Regulatory T cells (Treg), characterized by CD4
+, CD25
+, Foxp3
+, and CD127
-, are T lymphocytes that are generated in the thymus (natural Treg) or induced in the periphery (induced Treg) when triggered by suboptimal antigen stimulation and stimulation with TGF-β and IL-10 [
69]. Treg are further characterized by the expression of glucocorticoid-induced TNF-receptor-related-protein (GITR), lymphocyte activation gene-3 (LAG-3), and cytotoxic T-lymphocyte-associated antigen 4 (CTLA4).
In cancer patients, Treg confer growth and metastatic advantages by inhibiting anti-tumor immunity. They have this pro-tumoral effect by promoting tolerance via direct suppressive functions on activated T-cells or via the secretion of immunosuppressive cytokines such as IL-10 and TGF-β [
70,
71]. Treg are present in tumor tissue [
72,
73] and increased in peripheral blood of NSCLC patients compared to healthy controls [
74,
75]. This increase in Treg was found to promote tumor growth and was correlated with lymph node metastasis [
56,
73,
76,
77] and poor prognosis [
73,
78]. Many factors can increase Treg in NSCLC tumors, among them are thymic stromal lymphopoietin (TSLP) [
79] and intratumoral cyclooxygenase-2 (COX-2) expression [
80]. Treg are considered the most powerful inhibitors of antitumor immunity [
81]. As a result, there is substantial interest for overcoming this barrier to enhance the efficacy of cancer immunotherapy. Strategies include I). Treg depletion by chemical or radiation lymphoablation or using monoclonal antibodies or ligand-directed toxins (daclizumab, basiliximab, denileukin diftitox [Ontak
TM, RFT5-SMPT-dgA, and LMB-2) or with metronomic cyclophosphamide. II). Suppression of their function (ipilimumab, tremelimumad [anti-CTLA4], DTA-1 [anti-GITR], denosumab [anti-RankL], modulation of Toll-like receptor, OX40 stimulation or inhibiting ATP hydrolysis using ectonucleotidase inhibitors). III). Inhibition of tumoral homing by blocking the selective recruitment and retention of Treg at tumor sites, e.g. CCL22, CXCR4, CD103, and CCR2. IV). Exploitation of T-cell plasticity by modulating IL-6, TGF-β, and PGE2 expression, e.g. the COX-2 inhibitor celecoxib [
82]. Till now, a strategy that specifically target only Treg and no effector T cells is lacking and procedures that depletes or modulates all Treg should be avoided to minimize the risk of autoimmune manifestations. However, studies modulating Treg in patients are providing some early encouraging results supporting the concept that Treg inhibitory strategies have clinical potential, particularly in those therapies that simultaneously stimulate antitumor immune effector cells.