<Oncology Frontier>: What are the definitions of immunoscore and immunoprofile? How do these two concepts relate and differ with each other?

　　《肿瘤瞭望》：请您介绍一下免疫评分（immunoscore）和免疫特征（immunoprofile）这两个概念，它们之间有何关联和差异？

　　Dr Fox: Immunoscore is the analysis or the evaluation of CD3+ cells and CD8+ cells on the invasive margin and in the center of the tumor. It grades the numbers and the frequencies of those phenotypes of cells in the tumor. Right now， it is only being used in colon cancer in the primary resected tumor sample. Immunoprofiling is a more complex analysis which includes more than just CD3+ and CD8+ cells but can include many other markers. Several groups， including our own， are evaluating as many as fifty markers to determine in an exploratory way， the right markers to characterize the immune response and suppressive mechanisms that are operational at the tumor site. The contrast is that one is relatively simple and straightforward looking at the influx of cytotoxic T-cells， and the other is one where you are evaluating the cytotoxic T-cell population and frequency but also looking at other markers that may relate to suppressive mechanisms or to alternative effector pathways.

　　Fox教授：免疫评分用于分析评估位于肿瘤中心和边缘的CD3+细胞和CD8+细胞。它是以肿瘤中这些表型的细胞数目和出现频率为依据进行积分的。这项技术目前仅用于手术切除的原发结肠癌样本。免疫特征则是一个更为复杂的分析方法，它不仅仅包含了CD3+和CD8+细胞，还包含了许多其他的表面标志。包括我们在内的几个研究团队运用探索性的方法正在评估多达50个表面标志，希望从中找到可以描绘肿瘤位点免疫反应和抑制机制的标志。这两者的区别在于前者可相对简单和直接地观察大量的细胞毒性T细胞，而后者在评估细胞毒性T细胞群及其出现频率的同时还可观察与免疫抑制机制或替代效应通路相关的其他表面标志。

　　<Oncology Frontier>: What influences will immunoscore bring to cancer diagnosis and clinical decision-making? Which kinds of tumors can it be applied to?

　　《肿瘤瞭望》：免疫评分对肿瘤的诊治带来哪些影响，可用于哪些肿瘤？

　　Dr Fox: For the decision-making step， we hypothesize that patients who are immunoscore positive for colon cancer will be good responders. Those will be the patients who will respond to any treatment whether it is chemotherapy or combination chemotherapy-radiation therapy or immunotherapy. That’s the hypothesis. For other cancers， we refer to a very nice review from Wolf Fridman in Nature Cancer Review a couple of years ago. He surveyed the literature and reported on more than one hundred publications in 18 different malignancies showing a correlation between immune infiltrate of some sort and a prognostic biomarker i.e. one that identifies the patients who are going to do well. That is the basis of where things are currently. We hypothesize that the infiltrates that are present if we do a more complex immunoprofile will actually be predictive biomarkers that will be able to be used to guide the therapeutic interventions for patients. For instance， possibly from an overly simplistic perspective， a PD-L1+ tumor would be someone who would respond to PD-L1 therapy. We know that there is an increased response rate in patients who have PD-L1 tumors and who are receiving anti-PD-L1 therapy. But that doesn’t explain everything because there is not a 100% responsive rate amongst those patients， even when the tumors are 90-100% positive (and we presented that here at the meeting earlier). So it is going to be more complex. Those of use who are working in the field believe that the immunoprofiling signals that are found will guide the next generation of combination therapies that will be effective in patients with cancer.

　　Fox教授：对于治疗方式的选择，我们猜测免疫评分阳性的结肠癌患者将是很好的应答者，即他们无论对于化疗、放-化疗联合还是免疫治疗都会有很好的反应。对于其他肿瘤，我们引用了几年前Wlof Fridman发表在Nature Cancer Review上的综述。Wlof Fridman查阅大量文献和报道后，得出免疫细胞的浸润程度和患者的预后存在相关性，即浸润程度越高，预后越好。这些都是我们目前研究的基础。我们猜想，如果做更为复杂的免疫特征来诠释免疫细胞的浸润程度，那么这个预测指标将可以用于指导患者的治疗。例如，一个PD-L1+的肿瘤就可能会对PD-L1的治疗有应答。实际上我们知道接受PD-L1抗体治疗的PD-L1+肿瘤患者有更高的应答率。但是这也解释不了所有的机制，因为即使在90～100%阳性的肿瘤中应答率也不能达到100%（我们在之前的会议中也展示过这个数据）。所以研究变得更为复杂，但是该研究领域的科学家都相信目前发现的免疫特征信息用于指导肿瘤患者的下一代联合治疗将会非常有效。

　　<Oncology Frontier>: As a laboratory index， immunoscore will face universal obstacles when widely promoted， like the control of inter-laboratory quality and reproducibility. What measures do you suggest to deal with this problem?

　　《肿瘤瞭望》：免疫评分的临床推广必然会面临实验室指标常见的困难，即在不同实验室之间的质量控制，结果的可重复性等问题。对此您有什么建议？

　　Dr Fox: The Society for the Immunotherapy of Cancer (SITC) and the global Immunoscore Taskforce have worked closely with Jerome Galon and Franck Pages as well as Francesco Marincola， Carlo Bifulco and Paolo Ascierto， to address those issues. The concept is to use a standardized platform which is universally applied whether done in China or Japan or North America， Europe， the Middle East or India. That part is standard. We are using two antibodies which are standard. And we are using the same reagents. With those standard reagents and a standard machine， it still takes a little bit of practice to have the same uniform result， but it is possible. This a concern for all standard validated tests for pathology. The second step is the digital imaging. The section is stained and then digitally imaged. That digital image can give you the quality control on the staining and that’s another important step. Third step is then the software and in this case we are using the Definiens software which actually counts the cells in the invasive margin and determines the numbers of cells that are there and it is that analysis that we think will give a standardized approach to assess immunoscore that will make it generally applicable globally. That has not been validated in all honesty. It looks like we can carry out this test but we don’t have the results of that global study yet to confirm the initial results from two publications from Jerome Galon and Franck Pages in Paris. We are optimistic it will do that and we are in the process of conducting that study.

　　Fox教授：癌症免疫治疗学会（SITC）和全球免疫评分工作团队已经与Jerome Galon、Franck Pages、Francesco Marincola、Carlo Bifulco、 Paolo Ascierto密切协作来解决这些问题。第一步，以一个在中国、日本、北美、欧洲、中东或印度已经广泛应用的标准化平台为基础，应用两个抗体作为标准、使用同样的试剂。尽管拥有标准的试剂和仪器，但还是需要通过一些实践来得到统一的结果，这个方法是具有可行性的。这也是病理学所有标准验证试验都需要关心的问题。第二步，应用数字化影像技术，将肿瘤切片染色并做数字成像分析。影像分析可以进行染色的质量控制，这是另一个重要的步骤。第三步，软件分析。我们使用的Definiens软件可以计算肿瘤边缘的细胞数，而且我们认为通过标准化的分析方法得到的免疫评分可以在全球广泛地应用。诚实地说，这些都没有验证过。似乎我们可以实施这些测试，但是目前还得不到全球广泛研究的结果来证实来自巴黎的Jerome Galon和Franck Pages发表在两本杂志上的结论。对于这个方法的可行性我们还是非常乐观的，而且我们也正在进行相关的研究。

　　<Oncology Frontier>: PD-1 and PD-L1 are highlights of this year’s new targets. Is there currently any therapy available? How do they work? And what benefits will they bring to cancer treatment?

　　《肿瘤瞭望》：PD-1和PD-L1是今年热门的靶点，靶向这一通路的药物有哪些，是如何发挥作用的？对肿瘤治疗带来了什么样的益处？

　　Dr Fox: It is a very exciting time. Those molecules are agents that block PD-1 or block PD-L1 and are two of the reasons why Science picked cancer immunotherapy as the breakthrough of the year for 2013. There are now agents available. In the US， Merck has just had an antibody approved. In Japan， a reagent is approved. So those two agents are now available for patients with the diseases for which they have been approved. Merck has already opened expanded access for patients with their agent before it had received FDA approval. So those are available with FDA and Japanese regulatory agency approval. But there is a pipeline of agents from several other companies that are becoming more likely to become available but are currently available through clinical trials. I might suggest that for patients who have cancers for which we don’t currently have treatments， that they consider going on clinical trials. I don’t know what the rates of clinical trial entrants are in China but it is really a great opportunity for patients to get access to these agents through clinical trials. For off-label， I don’t know what is available here but we are very excited about the future of these agents becoming available more broadly and the next generations of agents becoming available. I will also say that it is not perfect yet. Even in the best situations we have seen with the combination of ipilimumab and nivolumab in data that was presented at ASCO this year by Mario Sznol， that was 79-94% two-year survival with very small cohorts but in a disease that only four years ago had 10-12% two-year survival. With ipilimumab approval， it was 22% survival. With PD-1 as a single agent， maybe 30-40% two-year survival. Now we are at 80-90% two-year survival. These are not curing all of these patients， but they are extending life and giving patients a shot at potential curative therapy. It is very exciting but there is still much more work to do. Only time will tell if those patients who are still alive after two years might experience a potential cure.

　　Fox教授：非常令人兴奋，研发了阻断PD-1和PD-L1的分子治疗新药，它们也是Science评选肿瘤免疫治疗作为2013年突破性研究进展的原因之一。在美国，Merck公司的抗体药物刚刚获得了批准，在日本，另一个药物也批准上市。这两个新药都可以应用于获批的相关肿瘤的治疗。在获得FDA批准之前，Merck已经开放了患者的准入通道。目前，这两个制剂获得了FDA和日本监管机构的批准，可以用于临床治疗。其他几个公司的制剂也可以使用，但是是以临床试验的方式进行。对于目前没有治疗的肿瘤患者可以考虑加入临床试验，这对于患者来说是一个很好的获得这些药物治疗的机会。我认为，这类药未来会有更广泛的适应证，期待下一代制剂的使用。

　　该类药物现在还是不完美的。目前可看到的最好结果是今年ASCO会议上Mario Sznol展示的数据：ipilimumab和nivolumab联合治疗在非常小的样本中获得了79%～94%的两年生存率，而四年前的两年生存率是10～12%。对于获批的ipilimumab，其生存率是22%。靶向PD-1分子单药治疗，其两年生存率是30～40%。现在我们的两年生存率达到了80～90%。虽然他们没有治愈所有的患者，但是延长了生存期，给患者一个获得根治性治疗的机会。这些成果非常令人兴奋，但是我们还有很多工作要做。只有时间能告诉我们这些生存了两年的患者是否得到的是有前景的治疗。