Immune recovery in patients with mantle cell lymphoma receiving long-term ibrutinib and venetoclax combination therapy

Abstract

Combination venetoclax plus ibrutinib for the treatment of mantle cell lymphoma (MCL) has demonstrated efficacy in the relapsed or refractory setting; however, the long-term impact on patient immunology is unknown. In this study, changes in immune subsets of MCL patients treated with combination venetoclax and ibrutinib were assessed over a 4-year period. Multiparameter flow cytometry of peripheral blood mononuclear cells showed that ≥12 months of treatment resulted in alterations in the proportions of multiple immune subsets, most notably CD4+ and CD8+ effector and central memory T cells and natural killer cells, and normalization of T-cell cytokine production in response to T-cell receptor stimulation. Gene expression analysis identified upregulation of multiple myeloid genes (including S100 and cathepsin family members) and inflammatory pathways over 12 months. Four patients with deep responses stopped study drugs, resulting in restoration of normal immune subsets for all study parameters except myeloid gene/pathway expression, suggesting long-term combination venetoclax and ibrutinib irreversibly affects this population. Our findings demonstrate that long-term combination therapy is associated with immune recovery in MCL, which may allow responses to subsequent immunotherapies and suggests that this targeted therapy results in beneficial impacts on immunological recovery. This trial was registered at www.clinicaltrials.gov as #NCT02471391.

Conflict of interest statement

Conflict-of-interest disclosure: M.A.A. is an employee of Walter and Eliza Hall Institute, which receives milestone and loyalty payments related to venetoclax (M.A.A. receives a financial benefit from these payments), and receives honoraria from AbbVie. A.W.R. receives research funding from AbbVie, is an unremunerated advisor to AbbVie Australia, and is an employee of Walter and Eliza Hall Institute of Medical Research, which receives milestone and royalty payments related to venetoclax (A.W.R. receives a financial benefit from these payments). J.F.S. and C.S.T. have received honoraria and institutional research funding from AbbVie. The remaining authors declare no competing financial interests.

© 2020 by The American Society of Hematology.

Figures

Graphical abstract

Figure 1.

Patients treated in AIM exhibit significant dysregulation of immune subsets at baseline. (A) Flow cytometric analysis of CD4+ and CD8+ T-cell subsets. P values from an unpaired Student t test with Holm-Sidak multiple corrections. (B) NK cells, CD16+ NK cells, γδ T cells, and CD14+ cells in AIM patients at baseline (n = 16) and age-matched healthy donors (HDs; n = 13). P values from a 2-tailed Mann-Whitney U test. *P < .05, **P < .01, ***P < .001.

Figure 2.

Responding patients exhibit changes in T-cell memory subsets, NK cells, CD16+NK cells, and γδ T cells with long-term treatment. Flow cytometric analysis of CD4+ and CD8+ memory subsets (A), NK cells, CD16+ NK cells, γδ T cells, and CD14+ cells at baseline (n = 13) (B), week 4 (W4; n = 13), week 16 (W16; n = 14), 12 months (M12; n = 13), 18 months (M18; n = 13), 24 months (M24; n = 11), 36 months (M36; n = 10), and 48 months (M48; n = 7). P values from 2-way analysis of variance with Dunnett’s multiple comparisons to B (A) and Kruskal-Wallis test with Dunn’s multiple comparisons to B (B). *P < .05, **P < .01, ***P < .001.

Figure 3.

Functional capacity but not TCR repertoire changes in T cells with long-term treatment. (A-B) TCRβ repertoire was measured at baseline and 12 months. Representative data from 1 patient (A) and inverse Simpson’s measurement of diversity (n = 13) (B). (C) Cytokine production in CD8+ T cells from PBMCs stimulated with CD3/28 T-cell activation beads at baseline and on treatment (n = 6): TNF+, IL-2+, and interferon γ positive (IFN+). Dotted line indicates average cytokine percentage in 8 age-matched donors. P values from a Wilcoxon’s matched-pairs signed rank test compared with baseline. *P < .05.

Figure 4.

Changes in immune profile assessed using NanoString Immune Profiling Panel shows significant upregulation of myeloid genes and pathways. (A) Pathway signature scores determined using NanoString Advanced Analysis Module at baseline (B; n = 8), week 4 (W4; n = 12), week 16 (W16; n = 10), and week 56 (W56; n = 10). (B) Expression of genes at all time points analyzed that showed a statistically significant (P < .05) change in expression between B and W56 listed from most to least significant. (C) Macrophage cell score determined using NanoString Advanced Analysis Module at B (n = 8), W4 (n = 12), W16 (n = 10), and W56 (n = 10). P values from a Kruskal-Wallis test with Dunn’s multiple comparisons. ***P < .001.

Figure 5.

Myeloid inflammation–associated pathways are upregulated with long-term treatment. PBMCs at baseline (B; n = 10), week 4 (W4; n = 11), week 16 (W16; n = 11), and week 56 (W56; n = 12) plus age-matched healthy controls (n = 9) were analyzed using NanoString Myeloid Inflammation Panel. (A) Pathway signature scores determined using NanoString Advanced Analysis Module. (B) Expression of genes at all time points analyzed that showed a statistically significant (P < .05) change in expression between B and W56 listed from most to least significant. (C) Expression profile of S100A11 and CTSS. P values from a Kruskal-Wallis test Dunn’s multiple comparisons to B. ***P < .001.

Figure 6.

Changes in innate populations and CD8 T cells are maintained in patients on DH for 12 months. Flow cytometric analysis of CD4+ and CD8+ memory subsets (A), NK cells, CD16+ NK cells, γδ T cells, and CD14+ cells (B) at baseline, 12 months (M12), start of DH, and 12 to 18 months off study drugs (DH+12M; n = 4). P values from a 2-way analysis of variance with Dunnett’s multiple comparisons to B (A) and Kruskal-Wallis test Dunn’s multiple comparisons to B (B). (C) NanoString myeloid inflammation analysis in patients on DH (n = 4). *P < .05, **P < .01, ***P < .001.