ALBERT

Description: Key Points Homeostatic recovery after allogeneic HSCT favors the production, expansion, and survival of effector T cells over CD4Tregs. Unbalanced reconstitution of regulatory and effector T-cell subsets contributes to the development of chronic graft-versus-host disease.

Description: Introduction: Cytokines play important roles in the activation, proliferation, differentiation and survival of T cells. Previous studies have revealed that individual cytokines selectively activate different T cell populations and also function at specific stages of T cell differentiation. For example, IL-2 supports the development of CD4 regulatory T cells. IL-7 is required for naive conventional CD4 T cell (Tcon) homeostasis, whereas naive CD8 T cell homeostasis requires both IL-7 and IL-15. In contrast, IL-6 promotes Th17 T cell differentiation. The functions of each cytokine are partly defined by the differential expression of specific multi-unit receptors but the selective homeostatic effects of individual cytokines are still incompletely understood. Methods: We stimulated peripheral blood mononuclear cells from healthy donors with varying concentrations of IL-2, IL-7, IL-15 and IL-6 for 15 min in vitro. Single cell mass cytometry (CyTOF) with a panel of 33 markers was used to simultaneously examine signaling pathways activated by each cytokine in distinct T cell subsets. viSNE, a cytometry analysis tool, was used to visualize high-dimensional cytometry data on a two-dimensional map. Expression of pSTAT5 was used to monitor activation induced by IL-2, IL-7 and IL-15; pSTAT3 was used to monitor activation by IL-6. Results: In CD4 Tcon, relatively high concentrations of IL-2 (100-1000 IU/ml) are required to induce pSTAT5 (Figure 1). However even at high concentrations, IL-2 activation was selective for memory Tcon subsets. In contrast, IL-7 induced pSTAT5 at very low concentrations (1-10 IU/ml). Although all Tcon were affected, activation was more robust in memory than naive Tcon subsets at all IL-7 concentrations. IL-15 activation of pSTAT5 required at least 10 IU/ml and only memory Tcon subsets were activated even at high IL-15 concentrations. Whereas IL-2, IL-7 and IL-15 preferentially activated memory Tcon subsets, IL-6 selectively activated pSTAT3 in naive and central memory (CM) Tcon subsets at low concentrations (10 IU/ml). At high IL-6 concentrations (100-1000 IU/ml) effector memory (EM) Tcon were also activated. CD8 T cells (Figure 2) are relatively insensitive to IL-2, and only CM CD8 T cells are activated at high IL-2 concentrations (100 IU/ml). Although all CD8 T cell subsets were activated at very high IL-2 concentrations (1000 IU/ml), pSTAT5 activation remained most evident in CM CD8 T cells. Similar to Tcon, IL-7 induced pSTAT5 in CD8 T cells at very low IL-7 concentrations (1-10 IU/ml). However unlike Tcon, pSTAT5 activation was most prominent in naive and CM CD8 T cells. EM CD8 T cells were activated at higher IL-7 concentrations but TEMRA CD8 T cells were resistant to IL-7 stimulation. IL-15 induced pSTAT5 equally in all CD8 T cell subsets but relatively high concentrations (100-1000 IU/ml) were required. Similar to CD4 Tcon, IL-6 induced selective pSTAT3 activation in naive CD8 T cells. Activation of naive CD8 T cells was observed at low concentrations of IL-6 and both EM and TEMRA were resistant to very high IL-6 concentrations (100-1000 IU/ml). Conclusion: This detailed analysis of cytokine signaling has identified differential effects of IL-2, IL-7, IL-15 and IL-6 on different subsets of CD4 Tcon and CD8 T cells. Whereas CD4 Treg are activated at low IL-2 concentrations, CD4 Tcon and CD8 T cells are relatively resistant to IL-2. At high IL-2 concentrations, activation was most prominent for memory CD4 Tcon and CM CD8 T cells. In contrast, low concentrations of IL-7 are sufficient to activate both CD4 Tcon and CD8 T cells. Within these populations, memory Tcon and naive CD8 cells were preferentially activated at low IL-7 concentrations. Within the CD8 T cell population, IL-15 activated all subsets equally. Within CD4 Tcon, IL-15 preferentially activates memory subsets. IL-6 acts at low concentrations and primarily on naive cells in both CD4 Tcon and CD8 T cells. In all experiments, these effects do not require TCR antigen activation and therefore reflect the potency and differential activity of homeostatic signals supported by these cytokines. Importantly, high concentrations used for in vitro experiments are not likely achieved in vivo but may reflect toxicities of high dose exogenous cytokine therapies or cytokine release syndromes. In contrast, differential effects observed at low concentrations more likely reflect physiologic homeostatic effects of these cytokines in vivo. Disclosures No relevant conflicts of interest to declare.

Description: Introduction: CD4+ FoxP3+ CD25+ regulatory T cells (Treg) play a central role in the maintenance of immune tolerance and prevention of chronic graft-versus-host disease (cGVHD) after allogeneic stem cell transplantation (SCT). Treg constitutively express high-affinity interleukin-2 (IL-2) receptors and murine models have established that IL-2 is a critical homeostatic regulator of Treg in vivo. We previously reported that daily administration of low-dose IL-2 in patients with cGVHD induces selective expansion of Treg and NK cells and results in clinical improvement in approximately 50% of patients. However, the mechanisms responsible for these selective effects and the influence of IL-2 therapy on other lymphocytes have not been established due to the limited resolution of traditional cell analytic methods such as flow cytometry. Methods: Single cell mass cytometry (CyTOF) with a panel of 33 markers was used to simultaneously examine the phenotypic and functional effects of low-dose IL-2 on lymphocyte populations in vitro and in vivo. The analytic panel included 22 cell surface markers to identify distinct T, B and NK cell subsets and 11 intracellular markers to measure functional status and activation of specific signaling pathways. viSNE, a cytometry analysis tool, was used to visualize high-dimensional cytometry data on a two-dimensional map. Results: In unstimulated lymphocytes from healthy donors, constitutive expression of CD25 (IL-2Ra) at high levels was restricted to Treg and CD56bright NK cells. Central memory (CM) and effector memory (EM) subsets of conventional CD4 T cells (Tcon) and CM CD8 T cells expressed low levels of CD25. Within the Treg population, the highest expression of CD25 was closely associated with expression of Helios transcription factor. Helios+ Treg also express higher levels of FoxP3, HLA-DR and CD95 and lower levels of BCL2 compared to Helios- Treg. To examine responses to IL-2, we stimulated peripheral blood mononuclear cells (PBMC) from healthy donors with IL-2 for 15 min in vitro (Figure 1). At low IL-2 concentrations (1 to 10 IU/ml), pSTAT5 was preferentially activated in Treg. Notably, pSTAT5 activation was more robust in memory Treg than naïve Treg and in Helios+ Treg than Helios- Treg. In addition, we observed activation of pSTAT5 in CD56bright NK cells at low concentrations of IL-2 (10 IU/ml). Higher IL-2 concentrations (100-1000 IU/ml) were required to activate pSTAT5 in Tcon, CD8 T cells and CD56dim NK cells. At high IL-2 concentrations, pSTAT5 was activated in all Treg, NK, Tcon and CD8 subsets. To examine the response to IL-2 in vivo, we examined PBMC from 14 patients with chronic GVHD receiving daily low-dose IL-2 using the same CyTOF panel of markers. Without additional in vitro stimulation, pSTAT5 expression was increased preferentially in Helios+ Treg. Peak pSTAT5 expression occurred 1 week after starting IL-2 and decreased with continued IL-2 therapy. Similarly, increased expression of FoxP3, CD25, HLA-DR and Ki67 occurred primarily in Helios+ Treg with peak expression at 1 week. At later time points during IL-2 therapy, changes in Treg included increased expression of CD95, CTLA4, PD-1, BIM and BCL2. Although there was no activation of pSTAT5 in CD4 Tcon and CD8 T cells, expression of PD-1 increased in effector memory subsets of Tcon and CD8 T cells 1 week after starting IL-2 therapy. Selective expansion of CD56bright NK cells was also noted, with peak activation at 1 week. No other changes were noted in Tcon, CD8 T cells and B cells. All changes observed during IL-2 therapy returned to baseline levels 4 weeks after treatment was stopped. However, examination of PBMC from 8 patients who received continuous daily low-dose IL-2 therapy for approximately 1 year showed that all of the changes noted above persisted during extended therapy. Conclusion: Comprehensive analysis of T, B and NK cells from healthy donors revealed that low concentrations of IL-2 result in selective activation of Helios+ Treg and CD56bright NK cells. Higher concentrations of IL-2 are required for activation of CD4 Tcon, CD8 T cells and CD56dim NK cells. Identical populations are activated in patients with cGVHD receiving daily low-dose IL-2 and these functional effects persist during extended IL-2 therapy. Although the function of Helios transcription factor is not well defined, Helios expression identifies those Treg most primed to respond to low concentrations of IL-2 in vitro and in vivo. Disclosures Armand: Infinity Pharmaceuticals: Consultancy; Merck: Consultancy, Research Funding; Bristol-Myers Squibb: Research Funding. Antin:Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Gentium S.p.A.: Membership on an entity's Board of Directors or advisory committees. Soiffer:Gentium SpA/Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees.

Description: Introduction: Idelalisib, a specific small molecule inhibitor of the delta isoform of PI3 kinase (PI3Kd), has recently been FDA approved for the treatment of relapsed CLL. Expression of PI3Kd is predominantly restricted to leukocytes, and inhibition of PI3Kd promotes apoptosis of neoplastic CLL cells. Patients who receive idelalisib often experience toxicities that appear to be immune mediated. In an ongoing phase II study of idelalisib-ofatumumab at DFCI, 16 of 21 patients experienced grade 3 or greater autoimmune toxicities (14 transaminitis, 2 enteritis/colitis and 3 presumed drug-induced pneumonitis). Methods: To identify potential causes of autoimmunity in patients receiving idelalisib, we used single cell mass cytometry (CyTOF) with a panel of 26 surface membrane and 9 intracellular markers to provide a comprehensive phenotypic and functional analysis of all peripheral blood lymphocytes. Blood samples were obtained at baseline prior to therapy and at onset of autoimmune symptoms, which occurred at a median of 28 days from start of therapy. Results in 5 severely affected patients were compared with 3 patients who did not develop autoimmune toxicities and 15 healthy donors. The second sample from unaffected patients was matched in time to the affected patient samples. Results: Within CD3 T cells, idelalisib therapy led to an increased percentage of CD4 T cells and decreased percentage of CD8 T cells. Within CD4 T cells, CD25high Foxp3+ regulatory T cells (Treg) were reduced, resulting in a marked increase of the ratio of conventional CD4 T (Tcon)/Treg and increased CD8/Treg ratio. These findings were similar in patients who developed autoimmune toxicities and those who did not. Analysis of effector memory (EM; 45RA- CCR7-), central memory (CM; 45RA- CCR7+), terminal effector (TEMRA; 45RA+ CCR7-) and naive (45RA+ CCR7+) subsets within Treg, Tcon and CD8 T cells was comparable before and after idelalisib therapy and with healthy individual controls. To evaluate the heterogeneity of each population we utilized viSNE, which allows visualization of complex high-dimensional cytometry data on a two-dimensional plot. Treg in patients who developed autoimmune phenomena were compared with Treg from patients who did not. In patients who developed autoimmunity, baseline Treg had higher expression of PD-1 and lower expression of functional markers, such as GITR, Tbet, CXCR3, PDL-1, granzyme-β and TIM-3. In some cases, expression of these functional markers declined further with idelalisib therapy (Figure 1). Cytotoxic T lymphocyte antigen 4 (CTLA4) is constitutively expressed by Treg, and its deficiency has been shown to limit suppressive function of Treg. Inducible co-stimulator (ICOS) also mediates the suppressive functions of CD4 Treg by regulating cell surface expression of CTLA-4. Interestingly, expression of CTLA-4 and ICOS did not change during idelalisib therapy (Figure 1). Susceptibility to apoptosis was monitored by expression of pro-survival Bcl-2 and pro-apoptotic CD95 (FAS). Treg from patients developing autoimmunity expressed lower levels of Bcl-2 and higher levels of CD95 compared to those who did not. Conversely, Treg of non-affected patients retained higher expression of functional markers and became more active, assessed by increased expression of HLA-DR. The use of CyTOF combined with our comprehensive panel allowed us to delineate up to 13 distinct Treg sub-populations among healthy controls. In contrast, CLL patients often lacked such broad Treg heterogeneity. Expression of functional markers by Tcon and CD8 T cells from patients who would develop side effects, were also slightly lower, suggesting that autoimmune toxicities were not due to expansion or activation of CD8 or Tcon effector cells but due to the defect in both number and function of Tregs, which became insufficient to maintain the immune tolerance. Conclusion: These studies allowed us to identify defects in both Treg number and function, which may be responsible for the autoimmune toxicities in patients receiving idelalisib therapy. Further studies may allow the development of a reliable predictor of these toxicities by evaluation of the Treg markers prior to drug exposure which could be used to guide therapy. Moreover, the identification of idelalisib as a Treg inhibitor suggests that it could be used as an immunomodulatory agent to target the Treg pathway, in patients with solid tumors. Disclosures No relevant conflicts of interest to declare.

Description: Key Points Idelalisib as upfront therapy for CLL caused an early hepatotoxicity in a subset of primarily younger patients with IGHV-mutated disease. Multiple lines of evidence suggest that this adverse effect is immune mediated, perhaps through inhibition of regulatory T cells.

Description: Introduction Phosphatidylinositol-3-kinase (PI3K) inhibition has emerged as a novel targeted mechanism for achieving durable remission in CLL in both the untreated and relapsed/refractory setting. Despite this profound efficacy, PI3K inhibition with the delta isoform inhibitor, idelalisib, has been linked with significant autoimmune toxicity including hepatitis and colitis. Treatment naïve patients receiving idelalisib with ofatumumab in a phase 2 trial had high rates of autoimmune hepatitis within the first month of treatment (Lampson, Blood, 2016). We have previously shown that a reduction in CD4+ regulatory T cells (Tregs) likely predisposes to this toxicity. Here we report additional details of T cell populations observed in these idelalisib-treated patients, with and without severe toxicity. Methods To better characterize the immunologic mechanism of this toxicity, we evaluated samples from study participants using single cell mass cytometry (CyTOF) with a panel of 26 surface membrane and 9 intracellular markers focused on T cell populations (Lampson et al). CyTOF was performed on 26 peripheral blood mononuclear cell (PBMC) samples from 14 patients, at baseline and one month on therapy, the timepoint of autoimmune hepatitis. Flow cytometry standard (fcs) files were processed using FlowJo to gate on viable, singlet cells. The CD3+ events from each sample were exported as individual fcs files to Cytobank.org for analysis. Patients were analyzed in two groups: absent or mild hepatitis (grades 0,1, and 2) vs severe hepatitis (grades 3 and 4) as defined by CTCAEv4.0. viSNE was used to visualize high-dimensional CyTOF data and identify islands for validation (Amir, Nature Biotechnology, 2013). We confirmed these findings by isolating cell populations as percentages of total CD4+ T cells. Results Our analysis of four individual groups demonstrated that CD4+ T cells as a percentage of CD3+ T cells were greater in high toxicity patients than in low toxicity, at baseline and one month, but without significant change during therapy (62.5 vs. 48.2 at baseline; n=9 and n=4, respectively). Evaluation of Tregs showed significant decrease following idelalisib exposure. This was seen when defining Treg cells as CD4+CD25+CD127- as well as when adding Foxp3 expression. viSNE analysis further identified discrete populations. CD4+CD39+Foxp3+ Tregs This is a Treg subset that expresses CD39 and Helios (Figure 1). Across timepoint and toxicity, it is more than two-fold higher in patients with high toxicity, representing 9.6% of CD4+ cells in high toxicity compared with 4.1% in low toxicity. After one cycle of treatment, these percentages declined to 7.5% and 3.2%, respectively. Further, CD39 is expressed by 67% of all Treg cells in this cohort and has been previously suggested to associate with autoimmune response (Zhao, Frontiers in Immunology, 2017). A relative decrease is observed in all patients after exposure, but the reduction of CD39 expressing Treg cells is more robust in low toxicity patients. Naïve CD4+ T Cell: CD62L+CCR7+CD45RA+HLA-DR- The population of naïve T cells is present at baseline in low and high toxicity patients, 5.4% and 10.5% of CD4+ cells, respectively (Figure 2). After one month of exposure to idelalisib, this population in high toxicity patients increased to 14% but remained the same in low toxicity. Conclusion This CyTOF analysis among patients with and without severe autoimmune hepatic toxicity on idelalisib demonstrates relative expansion of CD4 populations in patients who developed toxicity. We identify two CD4 T cell subsets in patients experiencing severe hepatotoxicity. The CD4+CD39+ Treg population emerges as a leading candidate for further evaluation. In leukemic cells, CD39 has been reported to promote differentiation of specific Tregs (Vaisitti, International Journal of Molecular Sciences, 2018). Furthermore, CD39 expression on T-cells has been shown to confer worse outcomes in CLL (Perry, Annals of Hematology, 2012). The mechanism for this remains unknown.The second population is a subset of naïve T cells that grows following treatment only in high toxicity patients. An expanded cohort from this trial is currently being analyzed with an updated T cell focused CyTOF panel to further evaluate these findings. If validated, CD39 expressing T cells may help predict susceptibility to severe autoimmune mediated hepatotoxicity prior to PI3K-based treatment of CLL. Disclosures Brown: TG Therapeutics: Consultancy; Verastem: Consultancy, Research Funding; Beigene: Membership on an entity's Board of Directors or advisory committees; Acerta / Astra-Zeneca: Membership on an entity's Board of Directors or advisory committees; Morphosys: Membership on an entity's Board of Directors or advisory committees; Loxo: Consultancy; Sunesis: Consultancy; Sun Pharmaceutical Industries: Research Funding; Roche/Genentech: Consultancy; Genentech: Consultancy; Boehringer: Consultancy; Pharmacyclics: Consultancy; Janssen: Consultancy; Celgene: Consultancy; Invectys: Membership on an entity's Board of Directors or advisory committees; Gilead: Consultancy, Research Funding; Abbvie: Consultancy.

Description: Introduction: CD4+ FoxP3+ CD25+ regulatory T cells (Treg) are required for maintenance of immune tolerance and immune homeostasis. Quantitative or functional Treg deficiency has been correlated with autoimmune disease, allergy, allograft rejection and graft versus host disease. Conversely, increased Treg can suppress tumor immunity resulting in tumor progression. Treg express a large number of cellular markers that reflect their level of maturation, functionality, activation and migratory capacity. Nevertheless, it has not previously been possible to integrate the expression of these various markers and correlate their expression with human Treg differentiation in vivo. Methods: We used single cell mass cytometry (CyTOF) to simultaneously study 36 phenotypic and functional markers of human Treg in samples obtained from umbilical cord blood (CB) (n=4) and healthy adult donors (n=10). Wanderlust trajectory detection algorithm was used to analyze temporal positioning of Treg across development. To quantify Treg heterogeneity we used ACCENSE; an analysis tool that combines a nonlinear dimensionality reduction algorithm (t-SNE) with spectral clustering algorithm and automated cell classification into subpopulations. Results: Using Wanderlust to characterize Treg maturation, the majority of CB Treg were naive (CD45RA+) and CB memory Treg (CD45RA-) were poorly differentiated with minimal expression of activation (HLA-DR) and pro-apoptotic (CD95) markers (Figure 1A). Adult Treg contained few naive cells and mature Treg effector cells expressed high levels of activation and pro-apoptotic markers. (Figure 1B). Using Wanderlust together with spearman correlation, 5 discrete stages of Treg maturation were identified; 1) recent thymic emigrants (RTE), 2) naive, 3) effector, 4) activated and 5) terminal effector. RTE Treg defined by expression of CD45RA, CD31 and CCR7, also expressed markers of proliferation (KI67) and functionality (Tbet, PDL-1, Helios) at low levels but lacked functional CTLA4 and TIM-3. Naive Treg lacked expression of CD31 but expressed other markers characteristic of RTE. Effector Treg expressed increased levels of CD95, CTLA-4, CCR7, GITR, Helios and FoxP3 but lacked HLA-DR. Activated effector Treg expressed the highest levels of FoxP3, Helios and Ki67, along with functional markers (CD28, CXCR3, ICOS, GITR, CD39, CTLA-4, TIM-3) and homing molecules (vascular endothelial CCR5, gut addressin ACT-1, skin addressins CCR4, CLA). Activated Treg express the highest levels and diversity of functional markers along with the ability to migrate to different tissues. Lastly, terminal effector Treg express a more restricted set of functional and homing markers (CD28, CTLA-4, ICOS and CCR5) with less diversity. Markers of exhaustion (PD-1 and TIM-3) are also expressed by effector, activated and terminal effector Treg. Pro-apoptotic markers (CD95high BCL2low) are primarily expressed by activated and terminal effector Treg. Using ACCENSE to evaluate Treg diversity allowed further identification of discrete Treg sub-populations within each maturation state. RTE and naive Treg appear very homogeneous and appear as a single cluster in both CB and adults. In contrast, effector, activated and terminal effector Treg are more heterogeneous and are visualized as 9 distinct clusters (Figure 1C, D). This clustering reflects distinct subsets of memory Treg that co-express various combinations of functional markers in our panel. All 9 Treg effector populations are present in CB, but at much lower levels. Treg effector cell diversity is maintained but does not increase as Treg mature and expand in adults and RTE/naive Treg become less prevalent. Conclusion: Our study is the first to quantify human Treg heterogeneity based on expression of a large set of activation, proliferation, tissue homing and functional markers in conjunction with stages of Treg maturation and differentiation. These studies define 5 stages of Treg maturation and 10 clusters of Treg diversity based on differential expression of phenotypic and functional markers. Similar approaches can be applied to describe maturation and diversity of other cell populations. Further application of this CyTOF panel can be used to study Treg maturation and diversity after hematopoietic stem cell transplantation and in immune and inflammatory diseases, to identify specific defects that may contribute to immune dysfunction. Disclosures No relevant conflicts of interest to declare.