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Although this anergic state in solid tumors may be attributable to the ARG1- and/or NOS-dependent suppressive activity of MDSCs, MDSC-mediated immunosuppression has not been previously reported in hematological malignancies. PBMCs from MM patients were stimulated with anti-CD3/CD28 antibody-coated beads in the presence of N-(omega)-hydroxy-nor-L-arginine (NorNOHA; an ARG1-specific inhibitor), NG-monomethyl-L-arginine (L-NMMA; an NOS2 inhibitor), both inhibitors, or neither. As shown in Fig. 8 A (top), T cell expansion was considerably enhanced in the presence of both NorNOHA and L-NMMA, whereas the single inhibitors failed to increase T cell proliferation over the baseline. Interestingly, sildenafil yielded results equivalent to the combination of NorNOHA and L-NMMA. These results suggest involvement of both ARG1 and NOS2 in MDSC-mediated immunosuppression in myeloma and confirm the in vitro results demonstrating the ability of PDE5 inhibitors to affect both pathways. Recent data from our lab identified human MDSCs as ARG+, CD14+ cells (unpublished data). We therefore examined T cell expansion in CD14+-depleted PBMCs under the same conditions (Fig. 8 A, bottom). Although CD14+ depletion alone increased CD3+ T cell expansion fourfold, pharmacologic inhibitors failed to further enhance proliferation, suggesting that CD14+ cells are the mediators of ARG1- and NOS2-mediated immunosuppression in MM. As seen with purified mouse T cells (Fig. 5 B), sildenafil also failed to enhance the CD3+ T cell proliferation of CD14-depleted PBMCs from cancer patients. Although most of the work to date on MDSCs has focused on mouse Gr-1+/CD11b+ cells, emerging data confirm the presence of these cells in human malignancies (7, 42, 49). In this paper we show that a nonlymphoid CD14+ population mediates the hypo-responsiveness in PBLs from MM patients. Although the low proliferative capacity may be caused by intrinsic T cell defects, an additional explanation for T cell unresponsiveness is the presence of a nonlymphoid suppressor population whose function is abrogated by PDE5 inhibition. Evidence supporting this is the ability of sildenafil to augment the proliferative index of lymphocytes obtained from unfractionated PBMCs but not from purified CD4+ or CD8+ T cells (Fig. 8 and Fig. S6). The ability of sildenafil to restore proliferation of PBLs from both head and neck and myeloma patients suggests that the mechanisms found in mice also play a major role in cancer-mediated immunosuppression in two very different human malignancies. Avanafil: This newer phosphodiesterase inhibitor is currently showing promise in clinical trials for the treatment of erectile dysfunction. 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