Lung cancer kills more people than any other type of cancer, including more than 130,000 people each year in the United States. Non-small cell lung cancer (NSCLC) is the most common subtype (82% of all lung cancers) and can arise from squamous or non-squamous lung epithelial cells. Combination treatment with immunotherapy (i.e., monoclonal antibodies targeted to PD-1 or PD-L1) plus concurrent chemotherapy (usually including cisplatin or carboplatin) is now part of the standard of care for many patients with NSCLC. Although in lab-based studies, chemotherapy has some effects that are expected to enhance the efficacy of immunotherapies, whether chemotherapy can also have paradoxical negative effects that diminish immunotherapy efficacy is not well understood at present. Based on our preliminary data, we propose to investigate how cisplatin, a chemotherapy commonly used to treat NSCLC, creates an immunosuppressive tumor microenvironment (TME) that limits the anti-tumor activity of anti-PD-1 immunotherapy. Specifically, we hypothesize the following steps: (a) cisplatin induces prostaglandin E2 (PGE2) production in tumor cells; (b) PGE2 leads to upregulation of CD73 enzyme on the surface of monocytic myeloid-derived suppressor cells (M-MDSCs); (c) CD73 catalyzes the production of extracellular adenosine from AMP (derived from ATP released from dying cells); and (d) adenosine inhibits the activation of effector T cells within the tumor microenvironment (TME) and thus limits the efficacy of chemo- immunotherapy. Furthermore, we propose a novel therapeutic strategy for overcoming this adenosine-mediated immunosuppression and sensitizing tumors to chemo-immunotherapy, whereby co-treatment with recombinant polyethylene glycol-conjugated adenosine deaminase enzyme (PEG-ADA) will convert immunosuppressive adenosine into immunostimulatory inosine. In Specific Aim 1 of this project, we will test our predictions about the key cellular and molecular players in this pathway, including cisplatin-induced PGE2 secretion, CD73 expression on M-MDSC, adenosine production and suppression of anti-tumoral T cell activity. We will use a variety of in vivo systems that provide a faithful representation of human NSCLC, including an orthotopic murine lung cancer model and humanized mice with patient-derived xenografts (PDX). In Specific Aim 2, we will test the effectiveness of selectively deleting CD73 in M-MDSCs or co-treating with PEG-ADA as approaches to increase the anti-tumor/immunostimulatory activities of chemo-immunotherapy (anti-PD-1 + cisplatin) in transgenic mouse models of non-squamous and squamous NSCLC. We will also examine tumor samples from NSCLC patients who have progressed on anti-PD-1/chemotherapy for correlative evidence of this novel mechanism. Completion of these aims will identify novel and actionable immunosuppressive mechanisms that mediate relapse and therapeutic resistance in metastatic NSCLC patients. Our studies will establish adding PEG-ADA (a drug that is FDA-approved for a non-cancer indication) to standard chemo-immunotherapy as a promising strategy that can be quickly translated into improved NSCLC treatment regimens.

Project Narrative Cancer therapy with a combination of cytotoxic drugs and with immune checkpoint inhibitors (ICIs)—agents that reinvigorate the suppressed immune system to attack cancer cells (e.g., anti-PD-1 antibody)—has revolutionized the treatment of metastatic lung cancer, nevertheless, therapeutic resistance is observed in a significant proportion of patients and a critical determinant of unresponsiveness in these patients is the intra- tumoral accumulation of adenosine, a molecule that actively suppresses the effectiveness of immunotherapies. To deplete the intra-tumoral adenosine, we have explored the use of an FDA approved drug, [PEGylated]- Adenosine Deaminase (PEG-ADA). Our proposed studies will confirm if depletion of adenosine with PEG-ADA can induce anti-tumor immunity and sensitize lung cancer to chemo-immunotherapy and such a therapeutic strategy can further extend the life of patient with a disease that is now a major health problem worldwide.