Cellular & Molecular Immunology www.nature.

com/cmi

REVIEW ARTICLE
Human immunology and immunotherapy: main achievements
and challenges
Jezabel Varadé1,2, Susana Magadán1,2 and África González-Fernández1,2

The immune system is a fascinating world of cells, soluble factors, interacting cells, and tissues, all of which are interconnected. The
highly complex nature of the immune system makes it difficult to view it as a whole, but researchers are now trying to put all the
pieces of the puzzle together to obtain a more complete picture. The development of new specialized equipment and
immunological techniques, genetic approaches, animal models, and a long list of monoclonal antibodies, among many other
factors, are improving our knowledge of this sophisticated system. The different types of cell subsets, soluble factors, membrane
molecules, and cell functionalities are some aspects that we are starting to understand, together with their roles in health, aging,
and illness. This knowledge is filling many of the gaps, and in some cases, it has led to changes in our previous assumptions; e.g.,
adaptive immune cells were previously thought to be unique memory cells until trained innate immunity was observed, and several
innate immune cells with features similar to those of cytokine-secreting T cells have been discovered. Moreover, we have improved
our knowledge not only regarding immune-mediated illnesses and how the immune system works and interacts with other
systems and components (such as the microbiome) but also in terms of ways to manipulate this system through immunotherapy.
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The development of different types of immunotherapies, including vaccines (prophylactic and therapeutic), and the use of
pathogens, monoclonal antibodies, recombinant proteins, cytokines, and cellular immunotherapies, are changing the way in which
we approach many diseases, especially cancer.

Keywords: Vaccines; CAR T cells; Trained immunity; Microbiota; Cancer; Monoclonal antibodies

Cellular & Molecular Immunology (2021) 18:805–828; https://doi.org/10.1038/s41423-020-00530-6

INTRODUCTION All of these advances can be applied to several immune-

The knowledge of human immunology has improved exponen- mediated pathologies, but overall, the success achieved with
tially in recent years, and more advances in the near future are some types of immunotherapies in recent years is revealing new
certainly imminent. The immune system is extremely complex, but ways to explore and manipulate the immune system for our
we are now developing new tools and skills to study it. Several benefit.
factors have been involved in these advancements, and the most Writing a review about human immunology is a significant
important ones include the development of thousands of different challenge, but we have attempted to bring together recent
monoclonal antibodies that allow the identification of a large knowledge about the immune system, immune-mediated illnesses
variety of cell subpopulations and the functional analysis of and types of immunotherapies.
immune cells. These tools, together with new and sophisticated
technologies, such as single-cell analysis, imaging techniques,
omics (including massive DNA-RNA sequencing, proteomics, and NEW FINDINGS IN FUNDAMENTAL IMMUNOLOGY
metabolomics data and new tools for processing these data, such The last two decades have witnessed a major revolution in the
as artificial intelligence and machine learning approaches, field of immunology. The traditional classification of the immune
mathematical modeling, etc.), newly designed animal models system into two different arms, namely, innate and adaptive
(using conventional transgenic/knockout/knock-in mice or new components that collaborate to respond to foreign antigens or to
technologies such as CRISPR-Cas9 (clustered regularly interspaced perform self-/nonself-discrimination, has become much more
short palindromic repeats–CRISPR-associated protein 9), are complex. The development and application of new technologies
increasing our knowledge about how our immune system have provided new findings and created a new landscape in
functions. The study of the interaction between the immune which the immune system establishes cross talk, not only between
system and other systems, such as the nervous and endocrine immune components but also with commensal microorganisms1,2
systems or the microbiome, in several illnesses has produced and other important systems, such as the endocrine and nervous
interesting results with important clinical applications. systems3–5. These developments have forced immunologists to

1
CINBIO, Centro de Investigaciones Biomédicas, Universidade de Vigo, Immunology Group, Campus Universitario Lagoas, Marcosende, 36310 Vigo, Spain and 2Instituto de
Investigación Sanitaria Galicia Sur (IIS-Galicia Sur), SERGAS-UVIGO, Vigo, Spain
Correspondence: África González-Fernández ([email protected])
These authors contributed equally: Jezabel Varadé, Susana Magadán, África González-Fernández

Received: 21 April 2020 Revised: 27 July 2020 Accepted: 31 July 2020

Published online: 2 September 2020

© CSI and USTC 2020

 Human immunology and immunotherapy: main achievements and challenges
J Varadé et al.
806
reformulate the immunological architecture that confers protec- but when uncontrolled, these cells drive allergic responses and
tion, which has made the study of the immune system especially metabolic disorders. Moreover, the depletion of ILC2s in animal
attractive. Moreover, these advances have led to an increased models suggests a role for these cells in atopic dermatitis and
interest in better understanding, managing, and manipulating the asthma23.
immune response in both health and disease. ILC3s are abundant in mucosal tissues, and NCR2+ ILC3s have
been proven to be essential for regulating the balance between
Cell subsets commensal and pathogenic bacteria through the production of IL-
The characterization of new immune cell subsets has been a 2224. In contrast, NCR2− ILC3s can promote colitis in a model of
constant feature in the immunology field. This evolution is clearly inflammatory bowel disease25. The lack of immunodeficiency in
reflected in the discovery of an innate counterpart of T ILC-deficient patients led to the proposal that ILCs are dispensable
lymphocytes, collectively named innate lymphoid cells (ILCs)6, in the presence of functional T cells and B cells26. However, recent
and in the identification of different types of effector CD4 and studies support the idea that ILCs cannot be considered to have
regulatory T cells7. functions that only duplicate those of the adaptive immune
system.
Innate lymphoid cells (ILCs). ILCs are lymphocytes, but in contrast In addition to those showing the essential role of LTi cells in the
to adaptive immune cells, they can colonize lymphoid and barrier formation of secondary lymphoid organs during embryogenesis
tissue sites during fetal development, do not undergo somatic and the postnatal development of intestinal lymphoid clusters,
recombination and do not express antigen-specific receptors8,9. In recent studies also provide evidence that subsets of ILCs express
addition to lymphoid organs, ILCs are enriched in barrier tissues, multiple factors that modulate the adaptive immune response in
such as the gastrointestinal tract, airways, and skin10,11. These health and disease27,28. In particular, ILC2s and ILC3s modulate the
innate cells have been considered to be tissue-resident cells, but T-cell response. Studies in mice suggest that in healthy intestine,
recent studies suggest that ILCs can migrate through the ILC3s express major histocompatibility complex (MHC) class II
lymphatic system during homeostasis or enter into the circulation molecules but lack the expression of costimulatory molecules;
upon infection and inflammation6,12. Currently, five different ILCs therefore, they inhibit microbiota-specific T-cell responses, thus
are defined on the basis of their transcription factor expression, preventing intestinal inflammation29. It seems that the interaction
different cytokine production and/or developmental patterns6: between ILC3s and Tfh cells limits IL-4 secretion and the
natural killer (NK) cells (discussed below), lymphoid tissue inducer production of IgA by mucosal B cells30.
cells (LTis) and three subsets of helper-like ILCs (ILC1s, ILC2s, and Studies with murine models have significantly contributed to
ILC3s), which are considered to be the innate counterparts of T the classification and understanding of the role of ILCs in the
helper (Th) 1, Th2, and Th17 cells, respectively. The main focus of immune system, especially since similarities have been observed
this review is ILCs. between ILCs identified in mice and humans15. However, the
ILC1s are dependent on the T-box transcription factor T-bet and differences between these two species present real challenges15,31
produce interferon gamma (INF-γ), but they differ in the because human ILCs have unique attributes that are only now
expression of eomesodermin transcription factor13. ILC1s express being elucidated, with further work required in this exciting field.
CD127 in humans and CD200R in mice, but the natural cytotoxicity The roles of ILCs in immunity and their cross talk with other
receptor NKp46 (also known as NCR1) is expressed in both components of the immune response await further analysis.
species14,15. Detailed coverage of this topic is beyond the scope of this review,
ILC2s constitute the most homogeneous class of ILCs; they are and we refer the reader to recent reviews that provide more
dependent on GATA3 and RORα, and they produce type 2 information on the biology of human32 and mouse33,34 ILCs.
cytokines, mainly interleukin 5 (IL-5) and IL-13. ILC2s are involved
in immune responses to parasite infection, and in humans, they T cells and plasticity. T cells are categorized as Tα/β and Tγ/δ
express chemoattractant receptor-homologous molecule cells, depending on the type of T-cell receptor (TCR) that they
expressed in TH2 cells (CRTH2) and high levels of CD161, whereas express35. Human Tγ/δ cells, similar to their murine counterparts,
most mouse ILC2s express ST2 (a member of the IL-1 receptor are a minor population (1–10% of nucleated cells) in peripheral
family)14,15. blood, but are especially abundant in barrier tissues such as the
The development and function of ILC3s depend on the epidermis35–37.
transcription factor RORγt. Both human and mouse ILC3s can The three main subsets of T cells carrying α/β receptor are the
produce granulocyte macrophage colony-stimulating factor (GM- CD4+T helper cells and CD8+cytotoxic and CD4+ CD25+
CSF), IL-17, and/or IL-2216,17. In humans, two major ILC3 subsets regulatory T cells38.
can be distinguished on the basis of the expression of the natural New effector CD4+ helper T-cell subsets (initially classified as
cytotoxicity receptor NKp44 (also known as NCR2)14,15. Both types Th1 and Th2)39,40 have been recently described, and at least six
can produce IL-17, but the production of IL-22 is mainly confined human Th cell subsets have been identified to date: Th1, Th2,
to NKp44+ ILC3s. Th17, Tfh, Th9, and Th22 cells38,41. All of these cells recognize
Extensive research has focused on deciphering the role of ILCs foreign peptides presented by class II MHC molecules on antigen-
to ensure the maintenance of tissue homeostasis and immune presenting cells (dendritic cells, macrophages, and B lympho-
protection11,18. ILCs express particular sets of receptors in a tissue- cytes).
specific manner, and these allow the detection of host-derived Th1 cells are required to activate macrophages and cell-
signals (including those from alarmins, neuronal mediators, mediated immunity to kill intracellular pathogens42, whereas
microbia, and the diet)19. The integration of these endogenous Th2 cells are important in facilitating eosinophils to fight against
signals is essential for the maintenance of tissue homeostasis, but parasitic helminths and B cells for antibody production and
dysregulation of ILC responses leads to inflammation and antibody class-switching to generate IgA or IgE43. Th17 cells are
disorder12,20. ILC are mainly involved in early protection against required to mobilize neutrophils for the clearance of fungi and
viruses and bacteria13,21, but their response to dysregulated local extracellular bacteria, and they are also involved in mucosal
proinflammatory cytokine production in adipose tissues leads to protection44. Th9 and Th22 cells are also involved in mucosal
the development of metabolic disorders and obesity20. IL-5 and IL- immunity; Th9 cells protect against parasites45,46, and Th22 cells
13 produced by ILC2s induce goblet cell differentiation and the prevent microbial translocation across epithelial surfaces and
recruitment of eosinophils, basophils, and mast cells22, which are promote wound healing47,48. As mentioned in the introduction to
involved in protection against infection by helminths and viruses, ILCs, studies on human Th cells isolated from lymphoid organs

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807
and blood samples, along with recent observations on the the original idea of Th lineage stability and provide new
developmental mechanism of distinct Th cell subsets, have possibilities for disease treatment aimed at inducing particular
revealed both similarities and differences of human and Th subsets to modulate the immune response against pathogens
mouse Th cells41,49,50. or to control detrimental immunity76,77,80.
Tfh cells are very important for germinal center reactions,
antibody class switching, affinity maturation, and the develop- Trained and adaptive immune memory
ment of high affinity antibodies and memory B cells51,52. At the Other classical concepts in fundamental immunology, such as
surface marker level, Tfh cells are generally characterized by the immune memory, are also changing. The specificity and the
expression of CXCR5, the chemokine receptor for CXCL13, which is capacity to generate long-lived memory cells are two properties
highly expressed on B-cell follicles for expressing inducible T-cell that have been classically used to distinguish innate immunity
costimulator (ICOS) and programmed death protein 1 (PD-1)53,54, from adaptive immunity. Adaptive immunity is clearly based on
which enable their involvement in the interaction of Tfh cells and the specific recognition of antigenic determinants by somatically
B cells55. diversified receptors (B cell and T cell receptors (BCR and TCRs,
The definition of a given T cell lineage is based on its ability to respectively)) and on its capacity to respond more effectively to
sense different inductive cytokines, to produce particular cyto- restimulation with the same antigen. In contrast, innate immune
kines or to express a lineage-specifying transcription factor. responses have traditionally been considered nonspecific and
Th1 cells produce IFN-γ and express T-bet56; Th2 cells are without the capacity to adapt81. However, the discovery of
characterized by IL-4, IL-5, and IL-13 production and GATA-3 germline-encoded pattern recognition receptors (PRRs) and the
expression57,58; pTregs, which are induced in the periphery from “trained innate” immunity (or innate immune memory) have
naïve precursors, produce TGF-β and express Foxp3 (Tr1 cells are provoked a shift in our understanding of the immune response. In
IL-10-secreting Tregs that do not express Foxp3)59. Th17 cells 1997, Medzhitov et al. demonstrated that pattern recognition
produce IL-17A, IL-17F, and IL-22 and express RORγt60,61, and Tfh receptors (PRRs) expressed on innate cells recognize invariant
cells produce IL-4 and IL-21 and express the BCL6 transcription molecular structures expressed by invading pathogens82. After the
factor. In addition, Th22 cells, which produce IL-22 and express the interaction, PRRs trigger the expression of costimulatory mole-
aryl hydrocarbon receptor (AHR)47,62, and Th9 cells, are character- cules and activate important signaling pathways to induce the
ized by the expression of IL-9 and the transcription factor PU.163. activation of innate and adaptive immune cells. PRRs mainly
Additional levels of regulation, such as the differential expression belong to four families: Toll-like receptors (TLRs), NOD-like
of microRNAs, long noncoding RNAs (lncRNAs), and protein receptors (NLRs), C-type lectin receptors (CLRs), and peptidoglycan
stability and function, have been found to control various aspects recognition proteins (PGRPs)83,84. The profiles of PRRs expressed
of Th cell differentiation and effector function64,65. by innate cells can lead to partially specific recognition of a type of
CD8+ cytotoxic T cells express the dimeric CD8 marker and microorganism; e.g., innate cells can distinguish between gram-
have specific lytic capacity to target cells through several negative and gram-positive bacteria and modulate the immune
mechanisms, including the release of cytotoxic granules, secretion response based on this recognition, although they cannot
of cytokine tumor necrosis factor alpha (TNFa) and interferon differentiate between bacterial species85.
gamma, and the induction of cell death through the interactions The idea that only jawed vertebrates developed immunological
of Fas and the Fas ligand38,66. Their TCRs are restricted to memory has also been challenged by the observation of
interactions with peptides presented by class I MHCs. resistance to reinfection in organisms that lack an adaptive
Regulatory T cells (Tregs) include thymically derived and immune response, such as plants86 and invertebrates87,88. Recent
peripherally induced regulatory T cells (tTregs and pTregs, studies have shown that monocytes and macrophages exposed to
respectively), and they produce either IL10, TGF-beta, IL-35 or Candida albicans or β-glucans exhibited an enhanced secondary
combinations of these proteins67. tTregs express the transcription response89. In addition, immunization of mice with bacillus
factor Foxp3 and secrete IL10 and TGF-β; pTregs, which are Calmette-Guérin (BCG, the tuberculosis vaccine) induces T cell-
induced in the periphery from naïve precursors, can also independent protection against secondary infections by Candida
be subdivided into IL-10-induced Tregs [Tr1 cells] (which secrete albicans, Schistosoma mansoni or influenza virus90–93. Thus,
large amounts of IL-10 and moderate levels of TGFβ), TH3 cells organisms are protected not only against the original microorgan-
(which produce IL-10 and TGF-β), and TGFβ-induced Tregs [iTregs], ism but also to unrelated pathogens.
which may or may not express Foxp3. The mechanisms underlying the establishment of this innate
Moreover, new subsets of regulatory T cells have been immune memory differ from those involved in adaptive immune
described. They include follicular regulatory T cells (which express memory81. After infection or vaccination, innate immune cells
Foxp3 and Bcl-6 and CXCR5), which modulate the function of Tfh (such as monocytes and macrophages) display long-term func-
cells and fine-tune the germinal center response68–70, and a IL-35- tional changes through epigenetic and metabolic reprogramming,
dependent regulatory population of cells (referred to as iTr35 including histone acetylation, methylation and modulation of
cells), which show potent suppressive potential in several mouse noncoding RNAs94–96. In turn, the faster and more pronounced
disease models71. Other regulatory populations have also been reactivity of adaptive immune cells (T and B lymphocytes) upon
described, including Bregs and CD8+ Tregs, which are the reinfection is characterized by permanent changes in the genome
analogous counterparts of Tregs72–74. of cells, such as mutations, gene rearrangement, clonal expan-
Recent studies have revealed the capacity of differentiated sions, as well as epigenetic modifications, all of which ensure a
T cells, particularly Th17 cell and pTreg subsets, to change their more persistent effect than is endowed by trained
phenotype in response to changing contexts75–79. Becattini et al.78 immunity81,94,95.
found that human memory CD4 T cells primed in vivo by Other cells for which immunological memory has been
pathogens (e.g., Candida albicans and Mycobacterium tuberculosis) described include Tγ/δ cells97 and innate lymphoid cells98.
or vaccines (Tetanus toxoid) are highly heterogeneous, both at the Recently, some authors have proposed that NK cells are also
population and clonal levels. With respect to studies on human capable of immunological memory99–102. Antigen-specific recall
arthritis, Nistala et al.79 proposed that Th17 cells are recruited to responses by human NK cells were observed by Nikzad et al.103 in
the joint and converted to Th17/1 or Th1 cells in response to local humanized mice and in varicella zoster virus (VZV)-exposed adult
IL-12 levels. This plasticity has also been observed with in vitro human volunteers, in which cytotoxic NK cells were recruited to
assays under conditions that mimic a disease site, namely, low sites of an VZV test antigen challenge on the skin. Sensitization
TGF-β and high IL-12 levels79. These results are inconsistent with with haptens using mice lacking T cells and B cells led to the

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 Human immunology and immunotherapy: main achievements and challenges
J Varadé et al.
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generation of hapten-specific memory NK cells99. The recall murine and human immunology are notable, and conclusions
response persisted for more than four months after priming, drawn from mouse studies are sometimes not fully translated to
and was adoptively transferred to naïve mice100. Interestingly, NK humans31. If we want to fully exploit the power of the immune
cells exhibit memory that is not only specific to a given virus, such system for human health, greater effort is required for under-
as cytomegalovirus101,102, but that is also induced in the absence standing human immunology. Immunologists, in cooperation with
of a defined antigen104,105. experts from other fields, have developed a variety of protocols
Furthermore, new studies suggest that trained immunity is not and tools to achieve greater selectivity in the identification and
a phenomenon that is restricted to immune cells, because analysis of human cell subsets, types of cytokines and receptors,
epithelial stem cells also retain memory of previous inflammatory chemokines, etc. These tools range from biological approaches
challenges by displaying an enhanced wound-healing capacity that rely on next-generation sequencing, mass spectrometry, and
upon skin damage106. Given the data outlined above, immuno- bioinformatics to immune monitoring technologies based on
logical memory is now recognized to be highly diverse and not multiparameter flow cytometry and single-cell gene expression
restricted to B cell- or T cell-mediated adaptive immunity. Much analysis. Although not without limitations, these techniques
remains to be learned in this field, but the different manifestations provide a much better picture of the whole immune system than
of immunological memory described above offer an important individual and independent approaches.
basis for clinical applications, such as the development of novel
vaccination strategies107 or new therapies for pathological
situations in which immunological memory can be detrimental, IMMUNE-MEDIATED ILLNESSES
such as allergies or autoimmune diseases94,108,109. Immune-mediated illnesses comprise a wide variety of diseases
characterized by the dysregulation of a normal immune response.
Interaction of the immune system and the microbiome Most of these illnesses are complex disorders believed to arise
The immune system has evolved in the presence of commensal from a combination of genetic and environmental factors126.
microorganisms that colonize barrier surfaces of vertebrates and
invertebrates1,110. The cross talk between the natural host Infectious diseases
microbiome and immune system is particularly interesting in the Infectious diseases are caused by pathogens (viruses, bacteria,
gastrointestinal tract, where the density and diversity of indigen- fungi or parasites that infect the host body), and they remain a
ous bacteria, viruses and fungi are greatest compared to those of leading cause of mortality worldwide. Prominent examples
other anatomical sites111. In the literature, reports of observed include illnesses produced by Mycobacterium tuberculosis, human
changes in microbial community composition during diseases are immunodeficiency virus (HIV), Plasmodium falciparum or the
diverse and include those in inflammatory bowel disease (IBD), current coronavirus disease 2019 (COVID-19) outbreak caused by
obesity, metabolic syndrome, and multiple sclerosis112–116. How- the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2),
ever, the microbiome can be influenced by different factors, such which has already infected millions of people and produced
as the specific niche that it occupies, diet, stress, environmental thousands of deaths in many countries.
factors, and host genetics, and a specific correlation does not For a number of years, many people believed Koch’s postulates,
necessarily infer causation. The presence of these commensals in which implied that virulence traits reside solely in the pathogen.
mucosal tissues has been known since before Metchnikoff, but the However, recent advances in molecular biology have shown that
current knowledge on the role of the microbiome in shaping the host genes play major roles in infection, together with a wide
immune system throughout life came mostly from the develop- range of environmental variables127.
ment of next-generation sequencing (in particular, the reduction To date, six gene products endowing infectious disease
in the cost of 16S ribosomal RNA gene sequencing) and the use of susceptibility have been validated in the literature: (1) hemoglobin
germ-free animal models, which can be colonized even with subunit beta; (2) band 3-anion transport protein; (3) Duffy antigen/
human microbiota117. receptor, which is associated with Plasmodium spp. infections; (4)
Germ-free mice are characterized by atrophy of Peyer’s patches the prion protein associated with Creutzfeldt–Jakob disease; (5)
with few germinal centers and isolated lymphoid follicles, a lower fucosyltransferase 2 and 3, which is associated with Norwalk virus
number of B, T, and dendritic cells and a decreased level of infections; and (6) C-C motif chemokine receptor 5 (CCR5)
immunoglobulins, particularly IgA and IgG118. These effects are coreceptor, encoded by an immune-related gene and leads to
observed at the mucosal and systemic levels, and they can be the impairment of the entry of the human immunodeficiency virus
reversed within weeks after the colonization of germ-free mice (HIV) into helper T cells, thus avoiding/decreasing the progression
with commensal bacteria119. Moreover, colonization with com- to acquired immunodeficiency syndrome128.
mensal Bacteroides fragilis revealed the immunomodulatory effect Another gene associated with infectious disease and the
of bacterial polysaccharides in restoring systemic cells and the immune system is the natural-resistance-associated macrophage
differentiation of CD4+ T cells into regulatory T cells (Foxp3+ protein (NRAMP1), which encodes an integral membrane protein
Tregs), which in turn favor mucosal immunomodulation120. The expressed exclusively in the lysosomal compartment of mono-
induction of Th17 cell maturation by segmented filamentous cytes and macrophages. It is a susceptibility locus for increased
bacteria has also been reported121. These important examples ratios of infection with Leishmania spp. parasites and certain
emphasize the major roles of the commensal microbiome in the strains of Salmonella spp., Mycobacterium bovis and Mycobacterium
maturation of mucus-associated lymphoid tissue and the systemic tuberculosis129,130. In addition, it has been suggested that
immune system. The development of new technologies to better functional variants of immunoglobulin Fc gamma RIIa (CD32) are
track the locations and activities of distinct microbial populations related to the development of invasive encapsulated bacterial
is essential to elucidate host-microbe interactions, through which infections131.
other systems, such as the nervous system, seem to play Moreover, because of recently acquired genomic data, new
important roles2,122–125. human polymorphisms have been discovered, some of which play
The better characterization of some immune cell subsets, roles in changing immunoglobulin levels, seroconversion rates or
trained immunity, and host-microbiome interactions provides a the intensity of antigen-specific immune responses. In addition,
few very good examples that prove the maturation of immunol- they also contribute to human susceptibility to infection by viruses
ogy in the last few decades. In this sense, studies with mouse such as influenza, rhinovirus and respiratory syncytial virus132.
models have significantly contributed to the increase in our These polymorphisms are mapped within the MHC (HLA-DQB1*03,
fundamental knowledge; however, the differences between HLA-DRβ1, or HLA-DPβ1), natural killer cell immunoglobulin-like

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 Human immunology and immunotherapy: main achievements and challenges
J Varadé et al.
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receptors 1 and 4 (KIR3DL1 and KIR2DS4) and natural killer lectin- (IRF5–TNPO3) is involved in the accumulation of lymphocytes
like receptor D1 (KLDR-1)133. within lymphoid organs and failed elimination of autoreactive
Several recent studies available as preprints have analyzed naïve T cells; BTB domain and CNC homolog 2 (BACH2) has a
certain genes that may explain the differences in the variable critical role in immunoglobulin class-switching recombination,
expression of and susceptibility to COVID-19 by patients, either by somatic hypermutation of immunoglobulin encoding genes and
affecting the host receptor for the virus (angiotensin I converting the activation of tissue macrophages. A more complete list of
enzyme 2 (ACE-2))134, immune genes (TLR7 and others) or blood genes associated with autoimmunity can be found in the review
groups (group O seems to be the most protective)135, and more by Wang et al.138
extensive omics studies are now underway with larger numbers of Researchers are currently looking for the missing heritability in
patients. autoimmune diseases by focusing on the study of methylome
profiles, genetic cargos in extracellular vesicles, genetic alterations,
Autoimmune diseases and ways in which the microbiome may affect these diseases.
In 1901, the physician Paul Ehrlich first used the term “Horror
autotoxicus” to describe the way autoimmunity contradicts the Rejection of transplants
natural aversion to self-injury (“Living with the Enemy”, reviewed Immune-mediated rejection of tissue allografts was first described
in136). Currently, according to the American Autoimmune Related in 1945 by the British immunologist Peter Medawar146,147. Only
Disorders Association, more than 100 autoimmune diseases have three years later, George Snell described the MHC, which carries
been identified. Historically, these diseases were considered to be the histocompatibility genes, and one decade later, Jean Dausset
rare, but current epidemiological data have shown that they affect described the human leukocyte antigen (HLA); each of these
approximately 3–5% of the population worldwide. Some of the scientists was recognized with the Nobel Prize in Physiology and
most common autoimmune diseases include type 1 diabetes, Medicine148. Since its discovery, MHC has emerged as the most
rheumatoid arthritis, systemic lupus erythematosus, and inflam- polymorphic gene locus in eukaryotes with 24093 HLA and related
matory bowel disease (https://www.aarda.org/diseaselist/). alleles, more than 362709 nucleotide variants reported in the
Although significant progress has been made in understanding Individual-Participant Data–International ImMunoGeneTics/
the mechanisms of autoimmune diseases and the nature of self- Human Leukocyte Antigen (IPD–IMGT/HLA) work group
tolerance, these disease remain major burdens on health systems database (https://www.ebi.ac.uk/ipd/imgt/hla/), release 3.39.0,
around the world. 2020/01/20149.
Autoimmune diseases arise when the immune system attacks Although the main barrier for long-term organ and tissue
normal components of the body137. The concept of immune grafting is driven by HLA incompatibilities, other important players
tolerance is defined as the ability of the immune system to play roles in transplant rejection. In particular, minor histocompat-
prevent the targeting of self-molecules, self-cells or self-tissues. On ibility antigens, which are peptides derived from allelic variants of
the other hand, the failure to distinguish self from nonself is often normal cellular proteins, presented by class I or II MHC antigens
termed a break of tolerance, and it is the basis for an autoimmune induce cellular immune responses in HLA-matched individuals
disease138. who lack the same allelic variant150.
What are the mechanisms that lead to a break in tolerance? Natural killer (NK) cells also play important roles in transplanta-
Autoimmune diseases are complex disorders that are believed to tion through their killer cell immunoglobulin-like receptors (KIRs),
arise from a combination of genetic (mutations and higher which are receptors for HLA class I molecules. NK cells expressing
inheritance frequency of some types of major histocompatibility an inhibitory KIR-binding self-HLA can be activated when
complex alleles), epidemiological (age and sex) and environmental exposed to allografts that lack a ligand for the inhibitory
(infections, microbiota, tobacco, chemicals and pharmaceutical receptor151. The locus that codifies these receptors displays a
drugs). factors These factors trigger a break in self-tolerance with considerable degree of polymorphism, with 1110 alleles
the activation of self-reactive lymphocytes through several reported in the Individual-Participant Data–International/Killer Cell
mechanisms, such as molecular mimicry, the overexpression and Immunoglobulin-Like Receptors (IPD/KIR) work group database,
abnormal expression of MHC class II molecules in peripheral release 2.9.0, 2019/12/11149.
tissues, thymic aging, and immunodeficiencies (discussed below) More recently, we have begun to appreciate the importance of
and many others. Some lymphocytes escape control due to non-HLA genetic factors in the development of transplant
polymorphisms in several genes that affect the routes of rejection; examples include polymorphisms in the genes encoding
lymphocyte activation. Other causes may include defective cytokines, such as tumor necrosis factors (TNF), interleukins (IL-1,
antigen presentation by some MHC variants with specific IL-6 and IL-10), interferon gamma (IFN-γ), and transforming growth
polymorphisms. Therefore, the self-reactive lymphocytes that factor-β3 (TGF-β3). Other genes encode pathogen recognition
have escaped control and react against self-constituents initiate receptors, with nucleotide-binding oligomerization domain-
the autoimmune process139. containing 2 (NOD2 (CARD15)) being the most widely studied,
Although a large number of genome-wide association studies although conclusive data have not been obtained to date148.
(GWAS) have led to the identification of hundreds of polymorph-
isms associated with the development of different autoimmune Immunodeficiencies
diseases, it has proven difficult to define the role of most of these Primary immunodeficiencies (PIDs) comprise a heterogeneous
polymorphisms in the breakdown of tolerance to a self- group of more than 400 genetic disorders that result in defects in
antigen139–145. It is worth highlighting, however, that the MHC the immune response152. PIDs are considered Mendelian disorders
remains the main genetic factor associated with human because they are mainly autosomal recessive disorders that often
autoimmunity138,139. display incomplete penetrance, which affects the severity and
Other gene variants identified are common to many auto- onset of the disease. With the exception of immunoglobulin A
immune diseases, such as rheumatoid arthritis, systemic lupus (IgA) deficiency, PIDs are considered to be rare disorders, as their
erythematosus, multiple sclerosis, type I diabetes, ulcerative colitis, prevalence worldwide ranges from 1 to 9 among 100,000
autoimmune hepatitis and numerous other autoimmune diseases. people153. Unsurprisingly, these types of diseases are not
For example, the protein tyrosine phosphatase nonreceptor type uncommon in highly consanguineous populations such as those
22 (PTPN22) gene encodes a protein that inhibits T-cell activation in the Middle East/Northern Africa (MENA) region. The incidence
in the adaptive immune system, whereas it promotes myeloid cell of consanguinity marriage in these areas ranges between 20 and
activation; interferon regulatory factor 5–transportin 3 56%, which leads to a unique population in which autosomal

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 Human immunology and immunotherapy: main achievements and challenges
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recessive diseases arise, with the prevalence of PID in these genes induced by IFN. The gain of function by variants of
countries as high as 30 in 100,000 people154. TMEM173 (transmembrane protein 173) is the core mani-
Although more than 400 genes have been described for PIDs, festation of this disorder group, but other genes have been
approximately 60% of the causal genes remain unknown, and identified, including DDX58 (DExD/H-box helicase 58),
next-generation sequencing studies performed in MENA popula- DNASE2 (lysosomal deoxyribonuclease 2), POLA1 (DNA
tions are contributing to the search for currently unknown genes polymerase alpha 1 subunit) and USP18 (ubiquitin-specific
that cause PIDs155. A complete and updated list of PID-causing peptidase 18)159,160.
genes and diseases can be found at the European Society for (3) Ubiquitination disorders. Ubiquitination is a process that
Immunodeficiencies (ESID) webpage (https://esid.org)156. marks proteins for degradation via the proteasome, which
Clinical manifestations of PIDs are highly variable; many is required for the processing of intracellular antigens
disorders involve an increased susceptibility to several types of (such as virus proteins or mutated tumor proteins) and
infections, but some patients develop autoimmune diseases. their presentation by class I HLA molecules. Ubiquitination
Patients usually present recurrent sinus or ear infections or involves three main steps: activation, conjugation and
pneumonia within a one-year period; other indicators are failure to ligation, which are performed by ubiquitin-activating
thrive, poor response to prolonged use of antibiotics, and enzymes (E1s), ubiquitin-conjugating enzymes (E2s), and
persistent thrush or skin abscesses153. ubiquitin ligases (E3s). Ubiquitination disorders are caused
Depending on the affected pathway, PIDs are associated with by variants of the PSMB8, PSMB9, PSMA3 and PSM4 genes
varying levels of severity, times of onset, and risks of infection by (proteasome 20S subunit beta 8, subunit beta 9, subunit
certain groups of microorganisms. According to the International alpha 3 and subunit alpha 4, respectively), affecting the
Union of Immunological Societies (IUIS) (https://iuis.org/ proteasome subunits, proteasome maturation protein
committees/iei/), 430 inborn errors of immunity can be classified gene (POMP) and/or proteasome assembly chaperone 2
as follows: (a) immunodeficiencies that affect cellular and humoral (PSMG2), by encoding proteasome assembly molecules161.
immunity; (b) combined immunodeficiency (CID) with associated In addition, other genes in this group, such as OTULIN
or syndromic features; (c) predominant antibody deficiencies; (d) (OTU deubiquitinase with linear linkage specificity),
diseases of immune dysregulation; (e) congenital defects of encode ubiquitin peptidases, i.e., proteins involved in
phagocyte number, function, or both; (f) defects in intrinsic and ubiquitination assembly complexes, such as HOIL-1 (heme-
innate immunity; (g) autoinflammatory disorders; (h) complement oxidized IRP2 ubiquitin ligase 1) and HOIP (NHP2-like
deficiencies; and (i) phenocopies of a PID156,157. protein 1 homolog). Finally, the loss of function due to
However, PIDs are broadly classified as follows according to the variants of the TNFAIP3 (TNF-alpha-induced protein 3, also
component of the immune system affected: known as A20) gene, which encodes a protein with
ubiquitin ligase and ubiquitinase activity, has also been
● T-cell immunodeficiency, e.g., defects in the IFN-γ/IL-12 described159.
pathway and mutations in the autoimmune regulator (4) Inflammatory or innate immune regulators. A large
(AIRE) gene. number of genes have been found to affect the pathways/
● B-cell (antibody-mediated) immunodeficiency: gamma-globu- mechanisms involved in macrophage and B-cell differ-
linemia, X-linked common variable immunodeficiency (CVID), entiation and lymph node development, among many
selective IgA deficiency, specific antibody deficiency, and IgG functions. Genes in this group include ADA2 (adenosine
subclass deficiency. deaminase 2), TNFRSF11A (TNF receptor superfamily
● Combined immunodeficiency: Wiskott–Aldrich syndrome, member 11a), ADGRE2 (adhesion G protein-coupled
ataxia telangiectasia, DiGeorge syndrome and severe com- receptor E2), TRNT1 (tRNA nucleotidyltransferase 1), LACC1
bined immunodeficiency (SCID). (laccase domain-containing 1) and AP1S3 (adaptor related
● Phagocyte defects: chronic granulomatous disease, hyperimmu- protein complex 1 subunit sigma 3)159.
noglobulin E (IgE) syndrome and leukocyte adhesion deficiency.
● Complement defects (deficiency in early, late or regulatory
complement components)158. Allergy
Allergic diseases can be termed complex diseases that involve
both genetic and environmental factors, and they influence not
Autoinflammatory diseases only the development of IgE-mediated sensitivity in the case of
Systemic autoinflammatory diseases (AIDs) are characterized by hypersensitivity type I allergies but also the subsequent develop-
recurrent acute inflammatory episodes secondary to a dysregu- ment of clinical symptoms in a range of tissues, including skin,
lated inflammatory process that typically develops during child- nose, and lung tissue162.
hood, with recurrent episodes of fever, rashes, and disease-specific Since the first report of a link between chromosome 11q12 and
patterns of organ inflammation. Genetically speaking, these are atopy in 1989163, knowledge about the common risk variants for
hereditary disorders, andto date, more than 40 genes (Table 1) allergic diseases has increased exponentially, mainly because of
have been identified as causes of AIDs, which can be grouped GWAS. Most allergic diseases have allergy-related traits such as
according to the pathway that is altered159. asthma, with the strongest association mapped to chromosome
17q21. However, the disease-associated gene at this locus remains
(1) Inflammasome. The inflammasome is a multiprotein unclear; one of the candidate genes is ORMDL3 (sphingolipid
intracellular complex that detects pathogenic microorgan- biosynthesis regulator 3) due to its role in sphingolipid synthesis
isms and stressors and activates the highly pro- and the regulation of eosinophils. Other genes associated with
inflammatory cytokines IL-1β and IL-18. Genes affected in asthma are interleukin 33 (IL33) and its receptor, IL1RL1
this group are MEFV (Mediterranean fever pyrin innate (interleukin 1 receptor-like 1), HLA region, SMAD3 (SMA- and
immunity regulator), which is related to familial Mediterra- MAD-related protein 3) and IL2RB (interleukin 2 receptor subunit
nean fever (FMF); NLRC4 (NLR family CARD domain- beta)164.
containing 4); NLRP1 (NLR family pyrin domain-containing As asthma and other allergic-associated traits could be present
1) and WDR1 (WD repeat domain 1)159. in patients without allergies, some researchers performed GWAS
(2) Type-I interferon (IFN)-mediated disorders. These dis- analysis on cohorts of patients who had high levels of allergen-
orders are characterized by the upregulated expression of specific immunoglobulin E (IgE) or a positive skin prick test. As a

Cellular & Molecular Immunology (2021) 18:805 – 828

 Table 1. Genes involved in autoinflammatory diseases and their pattern of inheritance

Gene Protein Disorder Mode of

inheritance

ADA2 ADA2 Deficiency of adenosine deaminase 2 (DADA2) AR

ADGRE2 ADGRE2 Vibratory urticaria AD
AP1S3 AP1S3 AP1S3-mediated psoriasis (AMPS) AD
CARD14 CARD14 CARD14-mediated psoriasis (CAMPS)/psoriasis susceptibility locus 2 (PSORS2) AD
DDX58 DDX58 Singleton–Merten Syndrome (SMS) AR
DNASE2 DNASE2 Interferon pathology Unknown
HLA-B*51 HLA-B Behçet disease (present epistasis over ERAP1) Complex
HLA-DRB1*11 HLA-DRB1 Systemic juvenile idiopathic arthritis Complex
IFIH1 MDA5 Singleton–Merten Syndrome (SMS) AD
IL10 IL-10 IL-10 deficiency (IL-10D) AR

Cellular & Molecular Immunology (2021) 18:805 – 828

IL10RA, IL10RB IL-10 receptor Very early-onset inflammatory bowel disease (VEOIBD) AR
IL1RN IL-1 receptor antagonist Deficiency of IL-1 receptor antagonist (DIRA) AR
IL36 RN IL-36 receptor Deficiency of IL-36 receptor antagonist (DITRA) AR
antagonist
LACC1 LACC1/FAMIN Monogenic form of systemic juvenile idiopathic arthritis (sJIA) AR
LPIN2 Lipin 2 Majeed syndrome AR
MEFV Pyrin/marenostrin Familial Mediterranean fever (FMF) AR
MEFV Pyrin/marenostrin Pyrin-associated autoinflammation with neutrophilic dermatosis (PAAND) AD
MVK Mevalonate kinase Hyperimmunoglobulinemia D with periodic fever syndrome (HIDS)/mevalonate kinase deficiency (MKD); AR
porokeratosis 3 (POROK3)/disseminated superficial actinic porokeratosis (DSAP)
NLRC4 NLRC4 NLRC4-macrophage activation syndrome (NLRC4-MAS) AD - mosaicism
NLRP12 NLRP12 Familial cold autoinflammatory syndrome 2 (FACS2)/NLRP12-associated periodic syndrome (NAPS12) AD
J Varadé et al.

NLRP12 NLRP12 Multiple self-healing palmoplantar carcinoma (MSPC); familial keratosis lichenoides chronica (FKLC)/NLRP1-associated AD
autoinflammation with arthritis and dyskeratosis (NAIAD)
NLRP3 Cryopyrin/NLRP3 Cryopyrin-associated periodic syndrome (CAPS) AD
NLRP3 Cryopyrin/NLRP3 Schnitzler syndrome AD - mosaicism
NLRP7 NLRP7 Hydatidiform mole AR
NOD2 NOD2 Blau syndrome/early-onset sarcoidosis AD
OUTLIN OUTLIN Otulipenia/otulin-related autoinflammatory syndrome (ORAS) AR
PLCG2 PLCγ2 Autoinflammatory PLCγ2-associated antibody deficiency and immune dysregulation (APLAID) AD
POLA1 POLA1 X-linked reticulate pigmentary disorder (XLPDR) X-linked
POMP POMP POMP-related autoinflammation and immune dysregulation disease (PRAID) AD
PSMA3 PSMB4 Immunoproteasome PRASS AR - digenism
PSMB9 POMP subunits
PSMB8 Immunoproteasome β5i Chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature (CANDLE) AR
subunit
PSMB8 Immunoproteasome β5i Proteasome-associated autoinflammatory syndrome (PRASS) AR - digenism
subunit
PSMG2 PSMG2 PRASS AR
PSTPIP1 PSTPIP1 Pyogenic arthritis, pyoderma gangrenosum, and acne (PAPA) AD
Human immunology and immunotherapy: main achievements and challenges

811
 Human immunology and immunotherapy: main achievements and challenges
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812

AD - mosaicism
result, 18 loci were identified, and the strongest association was
on chromosome 11q13. This locus has been associated with two
inheritance
Mode of genes: C11orf30 (EMSY transcriptional repressor, BRCA2 interact-
ing), a potential regulator of interferon-stimulated gene, and
LRRC32 (leucine rich repeat-containing 32), which is involved

AD

AD
AD
AD

AD
AR
AR
AR

AR

AR
in Transforming Growth Factor Beta (TGFβ)-signaling in
T regulatory cells.
The rest of the associated loci involved in the pathogenesis of
allergy highlight the importance of the Th2 responses (STAT6
(signal transducer and activator of transcription 6), TSLP (thymic
stromal lymphopoietin), BCL6 (B-cell lymphoma 6 protein), IL1RL1
(interleukin 1 receptor-like 1), IL33 (interleukin 33), GATA3 (trans-
acting t-cell-specific transcription factor binding protein 3)); innate
immunity (TLR1/6/10 (Toll-like receptor 1/6/10)); TGFβ-signaling
(LRRC32 (leucine rich repeat-containing 32), SMAD3 (mothers
against decapentaplegic homolog 3)); T-cell (IL2 (interleukin 2),
PTGER4 (Prostaglandin E Receptor 4)) and T regulatory box
Sideroblastic anemia with B-cell immunodeficiency, periodic fevers, and developmental delay (SIFD)

(LRRC32 (leucine rich repeat-containing 32), IL-2, NFATC2 (nuclear

factor of activated T cells 2), FOXA1 (forkhead box A1))164.
In the last two years, researchers have focused on epigenome-
wide association study (EWAS) of allergy processes. The epigenetic
landscape is specific for a given cell; thus, EWAS requires careful
selection of the relevant cell type for a given biomedical condition.
For allergies, EWAS has mainly been performed on nasal mucosal
cells and whole blood (although the result was later normalized by
the number of circulating eosinophils). Nasal mucosal cells
comprise CD8+ T cells, CD4+ T cells, myeloid cells, innate
Tumor necrosis factor receptor-associated periodic syndrome (TRAPS)

lymphoid cells, B cells, double-negative T cells, granulocytes,

CD117+ cells, and plasma cell populations165. In all of these
studies, 36 CpG-associated regions were identified, from which the
Periodic fever, immunodeficiency, and thrombocytopenia (PFIT)

SMAD3 gene, coding for an important regulator of T-cell

STING-associated vasculopathy with onset in infancy (SAVI)

differentiation, was replicated in three independent cohorts166.

Of all of the genes in whole blood identified using EWAS, only the
TNFRSF11A-associated periodic syndrome (TRAPS11)

ACOT7 (acyl-CoA thioesterase 7), EPX (eosinophil peroxidase), GJA4

(gap junction protein alpha 4) and METTL1 (methyltransferase-like
1) genes were confirmed in the nasal cell populations167.
Histiocytosis-lymphadenopathy plus syndrome

Cancer immunology
In 1909, Ehrlich proposed the idea that mutant cells arise
continuously and that the immune system scans for and
eradicates these mutant cells before they manifest clinically168.
A20 haploinsufficiency (HA20)

However, immune surveillance remained a controversial topic

102,103

until its acceptance in the 1990s169.

Immune surveillance is the recognition and elimination of
AD autosomal dominant, AR autosomal recessive. Modified from Jéru et al.

cancerous cells by lymphocytes, which act as sentinels that

TORCH Syndrome

recognize transformed cells. Ultimately, during tumor progression,

HOIL-1 deficiency
HOIP deficiency

cancer cells show low immunogenicity and resistance to immune

effector cells, thus expanding and escaping immune control. The
Cherubism

way in which cancer cells modify the immune system has been
Disorder

called immune editing169.

The key of immunosurveillance is cancerous cell expression of
tumor antigens that can activate various immune cell phenotypes;
for simplicity, any overexpressed, mutated, dysregulated, or
rearranged gene product expressed by a cancerous cell may be
considered a tumor antigen. It is critical to consider that most of
these proteins, except those derived from virus-infected cancer
TNFRSF11A

cells, are primarily self-proteins, but they are expressed with

mutation(s) or minor changes in their antigenic structure170.
SH3BP2
Protein

HOIL-1

hENT3

TRNT1
TNFR1

UPS18
WDR1
STING

One mechanism by which cancer cells escape from immune

HOIP

A20

recognition is antigenic modulation. For example, the loss of MHC

class I molecule expression leads to aberrant antigen masking,
continued

which is one of the mechanisms described for tumor cells that

escape specific antitumor T-cell immune responses171. In addition,
the MHC-peptide-T cell receptor complex elicited by a tumor
TNFRSF11A

antigen shows weak stability, since high-affinity T-cells tend to be

TNFRSF1A
TMEM173
SLC29A3

TNFAIP3

rendered tolerant to these antigens172.

SH3BP2
Table 1.

RNF31
RBCK1

TRNT1
UPS18
WDR1
Gene

Another mechanism is the direct inhibition induced by cancer

cells due to their interaction with surface regulatory molecules,

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 Human immunology and immunotherapy: main achievements and challenges
J Varadé et al.
813
also called checkpoint molecules. These molecules include ‘inflammaging’, which is related to elevated self-reactivity and
programmed cell death-1 (PD1) and cytotoxic T-lymphocyte- results in the typical chronic low-grade, systemic inflammatory
associated protein 4 (CTLA-4), which induce the inhibition of host phenotype observed in the elderly in the absence of acute
T cells. Although these checkpoints usually help conventional infection. Currently, it is believed that self-reactive T cells are the
immune responses control immune activation, they can also be main contributors to this process. It has been proposed that this
used by tumor cells to inhibit antitumoral T-cell responses173. basal inflammatory state contributes to the development of some
PD1) is a transmembrane protein expressed on T, B, and NK diseases, such as Type II diabetes, Alzheimer’s disease and
cells, and it binds to PD1 ligands (PD-L1 and PD-L2) on target cells. atherosclerosis178. Understanding the mechanisms of age-related
When it binds to its ligand on tumor cells, PD1 inhibits tumor cell disorders in immune regulation is important for identifying more
apoptosis, causes peripheral effector T-cell exhaustion, and efficient strategies of immune rejuvenation and for the effective
promotes the conversion of effector T cells into regulatory induction of vaccination-mediated immunity in older
T cells172,174. individuals177.
CTLA4 is also a physiological negative regulator of T-cell
activation. The interaction with CD80/CD86 in the tumor leads
to the inhibition of T-cell function and suppressed effector IMMUNOTHERAPY
activity175. Knowledge of these two checkpoint inhibitors has Immunotherapy includes the use of certain components of
opened the door to new antitumoral therapeutic approaches, the immune system (antibodies, cells, cytokines, etc.) for the
such as the use of monoclonal antibodies that block the treatment of various cancers and autoimmune diseases and
aforementioned interactions (anti-PD1, anti-PD-L1, or anti-CTLA- the manipulation of the immune system through vaccines for the
4), which are called checkpoint inhibitors176. prevention and treatment of infectious and allergic diseases
In addition, tumor cells create an inhibitory microenvironment (Fig. 1).
around them. Malignant cells can recruit other cells, such as Immunotherapy using microorganisms or their components in
immune cells and fibroblasts, which can be corrupted by tumor vaccines was first practiced centuries ago; soluble substances such
cells. The interaction between tumor and nontumor cells creates as poly- and monoclonal antibodies, as well as cytokines, have
the tumor microenvironment, which is mostly driven by the been used for many years, but recently, cellular immunotherapy
dynamics of the tumor promoting the proliferation/expansion of has emerged in clinical practice. Although immunotherapy can be
cancer cells. For example, tumor and stromal cells release multiple used for many diseases (infections, autoimmune diseases, macular
factors, such as the chemokine CCL28 (C-C motif chemokine degeneration, allergic diseases, etc.), it is being used most
ligand 28), which inhibits effector T-cell functions and attracts expansively in the cancer field. The main goal is to destroy the
Tregs to the microenvironment172. tumor, either directly or indirectly (by enhancing the patient’s
Tumor cells use different mechanisms to promote cancer immune system), while offering greater specificity and fewer side
progression and further metastasis. The complete immunological effects than conferred by conventional therapies.
eradication of cancer is the goal of antitumoral immunotherapy
and is discussed later in this review. Pathogens and vaccines for infectious diseases
Immunotherapy associated with pathogens was first linked to the
Immunosenescence and inflammaging prevention of infectious diseases, starting from variolization (in the
Aging is accompanied by the decline and dysregulation of X century), followed by Edward Jenner’s vaccination against
immune efficacy, which results in an increased vulnerability to smallpox (in the XVIII century) and subsequently many other
infectious diseases, diminished responses to vaccination, and preventive vaccines for infectious diseases. The great advances in
reduced tumor clearance. Immune alterations mainly manifest as a the knowledge about infectious diseases took place in the
reduction in the number of naïve peripheral blood cells and a nineteenth century, but the XX and XXI centuries are clearly the
relative increase in some types of memory cells177. vaccination centuries, as many new successful vaccines (with
Natural aging causes progressive atrophy of the thymus, which attenuated or dead pathogens, subunits, recombinant proteins,
is called thymic involution. The endpoint is a significant decrease carbohydrates or DNA) introduced against a variety of pathogens.
in naïve T cells, which reduces the diversity of the T-cell antigen
receptor (TCR) repertoire and culminates in disrupted T-cell Bacterias
homeostasis178. The cellular and molecular hallmarks of aging Vaccines Oncolyc virus
have been described as genomic instability, telomere attrition,
epigenetic alterations, sarcopenia, changes in intracellular com-
Monoclonal
munications, cellular senescence, immunosenescence and mito- Anbodies
Cytokines
chondrial dysfunction179. TYPES
The process of aging alters the innate and adaptive immune TIPOS
OF DE
systems. In terms of innate immunity, aging results in a decreased INMUNOTERAPIA
IMMUNOTHERAPY Lymphokine
Fusion
number of circulating monocytes and dendritic cells, reduced acvated killer (LAK)
proteins
and Natural killer
phagocytic properties of macrophages and neutrophils, and (NK) cells
impaired antigen presentation by dendritic cells179. As mentioned
above, aging also generates a reduction in the T-cell and B-cell Treg
CAR Treg
receptor repertoire due to the accumulation of senescent or cells T cells
exhausted lymphocytes, together with a decrease in the number Tumor infiltrang Tγ/δ
of circulating naïve T and B cells178,179. On the other hand, NK cell Dendric cells
lymphocytes Tγ/δ

cytotoxicity is maintained in centenarians, and an increase in the Mesenchymal cells

number of these cells is observed in healthy aging people177.
Moreover, CD4+ T cells exhibit cytotoxic features in centenarians; Fig. 1 Examples of immunotherapy, including the use of vaccines,
monoclonal antibodies, fusion proteins, bacteria, oncolytic viruses,
this is an acquired characteristic for CD4+ T cells that usually have cytokines, and different types of cellular immunotherapy: chimeric
helper, but not cytotoxic functions under physiological antigen receptor (CAR) T cells, dendritic and mesenchymal cells,
conditions180. tumor-infiltrating lymphocytes, regulatory (Treg) and gamma/delta
In addition to these features, chronic inflammation is consid- (Tγ/δ) T cells, lymphocyte activated killer (LAK) and natural killer
ered the key that underlies the phenomenon called (NK) cells

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 Human immunology and immunotherapy: main achievements and challenges
J Varadé et al.
814
Currently, vaccines are among the factors that, together with
hygiene, antibiotics and surgery, save the most lives181. Vaccina-
tion enabled the eradication of smallpox infection worldwide in
1980, and we are quite close to eradicating polio182. However, new
and better vaccines are urgently needed; e.g., a vaccine against
the new coronavirus 2019, SARS-Cov-2; prevalent pathogens, such
as human immunodeficiency virus (HIV); parasites, such as
Plasmodium spp., which produce malaria; and bacteria, such as
Mycobacterium tuberculosis. However, anti-vaccine groups in more
affluent countries are putting society at risk for a return of the Fig. 2 Effect of oncolytic virus on cancer cells. Oncolytic viruses
serious illnesses that had almost been forgotten, such as replicate inside tumor cells, which causes cell lysis. In addition, the
diphtheria and tetanus183, with an increase in measles in expression of viral antigens induces an antiviral immune response
unvaccinated people at epidemic levels, thus negating many of that helps destroy tumor cells
the advances made over many years.

Therapy with microorganisms Viral sequences can be modified by genetic engineering

Bacteria. Whole pathogens or their products can also be used in techniques, thus making the virus more prone to infect some cells
human therapy for some types of cancer. At the end of the XIX and enhancing viral infiltration and tumor tropism. Combinations
century, the father of immunotherapy, Dr. Coley, popularized the with other components (immunomodulators, drugs, and cytokines)
use of extracts from cultures of Streptococcus pyogenes and are also being explored to suppress antiviral immunity and enhance
Serratia marcescens184 (called Coley’s toxin) for the treatment of antitumoral cytotoxicity199.
patients with sarcoma, lymphoma, testis cancer, etc., but because
of variable results and, indeed, cases of death, these treatments Other vaccines
were discontinued. Later, because of the research on cancer Vaccines for cancer prevention. It is clear that certain viruses and
performed by Dr. Lloyd J. Old with Mycobacteria, bacillus Calmette- bacteria play roles in cancer development. Viruses such as genital
Guérin (BCG) was approved by the American Food and Drug herpes, hepatitis B, Epstein Barr or human papilloma and bacteria
Administration (FDA) in 1976 for use in a therapeutic procedure such as Helicobacter pylori have been associated with cancers of
for bladder cancer —a treatment that is still in use today185,186. the uterus and liver, in Burkitt’s lymphoma, and oral/genital and
More recently, and with the increased knowledge of the human stomach cancers, respectively200. Therefore, immunization against
microbiome, the use of microorganisms in therapy has seen a these pathogens offer protection not only from infection but also
resurgence. Some intestinal infections, such as those produced by from cancer.
Clostridium difficile, can be cured with the transfer of intestinal
bacteria from healthy people (feces transplantation)187. Numerous Therapeutic vaccines. Once an illness has developed, the inten-
other attempts to use microorganisms to cure inflammatory tion of a therapeutic vaccine is to eliminate or decrease its
illnesses (Crohn’s disease, ulcerative colitis, etc.) have met with pathology. Thus, vaccines are used for cases of allergies, cancers
limited success188, which indicates that this type of therapy is and autoimmune diseases.
much more complex than initially anticipated. As a consequence,
many more studies are required to ensure that this approach can Allergy (Type 1): Allergen-specific immunotherapy (AIT) aims to
be used for curative immunotherapy. Researchers are also working modulate the immune system against an allergen, thus modifying
on genetically modified or artificial bacteria (e.g., based on the natural course of the allergic disease and conferring long-
Salmonella enterica, Listeria monocytogenes or Lactobacillus lactis), lasting benefits201. The basic AIT involves the introduction of
but only limited effects have been observed to date189. repeated doses of allergen (either injectable or sublingual allergen
extract tablets) and often in escalating doses in a controlled
Oncolytic viruses (OVs). Although the use of bacteria in anti- manner, followed by a maintenance phase. In cases for which
tumoral therapy has been largely restricted, the use of therapeutic long-lasting tolerance is acquired, therapy may be discontinued.
viruses is increasing. Virus-based therapy was introduced in the Allergen extracts can be obtained from different sources, such as
1990s with the use of adenovirus, but only in recent years has it cat hair and pelt, mites, different types of pollen, venom protein,
been used in practice in the clinic. Oncologic viruses190 have the foods, etc. Allergy vaccines are currently the only effective therapy
capacity to attack tumor cells in a preferential manner and induce that can stop the progression of the illness because treatment
immunogenic cell death (ICD) and host antitumor immunity with anti-inflammatory drugs, such as anti-histaminic drugs or
(Fig. 2). corticoids, mitigates the symptoms of the allergic processes but
The first virus approved for use in therapy was a recombinant does not modify the natural course of the disease202,203.
oncolytic adenovirus named H101, which was licensed in 2005 by AIT has been shown to induce the activation of antigen-specific
the China Food and Drug Administration (CFDA) for treating head Tregs and IL-10-producing Bregs (Br1) subtype cells, which is
and neck carcinoma in combination with chemotherapy191. Ten combined with anergy caused by Th2 cells201 and the production
years later, the oncolytic attenuated-modified virus herpes simplex of allergen-specific IgG antibodies that can compete with IgE for
I-talimogene laherparepvec (T-VEC, Imlygic®) was approved by binding to allergens204.
both European (EMEA) and American (FDA) agencies for the In the past, most vaccines were developed using natural
treatment of melanoma192. The virus is modified by the insertion allergen extracts. However, significant progress has been made in
of human GM-CSF and deletion of the ICP47 gene. Since the recent years to correctly characterize the allergen at the molecular
approval of T-VEC, a new era has dawned on the use of OVs in level, and some of these allergens are now being produced by
cancer therapy193,194. recombinant technologies, nucleic acid-based strategies, or
Currently, oncolytic viruses from the Adenoviridae, Herpesviridae, synthetic peptide chemistry205.
Picornaviridae, Reoviridae and Poxviridae families are in different
phases of clinical studies for several types of tumors194,195. For Cancer: Another therapeutic approach for vaccines is in the field
example, reovirus against brain tumors (alone or combined with of cancer. Therapeutic cancer vaccines that contain self- or
other therapies)196 or Maraba virus against triple-negative breast nonself-patient tumor lysates, viral vectors, mutated tumor
tumors197,198 offer some hope to patients with these types of cancer. proteins or peptides, among other types206 administered in the

Cellular & Molecular Immunology (2021) 18:805 – 828

 Human immunology and immunotherapy: main achievements and challenges
J Varadé et al.
815
presence of adjuvants can activate the immune system to induce many patients with humoral immunodeficiencies are successfully
antitumoral responses207. The goal is to activate the Th and Tc cell being treated to prevent them from catching infectious diseases.
compartments to expand specific cytotoxic T and NK cells directed More recently, the therapeutic applications of immunoglobulins
against tumor cells. have expanded to other diseases, such as against COVID-19
Some vaccines are more immunogenic than others, and this caused by SARS-Cov-2 infection (see below), autoimmune
effect can be related to several factors, such as the types/numbers disorders and Kawasaki syndrome in children218. The beneficial
of genetic mutations in the tumor, expression of neoantigens, effects seem to be mediated by several immunological mechan-
production of viral proteins, an immunosuppressive environment, isms, including viral neutralization, inhibition of inflammatory cells
lack of expression of histocompatibility complex molecules, etc., and activation of immune regulators214.
which together may explain the large variability in tumor
elimination208. Therapeutic cancer vaccines are generally very Monoclonal antibodies (mAbs)
safe, and major secondary effects have not been observed, The development of monoclonal antibodies (mAbs) by C. Milstein
although large differences in patient responses are detected. and G. Köhler in 1975219 (Nobel Prize winners for Physiology/
Moreover, this strategy may be used in conjunction with other Medicine in 1984) changed medicine and immunology comple-
complementary therapies209, such as monoclonal antibodies, tely, along with many other disciplines. Monoclonal antibodies are
chemotherapy or cellular therapy209,210. Several patients are produced from the fusion of two cells to generate a hybrid cell or
currently taking part in clinical trials and are receiving therapeutic hybridoma with two characteristics, i.e., the production of one
cancer vaccines against different types of tumors, such as lung specific antibody and immortality. Dr. Milstein is considered to be
(ClinicalTrials.gov Identifier: NCT04397926), prostate (ClinicalTrials. the father of modern immunology for his crucial contribution220.
gov Identifier: NCT03525652) or pancreas (ClinicalTrials.gov The development of many different mAbs has enabled the
Identifier: NCT04161755), using individual or combined therapies. identification of new molecules and the development of more
accurate diagnostic approaches; specific, fast and inexpensive
Autoimmunity: In the case of therapeutic vaccines for auto- technologies; processes for the purification/concentration of
immune diseases, such as multiple sclerosis, diabetes, Myasthenia compounds; and better and more specific therapy. mAbs can
gravis or Guillain Barré syndrome, the intention is to induce now be used against specific targets according to the concept of
tolerance to self-antigens through the activation of regulatory the “magic bullet”, a term coined by Dr. Paul Ehrlich at the
cells (Tregs and Bregs) and tolerogenic dendritic cells, thus beginning of the XX century (reviewed in ref. 221).
avoiding the immune response to self-components211. Due to the Numerous different mouse and rat mAbs were produced
large variety of autoimmune diseases, the different etiologies and against several molecules, but due to their murine origin, patients
extensive variability, even in the same type of disease, designing a treated with these mAbs suffered from hypersensitivity and
vaccine that can be useful for a wide range of patients is very immune responses222,223. Thus, most mAbs currently used in
difficult. clinical applications are linked to radioactive elements and used
However, several researchers are obtaining good results in for diagnostic purposes (Table 2).
animal models with nanostructures and peptides that In an effort to avoid immunogenicity, mAbs were
induce specific tolerance, and it is predicted that, in the near subsequently modified by genetic engineering approaches to
future, these types of therapies will be applied to patients carry mostly sequences of human origin. Several research groups
suffering from autoimmune diseases (reviewed by Serra and and companies developed chimeric and humanized mAbs
Santamaria212). (Table 2), and these mAbs included additional modifications,
such as changes in the carbohydrates (glycosylation) and/or
Polyclonal antibodies (pAbs)—serotherapy antibody regions, with the aim of improving their therapeutic
The discovery of antibodies by Dr. E. von Behring and Kitasato213 action224–228. Moreover, fragments of recombinant antibodies
at the end of the XIX century highlighted the potential of (Fabs, single-chain Fvs, different V regions, fusion proteins, smaller
antibodies to neutralize tetanus and diphtheria toxins. This antibodies, etc.) increased the variability of these potential
discovery opened the way to exploring the potential clinical therapeutic agents.
applications of conventional antiserum-containing polyclonal The generation of fully human mAbs took more time due to
antibodies from immunized animals/humans214. This “serother- technical difficulties and ethical issues; therefore, researchers
apy” was initiated by Dr. Roux and Dr. Yersin, who used anti- sought alternative methods to conventional approaches, such as
diphtheria serum to treat several children215. After this initial the development of transgenic animals carrying human immu-
success, the use of serotherapy was increased for use against noglobulin genes using minilocus vectors, artificial yeast/human
diphtheria and other diseases but also led to the identification of chromosomes or P1 vectors. The generation of knockout mice (in
problems, such as immunogenicity with the formation of immune which mice lack Ig genes) and further crosses with transgenic
complexes (Arthus reaction), the variability and limitation of the mice carrying human antibody sequences led to the generation of
antibody batches, the content of a mixture of classes and mouse strains that were able to produce fully human mAbs229,230.
subclasses of antibodies with different biological activities, and Other initiatives, such as the generation of immunodeficient mice
their temporal effects. For all of these reasons, therapy with in which human bone marrow or libraries of recombinant phages
polyclonal antibodies was very much restricted to special cases, carrying human variable genes were reconstituted, allowed the
such as the use of gamma-globulins for the prevention of Rhesus development of more fully human antibodies (Table 2). Sir Greg
(RH) maternal-fetal incompatibility and tetanus or snake venom Winter, Nobel Prize winner in Chemistry in 2018231,232, became the
toxicity216. pioneer of mAb humanization through the genetic engineering of
With the identification of gamma-globulin-deficient patients by an antibody (Campath 1), later developing a fully human antibody
Dr. Bruton in 1952217, the use of immunoglobulins as therapeutic (antitumor necrosis factor alfa, TNF-a) using recombinant phage
molecules for the treatment of humoral immunodeficiencies was technology225,233,234. Several companies are currently developing
initiated. However, some problems were encountered in the initial human antibodies using these and new technologies (reviewed
phases, mostly related to the serum preparation and aggregation/ in225,227,233,234).
fragmentation of antibodies. Since their initial use, several efforts Since 1975, the list of approved mAbs for human therapy has
have been made to avoid impurities and to improve the continued to increase (Table 2), and many more mAbs are in
purification process, and several commercial products are now clinical trials235–237. The versatility of mAbs is based on a different
available (as intravenous or subcutaneous preparations). Currently, mechanism of action238:

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 816
Table 2. List of some approved monoclonal antibodies for clinical applications

FDA Antibody Commercial name Target antigen Clinical application

Murine
1996 Arcitumomab CEA-scan Murine- CEA (carcinoembryonic Diagnostic imaging of colorectal cancers
(99mTc) antigen)
2014 Blinatumomab Blincyto CD19 B-cell precursor acute lymphoblastic leukemia
1996 Capromab pendetide ProstaScint Murine- PSMA (prostate specific Detection of prostate tumor
(111In) membrane antigen)
2004 Fanolesomab NeutroSpec Murine- CD15 Diagnosis of appendicitis
(99mTc)
2002 Ibritumomab tiuxetan Zevalin Murine-(90Y) CD20 Non-Hodgkin lymphoma therapy
1996 Imciromab-Pentetate Myoscint Murine- Heart myosin Cardiac imaging
(111In)
1986 Muromonab-CD3 OKT3 Murine CD3 Prevention of rejection of kidney, heart and liver allografts. No longer in production.
1996 Nofetumomab merpentan Verluma Murine CAA (carcinoma-associated Diagnosis of several cancers (lung, gastrointestinal, breast, ovary, pancreas, etc.)
Fab—(99mTc) antigen)
1992 Satumomab pendetide OncoScint Murine- TAG-72 Ovarian and colorectal cancer diagnosis (radioimaging)
(111In)
2003 Tositumomab/Iodine 131 Murine-(131I) CD20 Non-Hodgkin follicular lymphoma
Tositumomab
Chimeric
J Varadé et al.
Human immunology and immunotherapy: main achievements and challenges

1994 Abciximab ReoPro Platelet glycoprotein High-risk angioplasty

1998 Basiliximab Simulect CD25 Immunosuppressant agent to prevent rejection in organ transplantation
2011 Brentuximab vedotin Adcetris CD30 + drug Anaplastic and cutaneous large cell lymphomas; Hodgkin lymphoma
2005 Catumaxomab Proxinium EpCAM Malignant ascites with EpCAM-positive carcinomas
2004 Cetuximab Erbitux EGFR Colorectal, head and neck cancer
2015 Dinutuximab, Unituxin/Isquette GD2 Neuroblastoma
Dinutuximab beta
1998 Infliximab Remicade TNF-α Psoriasis, Crohn’s disease, ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis and ulcerative colitis.
2016 Infliximab Inflectra and other TNF -α Psoriasis, Crohn’s disease, ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis and ulcerative colitis.
biosimilars
2016 Obiltoxaximab Anthim B. anthracis toxin Bacillus anthracis toxin
1997 Rituximab Rituxan, and other CD20 Non-Hodgkin lymphoma, rheumatoid arthritis, chronic lymphocytic leukemia, and others
biosimilars
2014 Siltuximab Sylvant IL-6 Multiple myeloma and other tumors
Humanized
2001 Alemtuzumab Campath CD52 Non-Hodgkin lymphoma, chronic lymphocytic leukemia, multiple sclerosis.
2016 Atezolizumab Tecentriq PD-L1 Urothelial carcinoma, small cell lung cancer, triple-negative breast cancer
2010 Atlizumab or tocilizumab Actemra/RoActemra IL-6R Rheumatoid arthritis, systemic juvenile idiopathic arthritis, giant cell arteritis, cytokine release syndrome.
2004 Bevacizumab Avastin VEGF-A Colon, lung, glioblastoma, renal-cell carcinoma; age-related macular degeneration.
2008 Certolizumab pegol Cimzia TNF-α Morbus Crohn, rheumatoid arthritis
1997 Daclizumab Zenapax CD25 Prevention of allograft rejection
2016 Daclizumab Zinbryta CD25 Multiple sclerosis. Withdrawn from the market in 2018
2007 Eculizumab Soliris C5-complement factor Paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome and neuromyelitis optica

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 Table 2. continued
FDA Antibody Commercial name Target antigen Clinical application

2003 Efalizumab Raptiva CD11a Psoriasis treatment. Withdrawn from the market in 2009
2015 Elotuzumab Empliciti SLAMF7-CD319 Multiple myeloma
2000 Gemtuzumab ozogamicin Mylotarg CD33-drug Relapsed acute myeloid leukemia.
2015 Idarucizumab Praxbind Dabigatran etexilate Reversal of anticoagulant effects of dabigatran
2016 Ixekizumab Taltz IL-17A Moderate to severe plaque psoriasis, active ankylosing spondylitis
2006 Natalizumab Tysabri α4β1 Multiple sclerosis, Crohn’s disease
2013 Obinutuzumab Gazyva CD20 Follicular lymphoma
2017 Ocrelizumab Ocrevus CD20 Immunosuppressive drug, relapsing forms of multiple sclerosis (MS)
2003 Omalizumab Xolair Ig E Severe asthma
1998 Palivizumab Synagis Protein F Prevention of respiratory syncytial virus infections
2014 Pembrolizumab/ Keytruda PD-1 Several types of cancer (metastatic solid tumors)
Lambrolizumab

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2012 Pertuzumab Perjeta HER2 HER2-positive metastatic breast cancer and as neoadjuvant
2006 Ranibizumab Lucentis VEGF-α Age-related macular degeneration
2016 Reslizumab Cinqair IL5 Eosinophil-meditated inflammation (asthma)
2010 Tocilizumab or atlizumab Actemra/RoActemra IL-6R Rheumatoid arthritis, systemic juvenile idiopathic arthritis, giant cell arteritis, cytokine release syndrome
1998 Trastuzumab Herceptin HER2/neu HER2-positive breast and stomach cancer
2013 Trastuzumab-emtansine Kadcyla HER2/neu HER2-positive metastatic breast cancer
2014 Vedolizumab Entyvio Integrin-α4β7 Ulcerative colitis and Crohn’s disease
Human
2002 Adalimumab Humira, Trudexa TNF-α Rheumatoid arthritis, psoriasis, Crohn’s disease
2006 Panitumumab Vectibix EGFR Metastatic colorectal carcinoma
2016 Adalimumab Amjevita and other TNF-α Arthritis rheumatoid, psoriasis, Crohn’s disease
J Varadé et al.

biosimilars
2015 Alirocumab Praluent PCSK9 High levels of LDL cholesterol
2017 Avelumab Bavencio PD-L1 Gastric cancer, Merkel-cell carcinoma
2011 Belimumab Benlysta BAFF Systemic lupus erythematosus
2016 Bezlotoxumab Zinplava C. difficile B toxin Prevention of recurrence of Clostridium difficile infection
2017 Brodalumab Siliq/Kyntheum IL-17RA Severe plaque psoriasis
2009 Canakinumab Ilaris/ACZ885 IL-1b Cryopyrin-associated periodic syndromes, autoinflammatory syndromes
2015 Daratumumab Darzalex CD38 Multiple myeloma
2010 Denosumab Prolia/Xgeva RANKL Osteoporosis at high risk of fractures
2017 Dupilumab Dupixent IL4Rα Allergic diseases, atopic dermatitis, asthma and nasal polyps
2017 Durvalumab Imfinzi PD-L1 Bladder and lung cancer; other tumors
2015 Evolocumab Repatha LDL-C/PCSK9 Hyperlipidemia
2009 Golimumab Simponi TNFα Rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis
2011 Ipilimumab Yerboy CTLA-4 Melanoma, renal cell carcinoma
2015 Necitumumab Portrazza EGFR Squamous non-small cell lung carcinoma
2015 Nivolumab Opdivo PD-1 Several types of cancer (melanoma, lung, renal, colon, liver, etc.)□
2009 Ofatumumab Arzerra CD20 Chronic lymphocytic leukemia
Human immunology and immunotherapy: main achievements and challenges

817
 Human immunology and immunotherapy: main achievements and challenges
J Varadé et al.
818
– Neutralization/blocking of soluble elements. For example, the

advanced gastric cancer, gastro-esophageal junction adenocarcinoma; other tumors (non-small cell lung
neutralization of cytokines (TNF-α) and growth factors
(vascular endothelium growth factor) prevents the exhibition
of their effects, i.e., inflammatory and angiogenic effects,
respectively239,240.
– Complement activation. IgG/IgM antibodies activate the
complement cascade by the classical route, which leads to
the death of the target cell241,242.
– Cytotoxicity mediated by NK cells. NK cells can facilitate mAb
killing of target cells. The mAb, after binding to a target cell,
can attach to Fc receptors on the surface of NK cells to trigger
the release of granzymes and perforin, thus inducing cell
target death243,244.
– Induction of cell death by apoptosis. Certain mAbs directed
against some membrane molecules can directly activate apop-
tosis243.
– Blocking activation signals. Antibodies can block some
membrane receptors and avoid cell activation/proliferation
activation/proliferation243,245.
carcinoma, colorectal cancer, hepatocellular carcinoma)
Prophylaxis and treatment of inhaled Bacillus anthracis

– Carriers of toxins, pro-drugs, enzymes, and radioactive

elements. mAbs are able to concentrate select compounds
Psoriasis, ankylosing spondylitis, psoriatic arthritis

around target cells, providing a much more selective therapy

than conventional chemo- or radiotherapy244.
Psoriasis, Crohn’s disease, ulcerative colitis

– Check point inhibitors. Leading to a recent revolution in

cancer therapy, the identification of several inhibitory
molecules can be blocked by mAbs, thus leading to the
activation and proliferation of antitumoral T cells.
Molecules such as CTLA-4 and PD1 and its ligand PDL-1,
maintain immune cells under controlled conditions. However,
it is possible to reactivate the antitumoral immune responses
by blocking some of these molecules with mAbs,
Soft-tissue sarcoma
Clinical application

either directed to only one of them or by using various

antibodies in combination (for example, against CTLA-4
and PD1)246.

The results obtained with these therapeutic mAbs against

checkpoint inhibitors in some types of cancer have been amazing.
For their contribution to the understanding of the roles of CTLA-
4247 and PD-1248, the Swedish academy gave the Nobel Prize in
2018 to Dr. J.P. Allison and Dr. T. Honjo, respectively249. However,
this therapy is not efficacious in all types of cancers for several
reasons, such as the expression of these and other checkpoint
inhibitors in immune cells, the number of antitumoral cells in each
Bacillus anthracis,
Target antigen

patient, an immunosuppressant microenvironment, the rate of

IL-12/IL23 p40
Anthrax toxin

cancer mutations, and the expression of histocompatibility

PDGFR-α

molecules.
VEGFR2

IL-17A

Recombinant proteins
There is a large list of recombinant proteins that are currently
being used for human therapy, including interleukin 2 (IL-2),
Commercial name

interferons (IFNs) and GM-CSF.

IL-2 was identified in 1976 as a growth factor for T lymphocytes,
and soon after Dr. Rosenberg started to use it in antitumoral
Cosentyx
Cyramza
Lartruvo

therapy250,251. Years later, in 1991, IL-2 was approved by the FDA

ABthrax

Stelara

for patients with metastatic renal cancer and in 1998 for the
treatment of metastatic melanoma251.
Interferon (IFN) was described in 1957 by Isaacs and Linden-
mann252. The interferon family is the largest family of cytokines
and is classified into three different types (I, II, and III). Type I IFNs
(including IFN-α and IFN-β) exhibit several molecular actions that
may be very relevant for use in therapy for a range of pathologies
2014 Ramucirumab

2015 Secukinumab
2012 Raxibacumab
Table 2. continued

2009 Ustekinumab

(such as autoimmune diseases and cancers)253. In 1986, the FDA

2016 Olaratumab
FDA Antibody

approved human IFN-α2a and IFN-α2b for patients with hairy cell
leukemia and later on for patients with multiple sclerosis. Since
their initial use, these interferon species have been approved for
many other diseases, including chronic hepatitis B and C,
lymphoma, advanced melanoma, and as adjuvants together with
other therapies for several types of cancers254,255.

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J Varadé et al.
819
Another cytokine is GM-CSF, which activates the production of recognized their potential in other situations, such as transplant
granulocytes and monocytes from bone marrow myeloid pro- rejection and pregnancy. NK cell lines, memory-like NK cells and
genitors and has shown adjuvant antitumoral effects256,257. Other stem cell-derived NK cells are additional types of cells that can be
cytokines, such as IL-5, IL-7, IL-12, IL-15, IL-18, and IL-21258,259, are used for tumor immunotherapy273.
being tested in several clinical trials, and it is expected that some Regarding other cellular therapies, NK cells as substitutes for
of them, either alone or in combination, can be used in future T cells for use upon transformation with an chimeric antibody
antitumoral therapy. receptor (CAR) are being explored (see below).
Other recombinant proteins are already on the market, some of
which are derived from antibodies, with some advantages such as Dendritic cells. Paul Langerhans identified dendritic cells in
small size, low immunogenicity and general ease of production. human skin in 1868274, but these cells were not named until
Examples are etanercept and abatacept (CTLA-4 Ig), which were 1973 by Dr. Ralph M. Steinman (Nobel Prize in 2011) and Dr. Zanvil
approved by the European Medicines Agency in 2000 and 2007, A. Cohn, who chose the term because the cell morphology, with
respectively. The former is a chimeric protein that carries the long extensions, resembles that of neuronal dendrites275. In
external portion of the tumor necrosis factor (TNF) receptor linked humans, dendritic cells are obtained from different sources that
to the IgG Fc region, which captures soluble TNF to block its vary in origin, maturation state and tissue distribution (skin,
inflammatory effects260. The latter example is a fusion protein that lymphoid tissue, circulating cells). Among the main types of
combines the extracellular portion of human CTLA-4 and IgG1 Fc. dendritic cells, plasmocytoids are conventional myeloid DC1 and
Abatacept is a competitive inhibitor that blocks T-cell activation DC2, pre-DC and monocyte-derived dendritic cells. In the
and can be used in the treatment of inflammatory illnesses such as epidermis, there are three types: Langerhans cells (LC),
rheumatoid arthritis261. monocyte-derived LC-like cells and inflammatory dendritic epi-
dermal cells (IDECS)276. As indicated above, DCs are antigen-
Cellular immunotherapy presenting cells and are the only cells that are able to activate
Natural killer (NK) and lymphokine-activated killer (LAK) cells. Nat- naïve T lymphocytes. A subpopulation of DCs also carries out a
ural killer (NK) cells were described in the 1970s based on their process known as cross-presentation. In this way, they facilitate
capacity to eliminate tumor cells without prior sensitization, with the activation of both helper and cytotoxic T lymphocytes277. In
differences observed compared with specific cytotoxic T cells addition to their participation in the immune response, they can
(which are activated based on the recognition of the target be used in antitumoral therapeutic vaccines277,278.
cells)262,263. In 1985, Piontek et al. reported that NK cells have the It is possible to generate a type of blood monocyte-derived
ability to preferentially kill cells that had lost the expression of the dendritic cell in the presence of a mixture of cytokines in
major histocompatibility complex class I molecules264,265. culture279—a process that induces their subsequent maturation
Lymphokine-activated killer (LAK) cells are a heterogeneous and activation in the presence of tumor antigens (cell lysates,
population that includes not only NK but also NKT and T cells, recombinant or purified antigens, peptides, RNA, DNA, and viral
which can be generated in an in vitro culture of peripheral blood vectors280). These cells can also be obtained from bone marrow
mononuclear cells (PBMCs) in the presence of IL-2266. Dr. hematopoietic CD34 + progenitor cells281. Other sources, such as
Rosenberg and collaborators carried out studies using these cells circulating or skin dendritic cells, are relatively scarce and are
in the presence of IL-2 (reviewed by Rosemberg251). These LAK therefore not usually used.
cells showed good antitumoral responses in 22% of the melanoma After their differentiation and activation in vitro278,282, DCs are
patients who received them as therapy250. However, secondary exposed to tumor antigens and infused back into the patient
effects such as liver toxicity and the expansion of the Treg (either by blood infusion or injected into areas near the lymph
population limited their therapeutic effect. Researchers started to nodes or even directly into them) to reach the secondary
design new recombinant IL-2 with some mutations to avoid the lymphoid organs as soon as possible, at which point they can
activation of Tregs267, with linking it to polyethylene glycol (PEG) present antigens to the T cells. This approach is a type of
to increase its half-life and efficacy268. individualized therapy and is therefore expensive.
Another cytokine described later, IL-15, showed similarities to The first approved vaccine in which autologous dendritic cells
IL-2 in many respects269, and it had some unique advantages, such were used was Sipuleucel-T (Provenge)283, which was a treatment
as the capacity to activate NK and cytotoxic T cells (Tc) but not for prostate cancer refractory to hormonal treatment. Immu-
Tregs. IL-15 is being used in different versions (alone, as a notherapy with dendritic cells is currently being tested in more
heterodimer with receptor IL-15/IL15Ra or IL15Rα IgFc, or in an than 200 clinical trials for various tumors: brain, pancreas,
agonist complex with ALT-803)269 and in combination with other mesothelioma, melanoma and many others (ClinicalTrials.gov
therapies in several clinical trials (examples: NCT01021059, Identifiers: NCT01204684, NCT02548169, NCT02649829, and
NCT03905135, and NCT03759184). NCT03300843, respectively). The data indicate that the therapy
More recently, researchers have focused their attention on is well tolerated and has led to increased patient survival in some
other cytokines and combinations (such as IL-15, IL-12, and IL- trials. Furthermore, complete cure and partial remission outcomes
18)270, which are able to activate NK cells in vitro and induce a have also been observed. The lack of efficacy on other tests was
good responses in animal models. In some human clinical trials, probably due to the presence of immunosuppressive factors in the
remission has been observed for patients with acute myeloid tumor environment.
leukemia271,272, which broadens the options for the use of NK cells Another therapeutic use of dendritic cells involves their
in the treatment of this pathology. induction of immunosuppression both in transplants and in
The properties of NK cells reveal their versatility as treatments autoimmune diseases284. In an autoimmune pathology such
against tumors. NK cells are able to kill tumors through several as multiple sclerosis, the intention is to achieve stable
mechanisms, including receptor-mediated cytotoxicity, antibody- tolerogenic dendritic cells that can act against some autoantigens
dependent cell-mediated cytotoxicity (ADCC) and death receptor- (such as myelin peptides) in the presence of vitamin D3,
mediated apoptosis, but they also secrete cytokines such as dexamethasone, or other agents285. Phase I clinical trials have
interferon gamma that enhance the antitumoral adaptive immune generally shown good tolerance to this therapy without serious
response. NK cell adoptive transfer (either autologous or allogenic adverse effects286.
NKs) is currently being tested in clinical trials for hematological However, greater control of this treatment is necessary in
diseases and solid tumors, and numerous research groups have several respects to obtain the best therapeutic results284; e.g., the

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 Human immunology and immunotherapy: main achievements and challenges
J Varadé et al.
820
type of dendritic cells and ex vivo differentiation, the antigens This situation changed because of one of the latest revolutions
used, and the injection route are important considerations. in antitumor therapy, the development of T lymphocytes that
carry a chimeric antigen receptor (CAR) based on a specific
Gamma/delta T cells (Tγ/δ). Human T cells expressing γ/δ TCR antibody directed to a target surface molecule299,300. These
cells have interesting properties, including the capacity to kill a modified T cells can directly recognize tumor cells without
broad range of tumor cells. The advantages of these cells in cancer required antigen processing or presentation by professional
therapy are based on their independence from MHC expression antigen-presenting cells. Moreover, the CAR includes all of the
on tumor cells and that their relative insensitivity to some inhibitor necessary elements for intracellular signaling and activation of
molecules (such as PD-1). The initial clinical application, with the helper and cytotoxic T lymphocytes.
adoptive transfer of autologous Vδ2+ cells after ex vivo expan- CAR therapy was developed by one of its pioneers, Dr. Carl June
sion, showed only sporadic responses287, and different exploratory at the University of Pennsylvania in the United States300, who used
studies are currently being carried out to increase their modified T lymphocytes that carried a chimeric antigen receptor
clinical therapeutic use. Allogeneic Vδ2+ cells are also being to target CD19+ leukemic B cells. After interacting with CD19+
explored in cancer therapy; e.g., they are being used against cells, these modified CAR T cells were activated and able to
refractory hematological malignancies288 and advanced proliferate and exert cytotoxic functions against target cells. In this
cholangiocarcinoma289. case, both tumor and healthy B cells were affected. Although bone
marrow continues to produce B lymphocytes, in cases of severe B
Regulatory T cells (Tregs). Although the basis of immune lymphopenia, it is possible to provide exogenous immunoglobu-
regulation was suggested centuries ago, regulatory T cells were lins periodically.
described by Sakaguchi et al. as CD4+ CD25+ natural regulatory The whole process of the current CAR T-cell therapy begins with
T cells290 that expressed the forkhead box P3 transcription factor blood donation, from which lymphocytes are purified and
(foxp3)291. Later, induced or adaptive regulatory T cells were also genetically modified in vitro by a viral vector, which carries
identified, including different subsets that carry several pheno- the genes coding for the chimeric antigen receptor. The cells are
typic markers and express various cytokine secretion profiles292. expanded in the presence of cytokines in culture and are
All of these factors play crucial roles in the maintenance of subsequently reinfused into the patient. This type of cellular
immunological self-tolerance by suppressing autoreactive T cells. immunotherapy is individualized for each patient, with his/her
The manipulation of Tregs to achieve therapeutic outcomes is a CAR T cells ultimately destroying the tumor.
field of great interest, because of both their expansion and Since the first generation of CARs appeared, namely, a chimeric
activation in diseases, such as allergic and autoimmune diseases, receptor composed of an anti-CD19-specific single-chain variable
and as a potential targets for cancer immunotherapy293. fragment linked to a transmembrane domain and intracellular
signaling domain of the T cell receptor (CD3 ζ chain), researchers
Tumor-infiltrating lymphocytes (TILs). Lymphocytes that infiltrate started to modify the original design. New generations of CARs,
solid tumors are called tumor-infiltrating lymphocytes (TILs). In including the CD3 ζ subunit together with other signaling
1957, Thomas and Burnet proposed that the immune system domains, such as CD28, CD134, CD137 (4–1BB), CD27, and ICOS,
performs tumor immune vigilance, with lymphocytes as sentinel or combinations (CD3 ζ, CD28, and CD134)301, have been
cells leading to the elimination of somatic cells transformed by developed in the second and third generations of CARs to
spontaneous mutations294,295. improve several aspects, such as the activation, proliferation and
Since the end of the 1980s, Dr. Rosenberg has been trying to survival of CAR T cells. The fourth generation of CARs show
prove and improve the effective use of TILs. The process starts improved the antitumoral effects by carrying additional molecules
with surgery and the isolation of TILs from a tumor, followed by (such as cytokines or drugs), improvements to the safety of CAR T-
TIL activation in culture in the presence of cytokines, cellular cell therapy through the use of suicide genes301 and many new
expansion and, finally reinfusion into the patient. Since its designs, such as dual CARs or the so-called split universal and
inception, this therapy has been improved markedly, with an programmable (SUPRA) CAR system302.
increase in optimal responses from less than 30% to the current In addition to T cells, other types of cells, such as NK cells, are
50–75%, in some cases. These higher success rates are due, in now being explored for use in antitumoral responses303. In an
particular, to the prior preparation of the patient, including the effort to avoid using personalized treatment, researchers are now
depletion of lymphoid tissues, to avoid an expansion of regulatory working on universal CARs that may be used on many different
cells296, myeloid suppressor cells and other cells that can compete patients without inducing the problem of rejection304–307.
with the transferred TILs. The encouraging results obtained with this therapy have led to
Currently, there are more than 200 trials in which TILs are being interest from companies, and some commercialized examples are
used alone or in combination with other immunotherapies on available, although many more “in-house” or academia-produced
several tumors, such as melanoma, metastatic colorectal cancer, CARs are in clinical trials. CAR T-cell therapy was initially designed
glioblastoma, pancreatic cancer, hepatobiliary cancer, ovarian for use against hematological cancers (leukemia and lymphomas),
cancer and breast cancer. This individualized therapy has but many new opportunities have been opened for its use against
limitations; it can only be used on solid tumors, and the number solid tumors308, infectious diseases (such as HIV)309, allotransplan-
and specificity of the TILs and the type of tumor and tation, autoimmune diseases310 and severe allergies311. China and
microenvironment make standardizing this therapy difficult. the USA are the leading countries in producing CAR T-cell therapy,
and numerous clinical trials are underway.
Chimeric antigen receptor (CAR). Since TILs include a variety of T
lymphocytes with different specificities, the next step was to Immunotherapy for COVID-19 patients
obtain T cells of a single type (monoclonal cells) carrying a clonal Coronavirus disease 2019 (COVID-19), which is produced by severe
receptor capable of recognizing tumor antigens. This effort was acute respiratory syndrome coronavirus 2 (SARS-Cov-2), affects
carried out for the first time in mice and subsequently, in 2006, in millions of people in many countries. Most of the infected patients
humans with a transgenic TCR against the MART-1 melanoma (80–85%) are asymptomatic or have mild symptoms, but
antigen297,298. These types of receptors are known as tTCRs, but the disease in some patients progresses to a moderate or severe
their ability to recognize antigens is restricted since they can only illness that requires hospitalization in intensive care units because
identify the peptides presented by antigen-presenting cells on of respiratory distress, multiorgan failure, and/or other patholo-
self-histocompatibility molecules. gies, and more than one-half million fatal cases have been

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reported worldwide. The most vulnerable population includes that can induce protective immune responses to all or most of the
aging patients and those with comorbidities such as hypertension, variants318.
diabetes and cardiovascular diseases. 4. Researchers are developing alternative routes of administration
There are several aspects of the COVID-19 pathogeny that (e.g., oral, inhaled, intranasal, skin, rectum, vagina) as substitutes for
suggest an overreaction of the immune system in severely ill intramuscular or subcutaneous injections. One of the problems to
patients, with increased levels of inflammatory cytokines such as be solved is the immune tolerance developed to elements
IL-6, IL-1 and others (creating the so-called “cytokine storm”), delivered by the oral route, but some vaccines are already
together with blood lymphopenia and CD8 T cell and NK cell effectively administered by this route (such as the oral polio,
exhaustion. Special therapies have not yet been identified to cure cholera, typhoid fever and rotavirus vaccines). The intranasal route
these patients, and preventive vaccines are not yet available, but has also proven effective for some vaccines (nasal influenza
some immunotherapies have been proposed as adjunct therapies, vaccine), and vaccines administered through other routes are
and some of these are currently in different phases of clinical under investigation.
trials312. 5. Researchers are seeking the early protection of newborns319.
The immunotherapeutic strategies include the following: Newborns are very susceptible to infections due to their immature
immune system320. Moreover, the protection exerted by maternal
1. Targeting inflammatory molecules. To attenuate the antibodies transferred through the placenta during pregnancy
cytokine storm (IL-6 receptor, IL-6, IL-1, GM-CSF, VEGF, against some pathogens interferes with the development of the
etc.), monoclonal antibodies against receptors and/or newborn’s own immune response. Greater knowledge on ways to
cytokines, receptor antagonists and/or inhibitors are pro- activate the immature immune system early will enable the
posed. development of vaccines for newborns. Moreover, immunization
2. Passive immunotherapy. Patients who were infected and of pregnant women may help to enhance neonatal protection
recovered, but developed neutralizing antibodies against against several pathogens321.
the SARS-Cov-2 virus, can donate plasma to treat severe/ 6. Researchers are developing new and more effective vaccines.
critical patients. Some reports have indicated promising This effort is crucial for very prevalent pathogens such as
results in a low number of patients who received Mycobacteria tuberculosis, HIV virus or plasmodium falciparum.
convalescent plasma313,314, but conclusions cannot be Although there are treatments against these pathogens, most are
drawn until several randomized studies and more patients not curative—as in the case of HIV; prevention is the best way to
are analyzed. In addition to the use of convalescence stop their spread.
plasma, hyperimmune globulin therapy or monoclonal 7. Researchers are working to address emerging pandemics. In
antibodies directed against the virus have also been the case of new pathogens, such as SARS-Cov-2, which has
proposed, and clinical assays are ongoing. produced a recent global outbreak, effective vaccines are urgently
3. Immunomodulation therapy. Intravenous immunoglobu- required322. New technologies for vaccine formulations and routes
lins are aimed at blocking inflammation and preventing of administration, the identification of immune-related factors of
secondary infections312. This approach is being used with protection and modifications to the governmental regulatory and
success in cases of Kawasaki syndrome in children. approval process for vaccines for emerging pathogens are
4. Cellular immunotherapy. To date, very little attention has challenges that must be faced to achieve a rapid vaccination
been paid to the cellular immunotherapy approach in procedure for outbreaks. Hundreds of vaccines against SARS-Cov-2
treatments of COVID-19, but several attempts may include (using different strategies such as live attenuated or inactivated
the use of SARS-Cov-2-specific T and NK cells to trigger pathogens, viral vector-based, viral RNA, DNA, recombinant
antiviral responses and autologous or allogenic Tregs to proteins, peptides, etc.)323 are now under development, and some
modulate inflammatory processes. are in clinical trials. However, the need to develop a new vaccine in
a short period of time should not negate the main principles of
vaccination use: safety and immune protection.
Future challenges in immunotherapy 8. Researchers are working on genetic (RNA, DNA) vaccines
Immunotherapy has been used for centuries, but only in recent because they have great advantages, including no requirement for
years has this area expanded rapidly in several respects, mostly by growing a pathogen. Genetic vaccines can be obtained in a much
the use of soluble elements (monoclonal antibodies and shorter time, with much faster and safer production processes, and
cytokines) and, more recently, with immune cells (cellular can be transported much more easily. However, the immunogeni-
immunotherapy). There are many fields in which immunotherapy city of these vaccines must be improved, and other problems need
faces a range of challenges: be avoided, such as the potential deleterious effects of integrating
vaccine sequences into cells324.
Vaccines. 1. Researchers are working on reducing the number of 9. Researchers are developing safer and more powerful
injections by employing a combination of vaccines. Several adjuvants. Many years ago, the only adjuvant authorized for
current vaccines contain components from 3–6 pathogens in a vaccines was aluminum hydroxide (alum), but currently, several
single injection, and these are able to provide adequate protection adjuvants are on the market325. The use of ligands that activate the
against all of these pathogens315. innate immune response, such as those linked to TLRs or
2. Researchers are developing more stable and durable vaccines. nanostructures with adjuvant effects, is currently under study.
Improvements in the half-lives of vaccines, for example, by 10. Researchers are boosting trained immunity, a new concept
lyophilization, while maintaining immunogenicity is expected to related to the innate immune memory-like described for NK cells
reduce current problems, especially those involved in the (expansion) and macrophages (epigenetic modifications). Knowl-
transportation of vaccines to remote areas316. In this respect, edge of how to handle trained immunity will enable better vaccine
nanotechnology can help in the design of more stable vaccines that design and more effective secondary responses326.
lead to slow antigen release and improved immunogenicity317. 11. Researchers are seeking to eradicate diseases from the earth.
3. Researchers are working on vaccines that confer protection The greatest challenge, eradicating disease is possible in the short
against all serotypes of a specific pathogen (universal). This term for some pathogens, such as poliovirus. Very few cases of
outcome is especially important for pathogens with high variability polio have been recently reported, and these reports came from
(such as the influenza virus). Researchers are designing vaccines only three countries; therefore, it is feasible that this disease can be
that can protect against several variants by using common regions eradicated in the near future.

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12. Advances are challenged by the anti-vaccine movement. limits the viral replication. Several obstacles, such as low viral
Paradoxically, there are people who doubt the beneficial effects of delivery and spread, resistance to therapy and antiviral immunity,
vaccines, and they are putting the health of their own children and have been observed330. Thus, the main challenges with oncolytic
society in general at risk327. The effectiveness of community viruses are addressed by improving their antitumoral efficacy,
protection conferred through vaccinated people is disrupted by including the optimization of viral delivery, the development of
decreased numbers of immunized persons. This lesser coverage OVs engineered to activate the immune system (e.g., by releasing
enables pathogens to infect the most susceptible people, such as cytokines), and their use as adjuvant therapies or in combination
small children, elderly patients and those who cannot be vaccinated with other immunotherapeutic agents, such as immunomodula-
due to certain pathologies or because they are undergoing tors331.
immunosuppression treatment. Thus, news about the return of Regarding gut microbiota manipulation as a therapeutic
illnesses that were nearly forgotten, such as tetanus in Italy (the first approach, fecal microbiota transplantation is an effective therapy
case in 30 years), the death of a child in Catalonia from diphtheria, for recurrent Clostridium difficile infection332 and is now being
or the exponential increase of measles cases (already counted in investigated for other indications, such as inflammatory bowel
the thousands) worldwide328, should make parents think carefully disease and cancer. Some of the challenges facing microbiome
about the risks of not protecting children by vaccines. The World transplantation are the lack of precise knowledge about the
Health Organization (https://www.who.int/topics/vaccines/en/) complete microbiome and the mechanisms of action involved in
argues that anti-vaccine movements can roll back all the its therapeutic capacity, the large variability of its effectiveness
achievements thus far in this field and have cited this issue as and the external factors that affect it. More studies are centered
one of the main challenges to be resolved. Addressing the anti- on understanding how to manipulate bacterial colonies, the
vaccine movement requires a coordinated effort of professionals to discovery of therapeutic molecules, nutrient competitions, etc.,
inform parents adequately and perhaps other types of coercive that are required for successful application. The best type of
measures that some countries are already applying (financial fines, therapy (either individual or the combination of bacteria) is also
denial of access to public assistance in childcare units, removal of under debate, along with how to reach the market by translating
authorization to travel/live in some countries, new laws, and so on). this individualized therapy into commercial scale products. The
safety and potential adverse long-term effects are also being
Antibodies and cytokines. Immunotherapy with monoclonal assessed.
antibodies has been a true revolution for many pathologies, as
has the use of certain cytokines and recombinant fusion proteins. Other components (nanomaterials and small molecules). Nano-
It is therefore predicted that these approaches may have a bright materials. To obtain approval for the use of other elements from
future, and regulatory agencies are expected to authorize many incipient fields, such as the use of different types of nanostruc-
more mAb-based therapies in the coming years, especially given tures, either alone or in combination with other immunotherapies,
the good results obtained in clinical trials. Complete antibodies or it is important to resolve certain issues. In the case of nanoparticle
those modified to increase their functionality or decrease their use, a better understanding of the interaction between nanoma-
immunogenicity, combinations of antibodies and cytokines, anti- terials and biological media; nanoparticle biodistribution, meta-
body fragments, etc., are only some of the many possibilities for bolism and biocompatibility; and the reproducibility of the
this type of product, which will expand the range of therapeutic synthesis and scaled up production of nanomaterials are among
options. the issues to address.
One of the main problems regarding the use of antibodies in Small molecules. A greater knowledge of several molecules
therapy, especially in cancer, is based on their often unpredictable involved in the immune system has led to the development of
efficacy. Large variability in terms of remission and durable clinical new therapeutic agents, which have been synthesized by
benefits between patients is observed (for example, in the traditional chemistry and block or activate intracellular signaling.
antitumoral responses by antibodies directed to the checkpoint The low cost of production of these molecules, along with the
inhibitors). Thus, the main challenge is to understand the scaling and reproducibility of small-molecule batches, has
situations in which an antibody will have the desired effect. It is attracted the attention of pharmaceutical companies interested
crucial to find validated biomarkers (with predictive and/or in a whole set of new immunomodulatory drugs. A better
prognostic value) that can help to stratify or select patients for understanding of the mechanism of action of small-molecule-
the best immunotherapy. A better understanding is also required based drugs and proof that they offer higher efficacy than existing
for tumor heterogeneity, resistance to some drugs and immuno- therapies, either in monotherapy or in combination therapy, are
suppressive microenvironments329. An in-depth immunological challenges that face those seeking to engineer new types of
study, together with a personalized approach, is certainly the way targeting molecules.
to improve the success of these types of therapies.
In combination with conventional therapies (radiotherapy, Cellular immunotherapy. To date, cellular immunotherapy has
chemotherapy, and surgery), other immunotherapeutic drugs or been an individualized therapy with high production costs, and it
cellular immunotherapies can also help to maximize the efficacy of requires the involvement of multidisciplinary groups in hospitals.
this immunotherapy, but increases in toxicity will be another A real challenge in the field of cellular immunotherapy is the
challenge to face. acquisition of universal off-the-shelf cell therapies to replace those
currently made to order in a very personalized manner. The
Pathogens. The use of oncolytic viruses (OVs), bacteriophages development of universal cells, for example, in the case of CAR T-
that selectively infect bacteria, modified pathogens for vaccines or cell therapy, would increase the number of patients who could
for antitumor immuno-activation, and the manipulation/ mod- benefit from this treatment at thus reduce the costs.
ification of the microbiota are some of the therapies that are being Other challenging aspects of cellular immunotherapy are the
considered. life-threatening toxicity of induced and their lack of effect on solid
OVs are designed to kill tumor cells and to activate the immune tumors, which is mostly due to the immunosuppressive tumor
system against those cells. However, many of OVs have shown microenvironment. This approach requires new strategies to
limited therapeutic effects when applied in monotherapy; there- overcome these difficulties. In addition to cancer, cellular
fore, much more work is required to improve their systemic immunotherapy has a long history of use against autoimmunity,
antitumor effects and avoid the attenuation of the virus, which infectious diseases, allergies and transplantation rejection. It is also

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 Human immunology and immunotherapy: main achievements and challenges
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