4‐1BB Delineates Distinct Activation Status of Exhausted Tumor‐Infiltrating CD8+ T Cells in Hepatocellular Carcinoma

Background and Aims Targeting costimulatory receptors with agonistic antibodies is a promising cancer immunotherapy option. We aimed to investigate costimulatory receptor expression, particularly 4‐1BB (CD137 or tumor necrosis factor receptor superfamily member 9), on tumor‐infiltrating CD8 + T cells (CD8 + tumor‐infiltrating lymphocytes TILs) and its association with distinct T‐cell activation features among exhausted CD8 + TILs in hepatocellular carcinoma (HCC). Approach and Results Tumor tissues, adjacent nontumor tissues, and peripheral blood were collected from HCC patients undergoing surgical resection (n = 79). Lymphocytes were isolated and used for multicolor flow cytometry, RNA‐sequencing, and in vitro functional restoration assays. Among the examined costimulatory receptors, 4‐1BB was most prominently expressed on CD8 + TILs. 4‐1BB expression was almost exclusively detected on CD8 + T cells in the tumor—especially on programmed death 1 (PD‐1) high cells and not PD‐1 int and PD‐1 neg cells. Compared to PD‐1 int and 4‐1BB neg PD‐1 high CD8 + TILs, 4‐1BB pos PD‐1 high CD8 + TILs exhibited higher levels of tumor reactivity and T‐cell activation markers and significant enrichment for T‐cell activation gene signatures. Per‐patient analysis revealed positive correlations between percentages of 4‐1BB pos cells among CD8 + TILs and levels of parameters of tumor reactivity and T‐cell activation. Among highly exhausted PD‐1 high CD8 + TILs, 4‐1BB pos cells harbored higher proportions of cells with proliferative and reinvigoration potential. Our 4‐1BB–related gene signature predicted survival outcomes of HCC patients in the The Cancer Genome Atlas cohort. 4‐1BB agonistic antibodies enhanced the function of CD8 + TILs and further enhanced the anti‐PD‐1–mediated reinvigoration of CD8 + TILs, especially in cases showing high levels of T‐cell activation. Conclusion 4‐1BB expression on CD8 + TILs represents a distinct activation state among highly exhausted CD8 + T cells in HCC. 4‐1BB costimulation with agonistic antibodies may be a promising strategy for treating HCCs exhibiting prominent T‐cell activation.