Abstract
The immune system involves a complex interplay between the host and its environment. Cancer cell growth requires immune tolerance in order to avoid rejection, this occurs despite tumour recognition by innate and adaptive immune components. As our understanding of the immune system and immunosurveillance improves, so too does our understanding of the complex mechanisms involved in tumour growth and local immunosuppression. Recent advances in tumour immunology and immunotherapy have lead to the development of an array of novel therapies with unprecedented efficacy in multiple tumour types, particularly in patients with metastatic melanoma. This review describes these advances in our understanding of the tumour-host interaction and discusses potential implications for patient care in the perioperative period.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Thomas L. Cellular and humoral aspects of the hypersensitive states. New York: Hoeber-Harper; 1959.
Burnet M. The processes of control. Br Med J. 1957;1:779–86.
Cheever MA, et al. The prioritization of cancer antigens: a national cancer institute pilot project for the acceleration of translational research. Clin Cancer Res. 2009;15(17):5323–37.
Porta MD, et al. Dendritic cells and vascular endothelial growth factor in colorectal cancer: correlations with clinicobiological findings. Oncology. 2005;68(2–3):276–84.
Steinman RM, Hawiger D, Nussenzweig MC. Tolerogenic dendritic cells. Annu Rev Immunol. 2003;21:685–711.
Restifo NP, Dudley ME, Rosenberg SA. Adoptive immunotherapy for cancer: harnessing the T cell response. Nat Rev Immunol. 2012;12(4):269–81.
Gyorki DE, et al. The delicate balance of melanoma immunotherapy. Clin Transl Immunology. 2013;2(8):e5.
• Schreiber RD, Old LJ, Smyth MJ. Cancer immunoediting: integrating immunity’s roles in cancer suppression and promotion. Science. 2011;331(6024):1565–70. This review defines the role of immune editing in tumorigenesis.
Curiel TJ, et al. Specific recruitment of regulatory T cells in ovarian carcinoma fosters immune privilege and predicts reduced survival. Nat Med. 2004;10(9):942–9.
Savage PA, Leventhal DS, Malchow S. Shaping the repertoire of tumor-infiltrating effector and regulatory T cells. Immunol Rev. 2014;259(1):245–58.
Gattinoni L, et al. Adoptive immunotherapy for cancer: building on success. Nat Rev Immunol. 2006;6(5):383–93.
Naito Y, et al. CD8+ T cells infiltrated within cancer cell nests as a prognostic factor in human colorectal cancer. Cancer Res. 1998;58(16):3491–4.
Piersma SJ, et al. High number of intraepithelial CD8+ tumor-infiltrating lymphocytes is associated with the absence of lymph node metastases in patients with large early-stage cervical cancer. Cancer Res. 2007;67(1):354–61.
Nakano O, et al. Proliferative activity of intratumoral CD8(+) T-lymphocytes as a prognostic factor in human renal cell carcinoma: clinicopathologic demonstration of antitumor immunity. Cancer Res. 2001;61(13):5132–6.
Mahmoud SM, et al. Tumor-infiltrating CD8+ lymphocytes predict clinical outcome in breast cancer. J Clin Oncol. 2011;29(15):1949–55.
Fortes C, et al. Tumor-infiltrating lymphocytes predict cutaneous melanoma survival. J Transl Med. 2015;13:2066.
Denkert C, et al. Tumor-associated lymphocytes as an independent predictor of response to neoadjuvant chemotherapy in breast cancer. J Clin Oncol. 2010;28(1):105–13.
Pardoll DM, Topalian SL. The role of CD4+ T cell responses in antitumor immunity. Curr Opin Immunol. 1998;10(5):588–94.
Antony PA, et al. CD8+ T cell immunity against a tumor/self-antigen is augmented by CD4+ T helper cells and hindered by naturally occurring T regulatory cells. J Immunol. 2005;174(5):2591–601.
Williams LM, Rudensky AY. Maintenance of the Foxp3-dependent developmental program in mature regulatory T cells requires continued expression of Foxp3. Nat Immunol. 2007;8(3):277–84.
Beyer M, Schultze JL. Regulatory T cells in cancer. Blood. 2006;108(3):804–11.
Chaudhary B, et al. Phenotypic alterations, clinical impact and therapeutic potential of regulatory T cells in cancer. Expert Opin Biol Ther. 2014;14(7):931–45.
Halvorsen EC, Mahmoud SM, Bennewith KL. Emerging roles of regulatory T cells in tumour progression and metastasis. Cancer Metastasis Rev. 2014;33(4):1025–41.
Kohrt HE, et al. Profile of immune cells in axillary lymph nodes predicts disease-free survival in breast cancer. PLoS Med. 2005;2(9):e284.
Gooden MJ, et al. The prognostic influence of tumour-infiltrating lymphocytes in cancer: a systematic review with meta-analysis. Br J Cancer. 2011;105(1):93–103.
• Galon J, et al. Type, density, and location of immune cells within human colorectal tumors predict clinical outcome. Science. 2006;313(5795):1960–4. This seminal paper highlighted the key prognostic significance of tumour infiltration by immune cells.
Schwartz RH. T cell anergy. Annu Rev Immunol. 2003;21:305–34.
Schietinger A, Greenberg PD. Tolerance and exhaustion: defining mechanisms of T cell dysfunction. Trends Immunol. 2014;35(2):51–60.
Pardoll DM. The blockade of immune checkpoints in cancer immunotherapy. Nat Rev Cancer. 2012;12(4):252–64.
Karasar P, Esendagli G. T helper responses are maintained by basal-like breast cancer cells and confer to immune modulation via upregulation of PD-1 ligands. Breast Cancer Res Treat. 2014;145(3):605–14.
Velu V, et al. Enhancing SIV-specific immunity in vivo by PD-1 blockade. Nature. 2009;458(7235):206–10.
Flies DB, et al. Blockade of the B7-H1/PD-1 pathway for cancer immunotherapy. Yale J Biol Med. 2011;84(4):409–21.
Hirano F, et al. Blockade of B7-H1 and PD-1 by monoclonal antibodies potentiates cancer therapeutic immunity. Cancer Res. 2005;65(3):1089–96.
Brahmer JR, et al. Safety and activity of anti-PD-L1 antibody in patients with advanced cancer. N Engl J Med. 2012;366(26):2455–65.
Taube JM, et al. Colocalization of inflammatory response with B7-h1 expression in human melanocytic lesions supports an adaptive resistance mechanism of immune escape. Sci Transl Med. 2012;4(127):127ra37.
Blank C, Gajewski TF, Mackensen A. Interaction of PD-L1 on tumor cells with PD-1 on tumor-specific T cells as a mechanism of immune evasion: implications for tumor immunotherapy. Cancer Immunol Immunother. 2005;54(4):307–14.
Ghiotto M, et al. PD-L1 and PD-L2 differ in their molecular mechanisms of interaction with PD-1. Int Immunol. 2010;22(8):651–60.
Talmadge JE, Donkor M, Scholar E. Inflammatory cell infiltration of tumors: Jekyll or Hyde. Cancer Metastasis Rev. 2007;26(3–4):373–400.
Hagemann T, et al. Enhanced invasiveness of breast cancer cell lines upon co-cultivation with macrophages is due to TNF-alpha dependent up-regulation of matrix metalloproteases. Carcinogenesis. 2004;25(8):1543–9.
Eccles SA, Alexander P. Macrophage content of tumours in relation to metastatic spread and host immune reaction. Nature. 1974;250(5468):667–9.
Serafini P, Borrello I, Bronte V. Myeloid suppressor cells in cancer: recruitment, phenotype, properties, and mechanisms of immune suppression. Semin Cancer Biol. 2006;16(1):53–65.
Stewart TJ, Smyth MJ. Improving cancer immunotherapy by targeting tumor-induced immune suppression. Cancer Metastasis Rev. 2011;30(1):125–40.
Zea AH, et al. Arginase-producing myeloid suppressor cells in renal cell carcinoma patients: a mechanism of tumor evasion. Cancer Res. 2005;65(8):3044–8.
de Waal Malefyt R, Yssel H, de Vries JE. Direct effects of IL-10 on subsets of human CD4+ T cell clones and resting T cells. Specific inhibition of IL-2 production and proliferation. J Immunol. 1993;150(11):4754–65.
Gallina G, et al. Tumors induce a subset of inflammatory monocytes with immunosuppressive activity on CD8+ T cells. J Clin Invest. 2006;116(10):2777–90.
Parmiani G, et al. Cytokines in cancer therapy. Immunol Lett. 2000;74(1):41–4.
Stewart TJ, Smyth MJ. Chemokine-chemokine receptors in cancer immunotherapy. Immunotherapy. 2009;1(1):109–27.
• Shankaran V, et al. IFNgamma and lymphocytes prevent primary tumour development and shape tumour immunogenicity. Nature. 2001;410(6832):1107–11. This seminal paper highlights the role of the immune response in shaping an evolving tumour.
Dunn GP, et al. Cancer immunoediting: from immunosurveillance to tumor escape. Nat Immunol. 2002;3(11):991–8.
Ohtani H. Focus on TILs: prognostic significance of tumor infiltrating lymphocytes in human colorectal cancer. Cancer Immun. 2007;7:4.
Siddiqui SA, et al. Tumor-infiltrating Foxp3-CD4+ CD25 + T cells predict poor survival in renal cell carcinoma. Clin Cancer Res. 2007;13(7):2075–81.
Kolbeck PC, et al. The relationships among tumor-infiltrating lymphocytes, histopathologic findings, and long-term clinical follow-up in renal cell carcinoma. Mod Pathol. 1992;5(4):420–5.
Templeton AJ, McNamara MG, Šeruga B, et al. Prognostic role of neutrophil-to-lymphocyte ratio in solid tumors: a systematic review and meta-analysis. J Natl Cancer Inst. 2014;106(6):dju124.
Paramanathan A, Saxena A, Morris DL. A systematic review and meta-analysis on the impact of pre-operative neutrophil lymphocyte ratio on long term outcomes after curative intent resection of solid tumours. Surg Oncol. 2014;23(1):31–9.
Aguirre-Ghiso JA. Models, mechanisms and clinical evidence for cancer dormancy. Nat Rev Cancer. 2007;7(11):834–46.
Koebel CM, et al. Adaptive immunity maintains occult cancer in an equilibrium state. Nature. 2007;450(7171):903–7.
Teng MW, et al. Opposing roles for IL-23 and IL-12 in maintaining occult cancer in an equilibrium state. Cancer Res. 2012;72(16):3987–96.
Mittal D, et al. New insights into cancer immunoediting and its three component phases–elimination, equilibrium and escape. Curr Opin Immunol. 2014;27:16–25.
Rabson A. Really essential medical immunology. 2nd ed. Oxford UK: Blackwell Publishing Ltd.; 2005.
Vesely MD, et al. Natural innate and adaptive immunity to cancer. Annu Rev Immunol. 2011;29:235–71.
Fourcade J, et al. PD-1 is a regulator of NY-ESO-1-specific CD8+ T cell expansion in melanoma patients. J Immunol. 2009;182(9):5240–9.
Egberts F, et al. Metastatic melanoma of unknown primary resembles the genotype of cutaneous melanomas. Ann Oncol. 2014;25(1):246–50.
Quaglino P, et al. Vitiligo is an independent favourable prognostic factor in stage III and IV metastatic melanoma patients: results from a single-institution hospital-based observational cohort study. Ann Oncol. 2010;21(2):409–14.
Bhatia S, Tykodi SS, Thompson JA. Treatment of metastatic melanoma: an overview. Oncology (Williston Park). 2009;23(6):488–96.
• Rosenberg SA, et al. Observations on the systemic administration of autologous lymphokine-activated killer cells and recombinant interleukin-2 to patients with metastatic cancer. N Engl J Med. 1985;313(23):1485–92. This was the first study to identify a use T cell modulation to achieve a tumour response.
Atkins MB, et al. High-dose recombinant interleukin-2 therapy in patients with metastatic melanoma: long-term survival update. Cancer J Sci Am. 2000;6(Suppl 1):S11–4.
• Sharma P, Allison JP. The future of immune checkpoint therapy. Science. 2015;348(6230):56–61. This review provides clear perspective of a rapidly evolving field.
Azuma M, et al. B70 antigen is a second ligand for CTLA-4 and CD28. Nature. 1993;366(6450):76–9.
Krummel MF, Allison JP. CD28 and CTLA-4 have opposing effects on the response of T cells to stimulation. J Exp Med. 1995;182(2):459–65.
Peggs KS, Quezada SA, Allison JP. Cancer immunotherapy: co-stimulatory agonists and co-inhibitory antagonists. Clin Exp Immunol. 2009;157(1):9–19.
•• Robert C, et al. Ipilimumab plus dacarbazine for previously untreated metastatic melanoma. N Engl J Med. 2011;364(26):2517–26. This was the first trial to demonstrate a survival benefit in patients with metastatic disease in the first line setting.
Prieto PA, et al. CTLA-4 blockade with ipilimumab: long-term follow-up of 177 patients with metastatic melanoma. Clin Cancer Res. 2012;18(7):2039–47.
Yang JC, et al. Ipilimumab (anti-CTLA4 antibody) causes regression of metastatic renal cell cancer associated with enteritis and hypophysitis. J Immunother. 2007;30(8):825–30.
Hodi FS, et al. Immunologic and clinical effects of antibody blockade of cytotoxic T lymphocyte-associated antigen 4 in previously vaccinated cancer patients. Proc Natl Acad Sci USA. 2008;105(8):3005–10.
van den Eertwegh AJ, et al. Combined immunotherapy with granulocyte-macrophage colony-stimulating factor-transduced allogeneic prostate cancer cells and ipilimumab in patients with metastatic castration-resistant prostate cancer: a phase 1 dose-escalation trial. Lancet Oncol. 2012;13(5):509–17.
Ahmadzadeh M, et al. Tumor antigen-specific CD8 T cells infiltrating the tumor express high levels of PD-1 and are functionally impaired. Blood. 2009;114(8):1537–44.
Robert C, Schachter J, Long GV, et al. Pembrolizumab versus Ipilimumab in Advanced Melanoma. N Engl J Med. 2015.
Postow MA, Chesney J, Pavlick AC, et al. Nivolumab and Ipilimumab versus Ipilimumab in Untreated Melanoma. N Engl J Med 2015.
Snyder A, et al. Genetic basis for clinical response to CTLA-4 blockade in melanoma. N Engl J Med. 2014;371(23):2189–99.
Tumeh PC, et al. PD-1 blockade induces responses by inhibiting adaptive immune resistance. Nature. 2014;515(7528):568–71.
Shahabi V, et al. Immune-priming of the tumor microenvironment by radiotherapy: rationale for combination with immunotherapy to improve anticancer efficacy. Am J Clin Oncol. 2015;38(1):90–7.
Knisely JP, et al. Radiosurgery for melanoma brain metastases in the ipilimumab era and the possibility of longer survival. J Neurosurg. 2012;117(2):227–33.
Postow MA, et al. Immunologic correlates of the abscopal effect in a patient with melanoma. N Engl J Med. 2012;366(10):925–31.
Therasse P, et al. New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J Natl Cancer Inst. 2000;92(3):205–16.
Eisenhauer EA, et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 2009;45(2):228–47.
Hamid O. Kinetics of response to ipilimumab (MDX-010) in patints with stage 3/4 melanoma. J Clin Oncol. 2007;25(18S):8252.
Wolchok JD, et al. Guidelines for the evaluation of immune therapy activity in solid tumors: immune-related response criteria. Clin Cancer Res. 2009;15(23):7412–20.
Postow MA. Current options and future directions in the systemic treatment of metastatic melanoma. J Community Support Oncol. 2014;12(1):20–6.
Gogas H, et al. Prognostic significance of autoimmunity during treatment of melanoma with interferon. N Engl J Med. 2006;354(7):709–18.
Phan GQ, et al. Factors associated with response to high-dose interleukin-2 in patients with metastatic melanoma. J Clin Oncol. 2001;19(15):3477–82.
Carthon BC, et al. Preoperative CTLA-4 blockade: tolerability and immune monitoring in the setting of a presurgical clinical trial. Clin Cancer Res. 2010;16(10):2861–71.
Neeman E, Ben-Eliyahu S. Surgery and stress promote cancer metastasis: new outlooks on perioperative mediating mechanisms and immune involvement. Brain Behav Immun. 2013;30(Suppl):S32–40.
Hiller J, Brodner G, Gottschalk A. Understanding clinical strategies that may impact tumour growth and metastatic spread at the time of cancer surgery. Best Pract Res Clin Anaesthesiol. 2013;27(4):427–39.
Horowitz M, et al. Exploiting the critical perioperative period to improve long-term cancer outcomes. Nat Rev Clin Oncol. 2015;12(4):213–26.
Exadaktylos AK, et al. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology. 2006;105(4):660–4.
Kim R, et al. Tumor-driven evolution of immunosuppressive networks during malignant progression. Cancer Res. 2006;66(11):5527–36.
Uotila P. The role of cyclic AMP and oxygen intermediates in the inhibition of cellular immunity in cancer. Cancer Immunol Immunother. 1996;43(1):1–9.
Landmann R. Beta-adrenergic receptors in human leukocyte subpopulations. Eur J Clin Invest. 1992;22(Suppl 1):30–6.
Ben-Eliyahu S, et al. Suppression of NK cell activity and of resistance to metastasis by stress: a role for adrenal catecholamines and beta-adrenoceptors. NeuroImmunoModulation. 2000;8(3):154–64.
Martinet L, Poupot R, Fournie JJ. Pitfalls on the roadmap to gammadelta T cell-based cancer immunotherapies. Immunol Lett. 2009;124(1):1–8.
Mantovani A, Sica A. Macrophages, innate immunity and cancer: balance, tolerance, and diversity. Curr Opin Immunol. 2010;22(2):231–7.
Costa C, et al. Cyclo-oxygenase 2 expression is associated with angiogenesis and lymph node metastasis in human breast cancer. J Clin Pathol. 2002;55(6):429–34.
Usman MW, et al. Chemopreventive effects of aspirin at a glance. Biochim Biophys Acta. 2015;1855(2):254–63.
Sloan EK, et al. The sympathetic nervous system induces a metastatic switch in primary breast cancer. Cancer Res. 2010;70(18):7042–52.
Lutgendorf SK, et al. Stress-related mediators stimulate vascular endothelial growth factor secretion by two ovarian cancer cell lines. Clin Cancer Res. 2003;9(12):4514–21.
Magnon C, et al. Autonomic nerve development contributes to prostate cancer progression. Science. 2013;341(6142):1236361.
van der Bij GJ, et al. The perioperative period is an underutilized window of therapeutic opportunity in patients with colorectal cancer. Ann Surg. 2009;249(5):727–34.
Roche-Nagle G, et al. Antimetastatic activity of a cyclooxygenase-2 inhibitor. Br J Cancer. 2004;91(2):359–65.
Thaker PH, et al. Chronic stress promotes tumor growth and angiogenesis in a mouse model of ovarian carcinoma. Nat Med. 2006;12(8):939–44.
Zheng Y, et al. Application of perioperative immunonutrition for gastrointestinal surgery: a meta-analysis of randomized controlled trials. Asia Pac J Clin Nutr. 2007;16(Suppl 1):253–7.
Marik PE, Zaloga GP. Immunonutrition in high-risk surgical patients: a systematic review and analysis of the literature. J Parenter Enteral Nutr. 2010;34(4):378–86.
Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. 1996;334(19):1209–15.
Beilin B, et al. Effects of mild perioperative hypothermia on cellular immune responses. Anesthesiology. 1998;89(5):1133–40.
Frank SM, et al. The catecholamine, cortisol, and hemodynamic responses to mild perioperative hypothermia. A randomized clinical trial. Anesthesiology. 1995;82(1):83–93.
Kavanagh T, Buggy DJ. Can anaesthetic technique effect postoperative outcome? Curr Opin Anaesthesiol. 2012;25(2):185–98.
Cata JP, et al. Inflammatory response, immunosuppression, and cancer recurrence after perioperative blood transfusions. Br J Anaesth. 2013;110(5):690–701.
Schriemer PA, Longnecker DE, Mintz PD. The possible immunosuppressive effects of perioperative blood transfusion in cancer patients. Anesthesiology. 1988;68(3):422–8.
Amato A, Pescatori M. Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane Database Syst Rev. 2006;1:CD005033.
Krarup PM, et al. Anastomotic leak increases distant recurrence and long-term mortality after curative resection for colonic cancer: a nationwide cohort study. Ann Surg. 2014;259(5):930–8.
Mirnezami A, et al. Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg. 2011;253(5):890–9.
Acknowledgments
Dr. Bernhard Riedel wishes to thank Drs. Donal Buggy, Vijaya Gottumukkala and Erica Sloan for their kind assistance in the development of this issue and the reviewing of the article.
Author information
Authors and Affiliations
Corresponding author
Additional information
This article is part of the Topical Collection on Cancer Anesthesia.
Rights and permissions
About this article
Cite this article
Koirala, R., Gyorki, D. Targeting the Immune System for Cancer Therapy: Lessons for Perioperative Management?. Curr Anesthesiol Rep 5, 257–267 (2015). https://doi.org/10.1007/s40140-015-0111-z
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40140-015-0111-z