Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Immune-Based Therapies for Sarcoma

Immune-Based Therapies for Sarcoma Hindawi Publishing Corporation Sarcoma Volume 2011, Article ID 438940, 7 pages doi:10.1155/2011/438940 Review Article Seth M. Pollack, Elizabeth T. Loggers, Eve T. Rodler, Cassian Yee, and Robin L. Jones Fred Hutchinson Cancer Research Center, University of Washington, 825 Eastlake Avenue East, G3630, Seattle, WA 98109-1023, USA Correspondence should be addressed to Robin L. Jones, rjones@seattlecca.org Received 15 October 2010; Accepted 3 January 2011 Academic Editor: Stephen Lessnick Copyright © 2011 Seth M. Pollack 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. Immunotherapy has shown promise in a number of tumor types, but its exact role in sarcoma remains to be defined. Advanced bone and soft tissue sarcomas are challenging diseases to treat with an unmet need for effective systemic therapy. Previous reports have suggested that immune-based treatments may be effective in sarcoma, but such approaches have not yet become part of standard clinical practice. A number of sarcoma subtypes express targets known as cancer testis antigens and hence may be excellent targets for immunotherapy. This paper will focus on the recent advances and understanding of cancer testis antigens in sarcoma and also clinical data of immunotherapeutic approaches in these diseases. 1. Introduction Here we discuss some of the potential targets for im- munotherapy trials with a focus on the cancer testis antigens Immunotherapy has recently had significant well-publicized (CTAs) and their expression in individual sarcoma subtypes. successes. Placebo controlled, randomized Phase III trials We also review prior trials of immunotherapy including have demonstrated a survival benefit for vaccine-based nonspecific immunomodulators, vaccines, and adoptive therapy in follicular lymphoma [1] and prostate cancer [2]. immunotherapy. Ipilimumab, an antibody that blocks the inhibitor of T-cell activation, CTLA-4, has been shown to improve survival in patients with metastatic melanoma [3]. 2. Completed Immunotherapy Trials Progress in the systemic treatment of sarcoma has Immunotherapies can be divided into the following three been frustratingly slow. Immunotherapy has long been categories: nonspecific immunomodulation, vaccines, and discussed as a promising method for the treatment of adoptive cellular therapy. Nonspecific immunomodulation patients with metastatic sarcoma [4, 5]. Sadly, despite a induces antitumor immunity without exposing the patient number of ambitious early phase immunotherapy trials, no to a target molecule. By contrast, vaccines expose patients immunological treatments have become part of standard to antigens in order to provoke an antitumor immune clinical management. However, because of significant strides response usually in the presence of adjuvant and occasionally in our understanding of cancer immunology and because in combination with immunomodulation [3, 6]. Some of of progress in other disease types, immunotherapy remains these vaccines have been targeted to sarcoma-specific fusion a source of hope that exciting new therapies are on the products such as SYT-SSX in synovial sarcoma, whereas horizon for patients with sarcoma. We now know that other vaccines are less antigen directed such as those that many of the most promising targets for immunotherapy are have used irradiated autologous tumor cells. Finally, adoptive frequently expressed in certain sarcoma subtypes. Lessons learned from other diseases, such as melanoma, can guide cellular therapy involves the ex vivo expansion of immune effector cells (often T cells and/or NK cells) from a patient a new generation of immunotherapy trials with the aim of preventing recurrent disease in resected sarcoma and for later reinfusion. This may be nonspecific, as in the improving the survival of patients with advanced disease. case of leukocyte-activated killer cells or tumor-infiltrating 2 Sarcoma lymphocytes, or may use antigen-specific cultures ex vivo or cell sarcomas [16, 17]. From 1971 to 1990, 89 consecutive genetically engineered to have tumor-directed specificity. patients with localized high-grade osteosarcoma received adjuvant therapy with interferon-α. Between 1971 and 1984, 70 patients were treated with a dose of 3 × 10 IU once 3. Nonspecific Immunomodulation a day for one month, and subsequently 3 times weekly for further 17 months. Nineteen patients were treated between Some of the first trials demonstrating the potential of 1985 and 1990 with a dose of 3 × 10 IU daily, with immunotherapy in cancer used high-dose interleukin-2 (IL- treatment extending for 2–5 years. With a median followup 2) in patients with metastatic melanoma and renal cell of 12 years (range 2–16), the observed 10-year metastases- carcinoma. Six sarcoma patients were included in these early free and sarcoma-specific survival rates were 39% and 43%, high-dose IL-2 trials used in combination with leukocyte- respectively. Detailed toxicity data was not available for activated killer cells. None of these patients responded the period following 1979, but excellent compliance with [7]. More recently, however, high-dose IL-2 was given treatment implies no major additional toxicity [18, 19]. in a pediatric population including several patients with Contrasting results have been observed by other investi- osteosarcoma [8]. In total, 10 pediatric patients with heavily gators. The German/Austrian cooperative study COSS-80 pretreated, progressive, or metastatic solid tumors were randomized 158 patients with localized osteosarcoma to treated with high-dose IL-2. The cohort included 4 patients receive methotvexate and doxorubicin with either cisplatin with osteosarcoma and 2 patients with Ewing’s sarcoma. Two alone or the combination of bleomycin, cyclophosphamide, of the four osteosarcoma patients had complete responses and dactinomycin. Patients were also randomized to receive that were durable with median followup of 28 months (range or not receive 22 weeks of interferon-β. Interferon-β was 11–36 months for the 10 patients treated on study). Given commenced at week 16, consisting of 2 injections weekly that in long-term follow-up studies of adult patients with for 2 weeks, then daily injections for 4 weeks and then metastatic solid tumors treated with high-dose IL-2, patients 2 injections weekly for further 16 weeks. The dose of who are disease-free 30 months following treatment are interferon-β was 100,000 U/kg. No significant difference in considered extremely unlikely to relapse [7], this pediatric 30-month continuous disease-free survival was observed study represents an encouraging finding that warrants more between patients treated with and without interferon-β investigation focused on osteosarcoma. (77% versus 73%, resp.) [20]. The differing results observed Muramyl tripeptide phosphatidylethanolamine (MTP) is in the Scandinavian and German/Austrian studies may be a synthetic analogue of a bacterial cell well that has been due to the relatively low interferon dose and duration of studied clinically as a nonspecific immune modulator. Early therapy in the COSS-80 trial. The current European and studies demonstrated that peripheral blood mononuclear American Osteosarcoma Study Group (EURAMOS 1) trial cells taken from patients following treatment with liposomal randomizes patients with localized osteosarcoma, who have MTP demonstrated increased tumor cell killing in vitro had a good histological response to neoadjuvant chemother- compared with baseline samples [9, 10]. Furthermore, the apy, to receive postoperative systemic therapy consisting of drug was associated with increased serum levels of TNF alpha methotrexate, doxorubicin, and cisplatin with or without and IL-6 [10]. pegylated interferon α-2b. The pegylated preparation of The Children’s Oncology Group’s Intergroup-0133 stud- interferon α has an extended half life and consequently can ied MTP using a 2 × 2 design. In the first randomization, be administered less frequently with higher dose delivery. patients either received or did not receive ifosfamide with a The results of this large randomized trial will, it is hoped, chemotherapy backbone of cisplatin, doxorubicin, and high- define the role of interferon in the adjuvant treatment of dose methotrexate. In the second randomization, patients osteosarcoma. either received or did not receive liposomal-MTP. Analysis of Ito and colleagues reported decreases in size of lung this study has been complicated; the first analysis published metastases in 2 out of 3 osteosarcoma patients treated with in 2005 showed a trend towards improved outcomes for the interferon. Edmonson et al. reported on a Phase II trial of MTP-containing arm that was not statistically significance. recombinant interferon α-2a in 20 patients with advanced With more mature followup, a 2008 report demonstrated a bone sarcomas, 17 of whom had osteosarcoma. Partial tumor statistically significant improvement in overall survival with regression was documented in 2 patients with osteosarcoma a strengthening of the event-free survival trend for the MTP- and one with malignant fibrous histiocytoma, for 1, 3, and 2 containing arm. A 2009 report in cancer suggested that months, respectively. Three other patients had stable disease improvements in outcomes may also be seen in patients with (each for 2 months), but all other patients had disease metastatic disease although this analysis was not powered to progression. demonstrate a statistically significant benefit in either event- free or overallsurvival[11–13]. To date, liposomal MTP has not secured FDA approval but is available at a number of 4. Targeted Immunotherapy centers for compassionate use. Alpha interferon has also been used in several sarcoma Potential targets for immunotherapy have been divided into subtypes, particularly osteosarcoma, with varying success. five categories: mutated, shared tumor specific, differenti- There have been case reports of responses to interferon ation antigens, overexpressed antigens, and viral antigens in osteosarcoma [14, 15] and complete responses in clear [21]. Sarcoma 3 “Mutated” antigens involve a mutation in the cancer not there are more than 70 CT gene families, many of which are present in normal tissues, thus making the target inherently being developed as T-cell targets for vaccine and adoptive specific. An example of this in sarcoma is the SYT-SSX fusion cellular therapy [29]. protein. This epitopes from this mutant protein have been targeted in two Phase I trials (described below). 4.2. Cancer Testis Antigen Expression in Specific Sarcoma Subtypes. Only a handful of articles have described can- “Shared tumor specific” antigens are frequently ex- cer testis antigen expression in specific sarcoma subtypes. pressed by a number of malignancies but rarely are expressed Complicating matters is that while all cancer testis antigens by normal tissue. This category includes the cancer testis are by definition immunogenic, they are not all necessarily antigens (described below). These antigens are highly immunogenic for all individuals. Each CTA has epitopes immunogenic and are important for early development. described for at least one HLA type but many HLA types They are frequently seen in the developing embryo but are are quite rare. Since the class I HLA type A 02.01 is not found in significant quantities in adults except in the relatively common, expressed by about half of the Caucasian testis and occasionally the placenta. population, targeting A 02.01 associated epitopes in pilot “Differentiation antigens” are antigens involved in the immunotherapy trials for sarcoma is a reasonable approach. normal differentiation of a specific tissue type. MART-1 is Some of the commonly expressed cancer testis antigens, for an example of this type of antigen that has been successfully which A 02.01 epitopes have been identified, are NY-ESO- targeted in melanoma. This protein is expressed as part of the 1, LAGE-1, PRAME, MAGE-A3, MAGE-A4, MAGE-A9, and normal differentiation of melanocytes and certain other cells SSX-2. The expression of these antigens in the most common from neural crest tissue. This differentiation antigen appears sarcomasubtypesisillustrated in Table 1. to be expressed in clear cell sarcoma as well [22]. Currently, there is more data available on the expression “Overexpressed” targets are expressed in normal tissue of these antigens for synovial sarcoma than any other but greatly overexpressed in tumors. This category includes sarcoma subtype. It is well documented that the majority HER2 which is frequently expressed in synovial sarcoma of these tumors express the cancer testis antigen NY-ESO- [23]. Some of these overexpressed antigens have been 1, particularly those with monophasic histology where it is described as “universal antigens,” as they may be more uni- frequently expressed homogenously [30]. The biphasic type formly expressed by tumors such as telomerase (hTERT) and also expresses NY-ESO-1 in the majority of cases, although survivin; these antigens may be associated with tumorigenic not always and occasionally these tumors may only express advantage thus targeting these antigens may circumvent the NY-ESO-1 in one of the biphasic compartments. Synovial potential for outgrowth of antigen-loss variants [24, 25]. sarcomas tend not to express MAGE-A1 or CT7, though Viral antigens from viruses such as EBV have been little is known about the prevalence of other CT antigens in shown to present immunogenic epitopes. This strategy may this histological subtype. One gene microarray study found be applicable to Kaposi’s sarcoma which is associated with that all four cases of synovial sarcoma included in that HHV8 [26]. study expressed PRAME [31]. This study included 7 cases of myxoid liposarcoma and 5 nonmyxoid. All the nonmyxoid 4.1. Cancer Testis Antigens. As described above, the cancer liposarcoma cases and 1 of the myxoid subtype expressed testis antigens (CTAs) are a group of proteins considered PRAME. LAGE-1 was expressed in over 70% of myxoid to be some of the most exciting potential targets for liposarcomas and in 60% of nonmyxoid liposarcomas [31]. immunotherapy. Investigators have long sought to char- One study by the Ludwig group in New York assessed acterize specific tumor-associated antigens that would be CT antigen expression for a number of different sarcoma considered “immunogenic,” that is, capable of inducing an subtypes and included 6 liposarcomas [32]. Three expressed immune response. Pioneering work by Thierry Boon and LAGE-1. colleagues at the Ludwig Institute for Cancer Research in Less is known about leiomyosarcoma and it is possible Brussels uncovered distinct antigens recognized by cytotoxic that uterine and nonuterine leiomyosarcoma have distinct T lymphocytes (CTLs). This group first described 4 distinct patterns of CT antigen expression. In the study by Ayyoub antigens in mice (A, B, C, and D), two of which were et al., for example, four of six uterine leiomyosarcomas products of the same gene, P1A [27, 28]. Following on the examined expressed MAGE-A3, while only one of the seven heels of this discovery, the Boon group identified the first nonuterine leiomyosarcomas expressed MAGE-A3 [32]. human tumor-associated T-cell-defined antigen, MAGE-1 Three of the six uterine leiomyosarcomas expressed NY-ESO (Melanoma Antigen-1, subsequently renamed MAGE-A1) by and 2 expressed LAGE-1. No nonuterine leiomyosarcomas screening target cells transfected with the cDNA library of a expressed NY-ESO and only 1 of 7 expressed LAGE-1. tumor line using autologous tumor reactive antigen-specific Many leiomyosarcomas, particularly uterine leiomyosar- CTL. comas, may express CTAs from the SSX family including More T-cell-defined antigens were discovered, and SSX-2 which has an A 02.01 epitope. In the study of SSX MAGE-1 was eventually recognized to be part of a family of antigens by Ayyoub et al. 3 of 4 expressed SSX-2 [33]. MAGE antigens which represent a broader class of antigens Among the skeletal sarcomas, osteosarcoma is known ultimately described by Lloyd Old as “cancer-testis” antigens. to express several CT antigens. One study of CT antigen These antigens have expression restricted to germline tissues, expression in pediatric solid tumors included 9 osteosar- placental trophoblasts, and a broad range of cancers. To date coma patients. All of these osteosarcoma samples expressed 4 Sarcoma Table 1: Selected CT antigen expression (all with A 02.01 epitopes) in selected sarcomas. Sarcoma subtype Reference Method NY-ESO-1 LAGE-1 PRAME MAGE-A3 MAGE-A4 MAGE-A9 SSX-2 MFH/pleomorphic spindle cell [32] RT-PCR 1/6 0/6 1/6 0/6 [33]RT-PCR 1/2 [31] Microarray 0/16 1/16 1/16 Liposarcoma [32] RT-PCR 2/2 1/2 1/2 2/2 [33]RT-PCR 1/2 Myxoid [31] Microarray 5/7 6/7 5/7 Nonmyxoid [31] Microarray 3/5 5/5 2/5 Leiomyosarcoma [31] Microarray 0/9 3/9 1/9 Uterine leiomyosarcoma [32] RT-PCR 3/5 2/5 3/5 4/5 [33]RT-PCR 3/4 Nonuterine leiomyosarcoma [32] RT-PCR 0/7 1/7 1/7 2/7 [32]RT-PCR 0/1 Synovial sarcoma [32] RT-PCR 2/2 1/2 1/2 2/2 [30] IHC 20/25 [31] Microarray 3/4 4/4 3/4 Skeletal sarcomas Osteosarcoma [32] RT-PCR 0/1 0/1 0/1 0/1 [33]RT-PCR 0/1 [34] qRT-PCR 8/9 (NY-ESO + LAGE) 9/9 4/9 Ewings Sarcoma [34] qRT-PCR 0/18 (NY-ESO + LAGE) 5/18 4/18 Chondrosarcoma [32] RT-PCR 2/2 2/2 2/2 1/2 MAGE-A3 by real-time PCR and all but one expressed complete regression of several sizable pulmonary sites of LAGE-1/NY-ESO [34]. By contrast, few of the Ewing’s sar- metastatic disease. coma patients in that study expressed cancer testis antigens. The largest dendritic cell vaccine trial to date for the treatment of patients with sarcoma targeted recurrent or 4.3. Vaccine-Based Trials. A number of small trials have metastatic Ewing’s sarcoma family tumors or alveolar rhab- immunized patients against sarcoma achieving varying levels domyosarcoma having a t(2;13) or t(11;22) translocation. of success using a variety of different vaccines. Some of Patients were treated with dendritic cells pulsed with tumor- these trials have targeted well-defined antigens, others have specific peptides derived from the fusion proteins as a targeted tumor lysate. In one such trial, sarcoma patients consolidative therapy after patients achieved a complete received an intradermal injection of irradiated autologous remission. Improved survival was seen in the group of tumor cells grown in culture to vaccinate against antigens patients receiving vaccination compared with those under- that would be released from these dying cells. Almost going leukapheresis but not receiving vaccination. However, all of the patients also received either interferon gamma this was a nonrandomized study in which patients not or GM-CSF as an adjuvant. An immune response was receiving vaccination were more likely to have progressive demonstrated using a delayed-type hypersensitivity (DTH) disease or declining performance status [36]. In the Phase skin test against autologous tumor which converted from I trial of these vaccines 16 patients with bulky metastatic negative to positive in 8 of 16 evaluable patients. Median disease were treated, one patient had a mixed response and survival was 16.6 months among patients who were DTH three patients had stabilization of disease [37]. responders compared with 8.2 months in those who were In the posttransplant setting, a dendritic cell vaccine nonresponders. This was a statistically significant difference trial was administered to 5 children with residual tumors that is hypothesis generating but is of questionable causality. following autologous transplantation [38]. Three patients There were no objective responses among the study partici- received dendritic cells pulsed with tumor lysate. Two pants with measurable disease. Of note, the study included patients received dendritic cells, pulsed with three synthetic one patient with resected pulmonary metastatic disease tumor-specific peptides related to either the SYT-SSX2 (without measurable disease at the time of vaccination) who translocation sometimes seen in synovial sarcoma or the was disease-free over 3 years following vaccination [6]. EWS-FLI-1 fusion gene often seen in Ewing’s sarcoma. One One vaccine trial gave intradermal injections of dendritic patient had a complete response that was durable for over cells pulsed with autologous tumor lysate [35]. Ten pediatric 77 months and was ongoing at the time of the report. This patients were treated; one patient with fibrosarcoma had was the only patient with Ewing’s sarcoma receiving DCs a partial response to the treatment which included the pulsed by EWS-FLI-1-related synthetic peptides and suggests Sarcoma 5 that these peptides may be worthy of further study. Two that a number of sarcoma subtypes do often have tumor other patients had stabilization of disease but ultimately infiltrating lymphocytes (unpublished data), this may be an progressed. area deserving further study. Several studies have used vaccines of peptide alone. One Furthermore, as more has been learned about the poten- trial focused on the study drug 105AD7, a vaccineagainst tial targets for adoptive immunotherapy, greater interest has the complement regulatory protein CD55 frequently over- been given to developing T cells targeted towards specific expressed in osteosarcoma, was able to induce cytokine antigens either by isolating rare tumor targeted cells from a production and antibody production in patients although patient’s peripheral blood or by genetically modifying T cells clinical response was modest [39, 40]. to target a specific antigen. Given the frequent expression of A peptide encompassing the SYT-SSX fusion region of CT antigens in certain sarcoma subtypes, sarcoma may be the gene resulting from the t(X;18) translocation has been an ideal target for antigen-specific adoptive immunotherapy. used to vaccinate six HLA-A 24.02 positive patients. The The Rosenberg group at the NCI has begun treating synovial peptide vaccine succeeded in generating peptide-specific sarcoma patients with lymphocytes using a transduced T-cell CTLs that were successfully detected from four patients receptor specific for NY-ESO-1. following vaccination although all patients had negative DTH skin testing. None of the patients experienced an 5. Conclusion objective clinical response although one patient’s disease stabilized [41]. The same group has produced interesting in While past attempts to use immunotherapy have failed to vitro data showing that while CTL generated to the wild-type dramatically shift the paradigm of care for the treatment of peptide killed tumor relatively poorly (the peptide used for patients with sarcoma, a great opportunity exists to shape the vaccine), a one amino acid substituted K9I peptide (also the future. Nonspecific immunomodulation with the use of an A 2402 associated epitope) produced CTL which killed muramyl tripeptide phosphatidylethanolamine in resected tumor far more effectively [42]. osteosarcoma has shown a significant survival benefit. Other There is an on-going randomized placebo controlled immune approaches have shown signals of potential in multicentered Phase II trial of a trivalent peptide vaccine isolated patients with dramatic responses to immunotherapy. to the gangliosides GD2, GD3, and GM2 in patients with A greater understanding of the immune system and the stage IV sarcoma who have no evidence of disease following ability to harness more potent approaches to utilize the resection. These gangliosides are thought to play a role in ability of the immune system to fight cancer could result cell adhesion and cell-cell interactions. They are usually in advances in the treatment of sarcoma. There remains expressed by melanomas and also may be expressed by some a need for novel effective therapy in advanced soft tissue sarcomas [43, 44], and in Ewing’s and osteosarcoma in sarcoma, particularly in chemoresistant subtypes where no particular [45, 46]. Moreover, soft tissue sarcoma patients conventional systemic therapy is available. Emphasis on frequently develop an antibody response to GD2 compared the immunological characteristics of individual sarcoma with healthy controls [47]. However, the promise of this subtypes and the consequent tailoring of therapy could vaccine must be tempered by the fact that a randomized trial increase the therapeutic options available. The exact role in melanoma failed to demonstrate improvement in patient- of immunotherapy in sarcoma is yet to be delineated. It is related outcome measures [48]. hoped with well-designed, multiinstitutional clinical trials that this treatment approach will result in improvements in 4.4. Adoptive Immunotherapy. In adoptive immunotherapy, survival in this challenging group of diseases. patients are treated with autologous lymphocytes taken from a patient and expanded ex vivo. Some of the most impres- Acknowledgement sive clinical results have come from studies using tumor- infiltrating lymphocytes (TILs) in patients with melanoma. This work was supported by the Bob and Eileen Gilman In these studies, tumor is taken from a patient and the Family Sarcoma Research Program. lymphocytes are separated and expanded ex vivo and then reinfused following patient lymphodepleting conditioning. References The most promising results were those patients whose con- dition involved an intensive regimen requiring autologous [1] S. J. Schuster, S. S. Neelapu, B. L. Gause et al., “Idiotype vaccine transplant with total body irradiation, cyclophosphamide therapy (BiovaxID) in follicular lymphoma in first complete and fludarabine conditioning followed by high-dose IL-2 remission: phase III clinical trial results,” Journal of Clinical postinfusion. The median survival for metastatic melanoma Oncology, vol. 27, supplement, no. 18S, 2009. is less than a year, however, a 2-year survival rate of over 40% [2] P.W.Kantoff, C. S. Higano, N. D. Shore et al., “Sipuleucel-T has been reported using this adoptive immunotherapeutic immunotherapy for castration-resistant prostate cancer,” New approach. It should be noted that considerable toxicity England Journal of Medicine, vol. 363, no. 5, pp. 411–422, has been reported in these trials [49]. Though some early work did seem to demonstrate that TIL could often be [3] F. S. Hodi, S. J. O’Day, D. F. McDermott et al., “Improved sur- grown in culture from patients with sarcoma, although vival with ipilimumab in patients with metastatic melanoma,” with lower yield compared with other tumor types, little New England Journal of Medicine, vol. 363, no. 8, pp. 711–723, follow-upworkhas been done [50, 51]. However, given 2010. 6 Sarcoma [4] R. G. Maki, “Soft tissue sarcoma as a model disease to examine [19] C. R. Muller ¨ , S. Smeland, H. C. F. Bauer, G. Sæter, and H. cancer immunotherapy,” Current Opinion in Oncology, vol. 13, Strander, “Interferon-α as the only adjuvant treatment in no. 4, pp. 270–274, 2001. high-grade osteosarcoma: long term results of the Karolinska Hospital series,” Acta Oncologica, vol. 44, no. 5, pp. 475–480, [5] R. G. Maki, “Future directions for immunotherapeutic inter- vention against sarcomas,” Current Opinion in Oncology, vol. [20] K. Winkler, G. Beron, and R. Kotz, “Neoadjuvant chemother- 18, no. 4, pp. 363–368, 2006. apy for osteogenic sarcoma: results of a cooperative Ger- [6] R. Dillman, N. Barth, S. Selvan et al., “Phase I/II trial of man/Austrian study,” Journal of Clinical Oncology, vol. 2, no. autologous tumor cell line-derived vaccines for recurrent or 6, pp. 617–624, 1984. metastatic sarcomas,” Cancer Biotherapy and Radiopharma- [21] P. Van der Bruggen, YI. Zhang, P. Chaux et al., “Tumor- ceuticals, vol. 19, no. 5, pp. 581–588, 2004. specific shared antigenic peptides recognized by human T [7] S.A.Rosenberg,M.T.Lotze,J.C.Yangetal., “Experience cells,” Immunological Reviews, vol. 188, pp. 51–64, 2002. with the use of high-dose interleukin-2 in the treatment of 652 [22] M. Hisaoka, T. Ishida, T. T. Kuo et al., “Clear cell sarcoma cancer patients,” Annals of Surgery, vol. 210, no. 4, pp. 474– of soft tissue: a clinicopathologic, immunohistochemical, and 485, 1989. molecular analysis of 33 cases,” American Journal of Surgical [8] W. Schwinger, V. Klass, M. Benesch et al., “Feasibility of Pathology, vol. 32, no. 3, pp. 452–460, 2008. high-dose interleukin-2 in heavily pretreated pediatric cancer [23] P. G. Nuciforo, C. Pellegrini, R. Fasani et al., “Molecular patients,” Annals of Oncology, vol. 16, no. 7, pp. 1199–1206, and immunohistochemical analysis of HER2/neu oncogene in synovial sarcoma,” Human Pathology, vol. 34, no. 7, pp. 639– [9] J. L. Murray, E. S. Kleinerman, J. E. Cunningham et al., 645, 2003. “Phase I trial of liposomal muramyl tripeptide phos- [24] R. H. Vonderheide, W. C. Hahn, J. L. Schultze, and L. phatidylethanolamine in cancer patients,” Journal of Clinical M. Nadler, “The telomerase catalytic subunit is a widely Oncology, vol. 7, no. 12, pp. 1915–1925, 1989. expressed tumor-associated antigen recognized by cytotoxic T [10] E. S. Kleinerman,S.F.Jia,J.Griffin, N. L. Seibel, R. S. lymphocytes,” Immunity, vol. 10, no. 6, pp. 673–679, 1999. Benjamin, and N. Jaffe, “Phase II study of liposomal mur-amyl [25] S. Reker, A. Meier, L. Holten-Andersen et al., “Identification tripeptide in osteosarcoma: the cytokine cascade and mono- of novel survivin-derived CTL epitopes,” Cancer Biology and cyte activation following administration,” Journal of Clinical Therapy, vol. 3, no. 2, pp. 173–179, 2004. Oncology, vol. 10, no. 8, pp. 1310–1316, 1992. [26] B. J. Van Den Eynde and P. Van Der Bruggen, “T cell defined tumor antigens,” Current Opinion in Immunology, vol. 9, no. [11] P. A. Meyers, C. L. Schwartz, M. Krailo et al., “Osteosarcoma: a randomized, prospective trial of the addition of ifosfamide 5, pp. 684–693, 1997. and/or muramyl tripeptide to cisplatin, doxorubicin, and [27] B. Van den Eynde, B. Lethe, A. Van Pel, E. De Plaen, and T. high-dose methotrexate,” Journal of Clinical Oncology, vol. 23, Boon, “The gene coding for a major tumor rejection antigen no. 9, pp. 2004–2011, 2005. of tumor P815 is identical to the normal gene of syngeneic DBA/2 mice,” Journal of Experimental Medicine, vol. 173, no. [12] P. A. Meyers, C. L. Schwartz, M. D. Krailo et al., “Osteosar- 6, pp. 1373–1384, 1991. coma: the addition of muramyl tripeptide to chemotherapy [28] D. Brandle, ¨ J. Bilsborough, T. Rulic ¨ ke, C. Uyttenhove, T. Boon, improves overall survival—a report from the children’s oncol- andB.J.Van DenEynde,“Thesharedtumor-specific antigen ogy group,” Journal of Clinical Oncology,vol. 26, no.4,pp. encoded by mouse gene P1A is a target not only for cytolytic 633–638, 2008. T lymphocytes but also for tumor rejection,” European Journal [13] A. J. Chou, E. S. Kleinerman, M. D. Krailo et al., “Addition of Immunology, vol. 28, no. 12, pp. 4010–4019, 1998. of muramyl tripeptide to chemotherapy for patients with [29] A. J. G. Simpson, O. L. Caballero, A. Jungbluth, Y. T. Chen, and newly diagnosed metastatic osteosarcoma: a report from the L. J. Old, “Cancer/testis antigens, gametogenesis and cancer,” Children’s Oncology Group,” Cancer, vol. 115, no. 22, pp. Nature Reviews Cancer, vol. 5, no. 8, pp. 615–625, 2005. 5339–5348, 2009. [30] A. A. Jungbluth, C. R. Antonescu, K. J. Busam et al., [14] H. Ito, K. Murakami, and T. Yanagawa, “Effect of human “Monophasic and biphasic synovial sarcomas abundantly leukocyte interferon on the metastatic lung tumor of osteosar- express cancer/testis antigen NY-ESO-1 but not MAGE-A1 or coma. Case reports,” Cancer, vol. 46, no. 7, pp. 1562–1565, CT7,” International Journal of Cancer, vol. 94, no. 2, pp. 252– 256, 2001. [15] J. H. Edmonson,H.J.Long, S. Frytak,W.A.Smithson, and [31] K. M. Skubitz, S. Pambuccian, J. C. Carlos, and A. P. N. L. M. Itri, “Phase II study of recombinant alfa-2a interferon Skubitz, “Identification of heterogeneity among soft tissue in patients with advanced bone sarcomas,” Cancer Treatment sarcomas by gene expression profiles from different tumors,” Reports, vol. 71, no. 7-8, pp. 747–748, 1987. Journal of Translational Medicine, vol. 6, p. 23, 2008. [16] S. Lauro, F. Bordin, L. Trasatti, G. Lanzetta, C. D. Rocca, and L. [32] M. Ayyoub, R. N. Taub, M. L. Keohan et al., “The frequent Frati, “Concurrent chemoimmunotherapy in metastatic clear expression of cancer/testis antigens provides opportunities for cell sarcoma: a case report,” Tumori, vol. 85, no. 6, pp. 512– immunotherapeutic targeting of sarcoma.,” Cancer Immunity, 514, 1999. vol. 4, p. 7, 2004. [17] G. G. Steger, F. Wrba, R. Mader, O. Schlappack, C. Dittrich, [33] M. Ayyoub, M. Brehm, G. Metthez et al., “SSX antigens as and H. Rainer, “Complete remission of metastasised clear cell tumor vaccine targets in human sarcoma,” Cancer Immunity, sarcoma of tendons and aponeuroses,” European Journal of vol. 3, p. 13, 2003. Cancer, vol. 27, no. 3, pp. 254–256, 1991. [34] J. F. M. Jacobs, F. Brasseur, C. A. Hulsbergen-van De Kaa et al., [18] H. Strander,H.C.Bauer,O.Brosjoetal., “Long-term adjuvant “Cancer-germline gene expression in pediatric solid tumors interferon treatment of human osteosarcoma. A pilot study,” using quantitative real-time PCR,” International Journal of Acta Oncologica, vol. 34, no. 6, pp. 877–880, 1995. Cancer, vol. 120, no. 1, pp. 67–74, 2007. Sarcoma 7 [35] J. D. Geiger, R. J. Hutchinson, L. F. Hohenkirk et al., [49] M. E. Dudley, J. C. Yang, R. Sherry et al., “Adoptive cell therapy “Vaccination of pediatric solid tumor patients with tumor for patients with metastatic melanoma: evaluation of intensive lysate-pulsed dendritic cells can expand specific T cells and myeloablative chemoradiation preparative regimens,” Journal mediate tumor regression,” Cancer Research, vol. 61, no. 23, of Clinical Oncology, vol. 26, no. 32, pp. 5233–5239, 2008. pp. 8513–8519, 2001. [50] S. L. Topalian, L. M. Muul, D. Solomon, and S. A. Rosenberg, [36] C. L. Mackall, E. H. Rhee, E. J. Read et al., “A pilot study “Expansion of human tumor infiltrating lymphocytes for use of consolidative immunotherapy in patients with high-risk in immunotherapy trials,” Journal of Immunological Methods, pediatric sarcomas,” Clinical Cancer Research, vol. 14, no. 15, vol. 102, no. 1, pp. 127–141, 1987. p. 4850, 2008. [51] C. M. Balch, L. B. Riley, Y. J. Bae et al., “Patterns of human [37] R. Dagher, L. M. Long, E. J. Read et al., “Pilot trial of tumor-infiltrating lymphocytes in 120 human cancers,” tumor-specific peptide vaccination and continuous infusion Archives of Surgery, vol. 125, no. 2, pp. 200–205, 1990. interleukin-2 in patients with recurrent Ewing sarcoma and alveolar rhabdomyosarcoma: an inter-institute NIH study,” Medical and Pediatric Oncology, vol. 38, no. 3, pp. 158–164, [38] A. Suminoe, A. Matsuzaki, H. Hattori, Y. Koga, and T. Hara, “Immunotherapy with autologous dendritic cells and tumor antigens for children with refractory malignant solid tumors,” Pediatric Transplantation, vol. 13, no. 6, pp. 746–753, [39] G. J. Ullenhag, I. Spendlove, N. F. S. Watson, C. Kallmeyer, K. Pritchard-Jones, and L. G. Durrant, “T-cell responses in osteosarcoma patients vaccinated with an anti-idiotypic antibody, 105AD7, mimicking CD55,” Clinical Immunology, vol. 128, no. 2, pp. 148–154, 2008. [40] K. Pritchard-Jones, I. Spendlove, C. Wilton et al., “Immune responses to the 105AD7 human anti-idiotypic vaccine after intensive chemotherapy, for osteosarcoma,” British Journal of Cancer, vol. 92, no. 8, pp. 1358–1365, 2005. [41] S. Kawaguchi, T. Wada, K. Ida et al., “Phase I vaccination trial of SYT-SSX junction peptide in patients with disseminated synovial sarcoma,” Journal of Translational Medicine, vol. 3, p. 1, 2005. [42] K. Ida, S. Kawaguchi, Y. Sato et al., “Crisscross CTL induction by SYT-SSX junction peptide and its HLA-A 2402 anchor substitute,” Journal of Immunology, vol. 173, no. 2, pp. 1436– 1443, 2004. [43] S. Zhang, C. Cordon-Cardo, H. S. Zhang et al., “Selection of tumor antigens as targets for immune attack using immuno- histochemistry: I. Focus on gangliosides,” International Jour- nal of Cancer, vol. 73, no. 1, pp. 42–49, 1997. [44] W. B. Hamilton, F. Helling, K. O. Lloyd, and P. O. Livingston, “Ganglioside expression on human malignant melanoma assessed by quantitative immune thin-layer chromatography,” International Journal of Cancer, vol. 53, no. 4, pp. 566–573, [45] J. P. Heiner, F. Miraldi, S. Kallick et al., “Localization of G(D2)- specific monoclonal antibody 3F8 in human osteosarcoma,” Cancer Research, vol. 47, no. 20, pp. 5377–5381, 1987. [46] M. Lipinski, K. Braham, and I. Philip, “Neuroectoderm- associated antigens on Ewing’s sarcoma cell lines,” Cancer Research, vol. 47, no. 1, pp. 183–187, 1987. [47] C. A. Perez, M. H. Ravindranath, D. Soh, A. Gonzales, W. Ye, and D. L. Morton, “Serum anti-ganglioside IgM antibodies in soft tissue sarcoma: clinical prognostic implications,” Cancer Journal, vol. 8, no. 5, pp. 384–394, 2002. [48] J. M. Kirkwood, J. G. Ibrahim, J. A. Sosman et al., “High-dose interferon alfa-2b significantly prolongs relapse-free and overall survival compared with the GM2-KLH/QS-21 vaccine in patients with resected stage IIB-III melanoma: results of intergroup trial E1694/S9512/C509801,” Journal of Clinical Oncology, vol. 19, no. 9, pp. 2370–2380, 2001. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Sarcoma Hindawi Publishing Corporation

Immune-Based Therapies for Sarcoma

Download PDF
8 pages

Loading next page...
 
/lp/hindawi-publishing-corporation/immune-based-therapies-for-sarcoma-FHjdWht9cJ

References (63)

Publisher
Hindawi Publishing Corporation
Copyright
Copyright © 2011 Seth M. Pollack 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.
ISSN
1357-714X
eISSN
1369-1643
DOI
10.1155/2011/438940
Publisher site
See Article on Publisher Site

Abstract

Hindawi Publishing Corporation Sarcoma Volume 2011, Article ID 438940, 7 pages doi:10.1155/2011/438940 Review Article Seth M. Pollack, Elizabeth T. Loggers, Eve T. Rodler, Cassian Yee, and Robin L. Jones Fred Hutchinson Cancer Research Center, University of Washington, 825 Eastlake Avenue East, G3630, Seattle, WA 98109-1023, USA Correspondence should be addressed to Robin L. Jones, rjones@seattlecca.org Received 15 October 2010; Accepted 3 January 2011 Academic Editor: Stephen Lessnick Copyright © 2011 Seth M. Pollack 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. Immunotherapy has shown promise in a number of tumor types, but its exact role in sarcoma remains to be defined. Advanced bone and soft tissue sarcomas are challenging diseases to treat with an unmet need for effective systemic therapy. Previous reports have suggested that immune-based treatments may be effective in sarcoma, but such approaches have not yet become part of standard clinical practice. A number of sarcoma subtypes express targets known as cancer testis antigens and hence may be excellent targets for immunotherapy. This paper will focus on the recent advances and understanding of cancer testis antigens in sarcoma and also clinical data of immunotherapeutic approaches in these diseases. 1. Introduction Here we discuss some of the potential targets for im- munotherapy trials with a focus on the cancer testis antigens Immunotherapy has recently had significant well-publicized (CTAs) and their expression in individual sarcoma subtypes. successes. Placebo controlled, randomized Phase III trials We also review prior trials of immunotherapy including have demonstrated a survival benefit for vaccine-based nonspecific immunomodulators, vaccines, and adoptive therapy in follicular lymphoma [1] and prostate cancer [2]. immunotherapy. Ipilimumab, an antibody that blocks the inhibitor of T-cell activation, CTLA-4, has been shown to improve survival in patients with metastatic melanoma [3]. 2. Completed Immunotherapy Trials Progress in the systemic treatment of sarcoma has Immunotherapies can be divided into the following three been frustratingly slow. Immunotherapy has long been categories: nonspecific immunomodulation, vaccines, and discussed as a promising method for the treatment of adoptive cellular therapy. Nonspecific immunomodulation patients with metastatic sarcoma [4, 5]. Sadly, despite a induces antitumor immunity without exposing the patient number of ambitious early phase immunotherapy trials, no to a target molecule. By contrast, vaccines expose patients immunological treatments have become part of standard to antigens in order to provoke an antitumor immune clinical management. However, because of significant strides response usually in the presence of adjuvant and occasionally in our understanding of cancer immunology and because in combination with immunomodulation [3, 6]. Some of of progress in other disease types, immunotherapy remains these vaccines have been targeted to sarcoma-specific fusion a source of hope that exciting new therapies are on the products such as SYT-SSX in synovial sarcoma, whereas horizon for patients with sarcoma. We now know that other vaccines are less antigen directed such as those that many of the most promising targets for immunotherapy are have used irradiated autologous tumor cells. Finally, adoptive frequently expressed in certain sarcoma subtypes. Lessons learned from other diseases, such as melanoma, can guide cellular therapy involves the ex vivo expansion of immune effector cells (often T cells and/or NK cells) from a patient a new generation of immunotherapy trials with the aim of preventing recurrent disease in resected sarcoma and for later reinfusion. This may be nonspecific, as in the improving the survival of patients with advanced disease. case of leukocyte-activated killer cells or tumor-infiltrating 2 Sarcoma lymphocytes, or may use antigen-specific cultures ex vivo or cell sarcomas [16, 17]. From 1971 to 1990, 89 consecutive genetically engineered to have tumor-directed specificity. patients with localized high-grade osteosarcoma received adjuvant therapy with interferon-α. Between 1971 and 1984, 70 patients were treated with a dose of 3 × 10 IU once 3. Nonspecific Immunomodulation a day for one month, and subsequently 3 times weekly for further 17 months. Nineteen patients were treated between Some of the first trials demonstrating the potential of 1985 and 1990 with a dose of 3 × 10 IU daily, with immunotherapy in cancer used high-dose interleukin-2 (IL- treatment extending for 2–5 years. With a median followup 2) in patients with metastatic melanoma and renal cell of 12 years (range 2–16), the observed 10-year metastases- carcinoma. Six sarcoma patients were included in these early free and sarcoma-specific survival rates were 39% and 43%, high-dose IL-2 trials used in combination with leukocyte- respectively. Detailed toxicity data was not available for activated killer cells. None of these patients responded the period following 1979, but excellent compliance with [7]. More recently, however, high-dose IL-2 was given treatment implies no major additional toxicity [18, 19]. in a pediatric population including several patients with Contrasting results have been observed by other investi- osteosarcoma [8]. In total, 10 pediatric patients with heavily gators. The German/Austrian cooperative study COSS-80 pretreated, progressive, or metastatic solid tumors were randomized 158 patients with localized osteosarcoma to treated with high-dose IL-2. The cohort included 4 patients receive methotvexate and doxorubicin with either cisplatin with osteosarcoma and 2 patients with Ewing’s sarcoma. Two alone or the combination of bleomycin, cyclophosphamide, of the four osteosarcoma patients had complete responses and dactinomycin. Patients were also randomized to receive that were durable with median followup of 28 months (range or not receive 22 weeks of interferon-β. Interferon-β was 11–36 months for the 10 patients treated on study). Given commenced at week 16, consisting of 2 injections weekly that in long-term follow-up studies of adult patients with for 2 weeks, then daily injections for 4 weeks and then metastatic solid tumors treated with high-dose IL-2, patients 2 injections weekly for further 16 weeks. The dose of who are disease-free 30 months following treatment are interferon-β was 100,000 U/kg. No significant difference in considered extremely unlikely to relapse [7], this pediatric 30-month continuous disease-free survival was observed study represents an encouraging finding that warrants more between patients treated with and without interferon-β investigation focused on osteosarcoma. (77% versus 73%, resp.) [20]. The differing results observed Muramyl tripeptide phosphatidylethanolamine (MTP) is in the Scandinavian and German/Austrian studies may be a synthetic analogue of a bacterial cell well that has been due to the relatively low interferon dose and duration of studied clinically as a nonspecific immune modulator. Early therapy in the COSS-80 trial. The current European and studies demonstrated that peripheral blood mononuclear American Osteosarcoma Study Group (EURAMOS 1) trial cells taken from patients following treatment with liposomal randomizes patients with localized osteosarcoma, who have MTP demonstrated increased tumor cell killing in vitro had a good histological response to neoadjuvant chemother- compared with baseline samples [9, 10]. Furthermore, the apy, to receive postoperative systemic therapy consisting of drug was associated with increased serum levels of TNF alpha methotrexate, doxorubicin, and cisplatin with or without and IL-6 [10]. pegylated interferon α-2b. The pegylated preparation of The Children’s Oncology Group’s Intergroup-0133 stud- interferon α has an extended half life and consequently can ied MTP using a 2 × 2 design. In the first randomization, be administered less frequently with higher dose delivery. patients either received or did not receive ifosfamide with a The results of this large randomized trial will, it is hoped, chemotherapy backbone of cisplatin, doxorubicin, and high- define the role of interferon in the adjuvant treatment of dose methotrexate. In the second randomization, patients osteosarcoma. either received or did not receive liposomal-MTP. Analysis of Ito and colleagues reported decreases in size of lung this study has been complicated; the first analysis published metastases in 2 out of 3 osteosarcoma patients treated with in 2005 showed a trend towards improved outcomes for the interferon. Edmonson et al. reported on a Phase II trial of MTP-containing arm that was not statistically significance. recombinant interferon α-2a in 20 patients with advanced With more mature followup, a 2008 report demonstrated a bone sarcomas, 17 of whom had osteosarcoma. Partial tumor statistically significant improvement in overall survival with regression was documented in 2 patients with osteosarcoma a strengthening of the event-free survival trend for the MTP- and one with malignant fibrous histiocytoma, for 1, 3, and 2 containing arm. A 2009 report in cancer suggested that months, respectively. Three other patients had stable disease improvements in outcomes may also be seen in patients with (each for 2 months), but all other patients had disease metastatic disease although this analysis was not powered to progression. demonstrate a statistically significant benefit in either event- free or overallsurvival[11–13]. To date, liposomal MTP has not secured FDA approval but is available at a number of 4. Targeted Immunotherapy centers for compassionate use. Alpha interferon has also been used in several sarcoma Potential targets for immunotherapy have been divided into subtypes, particularly osteosarcoma, with varying success. five categories: mutated, shared tumor specific, differenti- There have been case reports of responses to interferon ation antigens, overexpressed antigens, and viral antigens in osteosarcoma [14, 15] and complete responses in clear [21]. Sarcoma 3 “Mutated” antigens involve a mutation in the cancer not there are more than 70 CT gene families, many of which are present in normal tissues, thus making the target inherently being developed as T-cell targets for vaccine and adoptive specific. An example of this in sarcoma is the SYT-SSX fusion cellular therapy [29]. protein. This epitopes from this mutant protein have been targeted in two Phase I trials (described below). 4.2. Cancer Testis Antigen Expression in Specific Sarcoma Subtypes. Only a handful of articles have described can- “Shared tumor specific” antigens are frequently ex- cer testis antigen expression in specific sarcoma subtypes. pressed by a number of malignancies but rarely are expressed Complicating matters is that while all cancer testis antigens by normal tissue. This category includes the cancer testis are by definition immunogenic, they are not all necessarily antigens (described below). These antigens are highly immunogenic for all individuals. Each CTA has epitopes immunogenic and are important for early development. described for at least one HLA type but many HLA types They are frequently seen in the developing embryo but are are quite rare. Since the class I HLA type A 02.01 is not found in significant quantities in adults except in the relatively common, expressed by about half of the Caucasian testis and occasionally the placenta. population, targeting A 02.01 associated epitopes in pilot “Differentiation antigens” are antigens involved in the immunotherapy trials for sarcoma is a reasonable approach. normal differentiation of a specific tissue type. MART-1 is Some of the commonly expressed cancer testis antigens, for an example of this type of antigen that has been successfully which A 02.01 epitopes have been identified, are NY-ESO- targeted in melanoma. This protein is expressed as part of the 1, LAGE-1, PRAME, MAGE-A3, MAGE-A4, MAGE-A9, and normal differentiation of melanocytes and certain other cells SSX-2. The expression of these antigens in the most common from neural crest tissue. This differentiation antigen appears sarcomasubtypesisillustrated in Table 1. to be expressed in clear cell sarcoma as well [22]. Currently, there is more data available on the expression “Overexpressed” targets are expressed in normal tissue of these antigens for synovial sarcoma than any other but greatly overexpressed in tumors. This category includes sarcoma subtype. It is well documented that the majority HER2 which is frequently expressed in synovial sarcoma of these tumors express the cancer testis antigen NY-ESO- [23]. Some of these overexpressed antigens have been 1, particularly those with monophasic histology where it is described as “universal antigens,” as they may be more uni- frequently expressed homogenously [30]. The biphasic type formly expressed by tumors such as telomerase (hTERT) and also expresses NY-ESO-1 in the majority of cases, although survivin; these antigens may be associated with tumorigenic not always and occasionally these tumors may only express advantage thus targeting these antigens may circumvent the NY-ESO-1 in one of the biphasic compartments. Synovial potential for outgrowth of antigen-loss variants [24, 25]. sarcomas tend not to express MAGE-A1 or CT7, though Viral antigens from viruses such as EBV have been little is known about the prevalence of other CT antigens in shown to present immunogenic epitopes. This strategy may this histological subtype. One gene microarray study found be applicable to Kaposi’s sarcoma which is associated with that all four cases of synovial sarcoma included in that HHV8 [26]. study expressed PRAME [31]. This study included 7 cases of myxoid liposarcoma and 5 nonmyxoid. All the nonmyxoid 4.1. Cancer Testis Antigens. As described above, the cancer liposarcoma cases and 1 of the myxoid subtype expressed testis antigens (CTAs) are a group of proteins considered PRAME. LAGE-1 was expressed in over 70% of myxoid to be some of the most exciting potential targets for liposarcomas and in 60% of nonmyxoid liposarcomas [31]. immunotherapy. Investigators have long sought to char- One study by the Ludwig group in New York assessed acterize specific tumor-associated antigens that would be CT antigen expression for a number of different sarcoma considered “immunogenic,” that is, capable of inducing an subtypes and included 6 liposarcomas [32]. Three expressed immune response. Pioneering work by Thierry Boon and LAGE-1. colleagues at the Ludwig Institute for Cancer Research in Less is known about leiomyosarcoma and it is possible Brussels uncovered distinct antigens recognized by cytotoxic that uterine and nonuterine leiomyosarcoma have distinct T lymphocytes (CTLs). This group first described 4 distinct patterns of CT antigen expression. In the study by Ayyoub antigens in mice (A, B, C, and D), two of which were et al., for example, four of six uterine leiomyosarcomas products of the same gene, P1A [27, 28]. Following on the examined expressed MAGE-A3, while only one of the seven heels of this discovery, the Boon group identified the first nonuterine leiomyosarcomas expressed MAGE-A3 [32]. human tumor-associated T-cell-defined antigen, MAGE-1 Three of the six uterine leiomyosarcomas expressed NY-ESO (Melanoma Antigen-1, subsequently renamed MAGE-A1) by and 2 expressed LAGE-1. No nonuterine leiomyosarcomas screening target cells transfected with the cDNA library of a expressed NY-ESO and only 1 of 7 expressed LAGE-1. tumor line using autologous tumor reactive antigen-specific Many leiomyosarcomas, particularly uterine leiomyosar- CTL. comas, may express CTAs from the SSX family including More T-cell-defined antigens were discovered, and SSX-2 which has an A 02.01 epitope. In the study of SSX MAGE-1 was eventually recognized to be part of a family of antigens by Ayyoub et al. 3 of 4 expressed SSX-2 [33]. MAGE antigens which represent a broader class of antigens Among the skeletal sarcomas, osteosarcoma is known ultimately described by Lloyd Old as “cancer-testis” antigens. to express several CT antigens. One study of CT antigen These antigens have expression restricted to germline tissues, expression in pediatric solid tumors included 9 osteosar- placental trophoblasts, and a broad range of cancers. To date coma patients. All of these osteosarcoma samples expressed 4 Sarcoma Table 1: Selected CT antigen expression (all with A 02.01 epitopes) in selected sarcomas. Sarcoma subtype Reference Method NY-ESO-1 LAGE-1 PRAME MAGE-A3 MAGE-A4 MAGE-A9 SSX-2 MFH/pleomorphic spindle cell [32] RT-PCR 1/6 0/6 1/6 0/6 [33]RT-PCR 1/2 [31] Microarray 0/16 1/16 1/16 Liposarcoma [32] RT-PCR 2/2 1/2 1/2 2/2 [33]RT-PCR 1/2 Myxoid [31] Microarray 5/7 6/7 5/7 Nonmyxoid [31] Microarray 3/5 5/5 2/5 Leiomyosarcoma [31] Microarray 0/9 3/9 1/9 Uterine leiomyosarcoma [32] RT-PCR 3/5 2/5 3/5 4/5 [33]RT-PCR 3/4 Nonuterine leiomyosarcoma [32] RT-PCR 0/7 1/7 1/7 2/7 [32]RT-PCR 0/1 Synovial sarcoma [32] RT-PCR 2/2 1/2 1/2 2/2 [30] IHC 20/25 [31] Microarray 3/4 4/4 3/4 Skeletal sarcomas Osteosarcoma [32] RT-PCR 0/1 0/1 0/1 0/1 [33]RT-PCR 0/1 [34] qRT-PCR 8/9 (NY-ESO + LAGE) 9/9 4/9 Ewings Sarcoma [34] qRT-PCR 0/18 (NY-ESO + LAGE) 5/18 4/18 Chondrosarcoma [32] RT-PCR 2/2 2/2 2/2 1/2 MAGE-A3 by real-time PCR and all but one expressed complete regression of several sizable pulmonary sites of LAGE-1/NY-ESO [34]. By contrast, few of the Ewing’s sar- metastatic disease. coma patients in that study expressed cancer testis antigens. The largest dendritic cell vaccine trial to date for the treatment of patients with sarcoma targeted recurrent or 4.3. Vaccine-Based Trials. A number of small trials have metastatic Ewing’s sarcoma family tumors or alveolar rhab- immunized patients against sarcoma achieving varying levels domyosarcoma having a t(2;13) or t(11;22) translocation. of success using a variety of different vaccines. Some of Patients were treated with dendritic cells pulsed with tumor- these trials have targeted well-defined antigens, others have specific peptides derived from the fusion proteins as a targeted tumor lysate. In one such trial, sarcoma patients consolidative therapy after patients achieved a complete received an intradermal injection of irradiated autologous remission. Improved survival was seen in the group of tumor cells grown in culture to vaccinate against antigens patients receiving vaccination compared with those under- that would be released from these dying cells. Almost going leukapheresis but not receiving vaccination. However, all of the patients also received either interferon gamma this was a nonrandomized study in which patients not or GM-CSF as an adjuvant. An immune response was receiving vaccination were more likely to have progressive demonstrated using a delayed-type hypersensitivity (DTH) disease or declining performance status [36]. In the Phase skin test against autologous tumor which converted from I trial of these vaccines 16 patients with bulky metastatic negative to positive in 8 of 16 evaluable patients. Median disease were treated, one patient had a mixed response and survival was 16.6 months among patients who were DTH three patients had stabilization of disease [37]. responders compared with 8.2 months in those who were In the posttransplant setting, a dendritic cell vaccine nonresponders. This was a statistically significant difference trial was administered to 5 children with residual tumors that is hypothesis generating but is of questionable causality. following autologous transplantation [38]. Three patients There were no objective responses among the study partici- received dendritic cells pulsed with tumor lysate. Two pants with measurable disease. Of note, the study included patients received dendritic cells, pulsed with three synthetic one patient with resected pulmonary metastatic disease tumor-specific peptides related to either the SYT-SSX2 (without measurable disease at the time of vaccination) who translocation sometimes seen in synovial sarcoma or the was disease-free over 3 years following vaccination [6]. EWS-FLI-1 fusion gene often seen in Ewing’s sarcoma. One One vaccine trial gave intradermal injections of dendritic patient had a complete response that was durable for over cells pulsed with autologous tumor lysate [35]. Ten pediatric 77 months and was ongoing at the time of the report. This patients were treated; one patient with fibrosarcoma had was the only patient with Ewing’s sarcoma receiving DCs a partial response to the treatment which included the pulsed by EWS-FLI-1-related synthetic peptides and suggests Sarcoma 5 that these peptides may be worthy of further study. Two that a number of sarcoma subtypes do often have tumor other patients had stabilization of disease but ultimately infiltrating lymphocytes (unpublished data), this may be an progressed. area deserving further study. Several studies have used vaccines of peptide alone. One Furthermore, as more has been learned about the poten- trial focused on the study drug 105AD7, a vaccineagainst tial targets for adoptive immunotherapy, greater interest has the complement regulatory protein CD55 frequently over- been given to developing T cells targeted towards specific expressed in osteosarcoma, was able to induce cytokine antigens either by isolating rare tumor targeted cells from a production and antibody production in patients although patient’s peripheral blood or by genetically modifying T cells clinical response was modest [39, 40]. to target a specific antigen. Given the frequent expression of A peptide encompassing the SYT-SSX fusion region of CT antigens in certain sarcoma subtypes, sarcoma may be the gene resulting from the t(X;18) translocation has been an ideal target for antigen-specific adoptive immunotherapy. used to vaccinate six HLA-A 24.02 positive patients. The The Rosenberg group at the NCI has begun treating synovial peptide vaccine succeeded in generating peptide-specific sarcoma patients with lymphocytes using a transduced T-cell CTLs that were successfully detected from four patients receptor specific for NY-ESO-1. following vaccination although all patients had negative DTH skin testing. None of the patients experienced an 5. Conclusion objective clinical response although one patient’s disease stabilized [41]. The same group has produced interesting in While past attempts to use immunotherapy have failed to vitro data showing that while CTL generated to the wild-type dramatically shift the paradigm of care for the treatment of peptide killed tumor relatively poorly (the peptide used for patients with sarcoma, a great opportunity exists to shape the vaccine), a one amino acid substituted K9I peptide (also the future. Nonspecific immunomodulation with the use of an A 2402 associated epitope) produced CTL which killed muramyl tripeptide phosphatidylethanolamine in resected tumor far more effectively [42]. osteosarcoma has shown a significant survival benefit. Other There is an on-going randomized placebo controlled immune approaches have shown signals of potential in multicentered Phase II trial of a trivalent peptide vaccine isolated patients with dramatic responses to immunotherapy. to the gangliosides GD2, GD3, and GM2 in patients with A greater understanding of the immune system and the stage IV sarcoma who have no evidence of disease following ability to harness more potent approaches to utilize the resection. These gangliosides are thought to play a role in ability of the immune system to fight cancer could result cell adhesion and cell-cell interactions. They are usually in advances in the treatment of sarcoma. There remains expressed by melanomas and also may be expressed by some a need for novel effective therapy in advanced soft tissue sarcomas [43, 44], and in Ewing’s and osteosarcoma in sarcoma, particularly in chemoresistant subtypes where no particular [45, 46]. Moreover, soft tissue sarcoma patients conventional systemic therapy is available. Emphasis on frequently develop an antibody response to GD2 compared the immunological characteristics of individual sarcoma with healthy controls [47]. However, the promise of this subtypes and the consequent tailoring of therapy could vaccine must be tempered by the fact that a randomized trial increase the therapeutic options available. The exact role in melanoma failed to demonstrate improvement in patient- of immunotherapy in sarcoma is yet to be delineated. It is related outcome measures [48]. hoped with well-designed, multiinstitutional clinical trials that this treatment approach will result in improvements in 4.4. Adoptive Immunotherapy. In adoptive immunotherapy, survival in this challenging group of diseases. patients are treated with autologous lymphocytes taken from a patient and expanded ex vivo. Some of the most impres- Acknowledgement sive clinical results have come from studies using tumor- infiltrating lymphocytes (TILs) in patients with melanoma. This work was supported by the Bob and Eileen Gilman In these studies, tumor is taken from a patient and the Family Sarcoma Research Program. lymphocytes are separated and expanded ex vivo and then reinfused following patient lymphodepleting conditioning. References The most promising results were those patients whose con- dition involved an intensive regimen requiring autologous [1] S. J. Schuster, S. S. Neelapu, B. L. Gause et al., “Idiotype vaccine transplant with total body irradiation, cyclophosphamide therapy (BiovaxID) in follicular lymphoma in first complete and fludarabine conditioning followed by high-dose IL-2 remission: phase III clinical trial results,” Journal of Clinical postinfusion. The median survival for metastatic melanoma Oncology, vol. 27, supplement, no. 18S, 2009. is less than a year, however, a 2-year survival rate of over 40% [2] P.W.Kantoff, C. S. Higano, N. D. Shore et al., “Sipuleucel-T has been reported using this adoptive immunotherapeutic immunotherapy for castration-resistant prostate cancer,” New approach. It should be noted that considerable toxicity England Journal of Medicine, vol. 363, no. 5, pp. 411–422, has been reported in these trials [49]. Though some early work did seem to demonstrate that TIL could often be [3] F. S. Hodi, S. J. O’Day, D. F. McDermott et al., “Improved sur- grown in culture from patients with sarcoma, although vival with ipilimumab in patients with metastatic melanoma,” with lower yield compared with other tumor types, little New England Journal of Medicine, vol. 363, no. 8, pp. 711–723, follow-upworkhas been done [50, 51]. However, given 2010. 6 Sarcoma [4] R. G. Maki, “Soft tissue sarcoma as a model disease to examine [19] C. R. Muller ¨ , S. Smeland, H. C. F. Bauer, G. Sæter, and H. cancer immunotherapy,” Current Opinion in Oncology, vol. 13, Strander, “Interferon-α as the only adjuvant treatment in no. 4, pp. 270–274, 2001. high-grade osteosarcoma: long term results of the Karolinska Hospital series,” Acta Oncologica, vol. 44, no. 5, pp. 475–480, [5] R. G. Maki, “Future directions for immunotherapeutic inter- vention against sarcomas,” Current Opinion in Oncology, vol. [20] K. Winkler, G. Beron, and R. Kotz, “Neoadjuvant chemother- 18, no. 4, pp. 363–368, 2006. apy for osteogenic sarcoma: results of a cooperative Ger- [6] R. Dillman, N. Barth, S. Selvan et al., “Phase I/II trial of man/Austrian study,” Journal of Clinical Oncology, vol. 2, no. autologous tumor cell line-derived vaccines for recurrent or 6, pp. 617–624, 1984. metastatic sarcomas,” Cancer Biotherapy and Radiopharma- [21] P. Van der Bruggen, YI. Zhang, P. Chaux et al., “Tumor- ceuticals, vol. 19, no. 5, pp. 581–588, 2004. specific shared antigenic peptides recognized by human T [7] S.A.Rosenberg,M.T.Lotze,J.C.Yangetal., “Experience cells,” Immunological Reviews, vol. 188, pp. 51–64, 2002. with the use of high-dose interleukin-2 in the treatment of 652 [22] M. Hisaoka, T. Ishida, T. T. Kuo et al., “Clear cell sarcoma cancer patients,” Annals of Surgery, vol. 210, no. 4, pp. 474– of soft tissue: a clinicopathologic, immunohistochemical, and 485, 1989. molecular analysis of 33 cases,” American Journal of Surgical [8] W. Schwinger, V. Klass, M. Benesch et al., “Feasibility of Pathology, vol. 32, no. 3, pp. 452–460, 2008. high-dose interleukin-2 in heavily pretreated pediatric cancer [23] P. G. Nuciforo, C. Pellegrini, R. Fasani et al., “Molecular patients,” Annals of Oncology, vol. 16, no. 7, pp. 1199–1206, and immunohistochemical analysis of HER2/neu oncogene in synovial sarcoma,” Human Pathology, vol. 34, no. 7, pp. 639– [9] J. L. Murray, E. S. Kleinerman, J. E. Cunningham et al., 645, 2003. “Phase I trial of liposomal muramyl tripeptide phos- [24] R. H. Vonderheide, W. C. Hahn, J. L. Schultze, and L. phatidylethanolamine in cancer patients,” Journal of Clinical M. Nadler, “The telomerase catalytic subunit is a widely Oncology, vol. 7, no. 12, pp. 1915–1925, 1989. expressed tumor-associated antigen recognized by cytotoxic T [10] E. S. Kleinerman,S.F.Jia,J.Griffin, N. L. Seibel, R. S. lymphocytes,” Immunity, vol. 10, no. 6, pp. 673–679, 1999. Benjamin, and N. Jaffe, “Phase II study of liposomal mur-amyl [25] S. Reker, A. Meier, L. Holten-Andersen et al., “Identification tripeptide in osteosarcoma: the cytokine cascade and mono- of novel survivin-derived CTL epitopes,” Cancer Biology and cyte activation following administration,” Journal of Clinical Therapy, vol. 3, no. 2, pp. 173–179, 2004. Oncology, vol. 10, no. 8, pp. 1310–1316, 1992. [26] B. J. Van Den Eynde and P. Van Der Bruggen, “T cell defined tumor antigens,” Current Opinion in Immunology, vol. 9, no. [11] P. A. Meyers, C. L. Schwartz, M. Krailo et al., “Osteosarcoma: a randomized, prospective trial of the addition of ifosfamide 5, pp. 684–693, 1997. and/or muramyl tripeptide to cisplatin, doxorubicin, and [27] B. Van den Eynde, B. Lethe, A. Van Pel, E. De Plaen, and T. high-dose methotrexate,” Journal of Clinical Oncology, vol. 23, Boon, “The gene coding for a major tumor rejection antigen no. 9, pp. 2004–2011, 2005. of tumor P815 is identical to the normal gene of syngeneic DBA/2 mice,” Journal of Experimental Medicine, vol. 173, no. [12] P. A. Meyers, C. L. Schwartz, M. D. Krailo et al., “Osteosar- 6, pp. 1373–1384, 1991. coma: the addition of muramyl tripeptide to chemotherapy [28] D. Brandle, ¨ J. Bilsborough, T. Rulic ¨ ke, C. Uyttenhove, T. Boon, improves overall survival—a report from the children’s oncol- andB.J.Van DenEynde,“Thesharedtumor-specific antigen ogy group,” Journal of Clinical Oncology,vol. 26, no.4,pp. encoded by mouse gene P1A is a target not only for cytolytic 633–638, 2008. T lymphocytes but also for tumor rejection,” European Journal [13] A. J. Chou, E. S. Kleinerman, M. D. Krailo et al., “Addition of Immunology, vol. 28, no. 12, pp. 4010–4019, 1998. of muramyl tripeptide to chemotherapy for patients with [29] A. J. G. Simpson, O. L. Caballero, A. Jungbluth, Y. T. Chen, and newly diagnosed metastatic osteosarcoma: a report from the L. J. Old, “Cancer/testis antigens, gametogenesis and cancer,” Children’s Oncology Group,” Cancer, vol. 115, no. 22, pp. Nature Reviews Cancer, vol. 5, no. 8, pp. 615–625, 2005. 5339–5348, 2009. [30] A. A. Jungbluth, C. R. Antonescu, K. J. Busam et al., [14] H. Ito, K. Murakami, and T. Yanagawa, “Effect of human “Monophasic and biphasic synovial sarcomas abundantly leukocyte interferon on the metastatic lung tumor of osteosar- express cancer/testis antigen NY-ESO-1 but not MAGE-A1 or coma. Case reports,” Cancer, vol. 46, no. 7, pp. 1562–1565, CT7,” International Journal of Cancer, vol. 94, no. 2, pp. 252– 256, 2001. [15] J. H. Edmonson,H.J.Long, S. Frytak,W.A.Smithson, and [31] K. M. Skubitz, S. Pambuccian, J. C. Carlos, and A. P. N. L. M. Itri, “Phase II study of recombinant alfa-2a interferon Skubitz, “Identification of heterogeneity among soft tissue in patients with advanced bone sarcomas,” Cancer Treatment sarcomas by gene expression profiles from different tumors,” Reports, vol. 71, no. 7-8, pp. 747–748, 1987. Journal of Translational Medicine, vol. 6, p. 23, 2008. [16] S. Lauro, F. Bordin, L. Trasatti, G. Lanzetta, C. D. Rocca, and L. [32] M. Ayyoub, R. N. Taub, M. L. Keohan et al., “The frequent Frati, “Concurrent chemoimmunotherapy in metastatic clear expression of cancer/testis antigens provides opportunities for cell sarcoma: a case report,” Tumori, vol. 85, no. 6, pp. 512– immunotherapeutic targeting of sarcoma.,” Cancer Immunity, 514, 1999. vol. 4, p. 7, 2004. [17] G. G. Steger, F. Wrba, R. Mader, O. Schlappack, C. Dittrich, [33] M. Ayyoub, M. Brehm, G. Metthez et al., “SSX antigens as and H. Rainer, “Complete remission of metastasised clear cell tumor vaccine targets in human sarcoma,” Cancer Immunity, sarcoma of tendons and aponeuroses,” European Journal of vol. 3, p. 13, 2003. Cancer, vol. 27, no. 3, pp. 254–256, 1991. [34] J. F. M. Jacobs, F. Brasseur, C. A. Hulsbergen-van De Kaa et al., [18] H. Strander,H.C.Bauer,O.Brosjoetal., “Long-term adjuvant “Cancer-germline gene expression in pediatric solid tumors interferon treatment of human osteosarcoma. A pilot study,” using quantitative real-time PCR,” International Journal of Acta Oncologica, vol. 34, no. 6, pp. 877–880, 1995. Cancer, vol. 120, no. 1, pp. 67–74, 2007. Sarcoma 7 [35] J. D. Geiger, R. J. Hutchinson, L. F. Hohenkirk et al., [49] M. E. Dudley, J. C. Yang, R. Sherry et al., “Adoptive cell therapy “Vaccination of pediatric solid tumor patients with tumor for patients with metastatic melanoma: evaluation of intensive lysate-pulsed dendritic cells can expand specific T cells and myeloablative chemoradiation preparative regimens,” Journal mediate tumor regression,” Cancer Research, vol. 61, no. 23, of Clinical Oncology, vol. 26, no. 32, pp. 5233–5239, 2008. pp. 8513–8519, 2001. [50] S. L. Topalian, L. M. Muul, D. Solomon, and S. A. Rosenberg, [36] C. L. Mackall, E. H. Rhee, E. J. Read et al., “A pilot study “Expansion of human tumor infiltrating lymphocytes for use of consolidative immunotherapy in patients with high-risk in immunotherapy trials,” Journal of Immunological Methods, pediatric sarcomas,” Clinical Cancer Research, vol. 14, no. 15, vol. 102, no. 1, pp. 127–141, 1987. p. 4850, 2008. [51] C. M. Balch, L. B. Riley, Y. J. Bae et al., “Patterns of human [37] R. Dagher, L. M. Long, E. J. Read et al., “Pilot trial of tumor-infiltrating lymphocytes in 120 human cancers,” tumor-specific peptide vaccination and continuous infusion Archives of Surgery, vol. 125, no. 2, pp. 200–205, 1990. interleukin-2 in patients with recurrent Ewing sarcoma and alveolar rhabdomyosarcoma: an inter-institute NIH study,” Medical and Pediatric Oncology, vol. 38, no. 3, pp. 158–164, [38] A. Suminoe, A. Matsuzaki, H. Hattori, Y. Koga, and T. Hara, “Immunotherapy with autologous dendritic cells and tumor antigens for children with refractory malignant solid tumors,” Pediatric Transplantation, vol. 13, no. 6, pp. 746–753, [39] G. J. Ullenhag, I. Spendlove, N. F. S. Watson, C. Kallmeyer, K. Pritchard-Jones, and L. G. Durrant, “T-cell responses in osteosarcoma patients vaccinated with an anti-idiotypic antibody, 105AD7, mimicking CD55,” Clinical Immunology, vol. 128, no. 2, pp. 148–154, 2008. [40] K. Pritchard-Jones, I. Spendlove, C. Wilton et al., “Immune responses to the 105AD7 human anti-idiotypic vaccine after intensive chemotherapy, for osteosarcoma,” British Journal of Cancer, vol. 92, no. 8, pp. 1358–1365, 2005. [41] S. Kawaguchi, T. Wada, K. Ida et al., “Phase I vaccination trial of SYT-SSX junction peptide in patients with disseminated synovial sarcoma,” Journal of Translational Medicine, vol. 3, p. 1, 2005. [42] K. Ida, S. Kawaguchi, Y. Sato et al., “Crisscross CTL induction by SYT-SSX junction peptide and its HLA-A 2402 anchor substitute,” Journal of Immunology, vol. 173, no. 2, pp. 1436– 1443, 2004. [43] S. Zhang, C. Cordon-Cardo, H. S. Zhang et al., “Selection of tumor antigens as targets for immune attack using immuno- histochemistry: I. Focus on gangliosides,” International Jour- nal of Cancer, vol. 73, no. 1, pp. 42–49, 1997. [44] W. B. Hamilton, F. Helling, K. O. Lloyd, and P. O. Livingston, “Ganglioside expression on human malignant melanoma assessed by quantitative immune thin-layer chromatography,” International Journal of Cancer, vol. 53, no. 4, pp. 566–573, [45] J. P. Heiner, F. Miraldi, S. Kallick et al., “Localization of G(D2)- specific monoclonal antibody 3F8 in human osteosarcoma,” Cancer Research, vol. 47, no. 20, pp. 5377–5381, 1987. [46] M. Lipinski, K. Braham, and I. Philip, “Neuroectoderm- associated antigens on Ewing’s sarcoma cell lines,” Cancer Research, vol. 47, no. 1, pp. 183–187, 1987. [47] C. A. Perez, M. H. Ravindranath, D. Soh, A. Gonzales, W. Ye, and D. L. Morton, “Serum anti-ganglioside IgM antibodies in soft tissue sarcoma: clinical prognostic implications,” Cancer Journal, vol. 8, no. 5, pp. 384–394, 2002. [48] J. M. Kirkwood, J. G. Ibrahim, J. A. Sosman et al., “High-dose interferon alfa-2b significantly prolongs relapse-free and overall survival compared with the GM2-KLH/QS-21 vaccine in patients with resected stage IIB-III melanoma: results of intergroup trial E1694/S9512/C509801,” Journal of Clinical Oncology, vol. 19, no. 9, pp. 2370–2380, 2001. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal

Sarcoma – Hindawi Publishing Corporation

Published: Jan 23, 2011

There are no references for this article.