Tumor-associated macrophage (TAM) phagocytic activity is emerging as a new mechanism to harness for cancer treatment. Currently, many approaches are investigated at the preclinical level and some modalities have now reached clinical trials, including the targeting of the phagocytosis inhibitor CD47. The rationale for increasing TAM phagocytic activity is to improve innate anticancer immunity, and to promote T-cell mediated adaptive immune responses. In this context, a clear understanding of the impact of TAM phagocytosis on both innate and adaptive immunity is critical. Indeed, uncertainties persist regarding the capacity of TAM to present tumor antigens to CD8 T cells by cross-presentation. This process is critical for an optimal cytotoxic T-cell immune response and can be mediated by dendritic cells but also potentially by macrophages. In addition, the engulfment of cancer cells affects TAM functionality, as apoptotic cell uptake (a process termed efferocytosis) promotes macrophage anti-inflammatory functions. Because of the abundance of TAM in most solid tumors and the common use of apoptosis inducers such as radiotherapy to treat patients with cancer, efferocytosis potentially affects the overall immune balance within the tumor microenvironment (TME). In this review, we will discuss how cancer cell phagocytosis by TAM impacts antitumor immunity. First, we will focus on the potential of the phagocytic activity of TAM per se to control tumor progression. Second, we will examine the potential of TAM to act as antigen presenting cells for tumor specific CD8 T cells, considering the different characteristics of this process in the tumor tissue and at the molecular level. Finally, we will see how phagocytosis and efferocytosis affect TAM functionality and how these mechanisms impact on antitumor immunity. A better understanding of these aspects will enable us to better predict and interpret the consequences of cancer therapies on the immune status of the TME. Future cancer treatment regimens can thereby be designed to not only impact directly on cancer cells, but also to favorably modulate TAM phagocytic activity to benefit from the potential of this central immune player to achieve more potent therapeutic efficacy.

Background: DZB is an oral small-molecule Fibroblast Growth Factor Receptor 1/2/3 inhibitor (FGFRi) with clinically relevant activity in FGFR2-fusion cholangiocarcinoma. Extensive kinase profiling identified Colony-Stimulating Factor 1 receptor (CSF1R) as an additional anti-cancer target for DZB. CSF1R plays a role in the maintenance of tumor-promoting M2-macrophages; inhibition facilitates repolarization to M1-type thus restoring tumor T cell activity. Screening of urothelial cancer (UC) models both in vitro and in vivo has provided information on potential response biomarkers additional to FGFR genetic aberrations. Methods: Kinase assays used a radiometric assay and anti-proliferative activity was assessed using crystal-violet (72h incubation). Bone-marrow derived mouse macrophages were CSF1 starved (12h), pre-incubated with DZB/BLZ945 (30/10m) and stimulated with 0.3 μM CSF1 (3m). CSF1R phosphorylation (pCSF1R) was analyzed by immunoblotting. Compound docking experiments used MOE software and public X-ray structures. DZB was tested at MTD (75 mg/kg, po, qd) in UC-CDX (8 mice/group) and -PDX (3 mice/group) models with FGFR-mutations and/or differing FGFR copy-number (CN)/RNA-seq expression levels. Efficacy and tolerability were quantified at the 3-week endpoint as a dT/C (treated/control). Results: Comparative kinase IC50s showed that DZB had 1:1 nM activity against FGFR1/2/3 and CSF1R, a potency not observed for other clinically relevant FGFRi’s. Structural analyses suggested a different size of the inhibitor binding-site of FGFR- and CSF1R-structures, with DZB efficiently occupying the smaller CSF1R kinase sub-pocket. Indeed, DZB reduced ligand-stimulated pCSF1R in mouse macrophages in a concentration-dependent manner, with a maximal effect similar to the selective CSF1R inhibitor BLZ945. Based on an in vitro anti-proliferative screen across 14 UC-lines, DZB had a mean GI50 of 1.7±0.2 μM (range 0.4-3.4 μM). The most sensitive lines were RT4 and RT112/84, both of which had FGFR3-TACC3 fusions, a known oncogenic-driver. In mice bearing s.c. RT4 tumors, DZB induced tumor-stasis (dT/C<0.1) and was well tolerated (dT/C>1.0) but no response was observed in the RT112/84 model suggesting that not only FGFR mutations contribute to DZB response. An unbiased UC-PDX screen indicated efficacy in 4/17 models (dT/C≤0.4; median=0.81) with DZB-response significantly positively-associated with high FGFR expression. The most sensitive tumor had high FGFR2 RNA-expression yet low CN. Data will be presented from confirmatory efficacy experiments and bioinformatic analyses. Conclusion: DZB is a potent FGFRi and CSF1R inhibitor. Screens in UC models indicate that DZB efficacy is driven by FGFR mutation and expression and, potentially, CSF1R modulation. A clinical trial is ongoing in UC patients (NCT04045613) to assess DZB monotherapy, and combination with the PD-L1 antibody atezolizumab. Citation Format: Paul McSheehy, Felix Bachmann, Nicole Forster-Gross, Marc Lecoultre, Mahmoud El Shemerly, Mila Roceri, Stefan Reinelt, Laurenz Kellenberger, Paul R Walker, Heidi Lane. Derazantinib (DZB): A dual FGFR/CSF1R-inhibitor active in PDX-models of urothelial cancer [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics; 2019 Oct 26-30; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2019;18(12 Suppl):Abstract nr LB-C12. doi:10.1158/1535-7163.TARG-19-LB-C12

Derazantinib (DZB) is an inhibitor of the fibroblast growth factor receptors 1–3 (FGFRi) with similar potency against colony-stimulating factor receptor-1 (CSF1R), a protein important in the recruitment and function of tumor-associated macrophages. DZB inhibited pCSF1R in the macrophage cell line RAW264.7, and tumor cells GDM-1 and DEL, and had the same potency in HeLa cells transiently over-expressing FGFR2. DZB exhibited similar potency against pCSF1R expressed by isolated murine macrophages, but as in the cell lines, specific FGFRi were without significant CSF1R activity. DZB inhibited growth of three tumor xenograft models with reported expression or amplification of CSF1R, whereas the specific FGFRi, pemigatinib, had no efficacy. In the FGFR-driven syngeneic breast tumor-model, 4T1, DZB was highly efficacious causing tumor stasis. A murine PD-L1 antibody was without efficacy in this model, but combined with DZB, increased efficacy against the primary tumor and further reduced liver, spine and lung metastases. Immunohistochemistry of primary 4T1 tumors showed that the combination favored an antitumor immune infiltrate by strongly increasing cytotoxic T, natural killer and T-helper cells. Similar modulation of the tumor microenvironment was observed in an FGFR-insensitive syngeneic bladder model, MBT-2. These data confirm CSF1R as an important oncology target for DZB and provide mechanistic insight for the ongoing clinical trials, in which DZB is combined with the PD-L1 antibody, atezolizumab.