\
`
`PERGAMON
`
`International Journal of Immunopharmacology 10 "0888# 68(cid:1)090
`
`Review Article
`
`The immunology and immunotherapy of breast cancer]
`an update
`J[W[ Hadden(cid:31)
`University of South Florida College of Medicine\ Division of Immunopharmacology\ Department of Internal Medicine\
`Tampa\ Florida\ U[S[A[
`
`Received 5 April 0887^ accepted 10 September 0887
`
`Abstract
`
`Adenocarcinomas of the breast behave clinically and epidemiologically in ways that show host resistance
`factors are important for outcome in addition to grade and stage of malignancy[ Immune reactivity to
`autologous tumors is indicated by the general presence of lymphoid in_ltration "LI# and regional lymph
`node changes^ however\ these changes predict favorable outcome only in non!metastatic disease[ LI is
`characterized by CD3(cid:27) and CD7(cid:27) tumor in_ltrating lymphocytes re~ecting latent cell!mediated immunity
`"CMI#[ CMI and humoral immune reactivity have been demonstrated to autologous tumor and a variety of
`tumor!associated antigens "TAA# have been implicated including CEA\ HER!1:neu\ MAGE!0\ p42\ T:Tn
`and MUC!0[ Immune incompetence involving CMI is progressive with the stage of breast cancer and is
`prognostically signi_cant[ Immunotherapy of several types has been designed to address this immuno!
`de_ciency and the TAAs involved[
`Animal models have employed drug therapy\ cytokine transfection\ vaccines with autologous tumor\
`cytokines like interferon alpha "IFN!a# and interleukin!1 "IL!1#\ TAA tumor vaccines\ and immunotoxins
`with evidence of tumor regression by immunologic means[
`Immunotherapy of human breast cancer is a rapidly growing experimental area[ Positive results have been
`obtained with natural IFN and interleukins\ particularly in combination strategies "but not with high dose
`recombinant IFN or IL!1#\ with autologous tumor vaccine "but not yet with transfected autologous tumor#^
`with a mucin carbohydrate vaccine "TheratopeTM# in a combination strategy "but not with mucin core
`antigen# and with several
`immunotoxins[ Combination strategies involving immunorestoration\ con!
`trasuppression\ adjuvant\ and immunotoxins are suggested for the future[ (cid:11) 0888 International Society for
`Immunopharmacology[ Published by Elsevier Science Ltd[
`
`(cid:31) Corresponding author[ Tel[] "702# 863!2306^ Fax] "702# 863!1859[
`
`9081!9450:88:,08[99 (cid:11) 0888 International Society for Immunopharmacology[ Published by Elsevier Science Ltd[
`PII] S 9 0 8 1 ! 9 4 5 0 " 8 7 # 9 9 9 6 6 ! 9
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`0[ Introduction
`
`Virtually all breast cancers are adenocarcinomas[ The major subtypes are in_ltrating ductal
`carcinomas "70)#\ medullary carcinoma "5)#\ and lobular carcinoma "4)# "Fisher\ Gregorio +
`Fisher\ 0863#[ Survival in breast cancer correlates with the original size of the tumor\ the extent of
`regional spread\ and the histological features of malignancy[ Alone\ and in combination\ these are
`important prognostic variables^ however\ it has been long known that breast cancer is a disease
`with extreme variability[ From an actuarial standpoint\ breast cancer survival curves\ depending
`upon the stage of the disease and the form of treatment\ take up to 09 years to plateau\ indicating
`variable rates of recurrence irrespective of the form of treatment[ The survival curves for most
`other malignancies reach a plateau within two\ and certainly _ve\ years[ Breast cancer is an
`exceptional disease amongst cancers[ It has been long thought that this variability results from
`important host factors independent of the grade of malignancy and the extent of local!regional
`invasion[
`It is the purpose of this article to summarize the immunologic studies in human breast cancer
`which indicate that breast cancers exhibit several antigens\ are reacted to by the host|s immunity\
`overcome progressively these defenses which then capitulate in generalized immunode_ciency and\
`_nally\ can respond to various forms of immunotherapy with regression[
`This article is abbreviated and the reader is referred to Hadden "0884# for full referencing[
`There are a number of unique epidemiological features of breast cancer which re~ect these host
`factors[ The incidence of non!invasive malignancies determined by mammography is in excess of
`predicted clinical frequency "Fisher\ 0879a#[ Histological detection of additional foci of tumor cells
`in the presence of a malignancy in a pathological specimen has a signi_cant frequency "Baak\ Van
`Dop\ Kurver + Hermans\ 0874#^ however\ it is extremely rare to have two clinical tumors in the
`same breast[ The co!existence of carcinoma in situ in a patient with breast cancer appears to have
`a {surveillance e}ect| and to be associated with signi_cantly improved survival and is thought to
`re~ect immunity to breast cancer antigens "Black\ Zachray\ Hankey + Feuer\ 0885#[
`Also\ it is not uncommon to _nd at autopsy\ foci of malignancy that never made clinical disease[
`In the estimated 39) of patients with involved lymph nodes not removed by surgery\ the recurrence
`rate is not 39) but only 04)\ indicating that these obviously malignant lesions either failed to
`progress or regressed "Fisher\ 0879b#[ Finally\ monoclonal antibodies detect a higher frequency of
`tumor cells in regional nodes and bone marrow than would be expected on the basis of recurrence
`rates "Cote\ Rosen\ Lesser\ Old + Osborne\ 0880^ Osborne + Rosen\ 0883#[ Thus\ persistent
`tumor cells can exist but may not cause recurrence[ Such _ndings indicate that {all cancers do not
`progress to overt lesions| "Fisher\ 0879b#[ This assertion re~ects the notion that the host provides
`an important component to the biology of breast cancer and the actuaries further re~ect this fact[
`If one superimposes the disease!free survival rates and overall survival rates in women with
`breast cancer treated with surgery and radiation\ it is clear that it takes seven years to de_ne the
`plateau in disease!free survival and nine years to de_ne overall survival rates[ If one compares
`these superimposed curves\ it is apparent that once recurrence takes place\ the time between
`recurrence and death progressively increases only a small amount\ indicating that the late recurring
`tumors are only slightly less aggressive than those recurring earlier[ These data indicate that
`di}erent growth rates of the same type of cancer cannot explain the period of clinical latency of
`up to seven years[ This period presumably results from host resistance to tumor growth[
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`Fisher "0879a# has pointed out a serious dilemma in considering chemotherapy after surgery
`and radiation] if\ as collected studies indicate\ 69(cid:1)79) of patients will remain free of disease as a
`result of surgery plus radiation\ should all patients be exposed to a toxic\ expensive therapy for
`the bene_t of 09(cid:1)04) of the patients< While chemotherapy can delay recurrence in early breast
`cancer\ it has only relatively recently been demonstrated to increase modestly 09 year survival
`"Anonymous^ Early Breast Cancer Trialists Collaborative Group\ 0881#^ it has only palliative
`value in advanced metastatic breast cancer[ Recognizing that breast cancer chemotherapy is
`immunosuppressive "Zielinsji\ Muller\ Kubista\ Sta}en + Eibl\ 0889# and will surely impact
`negatively on host resistance mechanisms\ one must ask if immunotherapy can enhance host
`resistance factors and delay or prevent recurrence[
`
`1[ Lymphoid in_ltration and nodal reactivity in breast cancer
`
`Moore and Foote "0838# noted that medullary carcinoma of the breast is generally associated
`with marked lymphoid in_ltration and has a more favorable prognosis[ These observations with
`medullary carcinoma are generally accepted and this lymphocyte reaction appears to re~ect a
`prominent role of humoral immunity with plasma cell in_ltration around the tumor and follicular
`"B cell# hyperplasia in regional lymph nodes[ "Fisher\ Gregorio\ Redmond\ Dekker + Fisher\ 0865^
`Hsu\ Raine + Nayak\ 0870#
`Black\ Kerpe and Speer "0842# were the _rst to observe a correlation between the survival of
`patients with breast cancer and sinus histiocytosis in the axillary nodes[ This favorable prognosis
`was irrespective of histology of the primary tumor\ the presence of nodal metastases\ or age[ In
`these studies\ 50) of the patients with various forms of breast cancer were noted to have sinus
`histiocytosis[ Several studies con_rmed the association of sinus histiocytosis "Hadden\ 0884# with
`favorable prognosis and noted further that chronic in~ammatory changes with hyaline deposition
`and _brosis follow sinus histiocytosis[ This latter in~ammatory condition is associated with nodal
`depletion and increased metastasis tendency[
`Hamlin "0857# formally postulated the importance of host resistance factors in which cellular
`in_ltration in or around the tumor and lymph node changes of follicular hyperplasia\ sinus
`histiocytosis\ and other reactive changes were focused upon[ Sixty!three percent of the 161 patients
`were considered to be positive for host!defense factors and showed a signi_cant improvement of
`survival compared to those considered negative[ Tsakraklides\ Olson\ Kersey and Good "0863#
`presented a retrospective series of 166 cases in which lymph nodes regional to breast cancer
`were designated lymphocyte predominant\ germinal center predominant\ lymphocyte depleted\ or
`unstimulated representing 43\ 06\ 3\ and 14) of the tumors\ respectively[ Ten year survival rates
`were 64\ 43\ 22\ and 28)\ respectively\ indicating that both T and B lymphocyte predominance
`favored survival[
`A subsequent multicenter prospective study "Fisher et al[\ 0865# of 292 patients concluded\ based
`upon only 19 month survival data\ that\ other than sinus histiocytosis\ no nodal changes predicted
`short!term treatment failure[ This publication marked the end of attempts to make meaning of the
`morphology of nodes regional to breast cancer and today seldom are references made to node
`_ndings[
`What can be drawn from the collected _ndings< Lymph nodes regional to in_ltrating ductal
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`carcinomas show lymphocyte dominance "(cid:29)69)# vs unstimulated "(cid:25)29)#[ Despite the lack of
`adequate control data on axillary nodes unrelated to breast cancer\ these _ndings suggest that a
`preponderance are lymphocyte reactive\ this implying immune mechanisms[ The _ndings of sinus
`histiocytosis\ which is marked in up to one!third of patients and present in the majority\ is a _nding
`on which pathologists must vary considerably[ While it probably predicts survival when present
`in uninvolved nodes\ it is a minor factor compared to tumor malignancy grade and the extent of
`nodal involvement and is not useful as a predictor on an individual patient basis[ Unfortunately\
`from an immunological standpoint\ it does not infer any particular mechanism\ only reactivity[
`These collected studies\ based upon morphology alone\ strongly suggest that the reactivity rep!
`resents immunologic response to tumor!associated antigens "TAA#[
`Lymphocyte in_ltration "LI# was noted in human breast cancers in a number of early studies
`before 0863\ but it is di.cult to determine whether medullary carcinoma was distinguished from
`other forms[ Of 02 studies reviewed by Underwood "0872#\ the majority reported a positive
`prognostic association[ Clearly\ a sharpening of focus occurred during this period and it became
`apparent that while medullary cancer is associated with diverse aggregates of lymphoid cells\ the
`majority of the tumors "i[e[ in_ltrating ductal carcinomas# have scattered cells in the stroma
`surrounding the tumor "tumor!associated lymphocytes (cid:2)TALs(cid:3)#\ and to a lesser extent within the
`tumor "tumor!in_ltrating lymphocytes (cid:2)TILs(cid:3)#[ As interest in and as more careful attention to LI
`grew\ its incidence grew[ The most extensive studies report 65) positive for LI "Fisher et al[\ 0863^
`Aaltomaa et al[\ 0881#[
`While the perception and incidence of LI grew in breast cancer of all types\ whether LI is a
`favorable prognostic sign continues to be controversial "cf[ Hadden\ 0883^ O|Sullivan + Lewis\
`0883#[ While several reports suggest LI may not be prognostically signi_cant "Rosen et al[\ 0878^
`Tang et al[\ 0889^ Scholl et al[\ 0883^ Ogmundsdottir\ Petursdottir + Gudmundsdottir\ 0884#\ and
`even associated with poor prognosis\ recent multivariate analyses "Rilke et al[\ 0880^ Aaltomaa et
`al[\ 0881^ Nistico et al[\ 0886#\ show that LI is positively correlated with axillary node status\ tumor
`diameter\ and histological variables\ all negative correlates themselves[ Nevertheless\ LI predicates
`recurrence!free survival "RFS# and overall survival in rapidly proliferating erbB:HER!1:Neu
`positive\ node!negative tumors[ In contrast\ highly curable\ small\ slowly proliferating tumors
`show little or no in_ltrate[ As with sinus histiocytosis\ it seems that tumor!associated lymphocytes
`are a predictor of survival only when the grade and extent of tumor are controlled for as variables[
`In highly malignant\ oncogene!positive tumors they may inhibit growth early but\ once overcome\
`the otherwise poor prognosis associated with the degree of malignancy becomes the overriding
`variable[
`As the LI phenomenon became documented\ attention turned to the type of cell involved in the
`in_ltrates[ Studies "Hadden\ 0884^ O|Sullivan + Lewis\ 0883^ Schondorf et al[\ 0886# showed
`these tumor!associated cells to be T!lymphocytes in the majority with a few B!lymphocytes and
`granulocytic cells including natural killer "NK# cells[ Both CD3(cid:27) and CD7(cid:27) mononuclear cells
`are present in approximately equal numbers[ Both CD3(cid:27) T!cells and macrophages predominate
`in aggregates and CD7(cid:27) T!cells in the isolated stromal cells "Bahn + Desmaraus\ 0872^ Chin et
`al[\ 0882^ O|Sullivan + Lewis\ 0883^ Grekou et al[\ 0885#[ Signi_cant numbers of CD3(cid:28)\ CD05(cid:27)
`macrophages have been observed "Claasen\ van Ravenssway\ Kluin + Fleuren\ 0881^ Pupa\
`Menard\ Andreola + Colnaghi\ 0882^ Scholl et al[\ 0883#\ particularly with erb 1 colony!stimulating
`factor!0 "CSF!0# positive tumors[
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`The controversy around the prognostic signi_cance of LI in breast cancer has produced two
`postulates] one that LI merely re~ects an in~ammatory reaction resulting from tumor!derived
`cytokines and the other that LI represents a defense reaction overridden by metastatic disease[
`Likely\ both explanations are true and that tumor!derived cytokines contribute to the overriding
`of e}ective resistance mechanisms[
`Studies on major histocompatibility complex!related antigen expression "HLA:class I or HLA!
`DR:class II# on tumor!associated lymphocytes and on the tumor itself show that\ in contrast to
`non!malignant breast tissue\ less than half of tumors had high expression of class I or II antigens
`"Maiorana et al[\ 0884#[ Loss of MHC antigens would favor escape from tumor surveillance
`immune responses[ Some tumor!associated lymphocytes are positive for class I\ class II antigens
`and interleukin 1 receptors "IL!1r#\ indicating activation[ Variable correlations exist for lymphocyte
`in_ltration and MHC antigen expression "Hadden\ 0884#[
`Analysis of T!cell receptor "TCR# expression of TALs show most to be an ab TCR!positive^
`however\ gd TCR!positive T cells have been recently observed "Bank et al[\ 0882#^ these gdT!cells
`may be cytotoxic but may also contribute to immune suppression "Seo + Esawa\ 0884#[ Analysis
`of the ab TCR spectrum indicates polyclonality "Durie\ George\ Campbell + Damato\ 0881# i[e[
`reactivity to multiple antigens[ Analysis of cytokine mRNA expression showed low level expression
`which increases with the intensity of in_ltration and is as high as 29) in mucin!positive tumors
`"Vitolo et al[\ 0881#[ These data indicate mixed T!cell in_ltrates occur in a high percentage of
`breast cancers and that the T cells involved show some evidence of activation[
`TILs:TALs from other cancers in general share low level interleukin!1 "IL!1# expression\ little
`or no reactivity to T!cell mitogens like phytohemagglutinin "PHA#\ or in mixed leukocyte culture
`"MLC#\ and little or no cytotoxicty[ These cells\ when grown in IL!1\ restore their proliferative
`and cytotoxicity responses[ To the extent studied\ TALs from breast cancer are similar in showing
`little or no killer cell reactivity\ and low PHA and MLC reactivity "Hadden\ 0884^ O|Sullivan +
`Lewis\ 0883^ Hudson et al[\ 0887#[ In two studies\ breast cancer had TILs which showed increased
`cytokine expression when cultured with autologous tumor cells "Ruppert et al[\ 0880^ Sch!
`wartenruber et al[\ 0881#[ TALs from lymph nodes regional to breast cancer also show reduced
`CD3 ] CD7 ratio\
`increased macrophages\ depressed mitogen responses\ variable cytokine
`expression\ and variable cytotoxic responses "Horny + Horst\ 0875^ Alam\ Clark\ George +
`Campbell\ 0882#[ Nodal TALs have cells which suppress normal lymphoproliferative responses
`"Vose + Moore\ 0868#[ Autologous tumor reactivity of nodal lymphocytes are manifested by
`increased clumping with tumor cells\ enhanced cytokine secretion\ proliferation\ and cytotoxicity
`with in vitro addition of tumor cells "Hadden\ 0884#[
`TILs from breast cancers cloned with IL!1 and\ in some cases\ with autologous tumor\ have
`yielded predominantly CD3(cid:27) T cells with variable but generally low cytotoxicty for autologous
`tumor "Whiteside\ Miescher\ Hurlimann\ Moritta + von Heidner\ 0875^ Belldegrun\ Kasid\ Uppen!
`kamp\ Topalian + Rosenberg\ 0878^ Radrizzani\ Gambacorti!Passerina\ Parmiani + Fossati\ 0878^
`Balch et al[\ 0889^ Skornick\ Topalian + Rosenberg\ 0889^ Yanelli et al[\ 0885#[ In other studies\
`T cells cloned from peripheral blood\ regional lymph nodes\ or pleural e}usions with IL!1 and\ in
`some cases\ with autologous tumor\ yielded CD7(cid:27) T lymphocytes with highly speci_c MHC!
`restricted and unrestricted killing of autologous tumor targets "Vose + Bonnard\ 0871^ Sato\ Sato\
`Takahasi\ Koshiba + Kikuchi\ 0875^ Roberts\ Shipton + Moore\ 0876^ Jerome et al[\ 0880^ Jerome\
`Domenech + Finn\ 0882^ Baxevanis et al[\ 0883^ Dadmarz\ Sgagias\ Rosenberg + Schwart!
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`zentruber\ 0884#[ Under these circumstances\ studies have notably reported cytotoxic CD7(cid:27) T!cell
`lines speci_c for MAGE!0 tumor!associated antigen "Toso et al[\ 0885#\ a HER 1:neu!derived
`peptide "Peoples et al[\ 0884#\ and the mucin MUC!0 gene products "Jerome et al[\ 0880\ 0882#[
`These studies support the notion that TILs are drawn to the tumor by antigen reactivity of the
`TCRs\ are tumor antigen!activated but then suppressed by tumor! or T cell!induced suppressor
`mechanisms[ Tumor reactive T cells from sites distal to the tumor appear more reactive[ The extent
`to which MAGE!0\ HER 1:neu and mucin!related antigens may be central is highly encouraging for
`immunotherapeutic purposes[ Additional studies are needed to determine the antigen reactivities of
`these T!cells from patients with breast cancer[
`
`2[ Immune competence of patients with breast cancer
`
`A number of tests of general immune competence have been applied to breast cancer patients
`at the time of surgery and later with progression "Hadden\ 0884^ Wei + Heppner\ 0885#[
`Early breast cancer patients generally have]
`
`"0# normal skin test responses to recall antigens and dinitrochlorobenzene "DNCB#^
`"1# normal or slightly depressed total and T!lymphocyte counts\ and somewhat decreased
`CD3 ] CD7 T cell ratios^
`"2# normal B!cell numbers and normal IgG\ IgA\ and IgM levels^
`"3# normal or slightly depressed T!lymphocyte proliferative responses to cell mitogens like PHA
`and Concanavalin A "ConA# or to antigen^
`"4# normal NK cell number and function[
`
`With advancing of disease\ these patients show progressive defects involving]
`
`"0# depressed skin test responses^
`"1# decreased total and T!lymphocyte counts^ low CD3 ] CD7 ratios^
`"2# normal B!cell numbers but possibly decreased IgG and increased IgA^
`"3# depressed T!lymphocyte proliferative responses to PHA with evidence of increased suppressor
`cell activity and serum suppressive factors^
`"4# depressed NK and LAK cell killing partially restored in vitro by removal of monocytes or by
`indomethacin to block monocyte prostaglandin "PG# production^
`"5# decreased monocyte function[
`
`These immunologic disturbances are similar to those observed in patients with other cancers
`and depict a progressive cellular immune de_ciency with decreased number and function of T
`lymphocytes and decreased function of monocyte!derived macrophages leading to defective
`delayed!type hypersensitivity "DTH# "hypoergy and anergy#[ Where analysed\ these defects are
`progressive with the stage of disease\ are compounded by radio! and chemotherapy and are
`prognostically signi_cant[ These defects are associated with a variety of immunosuppressive in~u!
`ences relating to tumor products "Stoger et al[\ 0882^ Rosen et al[\ 0885^ Reinerova\ Veselovska\
`Ausch + Rosen\ 0885#\ suppressor lymphocytes "Kuroi\ Sato\ Yamaguchi + Toge\ 0883#\ sup!
`pressor PG!producing monocytes "Baxevanis et al[\ 0882#\ and serum suppressive factors "Stoger
`et al[\ 0882^ Muster!Bloy\ Elsasser!Beile\ Weber\ Monting + von Kleist\ 0885^ Rosen et al[\ 0885#
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`including IL!09 "Merendino\ Arena\ Capozza\ Chillema + Mesiti\ 0885#[ Recent evidence indicate
`that MUC!0 antigen induces apoptosis of T!lymphocytes "Gimmi et al[\ 0885# providing an
`important new insight into mechanisms of escape from immune surveillance by tumors[ Immu!
`notherapy e}orts\ particularly those to immunize patients with breast cancer TAAs as a form of
`treatment will have to contend with this immunode_ciency in order to obtain e}ective tumor
`rejection responses[
`
`3[ Breast tumor antigenicity
`
`In addition to the TIL and TAL studies described in the previous section\ evidence of cellular
`immune reactivity "CMI# to breast cancer related antigens has been developed using autologous
`tumor extracts for testing in vitro with lymphoproliferative responses of peripheral blood lym!
`phocytes\ lymphocytotoxicity\ etc[ and in vivo using skin tests for delayed!type hypersentitivity
`skin tests "Hadden\ 0883^ Elliot\ Head + McCoy\ 0883#[ In studies involving more than 249
`patients\ approximately 49) of the in vitro and 39) of the in vivo tests were reported to be
`positive[ Evidence of serological responses to breast cancer extracts have been reported in over
`39) of patients[
`Historically\ a number of tumor markers have been detected in the serum of breast cancer
`patients and tested for diagnostic purposes "Schwartz\ 0883^ Seregni et al[\ 0886#^ these include
`carcinoma embryonic antigen "CEA#\ tissue polypeptide speci_c antigen "TPS#\ cancer!associated
`serum antigen "CASA#\ mammary serum antigen "MSA#\ mucinous carcinoma antigen "MCA#\
`CA!04!2\ CA!M15\ CA!M18\ and CA!M438[ There seems to be general agreement that] "0# these
`markers measure tumor!derived peptides\ yet their presence on the tumor and in the serum is not
`correlated^ "1# their presence in serum occurs with advanced disease so they are not useful for
`primary diagnostics\ but^ "2# their presence in serum can be used to monitor the e.cacy of
`treatment[
`The identi_cation of the antigens involved in CMI and humoral immune responses to breast
`cancer has been the focus of intense investigation over the last decade[ Many of these markers
`which are de_ned by monoclonal antibodies represent epitopes of mucin!related antigens "e[g[ CA!
`04!2^ MCA^ MSA^ CA!M15^ CA!M18#[ Thus\ CEA\ TPS\ and CA!042 appear to represent three
`distinct groups of markers[ Of greater relevance are those antigens which are present on the tumor
`and re~ect resistance epitopes[
`Carcinoembryonic antigen is expressed on approximately 49) of breast cancers[ Apparently\
`CEA is not naturally immunogenic\ yet peptide epitopes of CEA are making possible immu!
`notherapy approaches "Schlom et al[\ 0885#[ A CEA!adenovirus construct has been employed in
`animal studies and has elicited cellular and humoral immune responses and tumor regression
`"Kantor et al[\ 0881^ Schlom et al[\ 0885#[ CEA peptide!pulsed dendritic cells are e}ective in
`eliciting speci_c cytotoxic T cells in vitro "Alters\ Gadea + Philip\ 0886#\ suggesting another vaccine
`strategy[
`The MAGE antigen series "0(cid:1)6# developed in melanoma using cytotoxic T!cell responses have
`representation in breast cancer with MAGE!0 and 2 being expressed in 19 and 15) of patients\
`respectively "Russo et al[\ 0884#[ Synthetic peptide epitopes of MAGE!2 are capable of eliciting
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`cytotoxic T cells in vitro "Celis et al[\ 0883#\ suggesting their use with or without dentritic cells as
`an immunogen for vaccine therapy[
`The HER!1:neu protooncogene "also known as C!erb B!1# codes for a surface growth factor
`receptor "p074# homologous to the epidermal growth factor receptor[ The function of this protein
`in the malignant process is not known[ In human breast cancer this gene\ without apparent
`mutations\ is overexpressed in up to 29) of patients\ particularly those with the comedo type of
`ductal carcinomas\ and is a highly unfavorable prognostic indicator[ Both spontaneous CMI and
`humoral immune responses to the HER!1:neu protein have been detected in approximately half
`of patients with p074 positive tumors "Pupa et al[\ 0882^ Disis et al[\ 0883#[ A transfected cell line
`expressing HER!1:neu have been shown to be an e}ective immunogen for both CMI and humoral
`immunity in Guinea pigs "Fendly et al[\ 0889#[
`Monoclonal antibodies have been raised to HER!1:neu protein and humanized "e[g[ MoAb
`3D4\ 3D4(cid:1)7\ MDX!109# and have proven active in animal tumor models "Carter\ Rodrigues\
`Lewis\ Figari + Shalaby\ 0883\ 0885^ Repp et al[\ 0884^ Disis + Cheever\ 0886#[
`The MDX!109 antibody has been made dimeric with anti FcyR antibody to make it a binder of
`Fc receptor positive cells\ like granulocytes\ and the tumor for the promotion of antibody!
`dependent cellular cytotoxicity "ADCC# "Carter et al[\ 0883#[ With this dimeric antibody and
`colony!stimulating factor "CSF#\ enhanced human granulocyte killing has been observed in vitro
`against HER!1:neu target cells "Stockmeyer et al[\ 0886#[ Clinical trials have begun with both
`MDX!109 and the dimeric antibody "see immunotherapy section#[
`Thus\ HER!1:neu protein constitutes an important target for both vaccine and immunotoxin
`development of therapy for a subset of breast cancer patients "Disis + Cheever\ 0886#[
`Another breast cancer marker\ the p42 gene\ is thought to function as a suppressor gene for
`tumor metastases and is overexpressed in 46) of breast cancers as a result of gene mutation and
`protein stabilization[ Overexpression of mutated p42 is associated with rapid cell proliferation and
`poor prognosis in breast cancer patients[ p42 protein\ a nuclear antigen\ in the presence of heat
`shock protein "HSP# 69\ is thought to form a complex which is expressed on the cell surface[ Both
`humoral and cellular immunity to p42 peptide have been observed in breast cancer "Crawford\
`Pim + Bulbrook\ 0871^ Schlinchtholz et al[\ 0881^ Tilken et al[\ 0884# and it has been suggested as
`a target for immunotherapy "Ozturk\ Ponchel + Puisieux\ 0881#[ More information is needed
`about this surface antigen and its relevance to tumor rejection[
`Clearly important tumor antigens relate to mucins "McKenzie + Xing\ 0889^ Korczak\ Goss\
`Fernandez\ Baker + Dennis\ 0883^ Xing\ Apostolopoulos\ Trapani\ Prenzoska + Mckenzie\ 0884^
`Peterson + Ceriani\ 0883^ Von Mensdor}!Pouilly et al[\ 0885#[ Mucins are major secretory products
`of breast as well as other epithelial cells "Peterson + Ceriani\ 0883^ Xing et al[\ 0883^ Korczak et
`al[\ 0883^ Miles\ 0886#[ Mucins are secreted glycoproteins found in milk[ MoAbs developed to the
`human milk fat globule "anti!HFMG# identify breast mucin[ Mucins are also expressed on the cell
`surface of breast epithelial cells[ MUC!0 is increased up to 09!fold in breast cancer in contrast to
`MUC!1 which disappears^ MUC!0 is expressed in 89) of breast tumors and when present in high
`levels\ is a indicator of poor prognosis[ In malignancy\ alterations of glycosylation occur so that
`shorter carbohydrate chains are produced allowing the exposure of normally cryptic carbohydrates
`and components of the tandem repeat peptide core segments[ When sialylated\ the carbohydrate
`antigens form STN antigens[ Expression of STN antigens in breast cancer signals poor prognosis[
`Humoral immunity to the saccharide antigens is normal and breast cancer development is
`
`IMMUNOGEN 2153, pg. 8
`Phigenix v. Immunogen
`IPR2014-00676
`
`

`

`J[W[ Hadden:International Journal of Immunopharmacolo‘y 10 "0888# 68(cid:1)090
`
`76
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`associated with a reduction in antibody response in 79)^ conversely\ DTH skin reactions to T!
`antigen are normally negative and breast cancer development is associated with conversion to
`positive in 68) "Springer\ 0873#[ A construct of T:Tna with antigens Keyhole limpet hemocyanin
`"KLH# called TheratopeTM with adjuvant "DetoxTM# and low dose cyclophosphamide has been
`shown to be a potent immunogen in animals and humans and is in clinical trials "Longenecker\
`Reddish\ Koganty + MacLean\ 0884^ Yacyshyn et al[\ 0884^ Springer\ 0884#[
`Both cellular and humoral immune responses have been demonstrated to MUC!0 peptide
`antigen in patients with breast cancer "Kotera\ Fontenot\ Pecher\ Metzger + Finn\ 0883^ Croce\
`Price + Segal!Eiras\ 0884^ Lui et al[\ 0884^ Von Mensdor}!Pouilly\ 0885#[ Both CMI and humoral
`immune responses to carbohydrate and core antigens have been elicited in animal tumor models
`in association with vaccine immunotherapy!induced tumor regression "Denton\ Sekowski + Price\
`0882^ Ding et al[\ 0882^ Ozzello\ DeRosa\ Blank\ Cantell\ Ceriani + Habif\ 0883^ Smorodinsky et
`al[\ 0883^ Peterson + Ceriani\ 0883^ Avichezer et al[\ 0886^ Peterson et al[\ 0886#[ Vaccines based
`on MUC!0 are under development "Apostolopoulos\ McKenzie + Pietersz\ 0885#[
`Monoclonal antibodies have been raised to these mucins and used in many studies on antibody!
`based therapy and immune localization in breast and other mucin positive cancers "Xing et al[\
`0881^ Nuti et al[\ 0881^ Friedman\ Chace\ Trail + Siegall\ 0882^ Siddiki et al[\ 0882^ Xing et al[\
`0883#[
`Mouse mammary tumor virus "MMTV# is a cause of breast cancer in mice[ Genetic evidence in
`humans suggests a phylogenetically!related virus may have entered the human genome long ago
`and is expressed not as a virus but as related DNA and peptide sequences "Acha!Orbea + Palmer\
`0880#[ Thus\ MMTV!related oncogenes may contribute to the causation of human breast cancer[
`Antibodies and CMI to MMTV peptide sequences have been observed in breast cancer patients
`and DNA sequences homologous to proviral sequences "gag\ pol\ env\ LTR# have been found in
`breast cancer tissues "De Ricqles\ Olomucki\ Gosselin + Lideraeau\ 0882^ Black\ Zachrau\ Ashkari
`+ Hankey\ 0878^ Malivanova + Litvinov\ 0889^ Szakacs + Moscinski\ 0880#[ MMTV!related
`peptides expressed on breast cancer cells have also been used to make immunogens for synthetic
`vaccines "Dion\ Knittel + Morneweck\ 0889#[
`Other secreted products of breast cancer may be relevant to immunotherapy[ The demonstration
`of a p04E!like peptide in the serum of breast cancer patients "Stoger et al[\ 0882# may re~ect a
`retrovirus!associated immunosuppressive factor contributive to the generalized defect of cellular
`immunity seen in advanced breast cancer[ Another contributive factor to cancer!induced immu!
`nosuppression is prostaglandin "PG# "Rolland\ Martin\ Jacquemier\ Rolland + Toga\ 0879#[
`Human breast cancers make PGs and extensive evidence supports the immunosuppressive e}ect
`of PG\ particularly on CMI "Young\ 0883#[ The production of PG by breast cancer provides the
`rationale for the use of PG synthesis inhibitors\ like indomethacin\ in immunotherapeutic strategies[
`Human breast cancers