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Introduction Immunotherapy has had a significant impact on the landscape of cancer treatment. However, with only a 20%–30% response rate, identifying novel tumour intrinsic mechanisms of resistance is key to advancing treatment success. Activation of CD8 + T cells, the main cellular mediators of adaptive tumour immunity, requires both T cell receptor (TCR) binding of MHC bound peptides and co-stimulation by antigen presenting cells (APCs). On tumour recognition, antigen-specific T cells become reactivated, leading to tumour cell lysis. Therefore, cytotoxic assays that measure CD8 + T cell responses against tumours, are crucial for understanding therapeutic outcomes. Material and methods We have developed an in vitro system in which we have engineered tumour cells to express single-chain (scFv) anti-CD3 (clone OKT3) which provides signal 1 to CD8 + T cells, in a co-culture assay. This system allows for understanding the relative contributions of MHC-independent mechanisms to T-cell killing of a panel of tumour cell lines, in parallel. As a model, we have transduced the EGFR mutant non-small cell lung cancer (NSCLC) cell lines PC-9, NCH-H1975 and NCI-H3255 to stably express anti-CD3. Results and discussions Immune checkpoint blockade yields a clinical response in a subset of NSCLC patients. However, EGFR mutant NSCLC patients show less favourable responses. This assay allows us to investigate how EGFR genotype might influence tumour cell susceptibility to T cell killing. The pre-activated CD8 + T cells used in the co-culture assay underwent two rounds of anti-CD3/CD28 stimulation to optimise effector function. This resulted in increased CD45RO but decreased CD45RA expression and a heightened ability to lyse P815 target cells. Co-cultures of these T cells with tumour cells showed that these cell lines differ in their sensitivities to T cell killing as NCI-H1975 cells appeared to be the most sensitive whilst PC-9 and NCI-H3255 showed similar levels of killing. The flow cytometry based readout also allows for exploring tumour effects on T cell phenotype. Our data showed that all three cell lines significantly induced Granzyme B production in T cells in co-culture, which decreased with increasing E:T ratios and was the lowest with NCI-H1975 cells. Conclusion Taken together, our results demonstrate that our co-culture system is a robust assay for evaluating T cell-mediated cytotoxicity across cell lines and can potentially be used to investigate the effects of immunomodulatory drugs on T cell killing of different tumour cell lines.

Background Oesophageal cancer is the 6th most common cause of cancer death with incidence of adenocarcinomas (EAC) increasing in western countries. Long term survival is poor ( Trial design CALIBRATION is a single-centre, open-label, pilot trial of durvalumab (1500mg/4w) for patients with EAC progressing to standard chemotherapy. Pts with measurable disease undergo biopsies at screening/C3/progression alongside weekly blood sampling. Primary objective: asses if early changes in TP53 ctDNA variant allele fraction (VAF) levels, by weeks 4 and/ or 7 can predict durable (6 month) RECIST V 1.1 responses (Complete or Partial Response, Stable Disease). We plan to recruit 19 pts with a 5 % significance (one-sided) and 80 % power to detect if ctDNA changes correctly predict radiological response in ≥ 70 % pts. The trial opened to recruitment in October 2018, 13 pts have been pre-screened and 4 pts included. An interim analysis is planned for September 2019. Secondary endpoints include characterization of paired blood/biopsy samples from pts pre/post durvalumab of: • genomic heterogeneity (evolution of mutational signatures under IO) and changes in the tumour microenvironment (dynamics of T-cell populations). • changes in ctDNA and PBMC markers to identify biomarkers of resistance/response. • predictive value of the mutagenic and DDR signatures to predict response to IO compounds. Clinical trial identification NCT03653052. Legal entity responsible for the study Cambridge University Hospitals NHS Foundation Trust and the University of Cambridge. Funding AstraZeneca. Disclosure S. Dovedi: Leadership role: AstraZeneca.

Immuno-oncology research relies heavily on murine syngeneic tumor models. However, whilst the median age for a cancer diagnosis is 65 years or older, for practical purposes the majority of preclinical studies are conducted in young mice, despite the fact that aging has been shown to have a significant impact on the immune response. Using aged mice bearing CT26 tumors, we analysed how aging impacts the immune composition of the tumor, spleen and tumor-draining lymph nodes by flow cytometry. We found many age-related changes between aged (60-72 weeks old) and young (6-8 weeks old) mice, such as a reduction in the naïve T cell population and a decreased CD8/Treg ratio in aged animals. Profiling of co-inhibitory and co-stimulatory receptor expression levels on immune cells in aged versus young mice also identified altered expression profiles in both the periphery and tumor. We hypothesised that these differences may contribute to impaired anti-cancer immune responses in aged mice. To investigate this, we compared the anti-tumor efficacy of immune checkpoint blockade (PD-L1 and CTLA-4) and T-cell costimulation (OX-40) in aged versus young mice. Our data demonstrate that aged mice retained their capacity to generate effective anti-tumor immune responses, albeit often attenuated when compared to the responses observed in young mice. These differences highlight the potential importance of age-related immunological changes in assessing and refining the translational insights gained from preclinical mouse models. Citation Format: Suzanne I. Sitnikova, Michelle Morrow, Viia Valge-Archer, Robert W. Wilkinson, Simon J. Dovedi, Matthew J. Robinson. Age-induced changes in anti-tumor immunity alter the tumor immune infiltrate and reduce response to immuno-oncology treatments [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4987.

Although topical TLR7 therapies such as imiquimod have proved successful in the treatment of dermatological malignancy, systemic delivery may be required for optimal immunotherapy of nondermatological tumors. We report that intravenous delivery of the novel small molecule TLR7 agonist, DSR-6434, leads to the induction of type 1 interferon and activation of T and B lymphocytes, NK and NKT cells. Our data demonstrate that systemic administration of DSR-6434 enhances the efficacy of ionizing radiation (IR) and leads to improved survival in mice bearing either CT26 or KHT tumors. Of the CT26 tumor-bearing mice that received combined therapy, 55% experienced complete tumor resolution. Our data reveal that these long-term surviving mice have a significantly greater frequency of tumor antigen specific CD8+ T cells when compared to age-matched tumor-naive cells. To evaluate therapeutic effects on spontaneous metastases, we showed that combination of DSR-6434 with local IR of the primary tumor significantly reduced metastatic burden in the lung, when compared to time-matched cohorts treated with IR alone. The data demonstrate that systemic administration of the novel TLR7 agonist DSR-6434 in combination with IR primes an antitumor CD8+ T-cell response leading to improved survival in syngeneic models of colorectal carcinoma and fibrosarcoma. Importantly, efficacy extends to sites outside of the field of irradiation, reducing metastatic load. Clinical evaluation of systemic TLR7 therapy in combination with IR for the treatment of solid malignancy is warranted. What's new? Recent evidence suggests that damage from ionizing radiation (IR) can render tumor cells immunogenic. Unfortunately, established tumors often suppress this anti-tumor immune response. Combination therapy with IR and immune-modulators such as Toll-like-receptor (TLR) family agonists may overcome this problem. In this proof-of-concept study, the authors examined one such small-molecule drug, called DSR-6434. They found that systemic administration of DSR-6434 can enhance the effectiveness of radiotherapy in mice, and that this occurs via the generation of tumor-specific immune responses. Easily delivered drugs that activate TLR-family molecules may thus offer a promising therapeutic approach.

The aim of this study was to assess the immunogenic potential of irradiated lymphoma cells in vivo and determine whether immunogenicity can be enhanced by modulation of the host immune system. Syngeneic murine lymphoma models irradiated ex vivo were used as an orthotopic cellular vaccination prior to challenge with viable tumor cells. We demonstrate that irradiated lymphoma cells are poorly immunogenic and that protective anti-tumor CD8 T-cell responses require the addition of immunostimulatory monoclonal antibody as an immune adjuvant, and increased frequency of antigen exposure by multiple vaccinations. Furthermore, we show the potential importance of macrophages in regulating immunogenicity of irradiated lymphoma cells and demonstrate that depletion of macrophages using clodronate-encapsulated liposomes considerably enhances primary vaccination efficacy in the presence of adjuvant anti-CD40 antibody. Our results demonstrate that the immunogenic potential of poorly immunogenic lymphoma cells dying after radiation therapy can be improved by modulation of the host immune system.

Murine syngeneic tumor models are critical to novel immuno-based therapy development, but the molecular and immunologic features of these models are still not clearly defined. The translational relevance of differences between the models is not fully understood, impeding appropriate preclinical model selection for target validation, and ultimately hindering drug development. Across a panel of commonly used murine syngeneic tumor models, we showed variable responsiveness to immunotherapies. We used array comparative genomic hybridization, whole-exome sequencing, exon microarray analysis, and flow cytometry to extensively characterize these models, which revealed striking differences that may underlie these contrasting response profiles. We identified strong differential gene expression in immune-related pathways and changes in immune cell–specific genes that suggested differences in tumor immune infiltrates between models. Further investigation using flow cytometry showed differences in both the composition and magnitude of the tumor immune infiltrates, identifying models that harbor “inflamed” and “non-inflamed” tumor immune infiltrate phenotypes. We also found that immunosuppressive cell types predominated in syngeneic mouse tumor models that did not respond to immune-checkpoint blockade, whereas cytotoxic effector immune cells were enriched in responsive models. A cytotoxic cell–rich tumor immune infiltrate has been correlated with increased efficacy of immunotherapies in the clinic, and these differences could underlie the varying response profiles to immunotherapy between the syngeneic models. This characterization highlighted the importance of extensive profiling and will enable investigators to select appropriate models to interrogate the activity of immunotherapies as well as combinations with targeted therapies in vivo. Cancer Immunol Res; 5(1); 29–41. ©2016 AACR.

The increasing number of drugs targeting specific proteins implicated in tumourigenesis and the commercial promotion of relatively affordable genome-wide analyses has led to an increasing expectation among patients with cancer that they can now receive effective personalised treatment based on the often complex genomic signature of their tumour. For such approaches to work in routine practice, the development of correspondingly complex biomarker assays through an appropriate and rigorous regulatory framework will be required. It is becoming increasingly evident that a re-engineering of clinical research is necessary so that regulatory considerations and procedures facilitate the efficient translation of these required biomarker assays from the discovery setting through to clinical application. This article discusses the practical requirements and challenges of developing such new precision medicine strategies, based on leveraging complex genomic profiles, as discussed at the Innovation and Biomarkers in Cancer Drug Development meeting (8th-9th September 2016, Brussels, Belgium).

Tumor cells dying after cytotoxic therapy are a potential source of antigen for T-cell priming. Antigen-presenting cells (APC) can cross-present MHC I–restricted peptides after the uptake of dying cells. Depending on the nature of the surrounding environmental signals, APCs then orchestrate a spectrum of responses ranging from immune activation to inhibition. Previously, we had demonstrated that combining radiation with either agonistic monoclonal antibody (mAb) to CD40 or a systemically administered TLR7 agonist could enhance CD8 T-cell–dependent protection against syngeneic murine lymphoma models. However, it remains unknown how individual APC populations affect this antitumor immune response. Using APC depletion models, we now show that dendritic cells (DC), but not macrophages or B cells, were responsible for the generation of long-term immunologic protection following combination therapy with radiotherapy and either agonistic CD40 mAb or systemic TLR7 agonist therapy. Novel immunotherapeutic approaches that augment antigen uptake and presentation by DCs may further enhance the generation of therapeutic antitumor immune responses, leading to improved outcomes after radiotherapy. Cancer Immunol Res; 4(7); 621–30. ©2016 AACR.

Several studies have linked tumor-infiltration by regulatory T cells with poor patient outcome. Targeting the mechanisms by which regulatory T cells traffic to and persist in the tumor may circumvent tumor immune-escape by de-restricting T cell-mediated cytotoxicity. In this review, we describe the principle axes that govern regulatory T cell migration and the mechanisms that underpin their immunosuppressive activity in cancer. Inhibiting either the migration or function of regulatory T cells may enhance host-anti-cancer immune responses and as such are attractive and tractable targets for therapeutic intervention.

Despite the recent breakthrough of checkpoint blockade antibodies targeting T cells to combat cancer, it has become apparent that the majority of patients are not fully responsive. Engaging innate immune cells is a promising way to fully exploit the anti-cancer potential of the immune system. Our strategy is to stimulate TOLL-like receptors (TLRs) with MEDI9197, a potent TLR7 and TLR8 agonist, which stimulates the release of interferon-alpha (IFN-α) from plasmacytoid dendritic cells (pDCs) and interleukin-12 (IL-12) and other cytokines from myeloid DCs. While several compounds including MEDI9197, CpG and STING agonists can induce the production of IFN-α, we show that only MEDI9197 is able to induce high levels of interferon-gamma (IFN-γ) and IL-12p70 in human PBMCs, a hallmark of TLR 7/8 agonists. We also demonstrate in vitro that MEDI9197 upregulates activation markers on both innate and adaptive human immune cells, repolarizes macrophages and skews immunity from a Th2 towards a Th1 phenotype in a PHA assay, thereby increasing the functional activity of NK and cytotoxic CD8 cells. MEDI9197 is an imidazoquinoline with a unique lipid tail and formulation designed for intratumoral (IT) dosing and retention at the site of injection to minimize unwanted systemic exposure. Mass spectrometry imaging of MEDI9197 in mouse tumors and whole-body autoradiography in rats confirm local retention of MEDI9197, with < 5% of the initial IT dose detectable in the rat serum. We show in the B16-OVA mouse syngeneic tumor model that a single IT dose increases the percentage of tumor infiltrating lymphocytes (TILs), enhances activation of T cells, and leads to a qualitative shift from single to dual cytokine production (IFN-γ and Tumor necrosis factor alpha, TNF-α). Gene expression analysis further reveals increased expression of activatory innate and adaptive immune gene signatures consistent with increased inflammation. As our mouse flow cytometry studies show elevated levels of PD-1 and PD-L1 on TILs, the combination of MEDI9197 with anti-PD-L1 mAb was also evaluated and resulted in enhanced efficacy compared to MEDI9197 alone. We further demonstrate in vitro that combining MEDI9197 with durvalumab (anti-PD-L1) augments cytokine production (e.g. IL-2, IFN-γ) in a co-culture of human DCs and allogenic T cells. These data showcase MEDI9197 as a potent modulator of the innate and adaptive immune system in the fight against cancer and support the rationale for evaluating MEDI9197 in combination with checkpoint blockade and costimulatory agonists in the clinic. MEDI9197 is currently being evaluated in human clinical trials for safety and efficacy (NCT02556463). Citation Format: Stefanie R. Mullins, John Vasilakos, Katharina Deschler, Iwen Grigsby, Song Ren, Matthew J. Elder, Simon J. Dovedi, Andrew J. Leishman, Patricia Ryan, Zachary Cooper, James Elvecrog, Ronald Herbst, Rakesh Kumar, Mark Tomai, Robert W. Wilkinson. Intratumoral immunotherapy with TLR7/8 agonist MEDI9197 modulates the tumor microenvironment leading to enhanced activity when combined with other immunotherapies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 711.

Studies have demonstrated that the clinical benefit of PD-1 blockade can be further improved by combination with an αCTLA-4 mAb in some indications. However, this increased activity is commensurate with significant immune related adverse events (irAE's). Therefore, novel approaches are required to uncouple toxicity from anti-tumour efficacy and realise the full potential of this combination. MEDI5752 is a monovalent bispecific human IgG1 monoclonal antibody (mAb) with an engineered fragment crystallisable (Fc) domain to reduce Fc effector function, that specifically binds two clinically validated negative T cell regulators; PD-1 (programmed cell death 1) and CTLA-4 (cytotoxic T-lymphocyte-associated protein 4). MEDI5752 has been designed to suppress the PD-1 pathway and provide modulated CTLA-4 inhibition to uncouple CTLA-4 dependent peripheral toxicity from tumour efficacy. PD-1 expression is a defining feature of tumour infiltrating lymphocytes (TILs). We show that MEDI5752 can saturate CTLA-4 on PD-1+ cells at orders of magnitude lower concentrations than required to saturate CTLA-4 on PD-1- cells. Moreover, our data demonstrate that monovalent targeting of CTLA-4 with MEDI5752 is significantly less potent (15 fold) than bivalent targeting with a parental αCTLA-4 mAb in reporter assays. In contrast, the switch to monovalent targeting of PD-1 has limited effect on potency (within 3-fold compared to a parental αPD-1 mAb) in a PD-1/L1 reporter assay. Together these data demonstrate the potential for MEDI5752 to inhibit CTLA-4 on TILs whilst sparing peripheral T cell populations and reducing toxicity. Furthermore, profiling of MEDI5752 in a range of primary T cell activation assays reveals equivalent activity to a combination of parental PD-1 and CTLA-4 antibodies. MEDI5752 is rapidly internalised upon target binding with kinetics similar to the parental αCTLA-4 mAb reflecting the rapid recycling of this receptor. However, in contrast to an αCTLA-4 mAb (or an αPD-1 mAb), MEDI5752, by tethering CTLA-4 to PD-1, leads to the internalisation and subsequent degradation of PD-1. This novel mechanism of action further differentiates MEDI5752 from a combination of mAb's targeting PD-1 and CTLA-4. MEDI5752 is a novel monovalent bispecific which may provide an improved therapeutic index when compared to a combination of bivalent αPD-1 and αCTLA-4 mAb's, and could provide benefit in cancer indications. Citation Format: Simon J. Dovedi, Yariv Mazor, Matthew Elder, Sumati Hasani, Bo Wang, Suzanne Mosely, Desmond Jones, Anna Hansen, Chuning Yang, Yanli Wu, Ikbel Achour, Nick Durham, Gareth Browne, Thomas Murray, James Hair, Michelle Morrow, Godfrey Rainey, Maria Jure Kunkel, John Gooya, Daniel Freeman, Ronald Herbst, Robert Wilkinson. MEDI5752: A novel bispecific antibody that preferentially targets CTLA-4 on PD-1 expressing T-cells [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2776.

CD137 is a costimulatory molecule associated with tumour infiltrating lymphocytes and cytotoxic T lymphocytes in particular. Murine anti-CD137 monoclonal antibodies (mAbs) have shown potent anti-tumour effects in syngeneic tumour models, which can be further enhanced by combination with checkpoint inhibitor (CPI) mAbs to PD-1, or CTLA-4 and OX40. Two anti-CD137 monoclonal antibodies (mAbs), Urelumab and Utomilumab, are in development for both haematological and solid cancers, and studies include combinations with other IO therapies such as anti-PD-1, anti-PD-L1 and anti-OX40 mabs. We studied the impact of combining anti-CD137 with CPIs anti-PD-L1, anti-CTLA4, and IO agonist GITRL fusion protein (GITRL-FP) and anti-OX40 on pharmacodynamic responses, tumour growth and survival in mouse syngeneic models. In a responsive model, CT26, combining anti-CD137 with anti-PD-L1 had a greater impact on tumour growth inhibition, which correlated with an enhanced proliferation of CD8 T cells, as determined Ki67 expression using flow cytometry. In MC-38, a model that is less sensitive to both monotherapies, the combination was synergistic and resulted in enhanced tumour growth inhibition. Next, we compared the anti-CTLA4, anti-OX40 and GITRL-FP as monotherapies and in combination with anti-CD137 in the CT26 model. As before, anti-CD137 alone induced CD8 T cell proliferation, whereas anti-OX40 and GITRL-FP stimulated expansion of CD8 and CD4 T cells. Interestingly, in all combinations anti-CD137 appeared to enhance both CD8 and CD4 T cell proliferation. Anti-CTLA4 and GITR-FP had a greater impact on tumour growth inhibition when combined with anti-CD137. In summary, in vivo models indicate that anti-CD137 mAbs are a promising therapy in cancer, but the most benefit may be obtained in combination with other IO therapies. Citation Format: Matthew J. Robinson, Ines Osma-Garcia, Jane Coates-Ulrichisen, Amanda Watkins, Suzanne Mosely, Chrisopher Lloyd, Geoff Williams, Michelle Morrow, Simon Dovedi, Ronald Herbst, Robert Wilkinson. An anti-CD137 antibody can show greater efficacy in syngeneic mouse tumor models when combined with other immuno-oncology (IO) therapies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3765.

Glucocorticoid-induced tumor necrosis factor receptor-related protein (GITR) is a co-stimulatory receptor, and programmed cell death protein 1 (PD-1) is an important co-inhibitory receptor involved in controlling T-cell activation and function. Preclinical studies using murine cross-reactive molecules demonstrate that the combination of an αPD-1 monoclonal antibody (mAb) with a GITR-ligand (GITRL) fusion protein can elicit synergistic antitumor activity and long-term survival benefit in syngeneic mouse tumor models. Here we describe the activity of two bispecific fusion proteins, each comprising two GITR ligand trimers fused to the Fc region of an αPD1 mAb, in an IgG1 (MEDI5771) or IgG4P (MEDI3387) format. We show that these bispecific molecules are able to concurrently engage both targets and are effective in cell-based PD-1 and GITR reporter assays, and in a range of human primary T-cell assays. Furthermore, the PD-1/GITRL FP bispecific constructs elicit T-cell responses in vitro that are at least equivalent to a combination of a) the parental molecules and b) MEDI1873 (a GITR agonist currently undergoing clinical evaluation) and an αPD-1 mAb. Moreover, using surrogate molecules we demonstrate that IV administration leads to dose-dependent pharmacodynamic responses on CD4+ and CD8+ T cells for both isotypes of the bispecific molecule. These data demonstrate that the antitumor activity for these novel molecules is equivalent to the combination of GITRL-FP and PD-1 mAb in the B16 model. In summary, the simultaneous dual targeting of PD-1 and GITR pathways mediated by these two novel bispecific molecules induces robust T-cell activity that is at least equivalent to a combination of molecules targeting these pathways, thereby demonstrating strong potential as a novel anticancer therapy. Citation Format: Simon J. Dovedi, Jonathan Seaman, Ines Osma-Garcia, Katharina Deschler, Edmund Poon, Ronald Herbst, Robert Wilkinson. Novel PD-1/GITRL bispecific fusion protein delivering concurrent T cell co-stimulation and checkpoint pathway inhibition [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3820.

Objectives Prostaglandin E 2 (PGE 2 ) is a potent immune modulator and known to suppress both tumour antigen-specific helper T (T H 1) cells and the generation of cytotoxic T lymphocytes (CTLs). We hypothesised that a combination of the cyclooxygenase 2 (COX-2) selective inhibitor celecoxib and intravesical bacillus Calmette-Guerin (BCG), an effective tumour immunoprophylaxis and ablative therapy for non–muscle-invasive bladder cancer, would be more effective than BCG alone. Methods We assessed urinary levels of PGE 2 in humans receiving BCG and in a murine model of urothelial cell carcinoma (UCC). The cytokine response to BCG plus celecoxib was assessed in murine dendritic cells (DCs) in vitro and tumour ablation was assessed in an orthotopic MBT2 murine bladder cancer model. Results Administration of intravesical BCG resulted in elevated urinary PGE 2 levels in patients with high-grade superficial UCC and in a mouse model of UCC. In vitro, activation of DCs with BCG stimulated COX-2 up-regulation and release of the archetypal tolerogenic factors, PGE 2 and interleukin 10. In a superficial mouse model of UCC, combination of celecoxib and intravesical BCG therapy resulted in increased tumour infiltration of CD4 + T cells and improved efficacy when compared to BCG alone. Further, celecoxib demonstrated marked antitumour efficacy when administered in the absence of BCG immunotherapy. Conclusions This study demonstrates that a combination strategy involving BCG immunotherapy and celecoxib may be more therapeutically beneficial than stand-alone intravesical therapy.

Strategies to augment anti-cancer immune responses have recently demonstrated therapeutic utility. To date clinical success has been achieved through targeting co-inhibitory checkpoints such as CTLA-4, PD-1, and PD-L1. However, approaches that target co-activatory pathways are also being actively being developed. Here we report that the novel TLR7-selective agonist DSR-29133 is well tolerated in mice and leads to acute immune activation. Administration of DSR-29133 leads to the induction of IFNα/γ, IP-10, TNFα, IL-1Ra and IL-12p70, and to a reduction in tumor burden in syngeneic models of renal cancer (Renca), metastatic osteosarcoma (LM8) and colorectal cancer (CT26). Moreover, we show that the efficacy of DSR-29133 was significantly improved when administered in combination with low-dose fractionated radiotherapy (RT). Effective combination therapy required weekly administration of DSR-29133 commencing on day 1 of a fractionated RT treatment cycle, whereas no enhancement of radiation response was observed when DSR-29133 was administered at the end of the fractionated RT cycle. Combined therapy resulted in curative responses in a high proportion of mice bearing established CT26 tumors which was dependent on the activity of CD8+ T-cells but independent of CD4+ T-cells and NK/NKT cells. Moreover, long-term surviving mice originally treated with DSR-29133 and RT were protected by a tumor-specific memory immune response which could prevent tumor growth upon rechallenge. These results demonstrate that DSR-29133 is a potent selective TLR7 agonist that when administered intravenously can induce anti-tumor immune responses that can be further enhanced through combination with low-dose fractionated RT.

After years of limited success, progress of anti-cancer immuno-therapeutics has been considerable over the past decade. Key to this progress has been the application of new biological insights around the importance and nature of immune checkpoints that are able to reverse down-regulation of anti-tumor immunity.An overview of the preclinical and recent clinical trial data on key immuno-regulatory agents currently in development, including antibody targeting of cytotoxic T-lymphocyte antigen 4 (CTLA-4), programmed death receptor 1 (PD-1) on T-lymphocytes and its principal ligand (PD-L1) on tumor cells as well as immune agonists (e.g., anti-CD40).Durable long-term responses in some patients with advanced melanoma, initially with ipilimumab (anti-CTLA-4) and more recently antibodies targeting either PD-1 or PD-L1 in patients with melanoma and renal cancer, non-small-cell lung, bladder and head and neck cancers with less toxicity, have provided real optimism that immunotherapeutic approaches can improve outcomes in a wide range of cancer. The manageable tolerability of PD-1-pathway blockers and their unique mechanism of action are encouraging combination approaches. Current efforts focus on registration trials of single agents plus combinations in many different tumor types and treatment settings and identifying and developing predictive biomarkers of immunological response.

Fractionated radiation therapy (RT) leads to adaptive changes in the tumor microenvironment that may limit the generation of an antitumor immune response. We demonstrated that fractionated RT led to increased tumor cell expression of programmed cell death ligand 1 (PD-L1) in response to CD8+ T cell production of interferon gamma. Our data reveal that the efficacy of fractionated RT can be significantly improved through the generation of durable systemic immune responses when combined with concurrent, but not sequential, blockade of the PD-1/PD-L1 pathway.

Intravesical bacillus Calmette-Guerin (BCG) therapy is the principal treatment for high risk, noninvasive urothelial carcinoma and carcinoma in situ of the bladder. However, up to 40% of patients fail to respond to this treatment. In this study the potential for inhibition of PGE2 production by BCG treated dendritic cells (DCs) was studied in the context of preferential polarization of the immune response toward a cancer clearing T-helper type 1 immune response.Murine bone marrow derived DCs were cultured with interleukin (IL)-4 and granulocyte-macrophage colony-stimulating factor. After 7 days the cells were stimulated with BCG. Cell surface expression of co-stimulatory molecules and phagocytic ability were measured by flow cytometry analysis to verify cell activation. The production of IL-10 and IL-12 was measured after DC stimulation with BCG in the presence of IL-10, prostaglandin E2(Cayman Chemical, Ann Arbor, Michigan), antiIL-10 antibody (Insight Biotechnology, Wembley, United Kingdom), NS-398 and indomethacin (Sigma, Poole, United Kingdom).Prostaglandin E2 stimulated a dose dependent increase in the levels of IL-10 produced by BCG activated DCs (p0.01). IL-10 significantly decreased IL-12 production (p0.001), while IL-10 blockade significantly increased IL-12 levels (p0.05). The COX-2 selective inhibitor NS-398 caused a dose dependent increase in the concentration of IL-12 produced by BCG activated DCs (p0.01). This effect was also seen with the partially selective COX-1 inhibitor indomethacin (p0.05).The inhibition of PGE2 synthesis by COX inhibition favored the production of IL-12 by BCG activated DC. This potentially will result in the generation of a T-helper type 1, polarized T-cell response that may improve the efficacy of BCG therapy.

Recent successes in immuno-oncology have focussed primarily on the T-cell synapse, targeting co-activatory /inhibitory pathways to modulate T cell function. However, strategies that target tumor-resident myeloid cells may be required to fully exploit the therapeutic potential of the anti-cancer immune response. TOLL-like receptors (TLRs) are expressed on a broad range of myeloid cells and function to recognise highly evolutionarily conserved pathogen-associated molecular patterns. Signalling through TLRs leads to the activation of antigen-presenting cells (APCs) and to expression of inflammatory cytokines. However, whilst topical application of TLR agonists have proved successful in the treatment of dermatological tumors, systemic administration have proved to be poorly tolerated. MEDI9197 (formerly 3M-052), is a novel lipophilic TLR7/8 agonist designed with a lipid tail to facilitate retention at the site of injection, limiting systemic exposure. These properties make MEDI9197 ideal for intratumoral (IT) administration. We have demonstrated that MEDI9197 is a potent TLR7 and TLR8 agonist and induces pro-inflammatory cytokines through activation of a diverse range of myeloid and lymphoid cells. In mice bearing established tumors, IT injection of MEDI9197 induces a local inflammatory response, characterized by upregulation of genes associated with the activation of innate and adaptive immunity in the injected tumor and tumor draining lymph nodes. Moreover, treatment leads to an increase in the frequency of tumor infiltrating lymphocytes (TILs), such as CD8+ cytotoxic T cells and increased expression of activation markers, such as CD69. Cellular depletion studies reveal that CD8+ T cells are required for therapeutic activity. Furthermore, using in vitro co-cultures we demonstrate that MEDI9197 is able to enhance cytotoxic activity of NK cell and T cells. Importantly, in models that respond poorly to mAbs targeting either PD-L1 or CTLA-4, combination with MEDI9197 significantly improved anti-tumor activity when compared to either monotherapy alone. These preclinical data demonstrate that MEDI9197 can modulate both the myeloid and lymphoid immune compartments to mediate anti-tumor activity and combines productively with immune checkpoint blockade. MEDI9197 is currently being evaluated as a monotherapy for safety and efficacy in human clinical trials (NCT02556463). Citation Format: Stefanie R. Mullins, Katharina Vogel, John Vasilakos, Iwen Grigsby, Simon Dovedi, Ryan Patricia, Zachary Cooper, Ronald Herbst, Rakesh Kumar, Mark Tomai, Robert W. Wilkinson. Intratumoral immunotherapy with TLR7/8 agonist MEDI9197 modulates the tumor microenvironment and holds potential for combination with immune checkpoint inhibitors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4697. doi:10.1158/1538-7445.AM2017-4697

Systemic administration of small molecule toll-like receptor (TLR)-7 agonists leads to potent activation of innate immunity and to the generation of anti-tumor immune responses. However, activation of TLRs with small molecule agonists may lead to the induction of TLR tolerance, defined as a state of hyporesponsiveness to subsequent agonism, which may limit immune activation, the generation of anti-tumor responses and clinical response. Our data reveal that dose scheduling impacts on the efficacy of systemic therapy with the selective TLR7 agonist, 6-amino-2-(butylamino)-9-((6-(2-(dimethylamino)ethoxy)pyridin-3-yl)methyl)-7,9-dihydro-8H-purin-8-one (DSR-6434). In a preclinical model of renal cell cancer, systemic administration of DSR-6434 dosed once weekly resulted in a significant anti-tumor response. However, twice weekly dosing of DSR-6434 led to the induction of TLR tolerance, and no anti-tumor response was observed. We show that TLR7 tolerance was independent of type I interferon (IFN) negative feedback because induction of TLR7 tolerance was also observed in IFN-α/β receptor knockout mice treated with DSR-6434. Moreover, our data demonstrate that treatment of bone marrow-derived plasmacytoid dendritic cells (BM-pDC) with DSR-6434 led to downregulation of TLR7 expression. From our data, dose scheduling of systemically administered TLR7 agonists can impact on anti-tumor activity through the induction of TLR tolerance. Furthermore, TLR7 expression on pDC may be a useful biomarker of TLR7 tolerance and aid in the optimization of dosing schedules involving systemically administered TLR7 agonists.

Effective anticancer treatments often result in the induction of large amounts of tumour cell death. In vivo, such dying tumour cells are a potential source of antigens for T-cell stimulation. Although apoptosis is generally considered nonimmunogenic, recent evidence suggests that some anticancer therapies that induce apoptosis can elicit antitumour immune responses. Here, a doxycycline-inducible, constitutively active caspase-3 (‘death switch') was constructed in a murine tumour model to explore the impact of the host immune response to rapid, synchronous and substantial tumour cell apoptosis. In vitro, up to 80% of tumour cells underwent apoptotic cell death within 24 h and death was accompanied by the release of potential ‘danger signal' molecules HMGB1 and HSP90. In vivo, death switch induction provoked rapid, pronounced tumour regression in immune-competent and immune-deficient mice, but sustained tumour eradication was observed only in immune-competent mice. Moreover, the majority of mice that were tumour free after death switch induction were protected from further tumour rechallenge. In addition, long-term remission after induction of the death switch was completely abrogated following depletion of CD8 T cells. These data suggest that sustained tumour eradication after substantial tumour apoptosis requires an antitumour host immune response that prevents tumour relapse. In many patients, cancer therapies produce encouraging initial responses that are only short lived. These results provide new insights that may have important implications for further development of strategies that result in long-term tumour clearance after initially effective anticancer treatment.

Although topical TLR7 therapies such as imiquimod have proved successful in the treatment of dermatological malignancy, systemic delivery may be required for optimal immunotherapy of nondermatological tumors. We report that intravenous delivery of the novel small molecule TLR7 agonist, DSR-6434, leads to the induction of type 1 interferon and activation of T and B lymphocytes, NK and NKT cells. Our data demonstrate that systemic administration of DSR-6434 enhances the efficacy of ionizing radiation (IR) and leads to improved survival in mice bearing either CT26 or KHT tumors. Of the CT26 tumor-bearing mice that received combined therapy, 55% experienced complete tumor resolution. Our data reveal that these long-term surviving mice have a significantly greater frequency of tumor antigen specific CD8+ T cells when compared to age-matched tumor-naïve cells. To evaluate therapeutic effects on spontaneous metastases, we showed that combination of DSR-6434 with local IR of the primary tumor significantly reduced metastatic burden in the lung, when compared to time-matched cohorts treated with IR alone. The data demonstrate that systemic administration of the novel TLR7 agonist DSR-6434 in combination with IR primes an antitumor CD8+ T-cell response leading to improved survival in syngeneic models of colorectal carcinoma and fibrosarcoma. Importantly, efficacy extends to sites outside of the field of irradiation, reducing metastatic load. Clinical evaluation of systemic TLR7 therapy in combination with IR for the treatment of solid malignancy is warranted. What's new? Recent evidence suggests that damage from ionizing radiation (IR) can render tumor cells immunogenic. Unfortunately, established tumors often suppress this anti-tumor immune response. Combination therapy with IR and immune-modulators such as Toll-like-receptor (TLR) family agonists may overcome this problem. In this proof-of-concept study, the authors examined one such small-molecule drug, called DSR-6434. They found that systemic administration of DSR-6434 can enhance the effectiveness of radiotherapy in mice, and that this occurs via the generation of tumor-specific immune responses. Easily delivered drugs that activate TLR-family molecules may thus offer a promising therapeutic approach.

Passive immunotherapy with monoclonal antibodies has improved outcome for patients with B-cell malignancies, although many still relapse and little progress has been made with T-cell malignancies. Novel treatment approaches are clearly required in this disease setting. There has been much recent interest in developing therapeutic approaches to enhance antitumor immune responses using novel immunomodulatory agents in combination with standard of care treatments. Here we report that intravenous administration of the Toll-like receptor 7 (TLR7) agonist, R848 in combination with radiation therapy (RT), leads to the longstanding clearance of tumor in T- and B-cell lymphoma bearing mice. In combination, TLR7/RT therapy leads to the expansion of tumor antigen-specific CD8+ T cells and improved survival. Furthermore, those mice that achieve long-term clearance of tumor after TLR7/RT therapy are protected from subsequent tumor rechallenge by the generation of a tumor-specific memory immune response. Our findings demonstrate the potential for enhancing the efficacy of conventional cytotoxic anticancer therapy through combination with a systemically administered TLR7 agonist to improve antitumor immune responses and provide durable remissions.

Topical TLR7 agonists such as imiquimod are highly effective for the treatment of dermatological malignancies; however, their efficacy in the treatment of nondermatological tumors has been less successful. We report that oral administration of the novel TLR7-selective small molecule agonist; SM-276001, leads to the induction of an inflammatory cytokine and chemokine milieu and to the activation of a diverse population of immune effector cells including T and B lymphocytes, NK and NKT cells. Oral administration of SM-276001 leads to the induction of IFNα, TNFα and IL-12p40 and a reduction in tumor burden in the Balb/c syngeneic Renca and CT26 models. Using the OV2944-HM-1 model of ovarian cancer which spontaneously metastasizes to the lungs following subcutaneous implantation, we evaluated the efficacy of intratracheal and oral administration of SM-276001 in an adjuvant setting following surgical resection of the primary tumor. We show that both oral and intratracheal TLR7 therapy can reduce the frequency of pulmonary metastasis, and metastasis to the axillary lymph nodes. These results demonstrate that SM-276001 is a potent selective TLR7 agonist that can induce antitumor immune responses when dosed either intratracheally or orally.

The active suppression of immune responses against tumor is a major barrier to the likely success of cancer immunotherapy. There is now compelling evidence implicating T regulatory cells (Tregs) as being key players driving immune suppression. Elevated frequencies of Tregs within the peripheral circulation and tumor microenvironment of cancer patients correlate with poor prognosis and reduced survival. Understanding the mechanism of Treg elevation is critical for the development of new approaches aiming to modulate the frequency and function of Tregs to enhance the efficacy of cancer immune-based therapies.This review focuses on current knowledge concerning Tregs in cancer and discusses putative mechanisms which underlie the expansion of Tregs in cancer patients. Additionally, we review current strategies to deplete/suppress Treg activity, the limitations of these strategies and future perspective for improving their efficacy.An insight of the current aspects concerning Treg subsets in cancer and an overview of recent advances in the identification of Treg-specific markers, in addition to the potential strategies to target Tregs for enhancing antitumor immunity.Mechanisms by which Treg functions modulate the immune response to tumors are becoming further understood. However, specific markers to tumor-specific/induced Tregs are yet to be clearly identified, which is a major limitation in optimizing strategies to specifically target Tregs in cancer. Despite this, strategies aimed at modulating Tregs in patients are providing some early encouraging results supporting the overall concept and indicating that further studies are clearly warranted.

T cells gene-modified to express chimeric Ag receptors (CARs) have shown potent antitumor activity in vivo and are in clinical trials at locations worldwide. However, CAR activity has been investigated in mouse models in which Ag expression is restricted to the tumor. To explore the impact of normal tissue expression of the target Ag, we developed a mouse CD19-specific CAR to investigate antitumor efficacy against a syngeneic B cell lymphoma cell line within a background of normal CD19+ host B cells. Mouse T cells engrafted with the amCD19CD3ζ CAR specifically lysed A20 lymphoma targets and B cells in vitro. These T cells also eradicated a 12-d established disseminated A20 lymphoma in mice preconditioned with 6 Gy total body irradiation. In the short-term (7 d after adoptive transfer), amCD19z T cells underwent Ag-dependent proliferation in vivo with a concomitant depletion in host B cell levels. However, the levels of amCD19z CAR+ T cells decreased significantly at later time points, at which point host B cells returned, eventually reaching normal levels. In contrast, CAR+ T cells lacking a signaling domain or specificity for mCD19 persisted over extended periods in blood and spleen. Importantly, no overt clinical signs of autotoxicity were observed in tumor-free or tumor-bearing mice treated with amCD19z T cells over an extended period of time. These observations highlight the importance of studying the activity of CAR+ T cells in autologous models that have the normal range of tissue expression of Ag.

Urothelial cell carcinoma is the fifth most common cancer and the costliest to treat. This is largely because of all new cases, about 70% present as superficial disease and this while rarely fatal, tends to recur, requiring long-term follow-up and repeat interventions. The standard of care, intravesical chemo- and immunotherapy, while effective, is associated with a considerable side-effect profile and approximately 30% of patients either fail to respond to treatment or suffer recurrent disease within 5 years. Muscle-invasive bladder cancer is life threatening, showing modest chemosensitivity, and usually requires radical cystectomy. Although bladder cancer is fairly well-genetically characterized, clinical trials with molecularly targeted agents have, in comparison to other solid tumors such as lung, breast and prostate, been few in number and largely unsuccessful, with no new agents being registered in the last 20 years. Hence, bladder cancer represents a considerable opportunity and challenge for molecularly targeted therapy.

Radiation therapy (RT) is administered to around 50% of all cancer patients making it one of the most important cancer treatments. In addition to the direct cytoreductive effect of RT there is increasing evidence that radiation-induces immunogenic tumor cell death. Despite the immunogenicity of RT-induced tumor cell death, RT delivered to tumours in the clinic rarely generates therapeutic systemic anti-cancer immune responses or ‘abscopal effects’. Here we show that tumor infiltrating CD8+ cytotoxic T lymphocytes (CTL) have increased expression of PD-1 following RT in vivo. Moreover, our data demonstrate that treatment of established syngeneic tumors with RT leads to upregulation of tumor cell expression of PD-L1 in vivo but not when cells are irradiated in vitro. Using depleting antibodies we determined that the depletion of CD8+ T cells but not CD4+ T cells or NK cells could abrogate this RT-induced increase in tumor cell expression of PD-L1 in vivo. Furthermore, silencing of IFNγR1 using ShRNA confirmed that this process was dependent on CD8+ T cell production of IFNγ suggesting an adaptive upregulation of PD-L1 following RT occurs in response to CTL activation. This novel finding suggests that the immunogenicity of RT may be limited via the PD-L1/PD-1 signalling axis and may contribute to treatment failure. We next sought to determine whether blockade of the PD-1/PD-L1 signalling axis could enhance the therapeutic response to RT. Our study demonstrates that administration of either an anti-PD-1 or anti-PD-L1 mAb in combination with RT leads to substantially improved survival when compared to either monotherapy alone with approximately 60% of treated mice undergoing a complete response. In addition, our data reveal that combination therapy generates long-term immunological memory in mice that have undergone complete response protecting against tumor rechallenge. This is the first report to our knowledge that demonstrates adaptive resistance through the upregulation of tumour cell PD-L1 expression in response to an RT-induced CTL response. This study demonstrates the potential for enhancing the efficacy of conventional RT through blockade of the PD-1/PD-L1 axis and warrants clinical evaluation. Citation Format: Simon J. Dovedi, Graznya Lipowska-Bhalla, Eleanor Cheadle, Edmund Poon, Michelle Morrow, Ross Stewart, Robert Wilkinson, Jamie Honeychurch, Timothy Illidge. The antitumor immune response generated by radiation therapy may be limited by tumor cell adaptive resistance and can be circumvented by PD-L1 blockade. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 5034. doi:10.1158/1538-7445.AM2014-5034

Introduction: Systemic administration of the small molecule Toll-like receptor (TLR)-7 agonist DSR-6434 leads to potent activation of innate immunity and to the generation of anti-tumor immune responses. However, clinical responses with systemically administered TLR7 agonists have been underwhelming, in part because activation of TLRs with small-molecule agonists can induce TLR tolerance; defined as a state of hyporesponsiveness to subsequent agonism. This study is undertaken to identify conditions to overcome TLR tolerance. Experimental procedures: To confirm the anti-tumor effect of DSR-6434, mice were inoculated with the mouse renal cell carcinoma cell line, Renca, at day 0, and then administrated DSR-6434 weekly from day 1, or twice weekly from day 6. To examine tolerance, wild-type or IFN-α/β receptor knockout (IFN-AR KO) mice were intravenously administrated DSR-6434 at intervals of 3, 7 or 10 days. Plasma samples were taken 2 hours after the second administration of DSR-6434 and IFN-α levels were measured. Splenocytes were isolated 24 hours following either single or sequential i.v. doses. To measure lymphocyte activation, CD69 expression was assessed and splenocyte-mediated cytotoxicity against YAC-1 target cells was determined. Bone-marrow derived pDC (BM-pDC) were also treated with DSR-6434 for 5 or 48 hours. Expression of TLR7 signaling-related genes was determined by real-time quantitative RT-PCR. Results: Weekly administration of DSR-6434 significantly reduced tumor burden when compared to vehicle-treated mice. By contrast, pre-inoculation and 2qw administration of DSR-6434 completely abolished anti-tumor activity. IFN-α induction was completely impaired following the second administration of DSR-6434 after 3 days, partially impaired after 7 days, and fully functional when the dosing interval was extended to 10 days. Sequential dosing of DSR-6434 reduced the frequency of activated splenocytes (defined as CD69+) and the level of cytotoxicity, compared with a single administration of DSR-6434. TLR7 tolerance was also observed in IFN-AR KO mice, suggesting this effect was independent of IFN signaling. Interestingly, TLR7 down-regulation was only observed after DSR-6434 dosing, while the expression of other TLR7-signaling related genes was unaltered. Conclusion: The dosing schedule of systemically administered TLR7 agonists significantly affect TLR tolerance and antitumor activity, offering a potential solution to overcome TLR tolerance . Furthermore, TLR7 expression on BM-pDC cells may serve as a useful biomarker of TLR7 tolerance and aid in the optimization of dosing schedules involving systemically administered TLR7 agonists. Citation Format: Erina Koga-Yamakawa, Masashi Murata, Simon J. Dovedi, Robert W. Wilkinson, Hiroki Umehara, Eiji Sugaru, Yuko Hirose, Hideyuki Harada, David T. Robinson, Philip J. Jewsbury, Setsuko Yamamoto, Chiang J. Li. Enhancement of antitumor activity of DSP-6434, a novel TLR7 agonist through reduction of TLR tolerance. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2567. doi:10.1158/1538-7445.AM2014-2567