Activated neutrophils as effector cells for bispecific antibodies

Neutrophils as immune effector cells in antibody therapy in cancer

Tumor-targeting monoclonal antibodies are available for a number of cancer cell types (over)expressing the corresponding tumor antigens. Such antibodies can limit tumor progression by different mechanisms, including direct growth inhibition and immune-mediated mechanisms, in particular complement-dependent cytotoxicity, antibody-dependent cellular phagocytosis, and antibody-dependent cellular cytotoxicity (ADCC). ADCC can be mediated by various types of immune cells, including neutrophils, the most abundant leukocyte in circulation. Neutrophils express a number of Fc receptors, including Fcγ- and Fcα-receptors, and can therefore kill tumor cells opsonized with either IgG or IgA antibodies. In recent years, important insights have been obtained with respect to the mechanism(s) by which neutrophils engage and kill antibody-opsonized cancer cells and these findings are reviewed here. In addition, we consider a number of additional ways in which neutrophils may affect cancer progression, in particular by regulating adaptive anti-cancer immunity.

Targeting myeloid cells with bispecific antibodies as novel immunotherapies of cancer

INTRODUCTION

Most bispecific antibody (BsAb) therapies focus on stimulating the adaptive immune system, in particular T cells, to promote tumor cell killing. Another method to promote tumor eradication is through the engagement of myeloid cells, including macrophages and neutrophils, which are abundantly present and possess intrinsic cytotoxic mechanisms for tumor cell killing, making them interesting effector cells to recruit for BsAb therapy.

AREAS COVERED

In this review, we describe the evolving knowledge of the role of macrophages and neutrophils in cancer in scientific literature. Moreover, we address the BsAbs that have been developed over the years to recruit these cell types as effector cells in immunotherapy of cancer. This includes the discussion of BsAbs that target Fc receptors (i.e. FcγR and FcαRI) to induce antibody-dependent cellular phagocytosis (ADCP) by macrophages or trogoptosis via neutrophils, as well as BsAbs that interfere with checkpoint inhibition, including the SIRPα-CD47 pathway.

EXPERT OPINION

Elucidating the complexity of macrophage and neutrophil heterogeneity in cancer may help to specifically enlist the cytotoxic ability of these cells through targeting Fc receptors and checkpoint pathways, which may further enhance anti-cancer immunity.

Targeting the CD47-SIRPα Innate Immune Checkpoint to Potentiate Antibody Therapy in Cancer by Neutrophils

Simple Summary

Immunotherapy aims to engage various immune cells in the elimination of cancer cells. Neutrophils are the most abundant leukocytes in the circulation and have unique mechanisms by which they can kill cancer cells opsonized by antibodies. However, neutrophil effector functions are limited by the inhibitory receptor SIRPα, when it interacts with CD47. The CD47 protein is expressed on all cells in the body and acts as a ‘don’t eat me’ signal to prevent tissue damage. Cancer cells can express high levels of CD47 to circumvent tumor elimination. Thus, blocking the interaction between CD47 and SIRPα may enhance anti-tumor effects by neutrophils in the presence of tumor-targeting monoclonal antibodies. In this review, we discuss CD47-SIRPα as an innate immune checkpoint on neutrophils and explore the preliminary results of clinical trials using CD47-SIRPα blocking agents.

Abstract

In the past 25 years, a considerable number of therapeutic monoclonal antibodies (mAb) against a variety of tumor-associated antigens (TAA) have become available for the targeted treatment of hematologic and solid cancers. Such antibodies opsonize cancer cells and can trigger cytotoxic responses mediated by Fc-receptor expressing immune cells in the tumor microenvironment (TME). Although frequently ignored, neutrophils, which are abundantly present in the circulation and many cancers, have demonstrated to constitute bona fide effector cells for antibody-mediated tumor elimination in vivo. It has now also been established that neutrophils exert a unique mechanism of cytotoxicity towards antibody-opsonized tumor cells, known as trogoptosis, which involves Fc-receptor (FcR)-mediated trogocytosis of cancer cell plasma membrane leading to a lytic/necrotic type of cell death. However, neutrophils prominently express the myeloid inhibitory receptor SIRPα, which upon interaction with the ‘don’t eat me’ signal CD47 on cancer cells, limits cytotoxicity, forming a mechanism of resistance towards anti-cancer antibody therapeutics. In fact, tumor cells often overexpress CD47, thereby even more strongly restricting neutrophil-mediated tumor killing. Blocking the CD47-SIRPα interaction may therefore potentiate neutrophil-mediated antibody-dependent cellular cytotoxicity (ADCC) towards cancer cells, and various inhibitors of the CD47-SIRPα axis are now in clinical studies. Here, we review the role of neutrophils in antibody therapy in cancer and their regulation by the CD47-SIRPα innate immune checkpoint. Moreover, initial results of CD47-SIRPα blockade in clinical trials are discussed.

Therapeutic exploitation of neutrophils to fight cancer

Antibody-based immunotherapy is a promising strategy in cancer treatment. Antibodies can directly inhibit tumor growth, induce complement-dependent cytotoxicity and induce Fc receptor-mediated elimination of tumor cells by macrophages and natural killer cells. Until now, however, neutrophils have been largely overlooked as potential effector cells, even though they are the most abundant type of immune cells in the circulation. Neutrophils display heterogeneity, especially in the context of cancer. Therefore, their role in cancer is debated. Nevertheless, neutrophils possess natural anti-tumor properties and appropriate stimulation, i.e. specific targeting via antibody therapy, induces potent tumor cell killing, especially via targeting of the immunoglobulin A Fc receptor (FcαRI, CD89). In this review we address the mechanisms of tumor cell killing by neutrophils and the role of neutrophils in induction of anti-tumor immunity. Moreover, possibilities for therapeutic targeting are discussed.

Monoclonal antibody-mediated killing of tumour cells by neutrophils

Neutrophils represent the most abundant population of circulating cytotoxic effector cells. Moreover, their number can be easily increased by treatment with granulocyte-colony stimulating factor or granulocyte macrophage-colony stimulating factor, without the need for ex vivo expansion. Because neutrophils express Fc receptors, they have the potential to act as effector cells during monoclonal antibody therapy of cancer. Additionally, as neutrophils play a role in the regulation of adaptive immune responses, exploiting neutrophils in mAb therapy may result in long-term antitumour immunity. There is limited evidence that neutrophils play a prominent role in current immunoglobulin G-based immunotherapy. However, as IgA induces neutrophil recruitment, novel therapeutic strategies that aim to target the IgA Fc receptor FcαRI may fully unleash the potential of enlisting neutrophils as cytotoxic effector cells in antibody therapy of cancer.

The human immunoglobulin A Fc receptor FcαRI: a multifaceted regulator of mucosal immunity

Immunoglobulin A (IgA) is commonly recognized as the most prevalent antibody (Ab) at mucosal sites with an important role in defense by shielding mucosal surfaces from invasion by pathogens. However, its potential to both actively dampen excessive immune responses or to initiate potent proinflammatory cellular processes is less well known. Interestingly, either functional outcome is mediated through interaction with the myeloid IgA Fc receptor FcαRI (CD89). Monomeric interaction of IgA with FcαRI triggers inhibitory signals that block activation via other receptors, whereas multimeric FcαRI crosslinking induces phagocytosis, reactive oxygen species production, antigen presentation, Ab-dependent cellular cytotoxicity, and cytokine release. Thus, FcαRI acts as a regulator between anti- and proinflammatory responses of IgA. As such, the biology of FcαRI, and its multifaceted role in immunity will be the focus of this review.

Immunoglobulin A: A next generation of therapeutic antibodies?

Although immunoglobulin (Ig) A is commonly recognized as the most prevalent antibody subclass at mucosal sites with an important role in mucosal defense, its potential as a therapeutic monoclonal antibody is less well known. However, IgA has multifaceted anti-, non-, and pro-inflammatory functions that can be exploited for different immunotherapeutical strategies, which will be the focus of this review.

Neutrophils in antibody-based immunotherapy of cancer

Monoclonal antibodies (mAb) are presently considered key therapeutic drugs for the treatment of malignancies. They can be designed to specifically target tumour-associated antigens and initiate several effector mechanisms, which potentially leads to elimination of the tumour. Through their Fc tail mAbs interact with Fc receptors (FcR) that are expressed on immune cells. Neutrophils are the most abundant circulating FcR-expressing white blood cells with potent cytotoxic ability that is enhanced in the presence of antitumour mAbs. They furthermore play a role in regulating adaptive immunity, which may lead to the initiation of antitumour immune responses. Yet, neutrophils receive surprisingly little attention as potential effector cell population. This article reviews the scientific data that supports the possibility of exploiting neutrophils for mAb-based immunotherapy of cancer. An increasing awareness and understanding of this topic may allow for future development of new anticancer therapies.

Mechanisms of G-CSF- or GM-CSF-stimulated tumor cell killing by Fc receptor-directed bispecific antibodies

Studies with gene-modified mice have recently reinforced the importance of Fc receptor-mediated effector mechanisms for the therapeutic efficacy of rituxan and herceptin - two clinically approved antibodies for the treatment of tumor patients. We investigated Fc receptor-dependent tumor cell killing by mononuclear and granulocytic effector cells - comparing human IgG1 antibodies against CD20 or HER-2/neu with their respective FcgammaRI (CD64)-, FcgammaRIII (CD16)-, or FcalphaRI (CD89)-directed bispecific derivatives. With blood from healthy donors as effector source, human IgG1 and FcgammaRIII (CD16)-directed bispecific antibodies proved most effective in recruiting mononuclear effector cells, whereas tumor cell killing by granulocytes was most potently triggered by FcalphaRI-directed bispecific constructs. Granulocyte-mediated tumor cell lysis was significantly enhanced when blood from G-CSF- or GM-CSF-treated patients was investigated. Interestingly, however, both myeloid growth factors improved effector cell recruitment by different mechanisms, which were furthermore dependent on the tumor target antigen, and on the selected cytotoxic Fc receptor.

Specific targeting immunotherapy of cancer with bispecific antibodies

In order to enhance cell mediated cytotoxicity, bispecific antibodies (BsAbs), molecules combining two or more antibodies with different antigenic specificities, have been developed as new agents for immunotherapy. Our recent studies revealed that simultaneous administration of two kinds of BsAbs (anti-tumor x anti-CD3 plus anti-tumor x anti-CD28) together with lymphokine activated killer cells with a T cell phenotype (T-LAK cells) inhibited growth of human xenotransplanted tumors in severe combined immunodeficient (SCID) mice, while single BsAb was without effect. Three kinds of BsAbs (anti-tumor x anti-CD3, anti-tumor x anti-CD28, anti-tumor x anti-CD2) showed the highest cytotoxicity against tumor cells when given simultaneously with T-LAK cells or peripheral blood mononuclear cells in vitro and in vivo. BsAbs can be preserved for immediate application, while cytotoxic T lymphocytes (CTLs) must be made-to-order, and are time-consuming to prepare. Tumor associated antigens, such as MAGE antigens, SART antigens, MUC1 antigen, c-erbB 2 antigen or cancer/testis antigens can be served to target antigens for BsAb production. By conjugation with antibodies to effector cells (anti-CD3, anti-CD28, anti-CD16, anti-CD64, anti-CD89 or anti-CD2), many kinds of BsAbs can be produced to cover most types of cancers from different organs. Therefore this strategy might be ubiquitously applicable to most malignancies.