Impact of the gut microbiota on the anti-tumoral efficacy of chemotherapy by cyclophosphamide

Plus de 50 ans après son approbation par les agences réglementaires, le cyclophosphamide (CTX) reste une drogue aux propriétés variées et aux effets pléiotropiques couramment utilisée en clinique. Cet agent cytotoxique, administré en cancérologie, possède des propriétés immuno-modulatrices et stimule les réponses immunitaires anti-tumorales. A doses métronomiques, le CTX induit notamment une polarisation des splénocytes CD4+ vers un profil Th1 et Th17, caractérisés par la sécrétion d’IFNet d’IL-17, nécessaire à l’activité tumoricide du CTX. Comme tout agent cytotoxique, le CTX cible les cellules en prolifération, qu’elles soient normales ou cancéreuses. Le CTX compromet ainsi l’intégrité de la barrière intestinale et l’homéostasie du tractus digestif. Nous avons démontré que l’individu sous CTX a une fragilisation de la barrière intestinale qui permet la rupture de la tolérance de celui-ci à sa flore commensale et son immunisation contre certaines espèces bactériennes. L’immunisation anti-bactérienne est composée de lymphocytes effecteurs CD4+, appelés « Th17 pathogéniques » et producteurs d’IL-17 et d’IFN, qui aident les lymphocytes anti-tumoraux à endiguer la croissance de tumeurs chez la souris. Nous avons mis en évidence que la stérilisation des animaux avec des antibiotiques à large spectre ou ciblant certaines populations bactériennes comme la vancomycine (ciblant les Gram+) et la colistine (ciblant les Gram-), abrogent l’efficacité anti-tumorale du CTX. Par ailleurs, nous avons identifié deux bactéries, une bactérie Gram+ Enterococcus hirae, capable de restaurer l’efficacité de cette chimiothérapie en induisant la polarisation de réponses Th1 et pTh17 stimulant la mise en place de réponses lymphocytaires T CD4 et T CD8 dirigées contre des antigènes tumoraux et une bactérie Gram- Barnesiella intestinihominis, impliquée dans la mise en place de réponses mémoires induites par la combinaison CTX+vaccin. Ces travaux démontrent ainsi l’importance de la flore intestinale dans la réponse à la chimiothérapie par CTX.More than 50 years after its approval by the Food and Drug Administration, cyclophosphamide (CTX) remains a drug with miscellaneous properties currently used in anti-cancer chemotherapy. This cytotoxic agent has immuno-modulatory properties and stimulate anti-tumoral immune responses. At metronomic doses, CTX induces the polarisation of splenocytes toward a Th1 and Th17 profile, characterized by the secretion of IFN et IL-17, both mandatory for the tumoricidal activity of this drug. CTX, as cytotoxic agent, targets proliferating cells, either normal or tumoral. Indeed, CTX is responsible for disrupting the gut barrier integrity as well as intestinal homeostasis. We have shown that people treated with CTX have a weaker intestinal barrier which breaks the tolerance toward the intestinal microbiota and leads to its immunization against some bacterial strains. This immunization is composed of CD4+ effector lymphocytes called « pathogenic Th17 » producing IFN and IL-17, which helps tumor-infiltrating lymphocytes to control the tumor growth in mice. Broad spectrum antibiotics as well as vancomycin (which mainly kills Gram positive bacteria) and colistin (which mainly eliminates Gram negative bacteria) all compromised the full-blown anticancer activity of CTX in vivo. Moreover, we have identified two bacteria, Enterococcus hirae and Barnesiella intestinihominis, able to rescue the efficacy of CTX abolished with antibiotics. E. hirae, a Gram+ bacterium, elicits Th1 immune responses and pathogenic Th17 cells capable of enhancing tumor-specific CD4+ and CD8+ T cell responses against candidate tumor antigens associated with tumor control. B. intestinihominis, a Gram- bacterium, was able to rescue the long term cognate responses lost with broad spectrum antibiotics or colistin treatment. Our data underscore the role of the gut microbiota in the efficacy of chemotherapy by CTX

Mouse models in oncoimmunology

Fundamental cancer research and the development of efficacious antineoplastic treatments both rely on experimental systems in which the relationship between malignant cells and immune cells can be studied. Mouse models of transplantable, carcinogen-induced or genetically engineered malignancies — each with their specific advantages and difficulties — have laid the foundations of oncoimmunology. These models have guided the immunosurveillance theory that postulates that evasion from immune control is an essential feature of cancer, the concept that the long-term effects of conventional cancer treatments mostly rely on the reinstatement of anticancer immune responses and the preclinical development of immunotherapies, including currently approved immune checkpoint blockers. Specific aspects of pharmacological development, as well as attempts to personalize cancer treatments using patient-derived xenografts, require the development of mouse models in which murine genes and cells are replaced with their human equivalents. Such 'humanized' mouse models are being progressively refined to characterize the leukocyte subpopulations that belong to the innate and acquired arms of the immune system as they infiltrate human cancers that are subjected to experimental therapies. We surmise that the ever-advancing refinement of murine preclinical models will accelerate the pace of therapeutic optimization in patients

Why should we need the gut microbiota to respond to cancer therapies?

Cyclophosphamide, one of the most efficient tumoricidal, antiangiogenic, and immunostimulatory drugs employed to date mediates part of its effects through intestinal bacteria, against which the host becomes immunized during treatment. Our recent work suggests that anti-commensal effector pT(H)17 and memory T(H)1 CD4(+) T-cell responses are indispensable for optimal anticancer effects as mediated by cyclophosphamide

Resistance mechanisms to immune-checkpoint blockade in cancer: tumor-intrinsic and -extrinsic factors

International audienceInhibition of immune regulatory checkpoints, such as CTLA-4 and the PD-1-PD-L1 axis, is at the forefront of immunotherapy for cancers of various histological types. However, such immunotherapies fail to control neoplasia in a significant proportion of patients. Here, we review how a range of cancer-cell-autonomous cues, tumor-microenvironmental factors, and host-related influences might account for the heterogeneous responses and failures often encountered during therapies using immune-checkpoint blockade. Furthermore, we describe the emerging evidence of how the strong interrelationship between the immune system and the host microbiota can determine responses to cancer therapies, and we introduce a concept by which prior or concomitant modulation of the gut microbiome could optimize therapeutic outcomes upon immune-checkpoint blockade

Gut Bacteria Composition Drives Primary Resistance to Cancer Immunotherapy in Renal Cell Carcinoma Patients

International audienceBackground: The development of immune checkpoint blockade (ICB) has revolutionized the clinical outcome of renal cell carcinoma (RCC). Nevertheless, improvement of durability and prediction of responses remain unmet medical needs. While it has been recognized that antibiotics (ATBs) decrease the clinical activity of ICB across various malignancies, little is known about the direct impact of distinct intestinal nonpathogenic bacteria (commensals) on therapeutic outcomes of ICB in RCC.Objective: To evaluate the predictive value of stool bacteria composition for ICB efficacy in a cohort of advanced RCC patients.Design, setting, and participants: We prospectively collected fecal samples from 69 advanced RCC patients treated with nivolumab and enrolled in the GETUG-AFU 26 NIVO-REN microbiota translational substudy phase 2 trial (NCT03013335) at Gustave Roussy. We recorded patient characteristics including ATB use, prior systemic therapies, and response criteria. We analyzed 2994 samples of feces from healthy volunteers (HVs). In parallel, preclinical studies performed in RCC-bearing mice that received fecal transplant (FMT) from RCC patients resistant to ICB (NR-FMT) allowed us to draw a cause-effect relationship between gut bacteria composition and clinical outcomes for ICB. The influence of tyrosine kinase inhibitors (TKIs) taken before starting nivolumab on the microbiota composition has also been assessed.Outcome measurements and statistical analysis: Metagenomic data (MG) from whole genome sequencing (WGS) were analyzed by multivariate and pairwise comparisons/ fold ratio to identify bacterial fingerprints related to ATB or prior TKI exposure and patients' therapeutic response (overall response and progression-free survival), and compared with the data from cancer-free donors.Results and limitations: Recent ATB use (n = 11; 16%) reduced objective response rates (from 28% to 9%, p < 0.03) and markedly affected the composition of the microbiota, facilitating the dominance of distinct species such as Clostridium hathewayi, which were also preferentially over-represented in stools from RCC patients compared with HVs. Importantly, TKIs taken prior to nivolumab had implications in shifting the microbiota composition. To establish a cause-effect relationship between gut bacteria composition and ICB efficacy, NR-FMT mice were successfully compensated with either FMT from responding RCC patients or beneficial commensals identified by WGS-MG (Akkermansia muciniphila and Bacteroides salyersiae).Conclusions: The composition of the microbiota is influenced by TKIs and ATBs, and impacts the success of immunotherapy. Future studies will help sharpen the role of these specific bacteria and their potential as new biomarkers.Patient summary: We used quantitative shotgun DNA sequencing of fecal microbes as well as preclinical models of fecal or bacterial transfer to study the association between stool composition and (pre)clinical outcome to immune checkpoint blockade. Novel insights into the pathophysiological relevance of intestinal dysbiosis in the prognosis of kidney cancer may lead to innovative therapeutic solutions, such as supplementation with probiotics to prevent primary resistance to therapy. (c) 2020 Published by Elsevier B.V. on behalf of European Association of Urology

The intestinal microbiota modulates the anticancer immune effects of cyclophosphamide

Cyclophosphamide is one of several clinically important cancer drugs whose therapeutic efficacy is due in part to their ability to stimulate antitumor immune responses. Studying mouse models, we demonstrate that cyclophosphamide alters the composition of microbiota in the small intestine and induces the translocation of selected species of Gram-positive bacteria into secondary lymphoid organs. There, these bacteria stimulate the generation of a specific subset of "pathogenic" T helper 17 (pT(H)17) cells and memory T(H)1 immune responses. Tumor-bearing mice that were germ-free or that had been treated with antibiotics to kill Gram-positive bacteria showed a reduction in pT(H)17 responses, and their tumors were resistant to cyclophosphamide. Adoptive transfer of pT(H)17 cells partially restored the antitumor efficacy of cyclophosphamide. These results suggest that the gut microbiota help shape the anticancer immune response

Cross-reactivity between tumor MHC class I-restricted antigens and an enterococcal bacteriophage

International audienceIntestinal microbiota have been proposed to induce commensal-specific memory T cells that cross-react with tumor-associated antigens. We identified major histocompatibility complex (MHC) class I-binding epitopes in the tail length tape measure protein (TMP) of a prophage found in the genome of the bacteriophage Enterococcus hirae Mice bearing E. hirae harboring this prophage mounted a TMP-specific H-2Kb-restricted CD8+ T lymphocyte response upon immunotherapy with cyclophosphamide or anti-PD-1 antibodies. Administration of bacterial strains engineered to express the TMP epitope improved immunotherapy in mice. In renal and lung cancer patients, the presence of the enterococcal prophage in stools and expression of a TMP-cross-reactive antigen by tumors correlated with long-term benefit of PD-1 blockade therapy. In melanoma patients, T cell clones recognizing naturally processed cancer antigens that are cross-reactive with microbial peptides were detected

Anticancer immunotherapy by CTLA-4 blockade relies on the gut microbiota

International audienceAntibodies targeting CTLA-4 have been successfully used as cancer immunotherapy. We find that the antitumor effects of CTLA-4 blockade depend on distinct Bacteroides species. In mice and patients, Tcell responses specific for B. thetaiotaomicron or B. fragilis were associated with the efficacy of CTLA-4 blockade. Tumors in antibiotic-treated or germ-free mice did not respond to CTLA blockade. This defect was overcome by gavage with B. fragilis, by immunization with B. fragilis polysaccharides, or by adoptive transfer of B. fragilis-specific T cells. Fecal microbial transplantation from humans to mice confirmed that treatment of melanoma patients with antibodies against CTLA-4 favored the outgrowth of B. fragilis with anticancer properties. This study reveals a key role for Bacteroidales in the immunostimulatory effects of CTLA-4 blockade

Escherichia coli–Specific CXCL13-Producing TFH Are Associated with Clinical Efficacy of Neoadjuvant PD-1 Blockade against Muscle- Invasive Bladder Cancer

International audienceBiomarkers guiding the neoadjuvant use of immune-checkpoint blockers (ICB) are needed for patients with localized muscle-invasive bladder cancers (MIBC). Pro-filing tumor and blood samples, we found that follicular helper CD4+T cells (TFH) are among the best therapeutic targets of pembrolizumab correlating with progression-free survival. TFH were associated with tumoral CD8 and PD-L1 expression at baseline and the induction of tertiary lymphoid structures after pembrolizumab. Blood central memory TFH accumulated in tumors where they produce CXCL13, a chemokine found in the plasma of responders only. IgG4+CD38+TFH residing in bladder tissues cor-related with clinical benefit. Finally, TFH and IgG directed against urothelium-invasive Escherichia coli dictated clinical responses to pembrolizumab in three independent cohorts. The links between tumor infection and success of ICB immunomodulation should be prospectively assessed at a larger scale. SIGNIFICANCE: In patients with bladder cancer treated with neoadjuvant pembrolizumab, E. coli– specific CXCL13 producing TFH and IgG constitute biomarkers that predict clinical benefit. Beyond its role as a biomarker, such immune responses against E. coli might be harnessed for future therapeutic strategies

Escherichia coli –Specific CXCL13-Producing TFH Are Associated with Clinical Efficacy of Neoadjuvant PD-1 Blockade against Muscle-Invasive Bladder Cancer

International audienceAbstract Biomarkers guiding the neoadjuvant use of immune-checkpoint blockers (ICB) are needed for patients with localized muscle-invasive bladder cancers (MIBC). Profiling tumor and blood samples, we found that follicular helper CD4+ T cells (TFH) are among the best therapeutic targets of pembrolizumab correlating with progression-free survival. TFH were associated with tumoral CD8 and PD-L1 expression at baseline and the induction of tertiary lymphoid structures after pembrolizumab. Blood central memory TFH accumulated in tumors where they produce CXCL13, a chemokine found in the plasma of responders only. IgG4+CD38+ TFH residing in bladder tissues correlated with clinical benefit. Finally, TFH and IgG directed against urothelium-invasive Escherichia coli dictated clinical responses to pembrolizumab in three independent cohorts. The links between tumor infection and success of ICB immunomodulation should be prospectively assessed at a larger scale. Significance: In patients with bladder cancer treated with neoadjuvant pembrolizumab, E. coli–specific CXCL13 producing TFH and IgG constitute biomarkers that predict clinical benefit. Beyond its role as a biomarker, such immune responses against E. coli might be harnessed for future therapeutic strategies. This article is highlighted in the In This Issue feature, p. 222