Levels of progesterone, testosterone and respective receptors in non-small cell lung cancer cells
a-b. Levels of progesterone (panel a) and testosterone (panel b), measured by ELISA (technical triplicates), in female (F)-derived NCI-H1385 and NCI-H1975 cells, and in male (M)-derived A549 and NCI-H1650 cells. Data are means+SD (n=3, biological replicates). °p<0.05: M-derived cells versus mean of F-derived cells (ANOVA). c-d. Progesterone receptor (PR; panel c) and androgen receptor (AR; panel d) mRNA, measured by RT-PCR (technical triplicates). The relative expression of each gene in NCI-H1385 cells was considered 1. Data are means + SD (n=3, biological replicates). ***p<0.001: NCI-H1975 cells versus NCI-H1385; °°p<0.01: M-derived cells versus mean of F-derived cells (ANOVA). e. Immunoblot of the indicated proteins in nuclear extracts. TBP is included as control of equal protein loading. The image is representative of one of three experiments.
Funding
Fondazione AIRC per la ricerca sul cancro ETS (AIRC)
Cassa di Risparmio di Torino
Compagnia di San Paolo (CSP)
European Cooperation in Science and Technology (COST)
ARTICLE ABSTRACT
The response to immune checkpoint inhibitors (ICI) often differs between genders in non–small cell lung cancer (NSCLC), but metanalyses results are controversial, and no clear mechanisms are defined. We aim at clarifying the molecular circuitries explaining the differential gender-related response to anti–PD-1/anti–PD-L1 agents in NSCLC.
We prospectively analyzed a cohort of patients with NSCLC treated with ICI as a first-line approach, and we identified the molecular mechanisms determining the differential efficacy of ICI in 29 NSCLC cell lines of both genders, recapitulating patients’ phenotype. We validated new immunotherapy strategies in mice bearing NSCLC patient-derived xenografts and human reconstituted immune system (“immune-PDXs”).
In patients, we found that estrogen receptor α (ERα) was a predictive factor of response to pembrolizumab, stronger than gender and PD-L1 levels, and was directly correlated with PD-L1 expression, particularly in female patients. ERα transcriptionally upregulated CD274/PD-L1 gene, more in females than in males. This axis was activated by 17-β-estradiol, autocrinely produced by intratumor aromatase, and by the EGFR-downstream effectors Akt and ERK1/2 that activated ERα. The efficacy of pembrolizumab in immune-PDXs was significantly improved by the aromatase inhibitor letrozole, which reduced PD-L1 and increased the percentage of antitumor CD8+T-lymphocytes, NK cells, and Vγ9Vδ2 T-lymphocytes, producing durable control and even tumor regression after continuous administration, with maximal benefit in 17-β-estradiol/ERα highfemale immune-xenografts.
Our work unveils that 17-β-estradiol/ERα status predicts the response to pembrolizumab in patients with NSCLC. Second, we propose aromatase inhibitors as new gender-tailored immune-adjuvants in NSCLC.See related commentary by Valencia et al., p. 3832
