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# Immunogenic Cell Stress and Death Sensitize Tumors to Immunotherapy

Oliver Kepp, Guido Kroemer

<figure><img src="image_2.png" /></figure>

## To cite this version:

Oliver Kepp, Guido Kroemer. Immunogenic Cell Stress and Death Sensitize Tumors to Immunotherapy. 2024. hal-04596695

HAL Id: hal-04596695

https://hal.science/hal-04596695

Preprint submitted on 6 Jun 2024

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Distributed under a Creative Commons Attribution 4.0 International License
<figure><img src="image_1.png" /></figure>

HAL
open science

# Immunogenic Cell Stress and Death Sensitize Tumors to Immunotherapy

Oliver Kepp, Guido Kroemer

► To cite this version:

Oliver Kepp, Guido Kroemer. Immunogenic Cell Stress and Death Sensitize Tumors to Immunotherapy. 2024. hal-04596695

HAL Id: hal-04596695

https://hal.science/hal-04596695v1

Preprint submitted on 6 Jun 2024

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_2.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
1 *Editorial*

2 Immunogenic cell stress and death sensitize tumors to immu-
3 notherapy

4 Oliver Kepp1,2,*, Guido Kroemer1-3,*

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1

Centre de Recherche des Cordeliers, Equipe Labellisée par la Ligue Contre le Cancer, Université de Paris
Cité, Sorbonne Université, Inserm U1138, Institut Universitaire de France, Paris, France;

2 Metabolomics and Cell Biology Platforms, Gustave Roussy Cancer Center, Villejuif, France;
3 Department of Biology, Institut du Cancer Paris CARPEM, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.

* Correspondence: to Oliver Kepp (captain.olsen@gmail.com) or Guido Kroemer (kroemer@orange.fr).

The efficacy of chemotherapy with cytotoxicants or that of targeted therapies with more sophisticated agents is limited due to the plasticity of malignant cells that leads to the inevitable development of resistance. Immune checkpoint inhibitors (ICI) that target inhibitory cytotoxic T lymphocyte associated protein 4 (CTLA4) or T cell exhaustion signals such as the programmed cell death-1 (PDCD1, better known as PD-1), and pro- grammed cell death-1 ligand 1 (CD-274, better known as PD-L1) are occupying a central stage in the first-line adjuvant and neoadjuvant treatment of advanced neoplasms (1, 2). ICIs are now broadly used through the oncological spectrum.

Nevertheless, certain cytotoxic agents have the ability to induce durable disease control exceeding the clinical treatment phase in many cancer patients. Retrospectively, it appears that those agents that were empirically selected by clinicians over decades due to their effectiveness, are particularly capable of triggering specific stress and death pathways in cancer cells rendering them recognizable to the immune system (3, 4). In pre-clinical mouse models, treatment of tumors with drugs inducing immunogenic cell death (ICD) is only efficient if functional dendritic cells (DCs) and T lymphocytes are available (5-7). In patients, the induction of ICD correlates with the recruitment of antigen presenting cells (APCs) as well as cytotoxic T lymphocytes (CTLs) into the tumor bed, and tumor infiltration by DCs and CTLs is indeed a biomarker of favorable prognosis (8-10). ICD inducers include conventional chemotherapeutic agents such as anthracyclines, oxaliplatin, taxanes, as well as more disease-specific targeted agents from the group of tyrosine kinase inhibitors (TKIs) (11, 12). Moreover, ionizing irradiation (13, 14), photo-dynamic therapy (PDT) (15, 16), as well as oncolytic viruses (17, 18), have been shown to induce ICD. In preclinical experimentation and in clinical routine, it appears that combinations of ICD inducers with immune checkpoint inhibitors (ICIs) are particularly efficient in mediating their therapeutic potential (19, 20).

ICD facilitates the onset of anticancer immune responses via an increase in both the antigenicity as well as the adjuvanticity of the malignant cells. Mechanistically, this involves the onset of coordinated premortem stress responses that can affect the antigenic makeup of cancer cells via genetic or epigenetic alterations of the transcriptome. Moreover, ICD-related cellular stress facilitates the emission of normally confined ‘danger associated molecular patterns’ (DAMPs) that act on pattern recognition receptors (PRRs) expressed on professional antigen DCs (21-24). Thus, immature DCs, which express the ATP receptor P2Y2 are chemotactically attracted into the tumor bed by ATP secreted from cancer cells undergoing ICD (15, 25). The final approximation of DCs towards dying cancer cells is facilitated by tumor-emitted annexin A1 (ANXA1) that acts on formyl peptide receptor-1 (FPR1) present on DCs (24). Antigen transfer from tumor cells to DCs

Citation: To be added by editorial
staff during production.

Academic Editor: Firstname 34
Lastname 35

Received: date 36

Revised: date 37

Accepted: date 38

Published: date 39

<figure><img src="image_4.png" /></figure>

Copyright: © 2023 by the authors
Submitted for possible open access
publication under the terms and
conditions of the Creative Commons
Attribution (CC BY) license
(https://creativecommons.org/licenses/by/4.0/).
1 *Editorial*

2 Immunogenic cell stress and death sensitize tumors to immu-
3 notherapy

4 Oliver Kepp1,2,*, Guido Kroemer1-3,*

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6

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The efficacy of chemotherapy with cytotoxicants or that of targeted therapies with more sophisticated agents is limited due to the plasticity of malignant cells that leads to the inevitable development of resistance. Immune checkpoint inhibitors (ICI) that target inhibitory cytotoxic T lymphocyte associated protein 4 (CTLA4) or T cell exhaustion signals such as the programmed cell death-1 (PDCD1, better known as PD-1), and pro- grammed cell death-1 ligand 1 (CD-274, better known as PD-L1) are occupying a central stage in the first-line adjuvant and neoadjuvant treatment of advanced neoplasms (1, 2). ICIs are now broadly used through the oncological spectrum.

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Nevertheless, certain cytotoxic agents have the ability to induce durable disease control exceeding the clinical treatment phase in many cancer patients. Retrospectively, it appears that those agents that were empirically selected by clinicians over decades due to their effectiveness, are particularly capable of triggering specific stress and death pathways in cancer cells rendering them recognizable to the immune system (3, 4). In pre-clinical mouse models, treatment of tumors with drugs inducing immunogenic cell death (ICD) is only efficient if functional dendritic cells (DCs) and T lymphocytes are available (5-7). In patients, the induction of ICD correlates with the recruitment of antigen presenting cells (APCs) as well as cytotoxic T lymphocytes (CTLs) into the tumor bed, and tumor infiltration by DCs and CTLs is indeed a biomarker of favorable prognosis (8-10). ICD inducers include conventional chemotherapeutic agents such as anthracyclines, oxaliplatin, taxanes, as well as more disease-specific targeted agents from the group of tyrosine kinase inhibitors (TKIs) (11, 12). Moreover, ionizing irradiation (13, 14), photo-dynamic therapy (PDT) (15, 16), as well as oncolytic viruses (17, 18), have been shown to induce ICD. In preclinical experimentation and in clinical routine, it appears that combinations of ICD inducers with immune checkpoint inhibitors (ICIs) are particularly efficient in mediating their therapeutic potential (19, 20).

ICD facilitates the onset of anticancer immune responses via an increase in both the
antigenicity as well as the adjuvanticity of the malignant cells. Mechanistically, this in-
volves the onset of coordinated premortem stress responses that can affect the antigenic
makeup of cancer cells via genetic or epigenetic alterations of the transcriptome. More-
over, ICD-related cellular stress facilitates the emission of normally confined ‘danger
associated molecular patterns’ (DAMPs) that act on pattern recognition receptors (PRRs)
expressed on professional antigen DCs (21-24). Thus, immature DCs, which express the
ATP receptor P2Y2 are chemotactically attracted into the tumor bed by ATP secreted
from cancer cells undergoing ICD (15, 25). The final approximation of DCs towards dy-
ing cancer cells is facilitated by tumor-emitted annexin A1 (ANXA1) that acts on formyl
peptide receptor-1 (FPR1) present on DCs (24). Antigen transfer from tumor cells to DCs

Citation: To be added by editorial
staff during production.

Academic Editor: Firstname 34
Lastname 35

Received: date 36
Revised: date 37
Accepted: date 38
Published: date 39

<figure><img src="image_3.png" /></figure>

Copyright: © 2023 by the authors
Submitted for possible open access
publication under the terms and
conditions of the Creative Commons
Attribution (CC BY) license
(https://creativecommons.org/licenses/by/4.0/)

<footnote n="1">¹ Centre de Recherche des Cordeliers, Equipe Labellisée par la Ligue Contre le Cancer, Université de Paris Cité, Sorbonne Université, Inserm U1138, Institut Universitaire de France, Paris, France;</footnote>

<footnote n="2">² Metabolomics and Cell Biology Platforms, Gustave Roussy Cancer Center, Villejuif, France;</footnote>

<footnote n="3">³ Department of Biology, Institut du Cancer Paris CARPEM, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.</footnote>

<footnote>* Correspondence: to Oliver Kepp (captain.olsen@gmail.com) or Guido Kroemer (kroemer@orange.fr).</footnote>
is mediated by an ‘eat-me’ signal, namely surface-exposed calreticulin that appears on the plasma membrane of malignant cells and then acts as on its receptor CD91 present on DCs (13). The maturation of DCs is ignited via the ligation of Toll like receptor 4 (TLR4) by high mobility group box 1 (HMGB1), emanating from the nuclear compartment of dying cancer cells. DC maturation further drives the production of type-1 interferons, which in turn amplifies the synthesis of the C-X-C motif chemokine ligand 10 (CXCL10), thus stimulating T cell priming. In sum, induction of ICD in malignant cells leads to a coordinated alteration of the cell surface and the local secretome, thereby facilitating the attraction, differentiation and maturation of DCs so that they present tumor-associated antigens to T cells and hence initiate adaptive anticancer immunity (22-24). Of note, malignant cells and pathogenic viruses can subvert ICD-associated DAMP emission, thus blunting the immune response. Moreover, inherited or acquired defects in the perception of ICD by the host immune system can undermine immunosurveillance and provoke failure of cancer treatments.

The concept of ICD has transcended the realm of preclinical experimentation and is now used for drug discovery (to identify novel ICD inducers) as well as for the design of clinical trials (to identify suitable drug combinations, in particular with ICIs). The present special issue "Immunogenic Cell Stress and Death", discusses different strategies for inducing anticancer immunity by facilitating the molecular crosstalk between cancer cells, DCs and T lymphocytes. The role of ICD is reviewed in the context of colorectal, gastric, pancreatic, and hepatocellular cancer as well as multiple myeloma. Moreover, it is revealed that combination treatment with cetuximab plus cisplatin for the treatment of head and neck cancer induced traits of ICD. Interestingly, high dose of the non-immunogenic cell death inducer cisplatin blunted antitumor immunity in this context. Additional aspects of immunogenic cell stress and death cover the role of ICD-associated chemokines and chemokine receptors in the activation of CD8 T-cells and clinical applications thereof. Furthermore, light is shed on the role of tumor-associated macrophages (TAMs) in the response to dying cancer cells. Finally, three-dimensional organ-on-chip technology is introduced for modeling the tumor microenvironment (TME). At the mechanistic level, evidence is presented that targeting the unfolded protein response (UPR) can increase the efficacy of anticancer therapy.

Altogether, in this special issue, ICD induction is discussed in different disease-relevant therapeutic approaches, novel immune signals are described, and the role of specific immune cell subtypes is elucidated. Advanced in vitro systems are helping to understand the apical targets of ICD, the organellar genesis of ICD signals, as well as the complex cellular interplay in the tumor microenvironment. Altogether, an ever more sophisticated pipeline of preclinical ICD-relevant exploration will prepare the bases for the clinical implementation of ICD-based anticancer therapies.

List of Contributions

1. Chiaravalli M, Spring A, Agostini A, Piro G, Carbone C, Tortora G. Immunogenic Cell Death: An Emerging Target in Gastrointestinal Cancers. Cells. 2022;11(19).

2. De Azevedo J, Mourtada J, Bour C, Devignot V, Schultz P, Borel C, et al. The EXTREME Regimen Associating Cetuximab and Cisplatin Favors Head and Neck Cancer Cell Death and Immunogenicity with the Induction of an Anti-Cancer Immune Response. Cells. 2022;11(18).

3. Johnstone M, Vinaixa D, Turi M, Morelli E, Anderson KC, Gulla A. Promises and Challenges of Immunogenic Chemotherapy in Multiple Myeloma. Cells. 2022;11(16).

4. Krysko DV, Demuynck R, Efimova I, Naessens F, Krysko O, Catanzaro E. In Vitro Veritas: From 2D Cultures to Organ-on-a-Chip Models to Study Immunogenic Cell Death in the Tumor Microenvironment. Cells. 2022;11(22).

5. Roussot N, Ghiringhelli F, Rebe C. Tumor Immunogenic Cell Death as a Mediator of Intratumor CD8 T-Cell Recruitment. Cells. 2022;11(22).

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is mediated by an ‘eat-me’ signal, namely surface-exposed calreticulin that appears on the plasma membrane of malignant cells and then acts as on its receptor CD91 present on DCs (13). The maturation of DCs is ignited via the ligation of Toll like receptor 4 (TLR4) by high mobility group box 1 (HMGB1), emanating from the nuclear compartment of dying cancer cells. DC maturation further drives the production of type-1 interferons, which in turn amplifies the synthesis of the C-X-C motif chemokine ligand 10 (CXCL10), thus stimulating T cell priming. In sum, induction of ICD in malignant cells leads to a coordinated alteration of the cell surface and the local secretome, thereby facilitating the attraction, differentiation and maturation of DCs so that they present tumor-associated antigens to T cells and hence initiate adaptive anticancer immunity (22-24). Of note, malignant cells and pathogenic viruses can subvert ICD-associated DAMP emission, thus blunting the immune response. Moreover, inherited or acquired defects in the perception of ICD by the host immune system can undermine immunosurveillance and provoke failure of cancer treatments.

The concept of ICD has transcended the realm of preclinical experimentation and is now used for drug discovery (to identify novel ICD inducers) as well as for the design of clinical trials (to identify suitable drug combinations, in particular with ICIs). The present special issue "Immunogenic Cell Stress and Death", discusses different strategies for inducing anticancer immunity by facilitating the molecular crosstalk between cancer cells, DCs and T lymphocytes. The role of ICD is reviewed in the context of colorectal, gastric, pancreatic, and hepatocellular cancer as well as multiple myeloma. Moreover, it is revealed that combination treatment with cetuximab plus cisplatin for the treatment of head and neck cancer induced traits of ICD. Interestingly, high dose of the non-immunogenic cell death inducer cisplatin blunted antitumor immunity in this context. Additional aspects of immunogenic cell stress and death cover the role of ICD-associated chemokines and chemokine receptors in the activation of CD8 T-cells and clinical applications thereof. Furthermore, light is shed on the role of tumor-associated macrophages (TAMs) in the response to dying cancer cells. Finally, three-dimensional organ-on-chip technology is introduced for modeling the tumor microenvironment (TME). At the mechanistic level, evidence is presented that targeting the unfolded protein response (UPR) can increase the efficacy of anticancer therapy.

Altogether, in this special issue, ICD induction is discussed in different disease-relevant therapeutic approaches, novel immune signals are described, and the role of specific immune cell subtypes is elucidated. Advanced in vitro systems are helping to understand the apical targets of ICD, the organellar genesis of ICD signals, as well as the complex cellular interplay in the tumor microenvironment. Altogether, an ever more sophisticated pipeline of preclinical ICD-relevant exploration will prepare the bases for the clinical implementation of ICD-based anticancer therapies.

List of Contributions

1. Chiaravalli M, Spring A, Agostini A, Piro G, Carbone C, Tortora G. Immunogenic Cell Death: An Emerging Target in Gastrointestinal Cancers. Cells. 2022;11(19).

2. De Azevedo J, Mourtada J, Bour C, Devignot V, Schultz P, Borel C, et al. The EXTREME Regimen Associating Cetuximab and Cisplatin Favors Head and Neck Cancer Cell Death and Immunogenicity with the Induction of an Anti-Cancer Immune Response. Cells. 2022;11(18).

3. Johnstone M, Vinaixa D, Turi M, Morelli E, Anderson KC, Gulla A. Promises and Challenges of Immunogenic Chemotherapy in Multiple Myeloma. Cells. 2022;11(16).

4. Krysko DV, Demuynck R, Efimova I, Naessens F, Krysko O, Catanzaro E. In Vitro Veritas: From 2D Cultures to Organ-on-a-Chip Models to Study Immunogenic Cell Death in the Tumor Microenvironment. Cells. 2022;11(22).

5. Roussot N, Ghiringhelli F, Rebe C. Tumor Immunogenic Cell Death as a Mediator of Intratumor CD8 T-Cell Recruitment. Cells. 2022;11(22).
6. Rufo N, Yang Y, De Vleeschouwer S, Agostinis P. The "Yin and Yang" of Unfolded Protein Response in Cancer and Immunogenic Cell Death. Cells. 2022;11(18).

7. Tatarova Z, Blumberg DC, Bensen A, Mills GB, Jonas O. Panobinostat Induced Spatial In Situ Biomarkers Predictive of Anti-PD-1 Efficacy in Mouse Mammary Carcinoma. Cells. 2023;12(2).

8. Vanmeerbeek I, Govaerts J, Laureano RS, Sprooten J, Naulaerts S, Borras DM, et al. The Interface of Tumour-Associated Macrophages with Dying Cancer Cells in Immuno-Oncology. Cells. 2022;11(23).

**Acknowledgments:** OK receives funding from the DIM elicit (Ile de France), Agence National de la Recherche (ANR) and Institut National du Cancer (INCa); GK is supported by the Ligue contre le Cancer (équipe labellisée); ANR- Projets blancs; AMMICa US23/CNRS UMS3655; Association pour la recherche sur le cancer (ARC); Cancéropôle Ile-de-France; Fondation pour la Recherche Médicale (FRM); a donation by Elior; Equipex Onco-Pheno-Screen; European Joint Programme on Rare Diseases (EJPRD); European Research Council (ICD-Cancer), European Union Horizon 2020 Projects Oncobiome and Crimson; Fondation Carrefour; INCa; Institut Universitaire de France; LabEx Immuno-Oncology (ANR-18-IDEX-0001); a Cancer Research ASPIRE Award from the Mark Foundation; the RHU Immunolife; Seerave Foundation; SIRIC Stratified Oncology Cell DNA Repair and Tumor Immune Elimination (SOCRATE); and SIRIC Cancer Research and Personalized Medicine (CARPEM). This study contributes to the IdEx Université de Paris ANR-18-IDEX-0001.

**Conflicts of Interest:** OK and GK have been holding research contracts with Daiichi Sankyo, Eleor, Kaleido, Lytix Pharma, PharmaMar, Osasuna Therapeutics, Samsara Therapeutics, Sanofi, Tollys, and Vascage. GK is on the Board of Directors of the Bristol Myers Squibb Foundation France. GK is a scientific co-founder of everImmune, Osasuna Therapeutics, Samsara Therapeutics and Therafast Bio. OK is a scientific co-founder of Samsara Therapeutics. GK is in the scientific advisory boards of Hevolution, Institut Servier and Longevity Vision Funds. GK is the inventor of patents covering therapeutic targeting of aging, cancer, cystic fibrosis and metabolic disorders. GK's brother, Romano Kroemer, was an employee of Sanofi and now consults for Boehringer-Ingelheim. LZ, has held research contracts with Glaxo Smyth Kline, Incyte, Lytix, Kaleido, Innovate Pharma, Daiichi Sankyo, Pilege, Merus, Transgene, 9 m, Tusk and Roche, was on the Board of Directors of Transgene, is a cofounder of everImmune, and holds patents covering the treatment of cancer and the therapeutic manipulation of the microbiota. The funders had no role in the design of the study; in the writing of the manuscript, or in the decision to publish the results.

## References

1. Sharma P, Goswami S, Raychaudhuri D, Siddiqui BA, Singh P, Nagarajan A, et al. Immune checkpoint therapy-current perspectives and future directions. Cell. 2023;186(8):1652-69.

2. Garbe C, Dummer R, Amaral T, Amaria RN, Ascierto PA, Burton EM, et al. Neoadjuvant immunotherapy for melanoma is now ready for clinical practice. Nat Med. 2023.

3. Galassi C, Klapp V, Yamazaki T, Galluzzi L. Molecular determinants of immunogenic cell death elicited by radiation therapy. Immunol Rev. 2023.

4. Kroemer G, Galassi C, Zitvogel L, Galluzzi L. Immunogenic cell stress and death. Nat Immunol. 2022;23(4):487-500.

5. Casares N, Pequignot MO, Tesniere A, Ghiringhelli F, Roux S, Chaput N, et al. Caspase-dependent immunogenicity of doxorubicin-induced tumor cell death. J Exp Med. 2005;202(12):1691-701.

6. de Mingo Pulido A, Gardner A, Hiebler S, Soliman H, Rugo HS, Krummel MF, et al. TIM-3 Regulates CD103(+) Dendritic Cell Function and Response to Chemotherapy in Breast Cancer. Cancer Cell. 2018;33(1):60-74 e6.

7. Ashour D, Arampatzi P, Pavlovic V, Forstner KU, Kaisho T, Beilhack A, et al. IL-12 from endogenous cDC1, and not vaccine DC, is required for Th1 induction. JCI Insight. 2020;5(10).

8. Senovilla L, Vitale I, Martins I, Tailler M, Pailleret C, Michaud M, et al. An immunosurveillance mechanism controls cancer cell ploidy. Science. 2012;337(6102):1678-84.

9. Broz ML, Binnewies M, Boldajipour B, Nelson AE, Pollack JL, Erle DJ, et al. Dissecting the tumor myeloid compartment reveals rare activating antigen-presenting cells critical for T cell immunity. Cancer Cell. 2014;26(5):638-52.

10. Stoll G, Iribarren K, Michels J, Leary A, Zitvogel L, Cremer I, et al. Calreticulin expression: Interaction with the immune infiltrate and impact on survival in patients with ovarian and non-small cell lung cancer. Oncoimmunology. 2016;5(7):e1177692.

11. Liu P, Zhao L, Pol J, Levesque S, Petrazzuolo A, Pfirschke C, et al. Crizotinib-induced immunogenic cell death in non-small cell lung cancer. Nat Commun. 2019;10(1):1486.
6. Rufo N, Yang Y, De Vleeschouwer S, Agostinis P. The "Yin and Yang" of Unfolded Protein Response in Cancer and Immunogenic Cell Death. Cells. 2022;11(18).

7. Tatarova Z, Blumberg DC, Bensen A, Mills GB, Jonas O. Panobinostat Induced Spatial In Situ Biomarkers Predictive of Anti-PD-1 Efficacy in Mouse Mammary Carcinoma. Cells. 2023;12(2).

8. Vanmeerbeek I, Govaerts J, Laureano RS, Sprooten J, Naulaerts S, Borras DM, et al. The Interface of Tumour-Associated Macrophages with Dying Cancer Cells in Immuno-Oncology. Cells. 2022;11(23).

**Acknowledgments:** OK receives funding from the DIM elicit (Ile de France), Agence National de la Recherche (ANR) and Institut National du Cancer (INCa); GK is supported by the Ligue contre le Cancer (équipe labellisée); ANR- Projets blancs; AMMICa US23/CNRS UMS3655; Association pour la recherche sur le cancer (ARC); Cancéropôle Ile-de-France; Fondation pour la Recherche Médicale (FRM); a donation by Elior; Equipex Onco-Pheno-Screen; European Joint Programme on Rare Diseases (EJPRD); European Research Council (ICD-Cancer), European Union Horizon 2020 Projects Oncobiome and Crimson; Fondation Carrefour; INCa; Institut Universitaire de France; LabEx Immuno-Oncology (ANR-18-IDEX-0001); a Cancer Research ASPIRE Award from the Mark Foundation; the RHU Immunolife; Seerave Foundation; SIRIC Stratified Oncology Cell DNA Repair and Tumor Immune Elimination (SOCRATE); and SIRIC Cancer Research and Personalized Medicine (CARPEM). This study contributes to the IdEx Université de Paris ANR-18-IDEX-0001.

**Conflicts of Interest:** OK and GK have been holding research contracts with Daiichi Sankyo, Eleor, Kaleido, Lytix Pharma, PharmaMar, Osasuna Therapeutics, Samsara Therapeutics, Sanofi, Tollys, and Vascage. GK is on the Board of Directors of the Bristol Myers Squibb Foundation France. GK is a scientific co-founder of everImmune, Osasuna Therapeutics, Samsara Therapeutics and Therafast Bio. OK is a scientific co-founder of Samsara Therapeutics. GK is in the scientific advisory boards of Hevolution, Institut Servier and Longevity Vision Funds. GK is the inventor of patents covering therapeutic targeting of aging, cancer, cystic fibrosis and metabolic disorders. GK's brother, Romano Kroemer, was an employee of Sanofi and now consults for Boehringer-Ingelheim. LZ, has held research contracts with Glaxo Smyth Kline, Incyte, Lytix, Kaleido, Innovate Pharma, Daiichi Sankyo, Pilege, Merus, Transgene, 9 m, Tusk and Roche, was on the Board of Directors of Transgene, is a cofounder of everImmune, and holds patents covering the treatment of cancer and the therapeutic manipulation of the microbiota. The funders had no role in the design of the study; in the writing of the manuscript, or in the decision to publish the results.

## References

1. Sharma P, Goswami S, Raychaudhuri D, Siddiqui BA, Singh P, Nagarajan A, et al. Immune checkpoint therapy-current perspectives and future directions. Cell. 2023;186(8):1652-69.

2. Garbe C, Dummer R, Amaral T, Amaria RN, Ascierto PA, Burton EM, et al. Neoadjuvant immunotherapy for melanoma is now ready for clinical practice. Nat Med. 2023.

3. Galassi C, Klapp V, Yamazaki T, Galluzzi L. Molecular determinants of immunogenic cell death elicited by radiation therapy. Immunol Rev. 2023.

4. Kroemer G, Galassi C, Zitvogel L, Galluzzi L. Immunogenic cell stress and death. Nat Immunol. 2022;23(4):487-500.

5. Casares N, Pequignot MO, Tesniere A, Ghiringhelli F, Roux S, Chaput N, et al. Caspase-dependent immunogenicity of doxorubicin-induced tumor cell death. J Exp Med. 2005;202(12):1691-701.

6. de Mingo Pulido A, Gardner A, Hiebler S, Soliman H, Rugo HS, Krummel MF, et al. TIM-3 Regulates CD103(+) Dendritic Cell Function and Response to Chemotherapy in Breast Cancer. Cancer Cell. 2018;33(1):60-74 e6.

7. Ashour D, Arampatzi P, Pavlovic V, Forstner KU, Kaisho T, Beilhack A, et al. IL-12 from endogenous cDC1, and not vaccine DC, is required for Th1 induction. JCI Insight. 2020;5(10).

8. Senovilla L, Vitale I, Martins I, Tailler M, Pailleret C, Michaud M, et al. An immunosurveillance mechanism controls cancer cell ploidy. Science. 2012;337(6102):1678-84.

9. Broz ML, Binnewies M, Boldajipour B, Nelson AE, Pollack JL, Erle DJ, et al. Dissecting the tumor myeloid compartment reveals rare activating antigen-presenting cells critical for T cell immunity. Cancer Cell. 2014;26(5):638-52.

10. Stoll G, Iribarren K, Michels J, Leary A, Zitvogel L, Cremer I, et al. Calreticulin expression: Interaction with the immune infiltrate and impact on survival in patients with ovarian and non-small cell lung cancer. Oncoimmunology. 2016;5(7):e1177692.

11. Liu P, Zhao L, Pol J, Levesque S, Petrazzuolo A, Pfirschke C, et al. Crizotinib-induced immunogenic cell death in non-small cell lung cancer. Nat Commun. 2019;10(1):1486.
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12. Kang X, Zhang Y, Song J, Wang L, Li W, Qi J, et al. A photo-triggered self-accelerated nanoplatform for multifunctional image-guided combination cancer immunotherapy. Nat Commun. 2023;14(1):5216.

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13. Obeid M, Panaretakis T, Joza N, Tufi R, Tesniere A, van Endert P, et al. Calreticulin exposure is required for the immunogenicity of gamma-irradiation and UVC light-induced apoptosis. Cell Death Differ. 2007;14(10):1848-50.

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14. Deutsch E, Chargari C, Galluzzi L, Kroemer G. Optimising efficacy and reducing toxicity of anticancer radioimmunotherapy. Lancet Oncol. 2019;20(8):e452-e63.

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15. Garg AD, Krysko DV, Verfaillie T, Kaczmarek A, Ferreira GB, Marysael T, et al. A novel pathway combining calreticulin exposure and ATP secretion in immunogenic cancer cell death. EMBO J. 2012;31(5):1062-79.

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