV Melanoma Survivor, I never dreamed that I would be here today to witness my children spread their wings and learn to fly. My daughter was just entering college when I was first diagnosed and my son, Chris was a sophmore in High School. Today, I am preparing to help my son relocate to Connecticut. He just landed an engineering job at an areospace company. My daughter, Jessica is globe-trotting around the world working on her dual Masters in "International Affairs" and "Natural Resources & Sustainable Development". This day, marks Dee and I as offically "Empty Nesters".

This all was made possible by entering a journey that entailed four clinical trials along with the best and internationally renowned medical team that makes climbing Mt. Everst apiece a cake. And you , My carepage friends that kept me on the "Yellow Brick Road". I have won the "lottery of life."

Many Thanks

“It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.”
~Charles Darwin~

Take Care,

 Jimmy B
 

Breaking Tolerance to Invoke an Immune Response to Cancer (Melanoma)..Jim Breitfeller

This post has been in the works for five years. It is with my tenacity and help from researchers around the world I am able to present this paper. It is still in draft form but I thought was important enough to just get it out there. It may be to technical for the average person/patient but, it is well worth downloading and presenting to your oncologist and or medical team.

The gist of the paper is we have responders and non-responders to therapy. WHY?? with the help of Four on the most influential reseachers in the Melanoma field, Dr. Craig Slingluff, Dr. Thomas Gajewski, Dr.Kingston Mills, Dr. Jim Allison and others, I was able to put some puzzle pieces together to tell a story. A story that may just save your life

In short, the non-responders may be/are missing the "Danger Signals" inflammatory Cytokines. Why, because their tumors are most likely harboring M2 phenotype macrophages (TAMs) Tumor assisted Macrophages.

But these TAMs have plasticity. This means they can change phenotype based on their miroenviroment. With some coaxing they can be change into M1 macrophages which in turn activate the T-cells. This means the patient needs to have therapies that promote M1 and Th1 cells. Well both Dr. Allison and Dr. Mills have discovered ways to do just that.

Please take some time to download and read this historic paper. It just may be the game changer for cancer.

Breaking Tolerance to Invoke an Immune Response to Cancer (Melanoma



I am going end with four slides.










“It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.”

~Charles Darwin~
Take Care,
Jimmy B

Identifying and Over Coming Immune Barriers at the Level of the Tumor Microenvironment..Melanoma .Jim Breitfeller

Eleventh International Conference on Progress in Vaccination Against Cancer

Dr. Thomas Gajewski
University of Chicago,Chicago,IL,USA

"Immunotherapeutic approaches for the treatment of melanoma, such as tumor antigen-based vaccines, can frequently boost immune responses. However, clinical responses as measured by tumor shrinkage are seen in only a minority of patients. This observation has prompted careful analysis of the tumor microenvironment for biologic correlates to clinical response and also to identify mechanisms of tumor resistance. Patients with advanced melanoma treated with antigen-specific vaccines had pre-treatment tumor biopsies analyzed by gene expression profiling. Supervised hierarchical clustering was performed based on clinical outcome. An expanded bank of tumors was analyzed to increase the sample size and better understand gene patterns.
Two major categories of melanoma metastases have been observed.

One subgroup of patient has an inflamed phenotype that includes expression of chemokines, T-cell markers, and other immunoregulatory factors. Clinical responders to melanoma vaccines appear to fall within this subset. This group also contains the highest expression of negative regulatory factors, including PD-L1, IDO, and FoxP3, suggesting that these immunosuppressive mechanisms may dominantly inhibit anti-tumor –cell function in those patients. In addition, absence of B7 expression supports classical T-cell anergy. Preclinical experiments have confirmed a critical role for these mechanisms in limiting anti-tumor T–cell efficacy in vivo, giving candidate treatment strategies for translation back into the clinic.

A second subset of patients is represented by tumors which are non-inflamed and lack chemokines for T cell recruitment. Therefore, a major barrier in these cases appears to be failed T –cell migration into tumor sites. Experimental strategies to augment T-cell migration can have important anti-tumor effects in preclinical models. The presence of the "inflamed" gene signature was associated with a type I IFN transcriptional profile, and murine experimental models have confirmed a critical role for type I IFN signaling in promoting adaptive immunity."


So,In the first subset, tumors had a suppresive nature that may be over riddden by Anti-CTLA-4 (Yervoy) and or Anti-PD-1 Therapy

The second subset was missing the "danger signal" inflammatory cytokines and chemoattractants most likely due to STAT3 signaling from the Tumor.

Stimulation of Toll-like receptor 4 (TLR-4) activates macrophages and results in the release of TNF-alpha. It is hypothesized that melanoma inhibits macrophage activation by suppressing TLR-4 signaling.








Cytokines are small proteins which allow cells of the immune system to communicate with one another via cytokine receptors expressed at the cell surface.
Activated macrophages defend against tumors by secreting cytokines to recruit secondary immune cells, presenting antigen to T cells, and by direct tumor cytotoxicity. Peritoneal macrophages harvested from melanoma-bearing mice are less cytotoxic to melanoma cells, and produce less superoxide, nitric oxide, and tumor necrosis factor-alpha (TNF-alpha) than those from nontumor-bearing mice. Similar impairment of macrophage activation occurs in vitro using media harvested from cultured melanoma cells.

Activated Macrophages secrete the following cytokines under different conditions:
IL-1,IL-12,IL-6, IFN-gamma/alpha/beta and TNF-alpha


IL-6


Interleukin 6 is a pro-inflammatory cytokine and is produced in response to infection and tissue injury. IL-6 exerts its effects on multiple cell types and can act systemically.

IL-6 stimulates liver secretion of acute phase proteins
IL-6 stimulates B-lymphocytes to produce antibodies
IL-6 in concert with IL-1b causes T-cell activation
IL-6 induces STAT 3 Signaling
IL-6 Plus TGF-b induces the Th17 cell phenotype


IL-1 beta

Interleukin-1b is a pro-inflammatory cytokine which is secreted by macrophages activated by a number of stimuli including TNF-alpha, bacterial endotoxin and IL-1b itself.
IL-1b exerts its effects on many different cell types locally at the site of production and systemically (at a distance).


IL-12


Interleukin-12 is a heterodimer consisting of a p35 and a p40 subunit. Both subunits are required for receptor binding and biological activity.
IL-12 stimulates growth of activated Natural Killer (NK) cells, CD8+ and CD4+ T- cells.
IL-12 increases NK and T-cell g-IFN production which shifts T-cell differentiation towards a Th1-type response.
IL-12 increases NK production of TNF-alpha which can act synergistically with IFN-gamma.
IL-12 suppresses IL-4 induced IgE production.


TNF-alpha


Tumor Necrosis Factor alpha is made by many other cells as well as macrophages, which are major sources, especially after priming by Interferon gamma.
TNF-alpha initiates a cascade of cytokines which mediate an inflammatory response. TNF-alpha effects are mediated through two types of receptor, a 75kDa TNFR-a receptor and a 55kDa TNFR-b receptor.
TNF-alpha regulates the expression of many genes in many cell types important for the host response to infection.

IFN-gamma/beta

Macrophages, and many other cells produce these Type I interferons which act as immunomodulatory, as well as antiviral cytokines. Distinct receptor from interferon gamma, mediates overlapping or competing effects on macrophages. Cellular signalling pathways involve Jak/Stats, and other pathways.

So, if Melanoma suppresses Macrophage Activation, then the tumor microenviroment is missing IL-6, IL-1b and other cytokines.

If you look at the above micrographs, you will see that the two patients that had relapsed (10710 and 10737) Had IL-1b and IL-6 missing. The macrophages were not activated!!!! The "Danger Signal" known as inflammation was missing!





The missing combination of IL-1 and IL-6 meant there is no T-cell activation. And no induction of the Th17 phenotype. It is now becoming a lot more clearer based on Dr. Gajewski's findings.


Now might be the time for a critical re-evaluation of our overall approaches to targeting STAT3 and for developing new models for disrupting the protein in order to accomplish the goal of delivering clinically useful direct STAT3 inhibitors as novel anticancer agents in a timely manner.






“It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.”

~Charles Darwin~
Take Care,
Jimmy B

Immunotherapeutic Barriers at the Level of the Tumor Microenvironment..Melanoma .Jim Breitfeller

Last year I Blogged about the Missing Link in T-cell activation with a vaccine. We were missing the Proflammatory Cytokines that produce the "Danger Signal" to the Immune system. Well Dr. Gajewski has come out and has backed up my theory.

Along with that, there are Two companies that are persuing this theory with Cytokine Therapy.


Thomas F. Gajewski, MD, PhD (University of Chicago) presented on the key role that the tumor microenvironment plays in determining the outcome of a tumor immune response. He noted the complexity of the tumor with respect to its structural and cellular composition and that the functional phenotypes of these cells may or may not permit an effective anti-tumor response at either the priming or effector phase. Characteristics of the tumor microenvironment may dominate during the effector phase of an anti-tumor T cell response, limiting the efficacy of current immunotherapies by inhibiting T cell trafficking into the tumor, eliciting immune suppressive mechanisms within the tumor, altering tumor cell biology and susceptibility to immune-mediated killing, or modifying the tumor stroma (i.e., vasculature, fibrosis). These features can be interrogated through pre-treatment gene expression profiling of the tumor site in individual patients; such an analysis may identify a predictive biomarker profile associated with clinical response. This strategy may also help identify biologic barriers that need to be overcome to optimize therapeutic efficacy of vaccines and other cancer immunotherapies. Mouse models have helped to define the hallmarks of an anti-tumor response, taking into account the effector phase within the tumor microenvironment. Based on these models, a DC subset (CD8α+) appears necessary for priming of host CD8+ T cells through cross-presentation of antigen within the draining lymph node. Antigen specific naïve CD8+ T cells that recognize the antigen within the lymph node and receive appropriate co-stimulatory and proliferative signals acquire their effector phenotype. In order to assert immune control over the tumor, these effector CD8+ T cells must enter the bloodstream, and via chemokine signals, traffic to the tumor site; once there, these T cells must overcome immune regulatory/suppressive mechanisms. In a small study of an IL-12-based melanoma vaccine, Dr. Gajewski and colleagues correlated pre-treatment biopsy gene expression to outcomes and noted that in responding patients, tumors expressed chemokines (e.g., CXCL9 which binds CXCR3 on activated CD8+ T cells), which in some instances were able to recruit T cells into the tumor site. A broader transcript analysis of banked melanoma tissue demonstrated a subset of tumors with T cell markers co-associated with a panel of chemokines. Among responders in the vaccine trial, there was a pattern of expression of T cell- recruiting chemokines, T cell markers, innate immune genes, and type I IFN—all of which indicate productive inflammation. These results were supported by other cancer vaccine studies that demonstrated a strong correlation between survival and the expression of T cell markers and chemokines within the tumors. The results from these gene expression studies may be useful in identifying biomarkers that could provide valuable information for selecting patients most likely to respond to immunotherapies. Additionally, these studies point toward specific strategies for overcoming immunologic barriers to immunotherapy at the level of the tumor microenvironment. Thus, based on gene expression profiling, tumors can be categorized as T cell poor tumors, which lack chemokines for recruitment and have few indicators of inflammation, and T cell rich tumors, which express T cell recruiting chemokines, contain CD8+ T cells in the tumor microenvironment, and have a broad inflammatory signature. A strong presence of T cells within the tumor is predictive of clinical benefit from vaccines.

These observations prompt several important questions:

1) What dictates recruitment of activated CD8+ T cells into the tumor?
2) Why are tumors with CD8+ T cells not spontaneously rejected?
3) What are the innate immune mechanisms that promote spontaneous T cell priming in a subset of patients?
4) What oncogenic pathways in tumor cells drive these two distinct phenotypes?

Studies of CD8+ T cell recruitment to the tumor site point to a panel of chemokines, all of which may be produced by the melanoma tumor cells themselves. These studies suggest potential strategies to promote effector T cell migration to the tumor site that may include: direct introduction of chemokines; direct induction of chemokine production from stromal cells; eliciting local inflammation that generates chemokines (e.g., via type I IFNs, TLR agonists and possibly radiation); and altering signaling pathways in melanoma cells to enable chemokines expression by the tumor cells. Studies that have been designed to evaluate why melanomas that attract CD8+ T cells are not spontaneously rejected have pointed to several mechanisms that may exert negative regulation of T cells within the tumor microenvironment, including T cell inhibition via IDO and PD-L1, extrinsic suppression via CD4+CD25+FoxP3+ Tregs, and T cell anergy due to deficiency of B7 costimulation in the tumor microenvironment. Dr. Gajewski presented data that indicate that the immune inhibitory mechanisms present in the melanoma tumor microenvironment are driven by the CD8+ T cells, not the tumor. For example, IFNγ is the major mediator for IDO and PD-L1; and CCL22 production by CD8+ T cells is the major mediator for Tregs. Thus, blockade of these mechanisms may represent attractive strategies to restore anti-tumor T cell function and promote tumor rejection in patients.
To address questions underlying the mechanisms that promote spontaneous T cell priming in a subset of melanoma patients, Dr. Gajewski and colleagues used gene array data to identify markers of innate immunity that correlated with T cell infiltration. Melanoma metastases that contained T cell transcripts also contained transcripts known to be induced by type I IFNs. A knock-out mouse model demonstrated the necessity of the type I IFN axis for effective priming of a spontaneous T cell response and tumor rejection. Additional studies in knock-out mice have demonstrated that the CD8α+ DC subset is responsible for this spontaneous T cell priming. In an effective anti-tumor response sensing of the tumor by a separate DC subset drives type I IFN production, which is required for CD8α+ DC cross-priming of T cells. This suggests additional pathways that could be altered to promote spontaneous priming and an effective tumor response (e.g., provision of exogenous IFNβ). In summary, there is heterogeneity in patient outcomes to cancer immunotherapies (e.g., melanoma vaccines). One component of that heterogeneity is derived from differences at the level of the tumor microenvironment. Key factors in the melanoma microenvironment include
chemokine-mediated recruitment of effector CD8+ T cells, local immune suppressive mechanisms, and type I IFNs/innate immunity. Understanding these aspects should improve patient selection for treatment with immunotherapies (predictive biomarker), as well as aid the development of new interventions to modify the microenvironment to better support T cell-mediated rejection of tumors.

Source: http://www.translational-medicine.com/content/pdf/1479-5876-9-18.pdf

















Induction of an immune response by antigen vaccination. Active immunization occurs following administration of tumor antigens, which are processed by antigen-presenting cells resulting in activation of immune effector cells such as T lymphocytes and B lymphocytes. Effector cells fight the tumor through several different effector pathways such as antibodies, cytokines or direct cellular interaction (Fas/Fas ligand, perforin/granzymes). Ideally this results in immunologic memory with long-lasting immunity against the tumor. Stimulation of the innate immune system is also known to have an important role in the evolution of an adaptive immune response (e.g. a rapid burst of inflammatory cytokines leads to activation of DC and macrophages). However, tumor-specific T cells also secrete chemokines (e.g. RANTES, MIP-1) that attract cells of the innate immune system to the tumor site. This mechanism may further contribute to the tumoricidal activitiy exhibited during T cell-mediated tumor regression. (TCR: T cell receptor, MHC: major histocompatibility complex, DC: dendritic cell, PMN: polymorphonuclear neutrophil, NK: natural killer cell, NKT: NK T cell, RANTES: regulated upon activation, normal T cell expressed, and secreted, (MIP-1): macrophage inflammatory protein 1)



Two companies that are pursuing Cytokine Therapies with a product of “Natural Mixtures of Cytokines.” They may provide the missing signal needed to raise the red flag, “The Danger Signal”

Multikine is in the Phase 3 and IRX-2 is in the Phase 1 clinical trial Phase
IRX Therapeutics seems to have the most appropriate mixture. Cel-SCI is missing the chemoattractants and proinflammatory cytokines.

If you combine the Cytokine therapy with anti-CTLA-4 blockage, will you get a synergistic immune response?



“It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.”
~Charles Darwin~
Take Care,
Jimmy B

Failure at the effector phase: immune barriers at the level of the melanoma tumor microenvironment Melanoma Jim Breitfeller

Thomas F. Gajewski
Author's Affiliation: Departments of Pathology and Medicine, University of Chicago, Chicago, Illinois

Requests for reprints: Thomas F. Gajewski, University of Chicago, 5841 South Maryland Avenue, MC2115, Chicago, IL 60637. Phone: 773-702-4601; Fax: 773-702-3163; E-mail: tgajewsk@medicine.bsd.uchicago.edu.



"Metastatic melanoma tumors seem to be deficient in expression of B7-1 and B7-2 (16), which are important costimulatory factors for full T-cell activation (17). Stimulation through the T-cell antigen receptor without B7 costimulation has been shown to induce a hyporesponsive state termed anergy (18, 19). In support of this possibility, we recently have observed in a mouse model that a T-cell hyporesponsive state consistent with anergy occurs in mice bearing B7-negative tumors (20). In this situation, tumor rejection indeed can occur when B7-1 is transfected into the tumor cells, an observation that has been reported by multiple laboratories in other model systems (21, 22)."

In my case we stimulated the B7 receptor with anti-CTLA-4 Blockage, in the present of the antigen presenting cell (APC) that activated the CD4+T-cell it was allowed to propagate for 49 days (43 days gave the maximum propagation. Than we added the IL-2 therapy which we know by experiments the done by Rosenberg that Il-2 is able to pass throught the Tumor's microenvironment.

In 1980, Dr. Steven A. Roesnberg and colleagues discovered novel novel method for killing metastatic cancer cells. They took lymphoid cells and exposed them to interluekin-2 (IL-2).These cells were able to lyse the tumor cells and kill them. The were a different population than the Natural Killer cells. They coined the term “Lymphokine-activated killer cells” (LAK) for short.

Also, When patients do IL-2 therapy, they have side-effect Known as cell leakage. Il-2 makes the cell wall porous.

With the tumor cells walls compromised and with the activated effector T cells, the assualt on the tumors begin.

At Least, that is the way I envision it. There is probably a lot more going on behind the scenes.

Jimmy B