Full Paper

BJC Open article

British Journal of Cancer advance online publication 6 July 2017; doi: 10.1038/bjc.2017.205

Lurbinectedin reduces tumour-associated macrophages and the inflammatory tumour microenvironment in preclinical models

Cristina Belgiovine1,5, Ezia Bello2,5, Manuela Liguori3, Ilaria Craparotta2, Laura Mannarino2, Lara Paracchini2, Luca Beltrame2, Sergio Marchini2, Carlos M Galmarini4, Alberto Mantovani1,3, Roberta Frapolli2,6, Paola Allavena3,6 and Maurizio D'Incalci2,6

  1. 1Department of Biomedical Sciences, Humanitas University, Via Manzoni 113, 20089 Rozzano, Milan, Italy
  2. 2IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
  3. 3IRCCS Humanitas Clinical and Research Center, Via Manzoni 56, 20089 Rozzano, Milan, Italy
  4. 4Cell Biology and Pharmacogenomics Department, Pharmamar, Madrid, Spain

Correspondence: Dr C Belgiovine, E-mail: Cristina.belgiovine@humanitasresearch.it; Dr P Allavena, E-mail: paola.allavena@humanitasresearch.it

5These authors share first authorship.

6These authors share last authorship.

Received 15 May 2017; Revised 1 June 2017; Accepted 7 June 2017
Advance online publication 6 July 2017





Lurbinectedin is a novel anticancer agent currently undergoing late-stage (Phase II /III) clinical evaluation in platinum-resistant ovarian, BRCA1/2-mutated breast and small-cell lung cancer. Lurbinectedin is structurally related to trabectedin and it inhibits active transcription and the DNA repair machinery in tumour cells.



In this study we investigated whether lurbinectedin has the ability to modulate the inflammatory microenvironment and the viability of myeloid cells in tumour-bearing mice.



Administration of lurbinectedin significantly and selectively decreased the number of circulating monocytes and, in tumour tissues, that of macrophages and vessels. Similar findings were observed when a lurbinectedin-resistant tumour variant was used, indicating a direct effect of lurbinectedin on the tumour microenviroment. In vitro, lurbinectedin induced caspase-8-dependent apoptosis of human purified monocytes, whereas at low doses it significantly inhibited the production of inflammatory/growth factors (CCL2, CXCL8 and VEGF) and dramatically impaired monocyte adhesion and migration ability. These findings were supported by the strong inhibition of genes of the Rho-GTPase family in lurbinectedin-treated monocytes.



The results illustrate that lurbinectedin affects at multiple levels the inflammatory microenvironment by acting on the viability and functional activity of mononuclear phagocytes. These peculiar effects, combined with its intrinsic activity against cancer cells, make lurbinectedin a compound of particular interest in oncology.


tumour-associated macrophages; inflammation; tumour immunology; novel drug

In the last decade, our knowledge on the tumour microenviroment (TME) has considerably increased and the current evidence is that reciprocal interactions between cancer and stromal cells are of pivotal importance for the survival of tumour cells and disease progression (Knowles and Harris, 2007; Mantovani et al, 2008; Allavena and Mantovani, 2012; Coussens et al, 2013; Noy and Pollard, 2014). The TME is the site of the cancer-promoting inflammation, now a recognised hallmark of cancer (Hanahan and Weinberg, 2011). Activated fibroblasts, endothelial cells and innate immunity cells concur to build up a reactive and deregulated environment, where several biological mediators and matrix-degrading enzymes are continuously produced, eventually favouring tumour growth. In this scenario, tumour-associated macrophages (TAM) have a prominent role, as they produce several growth factors for tumour cells and the vessel network, and inflammatory cytokines and chemokines that amplify the tumour-associated inflammation (Knowles and Harris, 2007; Noy and Pollard, 2014; Mantovani and Allavena, 2015; Belgiovine et al, 2016). Strong evidence demonstrates that in most tumours, TAM stimulate tumour progression and limit therapeutic responses (Kryczek et al, 2006; De Palma and Lewis, 2013; Galluzzi et al, 2014; Mantovani and Allavena, 2015; Belgiovine et al, 2016). Furthermore, TAM have strong immunosuppressive functions: they have been described to directly invalidate antitumour T-cell activity by suppressing CD8+ T-cell proliferation and IFNγ expression through programmed death ligand 1 (Mantovani et al, 2005; Kryczek et al, 2006; Kuang et al, 2009; Bloch et al, 2013). Notably, the response rates in the PD-1/PD-L1 trials relate, at least partially, to PD-L1 expression in the stroma (Herbst et al, 2014; Tumeh et al, 2014; Zhu et al, 2014; Qu et al, 2016), consistent with a role for macrophages and/or other stromal cells in blocking antitumour T-cell responses. Therefore, drugs affecting the TME are regarded with particular interest in the oncology field. Already available examples include anti-angiogenic drugs, immune checkpoints inhibitors and, more recently, drugs targeting macrophages, such as kinase inhibitors or antibodies directed to the CSF-1 receptor (Zeisberger et al, 2006; Priceman et al, 2010; DeNardo et al, 2011; Hume and MacDonald, 2011; Pyonteck et al, 2013; Ries et al, 2014). These drugs have recently entered the clinic with much expectation. However, strategies solely targeting tumour macrophages are unlikely to be successful and combination treatments with conventional or biological therapies are under investigation to improve the anti-tumour efficacy.

Lurbinectedin (PM01183) is an analogue of trabectedin that has shown very promising clinical activity in a broad range of clinical trials and is currently under investigation in pivotal phase III studies in patients with platinum-resistant ovarian cancer (NCT02421588) and small-cell lung cancer (NCT02566993). In tumour cells, lurbinectedin inhibits active transcription through the following: (1) its binding to CG-rich sequences, mainly located around promoters of protein coding genes; (2) the irreversible stalling of elongating RNA polymerase II on the DNA template and its specific degradation by the ubiquitin/proteasome machinery; and (3) the generation of XPF-dependent single-strand and double-strand DNA breaks, and subsequent apoptosis (Elez et al, 2014; Moneo et al, 2014; Pernice et al, 2016; Santamaria Nunez et al, 2016). In addition, lurbinectedin is extremely effective against cancer cells with impairment of homologous recombination repair (Romano et al, 2013). However, the role of lurbinectedin on the TME is unknown.

Our previous studies reported that trabectedin is a unique example of an antitumour agent impacting both on cancer cells and on the TME (Germano et al, 2010; Germano et al, 2013). We demonstrated that trabectedin induces caspase-dependent apoptosis specifically in the monocyte-macrophage lineage and this effect is remarkably selective as other leukocyte subsets are not affected (Germano et al, 2013). We further found that trabectedin significantly inhibits the transcription of several biological mediators, including CCL2, CXCL8, IL-6 and VEGF, which have an important role in cancer-promoting inflammation (Germano et al, 2010). These effects of trabectedin on mononuclear phagocytic cells were confirmed in vivo in mouse tumour models and in treated patients, and likely constitute an important determinant of its antitumour efficacy (Germano et al, 2013). In this study, we addressed the question whether lurbinectedin shares similar modulating effects on the tumour microenvironment. Our results demonstrate that lurbinectedin significantly reduces monocyte viability by inducing apoptotic cell death. In mouse tumour models, lurbinectedin decreases the number of circulating monocytes and tumour macrophages, inhibits angiogenesis and restrains tumour growth, even when cancer cells were resistant to its direct effect. A global gene expression analysis of human monocytes treated with lurbinectedin revealed a previously unidentified strong inhibition of the Rho GTPase pathway, which significantly impacts on monocyte-macrophage functional activities.


Materials and methods


Lurbinectedin and trabectedin (PharmaMar, Colmenar Viejo, Madrid, Spain) were dissolved in DMSO to 1mM and kept at −20°C. Doxorubicin (Sigma) was dissolved in water to 2mM and kept −20°C.

Human monocytes in vitro studies

Human monocytes were obtained from the leukocyte-rich component (buffy coat) of blood healthy donors along a protocol approved by the Ethical committee of Humanitas Institute. Before blood donation, volunteers sign an informed consent at the Transfusion Centre (San Matteo Hospital, Pavia, Italy) where blood is collected. The informed consent clearly specifies that their blood donation can be used for research activity.

Monocytes were purified through density gradients, as described (Liguori et al, 2016). Cells were treated with lurbinectedin or trabectedin (2.5–10nM) for different time points as indicated. Cell death was quantified with propidium iodide staining; caspase-dependent apoptosis was evaluated as caspase 8 activation on permeabilised cells in flow cytometry (Germano et al, 2013). Cytokine production was quantified by ELISA in the supernatants of LPS-stimulated monocytes pretreated with lurbinectedin or trabectedin at non-cytotoxic concentration (5nM for 1h). Cells were then washed, stimulated with LPS (Alexis) at 1μgml−1 and supernatants collected after 24h incubation at 37°C. Monocyte migration was performed in Transwell as described (Germano et al, 2013). Cells were pre-treated under non-cytotoxic conditions, washed, incubated for 5h in medium with 1% FBS and then seeded in the upper compartment of Transwell. CCL2 (100ngml−1) was placed in the lower compartment. After incubation at 37°C for 90min, migrated cells were counted in the lower filter face and in the well. Cell adhesion in pretreated cells was investigated as the number of plastic-adherent cells after 1h incubation at 37°C.

Microarray analysis and RT-PCR validation analysis

Human monocytes were pre-treated for 1h with 10nM lurbinectedin or trabectedin or doxorubicin (1μM) and then stimulated with LPS (100ngml−1) for 6h. Total RNA was extracted and purified using a commercial available kit (miRNAesy Qiagen, Milano, Italy); this step was in part mechanised using an automatic extraction system (Qiacube, Qiagen). The amount of total RNA was determined by an innovative high-speed microfluidic UV/VIS spectrophotometer QIAxpert (Qiagen), and the integrity and quality of RNA was evaluated by 2100 Bioanalyzer (Agilent Technologies, Santa Clara, CA, USA).

For microarray experiments, 150ng of RNA were labelled with Cy3 using LowInput QuickAmp labelling kit (Agilent Technologies, Santa Clara, CA, USA) and hybridised according to the manufacturer’s instructions. After 20h incubation at 65°C in rotation at 20r.p.m., arrays were washed and scanned with a laser confocal scanner (G2565B, Agilent Technologies, Santa Clara, USA).

Data obtained from the scanner were pre-processed, discarding probes that were marked as unreliable by Feature Extraction in at least 60% of the samples. The resulting filtered data set was then normalised using the ‘quantile’ method, without subtracting background intensities. Differential expression was calculated with the Rank Product method (Breitling et al, 2004), calling genes differentially expressed if their percentage of false positives was <5%.

Functional enrichment was calculated with the ‘impact factor’ method as implemented in the graphite R package (Draghici et al, 2007; Sales et al, 2012) over two pathway repositories (KEGG and Reactome). The P-values from the test were corrected for multiple testing with the false discovery rate (Benjamini and Hochberg, 1995). In accordance to the MIAME guidelines, array data files have been submitted to Array Express (ID E-MTAB-5366).

RT-PCR analysis

Five hundred nanograms of total RNA was reverse transcribed using the High-Capacity cDNA Archive Kit following the manufacturer’s instructions (Applied Biosystems, Foster City, CA, USA), to assess the differential expression of genes in control-stimulated cells and cells treated with different drugs by quantitative real-time PCR. mRNA expression was analysed using QuantiFast SYBR Green PCR Master Mix (Qiagen) and dedicated primers that were designed (Table 1). Data were normalised using geometric mean of four independent house-keeping genes (cyclophilin A, GAPDH, G6PD and B2M). Experiments were run in triplicate for each case to assess technical variability, using an automatic liquid handling station (QIAgility, Qiagen), on Rotor-Gene Q (Qiagen). Analysis was performed by using the 2−ΔΔCt protocol and expressed as fold changes (arbitrary unit) compared with control-stimulated cells, set as 1.

Mouse tumour models

Procedures involving animals and their care were conducted in conformity with the following laws, regulations and policies governing the care and use of laboratory animals: Italian Governing Law (D.lgs 26/2014, authorisation number19/2008-A issued 6 March 2008 by Ministry of Health); Mario Negri Institutional Regulations and Policies providing internal authorisation for persons conducting animal experiments (Quality Management System Certificate—UNI EN ISO 9001:2008—registration number 6121); the NIH Guide for the Care and Use of Laboratory Animals (2011 edition); EU directives and guidelines (EEC Council Directive 2010/63/UE), and in line with Guidelines for the welfare and use of animals in cancer research (Workman et al, 2010). Animal experiments has been reviewed and approved by the IRFMN Animal Care and Use Committee that includes members ‘ad hoc’ for ethical issues. Animals were housed in the Institute’s Animal Care Facilities, which meet international standards; they are regularly checked by a certified veterinarian who is responsible for health monitoring, animal welfare supervision, experimental protocols and procedures revision.

C57/BL/6J mice between 6 and 10 weeks of age were purchased from Charles River (Calco, Como, Italy). The transplantable MN/MCA1 mouse fibrosarcoma and the trabectedin-resistant variant MN/MCA1-RES were used. The MN/MCA1-RES variant was generated by in vitro exposure to stepwise increasing concentrations of trabectedin, until stable resistance was achieved. Resistance was verified as drug susceptibility (apoptosis) in vitro and in tumour cells ex vivo after growth in mice (Germano et al, 2013). Tumour cells were inoculated i.m. (105 cells); treatments (10 mice per group) started when tumours were palpable.

Lurbinectedin and trabectedin were used at the doses of 0.13 and 0.10mgkg−1, respectively (sub-optimal doses) in the wild-type MN/MCA1 model and at the doses of 0.2 and 0.15mgkg−1, respectively in the MN/MCA1-RES model. These treatments did not completely abrogate tumour growth. This choice was made to optimally study the tumour microenvironment. Drugs were administered i.v. once a week for 3 weeks (q7d × 3). The tumour growth inhibition %T/C (treated/control × 100) ratio was used to quantify treatment effects of the drugs under study.

Analysis of the tumour microenvironment

Blood cells were collected from the eye vein of anaesthetised mice; splenocytes from disaggregated spleens were filtered through Falcon strainers. Mouse tumours were cut into small pieces, disaggregated with collagenase (0.5mgml−1) and filtered through strainers. Cells (106) were stained with live and death dye (Invitrogen, Carlsbad, CA, USA), and with the following specific antibodies: PerCp- Rat CD45 (30F11), APCRat CD11b (M1/70), PE Hamster CD3 (145-2C11), PE Rat Ly6C and Ly6C (RB6-8C5), FITC Rat Ly6C (AL-21), PE Rat Ly-6G (1A8), as well as relative control antibody Alexa Fluor 647 CD19 (1D3) (eBioscience, Waltham, MA, USA). PacificBlue Annexin V was purchased from Invitrogen, and streptavidin dye-conjugated (APC) and BD TruCOUNT tubes were obtained from BD Biosciences (San Jose, CA, USA). Flow cytometry was performed by FACS CantoTM instrument and FACS Diva software version 6.1.1 (BD Biosciences).

Immunohistochemistry of mouse tumours was performed with anti-mouse PE F4/80 (A3-1, Serotec (Oxford, UK), anti-mouse CD31 (clone MEC13.3; BD Biosciences). In each experiment, five to eight tumours per group were analysed; results are the mean of positive cells in four slices per tumour. To perform analysis we used ImageJ programme.

Statistical analysis

Statistical analysis was performed using a paired Student’s t-test. P-values of <0.05 were considered significant.



Lurbinectedin induces apoptosis of human monocytes and affects their functional activity

We first verified the in vitro cytotoxic effect of lurbinectedin on human monocytes obtained from healthy donors. As shown in Figure 1A, treatment with different concentrations of lurbinectedin at different times significantly reduced monocyte viability in a concentration-dependent manner. At 24h, 10nM lurbinectedin caused 50% monocyte death, which raised to 75% after 48h. The dose of 5nM reduced viability of 25–30%. We checked the activation of caspase-8 in treated human monocytes by flow cytometry with an anti-caspase-8 antibody recognising its specific cleaved form. Lurbinectedin strongly activated caspase-8 with a peak at 12h (Figure 1B). In both experiments, similar results were obtained with trabectedin (Figure 1A and B).

Figure 1.
Figure 1 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Effects of lurbinectedin on human purified monocytes in vitro. (A) Cell viability of monocytes treated with lurbinectedin or trabectedin at two different doses (5 and 10nM) for up to 48h, evaluated with Annexin/PI staining by flow cytometry; results are shown as % of live cells compared with untreated cells (mean±s.e. of three experiments). (B) Caspase-8 activation in treated monocytes evaluated by flow cytometry with anti-cleaved CASP8 antibody. Caspase-8 activation peaks at 12h and remains at plateau at 18h. (C) Modulation of cytokine production (ELISA) by lurbinectedin and trabectedin in human LPS-stimulated monocytes. Monocytes were treated with drugs (5nM) for 1h, washed and cultured with fresh medium for 24h. Both drugs significantly and similarly inhibited the production of CCL2, CXCL8 and VEGF. (D) Migration assay (left) and adhesion assay (right) of human monocytes pre-treated with lurbinectedin and trabectedin (5nM), in response to CCL2 (100ngml−1). Statistical analysis: *P<0.05, **P<0.01 and ***P<0.001 (Student’s t-test).

Full figure and legend (129K)

In order to evaluate the drug effect on the functional activity of monocytes, we tested a short treatment (1h) with 5nM lurbinectedin. This concentration was chosen to avoid the high levels of apoptosis observed with higher concentrations and longer incubation. As shown in Figure 1C, the production of specific inflammatory cytokines was inhibited in LPS-stimulated monocytes. The chemokines CCL2 and CXCL8, and the angiogenic factor VEGF were strongly reduced by both lurbinectedin and trabectedin (Figure 1C). To determine whether this effect was specific to monocytes or also occurred in tumour cells, we have tested the cytokines produced by the human myxoid liposarcoma cell line 402.91 using the same experimental non-cytotoxic conditions. The results showed that while CCL2 was strongly inhibited by drug treatment, CXCL8 was reduced to a lesser extent by lurbinectedin compared to LPS-stimulated monocytes (Supplementary Figure 1). Pentraxin-3 was also tested as liposarcoma cells are known high producers of this protein (Germano et al, 2010). Both drugs significantly attenuated its production (Supplementary Figure 1).

We further investigated the effect of drug treatment on the adhesion and migration ability of monocytes. A short treatment with lurbinectedin (5nM for 1h) had a dramatic effect on monocytes, significantly reducing their migration in response to the chemokine CCL2 and their adhesion to plastic surfaces (Figure 1D).

Global gene expression analysis of human monocytes

To have a broader view of the impact of lurbinectedin on monocytes, we performed a gene profiling analysis of LPS-stimulated monocytes pre-treated with lurbinectedin, with trabectedin for comparison or with doxorubicin as unrelated drug. A global analysis revealed that the transcriptomes modulated by lurbinectedin and trabectedin were similar to each other and distinct from that modulated by doxorubicin (Figure 2A). Among the genes down-modulated by trabectedin, 95% were also inhibited by lurbinectedin. One of the top affected pathways was that of the Rho GTPase family. Rho GTPases are crucial molecular switches that control many signalling events involved in diverse functions, such as actin-cytoskeleton organisation and cell motility (Etienne-Manneville and Hall, 2002). Several genes of the RhoGTPase family were significantly downregulated by both lurbinectedin and trabectedin. To support the robustness of our findings, RT-qPCR was used to validate expression changes in five genes members of this pathway (arhgap26, arhgap32, srgap2, vav3 and myo9a). In monocytes as well as in myeloid leukaemia cells (THP-1, U937 and HL-60) these genes were significantly inhibited (Figure 2B and data not shown). In contrast, none of these genes were inhibited in primary activated T lymphocytes or in fibrosarcoma tumour cells (Figure 2B). These findings indicate specific selectivity of lurbinectedin and trabectedin for myeloid-derived cells and are in accordance with the results described above of impaired adhesion and migration ability of monocytes in functional assays.

Figure 2.
Figure 2 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Modulation of gene expression by lurbinectedin in human LPS-stimulated monocytes. Monocytes were treated with lurbinectedin (10nM), trabectedin (10nM) or doxorubicin (1μM) for 6h (mean±s.e. of five donors). (A) Dendogram plot showing the similarity of gene modulation for lurbinectedin (PM) and trabectedin (ET), in contrast with doxorubicin. (B) Modulation of Rho GTPase genes in human LPS-stimulated monocytes, in the myeloid cell line THP1, primary IL-2-activated human T lymphocytes and the murine fibrosarcoma MN/MCA1. Both lurbinectedin and trabectedin inhibit Rho GTPase genes selectively in myeloid cells. Statistical analysis: *P<0.05, **P<0.01 and ***P<0.001 (Student’s t-test). Data were analysed by the DDCT method and expressed as fold change (arbitrary unit) compared with untreated control (set as 1). Values below 0.5 or above 2 (red dashed lines) are genes differentially expressed.

Full figure and legend (275K)

In vivo anti-tumour efficacy of lurbinectedin and effects on the tumour microenvironment

The results presented above with human monocytes raised the question whether the apoptotic-inducing effect of lurbinectedin has a role in its in vivo anti-tumour activity. This was addressed by testing a variant of the fibrosarcoma MN/MCA1 with stable resistance to trabectedin (MN/MCA1-RES) (Germano et al, 2013), which was confirmed to have cross-resistance with lurbinectedin (Supplementary Figure 2). In previous experiments we reported that the wild-type fibrosarcoma MN/MCA1 is highly susceptible to standard doses of trabectedin and lurbinectedin (0.15 and 0.2mgkg−1) with a treatment-to-control ratio T/C of 13% and 15%, respectively. Furthermore, spontaneous lung metastases were significantly reduced: untreated (median 45); trabectedin: (median 4); lurbinectedin: (median 2) (Romano et al, 2013). Thus, the two compounds showed similarly high anti-tumour activity.

In this study, to investigate the tumour microenvironment, we employed doses that did not completely abrogate tumour growth (i.e., 0.10mgkg−1 of trabectedin and 0.13mgkg−1 of lurbinectedin, i.v., q7d × 3, in the wild-type MN/MCA1 model; and 0.20mgkg−1 of lurbinectedin and 0.15mgkg−1 of trabectedin i.v., q7d × 3, in the resistant model). In vivo treatment of mice bearing the wild-type fibrosarcoma achieved a T/C of 43% and 40% (lurbinectedin and trabectedin) (Figure 3A). In mice bearing the resistant fibrosarcoma, T/C was 53% and 41.5% (Figure 3B).

Figure 3.
Figure 3 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

In vivo anti-tumour activity of lurbinectedin in mice. The syngenic fibrosarcoma MN/MCA1 (A) and its resistant variant RES-MN/MCA1 (B) were used. Mice were treated with lurbinectedin or trabectedin i.v. q7d × 3, respectively, at the indicated doses (see text). A representative experiment of two performed with similar results is shown. Lurbinectedin and trabectedin have similar anti-tumour efficacy. Statistical analysis: ***P<0.001 (two-way ANOVA; Bonferroni post hoc test).

Full figure and legend (56K)

A significant anti-tumour activity on cancer cells with demonstrated in vitro resistance to lurbinectedin is indicative of an effect on the tumour microenvironment. We therefore analysed circulating monocytes as well as tissue macrophages in tumour-bearing treated mice. After the first drug cycle, blood was collected and leukocytes analysed by flow cytometry. Monocytes (CD11b+CD115+) were strongly reduced in lurbinectedin-treated mice, whereas other leukocyte populations (PMN, T and B cells) were not affected; Figure 4A shows the results obtained with the susceptible fibrosarcoma (MN/MCA1) and Figure 5A with the resistant variant (MN/MCA1-RES). The extent of monocyte reduction exceeds 50% and was totally confined to the Ly6Chigh subset, which was reduced up to 80%. Ly6Chigh monocytes are those predominantly recruited at peripheral inflammatory sites and at tumour tissues (Yona et al, 2013).Similar results were observed with trabectedin.

Figure 4.
Figure 4 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Effects of lurbinectedin on the tumour microenvironment of the fibrosarcoma MN/MCA1. (A) Flow cytometry analysis of circulating leukocytes of mice treated with lurbinectedin or trabectedin as detailed in the legend of Figure 3. Results are shown after 1 cycle of treatment. Both drugs selectively decrease the number of total monocytes (CD11b+CD115+), especially the Ly6Chigh monocyte subset. (B) Flow cytometry analysis of splenic leukocytes in mice treated after three cycles. Both drugs selectively decrease the number of macrophages (CD11b+ F4/80+Ly6Chigh). Statistical analysis: *P<0.05, **P<0.01 and ***P<0.001 (two-way ANOVA; Bonferroni T-test. (C) Representative immunohistochemistry pictures of tumour sections after treatment (three cycles), stained for macrophages (F4/80) or blood vessels (CD31). (D) Quantification of immunohistochemistry. Both macrophages and vessels were significantly reduced in tumours treated with lurbinectedin and trabectedin. The immunoreactive areas are calculated as mean from five microscopic fields for each sample, five mice per group. Images were analysed using Image-Pro Analyzer software. Original magnification, × 20. Statistical analysis: *P<0.05, **P<0.01 and ***P<0.001 (Student’s t-test).

Full figure and legend (318K)

Figure 5.
Figure 5 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Effects of lurbinectedin on the tumour microenvironment of the fibrosarcoma resistant variant RES-MN/MCA1. (A) Flow cytometry analysis of circulating leukocytes of mice treated with lurbinectedin or trabectedin as detailed in the legend of Figure 3. Results are shown after one cycle of treatment. Both drugs selectively decrease the number of total monocytes (CD11b+CD115+), especially the Ly6Chigh monocyte subset. (B) Flow cytometry analysis of splenic leukocytes in mice treated after three cycles. Both drugs selectively decrease the number of macrophages (CD11b+ F4/80+Ly6Chigh). Statistical analysis: *P<0.05, **P<0.01 and ***P<0.001 (two-way ANOVA; Bonferroni T-test. (C) Representative immunohistochemistry pictures of tumour sections after treatment (three cycles), stained for macrophages (F4/80) or blood vessels (CD31). (D) Quantification of immunohistochemistry. Both macrophages and vessels were significantly reduced in tumours treated with lurbinectedin and trabectedin. The immunoreactive areas are calculated as mean from five microscopic fields for each sample, five mice per group. Images were analysed using Image-Pro Analyzer software. Original magnification, × 20. Statistical analysis: *P<0.05, **P<0.01 and ***P<0.001 (Student’s t-test).

Full figure and legend (308K)

After three treatment cycles with lurbinectedin or trabectedin, mice were killed, and spleens and tumours analysed. Flow cytometry revealed that splenic macrophages (CD11b+ F4/80+ Ly6Chigh) were significantly and selectively reduced (Figures 4B and 5B). Macrophages within tumours were investigated by immunohistochemical staining with F4/80. Representative pictures of treated tumours are shown in Figures 4C and 5C; the quantification analysis of different tumour sections indicated a significant reduction in the number of TAM, as well as of blood vessels (CD31) (Figures 4D and 5D). Indeed, the effect of lurbinectedin in the resistant fibrosarcoma, was slightly more significant compared with that of trabectedin (Figure 5D).

We next used a xenograft model of human ovarian cancer previously characterised (Massazza et al, 1989; Oliva et al, 2012). In line with the above mentioned results, treated tumours showed a significant decrease in the number of infiltrating macrophages and blood vessels (Supplementary Figure 3).

Overall, the results indicate that lurbinectedin in vivo selectively reduces the number of circulating monocytes, spleen macrophages and the density of TAM and blood vessels in the tumour microenvironment.



It is now established that macrophages within the tumour tissue fuel the buildup of an inflammatory milieu and favour disease progression (Knowles and Harris, 2007; Mantovani et al, 2008; Hanahan and Weinberg, 2011; Allavena and Mantovani, 2012; Coussens et al, 2013; De Palma and Lewis, 2013; Galluzzi et al, 2014; Noy and Pollard, 2014; Mantovani and Allavena, 2015; Belgiovine et al, 2016). Targeting of TAM for therapeutic purposes has been extensively pursued and is providing positive results in various experimental settings, either as monotherapy or combined with conventional and anti-angiogenic therapies (Zeisberger et al, 2006; Zhu et al, 2014). Along this subject, we have previously reported that trabectedin can be considered as the prototype of a new class of anti-tumour agents with dual effects on cancer cells and on the tumour microenvironment, by specifically targeting TAM (Germano et al, 2010; Germano et al, 2013).

Lurbinectedin, an analogue of trabectedin, presents interesting clinical features with pharmacokinetic and pharmacodynamics differences compared to trabectedin (Elez et al, 2014; Paz-Ares et al, 2017; Santamaria Nunez et al, 2016).

In this study we have performed in vitro studies on human monocytes and in vivo experiments on macrophages from tumour-bearing mice, and demonstrated that lurbinectedin is as active as trabectedin in its selective effects on the tumour microenvironment. Mechanistically, lurbinectedin activates caspase-8-dependent apoptosis in human monocytes within few hours and at low nanomolar concentrations. We previously demonstrated that the selectivity of trabectedin for the mononuclear phagocyte lineage relies on the fact that only monocytes and macrophages express appreciable levels of functional TRAIL-R, whereas neutrophils and T lymphocytes express high levels of the decoy non-signalling TRAIL-R3, and therefore are spared by the drug (Germano et al, 2013; Liguori et al, 2016). In treated monocytes, trabectedin upregulates the transcription of TRAIL-R and this increase appears to be sufficient to trigger caspase-8 activation and apoptosis. We also observed an increase of TRAIL-R expression in lurbinectedin-treated monocytes, indicating that a similar mechanism of monocyte apoptosis is occurring also with this analogue (not shown).

Another common effect of the two drugs is on selected inflammatory chemokines (CCL2 and CXCL8) and on VEGF, which were reduced after treatment, both in myeloid cells and in cancer cells.

The lurbinectedin-mediated effect on the tumour microenvironment was confirmed in in vivo experiments using a drug-resistant fibrosarcoma cell line. Even in conditions where tumour cells were totally unresponsive in vitro to lurbinectedin, a significant anti-tumour activity was observed, along with decreased number of circulating monocytes and TAM, and reduced tumour angiogenesis. Since at full doses the antitumour activity of trabectedin and lurbinectedin in the wild-type fibrosarcoma model was higher than that found in MN/MCA1-RES, it seems plausible to hypothesise that the drug were active by both inhibiting cancer cell growth and decreasing TAM. Comparing the two compounds for their features to impact on myeloid cells, in vitro and in vivo, we conclude that lurbinectedin and trabectedin display a very similar efficacy.

A gene expression analysis of human monocytes treated with lurbinectedin or trabectedin also indicated that similar pathways were modulated. Of particular interest are a series of genes from the Rho GTPase family that were not identified in previous analyses. RhoGTPases regulate many aspects of intracellular actin dynamics and are involved in fundamental biological functions such as signalling from integrin receptors, cell adhesion, migration and endocytosis. We confirmed that monocytes treated with lurbinectedin or trabectedin have a severe impairment in their migration activity in response to the chemokine CCL2. This finding bears importance during the active recruitment of circulating monocytes within tumours. Unlike tissue-resident macrophages, TAM originate from blood monocytes and are recalled in the TME by CCL2 and other chemotactic signals expressed by cancer or stromal cells (Noy and Pollard, 2014). Inhibition of monocyte accumulation in tumours would result in decreased TAM numbers, as observed in our in vivo experiments. Overall, as simplified in the scheme of Figure 6, lurbinectedin has multiple effects on the cells of the mononuclear phagocyte system: at higher doses it induces a rapid apoptosis in monocytes and TAM; at lower concentrations it affects adhesion and migration of monocytes by inhibiting the expression of genes that modulate and organise the actin cytoskeleton; at these low concentrations, lurbinectedin also inhibits the production of selected inflammatory mediators and angiogenic factors, which are important for tumour progression.

Figure 6.
Figure 6 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Schematic representation of the mechanisms of action of lurbinectedin on the tumour microenvironment. Lurbinectedin induces the apoptotic death of monocytes; at sub-cytotoxic concentrations lurbinectedin inhibits the cell migration in response to chemotactic signals (CCL2) and the production of inflammatory mediators produced in the tumour microenvironment (CCL2 and CXCL8) and the angiogenic factor VEGF.

Full figure and legend (76K)

Of interest, it was recently published that the lurbinectedin-gemcitabine synergism observed in preclinical and clinical studies can be explained by the sum of the effects in both tumour cells and TAM exerted by lurbinectedin and gemcitabine (Céspedes et al, 2016; Paz-Ares et al, 2017). Indeed, TAM mediates acquired resistance of cancer cells to gemcitabine as they upregulate cytidine deaminase (CDA), one of the enzymes that catabolise gemcitabine (dFdC) in tumours into its inactive derivative dFdU (Galmarini et al, 2002). As a consequence, the enhanced CDA activity decreases gemcitabine intracellular levels and thus gemcitabine-induced apoptosis. Thus, the synergistic effect of the combination was explained by the effects of lurbinectedin on TAM.

Previous studies revealed different toxic effects for the two compounds. From the results obtained in phase I and phase II studies, it emerged that lurbinectedin maximal tolerated and recommended doses are more than three times higher than those of trabectedin (Elez et al, 2014; Santamaria Nunez et al, 2016) and plasmatic levels with an area under the curve are ~5–10 higher than that of trabectedin. As the in vitro cytotoxic potency of lurbinectedin towards either cancer cells or macrophages appears to be similar, it seems plausible to hypothesise that the therapeutic effect of lurbinectedin could be more marked than those of trabectedin.

Studies performed in sarcoma patients have indicated that it is possible to predict the anticancer activity of trabectedin based on the expression of DNA repair proteins. The present study suggests that other biomarkers related to tumour microenvironment should be developed to have a better prediction of patient’s response.

In conclusion, our study has identified interesting mechanisms of action of lurbinectedin on the inflammatory microenvironment and selectively on the leukocyte subset of monocytes-macrophages. Macrophage targeting in tumours is now extensively pursued, but is unlikely to be successful as monotherapy. The pro-apoptotic activity of lurbinectedin on cells of the monocyte-macrophage lineage, combined with its intrinsic anti-tumour activity, makes this compound of particular interest in oncology.



  1. Allavena P, Mantovani A (2012) Immunology in the clinic review series; focus on cancer: tumour-associated macrophages: undisputed stars of the inflammatory tumour microenvironment. Clin Exp Immunol 167(2): 195–205. | Article | PubMed | ISI | CAS |
  2. Belgiovine C, D’Incalci M, Allavena P, Frapolli R (2016) Tumor-associated macrophages and anti-tumor therapies: complex links. Cell Mol Life Sci 73(13): 2411–2424. | Article | PubMed |
  3. Benjamini Y, Hochberg Y (1995) Controlling the false discovery rate: a practical and powerful approach to multiple testing. J R Stat Soc Ser B (Methodol) 57(1): 289–300. | ISI |
  4. Bloch O, Crane CA, Kaur R, Safaee M, Rutkowski MJ, Parsa AT (2013) Gliomas promote immunosuppression through induction of B7-H1 expression in tumor-associated macrophages. Clin Cancer Res 19(12): 3165–3175. | Article | PubMed | ISI | CAS |
  5. Breitling R, Armengaud P, Amtmann A, Herzyk P (2004) Rank products: a simple, yet powerful, new method to detect differentially regulated genes in replicated microarray experiments. FEBS Lett 573(1–3): 83–92. | Article | PubMed | ISI | CAS |
  6. Céspedes MV, Guillén MJ, López-Casas PP, Sarno F, Gallardo A, Álamo P, Cuevas C, Hidalgo M, Galmarini CM, Allavena P, Avilés P, Mangues R (2016) Lurbinectedin induces depletion of tumor-associated macrophages (TAM), an essential component of its in vivo synergism with gemcitabine. Dis Model Mech 9: 1461–1471. | Article | PubMed |
  7. Coussens LM, Zitvogel L, Palucka AK (2013) Neutralizing tumor-promoting chronic inflammation: a magic bullet? Science 339(6117): 286–291. | Article | PubMed | ISI | CAS |
  8. De Palma M, Lewis CE (2013) Macrophage regulation of tumor responses to anticancer therapies. Cancer Cell 23(3): 277–286. | Article | PubMed | ISI | CAS |
  9. DeNardo DG, Brennan DJ, Rexhepaj E, Ruffell B, Shiao SL, Madden SF, Gallagher WM, Wadhwani N, Keil SD, Junaid SA, Rugo HS, Hwang ES, Jirström K, West BL, Coussens LM (2011) Leukocyte complexity predicts breast cancer survival and functionally regulates response to chemotherapy. Cancer Discov 1(1): 54–67. | Article | PubMed | ISI | CAS |
  10. Draghici S, Khatri P, Tarca AL, Amin K, Done A, Voichita C, Georgescu C, Romero R (2007) A systems biology approach for pathway level analysis. Genome Res 17(10): 1537–1545. | Article | PubMed | ISI | CAS |
  11. Elez ME, Tabernero J, Geary D, Macarulla T, Kang SP, Kahatt C, Pita AS, Teruel CF, Siguero M, Cullell-Young M, Szyldergemajn S, Ratain MJ (2014) First-in-human phase I study of lurbinectedin (PM01183) in patients with advanced solid tumors. Clin Cancer Res 20(8): 2205–2214. | Article | PubMed |
  12. Etienne-Manneville S, Hall A (2002) Rho GTPases in cell biology. Nature 420(6916): 629–635. | Article | PubMed | ISI | CAS |
  13. Galluzzi L, Vacchelli E, Bravo-San Pedro JM, Buqué A, Senovilla L, Baracco EE, Bloy N, Castoldi F, Abastado JP, Agostinis P, Apte RN, Aranda F, Ayyoub M, Beckhove P, Blay JY, Bracci L, Caignard A, Castelli C, Cavallo F, Celis E, Cerundolo V, Clayton A, Colombo MP, Coussens L, Dhodapkar MV, Eggermont AM, Fearon DT, Fridman WH, Fučíková J, Gabrilovich DI, Galon J, Garg A, Ghiringhelli F, Giaccone G, Gilboa E, Gnjatic S, Hoos A, Hosmalin A, Jäger D, Kalinski P, Kärre K, Kepp O, Kiessling R, Kirkwood JM, Klein E, Knuth A, Lewis CE, Liblau R, Lotze MT, Lugli E, Mach JP, Mattei F, Mavilio D, Melero I, Melief CJ, Mittendorf EA, Moretta L, Odunsi A, Okada H, Palucka AK, Peter ME, Pienta KJ, Porgador A, Prendergast GC, Rabinovich GA, Restifo NP, Rizvi N, Sautès-Fridman C, Schreiber H, Seliger B, Shiku H, Silva-Santos B, Smyth MJ, Speiser DE, Spisek R, Srivastava PK, Talmadge JE, Tartour E, Van Der Burg SH, Van Den Eynde BJ, Vile R, Wagner H, Weber JS, Whiteside TL, Wolchok JD, Zitvogel L, Zou W, Kroemer G (2014) Classification of current anticancer immunotherapies. Oncotarget 5(24): 12472–12508. | Article | PubMed | ISI |
  14. Galmarini CM, Mackey JR, Dumontet C (2002) Nucleoside analogues and nucleobases in cancer treatment. Lancet Oncol 3(7): 415–424. | Article | PubMed | ISI | CAS |
  15. Germano G, Frapolli R, Belgiovine C, Anselmo A, Pesce S, Liguori M, Erba E, Uboldi S, Zucchetti M, Pasqualini F, Nebuloni M, van Rooijen N, Mortarini R, Beltrame L, Marchini S, Fuso Nerini I, Sanfilippo R, Casali PG, Pilotti S, Galmarini CM, Anichini A, Mantovani A, D'Incalci M, Allavena P (2013) Role of macrophage targeting in the antitumor activity of trabectedin. Cancer Cell 23(2): 249–262. | Article | PubMed | ISI | CAS |
  16. Germano G, Frapolli R, Simone M, Tavecchio M, Erba E, Pesce S, Pasqualini F, Grosso F, Sanfilippo R, Casali PG, Gronchi A, Virdis E, Tarantino E, Pilotti S, Greco A, Nebuloni M, Galmarini CM, Tercero JC, Mantovani A, D'Incalci M, Allavena P (2010) Antitumor and anti-inflammatory effects of trabectedin on human myxoid liposarcoma cells. Cancer Res 70(6): 2235–2244. | Article | PubMed | ISI | CAS |
  17. Hanahan D, Weinberg RA (2011) Hallmarks of cancer: the next generation. Cell 144(5): 646–674. | Article | PubMed | ISI | CAS |
  18. Herbst RS, Soria J-C, Kowanetz M, Fine GD, Hamid O, Gordon MS, Sosman JA, McDermott DF, Powderly JD, Gettinger SN, Kohrt HE, Horn L, Lawrence DP, Rost S, Leabman M, Xiao Y, Mokatrin A, Koeppen H, Hegde PS, Mellman I, Chen DS, Hodi FS (2014) Predictive correlates of response to the anti-PD-L1 antibody MPDL3280A in cancer patients. Nature 515(7528): 563–567. | Article | PubMed | ISI | CAS |
  19. Hume DA, MacDonald KPA (2011) Therapeutic applications of macrophage colony-stimulating factor-1 (CSF-1) and antagonists of CSF-1 receptor (CSF-1R) signaling. Blood 119(8): 1810–1820. | Article | PubMed | CAS |
  20. Knowles HJ, Harris AL (2007) Macrophages and the hypoxic tumour microenvironment. Front Biosci 12: 4298–4314. | Article | PubMed |
  21. Kryczek I, Zou L, Rodriguez P, Zhu G, Wei S, Mottram P, Brumlik M, Cheng P, Curiel T, Myers L, Lackner A, Alvarez X, Ochoa A, Chen L, Zou W (2006) B7-H4 expression identifies a novel suppressive macrophage population in human ovarian carcinoma. J Exp Med 203(4): 871–881. | Article | PubMed | ISI | CAS |
  22. Kuang D-M, Zhao Q, Peng C, Xu J, Zhang JP, Wu C, Zheng L (2009) Activated monocytes in peritumoral stroma of hepatocellular carcinoma foster immune privilege and disease progression through PD-L1. J Exp Med 206(6): 1327–1337. | Article | PubMed | ISI | CAS |
  23. Liguori M, Buracchi C, Pasqualini F, Bergomas F, Pesce S, Sironi M, Grizzi F, Mantovani A, Belgiovine C, Allavena P (2016) Functional TRAIL receptors in monocytes and tumor-associated macrophages: a possible targeting pathway in the tumor microenvironment. Oncotarget 7(27): 41662–41676. | PubMed |
  24. Mantovani A, Allavena P (2015) The interaction of anticancer therapies with tumor-associated macrophages. J Exp Med 212(4): 435–445. | Article | PubMed | CAS |
  25. Mantovani A, Allavena P, Sica A, Balkwill F (2008) Cancer-related inflammation. Nature 454(7203): 436–444. | Article | PubMed | ISI | CAS |
  26. Mantovani A, Sica A, Locati M (2005) Macrophage polarization comes of age. Immunity 23(4): 344–346. | Article | PubMed | ISI | CAS |
  27. Massazza G, Tomasoni A, Lucchini V, Allavena P, Erba E, Colombo N, Mantovani A, D'Incalci M, Mangioni C, Giavazzi R (1989) Intraperitoneal and subcutaneous xenografts of human ovarian carcinoma in nude mice and their potential in experimental therapy. Int J Cancer 44(3): 494–500. | Article | PubMed |
  28. Moneo V, Martinez P, de Castro B, Cascajares S, Avila S, Garcia-Fernandez LF, Galmarini M (2014) Abstract A174: Comparison of the antitumor activity of Trabectedin, Lurbinectedin, Zalypsis and PM00128 in a panel of human cells deficient in transcription/NER repair factors. Mol Cancer Ther 12(11_Supplement): A174. | Article |
  29. Noy R, Pollard JW (2014) Tumor-associated macrophages: from mechanisms to therapy. Immunity 41(1): 49–61. | Article | PubMed | ISI | CAS |
  30. Oliva P, Decio A, Castiglioni V, Bassi A, Pesenti E, Cesca M, Scanziani E, Belotti D, Giavazzi R (2012) Cisplatin plus paclitaxel and maintenance of bevacizumab on tumour progression, dissemination, and survival of ovarian carcinoma xenograft models. Br J Cancer 107(2): 360–369. | Article | PubMed |
  31. Paz-Ares L, Forster M, Boni V, Szyldergemajn S, Corral J, Turnbull S, Cubillo A, Teruel CF, Calderero IL, Siguero M, Bohan P, Calvo E (2017) Phase I clinical and pharmacokinetic study of PM01183 (a tetrahydroisoquinoline, Lurbinectedin) in combination with gemcitabine in patients with advanced solid tumors. Invest New Drugs 206(2): 198–206. | Article |
  32. Pernice T, Bishop AG, Guillen MJ, Cuevas C, Aviles P (2016) Development of a liquid chromatography/tandem mass spectrometry assay for the quantification of PM01183 (lurbinectedin), a novel antineoplastic agent, in mouse, rat, dog, Cynomolgus monkey and mini-pig plasma. J Pharm Biomed Anal 123: 37–41. | Article | PubMed |
  33. Priceman SJ, Sung JL, Shaposhnik Z, Burton JB, Torres-Collado AX, Moughon DL, Johnson M, Lusis AJ, Cohen DA, Iruela-Arispe ML, Wu L (2010) Targeting distinct tumor-infiltrating myeloid cells by inhibiting CSF-1 receptor: combating tumor evasion of antiangiogenic therapy. Blood 115(7): 1461–1471. | Article | PubMed | CAS |
  34. Pyonteck SM, Akkari L, Schuhmacher AJ, Bowman RL, Sevenich L, Quail DF, Olson OC, Quick ML, Huse JT, Teijeiro V, Setty M, Leslie CS, Oei Y, Pedraza A, Zhang J, Brennan CW, Sutton JC, Holland EC, Daniel D, Joyce JA (2013) CSF-1R inhibition alters macrophage polarization and blocks glioma progression. Nat Med 19(10): 1264–1272. | Article | PubMed | ISI | CAS |
  35. Qu Q-X, Huang Q, Shen Y, Zhu Y-B, Zhang X-G (2016) The increase of circulating PD-L1-expressing CD68+ macrophage in ovarian cancer. Tumor Biol 37(4): 5031–5037. | Article |
  36. Ries CH, Cannarile MA, Hoves S, Benz J, Wartha K, Runza V, Rey-Giraud F, Pradel LP, Feuerhake F, Klaman I, Jones T, Jucknischke U, Scheiblich S, Kaluza K, Gorr IH, Walz A, Abiraj K, Cassier PA, Sica A, Gomez-Roca C, de Visser KE, Italiano A, Le Tourneau C, Delord JP, Levitsky H, Blay JY, Rüttinger D (2014) Targeting tumor-associated macrophages with anti-CSF-1R antibody reveals a strategy for cancer therapy. Cancer Cell 25(6): 846–859. | Article | PubMed | ISI | CAS |
  37. Romano M, Frapolli R, Zangarini M, Bello E, Porcu L, Galmarini CM, García-Fernández LF, Cuevas C, Allavena P, Erba E, D'Incalci M (2013) Comparison ofin vitroandin vivobiological effects of trabectedin, lurbinectedin (PM01183) and Zalypsis (PM00104). Int J Cancer 133(9): 2024–2033. | Article | PubMed |
  38. Sales G, Calura E, Cavalieri D, Romualdi C (2012) graphite—a Bioconductor package to convert pathway topology to gene network. BMC Bioinformatics 13(1): 20. | Article | PubMed |
  39. Santamaria Nunez G, Robles CMG, Giraudon C, Martínez-Leal JF, Compe E, Coin F, Aviles P, Galmarini CM, Egly JM (2016) Lurbinectedin specifically triggers the degradation of phosphorylated RNA polymerase II and the formation of DNA breaks in cancer cells. Mol Cancer Ther 15(10): 2399–2412. | Article | PubMed |
  40. Tumeh PC, Harview CL, Yearley JH, Shintaku IP, Taylor EJ, Robert L, Chmielowski B, Spasic M, Henry G, Ciobanu V, West AN, Carmona M, Kivork C, Seja E, Cherry G, Gutierrez AJ, Grogan TR, Mateus C, Tomasic G, Glaspy JA, Emerson RO, Robins H, Pierce RH, Elashoff DA, Robert C, Ribas A (2014) PD-1 blockade induces responses by inhibiting adaptive immune resistance. Nature 515(7528): 568–571. | Article | PubMed | ISI | CAS |
  41. Workman P, Aboagye EO, Balkwill F, Balmain A, Bruder G, Chaplin DJ, Double JA, Everitt J, Farningham DA, Glennie MJ, Kelland LR, Robinson V, Stratford IJ, Tozer GM, Watson S, Wedge SR, Eccles SA Committee of the National Cancer Research Institute (2010) Guidelines for the welfare and use of animals in cancer research. Br J Cancer 102(11): 1555–1577. | Article | PubMed | ISI | CAS |
  42. Yona S, Kim K-W, Wolf Y, Mildner A, Varol D, Breker M, Strauss-Ayali D, Viukov S, Guilliams M, Misharin A, Hume DA, Perlman H, Malissen B, Zelzer E, Jung S (2013) Fate mapping reveals origins and dynamics of monocytes and tissue macrophages under homeostasis. Immunity 38(1): 79–91. | Article | PubMed | ISI | CAS |
  43. Zeisberger SM, Odermatt B, Marty C, Zehnder-Fjällman AH, Ballmer-Hofer K, Schwendener RA (2006) Clodronate-liposome-mediated depletion of tumour-associated macrophages: a new and highly effective antiangiogenic therapy approach. Br J Cancer 95(3): 272–281. | Article | PubMed | ISI | CAS |
  44. Zhu Y, Knolhoff BL, Meyer MA, Nywening TM, West BL, Luo J, Wang-Gillam A, Goedegebuure SP, Linehan DC, DeNardo DG (2014) CSF1/CSF1R blockade reprograms tumor-infiltrating macrophages and improves response to T-cell checkpoint immunotherapy in pancreatic cancer models. Cancer Res 74(18): 5057–5069. | Article | PubMed | CAS |


This work was supported by the Italian Association for Cancer Research to PA (Project Number 16007) and MD’I (Project Number 6595); and by the Worldwide Cancer Research grant to PA. CB was supported by a fellowship from Fondazione Veronesi, Italy.

Supplementary Information accompanies this paper on British Journal of Cancer website

BJC Open article

This work is licensed under the Creative Commons Attribution-Non-Commercial-Share Alike 4.0 International License.
To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/