Basic Science Research
On-going Research within Dermatology Includes:
1. Clinical trial using Imiquimod (an immune modulator) to
alter the course of atypical or dysplastic nevi.
Participants: Jane Grant-Kels, Carolyn Ray, Bijay Mukherji,
Victor Moyo, Upendra Hegde, Michael Murphy, Nitya Chakraborty,
Imiquimod cream, 5%, (FDA approved “Aldara” for topical
treatment of external genital/perianal warts) is an immune
response modifier that induces interferon production by
monocytes/ macrophages. It has been shown to induce immunologic
activity against human papillomavirus (HPV) by stimulating
significant increases in numerous cytokines including
interferon-alpha, interferon-gamma and IL-12. Additionally,
there is a suggestion of activation of the helper T-cell type
1-mediated response by increases in CD4, CD8, and tumor necrosis
factor-alpha (TNF-alpha) . In recent studies, Imiquimod has been
shown to be an effective treatment of superficial basal cell
carcinoma (sBCC) with response rates varying between 87.1% and
100% when used QD or BID respectively. There have been case
reports of the use of Imiquimod in the treatment of Malignant
Melanoma (MM); however, to our knowledge, there are no published
studies on the use of imiquimod in the treatment of dysplatic
nevi. The indication for interferon in the treatment of MM is
well established. Therefore, we postulate that a topical agent
capable of inducing interferon production might play a role in
the treatment of dysplastic nevi. Given the unique mechanism of
action of Imiquimod, the ease of its application to the skin,
and its effect in the treatment of sBCC and MM we propose that
it may also play a role in the treatment of dysplastic nevi. Our
pilot study will examine whether topical administration of 5%
Imiquimod cream will induce a localized inflammatory reaction
capable of reversing dysplasia in dysplastic nevi. If such a
response is observed, a case could be made for a potential role
for Imiquimod in the treatment of dysplastic nevi and in the
prevention of melanoma.
The immunologic effect of Imiquimod will be evaluated at the
local and systemic levels. It has been shown that Imiquimod acts
on the innate immune system by activating monocytes/macrophages
and dendritic cells through specific toll-like receptors (TLRs).
Although we do not anticipate major effect of topical
application on systemic immunity, we will undertake a full
phenotypic and functional characterization of the circulating
immunocytes at baseline and several times within the treatment
phase. This will include phenotypic analysis of the circulating
monocytes, NK cells and B and T cells. Specific attention will
be focused on their relative number, activation markers, and
cytoplasmic cytokines (IFNgamma, IL-12, IL-2, TNF, etc.). This
will be done using appropriate flow cytometric analysis. In
addition, natural killer cell activities will be assessed in
cytotoxicity assay against the NK sensitive target cells, K-562.
The local effect of Imiquimod will be evaluated by
immunohistochemistry and by in situ hybridization techniques.
Accordingly, a site treated with imiquimod (the IMTN) and an
untreated site (the IMCN) will be excised one week after the
initiation of topical Imiquimod application. These studies will
examine the nature of the response, in situ, by histopathology
and immunohistochemistry. This will allow us to determine the
nature of the infiltrating cells: Are they T cells, B cells, or
dendritic cells (DCs)? Do the infiltrating DCs express
upregulated co-stimulatory molecules, MHC class II molecules?
What type of cytokines [IL-2, IL-4, IL-10, IFNg , TNFa] can we
detect in their cytoplasm?
In addition, considering that Imiquimod is likely to activate
dermal antigen presenting cells (Langerhans cells and dermal DCs),
a concerted effort will be made to determine if the Imiquimod
treatment leads to the activation of DCs and antigen
presentation so as to generate melanocyte-associated epitope-specific
cytotoxic lymphocyte (CTL) response. For this purpose, T cells
will be expanded in culture from the treated and untreated
lesions. The expanded T cells will be phenotypically and
functionally chracterized with specific attention focused on
determining if the treatment activates and then recruits
antigen-specific CTLs, in situ, as another potential mechanism.
2. Proposal for future research: To carry out a phase I/II
clinical trial, in the melanoma model, with synthetic
peptide-based vaccines administered intradermally in sites
pretreated with imiquimod to create an inflammatory context as
well as to recruit and activate DCs, in situ.
Participants: Bijay Mukherji, Upendra Hegde, Jane Grant-Kels,
The principle on which we and others had based the approach
to cancer vaccine with peptide loaded APCs or with specific
peptides alone has been validated to a certain extent. These
approaches have shown biological and even some clinical
activities, however modest they may be. The modest clinical
gains have understandably led to a pessimistic view on peptide
and DC-based vaccines on one hand and raised the yearning for
better and more ideal cancer antigens as well as for alternate
forms of vaccination on the other. The major rationale for our
proposal is that, while the field waits for ideal antigens and
alternative forms vaccines, time has come for innovative steps
that could improve upon the result and move the field forward.
Considering that dealing with ex vivo cultured DCs has many
drawbacks yet recognizing the powerful and indispensable role of
DCs in antigen presentation, we believe that developing a
strategy(s), alternative to but still centering around the
pivotal role of recruiting DCs in the peptide vaccination
process, will be a step in the right direction. Since most
vaccines work through resident DCs and DCs recruited at the
sites, a strong rationale exists to develop an in vivo strategy
that could recruit as well as activate DCs in the process.
Adjuvants usually serve the purpose. Unfortunately, a good
adjuvant suitable for human use in peptide or protein-based
vaccines is not yet available although a number of agents are
being tested. We believe that imiquimod has the properties that
are essential – if not ideal – for the purpose of activating
resident DCs plus LCs, recruiting plus activating DCs from the
DC pool, and creating an inflammatory milieu through the
induction of critical pro-inflammatory cytokines, in situ.
Imiquimod has undergone extensive testing prior to receiving
FDA approval and additional information has since emerged to
clearly establish its biological and immunological properties.
Even its chronic topical use is well tolerated yet it is locally
inflammatory after two- three applications. Most importantly,
recent works have provided compelling proofs of its properties
as a biologic response modifier, in general, and its effect on
dermal DCs and LCs, in particular. As such, we believe that all
the essential ingredients are in place to move it to human
clinical trial as a potentially useful vaccine adjuvant without
additional in vitro studies or in vivo testing in animal models.
Finally, unprecedented opportunity now exists to carry out more
precise quantitative as well as qualitative assessments of the
outcome (i.e., generation of peptide specific and tumor reactive
CTL response). For example, some of the latest state of the art
assays – such as tetramer staining assay, ELIspot assay, and
Fastimmune assays – have changed the very nature of patient
monitoring by making it exquisitely precise and sensitive. Thus,
any improvement of outcome can be reliably monitored.
Imiquimod, an imidazoquinoline, is now used in the treatment
of anogenital warts and a number viral or non-viral cutaneous
neoplasms with considerable success. Imiquimod does not possess
direct anti-viral activities in in vitro assays. The mechanism
of its anti-tumor effect is also not fully understood. It is
believed that the anti-viral and anti-tumor activities, in vivo,
might be mediated through the induction of cytokines and
enhancement of cell mediated immunity. Indeed, a considerable
body of data has emerged to suggest that imiquimod stimulates
the innate as well as the acquired arms of the immune system.
Further, when applied topically, it activates resident DCs and
LCs in the skin, and importantly, imiquimod stimulates innate
immunocytes – such as macrophages, DCs, etc. – via the toll
receptor TLR7 and induces a number of inflammatory cytokines (IFNa,
IL-12, TNFa,, etc.) in DC precursors and DCs. These properties,
therefore, suggest that imiquimod might be an ideal agent to
create an inflammatory context, in situ, for specific
peptide-based immunization. In short, imiquimod is a potentially
useful topical adjuvant for vaccine therapy.
The field of peptide-based cancer vaccine approach has been
too good to be abandoned. It needs additional innovative
strategies to harness the full potential of the basic approach.
We have proposed to test a novel approach based on a sound
hypothesis. We, therefore, believe that the proposed work could
move the filed forward and if our hypothesis is proven to be
correct, the approach will have application beyond melanoma.
This, then, is the major significance of our proposal.
- 2003 – 2004: Jane Grant-Kels, M.D., in collaboration
with Richard Nuccitelli, Ph.D.
Worked with Mouse model for melanoma in which you inject
mouse melanoma cells just beneath the skin in a mouse and a
tumor developed within five days. The melanomas were then
investigated with the bioelectric field imager.
The specific aim of this animal research project was to
determine if a new instrument designed for BioElectric Field
Imaging (BFI) could be used for the diagnosis of melanomas
by measuring local perturbations in the electric fields in
skin near the melanoma. Our hypothesis was that melanomas
exhibit increased rates of cell division and this could lead
to a reduction in the local transepidermal resistance that
could be manifested as a local electric field perturbation
- 2003 – 2004: In collaboration with Tim Hla, Ph.D.,
Michael Murphy, M.D., Jane Grant-Kels, M.D., and Michael
Kruk, Ph.D., and M.D., student . Study using archival tissue
of the expression of S1P1/Edg-1 in melanoma and psoriasis.
- 2002 – 2004: Differentiation of histologic response to
collagen injection Vs particulate fascia lata injection for
treatment of dermal defects. Jane Grant-Kels, M.D., in
collaboration with Neil Sadick, M.D., 772 Park Avenue, NY,
NY 10021 and Cornell University/New York Hospital Department