Abstract Transcriptomics and sequencing analyses of tumors from patients provide invaluable information about the cells present in the tumor microenvironment (TME); however, nerves, whose cell bodies are absent from most peripheral TMEs, have eluded such approaches. Recent emerging data highlight the functional importance of innervation in the TME and its contribution to tumor progression, metastasis, and treatment resistance. The Exoneural Platform developed at Cygnal Therapeutics allows for investigation of complex biology in the context of multi-cell culture conditions in vitro and in vivo. As part of this platform, we have developed tools for rapid and selective manipulation of different cell types with the ability to monitor multiple cell specific read-outs. Here, we used a combination of approaches including RNA-seq, bioinformatics, immunohistochemistry, and microscopy to investigate the role of synaptic function in cancer biology. Transcriptomics analyses on co-cultures revealed a direct interaction between nerves and cancer cells based on cell type specific gene expression and ligand - receptor interaction assessment. Both neurons and cancer cells showed a profound shift in their gene expression profile when cultured together. This differential gene expression was reversed if neurons were ablated, pointing to the reversibility of this change and, potentially, the disease state itself. Examination for presence and function of synaptic proteins showed that synaptic proteins, such as PSD95 and synapsin1, were expressed in co-cultures, and in many cases, a co-localization of pre - and post - synaptic markers was observed. Selective stimulation of dorsal ganglion root (DRG) neurons, co-cultured with cancer cells, resulted in a robust and acute increase of cytosolic calcium in cancer cells. Bioinformatic image analysis confirmed that this calcium influx in cancer cells directly correlated with proximity and density of neurites to cancer cells. A calcium response was not observed if DRGs and cancer cells were cultured in two separate chambers between which media can freely travel, confirming that close proximity is required for this interaction. Pharmacological and genetic knock down of key synaptic proteins resulted in changes in cancer cell calcium influx and affected proliferation and gene expression. Bioinformatics analyses, based on public and proprietary data, have identified the synaptic pathway as a major contributing node that influences cancer cell biology in the context of several cancer types. These data collectively point to the importance of exoneural biology, and more specifically, synaptic biology in cancer. More importantly, these results are likely to suggest new oncology targets that have not been identified or pursued previously. Citation Format: Monica Thanawala, Chih-Chieh Wang, Jesse G. Turner, Kai-Chih Huang, Lexiang Ji, Alison Miller, Alexandria Fink, Shan Lou, Alexandra B. Lantermann, Hongyue Dai, John A. Wagner, Grazia Piizi, Jonathan B. Hurov, Pearl Huang, Amir M. Sadaghiani. Neural communication to peripheral tumors regulates cancer cell activity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1450.