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Gr-1+ cells are known to facilitate tumor outgrowth. As such, it is conceivable that strategies seeking to eliminate this population may have a measurable antitumor effect. In certain tumor models, the Gr-1 depleting antibody inhibited tumor outgrowth even in the absence of T cells, although the antitumor effect was more pronounced in immune competent mice (32, 33). In light of these results and to verify that MDSCs are the target of sildenafil-mediated antitumor activity, we examined the effect of antibody-mediated MDSC depletion in combination with PDE5 inhibition in vivo. BALB/c mice were challenged on day 0 with C26GM tumor and were (a) left untreated; (b) injected with 100 µg of anti–Gr-1 antibody i.p. on days 0, 3, and 6; (c) treated with sildenafil; or (d) treated with a combination of the two treatments. As shown in Fig. 6 E, Gr-1 depletion delayed tumor outgrowth similarly to PDE5 inhibition, whereas no synergistic effect was seen with the combination. Collectively, these data demonstrate the immunosuppressive nature of Gr-1+ cells and the ability of PDE5 inhibition to reduce their suppressive phenotype in vivo. Although the hallmark feature of MDSCs is immunosuppression, emerging data reveal that the degree of immunosuppression varies among populations of MDSCs isolated from different organs, with intratumoral MDSCs being the most immunosuppressive. Interestingly, these MDSCs express greater levels of NOS2 and ARG1 than their splenic counterparts (5). ARG1 expression is mainly regulated by the STAT-6–IL-4R pathway (30). We recently correlated IL-4R expression on CD11b+/Gr-1+ with an immunosuppressive phenotype (29), and our in vitro data (Fig. 5) indicate that sildenafil down-regulates IL-4R on MDSCs. We then asked whether in vivo PDE5 inhibition reduced ARG1 and NOS2 and down-regulated IL-4R in tumor-associated MDSCs. BALB/c mice were challenged with CT26WT, and half were treated with sildenafil. Mice were killed 15 d later, and intratumoral MDSCs were obtained. Sildenafil increased cGMP (Fig. 6 A), reduced IL-4R expression (Fig. 6 B), and down-regulated NOS2 and ARG1 expression and reduced their enzymatic activity in the intratumoral MDSCs (Fig. 6, C and D). Considering that ARG1 and NOS2 are key enzymes in MDSC suppressive pathways (8, 31), these findings support the hypothesis that PDE5 inhibition is a novel pharmacologic approach to regulate MDSC-mediated immunosuppressive pathways. Advice for women on how to cope with their partner's erectile dysfunction. 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