Surgical ablation or broad radiation of tumor-draining lymph nodes can eliminate the primary tumor response to immunotherapy, highlighting the crucial role of these nodes in mediating the primary tumor response. Here, we show that immunoradiotherapy efficacy is dependent on treatment sequence and migration of modulated dendritic cells from tumor to sentinel lymph nodes. Using a tamoxifen-inducible reporter paired with CITE-sequencing in a murine model of oral cancer, we comprehensively characterize tumor immune cellular migration through lymphatic channels to sentinel lymph nodes at single-cell resolution, revealing a unique immunologic niche defined by distinct cellular phenotypic and transcriptional profiles. Through a structured approach of sequential immunomodulatory radiotherapy and checkpoint inhibition, we show that sequenced, lymphatic-sparing, tumor-directed radiotherapy followed by PD-1 inhibition achieves complete and durable tumor responses. Mechanistically, this treatment approach enhances migration of activated CCR7+ dendritic cell surveillance across the tumor-sentinel lymph node axis, revealing a shift from their canonical role in promoting tolerance to driving antitumor immunity. Overall, this work supports rationally sequencing immune-sensitizing, lymphatic-preserving, tumor-directed radiotherapy followed by immune checkpoint inhibition to optimize tumor response to immunoradiotherapy by driving activated dendritic cells to draining sentinel lymph nodes.

Background: Neuroblastoma (NB) is considered an immunologically cold tumor and is usually less responsive to immune checkpoint blockade (ICB). Tumor-associated macrophages (TAMs) are highly infiltrated in NB tumors and promote immune escape and resistance to ICB. Hence therapeutic strategies targeting immunosuppressive TAMs can improve responses to ICB in NB. We recently discovered that spleen tyrosine kinase (Syk) reprograms TAMs toward an immunostimulatory phenotype and enhances T-cell responses in the lung adenocarcinoma model. Here we investigated if Syk is an immune-oncology target in NB and tested whether a novel immunotherapeutic approach utilizing Syk inhibitor together with radiation and ICB could provide a durable anti-tumor immune response in an MYCN amplified murine model of NB.Methods: Myeloid Syk KO mice and syngeneic MYCN-amplified cell lines were used to elucidate the effect of myeloid Syk on the NB tumor microenvironment (TME). In addition, the effect of Syk inhibitor, R788, on anti-tumor immunity alone or in combination with anti-PDL1 mAb and radiation was also determined in murine NB models. The underlying mechanism of action of this novel therapeutic combination was also investigated.Results: Herein, we report that Syk is a marker of NB-associated macrophages and plays a crucial role in promoting immunosuppression in the NB TME. We found that the blockade of Syk in NB-bearing mice markedly impairs tumor growth. This effect is facilitated by macrophages that become immunogenic in the absence of Syk, skewing the suppressive TME towards immunostimulation and activating anti-tumor immune responses. Moreover, combining FDA-approved Syk inhibitor, R788 (fostamatinib) along with anti-PDL1 mAb provides a synergistic effect leading to complete tumor regression and durable anti-tumor immunity in mice bearing small tumors (50 mm³) but not larger tumors (250 mm³). However, combining radiation to R788 and anti-PDL1 mAb prolongs the survival of mice bearing large NB9464 tumors.Conclusion: Collectively, our findings demonstrate the central role of macrophage Syk in NB progression and demonstrate that Syk blockade can “reeducate” TAMs towards immunostimulatory phenotype, leading to enhanced T cell responses. These findings further support the clinical evaluation of fostamatinib alone or with radiation and ICB, as a novel therapeutic intervention in neuroblastoma.

Human papillomavirus (HPV)–associated head and neck squamous cell carcinoma (HPV+ HNSCC) is one of the most rapidly increasing cancers in the United States. Although patients with HPV+ HNSCC exhibit better responses to chemoradiation compared with patients with HPV− HNSCC, a subset still develops recurrent/refractory disease. In this study, we investigated the role and mechanisms by which the HPV E5 oncogene promotes resistance to conventional chemotherapy and radiation. After treatment with chemotherapy and radiation, HNSCC cells expressing HPV E5 had decreased apoptosis, improved cell viability, enhanced DNA damage response, and increased tumor growth in murine xenograft models when compared with empty vector controls. Transcriptomic analysis showed an enrichment of signaling pathways associated with epithelial development and increased expression of stem cell markers, including SOX9 and SOX4, in HPV E5 cells compared with empty vector cells. Knockdown of SOX9 restored sensitivity to chemo- and/or radiotherapy in HPV E5–expressing cells. In patients with HNSCC, RNA sequencing analysis showed that high expression of HPV E5 was associated with enrichment of pathways involved in cellular senescence and stem cell pluripotency. Furthermore, an HPV E5–associated gene set was identified that correlates with poor patient prognosis and is significantly overexpressed in recurrent HPV+ HNSCC tumors. Taken together, these data identify HPV E5 as a viral mediator of resistance to standard-of-care therapies for HPV+ HNSCC by promoting a stem cell–like phenotype that enhances DNA damage responses and tumor cell survival. Thus, HPV E5 may contribute to chemotherapy resistance, tumor recurrence after radiation, and poor prognosis of patients with refractory or metastatic disease. Significance: HPV E5 upregulates SOX9 to induce stem cell-like characteristics in head and neck cancer that drive resistance to chemotherapy and radiation, providing rationale for developing therapeutic agents targeting HPV E5.

Head and neck squamous cell carcinoma (HNSCC) is a significant cause of morbidity and mortality worldwide, with limited treatment options for patients with locally advanced disease. CD47 immune checkpoint inhibitors have been used to block the CD47/SIRPa interaction that inhibits antigen-presenting cell phagocytosis, thereby enhancing antigen presentation to cytotoxic T-cells, and have shown promise in combination with anti-PD1 immunotherapy in tumors, including recurrent/metastatic HNSCC. We found that CD47 expression is associated with poor prognosis in HNSCC and explored the anti-tumor activity of an anti-CD47 fusion protein in combination with anti-PD1 and lymphatic-sparing radiotherapy in a locally advanced HNSCC model. In the 4MOSC1 syngeneic HPV-negative HNSCC mouse model, ALX301 (an engineered CD47-blocking SIRPα fusion for murine models) induced complete tumor regression when combined with anti–PD-1, and produced a partial tumor response as a monotherapy. An anti-PD1 immune checkpoint inhibitor in a CD47-null tumor background led to complete tumor regression confirming a key role for CD47 in tumor immunity. ALX301 treated mice demonstrated increased MHC-II expression on dendritic cells within the tumor and upregulation of CD86 co-stimulatory molecule on dendritic cells within the tumor, sentinel lymph nodes, and contralateral lymph nodes. Combination ALX301 and anti-PD1 treatment in an anti-PD1 resistant 4MOSC2 model demonstrated significant tumor regression, enhanced survivability, improved response with neoadjuvant radiotherapy, and greater retention of CD8 + T-cells within the tumor microenvironment. Notably, T-cell receptor sequencing revealed increased shared clonality between the tumor and sentinel lymph nodes of ALX301 treated mice. These data demonstrate that a combination of CD47 blockade and anti-PD1 therapy enhances tumor antigen presentation and immune cell infiltration, while further improving anti-tumor responses in combination with tumor-targeted radiotherapy. This study provides support for the rational design of combinatorial immunoradiotherapy, using anti-CD47 inhibitors and anti-PD1 therapy, in a clinical trial targeting locally advanced HPV-negative HNSCC.

Human papillomavirus-associated head and neck squamous cell carcinoma (HPV+ HNSCC) is one of the fastest-rising cancers in the US. While HPV+ HNSCC patients exhibit better responses to chemoradiation compared to HPV- HNSCC patients, a subset of HPV+ patients do not respond as well and develop recurrent/refractory disease. In this study, we investigated the potential role of HPV E5 in promoting resistance to conventional chemo- and radiotherapy, and the underlying molecular mechanisms. HPV E5 is a small hydrophobic viral oncoprotein with multiple functions including regulation of tumor cell differentiation and apoptosis, modulation of H+ ATPase responsible for acidification of late endosomes, and immune modulation. To test the impact of HPV E5 on therapeutic resistance, we generated HNSCC cell lines and normal keratinocytes expressing HPV16 E5. Upon treatment with radiation (2Gy, 4Gy, 8Gy) and/or cisplatin, HNSCC cells and keratinocytes expressing HPV 16 E5 had increased cell viability, decreased apoptosis, and increased colony-forming capacity compared to empty vector (EV) control lines. Specifically, treatment with 4Gy radiation, 4µM cisplatin, or the combination led to a ~2-fold decrease in % of apoptotic cells in HPV16 E5-expressing HNSCC cells compared to EV and HPV16 E6/E7 HNSCC cells (p <0.05). Examination of DNA damage response and repair pathways indicated that while HPV16 E5 HNSCC cells initially had increased phosphorylation of H2AX 6 hours post treatment, at 24 hours post treatment H2AX phosphorylation in HPV16 E5 cells was significantly decreased compared to EV or HPV16 E6/E7 HNSCC cells. These findings indicate increased DNA repair capacity of HPV16 E5 HNSCC cells. To identify mechanisms underlying this phenotype, we performed RNA-seq and observed enhanced signaling pathways associated with epithelial development and increased expression of stem cell markers in HPV16 E5 HNSCC cells compared to EV control lines. Functionally, we observed a ~2.5-fold increase in sphere-forming capacity and increased expression of markers associated with stem cell phenotype in HPV16 E5 HNSCC cells compared to EV and HPV E6/E7 HNSCC cells. To determine whether these findings translated clinically, 18 HPV+ HNSCC patients from the GSE74927 dataset were grouped according to median expression level of HPV E5 (High vs Low). In support of our hypothesis, HPV E5-High patients exhibited enrichment of pathways associated with extrinsic apoptotic signaling, pluripotency of stem cells, and positive regulation of DNA repair. Taken together these results identify HPV E5 as a potential mediator of resistance to conventional radiation and chemotherapy in HNSCC and suggest that patient tumors expressing HPV E5 may have increased DNA repair capacity and cell survival after cytotoxic therapies. Citation Format: Souvick Roy, Sayuri Miyauchi, Riley Jones, Sangwoo Kim, Andrew B. Sharabi. Resistance to conventional chemo and radiotherapy associated with increased DNA repair and stem cell-like phenotype in head and neck squamous cell carcinoma expressing HPV E5 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2875.

Background/Objectives: Non-melanoma skin cancer, which includes cutaneous squamous cell carcinoma (cSCC), ranks as the 5th most common cancer globally with high morbidity and more total deaths than melanoma despite having a lower mortality rate. While most cSCC cases can be treated with surgery, locally advanced, metastatic, and high-risk cSCC tumors are associated with a worse prognosis with higher rates of recurrence and require multimodality therapy. However, there is limited data on animal models of cutaneous squamous cell carcinoma for the use of combinatory immunotherapy and radiation. Methods: In this study, spontaneously generated tumors using DMBA/TPA were treated over three weeks with either IgG control, anti-PD1 antibody monotherapy, 8 Gy of localized radiation, or a combination of anti-PD1 and 8 Gy of radiation followed by anti-PD1 therapy. Results: We found that while anti-PD1 therapy showed a trend toward slowed tumor growth compared to controls, this difference was not statistically significant (p = 0.0775), with most mice showing continued tumor progression. Preliminary histological analysis suggested that anti-PD1 treatment increased CD8+ T cell infiltration, and the addition of radiation further enhanced CD8+ responses but added greater variability. A pathologic review revealed that irradiated tumors were associated with fibroblastic spindle-like cell morphology. Conclusions: This animal model represents a potential preclinical model for studying CSCC with limited responses to immunotherapy to understand potential mechanisms of resistance.