Cutaneous T-cell lymphoma (CTCL) is a rare, incurable CD4+ T cell malignancy of the skin with a 5-year survival rate of less than 30% in advanced stages. Immune checkpoint inhibitors, such as anti-PD-1 antibodies, have shown dramatic clinical efficacy in multiple advanced cancers, but the majority of cancer patients do not respond to these treatments. The clinical use of immunotherapies will increase considerably in the near future; therefore, predictive biomarkers of response to stratify patients for treatment are needed to limit potentially devastating adverse effects and reduce costs for healthcare systems. A clinical trial of the anti-PD-1 antibody pembrolizumab in CTCL showed that 38% of patients have a durable clinical response. However, standard tests, including comprehensive immunohistochemistry and single-cell quantification of PD-1 expression, have so far failed to identify a predictive biomarker for pembrolizumab response in this cohort. We reasoned that deep profiling of the CTCL tumor microenvironment (TME) using CODEX–a novel technology that allows for highly multiplexed tissue microscopy with >50 simultaneous parameters–could provide insight into the mechanisms of pembrolizumab response and enable prediction. We analyzed the CTCL TME using a tissue microarray of matched biopsies taken before and after pembrolizumab therapy in 7 responders and 7 non-responders. Imaging of 55 markers allowed discriminating malignant CD4+ tumor cells from reactive CD4+ T cells based on nuclear size and differential expression of CD7, CD25 and Ki-67. Unsupervised machine learning followed by supervised curation identified 21 different cell type clusters with spatial information. Integrating these data using advanced computational analysis revealed 10 distinct, conserved cellular neighborhoods (CNs) in the CTCL TME that changed in frequency and distribution during pembrolizumab therapy. In responders, effector-type CNs, including a tumor/dendritic cell CN and a tumor/CD4+ T cell CN, were significantly increased after treatment. In contrast, in non-responders, an immunosuppressive-type CN enriched in regulatory T cells was significantly increased before and after therapy. Importantly, the global frequencies in the tissues of the cell types defining these CNs were not different between patient groups. In addition, RNA sequencing of matched tissue sections revealed higher expression of effector-type cytokines and chemokines in responders. In sum, highly multiplexed analysis of the CTCL TME architecture in combination with RNA sequencing allows discovering novel, predictive spatial biomarkers of immunotherapy response and will pave the way for future studies that functionally address the identified cell types and cellular interactions.

Citation Format: Christian M. Schürch, Darci J. Phillips, Belén Rivero Gutierrez, Magdalena Matusiak, Salil S. Bhate, Graham L. Barlow, Steven P. Fling, Nirasha Ramchurren, Robert H. Pierce, Martin A. Cheever, Michael S. Khodadoust, Robert West, Youn H. Kim, Garry P. Nolan. Cellular neighborhoods predict pembrolizumab response in cutaneous T cell lymphoma [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 6669.