Department of pharmacy, Faculty of Engineering and Technology, Annamalai university, Tamil Nadu, India.
The understanding about tumor-infiltrating lymphocytes (TIL) plays a monumental role in the treatment of cancer, creating a hitting spot in immuno-oncology. Apart from being used as a prognostic marker for other chemotherapy, TIL places its own importance in the treatment as well. TIL therapy uses autologous tumor-infiltrating lymphocytes extracted from the tumor following the expansion in an in vitro manner. After completing lymphodepletion, the patient was ready to receive the TIL therapy. Herein, we concisely describe the process of preparing TIL for therapy. Later, we emphasize the role of TIL in various cancers. And discuss the challenges, combination drugs, and future scope of TIL therapy.
For the past twenty-five decades, the cancer was an unfathomable condition, in which the research is still ongoing to identify an unbeatable treatment to cure it [1]. Treating cancer patients with remission and metastasis is always a challenge in the field of cancer research. The existing treatments, such as surgery, chemotherapy, radiotherapy, and biologics, provide better results in cancer patients. But, they also result in early and late remission. These treatments only focus on the tumor cells, ignoring the complex tumor microenvironment (TME). This is why these treatments are not effective in treating cancer remission and metastasis [2]. Until 1940, cancer immunotherapy was not considered a treatment option by the medical community. After 1980, the immunotherapy era in cancer begins with lots of research [3]. Nowadays, cancer immunotherapy is much more interestingly expanded through the role of immune checkpoint inhibitors like anti-PD-L 1 (programmed cell death receptor 1/programmed cell death receptor ligand 1) and anti-CTLA-4 (cytotoxic T-lymphocyte-associated protein 4) agents, oncolytics virus therapy, cancer vaccines, cytokine therapy, immunomodulatory therapy and most recently, adoptive cell transfer (ACT) therapy [4]. ACT therapy was classified into three types: tumor-infiltrating therapy (TIL), engineered T cell receptor (TCR)-T cell therapy, and chimeric antigen receptor (CAR)-T cell therapy. In recent days, CAR-T cell therapy has extensively been used for the treatment of hematological cancers such as lymphoma and leukemia. And turns the world treatment towards the development of ACT therapy. Through this, TIL therapy research is widely expanded. Comparatively, TIL therapy has many advantages over CAR-T cell therapy because of its large antigen specificity [5,6]. In ACT therapy, TIL transfer was considered as a treatment option for metastasis patients. In the study in the early 1980s by Rosenberg et al., they performed an excision of tumors from the mice and isolated and expanded their lymphocytes under an aseptic condition that opened the field of adoptive cell therapy (ACT) using tumor-infiltrating lymphocytes (TIL) [7]. After the success of expanding TIL, there is an insufficient number of lymphocytes in that culture. In order to increase the number, interleukin-2 (IL-2) was administered during the expansion period of lymphocytes in the cell suspension [8]. Later on, lymphokine-activated killer (LAK) cells with recombinant IL-2 provide a significant lytic action towards pulmonary metastases in mice [9]. In 1986, Rosenberg et al. concluded that the potent antitumor activity of TIL therapy over the LAK cells with IL-2 treatment against lung and liver metastases in mice [10]. Following the subsequent years, he identified that TIL activity was increased fivefold when co-administered with IL-2 and cyclophosphamide. That increases the overall response rate in advanced metastases melanoma patients [11,12]. And his work in non-myeloablative (NMA) lymphodeletion plays a monumental role in the entire development of TIL therapy [13]. Recently, TIL got FDA approval for treating metastatic melanoma [14]. As well, further developments of TIL are emerging in the prognosis and targeted therapy for solid tumors like breast cancer, lung cancer, colorectal cancer, liver cancer, and cervical cancer. In TIL therapy, tumor immune microenvironment (TIME) provides a significant part. It consists of mainly tumor cells surrounded by the immune cells along with the extracellular matrix. It was considered a biomarker for many cancer treatments. [15] The information about TIME was not completely understood due to its complexity and heterogenicity. From researchs, TIME laid the path for the invention of many immunotherapies. TIME was behind the reason for chemotherapeutic drug resistance through various mechanisms, such as activation of P-glycoprotein through the ATP-binding cassette pathway. It was responsible for the metastasis of cancer too. The presence of specific lymphocytes in the tumor microenvironment (TIME) is called tumor infiltrating lymphocytes [16]. Major components of the TIL architecture was composed of T cells, B cells, and NK cells which essentially contribute to tumor elimination. In T cells, there are various subtypes such as TCR???, TCR??? CD4? CD8? double positive cell, TCR??? CD4? CD8? double negative cell, CD8? TCR?? cell, CD3? T cell and finally CD4? TCR?? cells. In CD8? TCR?? subsets, they all together to produce high cytotoxic action towards the tumor. In CD4? TCR?? subsets, the T helper cells exhibit the role of CD8? cell activation and perform rapid lytic action. On the contrary, T regulatory (Treg) cells inhibit the activation of T cells through suppressing the cytokine production. In B cells, there are antigen presenting cells, plasma cells and B regulatory cells to preform the role of production and activation of antibodies [17]. Dysfunction of normal T cells leads to the growth of cancer. Due to the continuous exposure of T cells to tumor cells, this results T cell exhaustion and sensescence. Exhaustion reduces the cytolytic activity of the existing T cell [18]. Some other cells, such as tumor-associated macrophages, marrow-derived suppression cells, and tumor-associated neutrophils, contribute towards immunosuppression [19]. Due to the immunosuppression, normal existing, TIL is unable to produce its action in TME. But in the case of TIL therapy, it overcomes the immunosuppression and produces a lytic action.
Construction And Working Of Til:
In the process of construction of TIL, the primary steps involve excision of the existing tumor and rapid expansion of TIL. In metastasis patients, excision of tumor performed, and that excised tumor made into a slice to create a single cell suspension [20]. Then it was kept in a culture medium preinstalled with the T cell-stimulating growth factor such as IL-2. The selection of TIL for culture was based on the presence of interferon-alpha traces initially in the 1990s. But this became a major limiting step in the TIL expansion. Later on, the selection was cancelled and said that unselected TILs. The unselected TILs, also called young TILs, are those having a prominent lytic activity from the beginning towards the tumor. After 2-4 weeks, the culture medium grows to attain the necessary count of T cells, then it is subjected to rapid expansion [21]. During rapid expansion, the culture medium was immerged with IL-2, anti-CD3 (initial phase only), and irradiated feeder cells. All these were used to enhance the T cell growth quickly. It would take nearly 14 days. After the success of complete TIL expansion, the secondary steps will begin with non-myeloablative (NMA) lymphodepletion. The execution of lymphodepletion takes the TIL therapy to the next step in its efficacy. It enhances the effect of TIL through removing the Treg cells from the TME and also improves the APC activity of other cells towards the TILs. The patient underwent NMA lymphodepletion through either chemotherapy or total body irradiation. The chemotherapy was done by the use of cyclophosphamide (60 mg/kg/day) and fludarabin (25 mg/m/day) for nearly two and five subsequent days, respectively [22].The completion of NMA lymphodepletion initiates the administration of expanded TIL along with a high dose of IL-2. IL-2 co-administration improves the cytolytic activity of TIL [23]. After the intravenous administration of TIL into the patient body, it travels through the blood to reach its target sites. Due to metastasis, it produced its antitumor effect in various area. By reaching its target site, it invades into the TME and try to recognise the neoantigen those expressed by the tumor itself. The presence of neoantigen, activate the autologous TIL to produce the cytolytic activity towards the tumor. Thereby, it decreases tumor size and produces a complete response in metastasis patients [24]. There is no reported adverse effect from the administration of expanded TIL. But from the administration, high doses of IL-2 produce grade 3 and grade 4 toxicities in clinical trials, and some reports recorded from the chemotherapy too. In order to reduce the toxicity, some studies instructed the subjects to take prophylactive medicine to prevent that effect [25]. The simple overview of constructing TIL was shown in Figure.1
Role Of Til In Cancer:
TIL is being an option for the treatment of all solid tumors, especially metastases melanoma, ovarian cancer, and non small cell lung cancer. [26] There are lots of clinical trials regarding the TIL therapy/TIL combination therapy. Some of them are noted in Table 1. [27]
Metastases melanoma:
Melanoma is the malignancy of the skin in which it involves the melanocytes present in the basal epidermis [26]. Melanoma is the seventeenth leading cancer in the world, with actual incidence and death of 331,647 and 58,645 per year, respectively [28]. In the mid-1970s, the first chemotherapeutic agent used for metastases of melanoma was decabracine, considered a first-line treatment even though its response is low [29]. Later on, lots of treatment options are identified, such as radiation therapy and immunotherapy. Those patients having resistance towards chemotherapy and radiation therapy are subjected to immunotherapy and get a better response due to the tumor immunogenicity [30]. In 2015, immunotherapy became the first line treatment of metastases melanoma through the prominent increase in ORR from the usage of immune checkpoint inhibitors (ICI) such as anti-PD-1 (pembrolizumab and nivolumab) and anti-CTLA-4 (ipilimumab) agents and targeted therapy such as B-Raf serine/threonine kinase inhibitors BRAK/MEK inhibitors as compared with decarbacine [31-33]. Following years, the patient develops resistance to ICB and (BRAK)/ mitogen-activated protein kinase (MEK) inhibitors, which create an unmet medical need for refractory metastases in melanoma. Fortunately, that was fulfilled by the development of ACT using TIL.
The study conducted by Chesney J. et al. involving 153 metastasis melanoma patients who already failed with ICB agents was subjected to TIL therapy using Iifileucel (Ln-144). It produced overall response rate (ORR) of 31.4% with eight complete responses and forty partial responses in the patients. Through this, the efficacy and safety of Ln-144 were elucidated and got FDA approval under the indication for treating metastases in melanoma disease [14]. During the TIL therapy, it increases the peripheral blood count of neoantigens, those specific to the T cell. That increases the antitumor activity though stimulates the immune system in metastases melanoma patients and produces a better survival rate of more than 108 months [24]. Some studies reveal that the length of telomerase and the clonal type of lymphocyte in TIL determine its antitumor activity [34]. Despite all immunotherapy, TIL becomes the foremost treatment for metastasis melanoma patients.
Table 1 : Some ongoing clinical trial related to TIL therapy [27]
|
Cancer Type |
Clinicaltrials.Gov Id |
Clinical Phase |
No.Of. Subjects |
Intervention |
Result |
|
Advanced melanoma |
NCT05098184 |
Early phase-I (Recruiting) |
50 |
Tumor Infiltrating Lymphocytes |
N/A |
|
NCT03991741 |
Phase-I (Recruiting) |
24 |
Autologous Tumor Infiltrating Lymphocytes and High-Dose Interleukin 2 |
N/A |
|
|
NCT06120712 |
Phase-I/II (Recruiting) |
20 |
GC101 TIL |
N/A |
|
|
NCT05869539 |
Phase-I (Recruiting) |
10 |
Combination of Tumor-infiltrating lymphocyte transfer with ANV419 |
N/A |
|
|
NCT02360579 |
Phase-II (Active) |
178 |
Lifileucel (LN-144) |
N/A |
|
|
Ovarian cancer |
NCT05152797 |
Phase-I/II (Not yet recruiting) |
91 |
Autologous tumor-infiltrating lymphocytes |
N/A |
|
NCT03449108 |
Phase-II (Active) |
30 |
LN-145/LN-145-S1 |
N/A |
|
|
Non small cell lung cancer (NSCLC) |
NCT03215810 |
Phase-I (completed) |
20 |
TIL+ Nivolumab |
OR (3) |
|
NCT05366478 |
Phase-I (Recruiting) |
15 |
LM103 |
N/A |
|
|
NCT05576077 |
Phase-I (Recruiting) |
60 |
TBio-4101 and Pembrolizumab |
N/A |
|
|
Head and neck squamous cell carcinoma |
NCT03083873 |
Phase-II (completed) |
64 |
LN-145/LN-145-S1 |
PFS (3.9 months), DCR (99.7%) |
|
NCT03645928 |
Phase-II (Recruiting) |
178 |
LN-145-S1/ LN-145-S1/ LN-145/ LN-145 + Pembrolizumab |
N/A |
|
|
Breast cancer |
NCT04111510 |
Phase-II (completed) |
6 |
LN-145 |
PD(5), SD(1) |
|
Colorectal and breast cancer |
NCT05576077 |
Phase-I (Recruiting) |
60 |
TBio-4101and pembrolizumab |
N/A |
N/A- Not Available, OR-Objective Response, PFS-Progression Free Survival, DCR-Disease Control Rate,
PD-Progressive Disease, SD-Stable Disease
Ovarian cancer:
Ovarian cancer (OC) was the most common cancer in women after breast cancer and cervix cancer in the world population. It nearly results in 206,839 deaths per year. [28] Debulking surgery along with platinum-paclitaxel chemotherapy was considered first-line treatment for OC. Due to the platinum resistance or platinum sensitivity, the remission of OC occurred in many patients. For them, the second-line therapy consisting of bevacizumab or a poly-ADP-ribose polymerase (PARP) inhibitor was used. But it does not increase the overall survival rate. [35-37] With the drawbacks of existing therapy results in early remission of OC, create a demand for the newer treatment. [38] Implementation of immunotherapy using ICB (anti-PD-1/PD-L1 or anti-CTLA 4) and TIL is under investigation. [39] R.S. Freedman et al. conducted the TIL therapy with a low dose of IL-2 through interperitoneal administration. In this study, TIL mostly contains either CD3?, CD8?, CD4? or CD3?, CD4?, TCR??? T cell lines. That resulted in tumor regression and increased the overall response rate in the patients. Due to the low dose of IL-2, it reduces the toxicity caused by high dose administration [40]. Sometimes, TIL therapy produces low results due to the activation of immunosuppression by the LAG3/MHC-II and PD-1/PD-L2 pathways. One of the major limitations in treating OC with immunotherapy was its low mutational burden and low neoantigen specificity [41]. In order to increase the antitumor activity of TIL, Amaria R. et al. used CD3 and 4-1BB in the process of harvesting TIL. And the expanded TIL had an increased number of CD8? cells with potent activity. The result had PFS as 2.53 months and overall survival (OS) as 18.86 with a lack of ORR [42]. Later on, combination therapy of TIL with carboplastin plus paclitaxel with or without interferon-alpha (IFN-?) was conducted. The immunosuppression caused by chemotherapy administration increased the activity of TIL and resulted in OR of 83% [43]. Still, there are many TIL combinational therapies under investigation for the treatment of OC.
Non small cell lung cancer:
Non-small cell lung carcinoma (NSCLC) is the leading cancer among all, with the incidence of 2,480,301 and mortality of 1,817,172 people per year [28]. Naturally, NSCLC has a high tumor mutational burden (TMB) and neantigen specificity. Due to these characteristics, immunotherapy provides a better treatment result for NSCLC than other treatments such as chemotherapy and radiation therapy. In immunotherapy, ICB (anti-PD-1/PD-L1) was considered the first-line treatment for it. If the patient gets resistance to the anti-PD-1/PD-L1 agent, then they are instructed to take the combination therapy of anti-PD-1/PD-L1 with platinum doublet chemotherapy. The research about the role of TIL in NSCLC shows its significant response to the refractory and metastasis patients. The recent development of ATL001, a product of clonal neoantigen reactive T cell (cNET) from the autologous TIL, performed its action by increasing the reactiveness of the immune system by overcoming the TIME heterogenicity. [44] Massarelli et al. perform an autologous TIL therapy (Ln-145) in NSCLC patients. It produces an ORR of 25% and signifies the role as well as efficacy of ln-145 for NSCLC. [45] Further, research about combination therapy of TIL with nivolumab results in two complete responses in NSCLC patients. Administration of nivolumab increases the antitumor activity of TIL; through this, it becomes able to recognize many mutations in tumors. [46] Schoenfeld A, Lee S, Paz-Ares L, et al. conducted monotherapy using Ln-145 for NSCLC that resulted in one complete response, five partial responses, and ORR of 21.4%. [47]
Other cancers:
Initially, TIL was used as a prognostic indicator to evaluate the clinical outcomes of treatment in cancers such as breast cancer, head and neck squamous cell carcinoma, and colorectal cancer. [48-50]. In breast cancer, TIL therapy is more significant for triple-negative breast cancer (TNBC) and human epidermal growth factor receptor 2 (HER2)-positive breast cancer. [51] In TNBC patients having a high level of T regulatory cells, those infiltrated into the tumor and resulted in immunosuppression tumor environment. Enriched CD8? cells in TIL overcome that immunosuppression and perform its antitumor activity. [52] Zacharakis et al. demonstrated the use of TIL therapy for metastases in breast cancer. Through his study, it gives a new path for TIL therapy in breast cancer. [53] In heads and neck squamous cell carcinoma, TIL therapy is still in the developmenal stage. The virus proteins on the cell surface of HPV and EPV were considered the target for TIL therapy. [48] A recent clinical trial shows the efficacy of TIL when combined with pembrolizumab for treating metastases. The patient reveals 42.9% ORR. [54] Now, LN-145/145-S1 drug treatment for head and neck squamous cell carcinoma is under phase 2 trial. In colorectal cancer, the CD8? and CD4? in TIL are initially considered for their biomarker roles. Later, usage of TIL for metastases in colorectal cancer shows promising clinical effects. Especially for KRAS mutant metastases patients, CD8-specific T cells target the KRAS G12D mutant [55]. Now, a phase I study of TBio-4101 with pembrolizumab for treating metastasis colorectal is still active and expected to have a better result in treating colorectal cancer patients.
Challenges In Til :
Implementing certain types of novel technologies and new strategies in the health care sector has been a great challenge. However, TILs also have a lot of consequences in their selection, isolation, differentiation, and development. Plesca et al. noted that the therapeutic strategy, using adoptive cellular transfer of TIL through the expansion of immune cells away from their suppressive TME [56], leads to the harvest and isolation of TILs from a resected tumor, expansion in an in vitro manner, and then reinfusion back into the patient. Several animal studies demonstrated the potential of isolated immune cells to mediate tumor regression [57]. Due to the complexity of TIL, it requires only highly educated and trained personnel. And resulted in limited accessibility, which became the major drawback in the implementation of TIL [58]. Unfortunately, these existing TILs are rendered ineffective because of the pre-infiltrated Treg cells in TME [59]. The tumor heterogeneity develops a fault in the recognizing ability of T cells towards tumor antigen. Also some other factors related to tumors are their location, blood flow, and costimulatory cytokine levels being a challenge in TIL therapy in order to provide the same efficacy [60]. Nowadays, much of the intratumoral heterogeneity is a concern in metastatic diseases that have been found and studied in multiple cancer types and may help to explain some forms of resistance mechanisms [61]. This TIL also has disadvantages, like manufacturing challenges. However, their expansion and persistence may not be produced in the sufficient members to achieve an effective anti-tumor response. So, Chensey et al. studied the duration, efficacy, and safety of lifileucel and denoted the manufacturing and infusion methods [14]. But standardizing the expansion technique of TIL is much more complex and difficult. Prolonged exposure to tumor antigens can lead to TIL exhaustion and reduced functionality. Upon persistent antigen stimulation, T cells show a gradual decrease in their effector functions known as T cell exhaustion, which is characterized by a decrease in proliferative and cytolytic capacity and upregulation of multiple inhibitory signals, including PD1, LAG-3, CD160, 2B4, TIM-3, and TIGIT [62]. Although characterizing the exhausted phenotype, these T cells retain their cytolytic and proliferative capacity [19]. There are patient-related challenges such as immune system activity and pre-exposed treatments, especially chemotherapy, being a challenge to get a prominent result from TIL [12]. So at last, the cost of the TIL therapy creates challenges in developing countries like India. TIL therapy is a highly payable therapy because of its own complexity of manufacturing process. Retel et al. compared the cost of TIL therapy and ipilumumab and concluded that the probability of TILs is most costlier than ipilumumab. The treatment was estimated approximately to be around €62,000 in the Netherlands, which was the first tested TIL therapy for melanoma patients, and in Europe it was estimated around €60,000. According to Indian currency, it nearly cost around 55–60 lakhs [63]. By overcoming these types of challenges wisely, TILs can be easily implemented in all types of tumor patients everywhere.
Combination Therapy Of Til:
The development of a healthy immune response, which is marked by certain immunological checkpoints that should stop undesirable and damaging self-directed activities such as autoimmunity. There are many combination therapies that combine with the TILs: ICI, BRAF, and others. Immune checkpoint inhibitors in cancer immunology have made some notable advances in the past few years. Tumor regresssion was acknowledged in cancer patients who underwent CTLA-4 and PD-1 or PD-L1 blockade treatment [64]. CTLA-4 blockade is an attractive immunotherapeutic strategy to significantly enhance the effector T cell-mediated antitumor immunity [65]. The combination of anti-PD-1 and TIL has the potential to harness a potent pool of tumor-reactive T cells and overcome their inhibition in vivo. With this in mind, we combined the anti-PD-1 blocking antibody, Nivolumab, with TIL therapy in anti-PD-1 and TIL treatment naïve patients with metastatic melanoma [66]. Some studies reported the successful combination of anti-PD-1 and TIL transfer in anti-PD-1 refractory metastatic non-small cell lung cancer patients with an initial reduction in tumor burden and a median change in target lesion size [46]. Overall, the combination therapy of ACT with TIL expanded ex vivo using anti-4-1BB along with systemically administered anti-PD-1 was found to be a safe and feasible treatment for metastatic melanoma patients [67]. Presently, the most widely accepted hypothesis is that tumors with more mutations are likely to generate more neoepitopes, which can be recognized by TIL. Checkpoint-blocking antibodies reactivate these T cells in vivo and thus lead to tumor regressions [68]. Also, not only the immune checkpoint inhibitors are the essential combination for TIL. The BRAF gene plays an important role in cell growth and differentiation. In some cancers, BRAF inhibitors change the cascade of ERK/MSPK signals, resulting in increased cell proliferation [69]. The combination of TIL and BRAF inhibitors may provide significant results in upcoming research [70-72]. In a clinical trial of TIL therapy combined with adenovirses in the treatment of metastatic melanoma, 5 patients achieved an objective response, of which 3 achieved a complete response. The virus can combat tumor immunosuppression by producing cytokines that promote the anti-tumor effects of TIL [73]. Preclinical mouse modeling demonstrated the extended persistence of adoptively transferred gp100-reactive T cells when combined with antigen-specific dendritic cell (DC) vaccination, resulting in superior tumor control [74]. To investigate the combination of lactoferrin-derived lytic peptide (LTX-315) and ACT using TIL, the combination of LTX-315 with TIL can induce a tumor-specific immune response in patients with soft tissue sarcoma. Further, the combination of LTX-315 and ACT using TIL is not only feasible and tolerable, but tumor-specific T cells can be expanded in vitro from tumors that have been pretreated by LTX-315 [75]. Nevertheless, LIFILEUCEL produced durable responses and a favorable safety profile across subgroups of heavily pretreated patients with high tumor burden, regardless of age, BRAF mutation status, PD-L1 status, baseline ECOGPS status, and presence of liver or brain lesions at baseline, which supports a potential benefit for a broad population of patients with melanoma [71]. So most of the new cancer treatment therapies are combined, producing some good results and increasing the quality of life of the patients.
CONCLUSION:
All existing therapy provides only a short span of disease-free life in cancer patients. Some of them experience either remission or resistance. This creates unfulfilled demands for future research. The emergence of immunotherapy in oncology has always played a magnificent role in the treatment option. Likewise, in ACT, using TIL showcases its efficiency in treating metastases in melanoma patients and gained FDA approval for it. This was the first approval related to TIL therapy. Being apart from other therapies, TIL therapy results in treating resistance patients from prior chemotherapy and ICI therapy. It comparatively increases the disease-free survival time and has a chance to become either a first-line or second-line treatment for cancers, especially for solid tumors. There are lots of clinical trials related to the TIL and its combination treatment for various types of cancer that are still ongoing and expect promising results. In the future, the development of TIL therapy and further research about TIME role in TIL therapy contribute to valuable insights in immuno-oncology.
Future Scope:
Due to the promising results from an existing clinical trial showing a complete tumor-free survival of advanced metastasis patients from TIL therapy. But this is not for all patients; some of them experience a partial reduction in the tumor size and do not well respond to it. If eliminating the challenges and unsolved question about TIL therapy may provide a foremost treatment for cancer in the future. And having a probability to become second-line treatment for all cancer tumor patients.
Declarations:
Ethics approval and consent to participate - Not applicable
Consent for publication - Not applicable
Availability of data and materials - Not applicable
Competing interests - The authors declare that they have no competing interests
Funding - Not applicable
Authors’ contribution:
TK, AS and DK analyse the recent clinical trial information and gathering information regarding the title of challenges and combination therapy of TIL.
Acknowledgements - Not applicable
REFERENCES
Swathi Madhavan*, T. Keerthana, A. Sowmiya, D. Kilimozhi, T Cell Line Treatment for Cancer Using Tumor-Infiltrating Lymphocytes, Int. J. of Pharm. Sci., 2024, Vol 2, Issue 11, 1653-1668. https://doi.org/10.5281/zenodo.14245431
10.5281/zenodo.14245431
