The trial was stopped following interim analysis,

as there was no significant difference between the two arms 42. We have reported that the mean number of DC injected into the skin was low (2.8×106per class I peptide) and highly variable (SD 1.1×106), and that in addition, the DC were of inferior quality (48% of applied vaccines contained more than 25% immature DC) 42. We have now performed immunomonitoring in a cohort of the patients and found that the vaccine responses were negligible when compared to the robust immunogenicity observed in our more recent 62-patient monocenter multi-peptide trial, in which peptide-loaded DC of high quality NVP-BEZ235 concentration were injected at a higher dose of 10 million DC/class I peptide (our unpublished data). In retrospect, the multicenter trial was premature because product development, standardization, and validation had not reached the level required to obtain a GMP manufacturing license.

In Europe, an EU directive dictates that GMP products have to be used in clinical trials of all phases 43. This implies that in all member states, only products of GMP quality can be used for the production of DC vaccines. The securing of the GMP quality of the end product, i.e. the DC vaccine, is, however, left to the national authorities and is guaranteed by the requirement for a GMP manufacturing license, which imposes substantial validation requirements, Autophagy Compound Library only in some European countries such as Germany. In contrast, in the USA,

there is not a strict need for full GMP quality of products (e.g. cytokines) in early phase I/II investigator-initiated trials. After more than Prostatic acid phosphatase 10 years of DC vaccination, it is now imperative to systematically address, in small two-armed, science-driven immunogenicity trials (which so far have been a rare exception 44–46) the important variables and opportunities to identify an optimized DC vaccine for later testing in randomized phase II and III trials. At this point, many factors remain to be systemically tested, including the dose, frequency, and route of DC vaccine administration, let alone the many ideas and possibilities arising from DC biology. DC, depending on their subset and maturation status, can induce and activate all kinds of T cells (including Treg), B cells, and antibodies 36, NKT 47, 48 and NK cells 49–52, in principle allowing a broad “coordinated anti-tumor response” 53. With respect to clinical testing, one priority is the induction of strong T-cell responses, which in my view has yet to be achieved. It will also be valuable to compare DC directly to other vaccine strategies, e.g. in case of HPV E6/E7 antigens to synthetic long peptide (SLP) vaccination, or in case of the prostatic acid phosphatase antigen to Dendreon’s Provenge™ that requires one apheresis for preparing a single vaccine.