Eficiencia de las Bacterias

The dearth of TAA with expression restricted to malignant tissues has been a limiting factor in developing adoptive CAR-T cell therapies. In addition to few TAA meeting the criteria, solid tumors are overwhelming heterogeneous [205]. Identifying a target antigen that is uniformly expressed on all tumor cells but not normal cells and universally expressed on the surface of tumor cells across various tissues would greatly aid in the development of an adoptive CAR-T cell therapy for solid tumors. B7-H3 (CD276) is an ideal target that has been identified as a pan-cancer antigen with high, homogenous expression in solid tumors [321, 322]. We took advantage of the fact that there is 88% homology between human and murine B7-H3 to probe the anti-activity and safety of a cross-reactive B7-H3.CAR and demonstrated that B7-H3.CAR-T cells do not cause on-target but off-tumor toxicity in immunocompetent mouse models [323].

The results of our studies favor the use of the B7-H3.CAR-T cells in the clinic. However, immunohistochemistry analysis of both human and murine normal tissues has demonstrated that there is conserved expression of B7-H3 in select tissues such as the adrenal and salivary glands and the stomach [323]. While we did not observe toxicity in

immunocompetent mice infused with B7-H3.CAR-T cells, it is plausible that the infusion of B7-H3.CAR-T cells in human patients can cause unexpected lethal toxicity observed in trials targeting HER2 [133] and carbonic anhydrase IX [324, 325]. As we move B7- H3.CAR-T cells to the clinic we have proposed two additional safeguards to prevent lethal toxicity. First, we have proposed transient B7-H3.CAR expression in T cells by RNA electroporation. Further, we have proposed the addition of the iCas9 safety switch in the B7-H3.CAR vector to ensure rapid elimination of CAR expressing T cells.

As we look towards the future of adoptive CAR-T cell therapies more emphasis may need to be placed on examining the cancer mutanome to identify targets for CAR-T cell therapy. Current technologies being used to identify target antigens are significantly limited in predicting in vivo safety and put patients at risk. While in depth mutanome analyses have not been pursued in the past due to the costly and labor-intensive procedures required to identify a target antigen for a single patient, recent reports of lethal toxicity are warranting such efforts. In comparison to current methodologies, which include immunohistochemistry guided protein expression and cDNA microarray data, examining next-generation sequence data using bioinformatics approaches can clarify unique therapeutic targets and predict optimal combinations of antigens to target. [326-328]

FUTURE CONSIDERATIONS

The field of adoptive immunotherapies has undergone revolutionary advances in the last several decades. The identification and purification of IL-2 allowed for in depth analyses of T cell biology, confirming early hypotheses that T lymphocytes play a critical

role in the rejection of tumors, and invigorated the field towards using autologous TILs as an adoptive immunotherapy against metastatic cancers. Unfortunately, the use of TILs as a cancer treatment was only effective in a few select cancers, such as melanoma [329]. We now understand that TIL treatment is effective in melanoma because TILs harbor high neoepitope reactivity. However, the vast majority of tumors have an underwhelming neoantigen burden and the effects of TIL therapy are transient to ineffective. [330-332]

In response to disappointing results with TIL therapy, the field utilized genetic engineering techniques to transduce polyclonal T cell populations with tumor-specific TCRs [48]. But due to MHC-dependent activation, TCR engineered T cells also failed to make significant advancements in the treatment of cancer patients [333, 334]. The CAR was born out of the idea that in order to overcome mechanisms tumors employ to prevent T cell activation, T cells must be endowed with MHC-independent activation. With CAR-expressing T cells, patients with B cell malignancies have achieved impressive complete durable response rates [130]. Despite the progress made thus far, limited options are available for patients who relapse due to adoptive CAR-T cell therapy resistance [198]. As the field of adoptive T cell therapy continues to mature, it will become increasingly critical to identify combinations of safe and homogeneously expressed tumor targets that effectively induce comprehensive anti-tumor responses and epitope spread. Epitope spread is a phenomenon in which the death of the tumor cells results in the release of secondary tumor antigens and a subsequent immune response. Epitope spreading, which has been observed in autoimmunity and infectious disease, can result in clinically significant responses. [335, 336] Epitope spreading has

not yet been studied extensively in adoptive T cell therapies. However, as more clinical data become available, it will be critical to investigate epitope spread induced by adoptive T cell therapies so that effective multi-pronged strategies can be designed. Doing so could ensure complete durable remission in patients with refractory and metastatic cancer.

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