Cancer is the second most common cause of death in the United States behind heart disease. While current treatments such as surgery, chemotherapy, and radiation therapy are effective and widely used, medicine is moving towards more targeted and personalized therapies. Immunotherapy is one such treatment that utilizes the patient’s own immune system to target and eliminate tumor cells. It allows for the patient’s adaptive immune system to bypass the self-tolerance mechanisms used by the cancerous cells and be activated against the cancer. Two such self-tolerant mechanisms that are co-opted by tumor cells are the interactions between CTLA-4 and T lymphocytes and the interactions between PD-1 and PD-L1. Blocking these interactions allows for the recruitment of CTLs to the site of the tumor and subsequent attack. CTLA-4 and PD-1 are inhibitory costimulators that play a role in the suppression of the adaptive immune system. The interaction of these receptors with their respective ligands leads to self-tolerance, and is a common mechanism used as a protective measure against autoimmune reactions. Monoclonal antibodies against these two receptors and ligand have been tested in clinical trials and have shown efficacy against ovarian cancers, non-small cell lung carcinomas, colon cancers, and melanomas. By targeting the inhibitory signals, these monoclonal antibodies expose cancer cells as being “non-self” thus prompting the immune system to attack. Now, studies are focusing on combination therapies, which combine chemotherapeutics or other monoclonal antibodies with PD-1 and CTLA-4 inhibitors to enhance the effectiveness of the drug. However, drawbacks and side effects to the therapy range from fatigue and nausea to development of autoimmune diseases. It brings forward that future studies will need a panel of predictive biomarkers to identify the best candidates for the immunotherapy. While there are many obstacles, such as a lower than expected efficacy of the immunotherapy, the progress made has important implications in the development of personalized medicine.

Malignant melanoma is a growing problem with more and more people in Sweden and the world suffering from this cancer. Malignant melanoma is a disease that when discovered in time can be treated successfully with surgical methods, but the real challenge lies in treating the disease after its spread. Treatment in the past for advanced malignant melanoma has been unsuccessful with no positive effect on overall survival. However, in the last couple of years, new treatment has arrived with focus on priming the immune system to eradicate the tumors. One new drug is the CTLA-4 inhibitor ipilimumab that is given as intravenous infusion. CTLA-4 is a protein located on regulatory T-cells and that is upregulated on activated cytotoxic T-cells. This protein mediates an inhibitory signal that attenuates T-cell-activation.  Treatment with the CTLA-4 inhibitor has been shown to increase overall survival. However, not much is known about how well ipilimumab synergizes with other drugs used for treatment of malignant melanoma.   This is a literature study with the aim to evaluate if ipilimumab is used best as monotherapy or if it is of better use as part of a combination therapy. Search was made in PubMed with the key-words "Ipilimumab", "Ipilimumab treatment", CTLA-4 inhibitor" and "treatment malignant melanoma”. Six articles were chosen and each of these analyzed the effect of ipilimumab alone or combined with other agents against malignant melanoma.   The combination of ipilimumab and the alkylating agent dacarbazine was shown to have a better impact on overall survival compared with monotherapy with dacarbazine, but this combination also showed an increase in serious adverse events. Ipilimumab also showed to work in synergy with both the PD-1-inhibitor nivolumab and the granulocyte macrophage colony-stimulating factor (GM-CSF) sargramostim. Combination with sargramostim was also shown to decrease the amount of serious adverse events. Combination with a gp100 peptide vaccine failed to show any positive effects on overall survival. Also prophylactic treatment with budesonide showed no further gain in overall survival. The effect of ipilimumab was found to have a dose-ranging effect, with higher dose treatment having a better effect but also with more serious adverse events.   The results of this literature study showed that ipilimumab has a better effect with higher dose and that it can work in synergy with other agents such as nivolumab and sargramostim. Results also showed that occurring adverse effects during treatment with ipilimumab may be treated with systemic glucocorticoids that did not affect the tumor-killing ability of ipilimumab. These results should be evaluated in bigger studies and with longer follow up time.

Au cours des dernières années, l’immunothérapie a révolutionné le paysage en oncologie. L’anti-CTLA-4 a montré son efficacité sur la survie globale des patients atteints de mélanome métastatique. Cependant, ce traitement présente des limites à son utilisation telles que l'efficacité clinique obtenu chez seulement 20% des patients et la survenue fréquente de colites pouvant être sévères. La recherche de biomarqueurs prédictifs de réponse clinique et/ou de développement de toxicité devient maintenant un enjeu majeur pour sélectionner les patients pouvant avoir un bénéfice à l’utilisation de ces traitements. En partant de l’observation que les colites induites par l’anti-CTLA-4 présentent des similitudes avec les maladies inflammatoires chroniques de l'intestin, nous avons émis l’hypothèse de l’existence d’un microbiote intestinal associé à une dysrégulation du système immunitaire pouvant prédire la réponse clinique et/ou la survenue d’une colite induite par l’anti-CTLA-4. Nous avons montré dans une cohorte de patients atteints de mélanome métastatique et traités par ipilimumab, qu'un microbiote intestinal enrichi en Faecalibacterium et autres Firmicutes est associé à une meilleure survie globale et sans progression ainsi qu'un risque accru de développer une colite. Les patients avec une flore enrichie en Firmicutes présentent également après traitement par ipilimumab, une activation lymphocytaire plus efficace. Par la suite, nous nous sommes intéressés aux métabolites issus du microbiote fécal et leur implication dans la réponse à l'anti-CTLA-4. Le butyrate est le principal métabolite produit par les Firmicutes. Nous avons observé chez la souris, une inhibition de l'efficacité anti-tumorale de l'anti-CTLA-4 lorsqu'elles étaient supplémentées en butyrate. In vivo, nous avons montré que le butyrate inhibe la surexpression sur les cellules dendritiques, des molécules CD80 et CD86 (molécules B7) induite par l'anti-CTLA-4. Cette immaturité des cellules dendritiques entraine un défaut d'activation des lymphocytes T spécifiques d'antigènes dépendant de l'axe CD28/B7 réduisant ainsi l'efficacité anti-tumorale. Chez l'Homme, nous avons valider cette hypothèse en montrant qu'une concentration sérique élevée en butyrate est associée à une diminution de la survie globale et sans progression comparativement aux patients avec un faible niveau de butyrate sérique.Ces travaux mettent en évidence le lien entre la composition du microbiote et les réponses immunologiques au blocage du CTLA-4. Ils apportent une explication sur un lien indirect via le butyrate entre la composition du microbiote intestinal et la réponse anti-tumorale aux immunothérapies. / In the last years, immunotherapy has revolutionized the landscape in oncology. The efficacy of anti-CTLA-4 has been demonstrated by improving overall survival of patients with metastatic melanoma. However, this treatment has limitations to its use such as the clinical efficacy obtained in only 20% of patients and the high incidence of severe colitis. Predictive biomarkers of clinical response and / or toxicity development are mandatory for a better selection of patients who will benefit from this treatment. Based on the observation that anti-CTLA-4-induced colitis has similarities with inflammatory bowel disease, we hypothesized that the gut microbiota associated with dysregulation of the immune system may predict the clinical response and / or occurrence of anti-CTLA-4-induced colitis.In a cohort of patients with metastatic melanoma treated with ipilimumab, we have shown that a gut microbiota enriched with Faecalibacterium and other Firmicutes is associated with a better of overall and progression-free survival as well as an increased risk of developing colitis. Firmicutes-driven microbiota is also associated with an improvement in lymphocyte T activation after ipilimumab treatment. Subsequently, we were interested in microbial metabolites and their involvement in the clinical response to anti-CTLA-4. Butyrate is the main metabolite produced by the Firmicutes. In mice, we observed an inhibition of anti-tumor effect of anti-CTLA-4 in butyrate-supplemented mice. In vivo, we have shown that butyrate inhibits the overexpression on dendritic cells, of CD80 and CD86 molecules (B7molecules) induced by anti-CTLA-4. This immaturity of the dendritic cells leads to a poor signaling of CD28 / B7 axis and activation of antigen-specific T-cells, thereby reducing anti-tumor efficacy. In humans, we validated this hypothesis by showing that a high serum concentration of butyrate is associated with decreased overall and progression-free survival compared to patients with low serum butyrate levels.This studie highlights the link between the composition of gut microbiota and the immunological responses to CTLA-4 blockade. They provide an explanation of an indirect link via butyrate, between the composition of the gut microbiota and the anti-tumor response to immunotherapies.

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Die adaptive Immunantwort wird von T-und B-Lymphozyten realisiert. Nachdem der Antigenrezeptor auf T-Zellen durch die Interaktion mit einem MHC-Peptid Komplex auf APZ getriggert wurde, sind kostimulatorische Moleküle ein zweiter Kontrollpunkt für die Immunantworten interagierender Zellen. Für das Abschalten von ungewollten Immunantworten, z.B. Autoimmunantworten, sind Moleküle der kostimulatorischen Molekülfamilien auf den T- und B-Zellen von außerordentlicher Bedeutung. Ein zentrales kostimulatorisches Molekül ist das Molekül CTLA-4. Wir untersuchten den Einfluss von regulatorischen Zellen auf den Verlauf einer EAE, die durch einen Wechsel von Remission und Rezidiv gekennzeichnet ist. Neben den CD4+CD25+Foxp3+CTLA-4+ T-Zellen konnten wir ebenfalls CD4+CD25-Foxp3+CTLA-4+ T-Zellen in den das Gehirn infiltrierenden Lymphozyten sichtbar machen. Wir fanden gleiche Zahlen an CD4+CD25+ Zellen, die auch intrazellulär CTLA-4 exprimierten, während der akuten Phase und ersten Remission, wobei aber Oberflächen CTLA-4+CD4+ Zellen während der akuten Phase deutlich erhöht waren. Eine Depletion der natürlich vorkommenden CD4+CD25+ Treg Zellen vor dem Auslösen einer EAE führte zu einem schnelleren Krankheitsausbruch und schwererem sekundär progressivem Krankheitsverlauf. Obwohl die erste Remission von der CD4+CD25+ Treg Zelldepletion unbeeinflußt blieb, konnten bereits im ersten Krankheitsschub signifikant erhöhte Antigen spezifische proinflammatorische Zytokine der T-Zellen detektiert werden. Damit wird deutlich, dass der sekundär progressive Verlauf durch CD4+CD25+ Treg Zelldepletion bereits zeitig während des Krankheitsverlaufes eingeleitet wird. Wir konnten CTLA-4 ebenfalls in B-Zellen nachweisen. Die Expression von intrazellulärem und Oberflächen CTLA-4 in aktivierten B-Zellen ist strikt T-Zellen abhängig und hat ihr Maximum 48-72h nach Stimulation in vitro. Durch den Einsatz hochsensitiver Zellanreicherungsverfahren konnte der Nachweis der mRNA für CTLA-4 in den B-Zellen aus T-Zellabhängigen Zellkultursystemen erbracht werden. Die Induktion der mRNA für CTLA-4 kann unter bestimmten Umständen durch CD19 Kreuzvernetzung in B-Zellen erfolgen. Durch den Einsatz von Knochenmarkschimären, in denen CTLA-4 spezifisch nur in B-Zellen deletiert wird, konnte gezeigt werden, dass CTLA-4 in B-Zellen die primäre IgE und IgM und die sekundäre IgM Produktion in Thymus abhängigen Immunantworten steuert. Diese Daten implizieren für alle Thymus abhängigen Immunantworten eine noch komplexere Regulation, bei der CTLA4 in B-Zellen deren Effektorfunktion intrinsisch modulieren kann. / T and B lymphocytes carry out the adaptive immune response. After the antigen receptor on T cells is triggered through interaction with an MHC:peptide complex on APCs, costimulatory molecules are a second checkpoint for immune responses of interacting cells. To terminate unwanted immune responses, such as autoimmune responses, molecules of the costimulatory molecule family on T and B cells are of great importance. A central costimulatory molecule is CTLA-4 (CD152). We investigated the influence of regulatory cells on the course of an EAE, a disease marked through alterations of remission and relapses. Apart from the CD4+CD25+Foxp3+CTLA-4+ T cells we also detected CD4+CD25-Foxp3+CTLA-4+ T cells within the brain-infiltrating lymphocyte population. Furthermore we found similar numbers of CD4+CD25+ cells that also expressed intracellular CTLA-4, during the acute phase and first remission from EAE, whereas surface CTLA-4+CD4+ cells were clearly elevated during the acute phase. The depletion of the natural occurring CD4+CD25+ Treg cells before EAE induction leads to an accelerated disease onset and an increase in disease severity combined with a secondary progressive disease course. Even though the first remission was unaffected by the depletion of CD4+CD25+ Treg cells before disease induction, the antigen specific proinflammatory cytokine production of T cells during the acute phase was already significantly increased. The data show, that the secondary progressive disease course after CD4+CD25+ Treg cell depletion is already determined early during the course of EAE. On a second approach we found CTLA-4 expression as well on B lymphocytes. The expression of intracellular and surface CTLA-4 on activated B cells is strictly T cell dependent and the expression is maximal 48-72h after stimulation in vitro. Through the use of highly sensitive cell sorting strategies we were able to detect the mRNA for CTLA-4 in B cells cultured with activated T cells. CTLA-4 mRNA in B cells is inducible in isolated B cells via crosslinking of CD19 in vitro. We generated bone marrow chimeric mice, in which only B cells were CTLA-4 deficient. With these mice we could show, that CTLA-4 on B cells controls the primary IgE and IgM, as well as the secondary IgM production in thymus dependent immune responses. These data imply a more complex regulation of thymus dependent immune responses, in which CTLA-4 on B cells can modulate B cell effector functions.

Le mélanome métastatique reste un enjeu majeur de santé publique. Les avancées fulgurantes de ces dernières années ont permis d’améliorer la prise en charge thérapeutique, notamment avec l’arrivée des anticorps bloquant ou agonistiques ciblant les molécules de co-inhibition ou de co-stimulation. Cependant, certains patients sont réfractaires à tout traitement. Il est donc nécessaire de mettre en évidence l’importance de certains paramètres immunologiques permettant d’améliorer le suivi des patients de stade III à haut risque de récidive. De plus, il est primordial de découvrir des marqueurs prédictifs associés à la réponse à ces différents traitements immunomodulateurs. Nous avons identifié une association entre une fréquence élevée de CD45RA+CD4+ et de CD3-CD56- au sein des métastases ganglionnaires avec la survenue d’une récidive anticipée.Une forte expression de NKG2D à la surface des lymphocytes T CD8+, une faible proportion de Tregs ou une faible expression de PD-L1 à la surface des T circulants sont associées à une meilleure survie. Aussi, la mise en place d’un test in-vitro étudiant les réactivités fonctionnelles des lymphocytes infiltrant les tumeurs a permis de dégager l’importance de l’expression de CD95/Fas sur les T CD4+ circulants et de CD137/4-1BB sur les T CD8+ circulants dans la prédiction de la réponse à l’ipilimumab (anti-CTLA-4) et à la combinaison ipilimumab + nivolumab (anti-PD-1). Par ailleurs, le pattern d’expression des récepteurs de chimiokines à la surface des lymphocytes T périphériques permet de détecter les localisations métastatiques de mélanome. Cette étude a révélé également l’importance biologique de l’axe CCR9/CCL25 dans l’immunosurveillance naturelle anti-tumorale. / Metastatic melanoma (MM) is an unmet medical need. The development of immune checkpoint blockers (ICB) improved patient’s clinical outcomes. However, some patients still do not respond to these therapies. To adress these issues, we must find some immunological parameters which predict the relapse of high risk resected stage III melanoma patients. Moreover, it is an urgent need to identify some predicting parameters to these ICB. In our studies, high frequencies of CD45RA+CD4+ and CD3-CD56- in metastatic lymph nodes are associated with a short relapse-free survival. Higher expression of NKG2D on CD8 T cells, low Tregs and low PD-L1 expression on circulating T cells are associated with a prolonged overall survival.Furthermore, we designed an in-vitro test to assess intratumor lymphocytes reactivities to ICB and cytokines (IL-2 and IFNα2a). Low expression of CD95/Fas on CD4+ circulating T cells and high expression of CD137/4-1BB on circulating CD8+ T cells are associated with the response to ipilimumab (anti-CTLA-4) and to the combination ipilimumab + nivolumab (anti-PD-1), respectively. In addition, the chemokine receptor pattern expressed at the surface of circulating lymphocytes could predict the metastatic spreading of melanoma. In this last study, we demonstrated the critical role of CCR9/CCL25 pathway in the natural anti-cancer immune surveillance.

Cancer immunotherapy has proven to be challenging as it depends on overcoming multiple mechanisms that mediate immune tolerance to self-antigens. In situ immunization is based on the concept that it is possible to break immune tolerance by inducing tumor cell death in situ in a manner that provides antigen presenting cells such as dendritic cells (DCs) with a wide selection of tumor antigens that can then be presented to the immune system and result in a therapeutic anticancer immune response. Based on recent advances in the understanding of antitumor immunity, we designed a three-step approach to in situ immunization to lymphoma: (1) Inducing immunogenic tumor cell death with the chemotherapeutic drug Doxorubicin (Dox). Dox enhances the expression of "eat-me" signals by dying tumor cells, facilitating their phagocytosis by dendritic cells (DCs). Due to the vesicant activity of Dox, microparticles (MPs) made of PLGA (a biodegradable polymer) can safely deliver Dox intratumorally and are effective vaccine adjuvants; (2) Enhancing antigen presentation and T cell activation using anti-OX40; (3) Sustaining T cell responses by checkpoint blockade using anti-CTLA-4. In vitro, Dox MPs were less cytotoxic to DCs than to B lymphoma cells, did not require internalization by the lymphoma cells, and significantly enhanced phagocytosis of tumor cells by DCs as compared to soluble Dox. In mice, this three-step therapy induced CD4- and CD8-dependent systemic immune responses that enhanced T cell infiltration into distant lymphoma tumors leading to their eradication and significantly improving survival. Our findings demonstrate that systemic antitumor immune responses can be generated locally by three-step therapy and merit further investigation of three-step therapy for immunotherapy of lymphoma patients. Furthermore, we designed another in situ immunization approach using PLGA MPs loaded with both Dox and CpG oligodeoxynucleotides (CpG). The addition of CpG was to further enhance the Dox MP design by including an agent that addresses Step Two in situ, by enhancing tumor antigen presentation by DCs. In vitro, we show that Dox/CpG MPs can kill B and T lymphoma cells and are less toxic to DCs than soluble Dox. In vivo, Dox/CpG MPs combined with anti-CTLA-4 and anti-OX40 generated systemic immune responses that suppressed injected and distant tumors in a murine B lymphoma model, leading to tumor-free mice. The combination regimen was also effective at reducing T cell lymphoma and melanoma tumor burdens. In conclusion, Dox/CpG MPs represent a versatile, efficient and safe tool for in situ immunization that could provide a promising component of immunotherapy for patients with a variety of types of cancer.

Type 1 Diabetes (T1D) is an autoimmune disorder caused by both genetic and environmental factors. The non-obese diabetic (NOD) mouse is one of the best and most commonly studied animal models for T1D. This mouse strain spontaneously develops diabetes through a process that closely resembles the human pathogenesis. More than 20 insulin dependent susceptibility (Idd) loci have been identified in the NOD mouse, contributing to disease susceptibility; however, the contribution of each of the various factors to disease pathogenesis is largely unknown. The aim of this thesis was to identify and functionally characterize candidate genes mediating susceptibility to murine T1D. Cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) is a negative regulator of T-cell activation and has been shown to be associated with autoimmune diseases. Genetic analyses of the NOD mouse have identified the Ctla-4 gene as a major candidate for the Idd5.1 diabetes susceptibility locus and NOD mice have been found to display an impaired expression of CTLA-4 upon anti-CD3 stimulation in vitro. In Paper I, we showed that a novel locus (Ctex) in the distal part of the chromosome 1 together with the Idd3 (Il-2) locus on chromosome 3, constitute the major factors conferring the observed difference in CTLA-4 expression levels. Moreover, we also demonstrated that the defective expression of CTLA-4 in NOD T-cells can in part be overcome by the addition of exogenous interleukin-2 (IL-2). In Paper II, using congenic mice, we confirmed that the Ctex locus contributes to decreased expression of CTLA-4 observed in NOD mice and restricted the region of interest to a 28.8 Mb region containing the Cd3ζ gene. We also demonstrated a phenotypic correlation between strains carrying the NOD versus C57BL/6 alleles of Cd3ζ, respectively and showed that expression of CD3ζ is impaired in activated NOD CD4+ T cells. The NOD allele of the Cd3ζ region was found to confer impaired T cell activation and the defective CD3 signalling could be surpassed by PMA plus ionomycin stimulation supporting the notion of CD3ζ as a prime candidate gene for Ctex. NOD lymphocytes display relative resistance to various apoptosis-inducing signals, which have been proposed to contribute to the pathogenesis of diabetes. Resistance to dexamethasone-induced apoptosis in NOD immature thymocytes has been mapped to the Idd6 locus. In Paper III we restricted the Idd6 locus to an 8 cM region on the telomeric end of chromosome 6 using a set of congenic mice. In addition, we could confirm that the Idd6 region controls apoptosis resistance in immature thymocytes and restricted the control of apoptosis resistance to a 3 cM region within the Idd6 locus. In Paper IV, we further restricted the Idd6 locus to a 3 Mb region and excluded the region controlling the resistance to apoptosis as directly mediating susceptibility to diabetes. We also showed that defective expression of the Lrmp/Jaw1 gene, encoding an endoplasmatic reticulum resident protein, is controlled by the Idd6 locus making it the prime candidate for Idd6.  Together, these results contribute to the identification and functional characterization of candidate genes that may confer susceptibility to T1D in the NOD mouse. These results offer important insights into the pathophysiological processes underlying this disease.

Diabetes mellitus represents a group of metabolic disorders caused by both environmental and genetic factors. The two most common forms of diabetes are type 2 diabetes (T2D) and type 1 diabetes (T1D). T2D is associated with obesity and the disease is caused by insulin resistance and pancreatic b-cell dysfunction. T1D is an autoimmune disease in which the insulin- producing b-cells in the pancreas are destroyed by infiltration of lymphocytes. The aim of this thesis was to identify genes conferring susceptibility to diabetes. This was approached using genetic methods, both linkage and association studies, within the population of northern Sweden. The northern Swedish population is well suited for genetic studies of familial forms of disease, since an internal expansion of the northern Swedish population, coupled with a low frequency of immigration and a high frequency of consanguineous marriages, has resulted in a relatively homogeneous gene pool. This simplified genetic background increases the probability of identifying genes contributing to disease. The family-based material used for the type 2 diabetes studies (papers I and II) consisted of 231 individuals from 59 families originating in northern Sweden. The type 2 diabetes case-control material (papers I and II) consisted of 872 cases and 857 matched controls, all from northern Sweden. In paper I we performed a genome-wide linkage scan, seeking T2D susceptibility loci. Linkage to the previously identified Calpain-10 region was found, however, association studies in the case-control material revealed no association to the CAPN10 gene. Using both the family-based and the case-control material, we were able to confirm the association of polymorphisms in the TCF7L2 gene to T2D in the population of northern Sweden (paper II). CTLA-4 is a negative regulator of T cell activity, belonging to the CD28 co-stimulatory receptor family. Numerous reports, including our own, have associated CTLA-4 variants with T1D as well as other autoimmune diseases, such as autoimmune thyroid disease (AITD). Allelic variation in the 3ÚTR of the CTLA-4 gene was associated to human T1D and this variant has also been suggested to affect the level of mRNA encoding the soluble form of the molecule (sCTLA-4). We confirmed the association of allelic variation in the 3ÚTR of the CTLA-4 gene in a T1D/AITD case-control material from northern Sweden, consisting of 104 individuals with ATID, 149 individuals with T1D and 865 matched controls. However, we were unable to identify any correlation between allelic variants in the 3ÚTR of the CTLA-4 gene and expression of sCTLA-4 (paper III). Based on recently published genome-wide association (GWA) scans, 33 single-nucleotide polymorphisms (SNPs) located within 16 genes were selected for an association analysis in T1D/AITD families from northern Sweden. The T1D/AITD family-based material consisted of 253 cases and 206 healthy individuals from 97 northern Swedish families. Analysis revealed association to T1D for SNPs in PTPN22, COL1A2, IL-2Ra and INS. In addition, SNPs in CTLA-4, IL-2 and C12orf30 were shown to be associated to AITD (paper IV). Together, these results underpin the notion that the population of northern Sweden is well suited for the detection of genes involved in complex diseases. The use of our more restricted patient material, compared to materials used in published GWA scans, enables the discovery of disease associated genes in a more cost effective manner and show that our population is capable of detecting general susceptibility genes.