Intratumoral injection of a combination of checkpoint modulators (antibodies to CTLA-4, PD-1, 4-1BB) and the STING agonist CDG in one flank of mice implanted with bilateral pancreatic tumors demonstrated tumor rejection and curative abscopal immunity. Mice had ulceration at the injection site; lower doses of CDG reduced toxicity without reducing survival benefit.

Coordinated manipulation of independent immune regulatory pathways in the tumor microenvironment - including blockade of T-cell checkpoint receptors and reversal of suppressive myeloid programs - can render aggressive cancers susceptible to immune rejection. Elevated toxicity associated with combination immunotherapy, however, prevents translation of the most efficacious regimens. We evaluated T-cell checkpoint modulating antibodies targeting CTLA-4, PD-1, and 4-1BB together with myeloid agonists targeting either STING or Flt3 in the TRAMP-C2 model of prostate cancer to determine whether low-dose intratumoral delivery of these agents could elicit systemic control of multi-focal disease. Intratumoral administration of the STING agonist cyclic di-GMP (CDG) or Flt3 Ligand (Flt3L) augmented the therapeutic effect of systemic triple checkpoint modulation and promoted the cure of 75% of mice with bilateral TRAMP-C2; however, when all agents were administered locally, only CDG mobilized abscopal immunity. Combination efficacy correlated with globally enhanced ratios of CD8+ T cells to regulatory T cells (Treg), macrophages, and myeloid derived suppressor cells, and downregulation of the M2 marker CD206 on tumor-associated macrophages. Flt3L improved CD8+ T-cell and dendritic cell infiltration of tumors, but was diminished in efficacy by concomitant Treg expansion. Although intratumoral CDG/checkpoint therapy invokes substantial ulceration at the injection site, reduced CDG dosing can preserve tissue integrity without sacrificing therapeutic benefit. For high order combinations of T-cell checkpoint antibodies and local myeloid agonists, systemic antibody administration provides the greatest efficacy; however, local administration of CDG and antibody provides substantial systemic benefit while minimizing the potential for immune-related adverse events.

Author Info: (1) Immunology Program, University of Texas Graduate School of Biomedical Sciences at Houston. (2) Cancer Medicine, University of Texas MD Anderson Cancer Center. (3) Immunology, U

Author Info: (1) Immunology Program, University of Texas Graduate School of Biomedical Sciences at Houston. (2) Cancer Medicine, University of Texas MD Anderson Cancer Center. (3) Immunology, University of Texas MD Anderson Cancer Center. (4) Immunology, University of Texas MD Anderson Cancer Center. (5) Immunology, University of Texas MD Anderson Cancer Center. (6) Immunology Program, University of Texas Graduate School of Biomedical Sciences at Houston mcurran@mdanderson.org.