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      Rethinking immune checkpoint blockade: ‘Beyond the T cell’


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          The clinical success of immune checkpoint inhibitors has highlighted the central role of the immune system in cancer control. Immune checkpoint inhibitors can reinvigorate anti-cancer immunity and are now the standard of care in a number of malignancies. However, research on immune checkpoint blockade has largely been framed with the central dogma that checkpoint therapies intrinsically target the T cell, triggering the tumoricidal potential of the adaptive immune system. Although T cells undoubtedly remain a critical piece of the story, mounting evidence, reviewed herein, indicates that much of the efficacy of checkpoint therapies may be attributable to the innate immune system. Emerging research suggests that T cell-directed checkpoint antibodies such as anti-programmed cell death protein-1 (PD-1) or programmed death-ligand-1 (PD-L1) can impact innate immunity by both direct and indirect pathways, which may ultimately shape clinical efficacy. However, the mechanisms and impacts of these activities have yet to be fully elucidated, and checkpoint therapies have potentially beneficial and detrimental effects on innate antitumor immunity. Further research into the role of innate subsets during checkpoint blockade may be critical for developing combination therapies to help overcome checkpoint resistance. The potential of checkpoint therapies to amplify innate antitumor immunity represents a promising new field that can be translated into innovative immunotherapies for patients fighting refractory malignancies.

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          PD-1 blockade induces responses by inhibiting adaptive immune resistance

          Therapies that target the programmed death-1 (PD-1) receptor have shown unprecedented rates of durable clinical responses in patients with various cancer types. 1–5 One mechanism by which cancer tissues limit the host immune response is via upregulation of PD-1 ligand (PD-L1) and its ligation to PD-1 on antigen-specific CD8 T-cells (termed adaptive immune resistance). 6,7 Here we show that pre-existing CD8 T-cells distinctly located at the invasive tumour margin are associated with expression of the PD-1/PD-L1 immune inhibitory axis and may predict response to therapy. We analyzed samples from 46 patients with metastatic melanoma obtained before and during anti-PD1 therapy (pembrolizumab) using quantitative immunohistochemistry, quantitative multiplex immunofluorescence, and next generation sequencing for T-cell receptors (TCR). In serially sampled tumours, responding patients showed proliferation of intratumoural CD8+ T-cells that directly correlated with radiographic reduction in tumour size. Pre-treatment samples obtained from responding patients showed higher numbers of CD8, PD1, and PD-L1 expressing cells at the invasive tumour margin and inside tumours, with close proximity between PD-1 and PD-L1, and a more clonal TCR repertoire. Using multivariate analysis, we established a predictive model based on CD8 expression at the invasive margin and validated the model in an independent cohort of 15 patients. Our findings indicate that tumour regression following therapeutic PD-1 blockade requires pre-existing CD8+ T cells that are negatively regulated by PD-1/PD-L1 mediated adaptive immune resistance.
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            PD-L1 is a novel direct target of HIF-1α, and its blockade under hypoxia enhanced MDSC-mediated T cell activation

            Hypoxia is a common feature of solid tumors (Semenza, 2011). Hypoxic zones in tumors attract immunosuppressive cells such as myeloid-derived suppressor cells (MDSCs; Corzo et al., 2010), tumor-associated macrophages (TAMs; Doedens et al., 2010; Imtiyaz et al., 2010), and regulatory T cells (T reg cells; Clambey et al., 2012). MDSCs are a heterogeneous group of relatively immature myeloid cells and several studies have described mechanisms of MDSC-mediated immune suppression (Gabrilovich et al., 2012). A large body of preclinical and clinical data indicates that antibody blockade of immune checkpoints can significantly enhance antitumor immunity (Pardoll, 2012; West et al., 2013). Recently, antibody-mediated blockade of preprogrammed death 1 (PD-1; Topalian et al., 2012) and its ligand, PD-L1 (Brahmer et al., 2012), was shown to result in durable tumor regression and prolonged stabilization of disease in patients with advanced cancers. PD-1, a cell surface glycoprotein with a structure similar to cytotoxic T lymphocyte antigen 4 (CTLA-4), belongs to the B7 family of co-stimulatory/co-inhibitory molecules and plays a key part in immune regulation (Greenwald et al., 2005). PD-1 has two known ligands, PD-L1 (B7-H1) and PD-L2 (B7-DC). Although hypoxia has been shown to regulate the function and differentiation of MDSCs (Corzo et al., 2010), several major questions remain unresolved. The influence of hypoxia on the regulation of immune checkpoint receptors (PD-1 and CTLA-4) and their respective ligands (PD-L1, PD-L2, CD80, and CD86) on MDSCs remains largely obscure. Furthermore, the potential contribution of these immune checkpoint receptors and their respective ligands on MDSC function under hypoxia is still unknown. In the present study, we showed that hypoxia via hypoxia-inducible factor-1α (HIF-1α) selectively up-regulated PD-L1 on MDSCs, but not other B7 family members, by binding directly to the HRE in the PD-L1 proximal promoter. Blockade of PD-L1 under hypoxia abrogated MDSC-mediated T cell suppression by modulating MDSCs cytokine production. RESULTS AND DISCUSSION Differential expression of PD-L1 on tumor-infiltrating MDSCs versus splenic MDSCs and selective up-regulation of PD-L1 in splenic MDSCs under hypoxic stress We first compared the level of expression of PD-L1 and PD-L2 between splenic MDSCs and tumor-infiltrating MDSCs from tumor-bearing mice. We found that the percentage of PD-L1+ cells was significantly higher on tumor-infiltrating MDSCs as compared with splenic MDSC in B16-F10, LLC (Fig. 1 A), CT26, and 4T1 (Fig. 1 B) tumor models. No significant difference was found in the percentage of PD-L2+ cells in splenic MDSCs as compared with tumor-infiltrating MDSCs in four tumor models tested (Fig. 1 C). We did not observe any significant difference in the expression levels of other members of the B7 family such as CD80, CD86, PD-1, and CTLA-4 on MDSCs from spleen and tumor (unpublished data). Youn et al. (2008) previously observed no significant differences in the percentage of PD-L1+ or CD80+ cells within the splenic MDSCs from tumor-bearing mice and immature myeloid cells from naive tumor-free mice. However, by comparing the expression of immune checkpoint inhibitors between splenic and tumor-infiltrating MDSCs, we showed that there is a differential expression of PD-L1 on tumor-infiltrating MDSCs. Figure 1. Tumor-infiltrating MDSCs differentially express PD-L1 as compared with splenic MDSCs, and hypoxia selectively up-regulates PD-L1 on splenic MDSCs in tumor-bearing mice. Surface expression level of PD-L1 and PD-L2 on Gr1+ CD11b+ cells (MDSCs) from (B16-F10 and LLC; A; CT26 and 4T1; B) in spleens (black dotted line histogram) and tumor (black line histogram) as compared with isotype control (gray-shaded histogram) was analyzed by flow cytometry. (C) Statistically significant differences (indicated by asterisks) between tumor-infiltrating MDSCs and splenic MDSCs are shown (*, P 20 fold for HRE-4), comparable to their binding to an established HRE in VEGF, LDHA, and Glut1 genes. To determine whether this HIF-1α site (HRE-4) was a transcriptionally active HRE, MSC-1 cells were co-transfected with pGL4-hRluc/SV40 vector and pGL3 EV, pGL3 HRE-4, or pGL3 HRE-4 MUT vectors (Fig. 3 M) and grown under normoxia or hypoxia. After 48 h, firefly and renilla luciferase activities were measured. As shown in Fig. 3 N, hypoxia significantly increased the luciferase activity of HRE-4 reporter by more than threefold as compared with normoxia. More interestingly, the luciferase activity of HRE-4 MUT was significantly decreased (>50%) as compared with HRE-4 under hypoxia (Fig. 3 N). The results presented in Figs. 3 (H–N) demonstrate that PD-L1 is a direct HIF-1α target gene in MSC-1 cells. Thus, we provide evidence here that HIF-1α is a major regulator of PD-L1 mRNA and protein expression, and that HIF-1α regulates the expression of PD-L1 by binding directly to the HRE-4 in the PD-L1 proximal promoter. Blocking PD-L1 decreases MDSC-mediated T cell suppression under hypoxia by down-regulating MDSC IL-6 and IL-10 To directly test the functional consequences of hypoxia-induced up-regulation of PD-L1 in MDSC-mediated T cell suppression, the expression of PD-L1 was blocked on ex vivo MDSCs by using anti–PD-L1 monoclonal antibody. Hypoxia increased the ability of MDSCs to suppress both specific and nonspecific stimuli-mediated T cell proliferation (Fig. 4, A and B). Interestingly, blockade of PD-L1 under hypoxia significantly abrogated the suppressive activity of MDSCs in response to both nonspecific stimuli (anti-CD3/CD28 antibody; Fig. 4 A) and specific stimuli (TRP-2(180–88) peptide; Fig. 4 B). Under hypoxia, MDSCs acquired the ability to inhibit T cell function (Fig. 4, C and D) by decreasing the percentage of IFN-γ+ CD8+ and CD4+ T cells; whereas the percentage of IFN-γ+ CD8+ (Fig. 4 C) and IFN-γ+ CD4+ T cells (Fig. 4 D) significantly increased after PD-L1 blockade under hypoxic conditions. Thus, the immune suppressive function of MDSCs enhanced under hypoxia was abrogated after blocking PD-L1, and hypoxic up-regulation of PD-L1 on MDSCs is involved in mediating the suppressive action of MDSCs, at least in part, as we were not able to completely restore T cell proliferation and function after PD-L1 blockade on MDSCs under hypoxia. Figure 4. Blockade of PD-L1 under hypoxia down-regulates MDSC IL-6 and IL-10 and enhances T cell proliferation and function. MDSCs isolated from spleens of B16-F10 tumor-bearing mice were pretreated for 30 min on ice with 5 µg/ml control antibody (IgG) or antibody against PD-L1 (PDL1 Block) and co-cultured with splenocytes under normoxia and hypoxia for 72 h. (A and B) Effect of MDSC on proliferation of splenocytes stimulated with (A) anti-CD3/CD28 coated beads or (B) TRP-2(180–88) peptide under the indicated conditions. Cell proliferation was measured in triplicates by [3H]thymidine incorporation and expressed as counts per minute (CPM). (C and D) MDSCs were cultured with splenocytes from B16-F10 mice stimulated with anti-CD3/CD28. Intracellular IFN-γ production was evaluated by flow cytometry by gating on (C) CD3+CD8+ IFN-γ+ and (D) CD3+CD4+ IFN-γ+ populations. Statistically significant differences (indicated by asterisks) are shown (**, P 95% as evaluated by FACS analysis. MDSC functional assays. For evaluation of T cell proliferation, splenocytes from B16-F10 mice were plated into U-bottom 96-well plates along with MDSCs at different ratios (50,000 MDSC:200,000 splenocytes/well). Plates were stimulated with either anti-CD3/CD28 beads (Miltenyi Biotec) or TRP-2 180–88 peptide for 72 h at 37°C. Co-cultures were pulsed with thymidine (1 µCi/well; Promega) for 16–18 h before harvesting, and [3H]thymidine uptake was counted using Packard’s TopCount NXT liquid scintillation counter and expressed as counts per minute (CPM). For assessment of T cell functions, MDSCs co-cultured with splenocytes from B16-F10 mice were stimulated with anti-CD3/CD28 beads. After 72 h, intracellular IFN-γ production was evaluated by flow cytometry by gating on CD3+CD8+ IFN-γ+ and CD3+CD4+ IFN-γ+ populations. MDSCs cytokine production (ELISA). MDSCs isolated from spleens of B16-F10 tumor-bearing mice were pretreated for 30 min on ice with 5 μg/ml control antibody (IgG) or Anti-Mouse PD-L1 (B7-H1) Functional Grade Purified antibody 5 µg/ml (clone MIH5; eBioscience; PDL1 Block) and cultured under normoxia and hypoxia for 72 h. Supernatants were collected and the secretion of IL-6, IL-10, and IL-12p70 (eBioscience) was determined by ELISA. ChIP assay. ChIP was performed with lysates prepared from MSC-1 by using SimpleChIP Enzymatic Chromatin IP kit (Cell Signaling Technology). SYBR Green RT-qPCR was performed using the primers detailed in Table S1. Arginase enzymatic activity and NO (nitric oxide) production. Arginase activity was measured in MDSC cell lysates, and for NO production, culture supernatants were mixed with Greiss reagent and nitrite concentrations were determined as described earlier (Youn et al., 2008). Luciferase reporter assay. A 653-bp section corresponding to mouse PD-L1 promoter containing HRE4 sequence was inserted into the NheI–XhoI sites of pGL3-Basic vector (Promega). Mutation of HRE4 was performed by site-directed mutagenesis and verified by sequencing. A 56-bp mouse PD-L1 gene sequence was inserted into the Bgl II site of pGL3-Promoter (Promega). MSC-1 cells were co-transfected with 0.2 µg of pGL4-hRluc/SV40 vector (which contains renilla luciferase sequences downstream of the SV40 promoter) and 1 µg of pGL3 empty vector, pGL3 HRE-4, or pGL3 HRE-4 MUT vectors in 6-well plates with Lipofectamine 2000 (Invitrogen) in OPTIMEM (Invitrogen) medium and grown under normoxia or hypoxia. After 48 h, firefly and Renilla luciferase activities were measured using the Dual-Luciferase Reporter assay (Promega) and the ratio of firefly/Renilla luciferase was determined. Statistics. Data were analyzed with GraphPad Prism. Student’s t test was used for single comparisons. Online supplemental material. Table S1 shows genomic oligonucleotide primers used for amplification of immunoprecipitated DNA samples from ChIP assays. Online supplemental material is available at http://www.jem.org/cgi/content/full/jem.20131916/DC1. Supplementary Material Supplemental Material
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              Predictive correlates of response to the anti-PD-L1 antibody MPDL3280A in cancer patients.

              The development of human cancer is a multistep process characterized by the accumulation of genetic and epigenetic alterations that drive or reflect tumour progression. These changes distinguish cancer cells from their normal counterparts, allowing tumours to be recognized as foreign by the immune system. However, tumours are rarely rejected spontaneously, reflecting their ability to maintain an immunosuppressive microenvironment. Programmed death-ligand 1 (PD-L1; also called B7-H1 or CD274), which is expressed on many cancer and immune cells, plays an important part in blocking the 'cancer immunity cycle' by binding programmed death-1 (PD-1) and B7.1 (CD80), both of which are negative regulators of T-lymphocyte activation. Binding of PD-L1 to its receptors suppresses T-cell migration, proliferation and secretion of cytotoxic mediators, and restricts tumour cell killing. The PD-L1-PD-1 axis protects the host from overactive T-effector cells not only in cancer but also during microbial infections. Blocking PD-L1 should therefore enhance anticancer immunity, but little is known about predictive factors of efficacy. This study was designed to evaluate the safety, activity and biomarkers of PD-L1 inhibition using the engineered humanized antibody MPDL3280A. Here we show that across multiple cancer types, responses (as evaluated by Response Evaluation Criteria in Solid Tumours, version 1.1) were observed in patients with tumours expressing high levels of PD-L1, especially when PD-L1 was expressed by tumour-infiltrating immune cells. Furthermore, responses were associated with T-helper type 1 (TH1) gene expression, CTLA4 expression and the absence of fractalkine (CX3CL1) in baseline tumour specimens. Together, these data suggest that MPDL3280A is most effective in patients in which pre-existing immunity is suppressed by PD-L1, and is re-invigorated on antibody treatment.

                Author and article information

                J Immunother Cancer
                J Immunother Cancer
                Journal for Immunotherapy of Cancer
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                19 January 2021
                : 9
                : 1
                [1 ]departmentDepartment of Medicine , Washington University School of Medicine in Saint Louis , Saint Louis, Missouri, USA
                [2 ]Siteman Cancer Center , St. Louis, Mo, USA
                Author notes
                [Correspondence to ] Dr David G DeNardo; ddenardo@ 123456wustl.edu
                © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See https://creativecommons.org/licenses/by/4.0/.

                Funded by: FundRef http://dx.doi.org/10.13039/100000054, National Cancer Institute;
                Award ID: CA177670
                Award ID: CA203890
                Award ID: CA244938
                Award ID: CA248917
                Award ID: F30CA254087
                Award ID: P50CA196510
                Funded by: BJC Cancer Frontier Fund;
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