Ann. N.Y. Acad. Sci.

ISSN 0077-8923

A N N A L S O F T H E N E W Y O R K A C A D E M Y O F SC I E N C E S
Special Issue: The Year in Immunology
REVIEW

Regulatory T cells: a potential target in cancer

immunotherapy
Kohei Shitara1 and Hiroyoshi Nishikawa2,3
1
Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan.
2
Division of Cancer Immunology, Research Institute/EPOC, National Cancer Center, Tokyo/Chiba, Japan. 3 Department of
Immunology, Nagoya University Graduate School of Medicine, Nagoya, Japan

Address for correspondence: Hiroyoshi Nishikawa, M.D., Ph.D., Division of Cancer Immunology, Research Institute/EPOC,
National Cancer Center, 6-5-1 Kashiwanoha Kashiwa, Chiba 277-8577, 5-1-1 Tsukiji Chuo-ku, Tokyo 104-0045, Japan.
hnishika@east.ncc.go.jp

Cancer immunotherapy involving blockade of immune checkpoint molecules, such as CTLA-4 and PD-1, has
shown remarkable clinical success across several types of malignancies. However, a fraction of patients experience
disease progression after treatment; thus, exploring resistant mechanisms for immune checkpoint inhibitors and
improving their treatment outcome with additional modalities are of great importance. CD4+ regulatory T (Treg ) cells
characterized by expression of the master regulatory transcription factor FOXP3 are a highly immune-suppressive
subset of CD4+ T cells that maintain immune homeostasis. Several preclinical and clinical studies suggest that
Treg cells hamper immune surveillance against cancer in healthy individuals, prevent the development of effective
antitumor immunity in tumor-bearing patients, and promote tumor progression. Therefore, targeting Treg cells
should be crucial to improving the treatment outcomes of cancer immunotherapy. Several clinical studies directly
or indirectly targeting Treg cells in combination with immune checkpoint inhibitors are ongoing or being planned.
Understanding the characteristics and roles of Treg cells in cancer settings could make disease-specific Treg -targeted
therapy more efficacious and reduce the incidence of immune-related adverse effects mediated by Treg cell inhibition.

Keywords: regulatory T cells; PD-1; PD-L1; CTLA-4; OX40

Introduction tumor-associated macrophages, and regulatory

T cells (Treg cells)), which interfere with antitumor
According to the cancer immunoediting hypoth-
immune responses3,4 (Fig. 1). The potential anti-
esis, less-immunogenic cancer cells are selected
tumor immune responses could be unleashed by
(immune selection), and immunosuppressive
blocking these immunosuppressive machineries or
networks to evade antitumor immune responses
the function of immunosuppressive cells.
are established (immune escape) during cancer
Cancer immunotherapies, including blockade
development in immune-competent hosts.1,2
of immune checkpoint molecules, such as CTLA-4
Clinically apparent cancers therefore harbor
and PD-1, reactivate cytotoxic CD8+ T cells and
several immune-inhibitory mechanisms: decreased
kill cancer cells,5 providing remarkable clinical
expression of cancer antigens and major histo-
efficacy across several cancer types, even in patients
compatibility complex (MHC) class I, resulting
with advanced disease.6–15 Long-term follow-up
in the failure of CD8+ T cells to recognize
in a pooled meta-analysis exhibited long-term
cancer cells; increased expression of various
survival in approximately 20% of patients treated
immunosuppressive molecules (e.g., cytotoxic T
with immune checkpoint inhibitors.16 On the other
lymphocyte–associated antigen-4 (CTLA-4) and
hand, more than half of treated patients do not
programmed cell death ligand 1 (PD-L1)); and
achieve clinical responses, indicating the impor-
induction/recruitment of immunosuppressive cells
tance of identifying biomarkers predicting clinical
(e.g., myeloid-derived suppressor cells (MDSCs),

doi: 10.1111/nyas.13625
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Regulatory T cells in cancer immunity Shitara & Nishikawa

Figure 1. Cancer immunoediting for cancer development: the three phases (3 Es: elimination, equilibrium, escape) of cancer
immunoediting. Abnormal transformed (cancer) cells, which are not controlled by intrinsic mechanisms, are detected and eliminated
by the immune system in the elimination phase (cancer immunosurveillance). In the equilibrium phase, dormant cancer cells with
decreased expression of cancer antigens and major histocompatibility complex class I are selected, and the balance of cancer
development and antitumor immunity enter into an equilibrium. Cancer cells gain immune-suppressive networks to escape attack
from the immune system. Established cancers therefore consist of a wide array of immune-suppressive cells, such as Treg cells,
MDSCs, and tumor-associated macrophages.

responses by exploring antitumor responses or T cells.18–20 Indeed, decreased numbers of FOXP3+

clarifying resistant mechanisms to the current can-
cer immunotherapies for the development of novel
ones. One intriguing case is immune checkpoint
blockade against CTLA-4, which is constitutively
expressed by forkhead box P3 (FOXP3)+ CD4+ Treg
cells and upregulated by CD4+ and CD8+ effector
T cells after activation. It was originally thought that
anti-CTLA monoclonal antibodies (mAbs) would
exhibit antitumor effects via blocking an inhibitory
signal on activated CD4+ and CD8+ effector
T cells and recovering their antitumor activity.17
Recent animal studies using anti-CTLA-4 mAbs
lacking antibody-dependent cellular cytotoxicity
(ADCC) activity revealed the importance of
FOXP3+ CD4+ Treg cell depletion by anti-CTLA-
4 mAbs from tumors to augment antitumor
immunity, rather than direct activation of effector
Treg cells in tumors following anti-CTLA-4 mAb
(ipilimumab, IgG1 subclass) treatment strongly cor-
related with clinical benefit,21 resulting in a potential
biomarker for identifying clinical responders.
Here, we review the current understanding of Treg
cell–mediated immune-suppressive mechanisms in
cancer and the possibility for Treg cell–targeted can-
cer immunotherapy, which can augment antitumor
immune responses, leading to a promising clinical
efficacy, as shown in several preclinical researches as
well as in early-phase clinical studies.
Classification of Treg cells
Treg cells are a highly immune-suppressive fraction
of CD4+ T cells, which were originally reported as
CD25+ CD4+ T cells by Sakaguchi et al.22 and have
been shown to play central roles in maintaining

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Table 1. Classification of FOXP3+ CD4+ T cells
Subset
Fraction I: naive Treg cells
(CD45RA+ FOXP3low CD4+ )
Fraction II: effector Treg cells
(CD45RA– FOXP3high CD4+ )
Fraction III: non-Treg cells
(CD45RA– FOXP3low CD4+ )
self-tolerance.23–26 FOXP3 was reported as the
master regulatory transcription factor for Treg
cells,27–29 because FOXP3 gene mutations induce
Treg cell deficiency, resulting in severe autoimmune
disorders and allergy in both mice and humans.30–32
In various types of cancers, immune-suppressive
cytokines, molecules, and cells constitute the
immunosuppressive tumor microenvironment that
inhibits effective antitumor immunity. Treg cells,
one of the most common immune-suppressive cells
in tumors, suppress antitumor immunity, thereby
promoting cancer progression.23–26
Treg cells are separated into natural/thymic and
peripherally induced Treg cells according to the sites
where they are generated and differentiated.23,33,34
Natural/thymic Treg cells stem from self-reactive
thymocytes in animal models. A fraction of CD4+
CD8– thymocytes receive T cell receptor (TCR)
stimulation by complexes of MHC plus self-peptide
and acquire CD25 expression, through which
IL-2 transmits signals via signal transducer and
activator of transcription 5 to express FOXP3,
resulting in differentiation into Treg cells.25,35
Peripherally induced Treg cells are converted from
conventional T cells by stimulation with TGF-␤
or retinoic acid in animal models.36 However,
FOXP3+ T cells induced from conventional
T cells by in vitro TCR stimulation with TGF-␤
do not gain suppressive function and produce
proinflammatory cytokines in humans.37,38 Several
cytokines or a specific microbiota environment
can reportedly induce Treg cells with a suppressive
function from CD25– CD4+ T cells, but it remains
unclear whether these peripherally induced Treg
cells are functionally stable.25,39,40
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Regulatory T cells in cancer immunity
Phenotype or markers Characteristics
CTLA-4low CD25low
r Weak suppressive activity
CD127low/– r Proliferate and differentiate into effector
Ki-67– Treg cells upon TCR stimulation
CTLA-4high CD25high
r Strong suppressive activity
Ki-67+
r Prone to apoptosis
PD-1+ , TIM-3+ , GITR+
r Tend to increase in peripheral blood with
Fas+ , IL-10+ , TGF-␤+ aging
IL-2+ , IFN-␥ + , IL-17+
r Heterogeneous population
r No suppressive activity
While FOXP3 expression represents the Treg cell
population in mice, to define Treg cells only by
FOXP3 expression is difficult in humans, since
FOXP3 is also upregulated following the acti-
vation of naive T cells, compromising the sup-
pressive function of the entire set of FOXP3+
T cells. Therefore, we established a classification of
human FOXP3+ T cells based on expression lev-
els of FOXP3 and the naive T cell marker CD45RA
that can reflect their immune-suppressive function
(Table 1):33,34 naive Treg cells (nTreg cells: CD45RA+
FOXP3low CD4+ cells), effector Treg cells (eTreg
cells: CD45RA– FOXP3high CD4+ cells), and non-
Treg cells (CD45RA– FOXP3low CD4+ cells). Naive
Treg cells with weak immune-suppressive function
have recently egressed from the thymus and have not
yet been activated in the periphery. Upon TCR stim-
ulation, nTreg cells proliferate and differentiate into
highly immune-suppressive eTreg cells. In contrast,
non-Treg cells do not possess immune-suppressive
function but rather are immune-stimulatory T cells,
producing inflammatory cytokines, such as IFN-␥
and IL-17.34
Suppressive mechanisms of Treg cells
FOXP3 directly suppresses IL-2 gene transcription
and upregulates transcription of CTLA-4 and
CD25. Treg cells exhibit their suppressive activity via
several cellular and humoral mechanisms,23 such as
inhibition of antigen-presenting cell (APC) matu-
ration through the CTLA-4 pathway; consumption
of IL-2 via high-affinity IL-2 receptor expression
with IL-2 receptor ␣-chain CD25; secretion of
inhibitory cytokines, including IL-10, TGF-␤, and
IL-35; degradation of ATP, an important source of
cellular energy; and expression of granzyme and/or
3
Regulatory T cells in cancer immunity Shitara & Nishikawa

Figure 2. Suppressive mechanisms of Treg cells. Treg cells mainly exhibit their suppressive activity through (1) suppression of
antigen-presenting cells through the CTLA-4 pathway, which downmodulates CD80/CD86 expression as a costimulatory signal to
effector T cells; (2) consumption of IL-2 via expression of CD25 (IL-2 receptor ␣-chain); and (3) secretion of inhibitory cytokines,
including IL-10 and TGF-␤, or expression of granzyme and/or perforin, which also downregulate or kill APCs and effector T cells.
TCR, T cell receptor; MHC, major histocompatibility complex.

perforin, which kills effector T cells and APCs.
CTLA-4 engages with B7 molecules on APCs, which
inhibit costimulatory signaling through B7 and
CD28 to effector cells, resulting in the inhibition of
maturation of APCs (Fig. 2).25,26
Treg cells in cancer immunity
Several preclinical animal models indicate the crit-
ical roles of Treg cells in tumor immunity. Treg cell
depletion by anti-CD25 depleting antibody or CD4
depletion in mice prevents tumor growth.41,42 Addi-
tionally, the secondary challenge of B16 melanoma
that does not spontaneously evoke concomitant
immunity, a phenomenon in which the tumor-
bearing host rejects an inoculation of the same
tumor cells at a distant site, was rejected when
Treg cells were depleted by anti-CD4 antibody.43
These results clearly show that Treg cells suppress
antitumor immunity and promote tumor progres-
sion. In clinical samples from several types of can-
cers, proportions of Treg cells are significantly higher
in tumor sites (i.e., tumor-infiltrating lymphocytes
(TILs)) than in peripheral blood.23,33,34 The prog-
nostic impact of high infiltration of Treg cells into
tumors remains controversial in humans,33,44,45 par-
ticularly colorectal cancer, in which high-FOXP3+
T cells are associated with better prognosis. One of
the issues is the inconsistent definition of Treg cells
or the use of FOXP3 as the sole marker for Treg cells
in these reports. We have recently shown that there
are two FOXP3+ CD4+ T cell subpopulations in col-
orectal cancer, and tumor-infiltrating bona fide Treg
cells are indeed associated with poor prognosis,46
suggesting that the proper classification of Treg cells
is important to elucidate their prognostic impact in
each cancer type.
Why are higher populations of Treg cells present
in tumors? Interaction with chemokines and their
receptors is reported to recruit Treg cells into
TILs, such as CCR4 with CCL22, CCR4 with
CCL17, CCR10 with CCL28, and CXCR4 with
CXCL1.25,47–54 In tumors, Treg cells exhibit highly
activated phenotypes, such as high expression of
suppression-related molecules like CTLA-4 and

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Shitara & Nishikawa
TIGIT.33,55 OX40 and GITR, members of the TNF
superfamily expressed by activated T cells, are also
expressed by Treg cells.25,56–62 Tumor-infiltrating
Treg cells are suspected to be activated by a large
number of self-antigens released from tumor cells,63
because Treg cells usually harbor high-affinity TCRs
against self-antigens, which make up a different TCR
repertoire compared with conventional T cells and
are predominantly activated in tumors.56,57
Role of Treg cells in the treatment of
currently approved immune checkpoint
inhibitors
Immune checkpoint molecules, such as CTLA-4
and PD-1, are also expressed by Treg cells. The
anti-CTLA-4 antibody ipilimumab inhibits inter-
actions between Treg cells and APCs.64 Analyses of
anti-CTLA-4 antibodies in mouse models revealed
that their antitumor efficacy was dependent on
the depletion of CTLA-4+ Treg cells in tumors
through ADCC, since the loss of crystallizable
fragment (Fc) function of anti-CTLA-4 mAbs
totally abrogates their antitumor effects.18–20 In
addition, ipilimumab-dependent cell-mediated
cytotoxicity for Treg cells was reportedly evoked by
nonclassical monocytes in melanoma patients.64
Notably, responders to ipilimumab displayed
significantly higher frequencies of peripheral
nonclassical monocytes at baseline and a selective
enrichment in tumor-infiltrating CD68+ CD16+
macrophages compared with nonresponders.64
During chronic viral infection, PD-1 upregulation
by Treg cells enhances the suppression of the
CD8+ T cell response rather than PD-1– Treg
cells.65 PD-1 expression modulates the activation
threshold of T cells, maintaining the balance
between regulatory and effector T cells.66 However,
the correlation of PD-1 expression by Treg cells
in tumors and clinical outcomes after anti-PD-1
blockade therapy remains unclear, which warrants
further investigation using clinical samples.
There are two types of tumor antigens: tumor-
specific antigens, which are either oncogenic viral
proteins or abnormal proteins stemming from
somatic mutations (neoantigens), and tumor-
associated antigens, which are highly or aber-
rantly expressed normal proteins. Several reports
have shown that many neoantigens are associ-
ated with favorable outcomes after treatment with
immune checkpoint inhibitors.67–69 Treg cells can
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Regulatory T cells in cancer immunity
more potently inhibit shared self-antigen–specific
CD8+ T cells compared with nonself-antigen–
specific CD8+ T cells.70 This might explain why
cancers with a lower number of neoantigens, in
which shared self-antigen–specific CD8+ T cells
may mainly contribute to the antitumor effect, do
not respond to immune checkpoint blockade, since
CD8+ T cells are under the control of Treg cell–
mediated immune suppression. However, it needs
to be addressed whether Treg cells contribute to
the resistance to immune checkpoint inhibitors,
although some studies showed that higher expres-
sion of FOXP3 is associated with resistance to
immune checkpoint inhibitors.71 We are currently
conducting a prospective study to examine the
immune phenotype in tumors to clarify the impact
of Treg cells as a resistance mechanism to immune
checkpoint inhibitors with samples from more than
1000 patients (UMIN00001912).
Treg cell–targeted therapy
There are several potential therapies to control
Treg cell suppression directly or indirectly. Some of
the candidates are targeted therapies for previously
mentioned molecules expressed by Treg cells, such as
CD25, CTLA-4, CCR4, OX40, and GITR. Depleting
CD25-expressing lymphocytes potentiated antitu-
mor immune responses, yet other studies failed to
show similar results. This might be due to CD25
expression in other lymphocytes, particularly effec-
tor CD4+ and CD8+ T cells. Additionally, systemic
depletion of Treg cells might increase the risk of caus-
ing autoimmunity. Therefore, selective depletion of
Treg cells in tumors should be developed to aug-
ment antitumor immunity without eliciting delete-
rious autoimmunity. Another strategy is targeting
other immune-suppressive cells or other factors in
the tumor microenvironment that may indirectly
influence Treg cells. Tumor-associated macrophages
or MDSCs produce Treg cell–recruiting chemokines,
such as CCL17 or CCL22. Vascular endothelial
growth factor (VEGF) and TGF-␤ are also immune-
suppressive factors that lead to the activation of Treg
cells. Thus, targeting these factors may indirectly
inhibit Treg cell suppression.
Anti-CD25 antibody
Daclizumab is a humanized mAb with IgG1 iso-
type that binds to the ␣-subunit of the IL-2 receptor
(CD25) and has been approved for the treatment
5
Regulatory T cells in cancer immunity
of patients with relapsed multiple sclerosis. Sequen-
tial treatment with dendritic cell vaccination fol-
lowed by daclizumab for 15 patients with metastatic
melanoma resulted in the depletion of not only Treg
cells but also activated effector cells, thus not induc-
ing the augmented T cell responses.72 In contrast,
in another study of breast cancer patients, admin-
istration of daclizumab followed by vaccination
with multiple tumor-associated peptides reduced
Treg cells and achieved durable, stable disease in six
of 10 patients, with median progression-free sur-
vival (PFS) of 4.8 months.73 No severe immune-
related adverse reaction was observed. Anti-CD25
mAb administration therefore may exhibit different
effects depending on the phase and state of antitu-
mor immune responses.
Anti-CCR4 antibody
Mogamulizumab (KW-0761) is a humanized anti-
human CCR4 mAb with enhanced ADCC activ-
ity that was approved in Japan in 2012 for
the treatment of relapsed or refractory adult
T cell leukemia/lymphoma. CCR4, a receptor for
CCL17 and CCL22, is highly expressed by tumor-
infiltrating Treg cells and is an important chemokine
receptor for Treg cell recruitment into tumors.
Ex vivo depletion of CCR4+ T cells by anti-
CCR4 mAb and subsequent in vitro stimulation
of the depleted cell population with the can-
cer/testis antigen NY-ESO-1 efficiently induced
NY-ESO-1–specific T cells.55 Additionally, in
vivo administration of anti-CCR4 mAb markedly
reduced the Treg cell fraction and augmented
NY-ESO-1–specific CD8+ T cell responses in an
adult T cell leukemia/lymphoma patient whose
leukemic cells expressed NY-ESO-1.55 Therefore,
mogamulizumab was investigated in a phase I trial
as a Treg cell–depleting reagent for solid cancer
patients.74 The results showed that mogamulizumab
at a dose range between 0.1 and 1.0 mg/kg was safe
and well tolerated. Four of 10 patients showed sta-
ble disease over 4 months. FOXP3+ Treg cells in
the peripheral blood during treatment were effi-
ciently depleted, even with the lowest dose of 0.1
mg/kg. Furthermore, the combination of anti-PD1
nivolumab and mogamulizumab is also being inves-
tigated in a Japanese phase I trial for solid tumors.75
No dose-limiting toxicity was observed in patients
enrolled in this dose-escalation study. Preliminary
results in 90 patients in the dose-expansion cohort
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Shitara & Nishikawa
showed confirmed objective responses in several
types of cancers, such as hepatocellular carcinoma
(four of 15, 26.7%), and one partial response and
five cases of stable disease among 15 patients with
pancreatic adenocarcinoma. Drug-related grade
3–4 adverse events occurred in 26%; the most
frequently observed events were skin toxicities,
followed by gastrointestinal toxicities.
Anti-OX40 antibody and anti-GITR antibody
Anti-OX40 antibody (OX86) augmented antitu-
mor immunity in animal models with several
types of cancers, and the antitumor effects were
mainly dependent on the reduction of Treg cells in
tumors. Several phase I trials with OX40 agonis-
tic antibodies, such as MOXR0916 or PF-04518600,
showed modest clinical activity with stable diseases
in some patients, even in combination with PD-1
blockade.76,77 The majority of treatment-related
adverse events were low in severity; a grade 3
pneumonitis was reported with combination of
MOXR091 and an anti-PD-L1 mAb.76 In the PF-
04518600 trial, two previously immunotherapy-
treated patients showed stable disease for more
than 6 months with PF-04518600 single agent
and with enhanced memory T cell proliferation at
0.3 mg/kg.77
In animal models, anti-GITR mAb or GITR lig-
and can inhibit the suppressive activity of Treg cells
and activate effector T cells, resulting in strong
tumor inhibition. Phase I clinical trials evaluating
GITR agonists, such as BMS-986156, AMG 228, and
TRX-518, in solid tumors are ongoing.78–80
IDO-1 inhibitors
Indoleamine 2,3-dioxygenase (IDO) is expressed in
many human cancers, and high IDO expression is
associated with advanced disease stage and tumor
metastases. IDO inhibits the activation of effector
T cells through depletion of the essential amino
acid tryptophan and promotes differentiation
and activation of Treg cells as well as MDSCs
through kynurenine production.81 Epacadostat
(INCB024360) is a potent and selective inhibitor of
IDO1 that showed acceptable feasibility in a first-
in-humans phase I trial.82 Dose-limiting toxicity
occurred at doses greater than 300 mg (grade 3 radi-
ation pneumonitis and fatigue). Prolonged stable
diseases were observed in seven of 52 patients, with
significant dose-dependent reductions in plasma
kynurenine levels and kynurenine/tryptophan
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Shitara & Nishikawa
ratio. Several phase II trials showed promising
activities with combinations of epacadostat and
PD-1 blockade.83,84 In ECHO-202/KEYNOTE-037,
a multicohort phase II study of epacadostat
and pembrolizumab with 244 patients, common
treatment-related toxicities were fatigue (23%); rash
(16%); diarrhea and nausea (7% each); increased
alanine aminotransferase, increased aspar-
tate aminotransferase, and pruritus (6% each); and
pyrexia (5%). Objective response rate (ORR) was
observed across multiple tumor types. Notably,
in nonsmall-cell lung cancer patients who had
fewer than two prior lines of treatment, ORR
was 39%, and that of renal cell cancer patients
was 47%. Currently, the phase III trial ECHO-
301/KEYNOTE-252 is ongoing for malignant
melanoma, and additional phase III studies for
other types of cancers are also planned.
VEGF-targeting therapy
The VEGFA–VEGF receptor 2 (VEGFR2) axis is
known to increase tumor-infiltrating Treg cells
in mice. Selective inhibition of VEGF binding
to VEGFR2 was reportedly effective at control-
ling tumor growth and inhibiting the infiltra-
tion of immune-suppressive cells, such as Treg
cells, MDSCs, and macrophages, with increased
mature dendritic cells.85 Furthermore, expression
of immune checkpoint molecules (PD-1, TIM3,
CTLA-4, and LAG3) on CD8+ T cells was sup-
pressed by treatment with an anti-VEGFA antibody
or anti-tyrosine kinase inhibitors for VEGFR2,86
supporting the use of VEGF blockade in combina-
tion with immune checkpoint inhibitors. A phase
I trial of bevacizumab, an anti-VEGFA mAb, and
atezolizumab, an anti-PD-L1 mAb, showed par-
tial responses in four of 10 patients with renal
cell carcinoma.87 Although the detailed analyses of
immune phenotypes including Treg cells were not
reported, intratumoral CD8+ T cells were increased
following the combination treatment with increased
expression of intratumoral MHC-I, TH 1, and
T effector markers, as well as chemokines, such as
CX3CL1.87 The bevacizumab–atezolizumab com-
bination was further examined in a randomized
phase II study (IMmotion150; NCT01984242) for
renal cell carcinoma in comparison with suni-
tinib or atezolizumab monotherapy.88 A combi-
nation of ramucirumab, an anti-VEGFR2 mAb,
and pembrolizumab, an anti-PD1 mAb, was tested
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Regulatory T cells in cancer immunity
in nonsmall-cell lung cancer and gastric cancer
patients. Thirty percent of patients (n = 27) with
previously treated advanced nonsmall-cell lung can-
cer responded to this combination therapy, and
median PFS was 9.7 months with no new safety
problems.89 Preliminary results of a gastric can-
cer cohort with 41 previously treated patients and
28 chemotherapy-naive patients also showed objec-
tive responses in 7% of pretreated patients and
14% of chemotherapy-naive patients.90 Median PFS
in chemotherapy-naive patients was 5.6 months,
which warrants further evaluation with large cohort
studies. We previously analyzed immune profiles of
TILs with paired samples from primary tumors of
pre- and postramucirumab-treated gastric cancer
patients. The frequency of FOXP3high CD45RAlow
CD4+ Treg (eTreg ) cells was significantly decreased
after ramucirumab therapy compared with that in
baseline (mean 19.5% versus 13.6%).91 In con-
trast, no significant changes were observed in the
frequency of CD8+ T cells (mean 36.7% versus
36.0%), which supports further investigation. Suni-
tinib, a multikinase inhibitor that blocks signals
downstream of VEGFR, improved type 1 T cell
cytokine responses in renal cell carcinoma patients
while reducing Treg cell function.92 A phase I trial
of sunitinib and nivolumab showed a 52% response
rate in renal cell carcinoma patients.93 Neoadjuvant
treatment with sorafenib, another tyrosine kinase
inhibitor, significantly reduced the percentage of
tumor-infiltrating Treg cells (mean 17.3% versus
28.1%) in renal cell carcinoma patients in com-
parison with nontreated patients.94 Lenvatinib, an
oral inhibitor of multiple receptor tyrosine kinases
targeting VEGFR, fibroblast growth factor receptor,
platelet growth factor receptor ␣, RET, and KIT,
also showed a decreased percentage of Treg cells in a
syngeneic mouse model.95 Many clinical studies of
these multikinase inhibitors in combinations with
immune checkpoint inhibitors are currently ongo-
ing (NCT03006887, NCT03406871, NCT02501096,
NCT02133742, and NCT03141177), and immune-
modulatory effects of multikinase inhibitors war-
rant further evaluation with exploratory biomarker
analyses.
PI3K inhibitor and HSP inhibitor
Another means of suppressing Treg cells is target-
ing the phosphoinositide 3-kinase (PI3K) path-
way or heat shock protein (HSP). Isoform-specific
7
Regulatory T cells in cancer immunity
PI3K inhibitors and a PI3K␦-deficient mouse strain
revealed that PI3K␦ is functionally critical in Treg
cells, and coadministration of a PI3K␦ inhibitor
with a tumor antigen–specific vaccine decreased
numbers of Treg cells and augmented antitumor
T cell responses, because PI3K␣ and PI3K␤ are
functionally redundant with PI3K␦ in conventional
T cells but not in Treg cells in animal models, result-
ing in selective depletion of Treg cells.96
HSP70 is a member of the conserved, ubiq-
uitously expressed HSP family and is a major
immunomodulatory molecule. HSP70-treated Treg
cells significantly inhibited the proliferation of
CD25– CD4+ T cells and reduced IFN-␥ and
TNF-␣ production. HSP70 increased secretion of
the suppressor cytokines IL-10 and TGF-␤ from
Treg cells, probably enhancing the suppressive capac-
ity of Treg cells.97 Modulation of Treg cells through
PI3K or HSP warrants further evaluation in clin-
ical studies (NCT02646748, NCT03257722, and
NCT03095781).
Targeting TGF-β
TGF-␤ is overexpressed in various types of
cancers corresponding to tumor stage. TGF-␤
signaling contributes to tumor progression by
promoting metastasis, stimulating angiogenesis,
and suppressing innate and adaptive antitumor
immunity.98 TGF-␤ directly suppresses the effector
function of effector T cells and natural killer cells.
Galunisertib (LY2157299), a type I TGF-␤ receptor
serine/threonine kinase inhibitor, reportedly
augmented the antitumor effects of anti-CTLA-4
mAbs with enhanced CD8+ T cell/Treg cell ratios in
melanoma tissues and suppressed IDO expression
by dendritic cells in the tumor-draining lymph
nodes.99 Currently, combinations of galunisertib
and anti-PD-1 mAb are being investigated in
clinical trials (NCT02423343 and NCT02734160).
Additionally, a phase I trial of a bifunctional fusion
protein targeting PD-L1 and TGF-␤ (M7824,
MSB0011359C) in advanced solid tumors is
ongoing.100
Local treatments
One of the issues in Treg cell–targeted therapy is sys-
temic autoimmune adverse effects. Therefore, local
treatment to target Treg cells is an efficient approach
without systemic toxicities. Photodynamic therapy
(PDT) by selective photosensitization of cancer cells
and subsequent laser application resulted in local
8 Ann. N.Y. Acad. Sci. xxxx (2018) 1–12 
Shitara & Nishikawa
tumor necrosis. Local treatment with PDT abro-
gated the suppressive capacity of peripheral Treg
cells in treated patients with esophageal cancer.101
Additionally, a preclinical study showed that CD25-
targeted near-infrared photoimmunotherapy selec-
tively depletes Treg cells, thereby activating CD8+ T
cells and natural killer cells.102
Future perspectives
Treg cells have been shown to play critical roles
in tumor immunity, becoming a promising ther-
apeutic target of cancer immunotherapy. However,
their contribution to current cancer immunother-
apy has not been fully determined. Detailed analy-
ses of immune phenotypes in tumors before, during,
and after treatment with cancer therapy are urgently
required. Deeper understanding of disease-specific
Treg cells, particularly their development, mainte-
nance, and function, could make disease-specific
Treg cell–targeted therapy more effective, resulting
in an improvement of efficacy and decrease of side
effects related to cancer immunotherapy.
Competing interests
The authors declare no competing interests.
References
1. Dunn, G.P., A.T. Bruce, H. Ikeda, et al. 2002. Cancer immu-
noediting: from immunosurveillance to tumor escape. Nat.
Immunol. 3: 991–998.
2. Schreiber, R.D., L.J. Old & M.J. Smyth. 2011. Cancer immu-
noediting: integrating immunity’s roles in cancer suppres-
sion and promotion. Science 331: 1565–1570.
3. Pardoll, D.M. 2012. The blockade of immune checkpoints
in cancer immunotherapy. Nat. Rev. Cancer 12: 252–264.
4. Zou, W. & L. Chen. 2008. Inhibitory B7-family molecules
in the tumour microenvironment. Nat. Rev. Immunol. 8:
467–477.
5. Wei, S.C., J.H. Levine, A.P. Cogdill, et al. 2017. Distinct
cellular mechanisms underlie anti-CTLA-4 and anti-PD-1
checkpoint blockade. Cell 170: 1120–1133.
6. Hodi, F.S., S.J. O’Day, D.F. McDermott, et al. 2010.
Improved survival with ipilimumab in patients with
metastatic melanoma. N. Engl. J. Med. 363: 711–723.
7. Topalian, S.L., F.S. Hodi, J.R. Brahmer, et al. 2012. Safety,
activity, and immune correlates of anti-PD-1 antibody in
cancer. N. Engl. J. Med. 366: 2443–2454.
8. Robert, C., G.V. Long, B. Brady, et al. 2015. Nivolumab in
previously untreated melanoma without BRAF mutation.
N. Engl. J. Med. 372: 320–330.
9. Brahmer, J., K.L. Reckamp, P. Baas, et al. 2015. Nivolumab
versus docetaxel in advanced squamous-cell non-small-cell
lung cancer. N. Engl. J. Med. 373: 123–135.
C 2018 New York Academy of Sciences.
Shitara & Nishikawa
10. Borghaei, H., L. Paz-Ares, L. Horn, et al. 2015. Nivolumab
versus docetaxel in advanced nonsquamous non-small-cell
lung cancer. N. Engl. J. Med. 373: 1627–1639.
11. Ansell, S.M., A.M. Lesokhin, I. Borrello, et al. 2015.
PD-1 blockade with nivolumab in relapsed or refractory
Hodgkin’s lymphoma. N. Engl. J. Med. 372: 311–319.
12. Larkin, J., V. Chiarion-Sileni, R. Gonzalez, et al. 2015.
Combined nivolumab and ipilimumab or monotherapy
in untreated melanoma. N. Engl. J. Med. 373: 23–34.
13. Motzer, R.J., B. Escudier, D.F. McDermott, et al. 2015.
Nivolumab versus everolimus in advanced renal-cell car-
cinoma. N. Engl. J. Med. 373: 1803–1813.
14. Ferris, R.L., G. Blumenschein, Jr., J. Fayette, et al. 2016.
Nivolumab for recurrent squamous-cell carcinoma of the
head and neck. N. Engl. J. Med. 375: 1856–1867.
15. Kang, Y.K., N. Boku, T. Satoh, et al. 2017. Nivolumab
in patients with advanced gastric or gastro-oesophageal
junction cancer refractory to, or intolerant of, at least
two previous chemotherapy regimens (ONO-4538-12,
ATTRACTION-2): a randomised, double-blind, placebo-
controlled, phase 3 trial. Lancet 390: 2461–2471.
16. Topalian, S.L., M. Sznol, D.F. McDermott, et al. 2014. Sur-
vival, durable tumor remission, and long-term safety in
patients with advanced melanoma receiving nivolumab.
J. Clin. Oncol. 32: 1020–1030.
17. Lenschow, D.J., Y. Zeng, J.R. Thistlethwaite, et al. 1992.
Long-term survival of xenogeneic pancreatic islet grafts
induced by CTLA4lg. Science 257: 789–792.
18. Bulliard, Y., R. Jolicoeur, M. Windman, et al. 2013. Acti-
vating Fc ␥ receptors contribute to the antitumor activities
of immunoregulatory receptor-targeting antibodies. J. Exp.
Med. 210: 1685–1693.
19. Selby, M.J., J.J. Engelhardt, M. Quigley, et al. 2013. Anti-
CTLA-4 antibodies of IgG2a isotype enhance antitumor
activity through reduction of intratumoral regulatory T
cells. Cancer Immunol. Res. 1: 32–42.
20. Simpson, T.R., F. Li, W. Montalvo-Ortiz, et al. 2013. Fc-
dependent depletion of tumor-infiltrating regulatory T
cells co-defines the efficacy of anti -CTLA-4 therapy against
melanoma. J. Exp. Med 201: 1695–1710.
21. Hodi, S.F., M. Butler, D.A. Oble, et al. 2008. Immunologic
and clinical effects of antibody blockade of cytotoxic T
lymphocyte-associated antigen 4 in previously vaccinated
cancer patients. Proc. Natl. Acad. Sci. USA 105: 3005–3010.
22. Sakaguchi, S., N. Sakaguchi, M. Asano, et al. 1995.
Immunologic self-tolerance maintained by activated T cells
expressing IL-2 receptor ␣-chains (CD25). Breakdown of a
single mechanism of self-tolerance causes various autoim-
mune diseases. J. Immunol. 155: 1151–1164.
23. Sakaguchi, S., M. Miyara, C.M. Costantino, et al. 2010.
Foxp3+ regulatory T cells in the human immune system.
Nat. Rev. Immunol 10: 490–500.
24. Wing, K. & S. Sakaguchi. 2010. Regulatory T cells exert
checks and balances on self tolerance and autoimmunity.
Nat. Immunol. 11: 7–13.
25. Takeuchi, Y. & H. Nishikawa. 2016. Roles of regula-
tory T cells in cancer immunity. Int. Immunol. 28: 401–
409.
Ann. N.Y. Acad. Sci. xxxx (2018) 1–12 
C 2018 New York Academy of Sciences.
Regulatory T cells in cancer immunity
26. Togashi, Y. & H. Nishikawa. 2017. Regulatory T cells: molec-
ular and cellular basis for immunoregulation. Curr. Top.
Microbiol. Immunol. 410: 3–27.
27. Fontenot, J.D., M.A. Gavin, A.Y. Rudensky, et al. 2003.
Foxp3 programs the development and function of
CD4+ CD25+ regulatory T cells. Nat. Immunol. 4: 330–336.
28. Hori, S., T. Nomura & S. Sakaguchi. 2003. Control of regu-
latory T cell development by the transcription factor Foxp3.
Science 299: 1057–1061.
29. Khattri, R., R. Khattri, T. Cox, et al. 2003. An essential
role for Scurfin in CD4+ CD25+ T regulatory cells. Nat.
Immunol. 4: 337–342.
30. Bennett, C.L., J. Christie, F. Ramsdell, et al. 2001. The
immune dysregulation, polyendocrinopathy, enteropathy,
X-linked syndrome (IPEX) is caused by mutations of
FOXP3. Nat. Genet. 27: 20–21.
31. Wildin, R.S., F. Ramsdell, J. Peake, et al. 2001. X-linked
neonatal diabetes mellitus, enteropathy and endocrinopa-
thy syndrome is the human equivalent of mouse scurfy.
Nat. Genet. 27: 18–20.
32. Brunkow, M.E., E.W. Jeffery, K.A. Hjerrild, et al. 2001. Dis-
ruption of a new forkhead/winged-helix protein, scurfin,
results in the fatal lymphoproliferative disorder of the
scurfy mouse. Nat. Genet. 27: 68–73.
33. Nishikawa, H. & S. Sakaguchi. 2014. Regulatory T cells in
cancer immunotherapy. Curr. Opin. Immunol. 27: 1–7.
34. Miyara, M., Y. Yoshioka, A. Kitoh, et al. 2009. Functional
delineation and differentiation dynamics of human CD4+
T cells expressing the FoxP3 transcription factor. Immunity
30: 899–911.
35. Jordan, M.S., A. Boesteanu, A.J. Reed, et al. 2001. Thymic
selection of CD4+ CD25+ regulatory T cells induced by an
agonist self-peptide. Nat. Immunol. 2: 301–306.
36. Coombes, J.L., K.R. Siddiqui, C.V. Arancibia-Cárcamo,
et al. 2007. A functionally specialized population of
mucosal CD103+ DCs induces Foxp3+ regulatory T cells
via a TGF-beta and retinoic acid-dependent mechanism.
J. Exp. Med. 204: 1757–1764
37. Walker, M.R., B.D. Carson, G.T. Nepom, et al. 2005. De novo
generation of antigen-specific CD4+ CD25+ regulatory T
cells from human CD4+ CD25– cells. Proc. Natl. Acad. Sci.
USA 102: 4103–4108.
38. Tran, D.Q., H. Ramsey, E.M. Shevach, et al. 2007. Induc-
tion of FOXP3 expression in naive human CD4+ FOXP3 T
cells by T-cell receptor stimulation is transforming growth
factor-beta dependent but does not confer a regulatory
phenotype. Blood 110: 2983–2990.
39. Atarashi, K., T. Tanoue, K. Oshima, et al. 2013. Treg induc-
tion by a rationally selected mixture of Clostridia strains
from the human microbiota. Nature 500: 232–236.
40. Hsu, P., B. Santner-Nanan, M. Hu, et al. 2015. IL-10 poten-
tiates differentiation of human induced regulatory T cells
via STAT3 and Foxo1. J. Immunol. 195: 3665–3674.
41. Onizuka, S., I. Tawara, J. Shimizu, et al. 1999. Tumor rejec-
tion by in vivo administration of anti-CD25 (interleukin-2
receptor ␣) monoclonal antibody. Cancer Res. 59: 3128–
3133.
42. Shimizu, J., S. Yamazaki & S. Sakaguchi. 1999. Induction
of tumor immunity by removing CD25+ CD4+ T cells: a
9
Regulatory T cells in cancer immunity
common basis between tumor immunity and autoimmu-
nity. J. Immunol. 163: 5211–5218.
43. Turk, M.J., J.A. Guevara-Patiño, G.A. Rizzuto, et al. 2004.
Concomitant tumor immunity to a poorly immunogenic
melanoma is prevented by regulatory T cells. J. Exp. Med.
200: 771–782.
44. Fridman, W.H., F. Pagès, C. Sautès-Fridman, et al. 2012.
The immune contexture in human tumours: impact on
clinical outcome. Nat. Rev. Cancer 12: 298–306.
45. Sato, E., S.H. Olson, J. Ahn, et al. 2005. Intraepithe-
lial CD8+ tumor-infiltrating lymphocytes and a high
CD8+ /regulatory T cell ratio are associated with favorable
prognosis in ovarian cancer. Proc. Natl. Acad. Sci. USA 102:
18538–18543.
46. Saito, T., H. Nishikawa, H. Wada, et al. 2016. Two
FOXP3+ CD4+ T cell subpopulations distinctly control the
prognosis of colorectal cancers. Nat. Med. 22: 679–684.
47. Gobert, M., I. Treilleux, N. Bendriss-Vermare, et al. 2009.
Regulatory T cells recruited through CCL22/CCR4 are
selectively activated in lymphoid infiltrates surrounding
primary breast tumors and lead to an adverse clinical out-
come. Cancer Res. 69: 2000–2009.
48. Svensson, H., V. lofsson, S. Lundin, et al. 2012. Accumu-
lation of CCR4+ CTLA-4 FOXP3+ CD25(hi) regulatory T
cells in colon adenocarcinomas correlate to reduced acti-
vation of conventional T cells. PLoS One 7: e30695.
49. Watanabe, Y., F. Katou, H. Ohtani, et al. 2009. Tumor-
infiltrating lymphocytes, particularly the balance between
CD8+ T cells and CCR4+ regulatory T cells, affect the
survival of patients with oral squamous cell carcinoma.
Oral Surg. Oral. Med. Oral Pathol. Oral Radiol. Endod. 109:
744–752.
50. Ishida, T., T. Ishii, A. Inagaki, et al. 2006. Specific recruit-
ment of CC chemokine receptor 4-positive regulatory T
cells in Hodgkin lymphoma fosters immune privilege. Can-
cer Res. 66: 5716–5722.
51. Curiel, T.J., G. Coukos, L. Zou, et al. 2004. Specific recruit-
ment of regulatory T cells in ovarian carcinoma fosters
immune privilege and predicts reduced survival. Nat. Med.
10: 942–949
52. Facciabene, A., X. Peng, I.S. Hagemann, et al. 2011. Tumour
hypoxia promotes tolerance and angiogenesis via CCL28
and T(reg) cells. Nature 475: 226–230.
53. Wei, S., I. Kryczek, R.P. Edwards, et al. 2007. Interleukin-
2 administration alters the CD4+ FOXP3+ T-cell pool
and tumor trafficking in patients with ovarian carcinoma.
Cancer Res. 67: 7487–7494.
54. Tan, M.C., P.S. Goedegebuure, B.A. Belt, et al. 2009. Dis-
ruption of CCR5-dependent homing of regulatory T cells
inhibits tumor growth in a murine model of pancreatic
cancer. J. Immunol. 182: 1746–1755.
55. Sugiyama, D., H. Nishikawa, Y. Maeda, et al. 2013. Anti-
CCR4 mAb selectively depletes effector-type FoxP3+ CD4+
regulatory T cells, evoking antitumor immune responses
in humans. Proc. Natl. Acad. Sci. USA 110: 17945–
17950.
56. Hindley, J.P., C. Ferreira, E. Jones, et al. 2011. Analysis of
the T-cell receptor repertoires of tumor-infiltrating con-
ventional and regulatory T cells reveals no evidence for
10 Ann. N.Y. Acad. Sci. xxxx (2018) 1–12 
Shitara & Nishikawa
conversion in carcinogen-induced tumors. Cancer Res. 71:
736–746.
57. Sainz-Perez, A., A. Lim, B. Lemercier, et al. 2012. The T-
cell receptor repertoire of tumor-infiltrating regulatory T
lymphocytes is skewed toward public sequences. Cancer
Res. 72: 3557–3569.
58. Shimizu, J., S. Yamazaki, T. Takahashi, et al. 2002. Stimu-
lation of CD25+ CD4+ regulatory T cells through GITR
breaks immunological self-tolerance. Nat. Immunol. 3:
135–142.
59. Jensen, S.M., L.D. Maston, M.J. Gough, et al. 2010. Signal-
ing through OX40 enhances antitumor immunity. Semin.
Oncol. 37: 524–532.
60. Griseri, T., M. Asquith, C. Thompson, et al. 2010. OX40 is
required for regulatory T cell-mediated control of colitis.
J. Exp. Med. 207: 699–709.
61. Hirschhorn-Cymerman, D., G.A. Rizzuto, T. Merghoub,
et al. 2009. OX40 engagement and chemotherapy com-
bination provides potent antitumor immunity with con-
comitant regulatory T cell apoptosis. J. Exp. Med. 206:
1103–1116.
62. Schaer, D.A., A.D. Cohen & J.D. Wolchok, et al. 2010. Anti-
GITR antibodies—potential clinical applications for tumor
immunotherapy. Curr. Opin. Investig. Drugs 11: 1378–
1386.
63. Nishikawa, H., T. Kato, I. Tawara, et al. 2005. Definition
of target antigens for naturally occurring CD4+ CD25+
regulatory T cells. J. Exp. Med. 201: 681–686.
64. Romano, E., M. Kusio-Kobialka, P.G. Houkas, et al. 2015.
Ipilimumab-dependent cell-mediated cytotoxicity of reg-
ulatory T cells ex vivo by nonclassical monocytes in
melanoma patients. Proc. Natl. Acad. Sci USA 112: 6140–
6145.
65. Park, H.J., J.S. Park, Y.H. Jeong, et al. 2015. PD-1 upregu-
lated on regulatory T cells during chronic virus infection
enhances the suppression of CD8+ T cell immune response
via the interaction with PD-L1 expressed on CD8+ T cells.
J. Immunol. 194: 5801–5811.
66. Zhang, B., S. Chikuma, S. Hori, et al. 2016. Nonoverlapping
roles of PD-1 and FoxP3 in maintaining immune tolerance
in a novel autoimmune pancreatitis mouse model. Proc.
Natl. Acad. Sci. USA 113: 8490–8495.
67. Snyder, A., V. Makarov, T. Merghoub, et al. 2014.
Genetic basis for clinical response to CTLA-4 blockade in
melanoma. N. Engl. J. Med. 371: 2189–2199.
68. Rizvi, N.A., M.D. Hellmann, A. Snyder, et al. 2015. Cancer
immunology. Mutational landscape determines sensitivity
to PD-1 blockade in non-small cell lung cancer. Science
348: 124–128.
69. Anagnostou, V., K.N. Smith, P.M. Forde, et al. 2017. Evolu-
tion of neoantigen landscape during immune checkpoint
blockade in non-small cell lung cancer. Cancer Discov. 7:
264–276.
70. Maeda, Y., H. Nishikawa, D. Sugiyama, et al. 2014. Detec-
tion of self-reactive CD8+ T cells with an anergic phenotype
in healthy individuals. Science 346: 1536–1540.
71. Haratani, K., H. Hayashi, T. Tanaka, et al. 2017. Tumor
immune microenvironment and nivolumab efficacy in
EGFR mutation-positive non-small cell lung cancer based
C 2018 New York Academy of Sciences.
Shitara & Nishikawa
on T790M status after disease progression during EGFR-
TKI treatment. Ann. Oncol. 28: 1532–1539.
72. Jacobs, J.F., C.J. Punt, W.J. Lesterhuis, et al. 2010. Dendritic 84.
cell vaccination in combination with anti-CD25 mono-
clonal antibody treatment: a phase I/II study in metastatic
melanoma patients. Clin. Cancer Res. 16: 5067–5078.
73. Rech, A.J., R. Mick, S. Martin, et al. 2012. CD25 blockade 85.
depletes and selectively reprograms regulatory T cells in
concert with immunotherapy in cancer patients. Sci. Transl.
Med. 4: 134ra62.
74. Kurose, K., Y. Ohue, H. Wada, et al. 2015. Phase Ia study 86.
of FoxP3+ CD4 Treg depletion by infusion of a humanized
anti-CCR4 antibody, KW-0761, in cancer patients. Clin.
Cancer Res. 21: 4327–4336. 87.
75. Yamamoto, N., K. Muro, H. Ishii, et al. 2017. Anti-CC-
chemokine receptor 4 (CCR4) antibody mogamulizumab
(Moga) and nivolumab (Nivo) combination phase I study
in patients with advanced or metastatic solid tumors. Ann. 88.
Oncol. 28(Suppl._ 5): v605–v649.
76. Infante, J.R., A.R. Hansen, M.J. Pishvaian, et al. 2016.
A phase lb dose escalation study of the OX40 ago-
nist MOXR0916 and the PD-L1 inhibitor atezolizumab
in patients with advanced solid tumors. J. Clin. Oncol. 89.
34(Suppl.): abstract No. 101.
77. Hamid, O., J.A. Thompson, A. Diab, et al. 2016. First in
human (FIH) study of an OX40 agonist monoclonal anti-
body (mAb) PF-04518600 (PF-8600) in adult patients (pts)
with select advanced solid tumors: preliminary safety and 90.
pharmacokinetic (PK)/pharmacodynamic results. J. Clin.
Oncol. 34(Suppl.; abstr 3079).
78. Siu, L.L., N. Steeghs, T. Meniawy, et al. 2017. Pre-
liminary results of a phase I/IIa study of BMS-986156
(glucocorticoid-induced tumor necrosis factor receptor– 91.
related gene [GITR] agonist), alone and in combination
with nivolumab in pts with advanced solid tumors. J. Clin.
Oncol. 35(Suppl.): abstract No. 104.
79. Tran, B., R.D. Carvajal, A. Marabelle, et al. 2017. Dose
92.
escalation results from a first-in-human, phase 1 study of
the glucocorticoid-induced TNF receptor-related protein
(GITR) agonist AMG 228 in patients (Pts) with advanced
solid tumors. J. Clin. Oncol. 35(Suppl.): abstract No.
93.
2521.
80. Koon, H.B., D.R. Shepard, T. Merghoub, et al. 2016.
First-in-human phase 1 single-dose study of TRX-518, an
anti-human glucocorticoid-induced tumor necrosis fac-
tor receptor (GITR) monoclonal antibody in adults with
94.
advanced solid tumors. J. Clin. Oncol. 34(Suppl.): abstract
No. 3017.
81. Holmgaard, R.B., D. Zamarin, Y. Li, et al. 2015. Tumor-
expressed IDO recruits and activates MDSCs in a Treg-
dependent manner. Cell Rep. 13: 412–424. 95.
82. Beatty, G.L., P.J. O’Dwyer, J. Clark, et al. 2017. First-in-
human phase I study of the oral inhibitor of indoleamine
2,3-dioxygenase-1 epacadostat (INCB024360) in patients
with advanced solid malignancies. Clin. Cancer Res. 23: 96.
3269–3276.
83. Hamid, O., T.M. Bauer, A.I. Spira, et al. 2017. Safety
of epacadostat 100 mg bid plus pembrolizumab 200 mg 97.
Q3W in advanced solid tumors: phase 2 data from ECHO-
Ann. N.Y. Acad. Sci. xxxx (2018) 1–12 
C 2018 New York Academy of Sciences.
Regulatory T cells in cancer immunity
202/KEYNOTE-037. J. Clin. Oncol. 35(Suppl.): abstract No.
3012.
Perez, R.P., M.J. Riese, K.D. Lewis, et al. 2017. Epacadostat
plus nivolumab in patients with advanced solid tumors:
preliminary phase I/II results of ECHO-204. J. Clin. Oncol.
35(Suppl.): abstract No. 3003.
Roland, C.L., K.D. Lynn, J.E. Toombs, et al. 2009. Cytokine
levels correlate with immune cell infiltration after anti-
VEGF therapy in preclinical mouse models of breast cancer.
PLoS One 4: e7669.
Voron, T., O. Colussi, E. Marcheteau, et al. 2015. VEGF-A
modulates expression of inhibitory checkpoints on CD8+
T cells in tumors. J. Exp. Med. 212: 139–148.
Wallin, J.J., J.C. Bendell, R. Funke, et al. 2016.
Atezolizumab in combination with bevacizumab enhances
antigen-specific T-cell migration in metastatic renal cell
carcinoma. Nat. Commun. 7: 12624.
McDermott, D., M. Huseni, B. Rini, et al. 2017. Molec-
ular correlates of differential response to atezolizumab ±
bevacizumab vs sunitinib in a phase II study in untreated
metastatic renal cell carcinoma patients. Cancer Res. 77(13
Suppl.): abstract No. CT081. NCT01984242.
Herbst, R.S., J. Martin-Liberal, E. Calvo, et al. 2017. Previ-
ously treated advanced NSCLC cohort from a multi-disease
phase 1 study of ramucirumab (R) plus pembrolizumab
(P): efficacy and safety data. Ann. Oncol. 28(Suppl._ 2):
ii28–ii51.
Chau, I., J.C. Bendell, E. Calvo, et al. 2017. Ramucirumab
(R) plus pembrolizumab (P) in treatment naive and previ-
ously treated advanced gastric or gastroesophageal junction
(G/GEJ) adenocarcinoma: a multi-disease phase I study.
J. Clin. Oncol. 35(Suppl.): abstract No. 4046.
Togashi, Y., Y. Tada, D. Kotani, et al. 2018. Immunological
impact of ramucirumab on tumor microenvironment in
advanced gastric cancer. J. Clin. Oncol. 36: (Suppl 5S; abstr
98).
Finke, J.H., B. Rini, J. Ireland, et al. 2008. Sunitinib reverses
type-1 immune suppression and decreases T-regulatory
cells in renal cell carcinoma patients. Clin. Cancer Res. 14:
6674–6682.
Amin, A., E.R. Plimack, J.R. Infante, et al. 2014. Nivolumab
(anti-PD-1; BMS-936558, ONO-4538) in combination
with sunitinib or pazopanib in patients (pts) with
metastatic renal cell carcinoma (mRCC). J. Clin. Oncol.
32(Suppl.): abstract No. 5010.
Desar, I.M., J.H. Jacobs, C.A. Hulsbergen-vandeKaa, et al.
2011. Sorafenib reduces the percentage of tumour infiltrat-
ing regulatory T cells in renal cell carcinoma patients. Int.
J. Cancer 129: 507–512.
Kato, Y., X. Bao, S. Macgrath, et al. 2016. Lenvatinib mesi-
late (LEN) enhanced antitumor activity of a PD-1 blockade
agent by potentiating Th1 immune response. Ann. Oncol.
27: 1–14.
Ali, K., D.R. Soond, R. Pineiro, et al. 2014. Inactivation of
PI(3)K p110␦ breaks regulatory T-cell-mediated immune
tolerance to cancer. Nature 510: 407–411.
Wachstein, J., S. Tischer, C. Figueiredo, et al.
2012. HSP70 enhances immunosuppressive function of
11
Regulatory T cells in cancer immunity
CD4+ CD25+ FoxP3+ T regulatory cells and cytotoxicity
in CD4+ CD25– T cells. PLoS One 7: e51747.
98. Wrzesinski, S.H., Y.Y. Wan & R.A. Flavell. 2007. Trans-
forming growth factor-␤ and the immune response: impli-
cations for anticancer therapy. Clin. Cancer Res. 13:
5262–5270.
99. Hanks, B.A., A. Holtzhausen, K. Evans, et al. 2014. Com-
binatorial TGF-␤ signaling blockade and anti-CTLA-4
antibody immunotherapy in a murine BRAFV600E-
PTEN–/– transgenic model of melanoma. J. Clin. Oncol.
32(Suppl.): abstract No. 3011.
100. Gulley, J.L., C.R. Heery, J. Schlom, et al. 2017. Preliminary
results from a phase 1 trial of M7824 (MSB0011359C), a
12 Ann. N.Y. Acad. Sci. xxxx (2018) 1–12 
Shitara & Nishikawa
bifunctional fusion protein targeting PD-L1 and TGF-␤, in
advanced solid tumors. J. Clin. Oncol. 35(Suppl.): abstract
No. 3006.
101. Reginato, E., J. Lindenmann, C. Langner, et al. 2014.
Photodynamic therapy downregulates the function of
regulatory T cells in patients with esophageal squa-
mous cell carcinoma. Photochem. Photobiol. Sci. 13: 1281–
1289.
102. Sato, K., N. Sato, B. Xu, et al. 2016. Spatially selec-
tive depletion of tumor-associated regulatory T cells with
near-infrared photoimmunotherapy. Sci. Transl. Med. 8:
352ra110.
C 2018 New York Academy of Sciences.