Reviews

Clinical relevance of tumour-associated

macrophages
Mikael J. Pittet 1,2,3,4,5,6 ✉, Olivier Michielin3,6,7 and Denis Migliorini3,4,5,6

Abstract | In the past decade, substantial advances have been made in understanding the biology
of tumour-associated macrophages (TAMs), and their clinical relevance is emerging. A particular
aspect that is becoming increasingly clear is that the interaction of TAMs with cancer cells and
stromal cells in the tumour microenvironment enables and sustains most of the hallmarks of can-
cer. Therefore, manipulation of TAMs could enable improved disease control in a substantial frac-
tion of patients across a large number of cancer types. In this Review, we examine the diversity of
TAMs in various cancer indications and how this heterogeneity is being revisited with the advent
of single-cell technologies, and then explore the current knowledge on the functional roles of
different TAM states and the prognostic and predictive value of TAM-related signatures. We also
review agents targeting TAMs that are currently being or will soon be tested in clinical trials, and
how manipulations of TAMs can improve existing anticancer treatments. Finally, we discuss how
TAM-targeting approaches could be further integrated into routine clinical practice, considering
a precision oncology approach and viewing TAMs as a dynamic population that can evolve under
treatment pressure.

1
Department of Pathology
and Immunology, University
of Geneva, Geneva,
Switzerland.
2
Ludwig Institute for Cancer
Research, Lausanne,
Switzerland.
3
Agora Cancer Research
Center, Lausanne,
Switzerland.
4
Department of Oncology,
Geneva University Hospitals,
Geneva, Switzerland.
5
Center for Translational
Research in Onco-Hematology,
University of Geneva, Geneva,
Switzerland.
6
Swiss Cancer Center Léman
(SCCL), Lausanne and
Geneva, Geneva, Switzerland.
7
Precision Oncology Center,
Department of Oncology,
Lausanne University Hospital,
Lausanne, Switzerland.
✉e-mail: mikael.pittet@
unige.ch
https://doi.org/10.1038/
s41571-022-00620-6
Immunotherapy has reshaped the therapeutic landscape
of many tumour types and can produce exceptional clin-
ical outcomes. Yet, only a minority of patients respond to
treatment and, therefore, more effective approaches
to stimulate the immune system against cancer are
urgently needed. Currently approved immunotherapies
mainly rely on enhancing the functions of endogenous
cytotoxic CD8+ T cells (for example, by administering
immune-checkpoint inhibitors (ICIs)) or on infus-
ing engineered T cells into the patient. In addition to
T cells, other immune components influence tumour
progression, either positively or negatively, and should
be considered as additional therapeutic targets1. Of these
components, macrophages are often the most abundant
in tumours, and growing evidence indicates that at least
some macrophage subpopulations potently influence
tumour progression and interfere with virtually all
types of cancer therapy2–4. Thus, increasing interest is
being focused on understanding the biology of macro­
phages, with the ultimate goal of overcoming the lim-
itations of current therapies. Several aspects currently
being addressed include: (1) the complexity and diver-
sity of macrophages, and whether distinct macrophage
states can be identified; (2) whether and how different
macrophage states contribute to disease progression or
suppression; (3) the possibility of rational manipulation
of macrophages to promote an antitumour immune
response while sparing non-malignant tissue; and (4) the
effect of such manipulations on the outcomes in patients
with certain cancers.
As interest in macrophages grows, researchers can
rely on new technologies and tools to better character-
ize these cells. For example, multiomic analyses5–7 and
machine-learning approaches for digitized and spatial
pathology8–12 are uncovering macrophage complexity
at unprecedented resolution and in the geographical
context of tumours. Combined with information on
clinical outcomes, these data provide a clearer picture of
macrophage states that might be functionally relevant
in the tumour setting, and are leading to a better under-
standing of how to harness macrophages for therapeutic
purposes. In this Review, we focus on the clinical rel-
evance of tumour-associated macrophages (TAMs). In
particular, we discuss the current knowledge of distinct
phenotypic states within the TAM population, and their
potential value as prognostic and predictive markers,
and as therapeutic targets. We also describe the agents
targeting TAMs that have already entered clinical trials
or might do so soon, and propose a strategy for effi-
ciently integrating TAM-based therapeutic approaches
into the clinical arena.
TAM diversity
TAMs can have multiple origins and functions, and are
distinct from other myeloid cell types also present in
tumours (Box 1). Our view of TAMs has evolved over the

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Key points
• Tumour-associated macrophages (TAMs) are phenotypically and functionally
diverse; therefore, some can promote tumour progression whereas others can exhibit
antitumour activity.
• Some TAM states have prognostic value because their abundance is associated with
distinct clinical outcomes, as is the case for TAM states in patients with melanoma
and lung, colorectal, ovarian, pancreatic, stomach and kidney cancers.
• Some TAM states are associated with response to treatment, or lack thereof, as
demonstrated in seminal studies involving patients with breast cancer, renal cell
carcinoma and melanoma.
• Not all tumour-promoting TAMs have M2-like phenotypes, thus highlighting the
importance of defining TAM states beyond the M1/M2 dichotomy.
• The diversity of TAMs suggests different possibilities for exploiting particular subsets
for therapeutic purposes; as a result, an arsenal of macrophage-targeted agents are
currently being tested in the clinic.
• With the integration of single-cell RNA sequencing and other omics in therapeutic
decision-making processes, the inclusion of TAM data in precision oncology molecular
tumour boards could become routine practice.
past decades, owing to an increasing understanding of
their complexity. About half a century ago, TAMs were
identified as cells of the immune system that can kill
and phagocytose cancer cells13 and, thus, can have anti-
tumour functions. Subsequent studies, however, showed
that TAMs can also promote tumour progression.
Indeed, a detailed exploration of the biological complex-
ity of tumour growth and metastasis revealed that the
tumour microenvironment (TME) can subvert TAMs, or
at least some of them, into becoming cancer-promoting
cells14. In this sense, an increased abundance of TAMs is
associated with an overall reduction in patient survival
across many cancer indications15.
The plasticity and diversity of TAMs helps to explain
their divergent functions, as well as the existence of
TAMs with antitumour potential16. Hence, identifying
markers that distinguish tumour-promoting from anti-
tumour TAMs has become of paramount importance.
Traditionally used flow cytometry and histological
approaches rely on a limited set of markers to define TAMs
and, therefore, might not capture the full diversity of these
cells or distinguish them from some other cell popula-
tions. In the past few years, single-cell omics approaches
have revealed TAM diversity with reduced bias.
Dual classification
Macrophage diversity has long been recognized and
thus, terms such as the so-called M1 and M2 pheno-
types were introduced to define the possible extremes
of in vitro-polarized cells17; the same terminology has
been widely adopted to define macrophages in vivo.
Bacterial products (for example, lipopolysaccharide) and
pro-inflammatory cytokines (such as interferons
and TNF) can induce M1 macrophages, which produce
angiostatic factors associated with antitumour immu-
nity (for example, IL-12 and CXCL10). By contrast,
immunoregulatory cytokines (such as IL-4, IL-10 and
TGFβ) can induce M2 macrophages, which secrete
tissue-remodelling and pro-angiogenic factors (such as
matrix metalloproteinases and VEGF) associated with
tumour promotion. TAMs rarely display bona fide M1
or M2 phenotypes14,17–21, and therefore the complexity
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of these cells cannot easily be resolved with this binary
classification.
To overcome this limitation, some researchers have
attempted to classify macrophage cell populations into
additional categories (such as M2a, M2b and M2c
instead of M2 (refs22,23)) or to use more permissive ter-
minologies (for example, M1-like and M2-like instead
of M1 and M2, respectively3). Supporting this approach,
M2-like TAMs can be enriched in hypoxic tumour
areas, where they have marked pro-angiogenic activity,
and their number increases with tumour progression.
Nevertheless, these adjustments in definitions might not
be sufficient to cover the full complexity of TAMs. For
example, TAM subsets can co-express M1 and M2 gene
signatures24, and tumour-promoting macrophages can
express genes other than those classically associated with
activation towards M2 (refs24–28).
Single-cell omics-based classification
Single-cell RNA sequencing (scRNA-seq) and other
single-cell analysis tools are increasingly being used to
define TAM states. For example, spectral clustering of
scRNA-seq data uncovered various macrophage states.
Initial studies of human tumours have focused on breast
cancer21,28,29, non-small-cell lung cancer (NSCLC)30,31,
small-cell lung cancer32, hepatocellular carcinoma33,
glioblastoma27,34, colorectal cancer (CRC)35 and renal
cell carcinoma (RCC)36, and a pan-cancer analysis is
available24. These scRNA-seq studies are important
because they reveal the complexity of TAMs without
defining their phenotypic attributes a priori. For exam-
ple, they have confirmed that macrophage activation
within tumours might not follow a simple M1/M2 acti-
vation model29,30. With this type of information, ration-
ally defining which TAM states need to be enhanced
or suppressed to treat cancer — and how to do so in a
therapeutic setting — should eventually become easier.
The different TAM states are not strongly demarcated
by transcriptional signatures, but rather characterized by
overlapping gene signatures and/or gradients of gene
expression, and might be fairly conserved between
patients who are diagnosed with the same cancer
indication30. As a consequence, researchers could hypo-
thetically obtain important insights into TAM biology
from small cohorts of patients, and use those insights
to develop widely applicable therapies. The overall rep-
ertoire of TAM states, however, is likely to differ across
cancer indications, at least in part24. Consequently, tar-
geting TAMs might require therapeutic agents that are
tailored to a given cancer type or tumour site. Another
important approach would involve defining both the
similarities and differences between TAMs in primary
and metastatic tumours in individual patients, and pos-
sibly integrating this information when considering
therapeutic options in patients with advanced-stage
disease. Overall, further studies are needed to highlight
the similarities and differences between TAMs that are
present in tumours arising in different tissues and, in
doing so, to define what can be considered comparable
or different in TAMs, beyond their M1-like and M2-like
phenotypes, which might only partially describe their
activity in vivo.
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Finally, additional TAM states might be discovered as
other cancer types are investigated, and/or some thera-
peutic interventions might lead to TAM states that have
not yet been revealed. Defining macrophage-associated
genes or programmes that are functionally involved in
tumour progression or regression might help to uncover
important TAM activities without defining macrophage
diversity in its entirety. Arguably, what matters most is
cell function, not phenotype.
Clinical relevance of TAM states
Once the diversity of TAMs is established, their func-
tionality needs to be addressed. Several approaches are
being considered to distinguish between ‘favourable’
and ‘unfavourable’ TAM states. Here, we discuss both
an indirect approach that consists of defining whether
TAM-related signatures have prognostic value and
a direct approach that involves assessing TAM func-
tion. Of note, in addition to TAMs, certain macro­
phages not located in tumours can influence tumour
progression24,37,38 and should also be considered.
Pan-macrophage markers and prognosis
Distinct TAM states can be divided into three groups:
those associated with unfavourable or with favoura-
ble clinical outcomes (thus possibly having tumour-
promoting or antitumour function, respectively),
and those not associated with clinical outcome (thus
potentially constituting bystander cells in the TME).
Consequently, therapeutic interventions should involve
agonists or antagonists, or be designed to not affect
certain states.
Box 1 | TAMs and other tumour-associated myeloid cells
Myeloid cells provide host defence against infection and injury, and include mononuclear
cells (such as macrophages and dendritic cells) and polymorphonuclear cells (such as
neutrophils, eosinophils and mast cells). All of these cells can infiltrate tumours and
regulate their growth.
• The macrophages present in tumours (or tumour-associated macrophages (TAMs))
often originate from circulating monocytes, which are derived from bone-marrow
haematopoietic stem cells. TAMs can also originate from tissue-resident cells, which
are seeded during embryogenesis and persist locally throughout life. TAMs from both
origins can affect tumour progression and have distinct functions61,67.
• Dendritic cells can present antigens and orchestrate antitumour T cell responses.
They are found in T cell areas of lymph nodes, where they activate CD4+ and CD8+
T cells, but also within tumours, where they control the fate of tumour-infiltrating
T cells74,199.
• Neutrophils can promote tumour growth. Their presence in tumours is often associ-
ated with a poor clinical outcome. Similarly, a high neutrophil to lymphocyte ratio in
blood often predicts a poor prognosis. Nevertheless, neutrophils are heterogeneous
cells, and some of them can have antitumour functions200,201.
• Eosinophils and mast cells can fight parasitic and other infections, but are also
involved in allergic reactions and can accumulate in tumours. The role of these
cells in cancer remains largely unresolved, although some of them could have either
antitumour or tumour-promoting functions202,203.
• Myeloid-derived suppressor cells (MDSCs) are a heterogeneous population of imma-
ture cells that suppress T cell responses and promote cancer growth. This terminology
has limitations: (1) the markers used to define MDSCs are also used to define bona
fide neutrophils and monocytes, which may or may not have immunosuppressive
functions; (2) this cell population might have functions other than immunosuppres-
sion, which should not be overlooked; and (3) mature myeloid cells, such as TAMs,
might also be immunosuppressive2.
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Initial studies used pan-macrophage markers to
reveal associations between TAM abundance and clin-
ical outcomes. These studies involved large cohorts
of patients across many cancer types, mostly with
advanced-stage cancers15. Typically, a high abundance
of TAMs was found to be associated with unfavourable
clinical outcomes, with some exceptions. CD68 is often
used for histological analyses as a pan-macrophage
marker, but its relevance might be limited because it
can be expressed by cells other than TAMs, and it might
not distinguish tumour-promoting TAMs from other
macro­phage populations. CD163, another marker often
used in these analyses, is associated with M2-like acti-
vation and might help to identify tumour-promoting
TAMs. Gene signatures have also been used to character-
ize TAMs in bulk RNA-seq studies39; for example, a TAM
signature including TNF, SIGLEC1, CCL8 and CSF1
was shown to be enriched in aggressive breast cancer
subtypes and associated with shorter disease-specific
survival26.
scRNA-seq-defined states and prognosis
A re-evaluation of TAM signatures is being performed
with single-cell transcriptomic data, and some have
been associated with a better or worse prognosis (Fig. 1a).
Studies using samples from patients with NSCLC and
mouse models of lung cancer revealed that, among all
TAMs, the MMP12-expressing state, which resembles
neither M1 nor M2 cells, is most strongly associated with a
poor clinical outcome30. A study of different cancer types
described other TAM signatures associated with tumour
progression24. For example, the SPP1-expressing TAM
state, which upregulates pro-angiogenic M2-associated
genes, was identified in multiple tumour types, including
NSCLC, CRC, ovarian cancer and pancreatic adenocar-
cinoma (PDAC), in which a high abundance of this cell
population was associated with a worse clinical outcome.
Additional TAM states with a pro-angiogenic signature
were found in tumours lacking SPP1-expressing TAMs,
including VCAN-expressing, INHBA-expressing and
FN1-expressing TAMs in melanoma, gastric cancer
and RCC, respectively; high expression of VCAN or
FN1 is also associated with worse clinical outcomes24.
Therefore, TAM states that are phenotypically distinct
might nevertheless exhibit overlapping functions that
contribute to tumour progression.
An scRNA-seq study investigating the evolution of
the TME during RCC progression40 showed an enrich-
ment of M2-like TAMs (expressing CD163, FOLR2 and
MS4A4A) with advancing disease stage. Additionally,
TAMs without M1/M2-demarcating features might be
functionally important. For example, scRNA-seq analy­sis
of human breast cancers revealed the existence of several
such TAM states, including CXCL10-expressing TAMs
with M1-like attributes, EGR1-expressing TAMs and
SIGLEC1-expressing TAMs with M2-like features,
and FABP5-expressing TAMs and APOE-expressing
TAMs that resemble lipid-associated macrophages.
Notably, FABP5-expressing TAMs were present at inva-
sive cancer regions, produced various immunoregula-
tory molecules (including PD-L1 and PD-L2) and their
presence was correlated with unfavourable survival28.
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a Prognostic value These data implicate FABP5-expressing TAMs as rele-

Brain vant therapeutic targets in patients with breast cancer,
– TREM2 although these cells would not have been identified as
tumour-promoting cells using the M2 terminology.
Lung
– • SPP1 FN1 VSIG4 CTSB TAM-related signatures and therapy
• TREM1
Monitoring of human tumours by scRNA-seq has also
Breast started to reveal changes in the TME following thera-
CXCL10 • FABP5 PDL1 PDL2 peutic intervention. Moreover, the presence of certain
• TNF SIGLEC10 CCL8 CSF1
TAM states has been associated with response to therapy
Liver or lack thereof (Fig. 1b). Such monitoring is likely to be
– TREM2 used more extensively in future studies, and will help
Kidney to formulate clearer hypotheses about the relevance of
• CD163 different states of TAMs and other cells in the context
–
• FABP5 of various therapeutic interventions. Yet, emerging
Pancreas studies are already highly informative.
– SPP1 An scRNA-seq study investigated the TME of
patients with breast cancer receiving anti-PD-1 anti-
Stomach bodies, and compared those with and those with-
– • INHBA out tumour-infiltrating T cell expansion following
• TREM2
treatment41. Pretreatment biopsy samples from patients
Ovary who subsequently had increased T cell infiltration
– SPP1 contained macrophages with distinct phenotypes. In
Colon and/or rectum comparison with patients without T cell expansion,
• SPP1 CD163 FOLR2 MS4A4A TAMs from these patients had higher expression
–
• TREM1 of genes encoding immune-checkpoint molecules
(such as CD274 and CD273, commonly referred to
Skin
– VCAN
as PDL1 and PDL2, respectively), pro-inflammatory
cytokines (CXCL9, CXCL10 and CXCL11) and pro-
teins from the interferon-stimulated gene (ISG) family
(RSAD2, ISG15 and IFI27). Conversely, a population
TAM state
of CX3CR1-expressing TAMs that also expressed C3,
Favourable TAMs
PLD4, TREM2 and CCL3, were largely absent from pre-
Unfavourable TAMs treatment biopsy samples from patients whose T cells
expanded, but present in patients whose T cells failed
to do so. The abundance of CX3CR1-expressing TAMs
remained much lower on treatment in patients whose
b Predictive value T cells expanded, suggesting that these cells might be
Melanoma24,209 mutually exclusive with tumour-reactive T cells in vivo.
Notably, other TAM states, including LYVE1+ TAMs
Anti-PD-1 VCAN
that co-expressed the M2 markers CD163, MRC1, IL10,
CD163+ PD-L1− FOLR2 and CD209, were detected at similar frequencies
in the two groups of patients.
Breast21,41 Additional studies have revealed associations
Anti-PD-1 PDL1 CXCL10 CX3CR1 TREM1
between the presence of certain TAM states and treat-
ISG C3 CCL3 ment outcomes in other disease contexts. Among
Anti-PD-1 + • CXCL9 MMP9 SPP1 TREM2
patients with triple-negative breast cancer (TNBC),
chemotherapy • CCL2 CXCL10 FN1 C3 those with a response to paclitaxel plus anti-PD-L1
• PLA2G2D antibodies initially had higher baseline levels of
TAMs that expressed MMP9, CXCL9, CXCL10 and
Kidney25,43 PLA2G2D, whereas non-responders had higher levels
Anti-PD-1 ISG of TAMs that expressed TREM2, SPP1, C3 and FN1
Sunitinib ISG (ref.21). In responders, MMP9-expressing TAMs were
co-enriched with CXCL13-expressing CD8+ T cells,
Fig. 1 | Prognostic and predictive value of TAM states. a | Reported tumour-associated whereas TREM2-expressing TAMs were inversely
macrophage (TAM) states with prognostic value in detectable tumours. Favourable and
correlated with CXCL13-expressing CD8 + T cells.
unfavourable TAM states are those for which an increased abundance within tumours
has been associated with shorter or longer overall survival, respectively. b | Reported
These data are consistent with those suggesting that
TAM states with possible predictive value. Favourable and unfavourable TAM states in an increased abundance of CXCL13-expressing CD8+
this context are those for which an increased abundance within tumours has been asso- T cells predicts a favourable response to treatment in
ciated with response to treatment or lack thereof, respectively. In both part a and part b, these patients42, and further indicate that TAMs can pro-
cancer types for which analyses of the TME have been performed are noted — some in foundly modulate tumour-reactive T cells in humans.
the setting of therapy21,24,25,41,43,209. ISG, interferon-stimulated gene. In patients with RCC, the presence of TAMs expressing

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ubiquitin-like proteins of the ISG family was also pre-
dictive of improved progression-free survival (PFS) with
sunitinib therapy43. Furthermore, in patients with mela-
noma, a lower baseline abundance of VCAN-expressing
TAMs (predicted from bulk RNA-seq datasets) was
associated with better responses (defined by RECIST
criteria) to immunotherapy24. An unresolved question
is the extent to which the TAM states identified in these
studies resemble or differ from each other; addressing
this question will require dedicated approaches that we
discuss below.
Other scRNA-seq studies have also indicated that
favourable TAMs can concomitantly upregulate genes
that might attenuate the antitumour immune response.
In a study involving patients with RCC, in those with
a response to anti-PD-1 antibodies, TAMs broadly
shifted towards an M1-like phenotype, with increased
pro­teasome function and antigen presentation; however,
the same TAMs upregulated several immunosuppres-
sive genes25. Similarly, neoadjuvant anti-PD-1 antibody
treatment in patients with recurrent glioblastoma trig-
gered a CD8+ T cell intratumoural response as well as
changes in TAMs, suggesting an interferon response
that might facilitate T cell recruitment and activation.
However, myeloid cells continued to express high levels
of immunosuppressive factors43, a phenomenon that
might prevent fully fledged antitumour responses after
anti-PD-1 antibody treatment and/or promote the devel-
opment of resistance to treatment. In addition, some
drugs might inadvertently activate tumour-promoting
TAMs, as seems to be the case with paclitaxel in patients
with TNBC, thus compromising the efficacy of ICIs21.
These studies only provide correlations between cell
state abundance and clinical outcome, do not indicate
a causal involvement of a given TAM state in tumour
Box 2 | Tools for investigating TAM function and clinical relevance
Phenotypic and functional characterization of TAMs will be crucial to guide therapeutic
decisions. Although the evidence on these variables is limited, new strategies are
becoming available to investigate them using mouse models and patient-derived
tumour samples.
Mouse models
Most of our current knowledge of TAM function comes from experiments in syngeneic
mouse models, owing to the availability of a vast armamentarium of mouse strains and
tools for mechanistic studies. In this regard, defining which TAM states in mice resemble
those in patients is important. The value of cross-species comparisons remains limited,
but current information indicates that phenotypic differences might exist between
human and mouse macrophage states30,204. These differences suggest potential chal-
lenges when using animal models as surrogates for human disease to study TAMs, and
indicate the need to define which TAM states are most relevant to assess mechanisti-
cally in these models. Humanized mice, such as MITRG and MISTRG, provide alternative
models205,206. These models might be a step closer to the human context, and indeed
TAMs from these mice express M2 markers such as CD163 and CD206; however, the
extent to which these mice recapitulate the different states of human TAMs remains
unknown.
Ex vivo models
Tumour explants190, organoids207 and cell co-cultures50 should also be considered as
useful models. New organoid developments, such as submerged Matrigel culture208,
are increasingly relevant to co-culture immune cells with other cell types, including
macrophages. Although these reductionist approaches do not fully recapitulate
the complexity and dynamics of tumour microenvironments in vivo, they enable
assessment of human cell functions and drug responses at a mechanistic level.
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progression or treatment response, and were performed
in a limited number of patients. Yet, other multidimen-
sional approaches, which are more feasible at larger
scale, are also revealing the relevance of TAMs in ther-
apy. For example, quantitative and spatially resolved
multispectral imaging of tumour tissue sections iden-
tified CD163+ PD-L1− TAMs that were associated with
lack of response to anti-PD-1 antibodies in pretreatment
melanoma specimens44.
Mechanistic studies of TAM functions
The functions of the TAM states identified in scRNA-seq
studies so far remain poorly understood; however, most
often, the TME of growing tumours seems to foster the
presence of TAM phenotypes that are associated with
tumour promotion. Accordingly, TAMs can produce
factors that enable most of the hallmarks of cancer,
including sustaining proliferative signalling, evading
growth suppression and immune destruction, activat-
ing invasion and metastasis, inducing angiogenesis and
resisting cell death2,4,45. Several tools are available to
investigate the functions of TAMs and their relevance
to treatment (Box 2).
Given the plasticity of macrophages, those at dif-
ferent locations within the same tumour might receive
different signals from their immediate microenviron-
ment and develop distinct functions. For example,
obesity can suppress the antitumour activity of TAMs46,
whereas cancer cell-derived succinate47, histamine and
allergic reactions48, and B cell-derived metabolites49
can all foster the generation of tumour-promoting
TAMs. Furthermore, cancer cells can amplify
tumour-promoting TAMs by producing factors includ-
ing CSF1 (ref.50), the E3 ubiquitin protein ligase COP1
(ref.51), or the metabolite β-glucosylceramide that sim-
ulates an unconventional endoplasmic reticulum stress
response52. Some of these processes preferentially occur
in the setting of antitumour CD8+ T cell infiltration, sug-
gesting that a TAM response can be viewed, at least in
part, as an adaptive resistance mechanism. Accordingly,
intravital imaging studies have shown that physical
interactions between TAMs and CD8+ T cells can be
long-lasting and promote T cell exhaustion53.
Association of TAMs with treatment outcomes
TAM functions have also been dissected following ther-
apeutic intervention. Indeed, TAMs can substantially
affect the outcome of various treatment modalities,
including ICIs, radiation, cytotoxic agents and small
molecules2, and therefore their influence in therapy
needs to be harnessed. For example, TAMs can limit
the efficacy of ICIs by capturing anti-PD-1 antibodies
from the surface of PD-1+ T cells. This process depends
on interaction of the antibody Fc-domain glycans with
FcγRs on TAMs, and can be alleviated by preventing
this interaction54. The relevance of this process is being
tested clinically with tislelizumab, a modified anti-PD-1
antibody that does not bind to FcγRs.
In some settings, TAMs might limit the efficacy of
radiotherapy. Indeed, combining radiation with the
CSF1R inhibitor sotuletinib controlled glioblastoma
progression in mice more efficiently than each modality
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alone55. By contrast, some TAMs might contribute to the
efficacy of radiotherapy, for example, when combined
with therapeutic nanoparticles. Indeed, TAMs adjacent
to the microvasculature can elicit ‘dynamic bursts’ of
drug extravasation after radiation of tumour xenografts
in mice, thereby enhancing drug uptake in neighbour-
ing cancer cells56. In other preclinical models, radiation
reduced the number of monocyte-derived macrophages,
which promoted the survival of antitumour T cells in
liver metastases38, and delayed the progression of brain
metastases, albeit only transiently57.
TAMs can have additional roles during anticancer
treatment. For example, PARP inhibitors enhanced both
antitumour and tumour-promoting characteristics of
macrophages through reprogramming of glucose and
lipid metabolism in a mouse model of TNBC58. Thus,
macrophage-mediated immunosuppression might be
a downside of PARP inhibitor therapy. Finally, TAMs
might contribute to the antitumour potency of some
monoclonal antibodies. For example, the antitumour
activity of the anti-SLAMF7 antibody elotuzumab in
a xenograft mouse model required macrophages and
antibody-dependent cellular phagocytosis (ADCP) of
cancer cells59.
Towards a unified definition
Although the diversity of TAMs remains poorly under-
stood, the available evidence clearly shows that it is broad.
The use of additional analytical methods will surely pro-
vide further insights into the complexity of these cells.
Indeed, cell states can be defined not only by transcrip-
tomic data, but also by other measurable dimensions,
such as proteomic and epigenomic data, and bodily
localization. The diversity of TAMs further lies in their
multiple origins; notably, TAMs include tissue-resident
cells that self-renew locally independently of adult
haematopoiesis60–64, as well as short-lived cells that are
derived from circulating monocytes65–68. Integrating
these variables to define TAMs will reveal even more
diversity57,61,69–71. TAM heterogeneity is daunting in itself,
but the results obtained by incorporating additional vari­
ables to define different cellular states could offer sub-
stantial benefits. For example, spatial analyses are likely
to enable a better understanding of how different pop-
ulations of TAMs interact with other cells and how they
operate within the TME72. Furthermore, the identifica-
tion of cell-surface proteins expressed in distinct TAM
states has at least two advantages: (1) it should enable the
study of newly identified cell states with less expensive
and therefore more easily applicable techniques, such
as immunohistochemistry and flow cytometry; and (2)
it should facilitate the development of new experimen-
tal drugs that target relevant TAM states while sparing
others, including macrophages in non-malignant tissue.
Furthermore, to consolidate our understanding of
TAM diversity, combining and comparing scRNA-seq
data generated by different research laboratories is an
urgent goal. Performing meta-analyses is technically
complicated by the fact that scRNA-seq studies often
use different protocols, platforms and bioinformatics
approaches; however, this endeavour is urgent given
the rapidity at which new studies are published and the
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need to integrate them with existing knowledge. Several
computational methods can be considered, such as those
projecting the new scRNA-seq data onto single-cell ref-
erence atlases73, or others directly comparing cell states
across different studies74. Meta-analyses have started
to reveal important information about mononuclear
phagocytes in various tissues75 and about TAMs in
diverse human tumours24,76. Such meta-analyses can
reveal important features of TAM states, including
whether some of them are dependent on the tumour
tissue in which they reside or, on the contrary, are con-
served across tissues and cancer types. They can also
reveal gene expression programmes35 that are shared by
multiple TAM states and are functionally important in
each one24. In addition, meta-analyses help to identify
whether different laboratories have given distinct names
to TAM states that are phenotypically similar, and thus
can occasionally lead to simplifying terminology.
Macrophage-targeting agents
The diversity of TAMs suggests that different approaches
can be taken to exploit them for therapeutic purposes,
including elimination, containment or suppression of
tumour-promoting macrophages, amplification or acti-
vation of antitumour macrophages, subtype switching,
or any combination thereof (Fig. 2). As discussed here,
most of the agents currently used are thought to inhibit
tumour-promoting macrophages, whereas others are
used owing to their agonistic properties against antitu-
mour TAMs. A first caveat for therapeutic interventions
targeting TAMs is that, ideally, they should not affect
macrophages that are not related to cancer, such as the
many tissue-resident macrophages that contribute to
the homeostasis of non-malignant organs. A second
caveat is that these agents will probably be insufficient
to control cancer in a durable manner if used as single
agents. This limited efficacy might be explained in part
by the fact that long-term tumour control requires active
engagement of the adaptive immune system, which
might not be fully triggered by TAM-targeting agents. In
addition, mechanisms of resistance to treatment are likely
to emerge. Therefore, the agents discussed here (Table 1;
Supplementary Tables 1 and 2) should be considered as
entities to be used in combination or sequential therapies
to achieve durable responses. Finally, the extent to which
certain approaches targeting TAMs are better suited to
specific tumour types or sites remains unclear. Given the
diversity of both TAMs and the resistance mechanisms
that might be triggered by TAM-targeting agents, a bet-
ter understanding of the mode of action of these agents,
when used either alone or in combination with other
drugs, will be important. This knowledge should enable
a rational definition of treatment modalities that control
disease progression in a greater number of patients and
are effective against a wider range of cancer types.
CSF1–CSF1R inhibitors
CSF1R is a chemokine receptor expressed by macro­
phages, and across all TAM states, whereas CSF1,
its ligand, can be produced by cancer cells and other
components of the TME, such as tumour-associated
neutrophils. Activation of the CSF1–CSF1R (CSF1(R))
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signalling pathway promotes the production and prolifer-
ation of macrophage precursors and/or their recruitment
and retention within inflamed sites, such as tumours14,77.
In experimental models, targeting CSF1(R) can either
reduce TAM numbers 78 or alter their phenotypes
suppressing tumour-promoting features55,79,80, leading to
reduced tumour progression in some models. CSF1(R)
targeting rarely leads to tumour elimination, but the effi-
cacy of treatment can be increased when combined with
other therapeutic agents2.

1. Preventing TAM recruitment 2. Depleting TAMs 3. Reprogramming TAMs

TLR
CXCR4 Tumour TREM1 CD40
parenchyma PI3Kγ TREM1
CLEVER-1
CSF1R
TREM2
CCR2 HDACs
TREM2 BACE1
CCR5 CSF1R
Blood vessel MARCO
CSF1(R) inhibitors
CSF1(R) inhibitors CCR2–CCL2 inhibitors See 1
AMG 820, ARRY-382, Carlumab, MLN1202, • Tissue remodelling factors: Activators of T, NK
TREM1 inhibitor MMPs, cathepsins and B cell responses:
axatilimab, sotuletinib,
PF-04136309
PY159 • Proangiogenic factors: interferons,
cabiralizumab, CXCR4 inhibitors
emactuzumab, TREM2 inhibitor VEGF, IL-8, semaphorin-4D chemokines, IL-12,
Motixafortide,
LY3022855, pexidartinib PY314 • Immunosuppressive factors: ISGs
LY2510924, mavorixafor
IL-10, TGFβ, PD-L1, XBP1
ANG2-targeted agents CCR5–CCL5 inhibitors FRβ
Trebananib, BI836880 Leronlimab, maraviroc CD40 agonists PI3K inhibitors
Sotigalimab, ChiLob7/4, Eganelisib, umbralisib,
selicrelumab, dacetuzumab, tenalisib
Example of a CAR T-cell mitazalimab, SEA-CD40, 2141 V-11 TLR agonists
Engineered construct designed to CLEVER-1 inhibitors Resiquimod, vidutolimod
macrophage deplete TAMs Bexmarilimab TREM inhibitors
HDAC inhibitors See 2
5 Vorinostat, TMP195
IFNγ,
Cancer cell CD40L IL-18 GM-CSF IL-12
RN7SL1
TAM CAF
B cell 1
T cell
TAN Examples of CAR T-cell constructs designed
Monocyte for TAM reprogramming
4 2
DC
4. Exploiting antitumour functions of TAMs

Blood SIRP1α CD47

3 vessel
Tumour Cancer
APMAP TAM cell
microenviroment

SIGLEC10 CD24
5. Infusing engineered macrophages
HER2-targeted SIRP1α–CD47 inhibitors
CAR-I mac IL12-GEMys CAR-147 CAR M AO-176, BI 765063, CC-90002, evorpacept, magrolimab,
SRF231, TTI-621, IBI188, ZL-1201
SIGLEC10–CD24 inhibitors
CD24–Fc

Cytokines IL-12 MMPs Targets

Macrophages engineered to reprogramme the TME and drugs
and/or eliminate cancer cells

Fig. 2 | TAM-targeting agents and engineered macrophages for the
treatment of solid tumours. Untreated detectable solid tumours are often
infiltrated by a variety of tumour-promoting immune cells, including
tumour-associated macrophages (TAMs), which locally suppress the
infiltration and/or activity of CD8+ T cells and other antitumour immune cells.
TAMs can also promote angiogenesis and foster cancer cell survival, invasion
and metastasis. A range of agents targeting and/or exploiting macrophages
have been developed and are listed according to their desired biological
effects. Successful therapeutic targeting of TAMs should result not only in a
reduction in tumour burden, but also in reprogramming of the tumour
microenvironment characterized by increased infiltration of cytotoxic T cells,
decreased numbers of M2-like TAMs, increased numbers of M1-like
TAMs, and reduced neoangiogenesis. APMAP, adipocyte plasma
membrane-associated protein; CAF, cancer-associated fibroblast; CAR,
chimeric antigen receptor; CAR M, CAR macrophage; DC, dendritic cell; FRβ,
folate receptor-β; HDAC, histone deacetylase; ISG, interferon-stimulated
gene; NK, natural killer; TAN, tumour-associated neutrophil; TLR, Toll-like
receptor; TREM, triggering receptor expressed on myeloid cells.

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Table 1 | Clinical trials involving TAM-targeting agents in combination with other drugs
Agent Combination Trial Cancer type Patients SDR ORR Reported biological Clinical trials registry
partners phase (n) (%) (%) responses identifiera
ANG2
Trebananib Anti-PD-1 I Solid tumours 18 22 7 NR NCT03239145
Chemotherapy III Ovarian cancer 1,056 0 0 NR NCT01493505
CCR2–CCL2
Carlumab Chemotherapy I Solid tumours 19 38 5 ↓ Free CCL2 (transient) NCT01204996
PF-04136309 FOLFIRINOX I PDAC 39 14 49 ↓ TAMs NCT01413022
CCR5–CCL5
Leronlimab Chemotherapy I/II CCR5+ TNBC 48 NR NR ↓ TAMs NCT03838367
Maraviroc Anti-PD-1 I CRC 20 5 5 NR NCT03274804
Maraviroc Chemotherapy I CRC 8 37 37 ↑ M1-like TAMs NCT01736813
CD40
Sotigalimab Anti-PD-1, I PDAC 30 30 58 NR NCT03214250
chemotherapy
Anti-PD-1 I/II Melanoma, 19 31 21 ↑ CD8+ T cells, CXCL9 NCT03123783
NSCLC and CXCL10
Selicrelumab Chemotherapy I PDAC 22 53 40 ↑ Inflammatory NCT00711191
cytokines, ↓ B cells
Chemotherapy I Solid tumours 32 NR 20 ↑ Inflammatory NCT00607048
cytokines, ↓ B cells
Anti-CTLA4 I Melanoma 22 NR 27 ↑ T cells NCT01103635
Chemotherapy I Mesothelioma 15 53 40 ↓ CD19 B cells, ↑ CD27
+ +
ACTRN12609000294257
B cells
Anti-CSF1R I Solid tumours 38 NR 41 ↑ CD8+ T cells, ↓ B cells NCT02760797
and monocytes
Chemotherapy I PDAC 16 NR NR ↓ M2-like TAMs, ↑ DC NCT02588443
activation, CXCL10 and
CCL22
Anti-PD-L1 I Solid tumours 80 NR 9 NR NCT02304393
CD47–SIRP1α
AO176 Chemotherapy, I/II Solid tumours 27 26 3 NR NCT03834948
anti-PD-1
CC-90002 Rituximab I CD20+ NHL 28 12 13 NR NCT02367196
Evorpacept Anti-PD-1 I HNSCC, 52 NR 40 NR NCT03013218
gastroesophageal
cancer
Trastuzumab I HNSCC, 30 NR 20 NR NCT03013218
gastroesophageal
cancer
Magrolimab Anti-PD-L1 I Solid tumours 19 5 56 NR NCT03558139
Azacitidine I AML, MDS 24 NR 53 NR NCT03248479
Rituximab I NHL 22 NR 73 NR NCT02953509
Cetuximab I/II Solid tumours 78 23 2 ↑ TAMs NCT02953782
TTI-621 Rituximab I B cell NHL 164 NR 13 NR NCT02663518
Anti-PD-1, I Lymphoma 19 NR 5 NR NCT03530683
anti-PD-L1
CSF1R–CSF1
Axatilimab Anti-PD-L1 I Solid tumours 32 9 0 ↓ Monocytes and NCT03238027
M2-like TAMs
Sotuletinib Anti-PD-1 I/II Solid tumours 49 45 NR NR NCT02829723
Cabiralizumab Anti-PD-1+ I Solid tumours 26 31 4 NR NCT03502330
anti-CD40

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Table 1 (cont.) | Clinical trials involving TAM-targeting agents in combination with other drugs
Agent Combination Trial Cancer type Patients SDR ORR Reported biological Clinical trials registry
partners phase (n) (%) (%) responses identifiera
CSF1R–CSF1 (cont.)
Emactuzumab Chemotherapy I Solid tumours 54 13 7 NR NCT01494688
Anti-CD40 I Solid tumours 37 40 41 ↓ Monocytes and B cells, NCT02760797
↑ CD8+ T cells
Pexidartinib MEK inhibitor I Genitourinary 2 100 0 NR NCT03158103
cancers
Chemotherapy I Advanced-stage 38 34 16 ↓ Monocytes NCT01525602
solid tumours
CXCL12–CXCR4
Motixafortide Anti-PD-1 I PDAC 15 10 5 ↑CD8+ T cells NCT02907099
Anti-PD-1 II PDAC 37 31 3 ↑ CD8+ T cells, ↓ Treg cells NCT02826486
Chemotherapy, II PDAC 22 45 32 NR NCT02826486
anti-PD-1
LY2510924 Chemotherapy, I Leukaemias 11 NR 36 Incomplete suppression NCT02652871
anti-PD-1 of CXCR4
Anti-PD-L1 I Solid tumours 9 0 0 NR NCT02737072
Mavorixafor Anti-PD-1 I Melanoma 13 NR NR ↑ CD8 T cells and IFNγ
+
NCT02823405
PI3K
Eganelisib Anti-PD-1 I Solid tumours 31 NR 6 ↑ CXCL9, CXCL10, NCT02637531
PD-L1 and T cell
activation
Umbralisib Brentuximab vedotin I Hodgkin 11 NR 64 NR NCT02164006
lymphoma
TLRs
Resiquimod NY-ESO-1 vaccine I/II Melanoma 6 NR NR ↑ NY-ESO-1-specific NCT00821652
CD4+ T cells
Representative list of clinical trials with agents targeting TAMs and for which clinical or biological responses have been reported. Targets are listed in alphabetical
order. Additional trials are included in Supplementary Tables 1 and 2. The results of each trial should be contextualized according to the type of tumour treated,
the drug combination used, and the parameters used to measure clinical outcomes. AML, acute myeloid leukaemia; CRC, colorectal cancer; DC, dendritic cell;
FOLFIRINOX, folinic acid, fluorouracil, irinotecan and oxaliplatin; HNSCC, head and neck squamous cell carcinoma; MDS, myelodysplastic syndrome; NHL,
non-Hodgkin lymphoma; NR, not reported; NSCLC, non-small-cell lung cancer; ORR, overall response rate; PDAC, pancreatic ductal adenocarcinoma; SDR, stable
disease rate; TAM, tumour-associated macrophage; TNBC, triple-negative breast cancer; Treg cell, regulatory T cell. aACTRN, Australia New Zealand Clinical Trials
Registry; NCT, ClinicalTrials.gov.

Various drugs targeting CSF1(R) have been or
are being tested in clinical trials. These drugs include
small-molecule inhibitors (such as sotuletinib, ARRY-
382 and pexidartinib) and antagonistic monoclonal
antibodies (such as emactuzumab, cabiralizumab,
LY3022855 and axatilimab). Emactuzumab has shown
efficacy as a single agent in patients with tenosynovial
sarcoma, a tumour type characterized by CSF1 overex-
pression (NCT01494688)78,81. In addition, both alone
or in combination with paclitaxel, emactuzumab can
reduce the number of M2-like macrophages in patients
with solid tumours (NCT01494688) 82. However,
CSF1(R)-targeting agents have mostly had limited effi-
cacy as single agents in clinical settings other than ten-
osynovial sarcoma; current trials are mostly evaluating
them in combination with other agents, including ICIs
or chemotherapeutic agents4,83. Two phase I trials have
reported responses: one found an objective response
with sotuletinib and the anti-PD-1 antibody spartal-
izumab in one patient with head and neck squamous
cell carcinoma (NCT02829723)84, and the other found
prolonged stable disease with pexidartinib and the
anti-PD-L1 antibody durvalumab in two patients with
MSI-H CRC (NCT02777710)85. No overt toxicity was
reported with CSF1(R)-targeting agents as monother-
apy or in combination with other immunotherapies or
standard chemotherapies.
Experimental studies have started to evaluate poten-
tial mechanisms leading to therapeutic resistance to
CSF1(R)-targeted agents. For example, in a glioblastoma
mouse model in which IGF1R–PI3K signalling was acti-
vated, the emergence of this pathway can lead to resistance
to sotuletinib, which therefore involves a crosstalk between
TAMs and cancer cells. Combining IGF1R or PI3K block-
ade with CSF1R inhibition delayed tumour progression
in these mice86. Another resistance mechanism to CSF1R
targeting, discovered in a mouse model of breast can-
cer brain metastasis, involves CSF2RB (also known as
CD131)–STAT5-mediated pro-inflammatory TAM
activation71; combining STAT5 signalling inhibition with
CSF1R blockade-induced tumour regression in this model.
These seminal studies highlight how pressure on macro­
phages from drug exposure can accelerate the emergence
of resistant cancers. Therefore, a better understanding of
how to control or prevent such evolution of resistance to
treatment in a clinical setting is urgently needed.

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CCL2–CCR2 inhibitors
The chemokine receptor CCR2 is expressed by inflam-
matory monocytes, which are circulating cells that can
differentiate into TAMs upon extravasation into the
tumour stroma. CCR2 binds to the chemokine CCL2,
which is produced by many cancer cell types and stromal
cells14. CCL2 overexpression can be driven by genetic
mutations, such as in GNA13, and promote immune
evasion87, and is often associated with a poor prognosis
in patients88. In mice, inhibition of CCL2–CCR2 signal-
ling can limit the accumulation of inflammatory mono-
cytes in tumours, and can also delay cancer metastasis
and delay tumour progression in mice68. Therefore, at
least some tumours might rely on this pathway to recruit
and retain TAMs with tumour-promoting functions.
However, interruption of exposure to CCL2-targeting
agents can accelerate monocyte accumulation in mouse
tumours and promote cancer growth 89, suggesting
the importance of prolonged administration of drugs
targeting the CCL2–CCR2 pathway.
Several antagonistic antibodies and small-molecule
inhibitors targeting CCR2 or CCL2 have been tested in
patients with cancer. For example, multiple early phase
trials investigated the anti-CCL2 antibody carlumab
in patients with solid tumours refractory to previous
standard-of-care (SOC) therapies. The findings indi-
cate an acceptable safety profile but a lack of objective
antitumour responses (NCT01204996) 90. Another
trial investigated the small-molecule CCR2 inhibitor
PF-04136309 in patients with non-metastatic pancreatic
cancer91. The number of TAMs was lower in tumours
from patients treated with PF-04136309 plus folinic acid,
fluorouracil, irinotecan and oxaliplatin (FOLFIRINOX)
compared with those receiving FOLFIRINOX alone
(NCT01413022). The combination treatment triggered
additional changes in the TME, including a concomitant
decrease in regulatory T cells, and an increase in effector
T cells. A single-arm trial combining the CCR2 inhibitor
CCX872 with FOLFIRINOX indicated the possibility for
increased overall survival (OS) in patients with locally
advanced or metastatic, non-resectable pancreatic can-
cer, and with no safety concerns (NCT02345408)92.
Intriguingly, favourable OS correlated with lower
peripheral blood monocyte counts at baseline, but no
information on TAM abundance was provided. Further
clinical data are needed to assess the effect of this com-
bination treatment on tumour progression and patient
survival.
CCR5 inhibitors
The chemokine receptor CCR5, which can be expressed
by TAMs, other myeloid cells and T cells, is activated by
a variety of inflammatory cytokines, including CCL3,
CCL4 and CCL5, which might be expressed by can-
cer cells or other cells in the TME. CCL5 and CCR5
are overexpressed in various cancer types (breast93,
colorectal94 and melanoma95 to name a few), suggesting
that CCL5–CCR5 signalling promotes tumour progres-
sion. Accordingly, various CCR5 inhibitors, including
maraviroc, vicriviroc, TAK-779 and anibamine, have
demonstrated antitumour effects in mouse models of
cancer96. The CCR5 inhibitors maraviroc, vicriviroc and
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leronlimab, and the dual CCR2 and CCR5 antagonist
BMS-813160 have been tested clinically. A phase I trial
involving patients with metastatic CRC or liver metas-
tasis from CRC showed that maraviroc treatment can
favourably alter TAM phenotypes, reducing the expres-
sion of M2-like markers (NCT01736813)94. In addition,
the FDA has granted Fast Track designation to leron-
limab combined with carboplatin for the treatment of
patients with CCR5+ metastatic TNBC97.
CXCL12–CXCR4 inhibitors
The chemokine receptor CXCR4, expressed by some
TAMs and other cells, can promote macrophage recruit-
ment to tumours by binding its ligand CXCL12, which
can be expressed by tumour-associated stromal cells.
CXCR4–CXCL12 signalling not only leads to TAM
chemotaxis along CXCL12 gradients, but also activates
cellular programmes that promote cancer cell prolifer-
ation and survival98. In combination with cyclophos-
phamide, the CXCR4 inhibitor plerixafor reduces TAM
accumulation in various tumour models and delays
tumour progression99. Further preclinical evidence
from organotypic cultures of human PDAC shows that
CXCR4 blockade can mobilize CD8+ T cells to tumours
and enhance the antitumour activity of anti-PD-1
antibodies100.
Accordingly, in the phase IIa COMBAT trial, the
peptide CXCR4 antagonist motixafortide increased
the efficacy of ICIs in patients with metastatic PDAC
(NCT02826486)101. The data suggest that the com-
bination treatment might decrease both TAMs and
tumour-infiltrating regulatory T cells, and foster a CD8+
T cell-inflamed TME. The ability of CXCR4-targeting
agents, such as plerixafor, to reduce the influx of TAMs
after radiation, a concept called macrophage exclusion
after radiotherapy, is also being tested102. Numerous other
phase I clinical trials are underway, which combine, for
example, the CXCR4 antagonist peptide LY2510924
with durvalumab in patients with advanced-stage solid
tumours, motixafortide with pembrolizumab (with an
overall response in 10 of 38 patients103) or other immu-
notherapeutics such as cemiplimab (NCT04543071) in
patients with PDAC or with the anti-PD-L1 antibody
atezolizumab in patients with acute myeloid leukae-
mia (AML) (NCT01838395), and the small-molecule
CXCR4 antagonist mavorixafor (given orally) with pem-
brolizumab in patients with advanced-stage melanoma
(NCT02823405).
SIRPα–CD47 antagonists
Tyrosine protein phosphatase non-receptor type sub-
strate 1 (commonly known as SIRPα) is an inhibitory
receptor expressed mostly by macrophages that interacts
with the ‘don’t-eat-me’ signal CD47 (ref.104). CD47 is a
cell-surface protein expressed ubiquitously by human
cells and often overexpressed by cancer cells. In pre-
clinical models, blockade of SIRPα–CD47 signalling,
for example with antagonistic anti-CD47 antibodies or
fusion proteins, can induce TAMs to phagocytose cancer
cells and stimulate antitumour T cell responses105–107.
The clinical relevance of inhibiting SIRPα–CD47
signalling has been confirmed in various settings.
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For example, the anti-CD47 antibody magrolimab has
shown clinical success in patients with non-Hodgkin
lymphoma, in whom it was associated with an over-
all response rate (ORR) of 73% when combined with
the anti-CD20 antibody rituximab (NCT02953509)108.
Additionally, in a phase Ib trial involving patients with
AML who were not eligible for intensive chemotherapy,
the ORR was 63% (NCT02678338)109. In 2020, the FDA
assigned Breakthrough and Fast Track designations
to magrolimab in combination with azacitidine for
the treatment of adult patients with newly diagnosed
myelodysplastic syndromes, diffuse large B cell lym-
phoma or follicular lymphomas. Magrolimab is also
being explored in combination with the anti-EGFR
antibody cetuximab in patients with solid tumours
(NCT02953782). This combination might provide ben-
efit to patients with CRC (with an overall response in
2 of 30 patients)110. In preclinical models, magrolimab
facilitates macrophage-mediated phagocytosis when
combined with anti-HER2 antibodies111, and thus this
approach could be tested in patients with breast can-
cer. Despite CD47 expression by non-malignant cells,
no overt toxicity was observed using CD47 targeting
approaches in patients. As an exception, treatment
with anti-CD47 antibodies can trigger on-target anae-
mia, which is manageable with prime and maintenance
dosing of these agents108. Also, it is possible that some
of these agents might trigger toxicities when used in
combination with other drugs112.
TREM inhibitors
Of the six isoforms of the triggering receptor expressed
on myeloid cells (TREM) family, TREM2 has received
the most attention in cancer research owing to its
expression on a subset of TAMs across various tumour
types113. TREM2-mediated signalling can control car-
dinal features in macrophages, including cytokine pro-
duction, migration and survival114. For example, TREM2
binding to phospholipids can simultaneously abrogate
the production of pro-inflammatory cytokines and
reactive oxygen species, and increase the production
of immunosuppressive factors. As a result, TREM2+
TAMs are often associated with a tumour-promoting
M2-like phenotype, and increased TREM2 expression
levels in tumour tissues might correlate with poorer
survival115–117. Preclinical studies have further indi-
cated a role for TREM2 in promoting cancer progres-
sion. For instance, the growth of cancer xenografts is
delayed in Trem2-deficient mice and in wild-type mice
receiving anti-TREM2 antibodies, and both responded
more effectively to anti-PD-1 antibodies than wild-type
mice not exposed to antibodies115. PY314 is a neutral-
izing anti-TREM2 humanized monoclonal antibody
currently being tested in a trial involving patients with
advanced-stage solid tumours refractory to all SOC
therapies, including anti-PD-1 antibodies. PY314 spe-
cifically binds TREM2 and depletes TREM2-expressing
TAMs through antibody-dependent cellular cytotoxicity
and/or ADCP.
TREM1, another TREM isoform that is expressed
by some myeloid cells, also controls inflammatory
processes118. High expression of TREM1 is associated
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with unfavourable clinical outcomes in patients with
certain solid tumour types 119–121. TREM1-targeted
agents, including the agonistic anti-TREM1 antibod-
ies PY319 and PY159, are being investigated in phase I
trials involving patients with refractory solid tumours
(NCT04682431).
SIGLEC10–CD24 inhibitors
Sialic acid-binding immunoglobulin-like lectins
(SIGLECs) belong to the immunoglobulin superfamily
and have important roles in the regulation of immune
cell functions. Among them, SIGLEC10 is an inhibitory
I-type lectin that can be expressed by TAMs and binds the
don’t-eat-me signal CD24, a small, heavily glycosylated,
glycosylphosphatidylinositol-anchored, cell-surface pro-
tein that can be overexpressed in several solid tumour
types. In preclinical models, xenografts in Cd24-deficient
mice or in wild-type mice exposed to an anti-CD24 anti-
body had a macrophage-dependent reduction in tumour
growth122. As such, the SIGLEC10–CD24 axis acts as an
innate immune checkpoint.
The expression of CD24 and CD47 is inversely cor-
related in patients with diffuse large B cell lymphoma,
suggesting the existence of distinct, and perhaps mutu-
ally exclusive anti-phagocytic signals that can pro-
mote cancer immune evasion. Consequently, some
tumours might respond differently to treatment with
anti-CD24 versus anti-CD47 antibodies. The ability of
CD24–Fc, a recombinant agonistic fusion protein, to
limit immunotherapy-related adverse events is being
tested in patients with advanced-stage solid tumours or
specifically with metastatic melanoma, and this agent
might also have antitumour activity. Chimeric antigen
receptor (CAR) natural killer (NK) cells123 and CAR
T cells124 targeting CD24, as well as antibody–drug con-
jugates, have also been developed and have antitumour
activity in vitro or in xenograft models.
PI3Kγ inhibitors
TAMs expressing the enzyme PI3Kγ can promote
immuno­s uppression and tumour angiogenesis 125.
Accordingly, T cell activation and antitumour activity
are more effective in mice deficient in PI3Kγ or exposed
to the PI3Kγ inhibitors IPI549 or TG100-115 than in
their wild-type counterparts not exposed to these agents,
particularly when PI3Kγ inhibitors are combined with
anti-PD-1 antibodies126. Several PI3K inhibitors are
approved for different cancer indications, including
idelalisib, which is used in combination with rituximab
in patients with chronic lymphocytic leukaemia (CLL),
non-Hodgkin lymphoma and other haematological
malignancies127. Of note, idelalisib seems to have more
potent activity against PI3Kδ, and perhaps its effect in
TAMs is indirect, at least in part.
CD40 agonists
CD40, a costimulatory molecule of the TNFR super-
family, is expressed by some macrophages, dendri­
tic cells (DCs), B cells, endothelial cells and some stromal
cells, such as bone marrow mesenchymal cells. CD40
signalling in macrophages and DCs can stimulate IL-12
production and promote T helper 1 (TH1) cell-dependent
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immunity, including the production of IFNγ by lympho-
cytes and the upregulation of MHC class I molecules,
which are features typically associated with antitumour
activity128. Agonistic anti-CD40 antibodies might be par-
ticularly useful to treat tumours that are poorly infiltrated
by T cells, because they could activate antigen-presenting
cells (such as macrophages or DCs) that would foster
T cell activation and expansion within tumours.
Agonistic anti-CD40 antibodies had substantial anti-
tumour activity as single agents in several preclinical
models129,130. Also, the combination of these antibodies
with other agents, such as anti-CSF1R50 or anti-PD-1
antibodies131, can effectively control tumour progres-
sion in animal models, including in those with resist-
ance to other agents. In mice, both macrophages and
DCs probably contribute to tumour control in response
to these antibodies. However, macrophages that reside
in non-malignant tissues can also be activated by ago-
nistic anti-CD40 antibodies, which might result in
immunotherapy-related adverse events132. Therefore, a
better understanding of how to maximize the antitumour
activity of these agents while preventing concomitant
activation of unwanted toxicities is important.
Seven agonistic anti-CD40 antibodies are currently
being tested in early phase clinical trials. Five of them
(SEA-CD40, sotigalimab, mitazalimab, ChiLob7/4 and
2141-V11) are of IgG1 isotype and therefore require
selective FcγR engagement, while the other two (seli-
crelumab and CDX-1140) are IgG2 antibodies. This
distinction could be important because the Fc region of
antibodies can strongly affect their overall functional-
ity, either positively or negatively, on the basis of their
relative affinity for Fc receptors133. Among these seven
antibodies, selicrelumab has been tested most exten-
sively to date, alone or in combination with radiation,
chemotherapy or ICIs128. This antibody has a favour­
able safety profile, but is associated with modest ORRs
when used as a single agent. By contrast, selicrelumab
was associated with an ORR of 41% in multiple solid
tumour types when combined with the anti-CSF1R
antibody emactuzumab134. Evaluations of other combi-
nations, such as one with atezolizumab (NCT02304393),
and with either the anti-ANG2 and VEGF bispecific
antibody vanucizumab or the anti-VEGF antibody
bevacizumab (NCT02665416), are underway.
Other phase I trials are testing the combination of
agonistic anti-CD40 antibodies with various ICIs and
cytotoxic agents, such as SEA-CD40 plus pembroli-
zumab and gemcitabine (NCT02376699)135, and soti-
galimab plus gemcitabine, nab-paclitaxel and nivolumab
(NCT03214250)136, both in patients with metastatic
PDAC. The sotigalimab combination was associated
with an ORR of 58%, although this study included a
high percentage of patients (27%) with KRAS wild-type
disease, who tend to have a favourable prognosis.
Randomized controlled trials will help to determine
whether treatment with a CD40 agonist could replace
chemotherapy alone as the SOC in this setting.
To avoid the systemic toxicities that can be seen after
intravenous delivery of CD40 agonists, some trials have
tested intratumoural administration of these drugs. For
example, intratumoural administration of mitazalimab
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was well tolerated and associated with pharmacody-
namic responses in patients with advanced-stage solid
tumours refractory to SOC therapies (NCT02379741)137.
The serum concentrations of mitazalimab and the
levels of pro-inflammatory cytokine release were both
higher in patients receiving injections into deep metas-
tases than in those receiving injections into superficial
metastases. These differences need to be confirmed and
understood, although they suggest that deep intral-
esional administration of CD40 agonists might be
preferred to activate CD40 signalling in patients.
Several approaches are being tested to improve the
activation of antitumour immune responses by CD40
agonists while sparing non-malignant tissues. For exam-
ple, Fc mutations to increase the affinity of this class
of antibodies for FcγR2b might result in more potent
agonistic activity138, whereas the use of bispecific anti-
bodies could be particularly effective in limiting CD40
agonist activity to tumours and thus preventing systemic
toxicities139.
TLR agonists
The human genome encodes several Toll-like recep-
tors (TLRs), which are expressed by macrophages and
other myeloid cells, and recognize pathogen-associated
and/or danger-associated molecular patterns. TLR
activation typically triggers potent inflammatory reac-
tions, including the generation of macrophages with
M1-like phenotypes, which might not only protect the
host against infections but also promote antitumour
immunity. Consequently, TLR agonists are considered
immune enhancers (or adjuvants) in cancer therapy. For
example, the TLR7 agonist motolimod, the TLR8 ago-
nist vesatolimod, and the dual TLR7/8 agonist resiqui-
mod can drive TAM repolarization towards an M1-like
phenotype. When loaded in β-cyclodextrin nanoparti-
cles, resiquimod could be efficiently delivered to TAMs
in mice, inducing IL-12 production by these cells and
promoting tumour control140.
Drugs that activate various TLRs, including TLR2,
TLR3, TLR4, TLR5, TLR7, TLR8 and TLR9, have
shown efficacy in preclinical studies and have been or
are being tested in clinical trials for indications other
than cancer. Studies comparing different agonists in
patients with cancer are currently lacking. Nevertheless,
activating TLRs might provide therapeutic benefit in
some settings. For example, the TLR7 agonist imiqui-
mod is approved by the FDA for topical treatment of
superficial basal cell carcinoma141, the TLR3 agonist
poly ICLC might be associated with meaningful clinical
and immune responses notably in patients with glioma
(NCT00766753 and NCT01920191)142–144; and the TLR9
agonist vidotolimod delivered intralesionally might be
useful in overcoming resistance to anti-PD-1 antibodies
in patients with metastatic melanoma145.
Studies in mice and patients with breast cancer have
further revealed that monophosphoryl lipid A, a TLR4
agonist, can be combined with IFNγ to stimulate a tumo-
ricidal phenotype in TAMs and produce the cytokines
IL-12 and TNF, which promote a cytotoxic CD8+ T cell
response146. This agent is already approved by the FDA
as a vaccine adjuvant and therefore could soon be tested
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in combination with the NY-ESO-1 vaccine in clinical
trials (NCT01584115).
TAM-targeted CAR T cells
CAR T cells can be used to eliminate TAMs. For
example, folate receptor-β-targeted CAR T cells can
kill human M2-like macrophages in vitro and mouse
M2-like TAMs in vivo147. This treatment can also pro-
mote amplification of tumour-infiltrating M1-like cells
and tumour-specific T cells, thereby delaying tumour
progression in mice147, and increase the efficacy of sub-
sequent treatments, suggesting the possibility of using
these cells for preconditioning of the TME147. Also, CAR
T cells expressing RN7SL1, an activator of RIG-I–MDA5
signalling, can eliminate immunosuppressive TAMs and
concurrently activate DCs148.
CAR T cells can also be used to promote antitumour
functions of TAMs. For example, preclinical studies have
shown that T cells engineered to release GM-CSF and
IFNγ can activate TAM precursors that produce IL-12
and promote tumour rejection149. Similarly, T cells engi-
neered to release inducible IL-12 upon CAR engagement
with cancer cells can eradicate antigen-negative cancer
cells that under regular conditions would have escaped.
In this elimination process, IL-12 activates endogenous
macrophages150. CAR T cells engineered to produce IL-18
can also increase the number of M1-like macrophages and
concomitantly decrease that of M2-like macrophages in
mice151. Finally, CAR T cells engineered to constitutively
express CD40L can elicit antitumour activity in mice; this
response is dependent on the activation of endogenous
CD40+ cells, including some DCs and TAMs152.
Thus, targeting TAMs with CAR T cell-derived
cytokines and other factors might be used to modify
the TME and induce antitumour immune responses.
Despite the complexity of CAR T cell engineering, one
can envisage the development of even more components
that target either cancer cells or different components
of the TME, including TAMs. In all these approaches,
stable expression of CAR T cell targets over time would
be an asset.
Engineered macrophages
Early work showed that TIE-2-expressing monocytes
modified to produce IFNα can be used to inhibit tumour
angiogenesis and promote an immune response against
cancer cells in mice153. Subsequently, primary human
macrophages were modified using an adenoviral vector
with a CAR targeting HER2 to recognize and eliminate
cancer cells. A single infusion of these so-called CAR
macrophages, which can be genetically engineered with
an M1-like phenotype, can decrease tumour burden and
delay progression of solid tumour xenografts in mice154.
This approach received Breakthrough designation by the
FDA (NCT04660929)155.
Several other CAR constructs have been reported.
CAR-147 macrophages become activated after CAR
binding to HER2 on cancer cells, which activates intra-
cellular CD147 signalling and leads to increased expres-
sion of matrix metalloproteinases; infusion of CAR-147
macrophages into mice reduced collagen deposition and
promoted T cell infiltration into tumours156. IL12-GEMys
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(genetically engineered myeloid cells), which produce
IL-12, reverse immunosuppression and promote anti-
tumour immunity in mice, thereby reducing metas-
tasis and delaying tumour growth157. CAR-I Mac are
CD19-targeted CAR macrophages induced from pluri-
potent stem cells (iPSCs) that acquire M1-like attributes
upon target recognition and mediate specific killing of
CD19+ leukaemia cells158. Additionally, nanoparticles
have been designed to contain both a mannose moiety
and DNA encoding for a molecule of interest, such as
a CAR and/or an inflammatory cytokine. The man-
nose moiety confers specificity for mannose receptors
expressed on macrophages and, together with the CAR
and/or cytokine, enable macrophage-mediated phagocy-
tosis of cancer cells and subsequent activation of adaptive
immunity through antigen presentation to T cells159.
At present, CAR macrophages pose some manufac-
turing challenges. For example, unlike CAR T cells, they
do not proliferate either ex vivo or in vivo160. Also, solid
tumours often have antigen heterogeneity, which might
facilitate tumour escape through antigen loss when using
a single CAR approach — the same principle is true for
CAR T cells. Finally, a high multiplicity of infection is
required to obtain sufficient levels of CAR expression
in macrophages, which are more resistant to viral trans-
duction than T cells154. Nevertheless, CAR macrophages
have desirable features: they can infiltrate solid tumours
more efficiently than CAR T cells; they could be derived
from iPSCs, which opens the possibility of allogeneic
treatment without triggering graft-versus-host disease
or host rejection; and they can not only naturally engulf
cancer cells, but also (cross)present antigens to T cells,
which is important for generating an adaptive antitu-
mour immune response160. Ongoing advances in gene
editing and cell engineering techniques could facilitate
clinical research on this technology.
Oncolytic viruses
A variety of oncolytic viruses have been used clinically
to infect cancer cells and produce factors that alter the
TME and thereby inhibit tumour growth. The first
oncolytic virus approved by several regulatory agencies
including the FDA and EMA, talimogene laherparepvec
(T-VEC), is a herpesvirus genetically engineered to pro-
duce GM-CSF. In patients with advanced-stage mela-
noma, T-VEC is associated with higher ORRs and OS
than GM-CSF alone161. Importantly, intratumoural
replication of T-VEC might not be restricted to cancer
cells, but also occur in immune cells and particularly
in TAMs162. Oncolytic viruses have also been used to
produce cytokines typically secreted by antitumour
TAMs. For example, a phase I trial tested the ability
of the oncolytic virus Ad-RTS-hIL-12 to deliver IL-12
to resection sites of recurrent high-grade gliomas
(NCT02026271). Re-resection in five of five patients
suspected to have recurrence after treatment revealed
primarily pseudoprogression with increased numbers of
IFNγ-producing lymphocytes, suggesting the presence
of treatment-induced antitumour immune responses163.
The non-pathogenic recombinant polio–rhinovirus
chimera (PVS–RIPO) recognizes the poliovirus recep-
tor CD155, which is expressed in multiple solid tumour
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types. PVS–RIPO immunotherapy is expected to induce
innate and adaptive antitumour immune responses and,
indeed, in a trial involving patients with grade IV gli-
oma resulted in extended OS compared with a histor-
ical control cohort (NCT01491893)164. Some oncolytic
viruses have also been used for intravenous infusion. For
example, viruses from the Orthoreoviridae family (also
referred to as reoviruses) are safe and also preferentially
infect cancer cells and increase tumour leukocyte infil-
tration in patients with malignant glioma or brain metas-
tases (Eudract 2011-005635-10)165. Data from a phase I
trial also suggest that such viruses lead to increased
cytotoxic T cell tumour infiltration and upregulate
IFN-regulated gene expression as well as PD-L1 expres-
sion in tumours. Reoviruses have also been tested in
combination with paclitaxel and carboplatin in a phase II
trial involving women with ovarian, tubal or peritoneal
cancer (NCT01166542)166, although no significant dif-
ference in PFS was observed in patients receiving the
combination therapy. A phase I trial (NCT02444546) is
testing the same oncolytic virus, in combination with
GM-CSF, in children with relapsed brain tumours.
The possibility of incorporating long genetic
sequences into oncolytic virus expression cassettes is
also being explored. For example, in preclinical stud-
ies, oncolytic viruses genetically engineered to express
full-length human anti-CD47 antibodies were function-
ally active and blocked CD47, thus promoting ADCP by
macrophages167. This approach opens the possibility of
making the oncolytic virus platform even more versatile.
Other therapeutic targets
Other factors are being explored as therapeutic targets
to modulate TAMs. Here we discuss notable candidates
whose relevance is mainly supported by preclinical stud-
ies at present. Some of these factors are being targeted
and tested in phase I clinical trials, and others are likely
to be tested soon.
ANG2. The growth factor angiopoietin 2 (ANG2)
enhances the pro-angiogenic activities of TIE2-
expressing monocytes168. Ang2 knockdown in mice can
reduce angiogenesis by inhibiting macrophage infiltra-
tion, thereby controlling tumour progression169. In a
phase III trial involving patients with advanced-stage
ovarian cancer, the ANG2 agonist trebananib did not
improve PFS when combined with standard chemother-
apy (NCT01493505)170. Nevertheless, the same agent is
being tested in combination with anti-PD-1 antibody
ezabenlimab in a phase Ib trial involving patients
with advanced-stage solid tumours (NCT03697304).
The bispecific ANG2–VEGF antibody BI836880 has
been tested preclinically for its ability to reprogramme
TAMs171 and to promote antitumour and anti-angiogenic
functions172,173.
APMAP. Genome-wide CRISPR knockout and over-
expression screens in cancer cells and macrophages
have identified regulators of susceptibility to ADCP.
One such regulator is the enzyme adipocyte plasma
membrane-associated protein (APMAP), which is
another don’t-eat-me signal of interest174.
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BACE1. Glioblastoma-promoting TAMs express
β-secretase 1 (also known as BACE1). Accordingly, the
small-molecule BACE1 inhibitor verubecestat can repro-
gramme TAMs and stimulate them to phagocytose can-
cer cells in xenograft tumour models of glioblastoma175.
Given that low-dose radiation can improve TAM
infiltration176, it might be combined with verubecestat to
further control tumour growth. Verubecestat and other
BACE1 inhibitors have already been developed for the
treatment of patients with Alzheimer disease and might
therefore be tested for the treatment of cancer in the
near future.
CLEVER-1. The scavenger receptor stabilin 1 (also
known as CLEVER-1) can be expressed by TAMs with
tumour-promoting phenotypes. The anti-CLEVER-1
antibody bexmarilimab has been tested in patients
with advanced-stage solid tumours, with an ORR of 3%
(NCT03733990). The available data, however, suggested
activation of TH1 cells, increases in the numbers of NK
and B cells, and higher levels of IFNγ and CXCL10
(ref.177), indicating that CLEVER-1 inhibition should
perhaps be tested in combination with ICIs.
HDACs. Histone deacetylase (HDAC) inhibitors can
open chromatin and thus be used to activate transcrip-
tion of genes that foster tumour control178. For example,
the class IIa HDAC inhibitor TMP195 can induce the dif-
ferentiation of phagocytic and stimulatory macrophages
within mammary tumours towards tumour-promoting
phenotypes179. TMP195 can also trigger the phagocytic
activity of macrophages in the context of CLL180.
MARCO. TAMs expressing macrophage receptor
with collagenous structure (also known as MARCO)
can promote tumour outgrowth, in part through their
immuno­suppressive properties181. Anti-MARCO anti-
bodies can alter TAM polarization towards antitumour
phenotypes in mice and induce activation of antitu-
mour NK cells181,182. Combined targeting of MARCO
and IL-37 was used to facilitate polarization of human
TAMs in vitro, resulting in amplification of antitumour
NK cells and T cells and decreased activity of regulatory
T (Treg) cells183.
Microbiota. Signals from microbiota can shape the func-
tions of TAMs and, in doing so, influence the efficacy
of various cancer treatments. For example, a favourable
microbiota can programme TAMs through the produc-
tion of STING agonists to secrete type I interferons and
promote antitumour immunity in mice184. The micro-
biota could be directly exploited to modulate TAMs;
indeed, a high-fibre diet or faecal transplantation has a
modulatory effect on the microbiota, which can promote
type I interferon responses by TAMs and improve the
efficacy of immunotherapy185,186.
TAM states and precision oncology
Knowledge of the functional relevance of TAM states
should help to define how best to harness them for
therapy; however, uncovering the biological activi-
ties of TAM states is challenging. Many studies have
volume 19 | June 2022 | 415
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characterized TAMs based on the expression of a selec-
tion of M1 and M2 markers. This reductionist approach
has the advantage of greatly simplifying our view of
TAM complexity and thus is easily exploitable; however,
M1 and M2 markers might not always provide informa-
tion on cell functions and cannot entirely capture the
diversity of TAM states, as discussed. Consequently, as
our knowledge of TAM diversity evolves, the readouts
used to assess TAM functions are likely to be refined.
Furthermore, the usefulness of animal models to study
TAM functions in vivo might be limited by the fact
that the diversity of TAMs in mice does not always
reflect that of TAMs in humans, highlighting the need
to develop additional tools to study macrophages,
which could include ex vivo-based or in vitro-based
experimental approaches.
Integrating TAMs in precision oncology
To date, TAMs have not been a direct focus of stand-
ard molecular tumour boards (MTBs), which have
mostly relied on bulk DNA and RNA sequencing data.
Nevertheless, the use of additional omics techniques
such as scRNA-seq as part of the routine sample process-
ing of next-generation MTBs187 creates an opportunity to
integrate TAM data within therapeutic decision-making
strategies (Fig. 3). Although no prospective studies have
validated the use of TAM data for precision oncology,
most MTBs are considering patients with disease pro-
gression after receiving SOC treatment, or patients for
whom several SOC options are available without vali-
dated predictive biomarkers. In both situations, includ-
ing TAM derived omics data to guide decisions, while
collecting and monitoring outcomes, is an interesting
alternative to empirical treatment assignment.
Exploiting fresh tissue samples. Transitioning to
scRNA-seq has important logistic consequences as it
requires moving away from using commonly accessi-
ble formalin-fixed paraffin-embedded archival mate-
rial to dedicated fresh biopsy samples, requiring active
patient involvement and, in most cases, immediate
on-site processing. MTBs are currently building the

Fresh tumour material

DC
TAM
TAN

Vessels
B cell
T cell CAF
Immune cells Fibroblasts
Fresh-tumour processing
• scRNA-seq
• FAST-FNA
• Organoids
• Xenografts
Cancer cells • Mechanistic studies

Fine needle aspirates,

liquid biopsies

Molecular
tumour board

Fixed tumour material

Fixed-tumour processing
• IHC, IF
Patient • Spatial transcriptomics
with disease • Digital pathology
progression

CT, MRI, PET molecular imaging TAM-based

innovative
Image processing therapeutic
• Radiomics options

Fig. 3 | Proposed integration of TAM-related data in precision oncology molecular tumour boards. Schematic over-
view of the various sample and image sources that can be used for this purpose. Fresh tumour material represents the rich-
est source of information because it can be used, in addition to standard omics techniques, in ex vivo strategies such as
developing organoids or xenograft models. Fixed samples remain of paramount importance as they facilitate an optimal
use of several omics approaches. This source of material is generally available prospectively as well as in large retrospec-
tive cohorts. Finally, clinical imaging is also expected to provide increasingly relevant information through new radiomics
approaches, which have the advantage of enabling simultaneous evaluation of all tumour sites. As these different data
streams are collected in various precision oncology centres, the inclusion of tumour-associated macrophage (TAM)-
derived data in the therapeutic decision-making process could become feasible. CAF, cancer-associated fibroblast;
FAST–FNA, fast analytical screening technique of fine-needle aspirates; IF, immunofluorescence; IHC, immunohistochemistry;
scRNA-seq, single-cell RNA sequencing; TAN, tumour-associated neutrophil.

416 | June 2022 | volume 19 www.nature.com/nrclinonc

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infrastructure to process fresh samples within clini-
cally relevant timeframes187 and integrated pipelines are
being developed for comprehensive analyses of surgical
specimens188. Additional emerging techniques can use
fresh tissue samples, including fast analytical screen-
ing techniques of fine-needle aspirates (FAST–FNA)189,
ex vivo tumour fragment platforms190, organoids191
and mouse co-clinical trials based on xenografts192.
Liquid biopsy enabled by contemporary cell capture
techniques193 can bring additional insights through
less invasive approaches, although blood-derived
data represent only surrogates of the tumour biology.
These analyses of rich fresh tumour material are likely
to bring highly valuable insights on the use of TAM
data to guide certain precision oncology programmes.
However, owing to the high complexity in establishing,
normalizing and validating biomarkers based on such
data, a crucial aspect for the successful development and
subsequent deployment of TAM-based predictive bio-
markers is the ability to bring back some of the features
derived from fresh samples to commonly accessible,
fixed tissue-based data sources.
Exploiting fixed-tissue material. Fixed-tissue material
constitutes a very rich source of data for TAM-based
biomarkers in precision oncology. Baseline predic­
tive biomarkers that use existing fixed material can be
based on multiplexed immunohistochemistry194, newer
spatial transcriptomics technologies194–196 or even standard
haematoxylin and eosin staining analysed with advanced
deep learning methodologies197. Owing to their widespread
use in clinical routine and the availability of large retro-
spective repositories for validation, fixed-tissue samples
could continue to have a key role in the coming years.
Translational end points. A precision oncology approach
targeting the TAM compartment could assess antitu-
mour programmes that are orthogonal to those trig-
gered by other immunotherapies. Given that a number
of preclinical studies and clinical data suggest that target-
ing TAMs might enhance antitumour T cell responses,
the extent to which or the circumstances under which
TAM-targeting approaches mostly unleash adaptive
immune responses against cancer remain to be defined.
In this context, such approaches might not present an
independent mechanistic route to treat tumours as com-
pared with existing T cell-focused immunotherapies;
instead, they would be used to enhance the activity of the
adaptive immune response and strengthen the efficacy
of ICIs. Additionally, TAM-targeting agents might con-
trol tumour progression at least in part independently
of T cells, for example, by fostering the production of
macrophages with cytotoxic functions. Whether this
phenomenon is quantitatively and qualitatively relevant
in human tumours remains to be defined and will be
assessed with the next-generation, omics-based MTB.
Monitoring treatment outcomes
As discussed, researchers have started to use scRNA-seq
to evaluate cells of the TME, including TAMs, before and
during therapeutic intervention. These studies are cru-
cial to our understanding of treatment effects in human
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tumours but are expensive and logistically complex. As
important TAM signatures emerge and are validated,
assessment of those specifically is likely to become eas-
ier. Multiplexed analyses will probably remain relevant
because they enable simultaneous analysis of multiple
components of the TME. Also, many cell states, includ-
ing TAM states, might each require several markers for
detection. Although tissue-based methods can be use-
ful to assess the composition of the TME, on-treatment
monitoring will require more accessible samples and
data sources given that direct access to the tumour com-
partment with serial biopsies can become clinically and
ethically challenging. FNAs can provide on-treatment
fresh material containing TAMs. Such procedures can be
performed frequently and, importantly, serially within
the same metastatic lesion, providing informative lon-
gitudinal data using FAST–FNA198. This approach might
be used to assess the evolving TME in patients and pro-
vide early insights into treatment response189. While this
minimally invasive technique can be used to assess a few
lesions simultaneously, it cannot provide a comprehen-
sive overview of all metastases. Liquid biopsies could
have an important role in providing such patient-level
evaluations, although most of the data will be correlative.
PET-based molecular imaging paired with advanced
radiomics analyses could provide essential data for the
patient-level longitudinal monitoring of all metastatic
lesions. Comparing radiomics features with tissue-based
data will help to ascertain what are the key radiomics
features that most truly reflect the ongoing TAM biology
at the tumour site.
Prediction of treatment resistance
Advanced on-treatment monitoring of changes in the
TME can yield fundamental insights into mechanisms
of response to immunotherapies and other anticancer
treatments. Another expected benefit of such close
follow-up examinations is the identification, or even
anticipation, of mechanisms of resistance to TAM-based
therapies. Limited evidence is currently available in this
area. Interesting data suggest that anticipating resistance
to CSF1R-targeted agents is feasible in mice with brain
tumours71,86,189, but these results remain to be confirmed
in other tumour types. In addition to determining the
biological mechanism of resistance at play in each clin-
ical setting, next-generation omics-based MTBs should
aim to characterize the dynamic patterns of treatment
resistance at different tumour sites, whether the resis­
tance mechanisms are exclusive for a tumour site or
systemic and, finally, how to counter them with optimal
treatment combinations or sequences.
Conclusions
TAMs are innate immune cells that are frequently
observed in large numbers in many types of cancer. Their
presence is increasingly recognized as a key parameter
of the tumour-associated immune response. TAMs are
especially important in this response because they can
either support or inhibit tumour growth depending on
their phenotypes and functions, which are diverse, and
can also affect the efficacy of virtually any type of ther-
apy. Therefore, understanding the complexity of TAMs
volume 19 | June 2022 | 417
Reviews

and exploiting it with treatments targeting defined
cellular states or their associated functions is crucial.
Moreover, as the phenotype of TAMs can change pro-
foundly in response to perturbations, assessing the evo-
lution of the repertoire and function of TAMs during a
given treatment is equally important.
Our understanding of TAM heterogeneity has
evolved with the advent of single-cell resolution omics
technologies. The resulting analyses indicate that the tra-
ditional M1/M2 classification of TAMs does not fully
capture the complexity of all their states. By contrast, the
fact that some TAM states have prognostic value because
their abundance is associated with the clinical outcomes
in patients across different types of cancer is becoming
increasingly clear. Some TAM states are also associated
with a response to immunotherapy, whereas others are,
instead, associated with resistance to treatment, which
further supports the utility of integrating information
of TAMs to better understand a particular tumour and
select a treatment.
In this Review, we describe some of the functional states
of TAMs that seem most relevant in clinical and therapeu-
tic settings. For some of these states, innovative therapeutic
interventions acting on target pathways are currently being
tested (Table 1; Supplementary Tables 1 and 2), with prom-
ising signs of activity already reported. Understanding
TAM states and their functions forms the basis for
ongoing efforts to include these cells in next-generation,
omics-based MTBs. We expect that the integration of
TAM-related parameters into precision immuno-oncology
will improve the quality of clinical decision-making.
Considering TAMs as a dynamic population should
be essential for tailoring drug regimens as cancer cells
and their TME evolve under treatment pressure.
Published online 30 March 2022

1. Binnewies, M. et al. Understanding the tumor
immune microenvironment (TIME) for effective
therapy. Nat. Med. 24, 541–550 (2018).
2. Engblom, C., Pfirschke, C. & Pittet, M. J. The role of
myeloid cells in cancer therapies. Nat. Rev. Cancer 16,
447–462 (2016).
3. Mantovani, A. et al. Tumour-associated macrophages
as treatment targets in oncology. Nat. Rev. Clin.
Oncol. 14, 399–416 (2017).
4. Bejarano, L., Jordāo, M. J. C. & Joyce, J. A.
Therapeutic targeting of the tumor microenvironment.
Cancer Discov. 11, 933–959 (2021).
5. Yofe, I., Dahan, R. & Amit, I. Single-cell genomic
approaches for developing the next generation of
immunotherapies. Nat. Med. 26, 171–177 (2020).
6. Cohen, M. et al. Lung single-cell signaling interaction
map reveals basophil role in macrophage imprinting.
Cell 175, 1031–1044.e18 (2018).
7. Hara, T. et al. Interactions between cancer cells and
immune cells drive transitions to mesenchymal-like
states in glioblastoma. Cancer Cell 39, 779–792.e11
(2021).
8. Alonso-Curbelo, D. et al. A gene-environment-induced
epigenetic program initiates tumorigenesis. Nature
590, 642–648 (2021).
9. La Manno, G. et al. Molecular architecture of the
developing mouse brain. Nature 596, 92–96 (2021).
10. Satpathy, A. T. et al. Massively parallel single-cell
chromatin landscapes of human immune cell
development and intratumoral T cell exhaustion.
Nat. Biotechnol. 37, 925–936 (2019).
11. Schede, H. H. et al. Spatial tissue profiling by
imaging-free molecular tomography. Nat. Biotechnol.
39, 968–977 (2021).
12. Wagner, D. E. & Klein, A. M. Lineage tracing meets
single-cell omics: opportunities and challenges.
Nat. Rev. Genet. 21, 410–427 (2020).
13. Evans, R. & Alexander, P. Cooperation of immune
lymphoid cells with macrophages in tumour immunity.
Nature 228, 620–622 (1970).
14. Qian, B. Z. & Pollard, J. W. Macrophage diversity
enhances tumor progression and metastasis. Cell 141,
39–51 (2010).
15. Zhang, Q. W. et al. Prognostic significance of
tumor-associated macrophages in solid tumor: a
meta-analysis of the literature. PLoS ONE 7, e50946
(2012).
16. Vesely, M. D. et al. Natural innate and adaptive
immunity to cancer. Annu. Rev. Immunol. 29,
235–271 (2011).
17. Locati, M., Curtale, G. & Mantovani, A. Diversity,
mechanisms, and significance of macrophage
plasticity. Annu. Rev. Pathol. 15, 123–147 (2020).
18. Gabrusiewicz, K. et al. Glioblastoma-infiltrated innate
immune cells resemble M0 macrophage phenotype.
JCI Insight 1, 85841 (2016).
19. Szulzewsky, F. et al. Glioma-associated microglia/
macrophages display an expression profile different
from M1 and M2 polarisation and highly express
Gpnmb and Spp1. PLoS ONE 10, e0116644 (2015).
20. Yang, M. et al. Diverse functions of macrophages in
different tumor microenvironments. Cancer Res. 78,
5492–5503 (2018).
21. Zhang, Y. et al. Single-cell analyses reveal key immune
cell subsets associated with response to PD-L1
blockade in triple-negative breast cancer. Cancer Cell
39, 1578–1593.e3 (2021).
22. Mantovani, A. et al. The chemokine system
in diverse forms of macrophage activation and
polarisation. Trends Immunol. 25, 677–686
(2004).
23. Murray, P. J. et al. Macrophage activation and
polarisation: nomenclature and experimental
guidelines. Immunity 41, 14–20 (2014).
24. Cheng, S. et al. A pan-cancer single-cell transcriptional
atlas of tumor infiltrating myeloid cells. Cell 184,
792–809.e23 (2021).
25. Bi, K. et al. Tumor and immune reprogramming during
immunotherapy in advanced renal cell carcinoma.
Cancer Cell 39, 649–661.e5 (2021).
26. Cassetta, L. et al. Human tumor-associated
macrophage and monocyte transcriptional landscapes
reveal cancer-specific reprogramming, biomarkers,
and therapeutic targets. Cancer Cell 35, 588–602.
e10 (2019).
27. Pombo Antunes, A. R. et al. Single-cell profiling
of myeloid cells in glioblastoma across species and
disease stage reveals macrophage competition
and specialization. Nat. Neurosci. 24, 595–610
(2021).
28. Wu, S. Z. et al. A single-cell and spatially resolved
atlas of human breast cancers. Nat. Genet. 53,
1334–1347 (2021).
29. Azizi, E. et al. Single-cell map of diverse immune
phenotypes in the breast tumor microenvironment.
Cell 174, 1293–1308.e36 (2018).
30. Zilionis, R. et al. Single-cell transcriptomics of human
and mouse lung cancers reveals conserved myeloid
populations across individuals and species. Immunity
50, 1317–1334.e10 (2019).
31. Leader, A. M. et al. Single-cell analysis of human
non-small cell lung cancer lesions refines tumor
classification and patient stratification. Cancer Cell
39, 1594–1609.e12 (2021).
32. Chan, J. M. et al. Signatures of plasticity, metastasis,
and immunosuppression in an atlas of human small
cell lung cancer. Cancer Cell 39, 1479–1496.e18
(2021).
33. Zhang, Q. et al. Landscape and dynamics of single
immune cells in hepatocellular carcinoma. Cell 179,
829–845.e20 (2019).
34. Chen, A. X. et al. Single-cell characterization of
macrophages in glioblastoma reveals MARCO as a
mesenchymal pro-tumor marker. Genome Med. 13,
88 (2021).
35. Pelka, K. et al. Spatially organized multicellular
immune hubs in human colorectal cancer. Cell 184,
4734–4752.e20 (2021).
36. Mujal, A. M. et al. Holistic characterization of tumor
monocyte-to-macrophage differentiation integrates
distinct immune phenotypes in kidney cancer.
Preprint at bioRxiv https://doi.org/10.1101/
2021.07.07.451502 (2021).
37. Pucci, F. et al. SCS macrophages suppress melanoma
by restricting tumor-derived vesicle-B cell interactions.
Science 352, 242–246 (2016).
38. Yu, J. et al. Liver metastasis restrains immunotherapy
efficacy via macrophage-mediated T cell elimination.
Nat. Med. 27, 152–164 (2021).
39. Gentles, A. J. et al. The prognostic landscape of genes
and infiltrating immune cells across human cancers.
Nat. Med. 21, 938–945 (2015).
40. Braun, D. A. et al. Progressive immune dysfunction
with advancing disease stage in renal cell carcinoma.
Cancer Cell 39, 632–648.e8 (2021).
41. Bassez, A. et al. A single-cell map of intratumoral
changes during anti-PD1 treatment of patients with
breast cancer. Nat. Med. 27, 820–832 (2021).
42. Yang, M. et al. CXCL13 shapes immunoactive tumor
microenvironment and enhances the efficacy of PD-1
checkpoint blockade in high-grade serous ovarian
cancer. J. Immunother. Cancer 9, e001136 (2021).
43. Krishna, C. et al. Single-cell sequencing links
multiregional immune landscapes and tissue-resident
T cells in ccRCC to tumor topology and therapy
efficacy. Cancer Cell 39, 662–677.e6 (2021).
44. Berry, S. et al. Analysis of multispectral imaging with
the AstroPath platform informs efficacy of PD-1
blockade. Science 372, eaba2609 (2021).
45. Hanahan, D. & Coussens, L. M. Accessories to
the crime: functions of cells recruited to the tumor
microenvironment. Cancer Cell 21, 309–322 (2012).
46. Ringel, A. E. et al. Obesity shapes metabolism in the
tumor microenvironment to suppress anti-tumor
immunity. Cell 183, 1848–1866.e26 (2020).
47. Wu, J. Y. et al. Cancer-derived succinate promotes
macrophage polarisation and cancer metastasis via
succinate receptor. Mol. Cell 77, 213–227.e5 (2020).
48. Li, H. et al. The allergy mediator histamine confers
resistanceto immunotherapy in cancer patients via
activation of the macrophage histamine receptor H1.
Cancer Cell 40, 36–52.e9 (2021).
49. Zhang, B. et al. B cell-derived GABA elicits IL-10+
macrophages to limit anti-tumour immunity. Nature
599, 471–476 (2021).
50. Neubert, N. J. et al. T cell-induced CSF1 promotes
melanoma resistance to PD1 blockade. Sci. Transl.
Med. 10, eaan3311 (2018).
51. Wang, X. et al. In vivo CRISPR screens identify the
E3 ligase Cop1 as a modulator of macrophage
infiltration and cancer immunotherapy target. Cell
184, 5357–5374.e22 (2021).
52. Di Conza, G. et al. Tumor-induced reshuffling of lipid
composition on the endoplasmic reticulum membrane
sustains macrophage survival and pro-tumorigenic
activity. Nat. Immunol. 22, 1403–1415 (2021).
53. Kersten, K. et al. Spatiotemporal co-dependency
between macrophages and exhausted CD8+ T cells
in cancer. Preprint at bioRXiv https://doi.org/10.1101/
2021.09.27.461866 (2021).
54. Arlauckas, S. P. et al. In vivo imaging reveals a
tumor-associated macrophage-mediated resistance
pathway in anti-PD-1 therapy. Sci. Transl. Med. 9,
eaal3604 (2017).
55. Akkari, L. et al. Dynamic changes in glioma
macrophage populations after radiotherapy reveal
CSF-1R inhibition as a strategy to overcome
resistance. Sci. Transl. Med. 12, eaaw7843
(2020).

418 | June 2022 | volume 19 www.nature.com/nrclinonc

0123456789();:

56. Miller, M. A. et al. Radiation therapy primes tumors
for nanotherapeutic delivery via macrophage-
mediated vascular bursts. Sci. Transl. Med. 9,
eaal0225 (2017).
57. Niesel, K. et al. The immune suppressive
microenvironment affects efficacy of radio-
immunotherapy in brain metastasis. EMBO Mol.
Med. 13, e13412 (2021).
58. Mehta, A. K. et al. Targeting immunosuppressive
macrophages overcomes PARP inhibitor resistance
in BRCA1-associated triple-negative breast cancer.
Nat. Cancer 2, 66–82 (2021).
59. Kurdi, A. T. et al. Antibody-dependent cellular
phagocytosis by macrophages is a novel mechanism
of action of elotuzumab. Mol. Cancer Ther. 17,
1454–1463 (2018).
60. Bowman, R. L. et al. Macrophage ontogeny underlies
differences in tumor-specific education in brain
malignancies. Cell Rep. 17, 2445–2459 (2016).
61. Casanova-Acebes, M. et al. Tissue-resident
macrophages provide a pro-tumorigenic niche to
early NSCLC cells. Nature 595, 578–584 (2021).
62. Loyher, P. L. et al. Macrophages of distinct origins
contribute to tumor development in the lung.
J. Exp. Med. 215, 2536–2553 (2018).
63. Zhang, N. et al. LYVE1+ macrophages of murine
peritoneal mesothelium promote omentum-independent
ovarian tumor growth. J. Exp. Med. 218, e20210924
(2021).
64. Zhu, Y. et al. Tissue-resident macrophages in
pancreatic ductal adenocarcinoma originate from
embryonic hematopoiesis and promote tumor
progression. Immunity 47, 323–338.e6 (2017).
65. Cortez-Retamozo, V. et al. Origins of tumor-associated
macrophages and neutrophils. Proc. Natl Acad. Sci.
USA 109, 2491–2496 (2012).
66. Cortez-Retamozo, V. et al. Angiotensin II drives
the production of tumor-promoting macrophages.
Immunity 38, 296–308 (2013).
67. Movahedi, K. et al. Different tumor microenvironments
contain functionally distinct subsets of macrophages
derived from Ly6C(high) monocytes. Cancer Res. 70,
5728–5739 (2010).
68. Qian, B. Z. et al. CCL2 recruits inflammatory
monocytes to facilitate breast-tumour metastasis.
Nature 475, 222–225 (2011).
69. Friebel, E. et al. Single-cell mapping of human
brain cancer reveals tumor-specific instruction of
tissue-invading leukocytes. Cell 181, 1626–1642.e20
(2020).
70. Guldner, I. H. et al. CNS-native myeloid cells drive
immune suppression in the brain metastatic niche
through Cxcl10. Cell 183, 1234–1248.e25 (2020).
71. Klemm, F. et al. Compensatory CSF2-driven
macrophage activation promotes adaptive resistance
to CSF1R inhibition in breast-to-brain metastasis.
Nat. Cancer 2, 1086–1101 (2021).
72. Bruni, D., Angell, H. K. & Galon, J. The immune
contexture and immunoscore in cancer prognosis and
therapeutic efficacy. Nat. Rev. Cancer 20, 662–680
(2020).
73. Andreatta, M. et al. Interpretation of T cell states
from single-cell transcriptomics data using reference
atlases. Nat. Commun. 12, 2965 (2021).
74. Gerhard, G. M. et al. Tumor-infiltrating dendritic
cell states are conserved across solid human cancers.
J. Exp. Med. 218, e20200264 (2021).
75. Mulder, K. et al. Cross-tissue single-cell landscape
of human monocytes and macrophages in health
and disease. Immunity 54, 1883–1900.e5 (2021).
76. Luca, B. A. et al. Atlas of clinically distinct cell states
and ecosystems across human solid tumors. Cell 184,
5482–5496.e28 (2021).
77. Lin, E. Y. et al. Colony-stimulating factor 1 promotes
progression of mammary tumors to malignancy.
J. Exp. Med. 193, 727–740 (2001).
78. Ries, C. H. et al. Targeting tumor-associated
macrophages with anti-CSF-1R antibody reveals a
strategy for cancer therapy. Cancer Cell 25, 846–859
(2014).
79. Pfirschke, C. et al. Macrophage-targeted therapy
unlocks antitumoral crosstalk between IFN-𝛾-secreting
lymphocytes and IL-12-producing dendritic cell.
Cancer Immunol. Res. 10, 40–55 (2021).
80. Pyonteck, S. M. et al. CSF-1R inhibition alters
macrophage polarisation and blocks glioma
progression. Nat. Med. 19, 1264–1272 (2013).
81. Cassier, P. A. et al. CSF1R inhibition with
emactuzumab in locally advanced diffuse-type
tenosynovial giant cell tumours of the soft tissue:
a dose-escalation and dose-expansion phase 1 study.
Lancet Oncol. 16, 949–956 (2015).
nATuRe RevIeWS | ClinicAl Oncology
82. Gomez-Roca, C. A. et al. Phase I study of emactuzumab
single agent or in combination with paclitaxel in
patients with advanced/metastatic solid tumors reveals
depletion of immunosuppressive M2-like macrophages.
Ann. Oncol. 30, 1381–1392 (2019).
83. DeNardo, D. G. & Ruffell, B. Macrophages as
regulators of tumour immunity and immunotherapy.
Nat. Rev. Immunol. 19, 369–382 (2019).
84. Lin, C.-C. et al. Phase I study of BLZ945 alone and
with spartalizumab (PDR001) in patients (pts) with
advanced solid tumors [abstract]. Cancer Res. 80
(Suppl. 16), CT171 (2020).
85. Cassier, P. A. et al. MEDIPLEX: a phase 1 study
of durvalumab (D) combined with pexidartinib (P)
in patients (pts) with advanced pancreatic ductal
adenocarcinoma (PDAC) and colorectal cancer
(CRC) [abstract]. J. Clin. Oncol. 37 (Suppl. 15), 2579
(2019).
86. Quail, D. F. et al. The tumor microenvironment
underlies acquired resistance to CSF-1R inhibition
in gliomas. Science 352, aad3018 (2016).
87. Martin, T. D. et al. The adaptive immune system
is a major driver of selection for tumor suppressor
gene inactivation. Science 373, 1327–1335 (2021).
88. Cassetta, L. & Pollard, J. W. Targeting macrophages:
therapeutic approaches in cancer. Nat. Rev. Drug
Discov. 17, 887–904 (2018).
89. Bonapace, L. et al. Cessation of CCL2 inhibition
accelerates breast cancer metastasis by promoting
angiogenesis. Nature 515, 130–133 (2014).
90. Sandhu, S. K. et al. A first-in-human, first-in-class,
phase I study of carlumab (CNTO 888), a human
monoclonal antibody against CC-chemokine ligand 2
in patients with solid tumors. Cancer Chemother.
Pharmacol. 71, 1041–1050 (2013).
91. Nywening, T. M. et al. Targeting tumour-associated
macrophages with CCR2 inhibition in combination with
FOLFIRINOX in patients with borderline resectable and
locally advanced pancreatic cancer: a single-centre,
open-label, dose-finding, non-randomised, phase 1b
trial. Lancet Oncol. 17, 651–662 (2016).
92. Linehan, D. et al. Overall survival in a trial of orally
administered CCR2 inhibitor CCX872 in locally
advanced/metastatic pancreatic cancer: correlation
with blood monocyte counts [abstract]. J. Clin. Oncol.
36 (Suppl. 5), 92 (2018).
93. Jiao, X. et al. CCR5 governs DNA damage repair and
breast cancer stem cell expansion. Cancer Res. 78,
1657–1671 (2018).
94. Halama, N. et al. Tumoral immune cell exploitation
in colorectal cancer metastases can be targeted
effectively by anti-CCR5 therapy in cancer patients.
Cancer Cell 29, 587–601 (2016).
95. Liu, J. et al. High expression of CCR5 in melanoma
enhances epithelial-mesenchymal transition and
metastasis via TGFβ1. J. Pathol. 247, 481–493
(2019).
96. Aldinucci, D., Borghese, C. & Casagrande, N. The
CCL5/CCR5 axis in cancer progression. Cancers 12,
1765 (2020).
97. CytoDyn. CytoDyn announces cancer update: 12-month
analysis of 28 mTNBC patients receiving leronlimab
suggests an increase of 3600% in 12-month OS in
75% of patients with a lower level of circulating cells
after leronlimab induction or at baseline; 12-month
PFS continues at near 600% increase. CytoDyn
https://www.cytodyn.com/newsroom/press-releases/
detail/574/cytodyn-announces-cancer-update-
12-month-analysis-of-28 (2021).
98. Guo, F. et al. CXCL12/CXCR4: a symbiotic bridge
linking cancer cells and their stromal neighbors in
oncogenic communication networks. Oncogene 35,
816–826 (2016).
99. Hughes, R. et al. Perivascular M2 macrophages
stimulate tumor relapse after chemotherapy.
Cancer Res. 75, 3479–3491 (2015).
100. Seo, Y. D. et al. Mobilization of CD8+ T cells via CXCR4
blockade facilitates PD-1 checkpoint therapy in human
pancreatic cancer. Clin. Cancer Res. 25, 3934–3945
(2019).
101. Bockorny, B. et al. BL-8040, a CXCR4 antagonist, in
combination with pembrolizumab and chemotherapy
for pancreatic cancer: the COMBAT trial. Nat. Med.
26, 878–885 (2020).
102. & Thomas, R. P. et al. CXCR4 blockade at the end
of irradiation to improve local control of glioblastoma
(GBM) [abstract]. J. Clin. Oncol. 36 (Suppl. 15), 2019
(2018).
103. Hidalgo, M. et al. A multi-center phase 2a trial
of the CXCR4 inhibitor motixafortide (BL-8040)(M)
in combination with pembrolizumab (P) and
chemotherapy (C), in patients with metastatic
0123456789();:
Reviews
pancreatic adenocarcinoma (mPDAC) [abstract].
Cancer Res. 81 (Suppl. 13), CT177 (2021).
104. Feng, M. et al. Phagocytosis checkpoints as new
targets for cancer immunotherapy. Nat. Rev. Cancer
19, 568–586 (2019).
105. Chao, M. P. et al. Anti-CD47 antibody synergizes with
rituximab to promote phagocytosis and eradicate
non-Hodgkin lymphoma. Cell 142, 699–713 (2010).
106. Gholamin, S. et al. Disrupting the CD47-SIRPα
anti-phagocytic axis by a humanized anti-CD47
antibody is an efficacious treatment for malignant
pediatric brain tumors. Sci. Transl. Med. 9, eaaf2968
(2017).
107. Weiskopf, K. et al. Engineered SIRPα variants
as immunotherapeutic adjuvants to anticancer
antibodies. Science 341, 88–91 (2013).
108. Advani, R. et al. CD47 blockade by Hu5F9-G4 and
rituximab in non-Hodgkin’s lymphoma. N. Engl. J.
Med. 379, 1711–1721 (2018).
109. Sallman, D. A. et al. The first-in-class anti-CD47
antibody magrolimab (5F9) in combination with
azacitidine is effective in MDS and AML patients:
ongoing phase 1b results [abstract]. Blood 134
(Suppl. 1), 569 (2019).
110. Fisher, G. A. et al. A phase Ib/II study of the anti-CD47
antibody magrolimab with cetuximab in solid
tumor and colorectal cancer patients [abstract].
J. Clin. Oncol. 38 (Suppl. 4), 114 (2020).
111. Upton, R. et al. Combining CD47 blockade with
trastuzumab eliminates HER2-positive breast cancer
cells and overcomes trastuzumab tolerance. Proc. Natl
Acad. Sci. USA 118, e2026849118 (2021).
112. Gilead. Gilead announces partial clinical hold for
studies evaluating magrolimab in combination with
azacitidine. GILEAD https://www.gilead.com/news-
and-press/press-room/press-releases/2022/1/gilead-
announces-partial-clinical-hold-for-studies-evaluating-
magrolimab-in-combination-with-azacitidine
(2022).
113. Deczkowska, A., Weiner, A. & Amit, I. The physiology,
pathology, and potential therapeutic applications of
the TREM2 signaling pathway. Cell 181, 1207–1217
(2020).
114. Shirotani, K. et al. Aminophospholipids are
signal-transducing TREM2 ligands on apoptotic cells.
Sci. Rep. 9, 7508 (2019).
115. Molgora, M. et al. TREM2 modulation remodels
the tumor myeloid landscape enhancing anti-PD-1
immunotherapy. Cell 182, 886–900.e17 (2020).
116. Katzenelenbogen, Y. et al. Coupled scRNA-seq
and intracellular protein activity reveal an
immunosuppressive role of TREM2 in cancer. Cell
182, 872–885.e19 (2020).
117. Binnewies, M. et al. Targeting TREM2 on
tumor-associated macrophages enhances
immunotherapy. Cell Rep. 37, 109844 (2021).
118. Klesney-Tait, J., Turnbull, I. R. & Colonna, M.
The TREM receptor family and signal integration.
Nat. Immunol. 7, 1266–1273 (2006).
119. Fontana, R. et al. Nuclear receptor ligands induce
TREM-1 expression on dendritic cells: analysis of
their role in tumors. Oncoimmunology 8, 1554967
(2019).
120. Kuemmel, A. et al. Soluble triggering receptor
expressed on myeloid cells 1 in lung cancer. Sci. Rep.
8, 10766 (2018).
121. Wu, J. et al. The proinflammatory myeloid cell
receptor TREM-1 controls Kupffer cell activation and
development of hepatocellular carcinoma. Cancer Res.
72, 3977–3986 (2012).
122. Barkal, A. A. et al. CD24 signalling through
macrophage Siglec-10 is a target for cancer
immunotherapy. Nature 572, 392–396 (2019).
123. Klapdor, R. et al. Characterization of a novel
third-generation anti-CD24-CAR against ovarian
cancer. Int. J. Mol. Sci. 20, 660 (2019).
124. Maliar, A. et al. Redirected T cells that target
pancreatic adenocarcinoma antigens eliminate tumors
and metastases in mice. Gastroenterology 143,
1375–1384.e5 (2012).
125. De Henau, O. et al. Overcoming resistance to
checkpoint blockade therapy by targeting PI3Kγ
in myeloid cells. Nature 539, 443–447 (2016).
126. Kaneda, M. M. et al. PI3Kγ is a molecular switch that
controls immune suppression. Nature 539, 437–442
(2016).
127. Furman, R. R. et al. Idelalisib and rituximab in
relapsed chronic lymphocytic leukemia. N. Engl. J.
Med. 370, 997–1007 (2014).
128. Vonderheide, R. H. The immune revolution: a case for
priming, not checkpoint. Cancer Cell 33, 563–569
(2018).
volume 19 | June 2022 | 419
Reviews
129. Beatty, G. L. et al. CD40 agonists alter tumor stroma
and show efficacy against pancreatic carcinoma in
mice and humans. Science 331, 1612–1616 (2011).
130. Kashyap, A. S. et al. Optimized antiangiogenic
reprogramming of the tumor microenvironment
potentiates CD40 immunotherapy. Proc. Natl Acad.
Sci. USA 117, 541–551 (2020).
131. Garris, C. S. et al. Successful anti-PD-1 cancer
immunotherapy requires T cell-dendritic cell crosstalk
involving the cytokines IFN-γ and IL-12. Immunity 49,
1148–1161.e7 (2018).
132. Siwicki, M. et al. Resident Kupffer cells and neutrophils
drive liver toxicity in cancer immunotherapy.
Sci. Immunol. 6, eabi7083 (2021).
133. Dahan, R. et al. Therapeutic activity of agonistic,
human anti-CD40 monoclonal antibodies requires
selective FcγR engagement. Cancer Cell 29, 820–831
(2016).
134. Machiels, J. P. et al. Phase Ib study of anti-CSF-1R
antibody emactuzumab in combination with CD40
agonist selicrelumab in advanced solid tumor patients.
J. Immunother. Cancer 8, e001153 (2020).
135. Grilley-Olson, J. E. et al. SEA-CD40, a non-fucosylated
CD40 agonist: interim results from a phase 1 study in
advanced solid tumors [abstract]. J. Clin. Oncol. 36
(Suppl. 15), 3093 (2018).
136. O’Hara, M. H. et al. CD40 agonistic monoclonal
antibody APX005M (sotigalimab) and chemotherapy,
with or without nivolumab, for the treatment of
metastatic pancreatic adenocarcinoma: an open-label,
multicentre, phase 1b study. Lancet Oncol. 22,
118–131 (2021).
137. Irenaeus, S. M. M. et al. First-in-human study with
intratumoral administration of a CD40 agonistic
antibody, ADC-1013, in advanced solid malignancies.
Int. J. Cancer 145, 1189–1199 (2019).
138. Garris, C. S. et al. Dendritic cell targeting with
Fc-enhanced CD40 antibody agonists induces durable
antitumor immunity in humanized mouse models of
bladder cancer. Sci. Transl. Med. 13, eabd1346 (2021).
139. Labiano, S. et al. CD40 agonist targeted to fibroblast
activation protein α synergizes with radiotherapy
in murine HPV-positive head and neck tumors.
Clin. Cancer Res. 27, 4054–4065 (2021).
140. Rodell, C. B. et al. TLR7/8-agonist-loaded
nanoparticles promote the polarisation of
tumour-associated macrophages to enhance cancer
immunotherapy. Nat. Biomed. Eng. 2, 578–588
(2018).
141. Geisse, J. et al. Imiquimod 5% cream for the
treatment of superficial basal cell carcinoma: results
from two phase III, randomized, vehicle-controlled
studies. J. Am. Acad. Dermatol. 50, 722–733 (2004).
142. Hilf, N. et al. Actively personalized vaccination trial for
newly diagnosed glioblastoma. Nature 565, 240–245
(2019).
143. Migliorini, D. et al. Phase I/II trial testing safety
and immunogenicity of the multipeptide IMA950/
poly-ICLC vaccine in newly diagnosed adult malignant
astrocytoma patients. Neuro Oncol. 21, 923–933
(2019).
144. Okada, H. et al. Induction of CD8+ T-cell responses
against novel glioma-associated antigen peptides and
clinical activity by vaccinations with α-type 1 polarized
dendritic cells and polyinosinic-polycytidylic acid
stabilized by lysine and carboxymethylcellulose in
patients with recurrent malignant glioma. J. Clin.
Oncol. 29, 330–336 (2011).
145. Ribas, A. et al. Overcoming PD-1 blockade resistance
with CpG-A Toll-like receptor 9 agonist vidutolimod in
patients with metastatic melanoma. Cancer Discov.
https://doi.org/10.1158/2159-8290.CD-21-0425
(2021).
146. Sun, L. et al. Activating a collaborative innate-adaptive
immune response to control metastasis. Cancer Cell
39, 1361–1374.e9 (2021).
147. Rodriguez-Garcia, A. et al. CAR-T cell-mediated
depletion of immunosuppressive tumor-associated
macrophages promotes endogenous antitumor
immunity and augments adoptive immunotherapy.
Nat. Commun. 12, 877 (2021).
148. Johnson, L. R. et al. The immunostimulatory RNA
RN7SL1 enables CAR-T cells to enhance autonomous
and endogenous immune function. Cell 184,
4981–4995.e14 (2021).
149. Spear, P. et al. Chimeric antigen receptor
T cells shape myeloid cell function within the tumor
microenvironment through IFN-γ and GM-CSF.
J. Immunol. 188, 6389–6398 (2012).
150. Chmielewski, M. et al. IL-12 release by engineered
T cells expressing chimeric antigen receptors can
effectively muster an antigen-independent
420 | June 2022 | volume 19
macrophage response on tumor cells that have shut
down tumor antigen expression. Cancer Res. 71,
5697–5706 (2011).
151. Chmielewski, M. & Abken, H. CAR T cells releasing
IL-18 convert to T-bethigh FoxO1low effectors that
exhibit augmented activity against advanced solid
tumors. Cell Rep. 21, 3205–3219 (2017).
152. Kuhn, N. F. et al. CD40 ligand-modified chimeric
antigen receptor T cells enhance antitumor function
by eliciting an endogenous antitumor response.
Cancer Cell 35, 473–488.e6 (2019).
153. De Palma, M. et al. Tumor-targeted interferon-α
delivery by Tie2-expressing monocytes inhibits tumor
growth and metastasis. Cancer Cell 14, 299–311
(2008).
154. Klichinsky, M. et al. Human chimeric antigen
receptor macrophages for cancer immunotherapy.
Nat. Biotechnol. 38, 947–953 (2020).
155. CARISMA Therapeutics. CARISMA Therapeutics
announces U.S. Food and Drug Administration grants
fast track designation to CT-0508 for the treatment
of patients with solid tumors. CISION https://prn.to/
3kvshij (2021).
156. Zhang, W. et al. Chimeric antigen receptor
macrophage therapy for breast tumours mediated
by targeting the tumour extracellular matrix. Br. J.
Cancer 121, 837–845 (2019).
157. Kaczanowska, S. et al. Genetically engineered myeloid
cells rebalance the core immune suppression program
in metastasis. Cell 184, 2033–2052.e21 (2021).
158. Zhang, L. et al. Pluripotent stem cell-derived
CAR-macrophage cells with antigen-dependent
anti-cancer cell functions. J. Hematol. Oncol. 13, 153
(2020).
159. Kang, M. et al. Nanocomplex-mediated in vivo
programming to chimeric antigen receptor-M1
macrophages for cancer therapy. Adv. Mater. 33,
e2103258 (2021).
160. Sloas, C., Gill, S. & Klichinsky, M. Engineered
CAR-macrophages as adoptive immunotherapies for
solid tumors. Front. Immunol. 12, 783305 (2021).
161. Andtbacka, R. H. et al. Talimogene laherparepvec
improves durable response rate in patients with
advanced melanoma. J. Clin. Oncol. 33, 2780–2788
(2015).
162. Ramelyte, E. et al. Oncolytic virotherapy-mediated
anti-tumor response: a single-cell perspective.
Cancer Cell 39, 394–406.e4 (2021).
163. Chiocca, E. A. et al. Regulatable interleukin-12 gene
therapy in patients with recurrent high-grade glioma:
results of a phase 1 trial. Sci. Transl. Med. 11,
eaaw5680 (2019).
164. Desjardins, A. et al. Recurrent glioblastoma treated
with recombinant poliovirus. N. Engl. J. Med. 379,
150–161 (2018).
165. Samson, A. et al. Intravenous delivery of oncolytic
reovirus to brain tumor patients immunologically
primes for subsequent checkpoint blockade.
Sci. Transl. Med. 10, eaam7577 (2018).
166. Cohn, D. E. et al. Randomized phase IIB evaluation
of weekly paclitaxel versus weekly paclitaxel with
oncolytic reovirus (Reolysin®) in recurrent ovarian,
tubal, or peritoneal cancer: an NRG Oncology/
Gynecologic Oncology Group study. Gynecol. Oncol.
146, 477–483 (2017).
167. Xu, B. et al. An oncolytic virus expressing a full-length
antibody enhances antitumor innate immune response
to glioblastoma. Nat. Commun. 12, 5908 (2021).
168. De Palma, M. & Naldini, L. Angiopoietin-2 TIEs up
macrophages in tumor angiogenesis. Clin. Cancer Res.
17, 5226–5232 (2011).
169. Yu, X. et al. Suppression of KSHV-induced
angiopoietin-2 inhibits angiogenesis, infiltration
of inflammatory cells, and tumor growth. Cell Cycle
15, 2053–2065 (2016).
170. Vergote, I. et al. Trebananib or placebo plus
carboplatin and paclitaxel as first-line treatment for
advanced ovarian cancer (TRINOVA-3/ENGOT-ov2/
GOG-3001): a randomised, double-blind, phase 3
trial. Lancet Oncol. 20, 862–876 (2019).
171. Kloepper, J. et al. Ang-2/VEGF bispecific antibody
reprograms macrophages and resident microglia
to anti-tumor phenotype and prolongs glioblastoma
survival. Proc. Natl Acad. Sci. USA 113, 4476–4481
(2016).
172. Kienast, Y. et al. Ang-2-VEGF-A CrossMab, a novel
bispecific human IgG1 antibody blocking VEGF-A
and Ang-2 functions simultaneously, mediates potent
antitumor, antiangiogenic, and antimetastatic efficacy.
Clin. Cancer Res. 19, 6730–6740 (2013).
173. Wong, E. C. et al. Preclinical evaluation of VEGF Ang2
bispecific nanobody BI836880 in patient-derived
0123456789();:
xenograft models of nasopharyngeal carcinoma
[abstract]. Cancer Res. 81 (Suppl. 13), 948 (2021).
174. Kamber, R. A. et al. Inter-cellular CRISPR screens
reveal regulators of cancer cell phagocytosis. Nature
597, 549–554 (2021).
175. Zhai, K. et al. Pharmacological inhibition of BACE1
suppresses glioblastoma growth by stimulating
macrophage phagocytosis of tumor cells. Nat. Cancer
2, 1136–1151 (2021).
176. Klug, F. et al. Low-dose irradiation programs
macrophage differentiation to an iNOS+/M1
phenotype that orchestrates effective T cell
immunotherapy. Cancer Cell 24, 589–602 (2013).
177. Virtakoivu, R. et al. Systemic blockade of Clever-1
elicits lymphocyte activation alongside checkpoint
molecule downregulation in patients with solid
tumors: results from a phase I/II clinical trial. Clin.
Cancer Res. 27, 4205–4220 (2021).
178. Bates, S. E. Epigenetic therapies for cancer. N. Engl. J.
Med. 383, 650–663 (2020).
179. Guerriero, J. L. et al. Class IIa HDAC inhibition reduces
breast tumours and metastases through anti-tumour
macrophages. Nature 543, 428–432 (2017).
180. Burgess, M. et al. HDAC7 is an actionable driver of
therapeutic antibody resistance by macrophages from
CLL patients. Oncogene 39, 5756–5767 (2020).
181. Georgoudaki, A. M. et al. Reprogramming
tumor-associated macrophages by antibody targeting
inhibits cancer progression and metastasis. Cell Rep.
15, 2000–2011 (2016).
182. Eisinger, S. et al. Targeting a scavenger receptor on
tumor-associated macrophages activates tumor cell
killing by natural killer cells. Proc. Natl Acad. Sci. USA
117, 32005–32016 (2020).
183. La Fleur, L. et al. Targeting MARCO and IL37R on
immunosuppressive macrophages in lung cancer blocks
regulatory T cells and supports cytotoxic lymphocyte
function. Cancer Res. 81, 956–967 (2021).
184. Lam, K. C. et al. Microbiota triggers STING-type I
IFN-dependent monocyte reprogramming of the
tumor microenvironment. Cell 184, 5338–5356.e21
(2021).
185. Spencer, C. N. et al. Dietary fiber and probiotics
influence the gut microbiome and melanoma
immunotherapy response. Science 374, 1632–1640
(2021).
186. Gopalakrishnan, V. et al. Gut microbiome modulates
response to anti-PD-1 immunotherapy in melanoma
patients. Science 359, 97–103 (2018).
187. Irmisch, A. et al. The Tumor Profiler Study: integrated,
multi-omic, functional tumor profiling for clinical
decision support. Cancer Cell 39, 288–293 (2021).
188. Maas, R. R. et al. An integrated pipeline for
comprehensive analysis of immune cells in human
brain tumor clinical samples. Nat. Protoc. 16,
4692–4721 (2021).
189. Oh, J. et al. Rapid serial immunoprofiling of the tumor
immune microenvironment by fine needle sampling.
Clin. Cancer Res. 27, 4781–4793 (2021).
190. Voabil, P. et al. An ex vivo tumor fragment platform
to dissect response to PD-1 blockade in cancer.
Nat. Med. 27, 1250–1261 (2021).
191. Wensink, G. E. et al. Patient-derived organoids as a
predictive biomarker for treatment response in cancer
patients. NPJ Precis. Oncol. 5, 30 (2021).
192. Kim, H. R. et al. Mouse-human co-clinical trials
demonstrate superior anti-tumour effects of buparlisib
(BKM120) and cetuximab combination in squamous
cell carcinoma of head and neck. Br. J. Cancer 123,
1720–1729 (2020).
193. Ignatiadis, M., Sledge, G. W. & Jeffrey, S. S. Liquid
biopsy enters the clinic – implementation issues and
future challenges. Nat. Rev. Clin. Oncol. 18, 297–312
(2021).
194. Taube, J. M. et al. The Society for Immunotherapy
of Cancer statement on best practices for multiplex
immunohistochemistry (IHC) and immunofluorescence
(IF) staining and validation. J. Immunother. Cancer 8,
e000155 (2020).
195. Ji, A. L. et al. Multimodal analysis of composition
and spatial architecture in human squamous cell
carcinoma. Cell 182, 497–514.e22 (2020).
196. Rao, A. et al. Exploring tissue architecture using spatial
transcriptomics. Nature 596, 211–220 (2021).
197. Bera, K. et al. Artificial intelligence in digital
pathology – new tools for diagnosis and precision
oncology. Nat. Rev. Clin. Oncol. 16, 703–715 (2019).
198. Pai, S. I. et al. New technology on the horizon: fast
analytical screening technique FNA (FAST-FNA)
enables rapid, multiplex biomarker analysis in head
and neck cancers. Cancer Cytopathol. 128, 782–791
(2020).
www.nature.com/nrclinonc

199. Wculek, S. K. et al. Dendritic cells in cancer
immunology and immunotherapy. Nat. Rev. Immunol.
20, 7–24 (2020).
200. Siwicki, M. & Pittet, M. J. Versatile neutrophil
functions in cancer. Semin. Immunol. https://doi.org/
10.1016/j.smim.2021.101538 (2021).
201. Coffelt, S. B., Wellenstein, M. D. & de Visser, K. E.
Neutrophils in cancer: neutral no more. Nat. Rev.
Cancer 16, 431–446 (2016).
202. Derakhshani, A. et al. Mast cells: a double-edged
sword in cancer. Immunol. Lett. 209, 28–35 (2019).
203. Khazaie, K. et al. The significant role of mast
cells in cancer. Cancer Metastasis Rev. 30, 45–60
(2011).
204. Geirsdottir, L. et al. Cross-species single-cell analysis
reveals divergence of the primate microglia program.
Cell 179, 1609–1622.e16 (2019).
205. Evren, E. et al. Distinct developmental pathways
from blood monocytes generate human lung
macrophage diversity. Immunity 54, 259–275.e7
(2021).
206. Rongvaux, A. et al. Development and function of
human innate immune cells in a humanized mouse
model. Nat. Biotechnol. 32, 364–372 (2014).
207. Tuveson, D. & Clevers, H. Cancer modeling meets
human organoid technology. Science 364, 952–955
(2019).
208. Yuki, K. et al. Organoid models of tumor immunology.
Trends Immunol. 41, 652–664 (2020).
nATuRe RevIeWS | ClinicAl Oncology
209. Cloughesy, T. F. et al. Neoadjuvant anti-
PD-1immunotherapy promotes a survival benefit
with intratumoral and systemic immune responses
in recurrent glioblastoma. Nat. Med. 25, 477–486
(2019).
Acknowledgements
M.J.P. receives support from the ISREC Foundation, Ludwig
Cancer Research, and NIH grants P01-CA240239 and
R01-CA218579. O.M. receives support from the ISREC
Foundation, the Ludwig Cancer Research, the Swiss National
Science Foundation (SNSF) 31003A_176168, the
Swiss National Cancer Ligue KFS-5034-02-2020, the Swiss
Personalized Health Network (SPHN), and the Personalized
Health and Related Technologies (PHRT). D.M. receives sup-
port from the ISREC Foundation, Association Frédéric Fellay,
Ernst and Lucie Schmidheiny Foundation, Fondation Dr Henri
Dubois-Ferrière Dinu Lipatti (DFDL), Ligue Genevoise contre
le cancer, Personalized Health and Related Technologies
(PHRT) ETH fund, Swiss Bridge Foundation, and Swiss
Innovation Agency (Innosuisse).
Author contributions
All the authors contributed to all aspects of preparation
of this manuscript.
Competing interests
M.J.P. has been a consultant for Aileron Therapeutics,
AstraZeneca, Cygnal Therapeutics, Elstar Therapeutics,
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Reviews
ImmuneOncia, KSQ Therapeutics, Merck, Siamab
Therapeutics, Third Rock Ventures and Tidal. O.M. has been
a consultant for Amgen, BMS, GSK, MSD, Novartis, Pierre
Fabre and Roche, and has received research support from
Amgen, BMS, MSD, Neracare and Pierre Fabre. D.M. is an
inventor on patents related to CAR T cell therapy, filed by the
University of Pennsylvania and the University of Geneva, and
has been a consultant for Limula Therapeutics and MPC
Therapeutics.
Peer review information
Nature Reviews Clinical Oncology thanks L. Akkari and the
other, anonymous, reviewer(s) for their contribution to
the peer review of this work.
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Supplementary information
The online version contains supplementary material available
at https://doi.org/10.1038/s41571-022-00620-6.
Related links
ClinicalTrials.gov: https://clinicaltrials.gov/
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