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Review
. 2021 Aug 20:12:715727.
doi: 10.3389/fimmu.2021.715727. eCollection 2021.

Beyond the Driver Mutation: Immunotherapies in Gastrointestinal Stromal Tumors

Affiliations
Review

Beyond the Driver Mutation: Immunotherapies in Gastrointestinal Stromal Tumors

Matthieu Roulleaux Dugage et al. Front Immunol. .

Abstract

Gastrointestinal stromal tumors (GISTs) are a subtype of soft tissue sarcoma (STS), and have become a concept of oncogenic addiction and targeted therapies.The large majority of these tumors develop after a mutation in KIT or platelet derived growth factor receptor α (PDGFRα), resulting in uncontrolled proliferation. GISTs are highly sensitive to imatinib. GISTs are immune infiltrated tumors with a predominance of tumor-associated macrophages (TAMs) and T-cells, including many CD8+ T-cells, whose numbers are prognostic. The genomic expression profile is that of an inhibited Th1 response and the presence of tertiary lymphoid structures and B cell signatures, which are known as predictive to response to ICI. However, the microtumoral environment has immunosuppressive attributes, with immunosuppressive M2 macrophages, overexpression of indoleamine 2,3-dioxygenase (IDO) or PD-L1, and loss of major histocompatibility complex type 1. In addition to inhibiting the KIT oncogene, imatinib appears to act by promoting cytotoxic T-cell activity, interacting with natural killer cells, and inhibiting the expression of PD-L1. Paradoxically, imatinib also appears to induce M2 polarization of macrophages. There have been few immunotherapy trials with anti-CTLA-4 or anti-PD-L1drugs and available clinical data are not very promising. Based on this comprehensive analysis of TME, we believe three immunotherapeutic strategies must be underlined in GIST. First, patients included in clinical trials must be better selected, based on the identified driver mutation (such as PDGFRα D842V mutation), the presence of tertiary lymphoid structures (TLS) or PD-L1 expression. Moreover, innovative immunotherapeutic agents also provide great interest in GIST, and there is a strong rationale for exploring IDO targeting after disease progression during imatinib therapy. Finally and most importantly, there is a strong rationale to combine of c-kit inhibition with immune checkpoint inhibitors.

Keywords: GIST - gastro intestinal stromal tumor; IDO - indoleamine 2,3-dioxygenase; KIT; PD-L1; imatinib; immunologic response; immunotherapy; macrophages (M1/M2).

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Immunosuppressive microenvironment in GIST is mediated by IDO and M2 macrophages. IDO expression is mediated through Etv4 and KIT activation, which results in an overexpression of IDO. IDO is responsible for a recruitment of regulatory T cells, an inhibition of CD8+ T Cells complementary to a macrophage M2-polarization.
Figure 2
Figure 2
Global characteristics of tumor microenvironment and immunotherapeutic perspectives in GIST. PGFRα: platelet derived growth factor receptor α, SDH, succinate dehydrogenase; NF1, Neurofibrimin 1; NK cell, Natural killer cells; IDO, Indoleamine 2,3-dioxygenase; MHC, Major histocompatibility complex; ICP, Immune checkpoint protein; VEGF, vascular endothelium growth factor; IFN- γ, Interferon- γ; TLS, Tertiary lymphoid structure; PD-1, programmed cell death 1; TIM-3, T-cell immunoglobulin and mucin containing protein-3; LAG-3, Lymphocyte-Activation Gene 3; GITR, Glucocorticoid-Induced TNFR-Related protein; ICOS, Inducible T-cell costimulatory; TIGIT, T cell immunoreceptor with Ig and ITIM domains); BITEs, Bispécific T cell Engager antibodies; ICI, immune checkpoint inhibitors.

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