WO2024083866A1

WO2024083866A1 - Cancer treatment

Info

Publication number: WO2024083866A1
Application number: PCT/EP2023/078886
Authority: WO
Inventors: Espen Basmo ELLINGSEN
Original assignee: Ultimovacs Asa
Priority date: 2022-10-17
Filing date: 2023-10-17
Publication date: 2024-04-25
Also published as: WO2024083867A1

Abstract

A polypeptide, a nucleic acid molecule, a T-cell receptor or a T-cell displaying the T-cell receptor for use in the prevention or treatment of mesothelioma in a subject is provided. A polypeptide, a nucleic acid, a T-cell receptor or a T-cell displaying the T-cell receptor for use in the prevention or treatment of an epithelioid cancer in a subject is also provided. The polypeptide comprises a region of at least 12 amino acids of a tumour- associated antigen or a sequence having at least 80% identity to the region. The nucleic acid molecule comprises a nucleotide encoding the polypeptide. The T-cell receptor is specific for the polypeptide. The polypeptide, nucleic acid molecule, T-cell receptor or T- cell is administered simultaneously, separately or sequentially with an immune checkpoint inhibitor.

Description

CANCER TREATMENT

Field of the Invention

The present invention relates to a polypeptide, a nucleic acid molecule, a T-cell receptor, or a T-cell displaying the T-cell receptor, and an immune checkpoint inhibitor for use in the prevention or treatment of mesothelioma or an epithelioid cancer. The invention also relates a method of preventing or treating mesothelioma or an epithelioid cancer in a subject. The invention further relates to a method of identifying a subject to whom a combination therapy is to be administered.

Background of the Invention

Cancer is a disease characterised by new and abnormal growth of cells within an individual. Cancer develops through a multi-step process involving several mutational events that allow cancer cells to develop and acquire properties of invasion and metastasis.

Numerous approaches have been proposed for the treatment of cancer. One approach to the treatment of cancer is to target proteins involved in immune checkpoints in order to modulate an individual’s immune response to cancer. Immune checkpoint mechanisms that normally down-regulate the immune system in order to prevent excessive and uncontrolled immune responses include cytotoxic T-lymphocyte- associated protein 4 (CTLA-4) and programmed cell death protein 1 (PD-1). CLTA-4 and PD-1 downregulate pathways of T-cell activation, and in individuals with cancer, this can result in the down-regulation of natural immune responses against cancers.

Antibody-mediated blockade of the PD-1 checkpoint has been shown to release the potency of the inhibited immune response and improve survival rates. For example, the KEYNOTE-006 study as reported in Robert et al. Lancet Oncol. 2019; 20: 1239-51 concerns a phase 3 trial of pembrolizumab in patients with advanced cancer and reports on its efficacy. A further immune checkpoint mechanism of relevance is the cytotoxic T- lymphocyte-associated protein 4 (CTLA-4) immune checkpoint.

Another approach to the treatment of cancer is the use of antigenic peptides which comprise fragments of tumour-associated antigens (i.e. peptide-based cancer vaccines). Such antigenic peptides, when administered to an individual, elicit an MHC class I or class II restricted T-cell response against cells expressing the tumour-associated antigens.

It is to be appreciated that in order for such T-cell responses to occur, the antigenic polypeptide must typically be presented on an MHC molecule. There is a wide range of variability in MHC molecules in human populations. In particular, different individuals have different HLA alleles which have varying binding affinity for polypeptides, depending on the amino acid sequence of the polypeptides. Thus an individual who has one particular HLA allele may have MHC molecules that will bind a polypeptide of a particular sequence whereas other individuals lacking the HLA allele will have MHC molecules unable to bind and present the polypeptide (or, at least, their MHC molecules will have a very low affinity for the polypeptide and so present it at a relatively low level). Therefore, variability in MHC molecules in the human population means that providing a peptide-based cancer vaccine with broad population coverage is problematic because not all individuals will mount an immune response against a given antigen.

WO 2011/101173 discloses vaccination with certain polypeptides from human telomerase reverse transcriptase (hTERT) for the treatment of cancer. WO 2017/207814 discloses a combination therapy for the treatment of cancer, without any definition of a patient subgroup, comprising vaccination with such hTERT polypeptides in combination with administration of an immune checkpoint inhibitor such as a PD-1/PD-L1 checkpoint inhibitor.

Malignant pleural mesothelioma (MPM) is a highly aggressive cancer originating from the mesothelial cells of the pleura. Asbestos exposure is linked to development of the cancer. MPM is typically unresectable at diagnosis with less than 10% of patients surviving 5 years or beyond. MPM may be categorised into the following major histological subtypes: epithelioid, biphasic and sarcomatoid. (Any subtypes which are not epithelioidal may collectively be termed “non-epithelioidal”.) The epithelioid subtype represents the largest histology-based subtype in MPM with approximately 75-80% of MPM patients exhibiting this subtype.

Until recently, approved systemic treatments for the treatment of MPM have been limited to chemotherapy regimens that have moderate survival benefit with poor outcomes. Monotherapy using pembrolizumab (anti-PD-1 antibody), nivolumab (anti-PD-1 antibody) or avelumab (anti-PD-L1 antibody) has demonstrated a response rate of 9.3- 20% (Alley et al., (KEYNOTE-028): The Lancet. 2017;18:623-630; Quispel-janssen et al., J Thorac Oncol. 2018;13:1569-1576; Hassan et al., JAMA Oncol. 2020; 5:351-357.)

A randomised, non-comparative phase 2 trial (IFCT-1501MAPS2) has demonstrated that treatment with nivolumab (anti-PD-1 antibody) alone, or treatment with a combination of nivolumab and ipilimumab (an anti-CTLA-4 antibody), shows some disease control at 12 weeks in relapsed patients with MPM, without unexpected toxicity (Scherpereel et al., The Lancet Oncology, 20, 239-253)

A more recent randomised, phase 3 study (Checkmate 743) demonstrated the clinical superiority of checkpoint inhibitor therapy using a combination of ipilimumab (an anti- CTLA-4 antibody) and nivolumab (anti-PD-1 antibody) over a standard platinum plus pemetrexed chemotherapy. The median overall survival was 18.1 months (95% Cl 16.8- 21.4) with the combined checkpoint inhibitor therapy versus 14.1 months (12.4-16.2) with chemotherapy. Patients deriving the greatest benefit from the combined checkpoint inhibitor therapy were those with non-epithelioid histology, a subgroup which is typically less responsive to chemotherapy. A benefit in the epithelioid subgroup was less evident. (The unstratified hazard ratio for death in the non-epithelioid subgroup was 0.46; 95% Cl; 0.31-0.68) versus 0.86 (95% Cl; 0.69-1.08) for the epithelioid subgroup).

Although these results are encouraging, the response rates seen are moderate compared to what has been documented for the combination of checkpoint inhibitors in other cancer diseases.

Accordingly, there remains a need for further cancer treatments, particularly for epithelioid cancers including epithelioid MPM which are highly prevalent amongst cancer populations, and which are generally associated with poor prognosis.

The present invention seeks to alleviate one or more of the above problems. Summary of the Invention

Aspects of the present invention are predicated on the finding that patients with mesothelioma showed a greater clinical response to treatment with a combination therapy of a tumour-associated antigen vaccine and one or more immune checkpoint inhibitors as compared to a monotherapy treatment with one or more immune checkpoint inhibitors in the absence of any vaccine. Further aspects of the present invention are predicated on the specific finding that cancer patients with epithelioid histology, in particular, epithelioid MPM, were more responsive to treatment with a combination therapy of a tumour-associated antigen vaccine and one or more immune checkpoint inhibitors as compared to a monotherapy treatment with one or more immune checkpoint inhibitors in the absence of any vaccine. In contrast, the difference in clinical efficacy between the combination therapy and immune checkpoint inhibitor therapy in cancer patients with non-epithelioid histology was less pronounced. This finding is unexpected because it is known that patients with an epithelioid histology demonstrate a reduced benefit associated with immune checkpoint inhibitor therapy as compared to conventional chemotherapy, when compared to patients with non-epithelioid histology. This finding makes it plausible that epithelioid cancer patient groups who have limited clinical response to immune checkpoint inhibitor monotherapy may be treated effectively with a combination therapy. Additionally, treatment with a combination therapy may be particularly advantageous in certain cancer indications such as mesothelioma where the majority of patients demonstrate an epithelioid subtype. Furthermore, treatment with the combination therapy of the invention is advantageous in respect of patients whose histology status (i.e. having epithelioid or non-epithelioid histology) is unknown since the combination therapy of the invention (unlike certain therapies involving only immune checkpoint inhibitors) demonstrates an improved treatment of both patient sub-types compared with conventional chemotherapy treatment. Likewise, treatment with the combination therapy of the invention is advantageous when treating a group of patients where it is desired to give all patients in the group the same treatment irrespective of their histology status (e.g. to simplify treatment options and/or the supply chain).

According to one aspect of the present invention, there is provided a polypeptide for use in the prevention or treatment of mesothelioma in a subject, wherein the polypeptide is administered to the subject simultaneously, separately or sequentially with an immune checkpoint inhibitor, wherein the polypeptide comprises a region of at least 12 amino acids of a tumour- associated antigen or a sequence having at least 80% identity to the region.

According to another aspect of the present invention, there is provided a nucleic acid molecule for use in the prevention or treatment of mesothelioma in a subject, wherein the nucleic acid molecule is administered simultaneously, separately or sequentially with an immune checkpoint inhibitor, and wherein the nucleic acid molecule comprises a nucleotide sequence encoding a polypeptide comprising a region of at least 12 amino acids of a tumour-associated antigen or a sequence having at least 80% identity to the region.

According to another aspect of the present invention, there is provided a T-cell receptor, or a T-cell displaying the T-cell receptor, for use in the prevention or treatment of mesothelioma in a subject, wherein the T-cell receptor or T-cell is administered simultaneously, separately or sequentially with an immune checkpoint inhibitor, and wherein the T-cell receptor is specific for a polypeptide consisting of at least 12 amino acids of a tumour-associated antigen, or a sequence having at least 80% identity to the polypeptide, when the polypeptide is presented on an MHC molecule.

According to another aspect of the present invention, there is provided an immune checkpoint inhibitor for use in the prevention or treatment of mesothelioma in a subject, wherein the immune checkpoint inhibitor is administered to the subject simultaneously, separately or sequentially with: i) a polypeptide comprising a region of at least 12 amino acids of a tumour- associated antigen or a sequence having at least 80% identity to the region; ii) a nucleic acid molecule comprising a nucleotide sequence encoding a polypeptide comprising a region of at least 12 amino acids of a tumour-associated antigen or a sequence having at least 80% identity to the region; iii) a T-cell receptor specific for a polypeptide consisting of at least 12 amino acids of a tumour-associated antigen, or a sequence having at least 80% identity to the polypeptide, when the polypeptide is presented on an MHC molecule; or iv) a T-cell displaying a T-cell receptor as defined in iii). According to another aspect of the present invention, there is provided a method of preventing or treating mesothelioma in a subject, comprising the steps of: i) administering an immune checkpoint inhibitor to the subject; and ii) simultaneously, separately or sequentially administering: a) a polypeptide comprising a region of at least 12 amino acids of a tumour- associated antigen or a sequence having at least 80% identity to the region; b) at least one nucleic acid molecule comprising a nucleotide sequence encoding at least one polypeptide comprising a region of at least 12 amino acids of a tumour-associated antigen or a sequence having at least 80% identity to the region; c) a T-cell receptor specific for a polypeptide consisting of at least 12 amino acids of a tumour-associated antigen, or a sequence having at least 80% identity to the polypeptide, when the polypeptide is presented on an MHC molecule; or d) a T-cell displaying a T-cell receptor as defined in c).

According to another aspect of the present invention, there is provided a polypeptide for use in the prevention or treatment of an epithelioid cancer in a subject, wherein the polypeptide is administered to the subject simultaneously, separately or sequentially with an immune checkpoint inhibitor, wherein the polypeptide comprises a region of at least 12 amino acids of a tumour- associated antigen or a sequence having at least 80% identity to the region.

According to another aspect of the present invention, there is provided a nucleic acid molecule for use in the prevention or treatment of an epithelioid cancer in a subject, wherein the nucleic acid molecule is administered to the subject simultaneously, separately or sequentially with an immune checkpoint inhibitor, and wherein the nucleic acid molecule comprises a nucleotide sequence encoding a polypeptide comprising a region of at least 12 amino acids of a tumour-associated antigen or a sequence having at least 80% identity to the region.

According to another aspect of the present invention, there is provided a T-cell receptor, or a T-cell displaying the T-cell receptor, for use in the prevention or treatment of an epithelioid cancer in a subject, wherein the T-cell receptor or T-cell is administered to the subject simultaneously, separately or sequentially with an immune checkpoint inhibitor, and wherein the T-cell receptor or T-cell is specific for a polypeptide consisting of at least 12 amino acids of a tumour-associated antigen, or a sequence having at least 80% identity to the polypeptide, when the polypeptide is presented on an MHC molecule.

According to another aspect of the present invention, there is provided an immune checkpoint inhibitor for use in the prevention or treatment of an epithelioid cancer in a subject, wherein the immune checkpoint inhibitor is administered to the subject simultaneously, separately or sequentially with: i) a polypeptide comprising a region of at least 12 amino acids of a tumour- associated antigen or a sequence having at least 80% identity to the region; ii) a nucleic acid molecule comprising a nucleotide sequence encoding at least one polypeptide comprising a region of at least 12 amino acids of a tumour-associated antigen or a sequence having at least 80% identity to the region; iii) a T-cell receptor specific for a polypeptide consisting of at least 12 amino acids of a tumour-associated antigen, or a sequence having at least 80% identity to the polypeptide, when the polypeptide is presented on an MHC molecule; or iv) a T-cell displaying a T-cell receptor as defined in iii).

According to another aspect of the present invention, there is provided a method of preventing or treating an epithelioid cancer in a subject, comprising the steps of: i) administering an immune checkpoint inhibitor to the subject; and ii) simultaneously, separately or sequentially administering: a) a polypeptide comprising a region of at least 12 amino acids of a tumour- associated antigen or a sequence having at least 80% identity to the region; b) at least one nucleic acid molecule comprising a nucleotide sequence encoding a polypeptide comprising a region of at least 12 amino acids of a tumour-associated antigen or a sequence having at least 80% identity to the region; c) a T-cell receptor specific for a polypeptide consisting of at least 12 amino acids of a tumour-associated antigen, or a sequence having at least 80% identity to the polypeptide, when the polypeptide is presented on an MHC molecule; or d) a T-cell displaying a T-cell receptor as defined in c). Preferably, the epithelioid cancer is epithelioid mesothelioma. More preferably, the epithelioid cancer is epithelioid pleural mesothelioma.

Advantageously, in each of the above aspects, the polypeptide comprises a region of at least 15, 20, 25 or 30 amino acids of a tumour-associated antigen or a sequence having at least 80% identity to the region.

Conveniently, the tumour-associated antigen comprises a universal tumour antigen. Preferably, the universal tumour-associated antigen is selected from the group consisting of: telomerase reverse transcriptase, survivin, DNA topoisomerase 2-alpha, cytochrome P450 1 B1 and E3 ubiquitin-protein ligase Mdm2. More preferably, the tumour-associated antigen comprises telomerase reverse transcriptase, and the polypeptide comprises: i) a polypeptide comprising a sequence of SEQ ID NO. 1 ; ii) an immunogenic fragment of i) comprising at least 12 amino acids; or iii) a sequence having at least 80% sequence identity to i) or ii).

Advantageously, the polypeptide comprises a cocktail of polypeptides which additionally comprises: a polypeptide comprising: a) a sequence of SEQ. ID NO. 2; b) an immunogenic fragment of a) comprising at least 12 amino acids; or c) a sequence having at least 80% sequence identity to a) or b), and optionally, a polypeptide comprising: a) a sequence of SEQ. ID NO. 3; b) an immunogenic fragment of a) comprising at least 12 amino acids; or c) a sequence having at least 80% sequence identity to a) or b).

Alternatively, the polypeptide comprises at least one polypeptide selected from: i) a polypeptide comprising a sequence of SEQ. ID NO:5 ii) an immunogenic fragment of i) comprising at least 12 amino acids; or iii) a sequence having at least 80% sequence identity to i) or ii); i) a polypeptide comprising a sequence of SEQ. ID NO:39 ii) an immunogenic fragment of i) comprising at least 12 amino acids; or iii) a sequence having at least 80% sequence identity to i) or ii); and i) a polypeptide comprising a sequence of SEQ. ID NO:40 ii) an immunogenic fragment of i) comprising at least 12 amino acids; or iii) a sequence having at least 80% sequence identity to i) or ii).

Advantageously, the polypeptide comprises a cocktail of polypeptides which further comprises: a) a sequence of SEQ. ID NO. 1 ; b) an immunogenic fragment of a) comprising at least 12 amino acids; or c) a sequence having at least 80% sequence identity to a) or b);

Preferably, the polypeptide additionally comprises: a polypeptide comprising: a) a sequence of SEQ. ID NO. 2; b) an immunogenic fragment of a) comprising at least 12 amino acids; or c) a sequence having at least 80% sequence identity to a) or b), and optionally, a polypeptide comprising: a) a sequence of SEQ. ID NO. 3; b) an immunogenic fragment of a) comprising at least 12 amino acids; or c) a sequence having at least 80% sequence identity to a) or b).

Advantageously, the immune checkpoint inhibitor comprises a CTLA-4 immune checkpoint inhibitor, a PD-1 immune checkpoint inhibitor and/or a PD-L1 immune checkpoint inhibitor.

Preferably, the CTLA-4 inhibitor comprises one or more selected from: an anti-CTLA-4 antibody or a functional fragment thereof, a peptide-based inhibitor of CTLA-4, and a small molecule inhibitor of CTLA-4; the PD-1 inhibitor comprises one or more selected from: an anti-PD-1 antibody or a functional fragment thereof, a peptide-based inhibitor of PD-1 , and a small molecule inhibitor of PD-1 ; and/or the PD-L1 inhibitor comprises one or more selected from an anti-PD-L1 antibody or a functional fragment thereof, a peptide- based inhibitor of PD-L1 , and a small molecule inhibitor of PD-L1 .

More preferably, the immune checkpoint inhibitor comprises an anti-CTLA4 antibody or a functional fragment thereof and an anti-PD-1 antibody or a functional fragment thereof.

Advantageously, the anti-CTLA-4 antibody of functional fragment thereof comprises one or more selected from: ipilimumab and tremelimumab; the anti-PD-1 antibody or functional fragment thereof comprises one or more selected from nivolumab and pembrolizumab; and/or the anti-PD-L1 antibody or functional fragment thereof comprises one or more selected from: durvalumab, atezolizumab and avelumab.

Further advantageously, the immune checkpoint inhibitor comprises ipilimumab and nivolumab.

Conveniently, the subject has been treated with a neoadjuvant therapy, preferably chemotherapy.

According to another aspect of the present invention, there is provided a method of identifying a subject to whom a combination therapy is to be administered, wherein the combination therapy comprises administration of:

(I) an immune checkpoint inhibitor,

(II) simultaneously, separately or sequentially with: a) a polypeptide comprising a region of at least 12 amino acids of a tumour- associated antigen or a sequence having at least 80% identity to the region; b) at least one nucleic acid molecule comprising a nucleotide sequence encoding a polypeptide comprising a region of at least 12 amino acids of a tumour-associated antigen or a sequence having at least 80% identity to the region; c) a T-cell receptor specific for a polypeptide consisting of at least 12 amino acids of a tumour-associated antigen, or a sequence having at least 80% identity to the polypeptide, when the polypeptide is presented on an MHC molecule; or d) a T-cell displaying a T-cell receptor as defined in c); the method comprising:

(i) determining the presence of an epithelioid cancer from a biological sample obtained from the subject; and

(ii) identifying the subject who provided the biological sample as a subject to whom the combination therapy is to be administered.

In this aspect, the polypeptide, tumour-associated antigen, immune checkpoint inhibitor and subject may be defined as above.

Preferably, the epithelioid cancer is mesothelioma. More preferably, the epithelioid cancer is epithelioid pleural mesothelioma.

Brief of the

Figure 1 is a schematic diagram showing a possible treatment regimen for the administration of the polypeptides of SEQ ID NOS. 1 , 2 and 3 (“UV1 vaccination”) in combination with ipilimumab and nivolumab (I Pl-N I VO).

Figure 2 is a Kaplan-Meier plot showing overall survival in MPM patients who had been administered polypeptides according to SEQ ID Nos: 1 , 2 and 3 in combination with ipilimumab and nivolumab, and in patients who had been administered ipilimumab and nivolumab only.

Figure 3 is a Kaplan-Meier plot showing overall survival in MPM patients with epithelioid histology who had been administered polypeptides according to SEQ ID Nos: 1 , 2 and 3 in combination with ipilimumab and nivolumab, and in patients who had been administered ipilimumab and nivolumab only.

Figure 4 is a Kaplan-Meier plot showing overall survival in MPM patients with nonepithelioid histology who had been administered polypeptides according to SEQ ID Nos: 1 , 2 and 3 in combination with ipilimumab and nivolumab, and in patients who had been administered ipilimumab and nivolumab only.

Figure 5 is a Kaplan-Meier plot showing investigator-determined progression free survival in MPM patients who had been administered polypeptides according to SEQ ID Nos: 1 , 2 and 3 in combination with ipilimumab and nivolumab, and in patients who had been administered ipilimumab and nivolumab only.

Figure 6 is a Kaplan-Meier plot showing investigator-determined progression free survival in MPM patients with epithelioid histology who had been administered polypeptides according to SEQ ID Nos: 1 , 2 and 3 in combination with ipilimumab and nivolumab, and in patients who had been administered ipilimumab and nivolumab only.

Figure 7 is a Kaplan-Meier plot showing investigator-determined progression free survival in MPM patients with non-epithelioid histology who had been administered polypeptides according to SEQ ID Nos: 1 , 2 and 3 in combination with ipilimumab and nivolumab, and in patients who had been administered ipilimumab and nivolumab only.

Figure 8 is a Kaplan-Meier plot showing a blinded independent central review (BICR) of progression free survival in MPM patients who had been administered polypeptides according to SEQ ID Nos: 1 , 2 and 3 in combination with ipilimumab and nivolumab, and in patients who had been administered ipilimumab and nivolumab only.

Figure 9 is a Kaplan-Meier plot showing a blinded independent central review (BICR) of progression free survival in MPM patients with epithelioid histology who had been administered polypeptides according to SEQ ID Nos: 1 , 2 and 3 in combination with ipilimumab and nivolumab, and in patients who had been administered ipilimumab and nivolumab only.

Figure 10 is a Kaplan-Meier plot showing a blinded independent central review (BICR) of progression free survival in PM patients with non-epithelioid histology who had been administered polypeptides according to SEQ ID Nos: 1 , 2 and 3 in combination with ipilimumab and nivolumab, and in patients who had been administered ipilimumab and nivolumab only. Definitions

The terms “polypeptide”, “peptide” and “protein” are used interchangeably herein to refer to a polymer of amino acid residues. The terms apply to amino acid polymers in which one or more amino acid residues is a modified residue, or a non-naturally occurring residue, such as an artificial chemical mimetic of a corresponding naturally occurring amino acid, as well as to naturally occurring amino acid polymers. In some embodiments, the term “polypeptide” refers to a polypeptide of a single sequence. In other embodiments the term “polypeptide” refers to a cocktail (i.e. a mixture) of polypeptides. In some embodiments, the term “polypeptide” refers to one or more (or each) polypeptide within the cocktail of polypeptides.

The term “amino acid” as used herein refers to naturally occurring and synthetic amino acids, as well as amino acid analogues and amino acid mimetics that have a function that is similar to the naturally occurring amino acids. Naturally occurring amino acids are those encoded by the genetic code, as well as those modified after translation in cells (e.g. hydroxyproline, gamma-carboxyglutamate, and O-phosphoserine). The phrase “amino acid analogue” refers to compounds that have the same basic chemical structure (an alpha carbon bound to a hydrogen, a carboxy group, an amino group, and an R group) as a naturally occurring amino acid but have a modified R group or modified backbones (e.g. homoserine, norleucine, methionine sulfoxide, methionine methyl sulphonium). The phrase “amino acid mimetic” refers to chemical compounds that have different structures from but similar functions to naturally occurring amino acids.

The term “fragment” as used herein in relation to a polypeptide means a consecutive series of amino acids that form part of the polypeptide. An “immunogenic fragment” of a polypeptide is a fragment as previously defined which is capable of eliciting an immune response, such as a T-cell response, when administered to a subject. In one embodiment, the “immunogenic fragment” is capable of eliciting a CD4+ T-cell response when administered to a subject. In one embodiment, the “immunogenic fragment” is capable of eliciting a CD4+ and/or CD8+ T-cell immune response when administered to a subject. In some embodiments, the immunogenic fragment comprises at least 8, 9, 10, 11 , 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 , 22, 23, 24, 25, 26, 27, 28 or 29 amino acids of the polypeptide from which it is derived. The terms “gene”, “polynucleotides”, and “nucleic acid molecules” are used interchangeably herein to refer to a polymer of multiple nucleotides. The nucleic acid molecules may comprise naturally occurring nucleic acids or may comprise artificial nucleic acids such as peptide nucleic acids, morpholin and locked nucleic acid as well as glycol nucleic acid and threose nucleic acid.

The term “nucleotide” as used herein refers to naturally occurring nucleotides and synthetic nucleotide analogues that are recognised by cellular enzymes.

The terms “cancer” and “tumour” as used herein refer to the presence of cells in a subject that exhibit new, abnormal and/or uncontrolled proliferation. In one embodiment, the cells have the capacity to invade adjacent tissues and/or to spread to other sites in the body (i.e. the cells are capable of metastasis). In one embodiment, the cancer cells are in the form of a tumour (i.e. an abnormal mass of tissue). The term “tumour” as used herein includes both benign and malignant neoplasms.

The term “treatment” as used herein refers to any partial or complete treatment and includes: inhibiting the disease or symptom, i.e. arresting its development; and relieving the disease or symptom, i.e. causing regression of the disease or symptom. Thus the term “treatment” as used herein can include delaying, terminating and/or suppressing the progression of a disease as well as the regression and/or disappearance of a disease site. In some embodiments, the term “treatment” as used herein refers to a therapy (e.g. a medicament or a combination therapy) that is suitable to be administered to a patient who is suffering from a disease, such as cancer.

The term “clinical outcome” as used herein refers to whether a patient develops a clinical response or a clinical non-response (as defined below) to a therapy.

The term “clinical response” as used herein refers to a patient exhibiting an improvement in a disease or symptom in response to a therapy. In one embodiment, the “clinical response” refers to a patient exhibiting a partial or a complete response to a therapy. Thus in one embodiment, a clinical response consists of a partial or a complete response to the therapy. In one embodiment, a partial response in a cancer patient refers to a decrease in the signs and/or symptoms of a tumour or cancer. In one embodiment, a complete response in a cancer patient refers to the disappearance of the signs and/or symptoms of a cancer or tumour. In a preferred embodiment, a partial or a complete response is assessed using RECIST 1.1 or iRECIST criteria (Eisenhauer EA et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 2009 Jan;45(2):228-47; or Seymour L, et al. iRECIST: guidelines for response criteria for use in trials testing immunotherapeutics. Lancet Oncol. 2017 Mar;18(3):e143-e152, both incorporated herein by reference). In an alternative embodiment, a partial or a complete response is assessed using RECIST (mRECIST) (Byrne et al., Annals of Oncology, 15, 257-260 (2004); incorporated herein by reference).

The term “clinical non-response” as used herein refers to a patient in whom a disease or symptom stays the same or progresses. In one embodiment, the “clinical non-response” refers to a patient exhibiting a stable or a progressive disease following administration of a therapy. Thus in one embodiment, a clinical non-response consists of a stable disease or a progressive disease. In one embodiment, a stable disease in a cancer patient refers to the signs and/or symptoms of a tumour or cancer staying the same. In one embodiment, a progressive disease in a cancer patient refers to the cancer or tumour (or the signs/symptoms thereof) growing, spreading and/or getting worse. In one embodiment, the term “progressive disease” incorporates confirmed progressive disease and/or unconfirmed progressive disease. In a preferred embodiment, a stable or a progressive disease is assessed using RECIST 1.1 or iRECIST criteria (Eisenhauer EA et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 2009 Jan; 45(2):228-47; or Seymour L, et al. iRECIST: guidelines for response criteria for use in trials testing immunotherapeutics. Lancet Oncol. 2017 Mar; 18(3):e143-e152, both incorporated herein by reference). In an alternative embodiment, a partial or a complete response is assessed using RECIST (mRECIST) (Byrne et al., Annals of Oncology, 15, 257-260 (2004); incorporated herein by reference).

The term “T-cell” (also known as “T lymphocyte”) as used herein refers to a cell of the immune system which has a cell surface T-cell receptor. In one embodiment, the term “T-cell” comprises different types of T cell, such as: CD4+ T-cells (also known as helper T-cells or Th cells), CD8+ T-cells (also known as cytotoxic T-cells or CTLs), memory T- cells and regulatory T-cells (Tregs). The term “CD4+ T-cell” as used herein refers to a T-cell comprising a CD4 glycoprotein on its cell surface. The term “CD8+ T-cell” as used herein refers to a T-cell comprising a CD8 glycoprotein on its cell surface.

The term “the T-cell receptor” as used herein refers to an antigen receptor of the T- cell. In some embodiments, the T-cell receptor recognises (i.e. binds to) a polypeptide when presented by an MHC molecule.

The term “a T-cell displaying the T-cell receptor” as used herein refers to a T-cell that comprises the T-cell receptor on its cell surface. In some embodiments, the T-cell receptor is responsible for recognising (i.e. binding to) a polypeptide such as when the polypeptide is presented by an MHC molecule. In some embodiments, the binding of the T-cell receptor to the polypeptide when presented by the MHC molecule results in activation of the T-cell displaying the T-cell receptor. T cell activation can be measured using T-cell response assays and ELISPOT assays (Gjertsen MK et al. J Mol Med (Berl) 2003;81 :43-50; Inderberg-Suso EM et al., Oncoimmunology 2012 1(5):670-686, both incorporated herein by reference).

The term “the T-cell receptor or T-cell is specific for a polypeptide” as used herein refers to a T-cell receptor or a T cell comprising the T-cell receptor that is capable of recognising (i.e. binding to) the polypeptide such as when the polypeptide is presented on an MHC molecule. In some embodiments, the polypeptide to which the T-cell receptor (or the T- cell displaying the T-cell receptor) is specific, is of a length that is longer than that which would normally be accommodated on an MHC molecule. In these embodiments, the term “the T-cell receptor or T-cell is specific for a polypeptide” as used herein refers to the recognition by the T-cell receptor or T-cell of an immunogenic fragment of the polypeptide when presented on the MHC molecule. In some embodiments, the binding of the T-cell receptor or T-cell to the polypeptide to which it is specific results in activation of a T-cell. T cell activation can be measured using T-cell response assays and ELISPOT assays (Gjertsen MK et al. J Mol Med (Berl) 2003;81 :43-50; Inderberg-Suso EM et al., Oncoimmunology 2012 1(5):670-686, both incorporated herein by reference).

The term “MHC molecule” as used herein refers to a protein structure which assembles with a polypeptide and which is capable of displaying the polypeptide at a cell surface to a T-cell. MHC molecules are encoded by genes within the major histocompatibility complex. In some embodiments, the term “MHC molecule” refers to an MHC class I molecules and/or an MHC class II molecule.

The term “immune checkpoint” as used herein refers to any point at which an immune response is limited. Immune checkpoints are inhibitory pathways that slow down or stop immune reactions and prevent excessive tissue damage from uncontrolled activity of immune cells. Examples of an “immune checkpoint” include the cytotoxic T-lymphocyte- associated protein 4 (CTLA-4) checkpoint and the programmed cell death protein 1 (PD- 1) checkpoint.

The term “immune checkpoint inhibitor” as used herein refers to any compound, substance or composition (e.g. any small molecule, chemical compound, antibody, nucleic acid molecule, polypeptide, or fragments thereof, a vaccine or viral vaccine) that is capable of down-regulating or blocking an immune checkpoint allowing more extensive immune activity. The term “checkpoint inhibitor” is used interchangeably herein with “immune checkpoint inhibitor”. In some embodiments, the immune checkpoint inhibitor is an antibody that specifically binds to a protein involved in the immune checkpoint pathway thereby disrupting and down-regulating the overall activity of the immune checkpoint. Examples of such an immune checkpoint inhibitor include an anti-CTLA-4 antibody (such as ipilimumab, tremelimumab or AGEN-1884) and an anti-PD-1 antibody (such as nivolumab or pembrolizumab). In alternative embodiments, the immune checkpoint inhibitor is a small molecule antagonist that interferes with and/or inhibits the activity of a protein involved in the immune checkpoint pathway and thereby down- regulates the overall activity of the immune checkpoint. In a preferred embodiment, the small molecule antagonist targets the CTLA-4 and/or PD-1 proteins in order to down- regulate the CTLA-4 and/or PD-1 checkpoints (i.e. the small molecule antagonist is a small molecule CTLA-4 antagonist or a small molecule PD-1 antagonist). In additional embodiments, the immune checkpoint inhibitor is targeted at another member of the CD28CTLA4 Ig superfamily such as BTLA, LAG3, ICOS, PDL1 or KIR (Page et al., Annual Review of Medicine 65:27 (2014)). In further additional embodiments, the immune checkpoint inhibitor is targeted at a member of the TNFR superfamily such as CD40, 0X40, CD137, GITR, CD27 or TIM-3. In a further embodiment, the immune checkpoint inhibitor targets Indoleamine 2,3-dioxygenase (IDO). In some cases targeting an immune checkpoint is accomplished with an inhibitory antibody or similar molecule. In other cases, it is accomplished with an agonist for the target; examples of this class include the stimulatory targets 0X40 and GITR.

In a preferred embodiment, the immune checkpoint inhibitor targets an immune checkpoint that is involved in the regulation of a T-cell. In some embodiments, the immune checkpoint that is targeted is a negative regulator of T-cell activity; thus the action of the immune checkpoint inhibitor allows for more extensive T-cell activity. As discussed above, in some embodiments, the immune checkpoint inhibitor targets a member of the CD28CTLA4 immunoglobulin (Ig) superfamily. Proteins in the immunoglobulin superfamily possess an immunoglobulin domain (also known an immunoglobulin fold) which is a characteristic beta-sheet fold. CTLA-4, PD-1 and PD- L1 are examples of members of the CD28CTLA4 Ig superfamily.

The term “inhibiting an immune checkpoint” as used herein refers to down-regulating or blocking an immune checkpoint in order to allow more extensive immune activity. In some embodiments, inhibiting an immune checkpoint is achieved using at least one of the immune checkpoint inhibitors described above.

The term “CTLA-4 immune checkpoint inhibitor” as used herein refers to any compound, substance or composition (e.g. as defined above) that is capable of down-regulating or blocking the CTLA-4 immune checkpoint. The term “CTLA-4 immune checkpoint inhibitor” is used interchangeably herein with “inhibitor of the CTLA-4 immune checkpoint”. CTLA-4 is an inhibitory receptor that acts as a major negative regulator of T-cell responses. CTLA-4 is upregulated on activated T-cells and binds to B7 family ligands (e.g. CD80 and/or CD86) expressed on antigen-presenting cells. This interaction suppresses further T-cell activity. In one embodiment, the “CTLA-4 immune checkpoint inhibitor” inhibits the interaction between CTLA-4 and a B7 family ligand. In one embodiment, the B7 family ligand is CD80 and/or CD86. In one embodiment, the “CTLA- 4 immune checkpoint inhibitor” is an inhibitor of CTLA-4. In one embodiment, the inhibitor of CTLA-4 is capable of interacting specifically with CTLA-4 in order to disrupt its function.

In some embodiments, the CTLA-4 immune checkpoint inhibitor comprises an antibody or a fragment thereof, preferably a functional fragment thereof, a peptide-based inhibitor and/or a small molecule inhibitor. In a preferred embodiment, the CTLA-4 immune checkpoint inhibitor comprises an anti-CTLA-4 antibody or a functional fragment thereof. That is to say, the antibody or the functional fragment thereof binds specifically to CTLA- 4. In one embodiment, the peptide-based inhibitor or the small molecule inhibitor comprises an inhibitor of CTLA-4. That is to say, it targets CTLA-4 specifically in order to disrupt its normal function and down-regulate or block the overall activity of the CTLA- 4 immune checkpoint. Thus in one embodiment, the peptide-based inhibitor or the small molecule inhibitor is a CTLA-4 antagonist.

The term “PD-1 immune checkpoint inhibitor” as used herein refers to any compound, substance or composition that is capable of down-regulating or blocking the activity of PD-1 , and consequently, the PD-1/PD-L1 immune checkpoint. In some embodiments, the terms “compound, substance or composition” as used herein refer to any one or more of: a small molecule, a chemical compound, an antibody or a fragment thereof (preferably a functional fragment thereof), a nucleic acid molecule or a fragment thereof, a polypeptide or a fragment thereof, a peptide-based compound, a vaccine or a viral vaccine. PD-1 is an inhibitory receptor on antigen-activated T-cells. It delivers inhibitory signals to the T-cells upon binding to its ligand PD-L1. In one embodiment, the “PD-1 immune checkpoint inhibitor” inhibits the interaction between the PD-1 receptor and the PD-L1 ligand. In one embodiment, the inhibitor of PD-1 is capable of interacting specifically with PD-1 in order to disrupt its function.

In some embodiments, the PD-1 immune checkpoint inhibitor comprises an antibody or a fragment thereof, preferably a functional fragment thereof, a peptide-based inhibitor and/or a small molecule inhibitor. In a preferred embodiment, the PD-1 immune checkpoint inhibitor comprises an anti-PD-1 antibody or a functional fragment thereof. That is to say, the antibody or the functional fragment thereof binds specifically to PD-1. In one embodiment, the peptide-based inhibitor or the small molecule inhibitor comprises an inhibitor of PD-L1. That is to say, it targets PD-1 specifically in order to disrupt its normal function and down-regulate or block the overall activity of the PD-1/PD-L1 immune checkpoint. Thus in one embodiment, the peptide-based inhibitor or the small molecule inhibitor is a PD-1 antagonist.

The term “PD-L1 immune checkpoint inhibitor” as used herein refers to any compound, substance or composition that is capable of down-regulating or blocking the activity of PD-L1 , and consequently, the PD-1/PD-L1 immune checkpoint. In some embodiments, the terms “compound, substance or composition” as used herein refer to any one or more of: a small molecule, a chemical compound, an antibody or a fragment thereof (preferably a functional fragment thereof), a nucleic acid molecule or a fragment thereof, a polypeptide or a fragment thereof, a peptide-based compound, a vaccine or a viral vaccine. PD-L1 , also known as CD274 and B7-H1 , is a transmembrane protein that is commonly expressed on the surface of antigen presenting cells and tumour cells. PD-L1 specifically binds to its receptor PD-1 , which as mentioned above, is an inhibitory receptor on antigen-activated T-cells. PD-L1 delivers inhibitory signals to the T-cells upon binding to its receptor PD-1. In one embodiment, the inhibitor of PD-L1 is capable of interacting specifically with PD-L1 in order to disrupt its function.

In some embodiments, the PD-L1 immune checkpoint inhibitor comprises an antibody or a fragment thereof, preferably a functional fragment thereof, a peptide-based inhibitor and/or a small molecule inhibitor. In a preferred embodiment, the PD-L1 immune checkpoint inhibitor comprises an anti-PD-L1 antibody or a functional fragment thereof. That is to say, the antibody or the functional fragment thereof binds specifically to PD- L1. In one embodiment, the peptide-based inhibitor or the small molecule inhibitor comprises an inhibitor of PD-L1 . That is to say, it targets PD-L1 specifically in order to disrupt its normal function and down-regulate or block the overall activity of the PD-1/PD- L1 immune checkpoint. Thus in one embodiment, the peptide-based inhibitor or the small molecule inhibitor is a PD-L1 antagonist.

The term “tumour-associated antigen” as used herein refers to an antigen that is associated with a tumour or cancer cell. In some embodiments, the “tumour-associated antigen” is expressed at a higher level on the tumour or cancer cell and at a lower level on the normal cell. In one embodiment, the “tumour-associated antigen” is a “universal tumour antigen”.

The term “universal tumour antigen” as used herein refers to an antigen that is expressed in a high proportion of tumour types. In one embodiment, the universal tumour antigen is expressed in at least 50%, 60% or 70% or all tumour types, more preferably in at least 80%, 85% or 90% of all tumour types. In a further embodiment, the universal tumour antigen is also expressed in a high proportion of patients within each tumour type. In one embodiment, the universal tumour antigen is generally expressed in at least 40%, 50%, 60%, 70%, 80% or 90% of patients within each tumour type. In one embodiment, the universal tumour antigen has a direct role in oncogenesis. In one embodiment the universal tumour antigen is selected from the group consisting of telomerase reverse transcriptase, survivin, DNA topoisomerase 2-alpha (Top2a), cytochrome P450 1 B1 (CYP1 B1) and E3 ubiquitin-protein ligase Mdm2. Preferably, the universal tumour antigen is human telomerase reverse transcriptase (hTERT).

The term “telomerase reverse transcriptase” (TERT) as used herein refers to the catalytic component of the telomerase holoenzyme complex whose main activity is the elongation of telomeres by acting as a reverse transcriptase that adds simple sequence repeats to chromosome ends by copying a template sequence within the RNA component of the telomerase enzyme. In some embodiments, the term “telomerase reverse transcriptase” refers to human telomerase reverse transcriptase (hTERT). The full-length hTERT sequence is set out in GenBank accession no. AF015950.1 and is also set forth in SEQ ID NO. 7.

The term “synergistic effect in the treatment of cancer” as used herein refers to presence of at least one of the following combination of factors in patients who have been administered a peptide-based (or a nucleic acid molecule-based) cancer vaccine and a checkpoint inhibitor in comparison with a control (for example, patients who have been administered the peptide-based cancer vaccine without the checkpoint inhibitor; or alternatively, patients who have been administered the checkpoint inhibitor without the peptide-based cancer vaccine).

1. A reduction in the time required by the immune system of the patients to mount a measurable immune response to the peptide(s) of the vaccine. In other words, an accelerated CD4+ T cell immune response is generated.

2. The mounting of a strong immune response to the peptide(s) of the vaccine by the patients. In one embodiment, a “strong immune response” as used herein refers to, when across an average of 10 patients, the mean peak immune response is an SI of at least 17, preferably at least 19.

3. An improved clinical outcome in the patients.

In some embodiments, the term “synergistic effect in the treatment of cancer” refers to the presence of at least two of said factors or all three of said factors in patients. In one embodiment, an additional factor, namely, the induction of a broad immune response (i.e. the mounting of an immune response against 2, 3 or more vaccine components), is further evidence of a synergistic effect in the treatment of cancer. In a preferred embodiment, immune responses are measured by a T cell response assay (proliferation by 3H-thymidine incorporation) using patient blood samples. A specific T-cell response is considered positive if the peptide response is at least 3 times the background (Stimulation Index, SI > 3). In one embodiment, a synergistic effect is provided when, across an average of ten patients, over 50% exhibit a positive immune response 7 weeks after the first administration of the peptide vaccine; and the mean peak immune response is an SI of at least 17, preferably at least 19. In some embodiments, an improved clinical outcome is a partial or complete response (also known as partial or complete remission) or stable disease. A complete response refers to the disappearance of detectable tumour or cancer in the body in response to treatment; a partial response refers to a decrease in tumour size, or in the extent of cancer in the body, in response to treatment; and stable disease means that tumour or cancer in the body is neither decreasing nor increasing in extent or severity.

The term “biological sample” as used herein refers to biological specimen obtained from a patient. In one embodiment, the biological sample is a sample of tumour or cancer tissue obtained by biopsy (i.e. a tumour biopsy or tissue biopsy) or a sample of tissue suspected of being a cancer or tumour. In one embodiment, the tumour biopsy is formalin fixed, paraffin embedded (FFPE). In an alternative embodiment, the tumour biopsy is snap frozen. In an alternative embodiment, the biological sample is a liquid sample (i.e. a liquid biopsy), preferably a blood sample. The term “blood sample” also comprises samples of plasma, serum and other blood derivatives. In one embodiment, the liquid biopsy comprises tumour-derived entities such as circulating tumour cells, cell free or circulating tumour DNA and/or tumour extracellular vesicles (e.g. exosomes).

In this specification, the percentage “identity” between two sequences is determined using the BLASTP algorithm version 2.2.2 (Altschul, Stephen F., Thomas L. Madden, Alejandro A. Schaffer, Jinghui Zhang, Zheng Zhang, Webb Miller, and David J. Lipman (1997), "Gapped BLAST and PSI-BLAST: a new generation of protein database search programs", Nucleic Acids Res. 25:3389-3402) using default parameters. In particular, the BLAST algorithm can be accessed on the internet using the URL http://www.ncbi.nlm.nih.gov/blast/. Detailed Description of the Invention

In one aspect, the present invention provides a polypeptide for use in the prevention or treatment of mesothelioma in a subject. In another aspect, the present invention provides a polypeptide for use in the prevention or treatment of an epithelioid cancer in a subject. In a further aspect, the present invention provides a method of preventing or treating mesothelioma in a subject, or preventing or treating an epithelioid cancer in a subject, comprising administering a polypeptide to the subject. In each of these aspects, polypeptide is administered to the subject simultaneously, separately or sequentially with an immune checkpoint inhibitor.

Polypeptides

In some aspects, the polypeptide comprises a region of at least 12 amino acids of a tumour-associated antigen or a sequence having at least 80% identity to the region.

A tumour-associated antigen is an antigen that is present in cancer cells but that is not expressed, or that is not as highly expressed, in healthy cells within an individual. Cancer cells may express certain tumour-associated antigens at a higher level than normal cells or the tumour-associated antigen may be expressed inappropriately given the tissue in which the cancer cell developed. These tumour-associated antigens thus represent a potential target for cancer therapy. It is preferred that the tumour-associated antigen is a universal tumour antigen, which is an antigen expressed in (nearly) all human tumours. Cancer is a heterogeneous disease and there is high degree of diversity between different types of cancer as well as between individuals with the same type of cancer. By targeting universal tumour antigens, the applicability of the cancer therapy is improved across the patient population (i.e. within and between cancer types).

In one embodiment, the universal tumour antigen is expressed in at least 50%, 60% or 70% or all tumour types, more preferably in at least 80%, 85% or 90% of all tumour types. In a further embodiment, the universal tumour antigen is also expressed in a high proportion of patients within each tumour type. In one embodiment, the universal tumour antigen is generally expressed in at least 40%, 50%, 60%, 70%, 80% or 90% of patients within each tumour type. In one embodiment, the universal tumour antigen has a direct role in oncogenesis. In one embodiment, and in some aspects of the present invention, the polypeptide comprises a region of at least 12 amino acids of hTERT (human telomerase reverse transcriptase).

Telomerase is an enzyme that has the function of replicating the 3’ end of the telomere regions of linear DNA strands in eukaryotic cells as these regions cannot be extended by the enzyme DNA polymerase in the normal way. The telomerase enzyme comprises a telomerase reverse transcriptase subunit (“TERT” or “hTERT” for humans) and telomerase RNA. By using the telomerase RNA as a template, the TERT subunit adds a repeating sequence to the 3’ end of chromosomes in eukaryotic cells in order to extend the 3’ end of the DNA strand. The full-length hTERT sequence is set out in GenBank accession no. AF015950.1 and is set forth in SEQ ID NO. 6.

In alternative embodiments, the tumour-associated antigen is from a protein other than hTERT. In one embodiment, the universal tumour antigen is selected from the group consisting of: survivin, DNA topoisomerase 2-alpha (Top2a), cytochrome P450 1 B1 (CYP1 B1) and E3 ubiquitin-protein ligase Mdm2. In one embodiment, the universal tumour antigen is survivin (Sorensen et al., Cancer Biol Ther. 2008 7(12):1885-7; Wobser et a/., Cancer Immunol Immunother. 200655(10):1294-8). Survivin (also known as Baculoviral IAP repeat-containing protein 5) is encoded by the BIRC5 gene in humans and is an inhibitor of apoptosis. A 142 amino acid isoform of Survivin is set out at UniProtKB reference 015392 (isoform 1). In one embodiment, the universal tumour antigen is DNA topoisomerase 2-alpha (Top2a) (Park et al., Cancer Immunol Immunother. 2010 (5):747-57). DNA topoisomerase 2-alpha is encoded by the TOP2A gene in humans and controls the topological states of DNA by transient breakage and subsequent rejoining of DNA strands. Topoisomerase II makes double-strand breaks. A 1 ,531 amino acid isoform of DNA topoisomerase 2-alpha is set out at UniProtKB reference P11388 (isoform 1). In one embodiment, the universal tumour antigen is cytochrome P450 1 B1 (CYP1 B1) (Gribben et al., Clin Cancer Res. 2005 11(12):4430-6). Cytochrome P450 1 B1 is encoded by the CYP1B1 gene in humans and is involved in the metabolism of a diverse range of xenobiotics and endogenous compounds. The 543 amino acid sequence of Cytochrome P450 1 B1 is set out at UniProtKB reference Q16678. In one embodiment, the universal tumour antigen is E3 ubiquitin-protein ligase Mdm2 (Gordan and Vonderheide, Cytotherapy. 2002;4(4):317-27). E3 ubiquitin-protein ligase Mdm2 is encoded by the MDM2 gene in humans and is a negative regulator of the p53 tumour suppressor. A 491 amino acid isoform of E3 ubiquitin-protein ligase Mdm2 is set out at UniProtKB reference Q00987 (Isoform Mdm2). The sequences of these universal tumour antigens are also reported in WO 2017/207814, the sequences of which are incorporated herein by reference.

In some embodiments, the at least one polypeptide is a cocktail (i.e. a mixture) of polypeptides. In one embodiment, the cocktail of polypeptides comprises at least two different polypeptides of the hTERT protein. However, in some embodiments, the cocktail of polypeptides comprises at least two different polypeptides selected from any one of the different tumour-associated antigens. In one embodiment, the cocktail of polypeptides comprises at least two different polypeptides selected from any one of: hTERT, Top2alpha, survivin or CYP1 B1.

As set out above, in some embodiments the polypeptide comprises a region of at least 12 amino acids of the tumour-associated antigen. It is to be appreciated that different lengths of polypeptide elicit different T cell responses. More specifically, in order to elicit a CD8+ T-cell response, the polypeptide must be presented on MHC class I molecules which will typically only bind polypeptides which are between 8 and 10 amino acid residues in length. On the other hand, in order to elicit a CD4+ T-cell response, it is typically necessary for the polypeptide to be presented on an MHC class II molecule for which the polypeptides may generally be longer, typically between 12 and 24 amino acid residues in length. Therefore, in one embodiment, the polypeptide comprising a region of at least 12 amino acids of the tumour-associated antigen is capable of eliciting a CD4+ T-cell response (i.e. a helper T cell response) because it is of a longer length (i.e. at least 12 amino acids in length).

In one embodiment, a CD4+ T-cell immune response is measured by a T-cell proliferation assay (3H-Thymidine) as previously described in Inderberg-Suso et al. Oncoimmunology. 2012 Aug 1 ; 1(5): 670-686. In one embodiment, the CD4+ T-cell immune response is considered positive if the response to the polypeptide is at least 3 times the background (Stimulation Index, SI > 3).

In some embodiments, the polypeptide comprising a region of at least 12 amino acids of the tumour-associated antigen is equal to or at least 15 amino acids in length. In some embodiments, the polypeptide is equal to or at least 16, 17, 18, 19, 20, 25 or 30 amino acids in length. In some embodiments, the polypeptide is equal to or less than 1000 amino acids in length, preferably equal to or less than 500, 200, 100, 50, 40 or 30 amino acids in length. More preferably, the polypeptide is equal to or less than 100 amino acids in length.

In embodiments where the tumour-associated antigen is telomerase (more specifically, hTERT), it is preferred that the polypeptide comprises a sequence selected from any one of SEQ. ID NOS. 1 to 5. It is particularly preferred that the polypeptide comprises the sequence of SEQ. ID NOS. 1 , 2 or 3. It is especially preferred that the polypeptide consists of the sequence of SEQ. ID NOS. 1 , 2 or 3. It is to be understood that such polypeptides are capable of eliciting a CD4+ T-cell response (i.e. a helper T cell response) because each of the polypeptides is at least 12 amino acids in length. SEQ. ID NO: 1 is 30 amino acids in length; SEQ. ID NOS: 2, 3 and 4 are 15 amino acids; and SEQ ID NO: 5 is 16 amino acids in length.

In some embodiments, the polypeptide comprises a sequence selected from any one of SEQ ID NOs: 5, 39 and 40. SEQ. ID NO: 5 is 16 amino acids in length. SEQ ID NO: 39 is 30 amino acids in length. SEQ ID NO: 40 is 30 amino acids in length. It is to be appreciated that polypeptides comprising the sequences of SEQ ID NO: 39 or 40 comprise the sequence of EARPALLTSRLRFIPK (SEQ ID NO: 5) which has been reported to induce immune responses in at least 50% of vaccinated individuals (see, for example, Bernhardt et al. Br J Cancer. 2006 Dec 4;95(11):1474-82; Inderberg-Suso et al. 2012; and Kyte et al. Clin Cancer Res July 1 2011 (17) (13) 4568-4580).

It is to be noted that some of the polypeptides of the present invention (e.g. the polypeptide of SEQ. ID NO. 1) are longer than would normally be accommodated in either an MHC class I or class II molecule. Peptides of this length have been shown to induce more robust immune responses, e.g. by groups working on HPV and cervical cancer vaccination (Welters et al, 2008). Without wishing to be bound by theory, it is believed that such polypeptides, following their administration to an individual, are endocytosed by cells, subjected to proteolytic degradation in the proteasome and then presented on an MHC class I or class II molecule. Thus such polypeptides may give rise to an MHC class I and/or an MHC class II restricted T-cell response. It is also to be appreciated that longer polypeptides remain extant within an individual for a greater period of time than shorter polypeptides and therefore there is a longer period of time during which they may elicit an immune response. This is particularly significant as regards those polypeptides which have a relatively low MHC binding affinity.

It is also to be appreciated that individuals will generally have developed some degree of immunological tolerance to polypeptides of tumour-associated antigens in a process whereby T-cells reactive with such polypeptides are destroyed in the thymus of the individual during T-cell development. Thus in some embodiments of the present invention, polypeptides of the present invention with a relatively low MHC binding affinity are desired. This is because polypeptides with lower MHC binding affinity will have been exposed to maturing T-cells at a lower rate and so it is less likely that all of the individual’s T-cells reactive with the polypeptide will have been deleted from the individual’s T-cell repertoire. Thus polypeptides having a relatively low MHC binding affinity are, in some embodiments, able to overcome immunological tolerance more readily.

In other embodiments, there are provided immunogenic fragments of the aforementioned polypeptides, which comprise at least 12 amino acids of SEQ. ID NOS: 1 to 5. In one embodiment, the immunogenic fragments comprise at least 12, 13 or 14 amino acids of SEQ. ID NOS. 1 to 5. In another embodiment, the immunogenic fragments comprise at Ieast 15, 16, 17, 18, 19, 20 or 25 amino acids of SEQ. ID NO. 1. Exemplary immunogenic fragments include those set out in SEQ ID NOS. 7 to 38. It is to be appreciated that the polypeptides of SEQ. ID NOS. 7 to 30 are all immunogenic fragments of the polypeptide of SEQ. ID NO. 1. The polypeptides of SEQ. ID NOS. 31 to 34 are all immunogenic fragments of the polypeptide of SEQ. ID NO. 2. The polypeptides of SEQ. ID NOS. 35 to 38 are all immunogenic fragments of the polypeptide of SEQ. ID NO. 3.

In the above described embodiments, a polypeptide of a single sequence is provided. However, in other embodiments, a cocktail (i.e. a mixture) of polypeptides is provided. In one embodiment, the cocktail comprises at least 2 or at least 3 different polypeptides of the tumour-associated antigen. It is particularly preferred that in the cocktail of polypeptides, the polypeptides in the cocktail are capable of being bound by MHC class II molecules of more than one HLA allele. It is also to be understood that in some embodiments the cocktail comprises more than two polypeptides having different sequences (e.g. 3, 4 or 5 polypeptides). It is preferred that the cocktail of polypeptides comprises polypeptides of the hTERT protein. In one embodiment, the cocktail of polypeptides comprises at least two different polypeptides comprising sequences from SEQ ID NOS. 1 to 5. It is particularly preferred that the polypeptides in the cocktail comprise the sequences of SEQ. ID NOS. 1 , 2 and 3. It is especially preferred that the polypeptides in the cocktail consist of the sequences of SEQ. ID NOS. 1 , 2 and 3. In some embodiments the cocktail comprises immunogenic fragments of the polypeptides, wherein the immunogenic fragments comprise at least 12 amino acids. In one embodiment, each polypeptide in the cocktail is equal to or less than 1000 amino acids in length, preferably less than 500, 200, 100, 50, 40 or 30 amino acids in length. More preferably, each polypeptide in the cocktail is equal to or less than 100 amino acids in length.

In one embodiment, the cocktail of polypeptides comprises one or more of the polypeptides as set out above and a further polypeptide. In one embodiment, the further polypeptide is derived from hTERT. In one embodiment, the further polypeptide is derived from a protein other than hTERT.

In one embodiment, the cocktail of polypeptides comprises any one or more sequences derived from hTERT according to SEQ ID NOS: 5, 39 and 40 in combination with any one or more of the sequences according to SEQ ID NOS: 1 , 2 and 3. Thus, the cocktail of peptides may comprise any one or more sequences selected from SEQ ID NOs: 1 , 2, 3, 5, 39 and 40.

In one embodiment, the polypeptides in the cocktail are capable of being bound by MHC class II molecules of more than one HLA allele. It is to be understood that in some embodiments the cocktail comprises more than two or more than three polypeptides having different sequences (e.g. 4, 5 or 6 polypeptides).

In further embodiments, the polypeptide or one or more of the polypeptides in the cocktail of polypeptides does not have an exact sequence identity to one of the aforementioned polypeptides. Instead, the polypeptide has at least 80% sequence identity to a polypeptide as set out above. It is particularly preferred that the sequence has at least 90%, 95% or 99% sequence identity to that set out above. It is also preferred that any addition or substitution of amino acid sequence results in the conservation of the properties of the original amino acid side chain. That is to say the substitution or modification is “conservative”.

Conservative substitution tables providing functionally similar amino acids are well known in the art. Examples of properties of amino acid side chains are hydrophobic amino acids (A, I, L, M, F, P, W, Y, V), hydrophilic amino acids (R, D, N, C, E, Q, G, H, K, S, T), and side chains having the following functional groups or characteristics in common: an aliphatic side-chain (G, A, V, L, I, P); a hydroxyl group containing side chain (S, T, Y); a sulphur atom containing side-chain (C, M); a carboxylic acid and amide containing side-chain (D, N, E, Q); a base containing side-chain (R, K, H); and an aromatic containing side-chain (H, F, Y, W). In addition, the following eight groups each contain amino acids that are conservative substitutions for one another (see e.g. Creighton, Proteins (1984):

1) Alanine (A), Glycine (G);

2) Aspartic acid (D), Glutamic acid (E);

3) Asparagine (N), Glutamine (Q);

4) Arginine (R), Lysine (K);

5) Isoleucine (I), Leucine (L), Methionine (M), Valine (V);

6) Phenylalanine (F), Tyrosine (Y), Tryptophan (W);

7) Serine (S), Threonine (T); and

8) Cysteine (C), Methionine (M).

In some embodiments, the sequence of the polypeptide or the sequence or one or more of the polypeptides in the cocktail of polypeptides is altered in order to change (e.g. increase) the binding affinity of the polypeptide to an MHC molecule of a particular HLA allele, preferably an MHC class II molecule. In other embodiments, a polypeptide as described above has further amino acids, in addition to those set out above, at the N- and/or C-terminal thereof. Such additional amino acids can also be used to alter (e.g. increase) the binding affinity of a polypeptide to an MHC molecule, preferably an MHC class II molecule.

It is to be understood that a polypeptide as set our above is not limited to having a sequence corresponding to a fragment of the tumour-associated antigen. That is to say, in some embodiments, the polypeptide comprises additional amino acid sequences at the N-terminal and/or C-terminal, in addition to the region corresponding to the tumour- associated antigen. However, the region corresponding to the tumour-associated antigen (or which is at least 80%, 90%, 95% or 99% identical to it as set out above) is at least 12 amino acids in length.

In some further embodiments, the polypeptide or one or more of the polypeptides in the cocktail of polypeptides is linked to a further substance. In one embodiment, the polypeptide is linked covalently to a further substance. The polypeptide, when linked to the further substance, retains its capability of inducing a CD4+ T-cell response. In one embodiment, the further substance comprises a lipid, a sugar or a sugar chain, an acetyl group, a further polypeptide, a natural or a synthetic polymer and the like. The polypeptide, in certain embodiments, contains a modification such as glycosylation, side chain oxidation or phosphorylation.

In some embodiments, a polypeptide as set out above is produced by conventional processes known in the art. Alternatively, the polypeptide is a fragment of a protein produced by cleavage, for example, using cyanogen bromide, and subsequent purification. Enzymatic cleavage may also be used. In further embodiments, the polypeptide is in the form of a recombinant expressed polypeptide. For example, a suitable vector comprising a polynucleotide encoding the polypeptide in an expressible form (e.g. downstream of a regulatory sequence corresponding to a promoter sequence) is prepared and transformed into a suitable host cell. The host cell is then cultured to produce the polypeptide of interest. In other embodiments, the at least one polypeptide is produced in vitro using in vitro translation systems.

Nucleic acid molecules

In another aspect, the present invention provides a nucleic acid molecule for use in the prevention or treatment of mesothelioma in a subject, or for use in the prevention of treatment of an epithelioid cancer in a subject. In a further aspect, the present invention provides a method of preventing or treating mesothelioma, or a method of preventing or treating an epithelioid cancer in a subject, comprising administering to the subject a nucleic acid. The nucleic acid molecule is administered simultaneously, separately or sequentially with an immune checkpoint inhibitor. The nucleic acid comprises a nucleotide sequence encoding a polypeptide as set out above, instead of (or in addition to) the polypeptide itself.

In embodiments where the tumour-associated antigen is telomerase, it is preferred that the nucleic acid molecule comprises a nucleotide sequence encoding a polypeptide comprising sequences from SEQ. ID NOS. 1 to 5. It is particularly preferred that the nucleic acid molecule comprises a nucleotide sequence encoding a polypeptide comprising the sequence of SEQ. ID NOS. 1 , 2 or 3. It is especially preferred that the nucleic acid molecule comprises a nucleotide sequence encoding a polypeptide consisting of the sequence of SEQ. I D NOS. 1 , 2 or 3.

In some embodiments, there is provided a cocktail (that is to say, a mixture) of nucleic acid molecules such as a cocktail of nucleic acid molecules comprising nucleotide sequences encoding polypeptides from the same tumour-associated antigen or from two or more different tumour-associated antigens. In one embodiment, the cocktail comprises at least 2 or at least 3 different nucleic acid molecules comprising nucleotide sequences encoding polypeptides of the tumour-associated antigen. It is particularly preferred that in the cocktail of nucleic acid molecules, the encoded polypeptides are capable of being bound by MHC class II molecules of more than one HLA allele. It is also to be understood that in some embodiments the cocktail comprises more than two nucleic acid molecules encoding different polypeptide sequences (e.g. 3, 4 or 5 nucleic acid molecules).

It is preferred that the cocktail of nucleic acid molecules comprise nucleotide sequences encoding polypeptides of the hTERT protein. It is preferred that the encoded polypeptide sequences in the cocktail comprise sequences from at least 2 different polypeptides comprising sequences from SEQ. ID NOS. 1 to 5. It is particularly preferred that the encoded polypeptides in the cocktail comprise the sequence of SEQ. ID NOS. 1 , 2 and 3. It is especially preferred that the encoded polypeptides in the cocktail consist of the sequences of SEQ. ID NOS. 1 , 2 and 3. In other embodiments, the polypeptide sequences encoded by the cocktail of nucleic acids are as set out above.

In alternative variants, the sequence of the encoded polypeptide is not identical to the aforementioned sequences but instead has at least 80%, 90%, 95% or 99% sequence identity thereto. In preferred embodiments, the encoded polypeptide is less than 1000 amino acids in length preferably less than 500, 200, 100, 50, 40 or 30 amino acids in length. In especially preferred embodiments, the encoded polypeptide is less than 100 amino acids in length.

In some further embodiments of the present invention, the one or more nucleic acid molecules are linked (e.g. covalently) to other substances.

It is to be appreciated that, owing to the degeneracy of the genetic code, nucleic acid molecules encoding a particular polypeptide may have a range of polynucleotide sequences. For example, the codons GCA, GCC, GCG and GCT all encode the amino acid alanine.

In some embodiments of the present invention, the one or more nucleic acid molecules comprises at least one nucleotide different from the naturally occurring sequence encoding the polypeptide. For example, the nucleic acid molecule, which encodes the polypeptide, is different from that comprised within a naturally-occurring hTERT gene. In some embodiments, this arises due to the degeneracy of the genetic code (i.e. the encoded polypeptide is the same). However, in other embodiments, the encoded polypeptide further comprises at least one amino acid at the N and/or C terminus that is different from the amino acid present in the naturally occurring polypeptide. For example, in the embodiments where the polypeptide is from hTERT, the nucleic acid molecule encodes a polypeptide which further comprises at least one amino acid at the N and/or C terminus that is not present in the corresponding position in the amino acid sequence in SEQ ID NO: 6.

The nucleic acid molecules may be either DNA or RNA or derivatives thereof. T-cell receptor or T-cell

In another aspect, the present invention provides a T-cell receptor (or an antigen-binding fragment thereof), or a T-cell displaying the T-cell receptor, which is specific for a polypeptide as set out above, instead of (or in addition to) the polypeptide itself, for use in the prevention or treatment of mesothelioma in a subject, or for use in the prevention of treatment of an epithelioid cancer in a subject. In a further aspect, the present invention provides a method of preventing or treating mesothelioma, or a method of preventing or treating an epithelioid cancer in a subject, comprising administering to the subject T-cell receptor or a T-cell.

In some embodiments, the T-cell receptor is an op T-cell receptor, or the antigen-binding fragment of the T-cell receptor is an antigen-binding fragment of an op T-cell receptor. In these embodiments, the T-cell receptor, or antigen-binding fragment thereof, is specific for a polypeptide as set out above when presented on an MHC molecule.

In some embodiments, the T-cell receptor is a y<5 T-cell receptor, or the antigen-binding fragment of the T-cell receptor is an antigen-binding fragment of a y<5 T-cell receptor. In these embodiments, the T-cell receptor does not necessarily require presentation of the polypeptide on an MHC molecule in order to recognise the polypeptide.

As set out above, the polypeptide comprises a region of at least 12 amino acids of a tumour-associated antigen. Polypeptides of this length may be presented on MHC class II molecules. Therefore, in some embodiments the T-cell receptor, or the T-cell displaying the T-cell receptor is capable of recognising and binding to a polypeptide when presented on an MHC class II molecule. MHC class II molecules typically bind polypeptides that are between 12 and 24 amino acids in length. In embodiments where the T-cell receptor, or the T-cell displaying the T-cell receptor, is described as specific for a polypeptide that is longer than 12 to 24 amino acids in length, it is to be understood that an immunogenic fragment of the polypeptide is presented on the MHC molecule.

In some embodiments where the tumour-associated antigen is telomerase (hTERT), it the T-cell receptor, or the T-cell displaying the T-cell receptor, is specific for a polypeptide consisting of a sequence selected from SEQ ID NOS. 1 to 5, or an immunogenic fragment thereof consisting of at least 12 amino acids. It is preferred that the T-cell receptor, or the T-cell displaying the T-cell receptor, is specific for a polypeptide consisting of the sequence of SEQ ID NOs: 1 , 2 or 3, or an immunogenic fragment thereof consisting of at least 12 amino acids. In some embodiments, the T-cell receptor, or the T-cell displaying the T-cell receptor, is specific for a polypeptide consisting of the sequence of SEQ ID NOs: 5, 39 or 40.

In some embodiments, there is provided a cocktail (i.e. a mixture) of T-cell receptors, or a cocktail of T-cells displaying the T-cell receptors. That is to say, the cocktail comprises different T-cell receptors, or T-cells displaying the different T-cell receptors, each of which is specific for a different polypeptide.

In one embodiment, the cocktail of different T-cell receptors, or the cocktail of T-cells displaying the different T-cell receptors is specific for different polypeptides from the same tumour-associated antigen, or alternatively, is specific for different polypeptides from two or more different tumour-associated antigens. In one embodiment, the cocktail of different T-cell receptors, or the cocktail of T-cells displaying the different T-cell receptors, is specific for at least 2 or at least 3 different polypeptides of a tumour- associated antigen, when each polypeptide is presented on an MHC molecule. That is to say, in some embodiments, the cocktail is specific for more than 2 or more than 3 polypeptides having different sequences, when each polypeptide is presented on an MHC molecule (e.g. 3, 4, or 5 polypeptides). It is particularly preferred that the cocktail of different T-cell receptors, or the cocktail of T-cells displaying the different T-cell receptors, is specific for polypeptides capable of being bound and presented by MHC class I and/or class II molecules of more than one HLA allele.

It is preferred that the cocktail of T-cell receptors, or the cocktail of T-cells displaying the T-cell receptors, is specific for different polypeptides of the hTERT protein, when each polypeptide is presented on an MHC molecule.

It is preferred that the polypeptides to which the cocktail of T-cell receptors, or the cocktail of T-cells displaying the T-cell receptors, are specific consist of sequences from at least 2 different polypeptides comprising sequences from SEQ. ID NOS. 1 to 5. It is particularly preferred that the polypeptides to which the cocktail of T-cell receptors, or the cocktail of T-cells displaying the T-cell receptors, are specific consist of the sequence of SEQ. ID NOS. 1 , 2 and 3. It is especially preferred that the polypeptides to which the cocktail of T-cell receptors, or the cocktail of T-cells displaying the T-cell receptors, are specific consist of the sequences of SEQ. ID NOS. 1 , 2 and 3. In other embodiments, the polypeptide sequences for which the cocktail of T-cell receptors, or the cocktail of T- cells displaying the T-cell receptors have specificity, are as set out above.

In some embodiments, a polypeptide to which the cocktail of T-cell receptors, or the cocktail of T-cells displaying the T-cell receptors, is specific is an immunogenic fragment of that polypeptide. It is to be understood that certain aforementioned polypeptides, such as SEQ ID NO. 1 , are longer than would normally be accommodated on an MHC class II molecule. Therefore, in embodiments in which a T-cell receptor, or a T-cell displaying the T-cell receptor, or a cocktail thereof, is described as specific for a polypeptide comprising or consisting of the sequence of SEQ ID NO. 1 , it is to be understood that an immunogenic fragment, comprising at least 12 amino acids of SEQ ID NO. 1 , may be presented on the MHC molecule. Analogous considerations apply to other aforementioned polypeptides.

In alternative variants, the sequence of the polypeptide for which the one or more T-cell receptors, or the one or more T-cells displaying the T-cell receptor, have specificity, is not identical to that aforementioned sequences but instead has at least 80%, 90%, 95% or 99% sequence identity thereto, provided that the polypeptide is still capable of being presented by an MHC molecule where necessary.

Immune checkpoint inhibitor

In another aspect, the present invention provides an immune checkpoint inhibitor for use in the prevention or treatment of mesothelioma, or for use in the prevention of an epithelioid cancer, in a subject. The immune checkpoint inhibitor is administered to the subject simultaneously, separately or sequentially with a polypeptide, nucleic acid, a T- cell receptor specific for a polypeptide, or a T-cell displaying the T-cell receptor, as set out above. The immune checkpoint inhibitor in accordance with any of the mentioned aspects of the invention is described below. An immune checkpoint inhibitor is any compound, substance or composition that is capable of down-regulating or blocking an immune checkpoint to allow more extensive immune activity. In some aspects, the invention involves the provision of a PD-1 or PD- L1 immune checkpoint inhibitor (collectively referred to as a PD-1/PD-L1 immune checkpoint inhibitor) and/or a CTLA-4 immune checkpoint inhibitor.

In one embodiment, the inhibitor of the PD-1/PD-L1 or CTLA-4 immune checkpoint comprises any one or more of the agents as shown in Table 1 A. Table 1A: Agents targeting PD-1/PD-L1 or CTLA-4 approved or in clinical development

PD-1, programmed death 1 receptor, PD-L1, programmed cell death ligand 1; IgG, immunoglobulin; mAb, monoclonal antibody; Fc, fragment crystallisable; N/A, not available; DDL1, delta like protein inhibitor.

In one embodiment, the inhibitor of the PD-1/PD-L1 immune checkpoint and/or CTLA-4 immune checkpoint comprises an antibody or a fragment thereof. In one embodiment, the antibody or the fragment thereof is capable of binding to a protein involved in the immune checkpoint pathway in order to disrupt or down-regulate the overall activity of the immune checkpoint. In a preferred embodiment, the fragment of the antibody is a functional fragment of the antibody (i.e. a partial fragment of an antibody that is capable of binding to an antigen). Examples of functional fragments of an antibody include Fab, F(ab')2, Fab', Fv, scFv, a diabody, a nanobody, a linear antibody and a multi-specific antibody. A multi-specific antibody is an antibody formed of two or more different antigen-binding fragments. An example of a fragment of an antibody is an Fc region. In one embodiment, the antibody or the fragment thereof is fucosylated or non-fucosylated, preferably non-fucosylated.

In one embodiment, the inhibitor of the PD-1/PD-L1 immune checkpoint comprises an anti-PD-L1 antibody or functional fragment thereof and/or an anti-PD-1 antibody or a functional fragment thereof. An anti-PD-L1 antibody or a functional fragment thereof is capable of binding specifically to PD-L1 . An anti-PD-1 antibody or a functional fragment thereof is capable of binding specifically to PD-1 . In this way, the antibody or functional fragment thereof inhibits the interaction between the receptor PD-1 and its ligand PD-L1 thereby down-regulating or blocking the overall activity of the PD-1/PD-L1 immune checkpoint.

In one embodiment, the inhibitor of the PD-1/PD-L1 immune checkpoint comprising an antibody or a functional fragment thereof is one or more as shown in Table 1A. In a preferred embodiment, the anti-PD-L1 antibody is one or more selected from: durvalumab, atezolizumab and/or avelumab, most preferably durvalumab. In a further preferred embodiment, the anti-PD-1 antibody is one or more selected from: pembrolizumab, nivolumab and/or cemiplimab, most preferably nivolumab.

In one embodiment, the inhibitor of the CTLA-4 immune checkpoint comprises an anti- CTLA-4 antibody or functional fragment thereof. An anti-CTLA-4 antibody or a functional fragment thereof is capable of binding specifically to CTLA-4. In this way, the antibody or functional fragment thereof inhibits the interaction between the receptor CTLA-4 and a B7 family ligand (e.g. CD80 and/or CD86) thereby down-regulating or blocking the overall activity of the CTLA-4 immune checkpoint. The anti-CTLA-4 antibody may comprise ipilimumab and/or tremelimumab. In a preferred embodiment, the anti-CTLA-4 antibody comprises ipilimumab.

In one embodiment, the inhibitor of the PD-1/PD-L1 immune checkpoint and/or CTLA-4 immune checkpoint comprises a probody. The probody comprises an antibody or fragment thereof specific for PD-1, PD-L1 and/or CTLA-4 as described above and a masking peptide that is linked to the antibody or fragment thereof by a cleavable linker peptide. When a probody reaches the tumour microenvironment, tumour-associated proteases cleave the linker, which releases the masking peptide, enabling the antibody or fragment thereof to bind the target antigen.

In one embodiment, the inhibitor of the PD-1/PD-L1 immune checkpoint or CTLA-4 immune checkpoint comprises a peptide-based inhibitor. In one embodiment, the peptide-based inhibitor comprises a linear peptide, a peptidomimetic, a branched- peptide, a cyclopeptide and/or a macrocyclic-peptide. In an alternative embodiment, the inhibitor of the PD-1/PD-L1 immune checkpoint or CTLA-4 immune checkpoint comprises a small molecule inhibitor. The peptide-based inhibitor or the small molecule inhibitor targets a protein involved in one or more of the aforementioned immune checkpoint pathways in order to disrupt or down-regulate the overall activity of the immune checkpoint.

In a preferred embodiment, the peptide-based inhibitor or the small molecule inhibitor is an inhibitor of PD-L1 , PD-1 or CTLA-4. That is to say, the peptide-based or small molecule inhibitor targets PD-L1 , PD-1 or CTLA-4 specifically in order to disrupt their normal function and down-regulate or block the overall activity of the PD-1/PD-L1 immune checkpoint or CTLA-4 immune checkpoint. Thus, in one embodiment, the peptide-based inhibitor or the small molecule inhibitor is a PD-L1 antagonist, a PD-1 antagonist and/or a CTLA-4 antagonist. In one embodiment, the peptide-based inhibitor is an inhibitor of PD-1 and is AUNP-12. In some embodiments, the antibody or the fragment thereof, preferably the functional fragment thereof, the peptide-based inhibitor or the small molecule inhibitor as described above is linked (e.g. covalently) or fused to a further substance. The antibody or the fragment thereof, preferably the functional fragment thereof, the peptide-based inhibitor or the small molecule inhibitor that is linked or fused to the further substance is capable of inhibiting the PD-1/PD-L1 immune checkpoint and/or the CTLA-4 immune checkpoint. In one embodiment, the further substance comprises a lipid, a sugar or a sugar chain, an acetyl group, a polypeptide, a natural or a synthetic polymer and the like. Thus, in one embodiment, the immune checkpoint inhibitor comprises a fusion protein. In some embodiments, the immune checkpoint inhibitor comprises a multi-specific or a bi-specific activity. In one embodiment, the bispecific activity comprises inhibiting the PD-1/PD-L1 immune checkpoint and inhibiting the CTLA-4 immune checkpoint. In one embodiment, a bispecific or multispecific antibody or fragment thereof is provided. In a preferred embodiment, the bispecific or multispecific antibody or fragment thereof inhibits the PD- 1/PD-L1 immune checkpoint and inhibits the CTLA-4 immune checkpoint. In one embodiment, the bispecific or multispecific antibody or fragment thereof is specific for PD-L1 , PD-1 and/or CTLA-4, preferably specific for PD-1 and CTLA-4. In some embodiments, multi-specific or a bi-specific activity comprises the activity of inhibiting the PD-1/PD-L1 immune checkpoint and/or inhibiting the CTLA-4 immune checkpoint as well as a further activity. In some embodiments, the immune checkpoint inhibitor comprises an antibody or a functional fragment thereof, a peptide-based inhibitor or a small molecule inhibitor which is specific for PD-L1 , PD-1 and/or CTLA-4 as well as a further substance (e.g. as described above) which is specific for a further target.

In a further embodiment, a plurality of immune checkpoint inhibitors is provided. That is to say, two, three, four, five or more different immune checkpoint inhibitors are provided. In one embodiment, each of the different immune checkpoint inhibitors targets the same immune checkpoint. In a preferred embodiment, each of the different immune checkpoint inhibitors targets a different immune checkpoint. In a preferred embodiment, a first and a second immune checkpoint inhibitor are provided. It is preferred that the first immune checkpoint inhibitor is an inhibitor of the PD-1/PD-L1 immune checkpoint and the second immune checkpoint inhibitor is an inhibitor of the CTLA-4 immune checkpoint. In an especially preferred embodiment, the immune checkpoint inhibitor comprises an anti-PD-1 antibody or a functional fragment thereof and an anti-CTLA-4 antibody or a functional fragment thereof. In another embodiment, the first immune checkpoint inhibitor comprises pembrolizumab and the second immune checkpoint inhibitor comprises ipilimumab. In an alternative embodiment, the first immune checkpoint inhibitor comprises durvalumab and the second immune checkpoint inhibitor comprises ipilimumab.

In a further embodiment, the immune checkpoint inhibitor targets another member of the CD28CTLA-4 Ig superfamily such as BTLA, LAG3, ICOS, PDL1 or KIR (Page et al., Annual Review of Medicine 65:27 (2014)). In further additional embodiments, the immune checkpoint inhibitor is targeted at a member of the TNFR superfamily such as CD40, 0X40, CD137, GITR, CD27 or TIM-3. In a further embodiment, the immune checkpoint inhibitor targets Indoleamine 2,3-dioxygenase (IDO). Examples of such suitable therapeutic agents are shown in Table 1 B below.

Table 1 B: Other immunotherapeutic agents in development

Heme, Haematologic tumours; ATL, acute T-cell leukemia; CTCL, cutaneous T-cel lymphoma; AML, acute myeloid leukemia

PD-1 and inhibitors of the PD-1 pathway

Whilst CTLA-4 serves to regulate early T cell activation, PD-1 signalling functions in part to regulate T cell activation in peripheral tissues. The PD-1 receptor is an immunoinhibitory receptor belonging to the CD28 family. PD-1 is expressed on a number of cell types including T regs, activated B cells, and natural killer (NK) cells, and is expressed predominantly on previously activated T cells in vivo. PD-1 binds to two ligands, PD-L1 and PD-L2. The endogenous ligands of the PD-1 receptor, PD-L1 and PD-L2, are expressed in activated immune cells as well as non-haematopoietic cells, including tumour cells. PD-1 as used herein is meant to include human PD-1 (hPD-1), variants, isoforms, and species homologs of hPD-1 , and analogs having at least one common epitope with hPD-1. The complete hPD-1 sequence can be found under GENBANK Accession No. LI64863. Programmed Death Ligand-1 (PD-L1) is one of two cell surface glycoprotein ligands for PD-1 (the other being PD-L2) that results in downregulation of T cell activation and cytokine secretion upon binding to PD-1. PD-L1 as used herein includes human PD-L1 (hPD-L1), variants, isoforms, and species homologs of hPD-L1 , and analogs having at least one common epitope with hPD-L1. The complete hPD-L1 sequence can be found under GENBANK Accession No. Q9NZQ7. Tumours have been demonstrated to escape immune surveillance by expressing PD-L1/L2, thereby suppressing tumour-infiltrating lymphocytes via PD-1/PD- L1 ,2 interactions (Dong et al. Nat. Med. 8:793-800. 2002). Inhibition of these interactions with therapeutic antibodies has been shown to enhance T cell response and stimulate antitumour activity (Freeman et al. J. Exp. Med. 192: 1027-34.2000).

As discussed above, in preferred embodiments, the anti-PD-1 antibody is nivolumab (CAS Registry Number: 946414-94-4). Alternative names for nivolumab include MDX-1 106, MDX-1 106-04, ONO-4538, BMS-936558. Nivolumab is a fully human lgG4 blocking monoclonal antibody against PD-1 (Topaliam et al., N. Engl. J. Med. 366:2443- 54. 2012). Nivolumab specifically blocks PD-1 , which can overcome immune resistance. The ligands for PD-1 have been identified as PD-L1 (B7-H1), which is expressed on all haemopoietic cells and many nonhaemopoietic tissues, and PD- L2 (B7-DC), whose expression is restricted primarily to dendritic cells and macrophages (Dong, H. et al. 1999. Nat. Med. 5: 1365; Freeman, G. J.et al. 2000. J. Exp. Med. 192: 1027; Latehman, Y. et al. 2001. Nat. Immunol 2:261 ; Tseng, S. Y. et al. 2001. J. Exp. Med. 193:839). PD- L1 is overexpressed in many cancers and is often associated with poor prognosis (Okazaki T et al, Intern. Immun. 2007 19(7):813) (Thompson RH et al, Cancer Res 2006, 66(7):3381), the majority of tumour infiltrating T lymphocytes predominantly express PD- 1 , in contrast to T lymphocytes in normal tissues and peripheral blood T lymphocytes, indicating that up-regulation of PD-1 on tumour-reactive T cells can contribute to impaired antitumour immune responses (Blood 2009 1 14(8): 1537). Specifically, since tumour cells express PD-L1 , an immunosuppressive PD-1 ligand, inhibition of the interaction between PD-1 and PD-L1 can enhance T-cell responses in vitro and mediate preclinical antitumour activity.

A number of clinical trials (Phase I, II and III) involving nivolumab have been conducted or are on-going. For example, in a phase I dose escalation trial, nivolumab was safe, and objective responses were 16-31% across tumour types, with most responses being durable for >1 year (Topaliam et al., Presented at Annu. Meet. Am. Soc. Clin. Oncol., Chicago, May 31 -June 4. 2013). In another study, the safety and clinical activity of nivolumab (anti-PD-1 , BMS-936558, Q Q-4538) in combination with ipilimumab in patients with advanced melanoma was investigated (Woichok, J Clin Oncol 31 , 2013 (suppl; abstr90122013 ASCO Annual Meeting). As of 2020, nivolumab (underthe brand name Opdivo®) has been approved by the FDA for use in a wide range of cancers including: melanoma; lung cancer (both small cell and non-small cell); renal cell carcinoma; Hodgkin’s lymphoma; head and neck cancer; urothelial carcinoma; colorectal cancer; hepatocellular carcinoma; oesophageal carcinoma; and malignant pleural mesothelioma.

Clinical trials have also led to a number of other PD-1 targeting agents being approved for use in various cancers including pembrolizumab (Keytruda®). As of 2020, pembrolizumab (under the brand name Keytruda®) has been approved for use in: melanoma; lung cancer (both small cell and non-small cell); head and neck cancer; refractory Hodgkin’s lymphoma; primary mediastinal large B-cell lymphoma; skin cancer (melanoma and Merkel cell carcinoma); endometrial carcinoma; renal cell carcinoma; hepatocellular carincoma; microsatellite instability-high or mismatch repair deficient colorectal cancer; and a number of other cancers in cases where tumours express PD- L1 , including urothelial carcinoma; gastric cancer; esophageal carcinoma, and cervical cancer.

A number of anti-PD-L1 inhibitory agents have undergone clinical investigations, such as several anti-PD-L1 inhibitory antibodies, including atezolizumab (also known as MPDL3280A, or under the brand name of Tecentriq®) (Genentech, South San Francisco, CA), BMS-936559 (also known as MDX-1105) (Bristol Meyers Squibb, New York, NY), durvalumab (also known as MEDI4736 or under the brand name IMFINZI®) and avelumab (also known as MSB0010718C or under the brand name Bavencio®). Like nivolumab and pembrolizumab, these antibodies are thought to function principally by blocking PD-1/PD-L1 signalling. PD-L1 antibodies generally do not affect interactions between PD-L2 and PD-1 , but these do additionally inhibit interactions between PD-L1 and CD80 (Park et al., 2010. Blood 3 16:1291-98). Atezolizumab was evaluated in multiple tumour types, with safety and preliminary efficacy identified in melanoma; renal cell carcinoma; non-small cell lung carcinoma (NSCLC); and colorectal, gastric, and head/neck squamous cell carcinoma (Herbst et al. presented at Annu. Meet Am. Soc. Clin. Oncol., Chicago, May 31 -June 4. 2013). Atezolizumab has now been approved for use in bladder cancer, breast cancer, lung cancer (both small and non-small cell) and urothelial carcinoma. Durvalumab has been evaluated clinically (e.g. NCT01693562) and has now been approved for use in lung cancer (both small and non-small cell) and urothelial carcinoma. Avelumab has also been approved for use in Merkel cell carcinoma, renal cell carcinoma and urothelial carcinoma.

CTLA-4 and inhibitors of the CTLA-4 immune checkpoint

Cytotoxic T-lymphocyte-associated antigen (CTLA-4), also known as CD 152, is a co- inhibitory molecule that functions to regulate T-cell activation.

CTLA-4 was initially identified as a negative regulator on the surface of T-cells that was upregulated shortly after initiation of a de novo immune response or stimulation of an existing response in order to dampen the subsequent immune T-cell response and prevent auto-immunity or uncontrolled inflammation. Thus, the magnitude of the developing immune response has been closely tied to CTLA-4 action. In certain embodiments, the anti-CTLA-4 antibody is ipilimumab or tremelimumab.

Checkpoint inhibitors function by modulating the immune system's endogenous mechanisms of T cell regulation. Ipilimumab (YERVOY, Bristol-Meyers Squibb, New York, NY) is a monoclonal antibody and is the first such checkpoint inhibitor to be approved by the US Food and Drug Administration (FDA). It has become standard treatment for metastatic melanoma (Hodi et al., N. Engl. J. Med. 363:711-23. 2010; Robert et al., N. Engl. J. Med. 364:2517-26. 2011). Ipilimumab binds to and blocks inhibitory signaling mediated by the T-cell surface co-inhibitory molecule cytotoxic T lymphocyte antigen 4 (CTLA-4). As the mechanism of action is not specific to one tumour type, and because a wealth of preclinical data supports the role of tumour immune surveillance across multiple malignancies (Andre et al, Clin. Cancer Res. 19:28-33. 2013; May et al. Clin. Cancer Res.17:5233-38. 201 1), ipilimumab is being investigated as a treatment for patients with prostate, lung, renal, and breast cancer, among other tumour types. Ipilimumab works by activating the immune system by targeting CTLA-4. Another CTLA-4-inhibitory antibody, tremelimumab, continues to be investigated in clinical trials and has also demonstrated durable responses in patients with melanoma (Kirkwood et al., Clin. Cancer Res. 16: 1042-48. 2010; Rihas et al. J. Clin. Oncol. 3 1 :616- 22, 2013).

In addition to CTLA-4 and PD-1/PD-L1 , numerous other immunomodulatory targets have been identified primarily, many with corresponding therapeutic antibodies that are being investigated in clinical trials. Page et al. (Annu. Rev. Med. 2014.65) details targets of antibody immune modulators in Figure 1 , incorporated by reference herein.

Additional components

In some embodiments, the polypeptide, the nucleic acid, the T-cell or T-cell receptor, and the immune checkpoint inhibitor for use according to the invention as described herein, may be administered in conjunction with one or more components such as a pharmaceutically acceptable adjuvant, diluent or excipient.

Exemplary adjuvants include Poly l:C (Hiltonol), CpG, liposomes, microspheres, viruslike particles (ISCOMS), Freund’s incomplete adjuvant, aluminium phosphate, aluminium hydroxide, alum, bacterial toxins (for example, cholera toxin and salmonella toxin). Further exemplary adjuvants include Imiquimod or glucopyranosyl Lipid A. A particularly preferred adjuvant is GM-CSF (granulocyte macrophage colony stimulating factor). Exemplary diluents and excipients include sterilised water, physiological saline, culture fluid and phosphate buffer. Exemplary adjuvants for use in vaccines targeting the T cell arm of the immune system, as in the present invention, are detailed in Petrovsky & Aguilar Immunol Cell Biol. 2004 82(5):488-96, which is incorporated herein by reference.

The polypeptide or nucleic acid molecule as described above is, in certain embodiments, coupled to an immunogenic carrier or incorporated into a virus or bacterium. Exemplary immunogenic carriers include keyhole limpet haemocyanin, bovine serum albumin, ovalbumin, fowl immunoglobulin and peptide fragments of immunogenic toxins. In one embodiment, the nucleic acid molecule is coupled to or integrated in a carrier selected from the group consisting of dendritic cells, yeast, bacteria, viral vectors, oncolytic viruses, virus like particles, liposomes, micellar nanoparticles or gold nanoparticles.

The subject to be treated is a cancer patient in need of treatment. In one aspect of the invention, the cancer is mesothelioma, preferably malignant mesothelioma. The mesothelioma may be pleural, peritoneal, pericardial or testicular mesothelioma. In preferred embodiments, the mesothelioma is pleural mesothelioma, preferably malignant pleural mesothelioma (MPM). Malignant mesothelioma may be localized as a solitary, nodular lesion without diffuse involvement of the serosal surface both macroscopically and histologically (local malignant mesothelioma). More commonly, malignant mesothelioma presents in a diffuse form (diffuse malignant mesothelioma). In some embodiments, the cancer to be treated is unresectable. Based on standard histological analysis, malignant mesothelioma may be classified into three major subtypes. These are: epithelioid, biphasic and sarcomatoid. A rarer subtype is rhabdoid mesothelioma. (Any subtypes which are not epithelioid may be collectively classified as “nonepithelioid”). Epithelioid mesothelioma is the most common subtype and may be found in up to 80% patients with malignant mesothelioma. It is known for its heterogeneous morphology. The mesothelioma to be treated in accordance with the use and method of the present invention may be any of the aforementioned subtypes. Preferably, the mesothelioma is epithelioid mesothelioma or epithelioid MPM.

Epithelioid mesothelioma may be diagnosed by standard histological analysis. Typically, epithelioid mesothelioma has a distinct cytology and is composed oval, polygonal or cuboidal cells with multiple secondary patterns. For example, cells may display a characteristic tubulopapillary growth pattern, and have round nuclei, eosinophilic cytoplasm and conspicuous nucleoli. A differential diagnosis of epithelioid mesothelioma may additionally or alternatively be made based on standard immunohistochemical phenotyping. Positive biomarkers for epithelioid mesothelioma may include one or more of Calretinin, Keratin 5/6, Podoplanin (D2-40) and WT1. Negative biomarkers for epithelioid mesothelioma may include one or more of TTF1 , Napsin A, PAX8, GATA3, GCDFP-15, mammaglobin, MOC31 , BerEp4, CEA, and Claudin 4.

In another aspect of the invention, the cancer is any epithelioid cancer, that is to say, any cancer with an epithelioid histology. As set out above, the polypeptide is of a tumour- associated antigen, and preferably a universal tumour-associated antigen which is associated with a wide range of cancer types. Therefore, in this aspect of the invention, the efficacy of the therapy not limited to any particular type of cancer, providing the cancer is associated with an epithelioid histology or morphology. For example, the cancer may be a soft tissue cancer with epithelioid histology or morphology including, but not limited to, epithelioid sarcoma, malignant extrarenal rhabdoid tumour, epithelioid malignant peripheral nerve sheath tumour, epithelioid glioblastoma, epithelioid leiomyosarcoma, epithelioid angiosarcoma, epithelioid hemangioendothelioma and sclerosing epithelioid fibrosarcoma. Epithelioid histology or morphology may be observed in various types of cancer including breast cancer, prostate cancer, pancreatic cancer, colorectal cancer, lung cancer, malignant melanoma, leukaemias, lymphomas, ovarian cancer, cervical cancer and biliary tract carcinomas. It is well-recognised that epithelioid cancers typically express characteristic patterns of immunohistochemical markers that can be used to identify the cancer. As demonstrated in the Examples, the present inventors have unexpectedly found that use of the polypeptide in combination with an immune checkpoint inhibitor as described herein is more effective in the treatment of an epithelioid cancer than in the treatment of a non-epithelioid cancer, thus providing clinical utility for a new subgroup of cancer patients.

Methods of the Invention

According to the use and method of the present invention, a combination therapy is administered to the subject. As set out above, in the combination therapy, the following are administered to an individual: the polypeptide, nucleic acid molecule, T-cell or T-cell receptor (or antigen-binding fragment thereof) as described above, or a combination thereof (hereinafter “the first component of the treatment”); and one or more immune checkpoint inhibitors as described above (hereinafter “the second component of the treatment”). In principle, any mode of administration of the components of the treatment may be used. Preferred modes are described below.

Following administration, the polypeptide is endocytosed by antigen presenting cells, may be subject to antigen processing and is then presented in a complex with an MHC class II molecule on the cell surface. Through interaction with T-cell receptors on the surface of T-cells, a CD4+ T-cell response is elicited. It is to be appreciated that as a result of antigen processing, the polypeptide may also be presented in a complex with an MHC class I molecule on the cell surface and thereby elicit a CD8+ T cell response. In embodiments which provide a nucleic acid molecule, the nucleic acid molecule is also endocytosed and is then transcribed (if the nucleic acid molecule is DNA) and translated, and the encoded polypeptide is synthesised through endogenous cellular pathways. Subsequently, the encoded polypeptide is processed and presented on an MHC molecule in order to elicit the T-cell response, as previously described. Thus the polypeptide or nucleic acid encoding the polypeptide may be used as a vaccine in order to elicit CD4+ T-cell (as well as CD8+ T cell) immunity.

The components of the treatment as explained above may each be administered simultaneously, separately or sequentially to a patient in need of treatment. That is to say, the first component of the treatment may be administered simultaneously, separately or sequentially to the second component of the treatment. Thus, the first and/or second component of the treatment may be administered at a different time or in a substantially simultaneous manner. The term “simultaneously” as used herein refers to administration of one or more agents at the same time. For example, in certain embodiments, the polypeptide and the immune checkpoint inhibitor are administered simultaneously. Simultaneously includes administration contemporaneously, that is during the same period of time. In certain embodiments, the components are administered simultaneously in the same hour, or simultaneously in the same day. In some embodiments, the term “sequentially” refers to the components of the treatment being administered within 1 , 3, 5, 7, 10, 28, 30 or 60 days of each other. In some embodiments, the term “sequentially” refers to the components of the treatment being administered within 2, 4 or 6 months of each other.

The second component of the treatment (i.e. the immune checkpoint inhibitor) is capable of down-regulating or blocking an immune checkpoint to allow more extensive immune activity. In some embodiments, it is preferred to administer the second component of the treatment subsequent to the first component of the treatment. In this way, the second component of the treatment takes effect as a T-cell immune response is initiated in response to vaccination with the first component of the treatment. In one embodiment, it is preferred to administer the second component of the treatment during the initiation phase of vaccination. In some embodiments, this is within 30, 21 , 14, 10, 7, 5, 3 or 1 days from the initial vaccination with the first component of the treatment. Further details on treatment regimes in accordance with embodiments of the present invention are described below.

Without wishing to be bound by theory, it is thought that the administration of the second component of the treatment subsequent to the first component of the treatment and within the aforementioned timeframe promotes a rapid and effective expansion of T-cells specific to the first component of the treatment from a population of naive T-cells in the primary lymphoid organs (i.e. a rapid and effective primary immune response). This is thought to be because the second component of the treatment takes effect as the T-cell response is developing and prevents dampening of the response by the immune checkpoint. Therefore, a strong de novo immune response is promoted, which translates into higher clinical benefit as described below. In addition, the administration of the second component of the treatment subsequent to the first component of the treatment and within the aforementioned timeframe is thought to contribute to the generation of an accelerated CD4+ T cell immune response.

In embodiments of the invention which are directed to the prevention of mesothelioma or an epithelioid cancer in a subject, administration of the first component of the treatment may be administered before diagnosis of the mesothelioma epithelioid cancer in order to generate immunological memory with respect to the tumour-associated antigen. In the event of a later diagnosis, the second component may be administered to facilitate or enhance the immune response to the tumour-associated antigen, optionally with a repeated administration of the first component.

Sequential or substantially simultaneous administration of each component of the treatment can be effected by any appropriate route including, but not limited to, intradermal routes, oral routes, intravenous routes, sub-cutaneous routes, intramuscular routes, direct absorption through mucous membrane tissues (e.g., nasal, mouth, vaginal, and rectal), and ocular routes (e.g., intravitreal, intraocular, etc.). The components of the treatment can be administered by the same route or by different routes, preferably the components of the treatment are administered by different routes. In one embodiment, one or more components of the treatment are administered by injection. In one embodiment, one or more components of the treatment are injected directly into a tumour in a patient. If the cancer to be treated is in the nose or mouth of a patient then in some embodiments, one or more components of the treatment are administered by spray and inhalation. In a preferred embodiment, the first component of the treatment is administered intradermally, preferably by an intradermal injection; and the second component of the treatment is administered intravenously.

A suitable dosage of the first component of the treatment (e.g. the polypeptide or the cocktail of polypeptides) is between 100 and 700 pg although dosages outside this range may occasionally be required (e.g. from 1-1500 pg). A dosage of 300 pg is particularly preferred. In one embodiment, the first component is a T-cell and a dose of 10⁶ to 10¹¹ cells is provided. In one embodiment, the first component of the treatment is administered simultaneously, separately or sequentially with an adjuvant, preferably GM- CSF, most preferably sargramostim. A suitable dosage of GM-CSF, preferably sargramostim, is between 20 and 100 pg. In one embodiment, the dosage is 37.5 pg to 100 pg, in a preferred embodiment, the dosage is 75 pg.

A suitable dosage of the second component of the treatment (i.e. the immune checkpoint inhibitor) is between 100 and 2000 mg. In a preferred embodiment, the dosage is 1500 mg. In an alternative embodiment, the dosage is 200 or 300 mg. In one embodiment, a dosage in a range from 1 microgram/kg to 10 mg/kg is given, preferably 3 mg/kg.

In some embodiments, a treatment regimen is pursued as follows. In one embodiment, the first component of the treatment (e.g. the polypeptide) is administered to the patient between 4 and 10 times. In a preferred embodiment, the first component of the treatment is administered 8 times. In a further preferred embodiment, the first component of the treatment is administered 8 times within 5 months. It is particularly preferred that 1 to 4 administrations of the first component of the treatment are provided within an initial period. In one embodiment, the initial period is 10 days or fewer. In one embodiment, the administrations within the initial period are each separated by at least 2 days. In some embodiments, the administrations subsequent to those in the initial period (e.g. administration 5 and onward) are separated by between 2 and 4 weeks, preferably each subsequent administration is given every 4 weeks (28 days).

In one embodiment, the second component of the treatment (i.e. the immune checkpoint inhibitor) is administered over at least 12 months, preferably over at least 24 months or until disease progression or unacceptable toxicity. In one embodiment, each administration of the second component is separated by between 2 and 6 weeks, preferably each administration is given every 4 weeks (28 days).

In some embodiments, one or more administrations of the first and second components of the treatment are given on the same day (e.g. administration 1 , 5, 6, 7 and 8 of the first component of the treatment). In such embodiments, the first component of the treatment is given prior to the administration of the second component of the treatment.

In preferred embodiments, the first component is administered: (i) prior to the first administration of the immune checkpoint inhibitor; (ii) prior to each re-administration of the immune checkpoint inhibitor; and (iii) following completion of the immune checkpoint inhibitor treatment regimen. It is preferred that multiple administrations of the first component are provided at stages (i), (ii) and (iii).

It is particularly preferred that one to five administrations of the first component are provided at stages (i) and (ii) in the seven days prior to the first administration or readministration of the checkpoint inhibitor respectively. It is especially preferred that one to three administrations of the first component are provided. In some embodiments, the administration of the first component at stage (i) is provided between one to three days prior to the first administration of the checkpoint inhibitor. It is also preferred that the first component is administered to the patient following completion of the immune checkpoint inhibitor treatment regimen on a monthly basis (i.e. stage (iii)). In an alternative embodiment, the administration of the first component at stage (iii) is on a quarterly basis.

In a particularly preferred embodiment, a treatment regimen as shown in Figure 1 is followed. In this regimen, UV1 vaccination is the first component and a combination of ipimilumab and nivolumab (IPI-NIVO) is the second component. However, it is to be understood that in alternative embodiments, the first and second components are not limited to UV1 vaccination and IPI-NIVO, respectively, and that the first and second components may be in accordance with any of the embodiments as described above.

As mentioned above, in a preferred embodiment, the polypeptide comprises amino acid sequences according to SEQ ID NOs: 1 , 2 and 3, and the immune checkpoint inhibitor comprises ipilimumab and nivolumab. In this embodiment, the polypeptide may be administered to the subject intradermally at a dose of 250 pg to 400 pg, preferably 300 pg, 5 to 10 times, preferably 6-8 times, over a period of 10 to 15 weeks. In this embodiment, ipilimumab may be administered to the subject at a dose of 1 mg/kg, once every 6 weeks, and nivolumab may be administered to the subject at a dose of 3mg/kg or at a dose of 220 to 260 mg, once every 2 weeks.

In one embodiment, the components of the treatment are administered to a subject who has undergone a neoadjuvant therapy, such as a chemotherapy or radiotherapy treatment. That is to say, the components of the treatment are administered as a second- line treatment. In one embodiment, the components of the treatment are administered to a subject subsequent to a platinum-based chemotherapy treatment. In one embodiment, the subject is in complete or partial response to the chemotherapy treatment. In another embodiment, the components of the treatment are administered as a first-line treatment. In this embodiment, the components of the treatment may be administered as a first-line treatment in conjunction with a further treatment such as surgery, chemotherapy or radiotherapy.

Synergistic effect

In some embodiments, the polypeptide which comprises a region of at least 12 amino acids of a tumour-associated antigen and the checkpoint inhibitor produce a synergistic effect in the treatment of cancer but it is to be understood that a synergistic effect is not essential to the invention. In some other embodiments, the nucleic acid molecule, the T-cell receptor, or the T-cell displaying the T-cell receptor, according to the present invention and the immune checkpoint inhibitor produce a synergistic effect in the treatment of cancer.

The synergistic effect in the treatment of cancer comprises: a reduction in the time required by the immune system of the patient to mount a measurable immune response against the polypeptide; the mounting of a strong immune response to the polypeptide (i.e. a Stimulation Index, SI > 3); and an improved clinical outcome (i.e. a partial or complete response (also known as partial or complete remission) or stable disease). In some embodiments, the synergistic effect in the treatment of cancer also comprises the induction of a broad immune response (i.e. the mounting of an immune response against 2, 3 or more vaccine components).

Without wishing to be bound by theory, it is believed that the ability of the polypeptide of the tumour-associated antigen to elicit a CD4+ T cell response is of central importance to the synergistic effect. By using long polypeptides of at least 12 amino acids, CD4+ T cells are stimulated. These cells play a complex role in the tumour microenvironment and are able to interact directly with tumour cells and a number of immune effectors, leading to tumour cell destruction. Dead tumour cells release more antigen which in turn is taken up by antigen presenting cells, stimulating a second wave of T-cell immunity targeting other tumour antigens, a phenomenon called “epitope spreading”.

The combination of the polypeptide capable of eliciting a CD4+ T cell response and the immune checkpoint inhibition results in a fast occurring immune response in a high proportion of patients as well as efficient augmentation of low/non-detectable immune responses in other patients. This results in a high clinical response rate (i.e. the proportion of patients with a partial or complete response (also known as partial or complete remission) or stable disease. In particular, the polypeptide comprising a region of the tumour-associated antigen provides a cancer-specific immune response to patients lacking such a response, and will also augment weak or suboptimal spontaneous immune response in the patients thus greatly extending the number of patients that may benefit clinically from immune checkpoint inhibition. The immune checkpoint inhibition removes the negative influence of the checkpoint on T cell proliferation and thus results in a more rapid and clinically efficient T cell response in a higher proportion of patients. This includes turning negative responses to the polypeptide of the self-antigen and/or tumour associated antigen into a positive response by allowing extended clonal expansion long after termination of vaccination with the polypeptide.

It is to be appreciated that the present invention is particularly useful in the following clinical settings. First, in patient groups in which the patient has a tumour where spontaneous immune responses are generally absent (i.e. tumour indications where immune checkpoint inhibition has previously failed to provide clinical benefit) and in patients groups where only a small fraction of patients are responsive to immune checkpoint inhibition. Second, in patient groups where previous cancer vaccines have demonstrated their capacity to elicit immune responses to long peptide vaccines and patients where cancer vaccines can be developed, but are unable to provide substantial clinical benefit despite their capacity to induce immune responses after vaccination. In one embodiment, the present invention is used in patient groups where immune checkpoint therapy currently has marginal or no clinical benefit and the invention elicits de novo immune responses following vaccination with the at least one polypeptide of a tumour-associated antigen.

Method of Identifying a Subject

In another aspect, the present invention provides a method of identifying a subject to whom a combination therapy is to be administered, wherein the combination therapy comprises administration of an immune checkpoint inhibitor simultaneously, separately or sequentially with a polypeptide, a nucleic acid, a T-cell receptor or a T-cell displaying the T-cell receptor, the method comprising:

In an alternative aspect there is provided a method of identifying a subject to whom a combination therapy is to be administered, wherein the combination therapy comprises administration of an immune checkpoint inhibitor simultaneously, separately or sequentially with a polypeptide, a nucleic acid, a T-cell receptor or a T-cell displaying the T-cell receptor, the method comprising:

(i) determining the presence of mesothelioma from a biological sample obtained from the subject; and

(ii) identifying the subject who provided the biological sample as a subject to whom the combination therapy is to be administered. In preferred embodiments, the mesothelioma is epithelioid mesothelioma. In particularly preferred embodiments, the mesothelioma is epithelioid pleural mesothelioma such as malignant epithelioid pleural mesothelioma.

In these methods, the immune checkpoint inhibitor, polypeptide, nucleic acid, T-cell receptor and T-cell displaying the T-cell receptor may be as defined above. In preferred embodiments, the epithelioid cancer is epithelioid mesothelioma. In particularly preferred embodiments, the epithelioid cancer is epithelioid pleural mesothelioma such as malignant epithelioid pleural mesothelioma.

Examples

Hereinafter, the invention will be specifically described with reference to the Examples. However, these Examples do not limit the technical scope of the invention.

Example 1 : Durable objective responses were observed in patients with malignant pleural melanoma who were administered the polypeptides of SEQ ID NOS. 1 , 2 and 3 in combination with a CTLA-4 immune checkpoint inhibitor and a PD-1 immune checkpoint inhibitor

Clinical Trial Design

The clinical trial was a Phase II, open-label study evaluating the efficacy and tolerability of ipilimumab and nivolumab combined with a vaccine comprising a cocktail of polypeptides having the sequences of SEQ ID NOS. 1 , 2 and 3 (referred to herein after as the “UV1” vaccine) as a second-line treatment in patients with malignant pleural mesothelioma (MPM).

Participants

118 patients with histologically or cytologically confirmed MPM progressing on first-line platinum-based chemotherapy were randomised in a 1 :1 ratio. The first group was treated with ipilimumab and nivolumab (I PI-NIVO) alone (Arm B), and the second group was treated with IPI-NIVO combined with the UV1 vaccine (Arm A). Other inclusion and exclusion criteria are previously described (Haakensen et al., J Transl Med 19, 232 (2021)).

Treatment Regimen

All participants received ipilimumab at a dose of 1mg/kg every six weeks (Q6) and nivolumab at a dose of 240 mg every two weeks (Q2), intravenously. The patients randomised to the experimental arm additionally received 300 pg UV1 intradermally together with 75 pg GM-CSF as 8 injections over 13 weeks. The study treatment was continued until disease progression, unacceptable toxicity or for a maximum of 2 years

Patient Population

The treatment arms were well balanced with regard to age, sex, ECOG performance status, histology and PD-L1 expression on tumour cells. Table 2 illustrates the clinical characteristics of the patients included in the study. Of particular note, out of the 113 patients that were randomised, 91 of the patients (77.1 %) had epithelioid histology, of which 47 received IPI-NIVO alone and 41 (79.7%) received IPI-NIVO in combination with UV1.

Arm A (N=59) Arm B (N=59) Total (N=118)

Sex

Female 14 (23.7%) 12 (20.3%) 26 (22.0%)

Male 45 (76.3%) 47 (79.7%) 92 (78.0%)

Age

Median 71.0 72.0 71.0

Range 39.0 - 79.0 42.0 - 83.0 39.0 - 83.0

ECOG 0 17 (28.8%) 18 (30.5%) 35 (29-7%)

1 42 (71.2%) 41 (69.5%) 83 (70.3%)

Histology

Epithelioid 44 (74.6%) 47 (79.7%) 91 (77.1%)

Sarcomatoid 5 (8.5%) 4 (6.8%) 9 (7.6%)

Biphasic 5 (8.5%) 7 (11.9%) 12 (10.2%)

Rhabdoid 1 (1.7%) 0 (0.0%) 1 (0.8%)

Unknown 4 (6.8%) 1 (1.7%) 5 (4.2%)

PD-L1(%) <1 31 (52.5%) 32 (54-2%) 63 (53-4%)

1-49 6 (10.2%) 4 (6.8%) 10 (8.5%)

>50 2 (3.4%) 4 (6-8%) 6 (5.1%)

Unknown 20 (33.9%) 19 (32.2%) 39 (33.1%) Assessments

Tumour response was assessed according to the modified Response Evaluation Criteria in Solid Tumours (mRECIST) (Byrne et al., Annals of Oncology, 15, 257-260 (2004)). Information on histology subtypes was collected from local pathology reports.

The primary end point of the trial was set to progression free survival (PFS) according to blinded independent central review (BICR) at the time of 69 events, detecting a hazard ratio of 0.6 with a power of 80% and a 1 -sided alpha level of 0.1. An investigator- determined PFS based on local assessment was also recorded. Secondary end points included inter alia, overall survival (OS) and objective response rate (ORR). The median follow-up time at 69 events was 12.5 months (95% Cl 9.7-15.6) and the median followup time to assess the secondary end points was 17.3 months (95% Cl 15.8-22.9 months).

Results i) Overall Survival (OS)

After an updated follow-up time of 17.3 months, the median OS was 15.4 months (range 11.1-22.6) in arm A and 11.1 months (range 8.8 -18.1) in arm B; p=0.37 (Figure 2), reducing the risk of death by 27% (HR=0.73 [80% Cl, 0.53-1.00], two-sided p value = 0.197). In patients with epithelioid histology, the median OS was 17.7 months (range 15.4-NA) in arm A and 17.7 months (range 10.1-24.2) in arm B; p=0.25 (Figure 3). In patients with non-epithelioid histology, the median OS was 9.3 months (range 4.7-N/A months) in arm A and 8.5 months (5.3-N/A months) in arm B; p=0.48 (Figure 4). ii) Investigator Evaluation

The median PFS as determined by investigator evaluation was 4.3 months (range 3.0- 6.8) in arm A (I PI-NIVO + UV1 vaccine) and 2.9 months (range 2.4-5.5) in arm B (IPI- NIVO); p=0.049 (Figure 5). In patients with epithelioid histology (77.1% of patients), the median PFS as determined by investigator evaluation was 5.5 months (range 3.8-9.7) in arm A and 2.9 months (range 2.1-5.7) in arm B; p=0.061 (Figure 6). In patients with non- epithelioid histology, the median PFS as determined by investigator evaluation was 3.0 months (range 1.3-N/A months) in arm A and 3.9 months (range 2.5-N/A months) in arm B; p=0.4 (Figure 7). iii) Blinded Independent Central Review (BICR)

Confirmed ORR by BICR was 31 % in arm A (IPI-NIVO + UV1 vaccine) compared to 16% in arm B (IPI-NIVO) at a median follow-up time of 12.5 months. The median PFS as determined by BICR was 4.2 months (range 2.9-9.8) in arm A and 4.7 months (range

3.9-7.0) in arm B, p=0.67 (Figure 8). The Hazard Ratio was evaluated to be 1.01 (80% Cl, 0.75-1.36, p=0.979). In patients with epithelioid histology, the median PFS as determined by BICR was 5.9 months (range 2.9-10.1) in arm A and 5.5 months (range

3.9-10.0) in arm B, p =0.69 (Figure 9). In patients with non-epithelioid histology, the median PFS as determined by BICR was 6.3 months (range 2.8-N/A months) in arm A and 3.9 months (3.0-N/A months) in arm B; p=0.42 (Figure 10).

Safety

The toxicity profile was not significantly different between the two treatment arms and was dominated by known toxicities to the IPI-NIVO combination.

Of particular note, it is well-recognised that MPM is radiologically difficult to assess. This is reflected in the need for a modified RECIST. Moreover, PFS may be less useful as a clinical indicator in rapidly progressive cancers such as MPM. In view of the above, in this trial, overall survival remains the most critical endpoint for evaluating clinical efficacy of treatment and any determination of PFS may need to be interpreted cautiously.

Conclusions

Malignant pleural mesothelioma (MPM) is a rare and aggressive tumour. For patients with inoperable disease, few treatment options are available after first line chemotherapy. As mentioned above, the combination of ipilimumab and nivolumab has recently shown increased survival compared to standard chemotherapy. However, almost all the benefit was seen in patients with non-epithelioid (biphasic or sarcomatoid) disease who form the minority of the MPM population, whereas those with epithelioid disease did not benefit significantly. There is hence a particular need for improved treatment options for patients with epithelioid cancer.

With particular reference to overall survival, the present inventors have demonstrated an improved clinical response to the combination therapy (IPI-NIVO in combination with UV1) as compared to immune-checkpoint inhibitor therapy (IPI-NIVO) in the total MPM population (Figure 2). This is further supported by PFS as determined by investigator evaluation (Figure 5). Additionally, whilst the trial evaluated the combination of IPI-NIVO and UV1 as a second-line treatment, IPI-NIVO has been approved for first-line treatment for MPM, and there is no reason to believe that the influence of combining the UV1 vaccine with immune checkpoint inhibitors would be poorer in a first-line setting than in a second-line setting.

Additionally, a differential overall survival and PFS (by investigator evaluation) is seen in seen in patients based on epithelial subtype: patients with epithelioid histology demonstrated an increased efficacy of the combination therapy relative to the immune checkpoint inhibitor therapy (Figure 3 and Figure 6). In contrast, the difference between the efficacy of the combination therapy and the immune checkpoint inhibitor therapy in patients with non-epithelioid histology, was less pronounced (Figure 4 and Figure 7).

In summary, based on the blinded independent central review (BICR), this trial did not meet its primary end point. However, the supportive analyses mentioned above based on local assessment of the PFS endpoint (by investigator evaluation), and overall survival demonstrates a treatment benefit with the combination therapy over checkpoint inhibitor therapy alone in patients with MPM. Further, the data make it plausible that patients with epithelioid tumours in general may derive greater clinical benefit from a cancer vaccine in combination with one or more immune checkpoint inhibitors than those with non-epithelioid tumours.

Schedule of Sequence Listing

Claims

CLAIMS:

1 . A polypeptide for use in the prevention or treatment of mesothelioma in a subject, wherein the polypeptide is administered to the subject simultaneously, separately or sequentially with an immune checkpoint inhibitor, wherein the polypeptide comprises a region of at least 12 amino acids of a tumour- associated antigen or a sequence having at least 80% identity to the region.

2. A nucleic acid molecule for use in the prevention or treatment of mesothelioma in a subject, wherein the nucleic acid molecule is administered simultaneously, separately or sequentially with an immune checkpoint inhibitor, and wherein the nucleic acid molecule comprises a nucleotide sequence encoding a polypeptide comprising a region of at least 12 amino acids of a tumour-associated antigen or a sequence having at least 80% identity to the region.

3. A T-cell receptor, or a T-cell displaying the T-cell receptor, for use in the prevention or treatment of mesothelioma in a subject, wherein the T-cell receptor or T- cell is administered simultaneously, separately or sequentially with an immune checkpoint inhibitor, and wherein the T-cell receptor is specific for a polypeptide consisting of at least 12 amino acids of a tumour-associated antigen, or a sequence having at least 80% identity to the polypeptide.

4. An immune checkpoint inhibitor for use in the prevention or treatment of mesothelioma in a subject, wherein the immune checkpoint inhibitor is administered to the subject simultaneously, separately or sequentially with: i) a polypeptide comprising a region of at least 12 amino acids of a tumour- associated antigen or a sequence having at least 80% identity to the region; ii) a nucleic acid molecule comprising a nucleotide sequence encoding a polypeptide comprising a region of at least 12 amino acids of a tumour-associated antigen or a sequence having at least 80% identity to the region; iii) a T-cell receptor specific for a polypeptide consisting of at least 12 amino acids of a tumour-associated antigen, or a sequence having at least 80% identity to the polypeptide, when the polypeptide is presented on an MHC molecule; or iv) a T-cell displaying a T-cell receptor as defined in iii).

5. A method of preventing or treating mesothelioma in a subject, comprising the steps of: i) administering an immune checkpoint inhibitor to the subject; and ii) simultaneously, separately or sequentially administering: e) a polypeptide comprising a region of at least 12 amino acids of a tumour- associated antigen or a sequence having at least 80% identity to the region; f) at least one nucleic acid molecule comprising a nucleotide sequence encoding at least one polypeptide comprising a region of at least 12 amino acids of a tumour-associated antigen or a sequence having at least 80% identity to the region; g) a T-cell receptor specific for a polypeptide consisting of at least 12 amino acids of a tumour-associated antigen, or a sequence having at least 80% identity to the polypeptide; or h) a T-cell displaying a T-cell receptor as defined in c).

6. A polypeptide for use in the prevention or treatment of an epithelioid cancer in a subject, wherein the polypeptide is administered to the subject simultaneously, separately or sequentially with an immune checkpoint inhibitor, wherein the polypeptide comprises a region of at least 12 amino acids of a tumour- associated antigen or a sequence having at least 80% identity to the region.

7. A nucleic acid molecule for use in the prevention or treatment of an epithelioid cancer in a subject, wherein the nucleic acid molecule is administered to the subject simultaneously, separately or sequentially with an immune checkpoint inhibitor, and wherein the nucleic acid molecule comprises a nucleotide sequence encoding a polypeptide comprising a region of at least 12 amino acids of a tumour-associated antigen or a sequence having at least 80% identity to the region.

8. A T-cell receptor, or a T-cell displaying the T-cell receptor, for use in the prevention or treatment of an epithelioid cancer in a subject, wherein the T-cell receptor or T-cell is administered to the subject simultaneously, separately or sequentially with an immune checkpoint inhibitor, and wherein the T-cell receptor or T-cell is specific for a polypeptide consisting of at least 12 amino acids of a tumour-associated antigen, or a sequence having at least 80% identity to the polypeptide, when the polypeptide is presented on an MHC molecule.

9. An immune checkpoint inhibitor for use in the prevention or treatment of an epithelioid cancer in a subject, wherein the immune checkpoint inhibitor is administered to the subject simultaneously, separately or sequentially with: i) a polypeptide comprising a region of at least 12 amino acids of a tumour- associated antigen or a sequence having at least 80% identity to the region; ii) a nucleic acid molecule comprising a nucleotide sequence encoding at least one polypeptide comprising a region of at least 12 amino acids of a tumour-associated antigen or a sequence having at least 80% identity to the region; iii) a T-cell receptor specific for a polypeptide consisting of at least 12 amino acids of a tumour-associated antigen, or a sequence having at least 80% identity to the polypeptide; or iv) a T-cell displaying a T-cell receptor as defined in iii).

10. A method of preventing or treating an epithelioid cancer in a subject, comprising the steps of: i) administering an immune checkpoint inhibitor to the subject; and ii) simultaneously, separately or sequentially administering: e) a polypeptide comprising a region of at least 12 amino acids of a tumour- associated antigen or a sequence having at least 80% identity to the region; f) at least one nucleic acid molecule comprising a nucleotide sequence encoding a polypeptide comprising a region of at least 12 amino acids of a tumour-associated antigen or a sequence having at least 80% identity to the region; g) a T-cell receptor specific for a polypeptide consisting of at least 12 amino acids of a tumour-associated antigen, or a sequence having at least 80% identity to the polypeptide; or h) a T-cell displaying a T-cell receptor as defined in c).

11 . The polypeptide for use according to claim 1 , the nucleic acid molecule for use according to claim 2, the T-cell receptor or T-cell for use according to claim 3, the immune checkpoint inhibitor for use according to claim 4, or the method according to claim 5, wherein the mesothelioma is epithelioid mesothelioma.

12. The polypeptide for use according to claim 6, the nucleic acid molecule for use according to claim 7, the T-cell receptor or T-cell for use according to claim 8, the immune checkpoint inhibitor for use according to 9, or the method of prevention or treatment according to claim 10, wherein the epithelioid cancer is epithelioid mesothelioma.

13. The polypeptide, nucleic acid, T-cell receptor, T-cell or immune checkpoint inhibitor for use according to claim 11 or claim 12, or the method of prevention or treatment according to claim 11 or claim 12, wherein the epithelioid mesothelioma is epithelioid pleural mesothelioma.

14. The polypeptide for use according to any one of claims 1 , 6, or 11 to 13, the nucleic acid for use according to any one of claims 2, 7, 11 or 11 to 13, the T-cell receptor or T-cell for use according to any one of claims 3, 8, or 11 to 13, the immune checkpoint inhibitor for use according to any one of claims 4, 9, or 11 to 13, or the method of prevention or treatment according to any one of claims 5, 10, or 11 to 13, wherein the polypeptide comprises a region of at least 15, 20, 25 or 30 amino acids of a tumour- associated antigen or a sequence having at least 80% identity to the region.

15. The polypeptide for use according to any one of claims 1 , 6, or 11 to 14, the nucleic acid for use according to any one of claims 2, 7, or 11 to 14, the T-cell receptor or T-cell for use according to any one of claims 3, 8, or 11 to 14, the immune checkpoint inhibitor for use according to any one of claims 4, 9, or 11 to 14, or the method of prevention or treatment according to any one of claims 5, 10, or 11 to 14, wherein the tumour-associated antigen comprises a universal tumour antigen, preferably wherein the universal tumour-associated antigen is selected from the group consisting of: telomerase reverse transcriptase, survivin, DNA topoisomerase 2-alpha, cytochrome P450 1 B1 and E3 ubiquitin-protein ligase Mdm2.

16. The polypeptide for use according to claim 15, the nucleic acid for use according to claim 15, the T-cell receptor or T-cell for use according to claim 15, the immune checkpoint inhibitor for use according to claim 15, or the method of prevention or treatment according to claim 15, wherein the tumour-associated antigen comprises telomerase reverse transcriptase, and wherein the polypeptide comprises: i) a polypeptide comprising a sequence of SEQ ID NO. 1; ii) an immunogenic fragment of i) comprising at least 12 amino acids; or iii) a sequence having at least 80% sequence identity to i) or ii).

17. The polypeptide for use according to claim 16, the nucleic acid for use according to claim 16, the T-cell or T-cell receptor for use according to claim 16, the immune checkpoint inhibitor for use according to claim 16, or the method of prevention or treatment according to claim 16, wherein the polypeptide comprises a cocktail of polypeptides and wherein the cocktail of polypeptides further comprises: a polypeptide comprising: d) a sequence of SEQ. ID NO. 2; e) an immunogenic fragment of a) comprising at least 12 amino acids; or f) a sequence having at least 80% sequence identity to a) or b), and optionally, a polypeptide comprising: c) a sequence of SEQ. ID NO. 3; d) an immunogenic fragment of a) comprising at least 12 amino acids; or c) a sequence having at least 80% sequence identity to a) or b).

18. The polypeptide for use according to claim 15, the nucleic acid for use according to claim 15, the T-cell receptor or T-cell for use according to claim 15, the immune checkpoint inhibitor for use according to claim 15, or the method of prevention or treatment according to claim 15, wherein the tumour-associated antigen comprises telomerase reverse transcriptase, and wherein the polypeptide comprises at least one polypeptide selected from: i) a polypeptide comprising a sequence of SEQ. ID NO:5 ii) an immunogenic fragment of i) comprising at least 12 amino acids; or iii) a sequence having at least 80% sequence identity to i) or ii); i) a polypeptide comprising a sequence of SEQ. ID NO:39 ii) an immunogenic fragment of i) comprising at least 12 amino acids; or iii) a sequence having at least 80% sequence identity to i) or ii); and i) a polypeptide comprising a sequence of SEQ. ID NO:40 ii) an immunogenic fragment of i) comprising at least 12 amino acids; or iii) a sequence having at least 80% sequence identity to i) or ii).

19. The polypeptide for use according to claim 18, the nucleic acid for use according to claim 18, the T-cell or T-cell receptor for use according to claim 18, the immune checkpoint inhibitor for use according to claim 18, or the method of prevention or treatment according to claim 18, wherein the polypeptide comprises a cocktail of polypeptides and wherein the cocktail of polypeptides further comprises: a) a sequence of SEQ. ID NO. 1 ; b) an immunogenic fragment of a) comprising at least 12 amino acids; or c) a sequence having at least 80% sequence identity to a) or b);

20. The polypeptide for use according to claim 18 or claim 19, the nucleic acid for use according to claim 18 or claim 19, the T-cell or T-cell receptor for use according to claim 18 or claim 19, the immune checkpoint inhibitor for use according to claim 18 or claim 19, or the method of prevention or treatment according to claim 18 or claim 19, wherein the at least one polypeptide or the cocktail of polypeptides further comprises: a polypeptide comprising: a) a sequence of SEQ. ID NO. 2; b) an immunogenic fragment of a) comprising at least 12 amino acids; or c) a sequence having at least 80% sequence identity to a) or b), and optionally, a polypeptide comprising: e) a sequence of SEQ. ID NO. 3; f) an immunogenic fragment of a) comprising at least 12 amino acids; or c) a sequence having at least 80% sequence identity to a) or b).

21. The polypeptide for use according to any one of claims 1 , 6, or 11 to 21 , the nucleic acid for use according to any one of claims 2, 7, or 11 to 21 , the T-cell receptor or T-cell for use according to any one of claims 3, 8, or 11 to 21 , the immune checkpoint inhibitor for use according to any one of claims 4, 9, or 11 to 21 , or the method of prevention or treatment according to any one of claims 5, 10, or 11 to 21 , wherein the immune checkpoint inhibitor comprises a CTLA-4 immune checkpoint inhibitor, a PD-1 immune checkpoint inhibitor and/or a PD-L1 immune checkpoint inhibitor.

22. The polypeptide for use according to claim 21 , the nucleic acid for use according to claim 21 , the T-cell or T-cell receptor for use according to claim 21 , the immune checkpoint inhibitor for use according to claim 21 , or the method of prevention or treatment according to claim 21 , wherein the CTLA-4 inhibitor comprises one or more selected from: an anti-CTLA-4 antibody or a functional fragment thereof, a peptide-based inhibitor of CTLA-4, and a small molecule inhibitor of CTLA-4; wherein the PD-1 inhibitor comprises one or more selected from: an anti-PD-1 antibody or a functional fragment thereof, a peptide-based inhibitor of PD-1 , and a small molecule inhibitor of PD-1 ; and/or wherein the PD-L1 inhibitor comprises one or more selected from an anti-PD-L1 antibody or a functional fragment thereof, a peptide-based inhibitor of PD-L1 , and a small molecule inhibitor of PD-L1 .

23. The polypeptide for use according to claim 22, the nucleic acid for use according to claim 22, the T-cell or T-cell receptor for use according to claim 22, the immune checkpoint inhibitor for use according to claim 22, or the method of prevention or treatment according to claim 22, wherein the immune checkpoint inhibitor comprises an anti-CTLA4 antibody or a functional fragment thereof and an anti-PD-1 antibody or a functional fragment thereof.

24. The polypeptide for use according to claim 22, the nucleic acid for use according to claim 22, the T-cell or T-cell receptor for use according to claim 22, the immune checkpoint inhibitor for use according to claim 22, or the method of prevention or treatment according to claim 22, wherein the anti-CTLA-4 antibody of functional fragment thereof comprises one or more selected from: ipilimumab and tremelimumab; wherein the anti-PD-1 antibody or functional fragment thereof comprises one or more selected from nivolumab and pembrolizumab; and/or wherein the anti-PD-L1 antibody or functional fragment thereof comprises one or more selected from: durvalumab, atezolizumab and avelumab.

25. The polypeptide for use according to claim 24, the nucleic acid for use according to claim 24, the T-cell or T-cell receptor for use according to claim 24, the immune checkpoint inhibitor for use according to claim 24, or the method of prevention or treatment according to claim 24, wherein the immune checkpoint inhibitor comprises ipilimumab and nivolumab.

26. The polypeptide for use according to any one of claims 1 , 6, or 11 to 25, the nucleic acid for use according to any one of claims 2, 7, or 11 to 25, the T-cell receptor or T-cell for use according to any one of claims 3, 8, or 11 to 25, the immune checkpoint inhibitor for use according to any one of claims 4, 9, or 11 to 25, or the method of prevention or treatment according to any one of claims 5, 10, or 11 to 25, wherein the subject has been treated with a neoadjuvant therapy, preferably wherein the neoadjuvant therapy comprises chemotherapy.

27. A method of identifying a subject to whom a combination therapy is to be administered, wherein the combination therapy comprises administration of:

(I) an immune checkpoint inhibitor,

(II) simultaneously, separately or sequentially with: a) a polypeptide comprising a region of at least 12 amino acids of a tumour- associated antigen or a sequence having at least 80% identity to the region; b) at least one nucleic acid molecule comprising a nucleotide sequence encoding a polypeptide comprising a region of at least 12 amino acids of a tumour-associated antigen or a sequence having at least 80% identity to the region; c) a T-cell receptor specific for a polypeptide consisting of at least 12 amino acids of a tumour-associated antigen, or a sequence having at least 80% identity to the polypeptide, when the polypeptide is presented on an MHC molecule; or d) a T-cell displaying a T-cell receptor as defined in c); the method comprising: (i) determining the presence of an epithelioid cancer from a biological sample obtained from the subject; and

28. The method according to claim 27, wherein the epithelioid cancer is as defined in claim 12 or claim 13, wherein the polypeptide is as defined in any one of claims 14 and 16 to 20, the tumour-associated antigen is as defined in claim 15, and/or the immune checkpoint inhibitor is as defined in any of claims 21 to 25.