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The combination of radiation with immune checkpoint inhibitors was reported in some cancers to have synergic effects both locally and distally. Our aim was to assess this combined therapy on both radiated and nonradiated bladder tumors and to characterize the immune landscape within the tumor microenvironment. Murine bladder cancer cells (MB49) were injected subcutaneously in both flanks of C57BL/6 mice. Mice were randomly assigned to the following treatments: placebo, anti-PD-L1 (four intraperitoneal injections over 2 weeks), radiation to right flank (10 Gy in two fractions), or radiation+anti-PD-L1. Tumor digestion, flow cytometry, and qPCR were performed. Log-rank analysis was used for statistical significance. Radiation+anti-PD-L1 group demonstrated statistically significant slower tumor growth rate both in the radiated and nonirradiated tumors (P < 0.001). Survival curves demonstrated superior survival in the combination group compared with each treatment alone (P = 0.02). Flow cytometry showed increased infiltration of immunosuppressive cells as well as CTL in the radiation and combination groups (P = 0.04). Ratio of immunosuppressive cells to CTL shifted in favor of cytotoxic activity in the combination arm (P < 0.001). The qPCR analysis revealed downregulation of immunosuppressive genes (CCL22, IL22, and IL13), as well as upregulation of markers of CTL activation (CXCL9, GZMA, and GZMB) within both the radiated and distant tumors within the combination group. Combining radiation with immune checkpoint inhibitor provided better response in the radiated tumors and also the distant tumors along with a shift within the tumor microenvironment favoring cytotoxic activity. These findings demonstrate a possible abscopal effect in urothelial carcinoma with combination therapy.

Complete gene list in the qPCR kit and respective expression fold changes per experimental condition

BACKGROUND: New bladder preserving strategies are needed for muscle invasive bladder cancer (MIBC). Combined therapy of immune-checkpoint inhibitors and radiation was shown to have synergistic antitumoral effects in preclinical studies. OBJECTIVES: We aim to evaluate whether the sequence of administration of this combined therapy impacts antitumoral response. METHODS: We developed an in-vivo syngeneic MIBC mouse model where murine bladder cancer cells (MB49) were injected subcutaneously in the right flank of C57BL/6 mice. Mice were then randomized to the following treatments: control, anti-programmed cell death ligand 1 (PD-L1) alone, radiation alone (XRT) consisting of 6.25 Gy x2 fractions, concurrent anti-PD-L1 with XRT, neoadjuvant anti-PD-L1 followed by XRT, or XRT followed by adjuvant anti-PD-L1 therapy. Tumor growth, survival, and rate of response were analyzed. RESULTS: Total of 60 mice were randomized. One-way analysis of variance showed statistically significant difference in tumor growth rate across the treatment arms (p = 0.029). Importantly, timing of immunotherapy (neoadjuvant, concurrent, or adjuvant) did not alter either tumor growth or survival (p > 0.05). The rate of response was also similar in each combination arm (p > 0.05). CONCLUSION: Combining anti-PD-L1 immunotherapy and radiation therapy offers optimal antitumoral responses. Timing of immunotherapy (neoadjuvant, concurrent, or adjuvant) does not appear to affect outcomes. Whether the toxicity profile differs across various sequential deliveries of combination therapy requires further evaluation.

The combination of radiation with immune checkpoint inhibitors was reported in some cancers to have synergic effects both locally and distally. Our aim was to assess this combined therapy on both radiated and nonradiated bladder tumors and to characterize the immune landscape within the tumor microenvironment. Murine bladder cancer cells (MB49) were injected subcutaneously in both flanks of C57BL/6 mice. Mice were randomly assigned to the following treatments: placebo, anti-PD-L1 (four intraperitoneal injections over 2 weeks), radiation to right flank (10 Gy in two fractions), or radiation+anti-PD-L1. Tumor digestion, flow cytometry, and qPCR were performed. Log-rank analysis was used for statistical significance. Radiation+anti-PD-L1 group demonstrated statistically significant slower tumor growth rate both in the radiated and nonirradiated tumors (P < 0.001). Survival curves demonstrated superior survival in the combination group compared with each treatment alone (P = 0.02). Flow cytometry showed increased infiltration of immunosuppressive cells as well as CTL in the radiation and combination groups (P = 0.04). Ratio of immunosuppressive cells to CTL shifted in favor of cytotoxic activity in the combination arm (P < 0.001). The qPCR analysis revealed downregulation of immunosuppressive genes (CCL22, IL22, and IL13), as well as upregulation of markers of CTL activation (CXCL9, GZMA, and GZMB) within both the radiated and distant tumors within the combination group. Combining radiation with immune checkpoint inhibitor provided better response in the radiated tumors and also the distant tumors along with a shift within the tumor microenvironment favoring cytotoxic activity. These findings demonstrate a possible abscopal effect in urothelial carcinoma with combination therapy.

INTRODUCTION AND OBJECTIVE:New bladder preserving strategies are needed for muscle invasive bladder cancer (MIBC). Combined therapy of immune-checkpoint inhibitors and radiation was shown to have s...

INTRODUCTION AND OBJECTIVES:Combining radiation with immune-checkpoint inhibitors was reported in some cancers to have synergic effects both locally and distally. Our aim was to assess this combine...

Objectifs De nouvelles strategies de preservation de la vessie sont necessaires pour le cancer de vessie infiltrant le muscle (TVIM). La therapie combinee des « checkpoints » immunitaires (anti-PD-L1) et de la radiotherapie a montre des effets antitumoraux synergiques dans des etudes precliniques. L’objectif de notre etude etait d’evaluer si la sequence d’administration de cette therapie combinee a un impact sur la reponse antitumorale. Methodes Nous avons developpe un modele murin de TVIM syngenique in vivo ou des cellules cancereuses de vessie murine (MB49) ont ete injectees par voie sous-cutanee dans le flanc droit de souris C57BL/6. Les souris ont ensuite ete randomisees selon les traitements suivants : controle, anti-PD-L1 seul, radiotherapie seule (XRT) composee de 2 fractions de 6,25 Gy, anti-PD-L1 concomitant avec XRT, anti-PD-L1 neoadjuvant suivi de XRT, ou XRT suivi d’une therapie adjuvante anti-PD-L1. La croissance tumorale, la survie et le taux de repondeurs ont ete analyses par ANOVA, Kaplan–Meier ou Chi2 respectivement. Resultats Au total, 60 souris ont ete randomisees. On retrouvait une difference statistiquement significative du taux de croissance tumorale entre les bras de traitement (p = 0,029). Le moment de l’administration de l’immunotherapie (neoadjuvante, concomitante ou adjuvante) n’a modifie ni la croissance tumorale ni la survie (p > 0,05). Le taux de repondeurs etait egalement similaire dans chaque bras de traitement combine (p > 0,05) ( Fig. 1 , Fig. 2 ). Conclusion La combinaison de l’immunotherapie anti-PD-L1 et de la radiotherapie offre des reponses antitumorales optimales. Le timing d’administration de l’immunotherapie (neoadjuvant, concomitant ou adjuvant) ne semble pas affecter les resultats. La question de leur profil de toxicite respectif reste a analyser.

Radical cystectomy (RC) together with bilateral pelvic lymph node dissection remains the standard treatment for muscle invasive bladder cancer (MIBC). However, radiation-based treatments such as tri-modal therapy (TMT) involving maximally performed transurethral resection of bladder tumor (TURBT), radiotherapy (XRT), and a chemosensitizer represent an attractive, less invasive alternative. Nevertheless, 25–30% of MIBC patients will experience local recurrence after TMT and half will develop metastasis. Radioresistance of tumor cells could potentially be one of the causes for local recurrence post treatment. High mobility group box-1 (HMGB1) was shown to play a role in bladder cancer radioresistance through its intracellular functions in promoting DNA damage repair and autophagy. Recently, HMGB1 was found to be passively released from irradiated tumor cells. However, less is known about the involvement of extracellular HMGB1 in impairing radiation response and its exact role in modulating the tumor immune microenvironment after XRT. We identified a novel mechanism of bladder cancer radioresistance mediated by the immunological functions of HMGB1. The combination of radiation plus extracellular HMGB1 inhibition markedly improved the radiation response of tumors and resulted in marked changes in the immune landscape. Moreover, combining radiation and HMGB1 inhibition significantly impaired tumor infiltrating MDSCs and TAMs -but not Tregs- and shifted the overall tumor immune balance towards anti-tumoral response. We conclude that extracellular HMGB1 is involved in bladder cancer radioresistance through promoting pro-tumor immune mechanisms.

The combination of radiation with immune checkpoint inhibitors was reported in some cancers to have synergic effects both locally and distally. Our aim was to assess this combined therapy on both radiated and nonradiated bladder tumors and to characterize the immune landscape within the tumor microenvironment. Murine bladder cancer cells (MB49) were injected subcutaneously in both flanks of C57BL/6 mice. Mice were randomly assigned to the following treatments: placebo, anti-PD-L1 (four intraperitoneal injections over 2 weeks), radiation to right flank (10 Gy in two fractions), or radiation+anti-PD-L1. Tumor digestion, flow cytometry, and qPCR were performed. Log-rank analysis was used for statistical significance. Radiation+anti-PD-L1 group demonstrated statistically significant slower tumor growth rate both in the radiated and nonirradiated tumors (

PURPOSE: Radiotherapy modifies diverse components of the tumor microenvironment and inflammation plays a pivotal role in modulating radiation responsiveness of tumors. Neutrophils are one of the first-line responders during the acute phase of inflammation and are increasingly being recognized as drivers of tumor progression. One mechanism by which neutrophils play a role in tumor progression is through the formation of neutrophil extracellular traps (NETs). NETs are web-like structures expelled by the neutrophil composed of DNA studded with various proteins. Initially, this was described as a mechanism of antimicrobial defense but lately NETs have been associated with a variety of adverse effects, such as pathogenesis of autoimmune diseases, surgical stress, tumor progression, and metastasis. Recent studies show that the protein High Mobility Group Box-1 (HMGB1), a key player in radioresistance can in fact promote NETs. Importantly, the impact of NETs has not yet been explored in the context of radiation, so we sought to explore this further. METHODS: In vitro: a) Human neutrophils isolated from healthy donors were stimulated with 50ng of rHMGB1 for 4 hours. NETs were quantified through Sytox green fluorescence. b) Neutrophils were co-cultured with irradiated or non-irradiated conditioned media from UM-UC3 human bladder cancer cell line in combination with glycyrrhizin (GLZ), a natural inhibitor of HMGB1. In vivo: Murine bladder cancer cell line (MB49) was subcutaneously implanted into flanks of C57BL/6 and NETosis deficient PAD4-/- mice. Tumors were irradiated (2x5Gy) using the XRAD Smart Irradiator. Intraperitoneal injections of GLZ were used to modulate HMGB1 and intramuscular injections of DNAse were used to deplete NETs. Tumor volumes were measured using a digital caliper till endpoint. RESULTS: Our in vitro results demonstrate incubation of neutrophils with 50ng rHMGB1 significantly induced NETs formation compared to controls (p CONCLUSION: NETs may induce radioresistance through interactions with HMGB1. Highlighting the role of HMGB1 in NET formation will provide valuable information on the responses that occur in the tumor microenvironment post radiation therapy. Citation Format: Surashri Shinde-Jadhav, Jose Joao Mansure, Roni Rayes, Mina Ayoub, Jonathan Spicer, Wassim Kassouf. Neutrophil extracellular traps and their implication with radioresistance in muscle invasive bladder cancer [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 3743.