Macrophages drive the earliest anti-tumoral response to BCG therapy by directly killing bladder cancer through TNF signaling

The Bacillus Calmette-Guerin (BCG) vaccine is the cancer immunotherapy longest in use. Despite its effectiveness in bladder cancer (BC), its initial mechanisms of action remain largely unknown. Therefore, proper diagnostic assessments to identify patients who will not respond to treatment or develop resistance are lacking. Here, we set-out to unravel the earliest innate cellular mechanisms involved in BCG-induced clearance of tumors. We show that BCG induces a massive recruitment of macrophages to the tumor microenvironment and modulates their morphology and behavior towards a proinflammatory phenotype, while also promoting macrophage fusion-like events. We demonstrate that macrophages directly induce apoptosis and clearance of cancer cells through TNF-signaling and that they are indispensable for this antitumoral response since their depletion completely abrogates the BCG-anti tumor effect. Contrary to the general concept that macrophage antitumoral activities uniquely rely on stimulating an effective adaptive response, we demonstrate that macrophages alone can directly induce tumor killing and clearance; revealing an additional step to the BCG-induced tumor immunity model, that was not previously considered. In addition, we also provide proof-of-concept experiments demonstrating the potential of this unique in vivo preclinical model to test new innate immunomodulators.