Monocytes Improves Antiangiogenic Therapy in Colorectal Cancer
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Targeting CXCR4-dependent immunosuppressive Ly6Clow monocytes improves antiangiogenic therapy in colorectal cancer Keehoon Junga,1, Takahiro Heishia,1, Joao Incioa, Yuhui Huanga, Elizabeth Y. Beecha, Matthias Pintera, William W. Hoa,b, Kosuke Kawaguchia, Nuh N. Rahbaria, Euiheon Chunga,2, Jun Ki Kimc,3, Jeffrey W. Clarkd, Christopher G. Willette, Seok Hyun Yunc,f, Andrew D. Lusterg, Timothy P. Paderaa, Rakesh K. Jaina,4,5, and Dai Fukumuraa,4,5 aEdwin L. Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, MA 02114; bDepartment of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139; cWellman Center for Photomedicine, Department of Dermatology, Harvard Medical School and Massachusetts General Hospital, Boston, MA 02114; dDepartment of Hematology/Oncology, Harvard Medical School and Massachusetts General Hospital, Boston, MA 02114; eDepartment of Radiation Oncology, Duke University Medical Center, Durham, NC 27710; fDivision of Health Sciences and Technology, Harvard–Massachusetts Institute of Technology, Cambridge, MA 02139; and gCenter for Immunology and Inflammatory Diseases, Division of Rheumatology, Allergy and Immunology, Harvard Medical School and Massachusetts General Hospital, Boston, MA 02114 Contributed by Rakesh K. Jain, August 10, 2017 (sent for review June 19, 2017; reviewed by Timothy T. Hla and Judith A. Varner) Antiangiogenic therapy with antibodies against VEGF (bevacizumab) (CXCL12)—also known as stromal cell-derived factor-1 alpha or VEGFR2 (ramucirumab) has been proven efficacious in colorectal (SDF-1α)—in primary tumor biopsies from rectal cancer patients cancer (CRC) patients. However, the improvement in overall survival treated with the anti-VEGF antibody bevacizumab compared with is modest and only in combination with chemotherapy. Thus, there baseline in the same patients (10, 11). However, the role of is an urgent need to identify potential underlying mechanisms of CXCL12/CXCR4 signaling in the resistance to anti-VEGF CRC resistance specific to antiangiogenic therapy and develop strategies therapy is not fully understood. While the role of CXCL12/CXCR4 to overcome them. Here we found that anti-VEGFR2 therapy up- regulates both C-X-C chemokine ligand 12 (CXCL12) and C-X-C chemokine receptor 4 (CXCR4) in orthotopic murine CRC models, Significance MEDICAL SCIENCES including SL4 and CT26. Blockade of CXCR4 signaling significantly enhanced treatment efficacy of anti-VEGFR2 treatment in both CRC The survival benefit of antiangiogenic therapies for cancer models. CXCR4 was predominantly expressed in immunosuppres- patients has been limited, potentially due to intrinsic/acquired sive innate immune cells, which are recruited to CRCs upon anti- resistance. Deciphering and targeting resistance mechanisms VEGFR2 treatment. Blockade of CXCR4 abrogated the recruitment are critical to improving treatment outcome, especially in can- of these innate immune cells. Importantly, these myeloid cells were cers where antiangiogenic therapies are standard of care, such mostly Ly6Clow monocytes and not Ly6Chigh monocytes. To selectively as colorectal cancer (CRC). Consistent with our clinical findings, deplete individual innate immune cell populations, we targeted key we found up-regulation of CXCL12/CXCR4 in orthotopic CRC − − pathways in Ly6Clow monocytes (Cx3cr1 / mice), Ly6Chigh monocytes models and conditional Apc mutant spontaneous rectal tumors −/− (CCR2 mice), and neutrophils (anti-Ly6G antibody) in combination after anti-VEGFR2 treatment. CXCR4 signaling recruited im- with CXCR4 blockade in SL4 CRCs. Depletion of Ly6Clow monocytes or munosuppressive innate immune cells such as Ly6Clow mono- neutrophils improved anti-VEGFR2–induced SL4 tumor growth delay cytes and Ly6G+ neutrophils to the CRCs, conferring resistance similar to the CXCR4 blockade. In CT26 CRCs, highly resistant to anti- to VEGFR2 blockade. Furthermore, we successfully targeted VEGFR2 therapy, CXCR4 blockade enhanced anti-VEGFR2–induced tu- these pathways genetically and pharmacologically, including + mor growth delay but specific depletion of Ly6G neutrophils did not. with an FDA-approved agent Plerixafor (AMD3100), which The discovery of CXCR4-dependent recruitment of Ly6Clow monocytes significantly enhanced treatment response. These strategies in tumors unveiled a heretofore unknown mechanism of resistance to have the potential for rapid clinical translation. anti-VEGF therapies. Our findings also provide a rapidly translatable strategy to enhance the outcome of anti-VEGF cancer therapies. Author contributions: K.J., A.D.L., T.P.P., R.K.J., and D.F. designed research; K.J., T.H., J.I., Y.H., E.Y.B., M.P., W.W.H., K.K., N.N.R., E.C., and J.K.K. performed research; J.W.C. and low C.G.W. contributed new reagents/analytic tools; K.J., T.H., S.H.Y., A.D.L., T.P.P., R.K.J., and tumor microenvironment | CXCR4 | Ly6C monocyte | tumor immunity | D.F. analyzed data; and K.J., S.H.Y., T.P.P., R.K.J., and D.F. wrote the paper. antiangiogenic therapy Reviewers: T.T.H., Boston Children’s Hospital and Harvard Medical School; and J.A.V., University of California, San Diego. ntivascular endothelial growth factor (anti-VEGF) therapy Conflict of interest statement: R.K.J. received consultant fees from Merck, Ophthotech, Ais widely used in many types of solid tumors and is the current Pfizer, SPARC, SynDevRx, and XTuit; owns equity in Enlight, Ophthotech, SynDevRx, and XTuit; and serves on the Board of Directors of XTuit and the Boards of Trustees of Tekla standard of care for metastatic colorectal cancer (CRC) (1). How- Healthcare Investors, Tekla Life Sciences Investors, Tekla Healthcare Opportunities Fund, ever, the beneficial effects from anti-VEGF therapy are often short- and Tekla World Healthcare Fund. Neither any reagent nor any funding from these lived due to intrinsic resistance and/or resistance acquired during organizations was used in this study. the treatment (1–8). Therefore, it is critical to identify mechanisms Freely available online through the PNAS open access option. and/or biomarkers of resistance to target these mechanisms and/or 1K.J. and T.H. contributed equally to this work. to stratify patients by biomarkers to improve the clinical outcome. 2Present address: Department of Medical System Engineering, School of Mechatronics, We recently found that Ly6Clow monocytes infiltrate into tumors in Gwangju Institute of Science and Technology, Gwangju 500-712, Republic of Korea. 3 a C-X3-C chemokine receptor 1 (CX3CR1)-dependent manner and Present address: Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea. confer resistance to anti-VEGFR2 therapy (9). However, there is 4R.K.J., and D.F. contributed equally to this work. no clinically available agent targeting this pathway, which signifi- 5To whom correspondence may be addressed. Email: [email protected] or cantly limits the possibility of clinical translation. [email protected]. We previously reported up-regulation of C-X-C chemokine This article contains supporting information online at www.pnas.org/lookup/suppl/doi:10. receptor 4 (CXCR4) and its ligand C-X-C chemokine ligand 12 1073/pnas.1710754114/-/DCSupplemental. www.pnas.org/cgi/doi/10.1073/pnas.1710754114 PNAS | September 26, 2017 | vol. 114 | no. 39 | 10455–10460 Downloaded by guest on September 25, 2021 axis in regulation of immune cells has been investigated, including we have previously shown (9), SL4 and CT26 tumor size was ∼45% a subset of monocytes (i.e., Ly6Chigh monocytes) (12–17), whether and ∼70% of that of the control after 12 d of DC101 monotherapy CXCR4 is involved in regulation of another subset of monocytes (Fig. 1 G and H). In addition, the extent of tumor growth inhibition (i.e., Ly6Clow monocytes) is not known. by the combined therapy was similar in both SL4 and CT26 models. In this study, building on our previous clinical finding that These data indicate that the mechanism making CT26 less sensitive CXCR4 is up-regulated in rectal cancer postbevacizumab ther- to anti-VEGFR2 treatment was abolished by the blockade of apy, we targeted CXCR4 using AMD3100, an FDA approved CXCR4. These data show that targeting CXCR4 enhances the ef- agent, which resulted in significant improvement of anti-VEGFR2 ficacy of antiangiogenic therapy in both CRC models, regardless of therapy in clinically relevant orthotopic murine CRC models. their sensitivity to anti-VEGFR2 monotherapy. Mechanistically, we found that CXCR4 is critical for tumor infiltration of Ly6Clow monocytes and that blockade of Ly6Clow Blockade of CXCR4 Alleviates Anti-VEGFR2 Therapy-Induced Lymphocyte monocyte recruitment improves the efficacy of anti-VEGFR2 Reduction but Does Not Directly Affect Tumor Cell Proliferation. Next, therapy in CRCs. Thus, targeting CXCR4-mediated Ly6Clow we sought the mechanisms of how the blockade of CXCR4 en- monocyte infiltration is a potential strategy to enhance the ef- hances the antitumor effect of anti-VEGFR2 therapy. First, we ficacy of anti-VEGF treatments for CRC patients. tested whether the blockade of CXCR4 directly inhibited pro- liferation of cancer cells themselves. MTT (methyl thiazolyl tet- Results razolium) assay results showed that CXCR4 is not involved in the Antiangiogenic Therapy Increases Expression of CXCL12 and CXCR4 in regulation of colon cancer cell proliferation (Fig.