Concomitant or delayed anti-TNF differentially impact on immune-related adverse events and antitumor efficacy after anti-CD40 therapy

Abstract

BackgroundConcomitant tumor necrosis factor (TNF) neutralization in combination with immune checkpoint inhibitors (ICIs) reduces clinical immune-related adverse events (irAEs) and appears to improve antitumor efficacy in preclinical tumor models. Agonistic antibodies targeting costimulatory receptors such as CD40 represent an additional strategy to boost antitumor immune response and potentiate the activity of ICIs. However, the dose-limiting toxicities observed in anti-CD40-treated cancer patients have hindered its clinical development.MethodsWe previously described a mouse model to assess both antitumor activity and irAEs induced by various effective combination immunotherapies. Using the BALB/c and C57BL/6 strains of FoxP3-GFP-DTR (FoxP3DTR) mice, transient depletion of T regulatory cells (Tregs) prior to immunotherapy with additional immunomodulatory antibodies, lowered immune self-tolerance, resulting in the development of a spectrum of physical and biochemical irAEs similar to that reported clinically. In MC38 and 4T1.2 tumor models, following transient Treg depletion, we evaluated the impact of anti-CD40 on antitumor efficacy and the development of irAEs and the impact of concomitant or delayed TNF blockade on both these parameters. Physical irAEs were scored and biochemical irAEs were measured in the serum (ALT and cytokine levels). Histopathological liver and colon tissue analysis were performed to assess immune cell infiltration and tissue damage.ResultsSimilar to early clinical trials of CD40 agonists, in our tumor models we observed liver toxicities and rapid release of proinflammatory cytokines (TNF, interleukin 6, interferon-γ). In the BALB/c strain, anti-CD40 induced severe physical and biochemical irAEs. Concomitant anti-TNF treatment abrogated weight loss, liver damage and colitis, which consequently resulted in an improved clinical score. However, concomitant anti-TNF impaired antitumor response in a proportion of anti-CD40-treated C57BL/6 FoxP3DTR mice. Delaying TNF blockade in these mice reduced biochemical but not physical irAEs while preserving antitumor efficacy.ConclusionsOur results suggest concomitant rather than delayed anti-TNF is most effective in reducing biochemical and physical irAEs induced by anti-CD40, although it had the potential to negatively impact antitumor efficacy. Furthermore, our findings highlight the utility of our mouse model to assess the severity of irAEs induced by novel immunotherapeutic agents and evaluate whether their toxicity and antitumor efficacy can be uncoupled.

TNF blockade uncouples toxicity from antitumor efficacy induced with CD40 chemoimmunotherapy

“…TNF inhibitors are used in the clinical management of toxicities associated with the use of anti–CTLA-4 antibodies ( 25 , 40 ). In mouse models, they have been shown to ameliorate age-associated hyperinflammatory cytokine responses produced by systemic immune activation of macrophages ( 42 ) as well as immune-related adverse events produced by anti-CD40 in the absence of chemotherapy ( 43 ). In our studies, we observed TNF-dependent hepatotoxicity triggered by CD40 chemoimmunotherapy even in young mice and independent of macrophages.…”

Harnessing Tumor Necrosis Factor Alpha to Achieve Effective Cancer Immunotherapy

“…Results showed that although the antitumor effect on breast and colon cancer models of anti-CD40 decreased, the most suitable combination was simultaneous rather than delayed treatment with anti-TNFα administration. In this way, irAEs were prevented [ 250 ]. In the clinical setting, a recent report on patients from the Dutch Melanoma Treatment Registry showed that those treated with ipilimumab and anti-PD1 with severe irAEs had longer survival.…”

The immunotoxicity, but not anti-tumor efficacy, of anti-CD40 and anti-CD137 immunotherapies is dependent on the gut microbiota

“…Depleting macrophages or neutrophils or blocking TNFa production was sufficient to prevent anti-CD40 induced liver damage, which is consistent with previous reports. 41,[53][54][55][56] Our study adds to these previous reports by demonstrating that the gut microbiota is critically required for anti-CD40-induced pathogenic immune cell infiltration/activation in the liver and for anti-CD40-induced cytokine release. While both macrophages and neutrophils were required for anti-CD40-induced liver damage, only macrophage depletion reduced anti-CD40-induced systemic TNFa release.…”