CCL2-CCR2 axis recruits tumor associated macrophages to induce immune evasion through PD-1 signaling in esophageal carcinogenesis

1Esophageal cancer is the sixth most common cancer in the world. It was estimated that over 570,000 cases occur and nearly 510, 000 died in 2018 worldwide. Most of cases are found in Eastern Asia and Europe, which respectively account for 76.3 and 10.2% of the five-year prevalence. In histology, although the incidence of esophageal adenocarcinoma (EAC) is increasing in Western countries, esophageal squamous cell carcinoma (ESCC) is still the predominant type, accounting for 90% of all esophageal cancer cases. Due to the lack of targeted approaches for early diagnosis and treatment, the five-year survival rate of ESCC patients remains dismal. The poor outcome urges development of novel preventive and therapeutic strategies against this disease, which highlights the need for better understanding of ESCC carcinogenesis.

2In the past decades, studies on ESCC carcinogenesis conventionally focused on the mutation and malignant transformation of esophageal epithelium squamous cells. Notably, a few of mutated genes governing cell cycle or apoptosis (e.g. CCND1, CDKN2A, SOX2, and TP53) have been identified in a fraction of ESCC patients by comprehensive genomic characterization. However, these discoveries have not been well translated to the bedside and yield significant benefit for patients, partially due to the inter- and intra-tumor genomic and epigenomic heterogeneity. On the other hand, accumulating results suggest that the interaction between mutant cells and immune cells in tissue microenvironment directly influences and even determines the development of cancer. Importantly, immunotherapies that target tumor microenvironment instead of tumor intrinsic cells have revealed remarkable efficacy in multiple cancer types, shedding light on the possible treatment of ESCC. However, the sophisticated immune responses and their biological significance during ESCC carcinogenesis is still unclear.

3In our previous study, transcriptional profiling with ESCC rat model suggested that migration and aggregation of immune cells regulated by chemokine signaling were markedly altered during esophageal carcinogenesis (Supplementary Figure S1a and b). It was worth noting that chemokine (C-C motif) ligand 2 (CCL2) as the leading chemokine was prominently over-expressed in esophageal tumors (Supplementary Figure S1c). In tumor microenvironment, CCL2 interacts with C-C motif chemokine receptor 2 (CCR2) to mediate chemotaxis of monocytes and tumor associated macrophages (TAMs), which consequently contributes to the shaping of tumor microenvironment and facilitates cancer progression. Though TAMs have been indicated as a promising therapeutic target to treat some cancers, our understanding on its activation and tumor-promoting mechanism is limited. Particularly, the involvement of CCL2-CCR2 and TAMs in ESCC has not been investigated yet. In this study, we demonstrated the antitumor activity of CCL2-CCR2 blockade in esophageal carcinogenesis and deciphered the mechanism underlying tumor evasion induced by TAMs.

4Human ESCC tissue microarray chips of two cohorts were obtained from the Shanghai Outdo Biotech Company (Shanghai, China). Cohort I contains normal mucosa (10 cases), dysplasia (22 cases), and ESCC (58 cases). Each case contains two independent tissue samples on the chip. In Cohort II, clinical samples containing tumors and matched adjacent tissues were obtained from 100 ESCC patients that enrolled from January 2009 to December 2010 and followed up for 6.5 years. The clinic pathological and follow-up data of patients were prospectively collected (Supplementary Table S1).

5Six-week-old male F344 rats and C57BL/6 mice were purchased from Beijing Vital River Laboratory Animal Technology Company (Beijing, China). C57BL/6 CCL2−/− mice (Ccl2tm1Rol/J), CCR2−/− mice (Ccr2tm1Ifc/J) and PPARγloxP mice (Ppargtm2Rev/J) were obtained from the Jackson laboratory. PPARγloxP mice were bred with Lyz2cre mice to generate macrophage-specific PPARG deletion mice (PPARG−/−ΔMacrophage). The mice were bred at the Shanghai Model Organisms Center (Shanghai, China) and used between the ages of 4 and 8 weeks. The ESCC rat model and mouse model have been previously established in our lab.

6The immortalized human normal esophageal epithelium cell line Het-1A (CRL-2692) and human monocyte cell line THP-1 (TIB-202) was obtained from American Type Culture Collection (ATCC, VA, USA). Het-1A cells were cultured in Bronchial epithelial cell basal medium (BEGM) with all the additives (Lonza, MD, USA). The human ESCC cell line TE-1 cells were obtained from the Cell Bank of Shanghai Institutes for Biological Sciences (Chinese Academy of Sciences, Shanghai, China). THP-1 cells and TE-1 cells were cultured in RPMI-1640 medium supplemented with 10% fetal bovine serum, penicillin (100 μg/ml) and streptomycin (100 μg/ml). All the cell lines were authenticated by short tandem repeats (STR) profiling (Supplementary materials).

7The provisional TCGA Esophageal Carcinoma data sets referenced during the study are available in a public repository from the Genomic Data Commons (https://portal.gdc.cancer.gov/) and from the TCGA manuscript publication page (https://www.cancer.gov/). The cases included in this study are listed in Supplementary Table S2. Gene set enrichment analysis (GSEA) was performed using GSEA software and Molecular Signatures Database (MSigDB) gene sets downloaded from Broad Institute (http://software.broadinstitute.org/gsea/index.jsp). RNA sequencing data is available through the National Center for Biotechnology Information Gene Expression Omnibus (NCBI–GEO) database (http://www.ncbi.nlm.nih.gov/geo/) under the accession number GSE134067.

8Statistical analysis was conducted using GraphPad Prism software. All data represents at least three independent experiments and are expressed as mean ± standard deviation. Log-rank test and multi-variate COX were used to estimate patients’ overall survival. Two-way analysis of variance (ANOVA) or one-way ANOVA followed by Bonferroni’s test was used for multiple groups’ analysis. Unpaired Student’s t-test was used to determine statistical significance in two-group experiments. P value less than 0.05 was considered statistically significant.

9Other detailed information on materials can be found in the Supplementary methods, Supplementary Figure S2, and Supplementary Tables S3-S4.

10To evaluate the association of CCL2 and TAMs in esophageal carcinogenesis, we firstly determined the distribution of CCL2 with human tumor tissue microarrays constructed from ESCC patients (cohort I). The expression level of CCL2 was low in normal mucosa and hyperplasia, but continuously increased in the progression of pathological lesions including dysplasia, papilloma and carcinoma (Fig. 1a and b). In another cohort, the expression of CCL2 was markedly enhanced in cancer tissues when compared to the paired para-cancer tissues (Fig. 1c). Next, we compared CCL2 expression with the number of cells expressing CD68, which is a common marker for TAMs. In ESCC cases with higher expression of CCL2, the number of TAMs was significantly elevated (Fig. 1d and e). Collectively, these data confirmed the tight association of CCL2 and TAMs with carcinogenesis in human ESCC. In addition, the correlation between expression of CCL2 and CD68 with the overall survival of patients was investigated. In the cohort followed up for 4.6 to 6.5 years, expressions of both CCL2 and CD68 were inversely associated with the overall survival of ESCC patients (Fig. 1f and g). Multivariate Cox analysis suggested that CCL2 expression was an independent prognosticator of overall survival for human ESCC (P = 0.013, Supplementary Table S5).

11To validate the effect of CCL2 on TAMs infiltration during esophageal carcinogenesis, we determined the tissue levels of CCL2 and CD68 with the ESCC rat model (Fig. 2a). In this animal model, NMBA-treatment (15 injections in 5 weeks) specifically induced noticeable tumors in rat esophagus after 35 weeks, with 100% tumor incidence and nearly 3 visible tumors per rat (Fig. 2a). Compared to the animals of vehicle control, the mRNA and protein levels of CCL2 were significantly increased in the esophageal epithelium of NMBA-treated rats (Fig. 2b). Consistent with our finding from human ESCC cohorts, the expression of CCL2 and the number of CD68 positive macrophages were remarkably elevated in concordance with the pathological progression of rat esophageal epithelium (Fig. 2c, d and e). Additionally, the inflammatory cytokines in esophageal tissue including IL-1α/β, IL-10, IL-18, G-CSF and GM-CSF were significantly increased during the development of tumors (Fig. 2f). Thus, our data from ESCC cohorts and rat model both suggested that escalated expression of CCL2 and TAMs accumulation play an important role in esophageal carcinogenesis.

12Next, we further studied the interaction between CCL2 and TAMs with human-origin cell models in vitro. Firstly, we compared the basal levels of CCL2 expression between normal human esophageal epithelial cells (Het-1A) and the ESCC cells (TE-1). In comparison with Het-1A cells, CCL2 secretion in culture medium was markedly higher in TE-1 cancer cells, and the chemotaxis assay with human monocyte THP-1 cells indicated that monocyte migration was also increased in TE-1 conditioned medium (Fig. 2g). To investigate how tumor cells affecting TAMs during ESCC carcinogenesis, we constructed a malignant transformation cell model with continuous NMBA-treatment in Het-1A cells (Supplementary Figure S3a). The NMBA treatment continuously elevated CCL2 expression over time until the malignant transformation was successfully induced at Week 25 (Fig. 2h). In parallel with CCL2 expression, chemotaxis of THP-1 cells was also increased by the conditioned medium from malignantly transformed cells, which was comparable to the effect of TE-1 cells (Fig. 2i). In addition, monocyte chemotaxis induced by transformed cells was significantly antagonized by CCL2-neutralizing antibody in a dose-dependent manner (Fig. 2j). These data further validated our in vivo observations regarding that CCL2 expression triggered TAMs infiltration during esophageal carcinogenesis.

13To further explore the function of tumor infiltrating macrophages in esophageal carcinogenesis, we constructed ESCC mouse model with CCL2 and CCR2 gene deletion. Similarly to the ESCC rat model, continuous increase of CCL2 expression and TAMs accumulation were also observed in the forestomach of wild type mouse during carcinogenesis (Supplementary Figure S4a). More importantly, gene knockout of CCL2 dramatically decreased the incidence and number of forestomach tumors in the mouse model (Fig. 3a), suggesting the crucial role of CCL2 in the development of ESCC. Furthermore, we found that deletion of CCL2 significantly inhibited the infiltration of CD11b+CCR2+ monocyte (Fig. 3b) as well as the accumulation of CD11b+F4/80+ TAMs (Fig. 3c) in tumors. In addition, CCL2 knockout induced marked suppression on TAMs-associated inflammatory cytokines such as IL-10, IL-12b, and IL-13, which were prominently elevated by NMBA-treatment in wild type animals (Fig. 3d).

14As the key functional receptor for CCL2, CCR2 is expressed primarily on the cell surface of monocyte and TAMs. Hence, we further conducted ESCC carcinogenesis study using the CCR2−/− mouse (Fig. 3e). In line with our findings with CCL2−/− mouse model, the loss of CCR2 markedly reduced the incidence of mouse forestomach tumors by nearly 60%, as compared with those in CCR2+/+ wild type and CCR2+/− heterozygous animals (Fig. 3f). The average number of tumors declined from 5.7 to 2.0 per mouse (Fig. 3g). Flow cytometry analysis showed that CD11b+Ly6Chigh inflammatory monocytes were notably infiltrated in forestomach tumors of CCR2+/+ and CCR2+/− mice after NMBA treatment; however, the infiltration was completely abolished in CCR2−/− mice (Fig. 3h). Furthermore, profiling of tissue cytokines indicated noticeable suppression of inflammatory chemokines including MIP-1α (CCL3), RANTES (CCL5), Eotoxin (CCL11), MDC (CCL22), and MIG (CXCL9) by the deletion of CCR2 (Fig. 3i), suggesting that the inflammatory responses prompted by TAMs accumulation was equilibrated by the blockade of CCL2-CCR2 axis.

15To explicate the mechanism underlying tumor promotive function of infiltrated TAMs, we carried out RNA-sequencing with tumors harvested from the CCR2−/− mouse model (Supplementary Figure S4b). In parallel with our previous findings from ESCC rat model (Supplementary Figure S1), gene expression changes during carcinogenesis were remarkably enriched in the pathways interconnected with immune responses, which were led by the pathway of “cytokine-cytokine receptor interaction” and “chemokine receptors bind chemokines”. Moreover, “PD-1 signaling” pathway that negatively controls T cells activities was identified to be most significantly suppressed by CCR2 knockout (Fig. 4a). In addition, the expression of genes specifically involved in PD-1 pathway was activated in NMBA-induced carcinogenesis, but notably repressed by the deletion of CCR2 (Fig. 4b). In concert with this, other pathways associated with PD-1 signaling including “CD28 family”, “ZAP-70”, “Phosphorylation of CD3” and “TCR signaling” were similarly constrained by the absence of CCR2.

16To validate the inhibitory effect of CCR2 blockade on PD-1 signaling, we further analyzed the expression of PD-1 in T cells using CCR2−/− mouse model. Flow cytometry analysis showed that the proportion of PD-1+ T cells in CD8+ CTLs was decreased from nearly 60% down to 20% by CCR2 deletion (Fig. 4c). Similarly, PD-1 expression in CD4+ cells of CCR2−/− mice was also significantly decreased. In addition, to better elucidate the correlation between TAMs and CTLs, we performed immunostaining of F4/80, PD-1 and CD8 in the tumors. In comparison with the CCR2+/+ animals, the numbers of F4/80+ TAMs and PD-1+ T cells in tumor microenvironment were markedly decreased in CCR2−/− mice. In contrast, distribution of CD8+ CTLs was notably recuperated by the knockout of CCR2 (Fig. 4d). Immunostaining of cleaved CASP-3 and TdT-mediated dUTP nick end labeling (TUNEL) indicated the activation of pro-death signaling in tumor cells, while Ki67 staining verified tumor suppression in CCR2−/− mice (Fig. 4d). Together, the inverse correlation of CD8+ CTLs with CCR2 and PD-1 suggested that TAMs mediate depletion of antitumor T cells and in consequence facilitates tumor cell evasion through PD-1 signaling pathway.

17To confirm the connection between CCL2-CCR2 and PD-1 in human esophageal carcinogenesis, we next performed the gene set enrichment analysis (GSEA) using ESCC expression profiles from TCGA database (Fig. 4e). Firstly, it was confirmed that CCL2 expression was significantly correlated with the levels of CCR2 and PD-1 in the 90 ESCC cases (Fig. 4f). Next, GSEA indicated that six KEGG pathways were significantly (with a stringent cutoff for FDR 5% and p value 0.01) enriched in the “High” expression group of CCL2, including “T cell receptor signaling”, “chemokines signaling”, “Toll-like receptor signaling”, “pathways in cancer”, “cytokine-cytokine receptor interaction”, and “focal adhesion” (Fig. 4g, Supplementary Table S6). This is in line with our observations with animal models, which suggest the prominent involvement of immune process in ESCC carcinogenesis (Fig. 4a, Supplementary Figure S1). Particularly, the expression of genes implicated in PD-1 signaling pathway was closely correlated with CCL2 expression in ESCC patients (Fig. 4h). Thus, TCGA data also indicates the tight connection between CCL2-CCR2 axis and PD-1 signaling. Taken together, these data strongly suggest that CCL2-CCR2 axis promotes carcinogenesis by inducing TAMs-mediated immune escape via PD-1 signaling pathway.

18Besides TAMs accumulation, the differentiation of macrophages in tumor microenvironment generates particular TAMs subtypes with diverse functional properties, thereby impacting the development of cancer. In this study, we observed that the activation state of TAMs in ESCC mouse model (CCR2+/+ wild type) was predominantly M2-type (over 70%), as indicated by the proportion of CD206+ in CD11b+F4/80+ macrophages (Fig. 5a). In addition to the decrease of TAMs accumulation by CCR2 knockout, M2-polorization was also dramatically inhibited in the CCR2−/− animals by nearly 70% when compared to the CCR2+/+ and CCR2+/− mice (Fig. 5a and c). Interestingly, we found that the proportion of CD8+ cytotoxic T cells (CTLs) in CD3+ lymphocytes was significantly elevated by the deletion of CCR2 (Fig. 5b and d). Similar results were also observed in the CCL2 knockout mouse model, in which F4/80+CD206+ M2-type of TAMs in total CD45+ cells was decreased by over 50% (Fig. 5e), while the number of CD8+ CTLs in tumors was inversely increased up to 2-fold of that in CCL2+/+ group (Fig. 5f). To further validate the impact of CCL2 on CTLs depletion, we detected the distribution of CCL2 and CD8 in tumor tissues with ESCC patients (cohort II). The immunohistochemistry (IHC) staining showed that higher expression of CCL2 was significantly correlated with decreased number of CD8 positive antitumor T cells (Fig. 5g). Taken together, these data suggested that M2-polorization of infiltrated TAMs facilitates the depletion of antitumor effector T cells in tumor microenvironment.

19To interpret the impact of TAMs polarization on PD-1 signaling, we next determined the expression of two specific ligands of PD-1 that responsible for T cells exhaustion, PD-L1 and PD-L2, in macrophages at particular activation states. In our cell model, THP-1 cells were induced into macrophages of M1-type by LPS and IFN-γ, and into M2-type by IL-4 and IL-13 following PMA treatment. The polarized M1 and M2 macrophages were distinguished from inactive M0 macrophage with the biomarker HLA-DR and CD209, respectively (Fig. 6a). Interestingly, PD-L1 was highly expressed in the HLA-DR+CD209− M1 macrophages, but not prominently expressed in the HLA-DR−CD209+ M2 macrophages (Supplementary Figure S6a). In contrast, PD-L2 was particularly expressed in the M2-type, which is higher than that in M1 macrophages (Fig. 6b). Similarly, PD-L2 expression in F4/80+CD206+ M2 TAMs was significantly higher than M1 TAMs in the ESCC mouse model (Fig. 6c). In wild type mouse, both PD-L1 and PD-L2 were increased by NMBA-induced carcinogenesis, but the over-expression of PD-L2 appeared more pronounced than PD-L1 (Fig. 6d). More importantly, blockade of CCL2 or CCR2 dramatically suppressed the expression of PD-L2 in tumors (Fig. 6d). Together with our finding that M2 was the prevailing subtype of TAMs in ESCC mouse model (Fig. 5a and c), this highlights the role of TAMs-specific PD-L2 in esophageal carcinogenesis. Consistent with cell models and mouse models, TCGA data also demonstrated the strong correlation of PD-L2 with CCL2 expression as well as the level of M2 marker CD209 in ESCC patients; in contrast, PD-L1 was not significantly correlated (Fig. 6e).

20To further validate the impact of M2-polarization, we next conducted esophageal carcinogenesis study using mice with macrophage-specific deletion of peroxisome proliferator activated receptor-γ (PPARG) which has been shown required for the maturation of M2 macrophages. The results indicated that macrophage-specific PPARG deletion significantly inhibited tumorigenesis in ESCC mouse model (Fig. 7a). The blockade of M2 polarization by PPARG deficiency dramatically decreased expression of PD-L2 in TAMs, but inversely increased the CD8+ antitumor effector T cells in tumors (Fig. 7b). In summary, these data are in line with our findings on the interaction between TAMs-M2 polarization and PD-1 signaling activation, suggesting that the presentation of PD-L2 by M2-TAMs constitutes an important mechanism underlying immune evasion in ESCC carcinogenesis.

21It has been recognized that the development of cancer is influenced by interactions between tumor cells and host immune response. Within tumor microenvironment, TAMs contribute substantially to inflammatory homeostasis and in consequence impacts cancer progression. The functions of TAMs have been characterized in various cancer types, but little is known about the mechanism of action in esophageal cancer. Here, we show the pivotal role of TAMs in esophageal carcinogenesis by targeting infiltration and polarization (Fig. 7c). We found that tumorigenesis was remarkably suppressed by the blockade of CCL2-CCR2 axis in ESCC animal models. Mechanistically, this can be attributed to the inhibition of TAMs recruitment and M2 polarization, thereby halting the immunosuppression on antitumor effector T cells through PD-1 signaling pathway. Since TAMs-targeted therapeutics are being clinically evaluated as a promising option for some cancer types, our findings harbor direct translational impact for the prevention and treatment of human ESCC.

22The accumulation of TAMs in microenvironment is due to self-proliferation and recruitment from circulating inflammatory Ly6C+CCR2+ monocytes. The latter is primarily mediated by elevated secretion of the monocyte chemoattractant protein MCP-1/CCL2 by tumor cells. Increasing studies indicated that inhibition of CCL2 could deplete inflammatory monocytes and macrophages, reduce tumor growth and dissemination in different experimental models such as prostate, melanoma, breast, lung and liver cancer. In regard to ESCC, early studies had shown the correlation of increased CCL2 expression with macrophage infiltration and tumor invasion. Paralleling previous reports, our study demonstrated that CCL2 acts to bridge tumor cells with TAMs-associated immune response rather than directly impact ESCC markers (Supplementary Figure S5) in the tissue microenvironment during esophageal carcinogenesis.

23The upstream molecular mechanism governing CCL2 expression in pre-malignant or malignant epithelial cells remains to be interpreted. Our microarray profiling with human esophageal cell (Het-1A) model suggested that continuous elevation of CCL2 during malignant transformation might be due to the activation of PI3K-AKT signaling pathway (Supplementary Figure S3b, c, and d). However, chemotherapeutic approaches usually result in limited clinical efficacy when aiming at tumor intrinsic signaling pathways, primarily due to heterogeneity in tumors and unexpected impacts on the favorable immune cells in ESCC microenvironment. In contrast, TAMs-centered therapeutic strategies have demonstrated remarkable potential to complement and synergize with chemotherapy and immunotherapy. As such, novel strategies targeting CCL2-CCR2 or TAMs might be promising options for ESCC, provided that the mechanism of action is elucidated.

24The differentiation of TAMs is directed by cytokines in tumor microenvironment. IL-4 and IL-13 are major drivers of M2 polarization, as is also validated by the THP-1 cell model and mouse models in our study. It is worth noting that monocyte chemotaxis was successfully induced by tumor-educated mediums but M2 polarization was not clearly observed in the same condition (Supplementary Figure S6b), suggesting that other non-cancer cells e.g. Th2 cells and cancer-associated fibroblasts (CAFs) are requisite for TAMs differentiation. Tumor promotive activity of M2-type TAMs has been observed in numerous studies. However, the underlying mechanism has not been clearly explained. It was reported that M2 phenotype macrophages infiltrated following infiltration of M1 macrophage and promoted esophageal carcinogenesis in a surgical rat model. In tumor biopsies of patients, reduced CD163+ M2-TAMs was inversely correlated with the increased CD8+/CD4+ T cells ratio. Consistent with these studies, our data demonstrated that M2 polarization of TAMs was tightly associated with reduced CD8+ T cells and promoted tumor growth. Furthermore, multiple evidences in this study suggested that PD-1 signaling pathway played a crucial role in TAMs-mediated immune evasion during esophageal carcinogenesis.

25Engagement of PD-1with its two ligands PD-L1and PD-L2 is responsible for tumor escape through defeating the antitumor capacity of tumor-specific CTLs. Immune checkpoint blockade targeting PD-1/PD-L1 has been proven effective for cancer treatment via the paradigm of “immune normalization”. Despite FDA approval of this strategy for multiple cancer types, the underlying mechanism for T cells regulation in microenvironment is not yet fully understood. Tumoral PD-L1 expression has been shown to be a predictive marker for response to anti-PD-1 targeted therapies. However, some PD-L1-positive patients of esophageal cancer did not benefit from such therapies, while some patients lack of PD-L1 still showed clinical response, implying that other molecular interacts with PD-1 such as PD-L2 may be important for immunotherapy efficacy in ESCC. In prostate cancer, PD-L2 was more highly expressed than PD-L1 and overwhelmingly correlated with immune-related pathways, suggesting the critical role of PD-L2 in immune response. Nonetheless, PD-L2 expression was independently associated with clinical response in pembrolizumab-treated (PD-1 mAb) patients with colorectal cancer, indicating that PD-L2 may be involved in response to PD-1 axis targeted therapies. Although antagonist PD-1 mAb could block both PD-L1 and PD-L2 binding to PD-1, better outcomes were observed for PD-L2-positive than PD-L2-negative patients in head and neck squamous cell carcinomas treated with pembrolizumab. Therefore, therapies targeting PD-L2/PD-1 interaction may provide notable clinical benefit for these cancers. However, studies that assess the prevalence of PD-L2 and especially the distribution in human tumors are limited. On the other hand, PD-L2 and PD-L1 could be differentially expressed by tumor cells or macrophages. Furthermore, we observed discrepant expression of PD-L2 in M1 and M2 macrophages in our animal and cell study. Importantly, this discrepancy is largely responsible for the tumor promotion induced by the M2-type TAMs in esophageal carcinogenesis. Thus, molecules controlling M2-polarization of TAMs e.g. PPARG activation may serve as promising novel immune checkpoint target for ESCC (Fig. 7c).

26In summary, our study highlights the role of CCL2-CCR2 axis in esophageal carcinogenesis. Blockade of CCL2-CCR2 axis strongly suppressed cancer development through inhibiting monocyte infiltration and TAMs accumulation in tumor microenvironment. Importantly, TAMs polarization to the immunosuppressive M2 type significantly increased expression of PD-L2 and consequently depleted antitumor effector T cells. These findings provide new insights into the mechanism of immune evasion mediated by TAMs in ESCC, which may advance the development of macrophages-based strategies for ESCC prevention and immunotherapy.