Tumors with DNA mismatch-repair deficiencies have high rates of somatic mutations and high initial response rates to PD-1 blockade, although most eventually progress. In mice with the Mlh1 DNA repair gene knocked out, tumors develop spontaneously. Salewski and Kuntoff et al. showed that response to PD-1 blockade was enhanced by vaccinating tumor-bearing mice with tumor lysate from an Mlh1-/- allograft. The combination regimen prolonged life, inhibited tumor growth via downregulation of the PI3K/Akt/Wnt and TGF pathways, and reduced levels of both MDSCs (intratumoral and circulating) and immune checkpoint-expressing T cells (intratumoral and splenic).

Contributed by Margot O’Toole

BACKGROUND: Mlh1-knock-out-driven mismatch-repair-deficient (dMMR) tumors can be targeted immunologically. By applying therapeutic tumor vaccination, tumor growth is delayed but escape mechanisms evolve, including upregulation of immune-checkpoint molecules (LAG-3, PD-L1). To counteract immune escape, we investigated the therapeutic activity of a combined tumor vaccine-immune-checkpoint inhibitor therapy using _-PD-L1. DESIGN: In this trial, Mlh1-knock-out mice with established gastrointestinal tumors received single or thrice injections of _-PD-L1 monoclonal antibody clone 6E11 (2.5 mg/kg bw, q2w, i.v.) either alone or in combination with the vaccine. Longitudinal flow cytometry and PET/CT imaging studies were followed by ex vivo functional immunological and gene expression assays. RESULTS: 6E11 monotherapy slightly increased median overall survival (mOS: 6.0 weeks vs. control 4.0 weeks). Increasing the number of injections (n_=_3) improved therapy outcome (mOS: 9.2 weeks) and was significantly boosted by combining 6E11 with the vaccine (mOS: 19.4 weeks vs. 10.2 weeks vaccine monotherapy). Accompanying PET/CT imaging confirmed treatment-induced tumor growth control, with the strongest inhibition in the combination group. Three mice (30%) achieved a complete remission and showed long-term survival. Decreased levels of circulating splenic and intratumoral myeloid-derived suppressor cells (MDSC) and decreased numbers of immune-checkpoint-expressing splenic T cells (LAG-3, CTLA-4) accompanied therapeutic effects. Gene expression and protein analysis of residual tumors revealed downregulation of PI3K/Akt/Wnt-and TGF-signaling, leading to T cell infiltration, reduced numbers of macrophages, neutrophils and MDSC. CONCLUSIONS: By successful uncoupling of the PD-1/PD-L1 axis, we provide further evidence for the safe and successful application of immunotherapies to combat dMMR-driven malignancies that warrants further investigation.

Author Info: (1) Department of Medicine Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany. (2) Departmen

Author Info: (1) Department of Medicine Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany. (2) Department of Medicine Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany. (3) Department of Internal Medicine B, Cardiology, University Medicine Greifswald, Greifswald, Germany. DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany. (4) Department of Internal Medicine B, Cardiology, University Medicine Greifswald, Greifswald, Germany. DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany. (5) Department of Internal Medicine B, Cardiology, University Medicine Greifswald, Greifswald, Germany. DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald, Greifswald, Germany. (6) Department of Medicine Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany. (7) Department of Medicine Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany. (8) Department of Medicine Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany. claudia.maletzki@med.uni-rostock.de.