Immune checkpoint blockade (ICB), such as anti-PD-1 and anti-PD-L1 antibody therapy, release the brakes on the immune system and enhance anti-tumor immune responses. However, PD-L1 upregulation and the immunosuppressive TME resulting from arginine metabolic reprogramming can contribute to ICB resistance
20. Therefore, combining therapies that target arginine metabolism with other immunotherapeutic approaches may hold great promise. For example, combining ADI-PEG20 or DFMO with ICB therapy may overcome ICB resistance in the arginine-dysregulated TME. Notably, ADI-PEG20 directly impedes the proliferation of tumor cells and downregulates the expression of PD-L1 on the surface of TAMs, which weakens suppression of other immune cells. DFMO serves a dual function through polyamine synthesis blockade. First, DFMO directly impairs polyamine-promoted tumor cell proliferation. Second, DFMO modulates the TME by inhibiting the polarization of TAMs towards the M2 phenotype, reducing the secretion of immunosuppressive factors, such as IL-10 and TGF-β by TAMs, which indirectly lowers PD-L1/PD-1 expression on tumor and immune cells and enhances the anti-tumor activity of immune cells. Consequently, the combination of targeting arginine metabolism and immunotherapy holds great promise in more potently activating the immune system and exerting a more robust anti-tumor effect.