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We present a case of a patient with multiply relapsed, refractory myeloma whose clinical course showed evidence of a synergistic abscopal-like response to chimeric antigen receptor (CAR) T-cell therapy and localized radiotherapy (XRT). Shortly after receiving B-cell maturation antigen (BCMA)–targeted CAR T-cell therapy, the patient required urgent high-dose steroids and XRT for spinal cord compression. Despite the steroids, the patient had a durable systemic response that could not be attributed to XRT alone. Post-XRT findings included a second wave of fever and increased CRP and IL6, beginning 21 days after CAR T cells, which is late for cytokine-release syndrome from CAR T-cell therapy alone on this trial. Given this response, which resembled cytokine-release syndrome, immediately following XRT, we investigated changes in the patient's T-cell receptor (TCR) repertoire over 10 serial time points. Comparing T-cell diversity via Morisita's overlap indices (CD), we discovered that, although the diversity was initially stable after CAR T-cell therapy compared with baseline (CD = 0.89–0.97, baseline vs. 4 time points after CAR T cells), T-cell diversity changed after the conclusion of XRT, with >30% newly expanded TCRs (CD = 0.56–0.69, baseline vs. 4 time points after XRT). These findings suggest potential synergy between radiation and CAR T-cell therapies resulting in an abscopal-like response.

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Introduction: Peripheral and cutaneous T cell lymphomas (TCL) are highly heterogeneous diseases that in the relapsed/refractory (R/R) stage have poor outcome. JAK/STAT, Pi3K/AKT and MAP kinase signaling are commonly involved in the pathogenesis of these lymphomas, and the efficacy of small molecule inhibitors targeting these pathways is being assessed in phase II trials. However, biomarkers to define patients most likely to benefit from specific inhibitors are lacking and mechanisms of acquired resistance in TCLs have not been reported. Methods: We are conducting two early phase trials in R/R TCL: 1) NCT02974647 targets JAK1/JAK2 with ruxolitinib (RUX, a JAK 1-2 inhibitor) and has enrolled 53 patients and 2) NCT02783625 targets Pi3K/AKT with duvelisib (DUV, a Pi3K gamma-delta inhibitor) in combination with either romidepsin or bortezomib and has enrolled 92 patients. We analyzed pre-, on and post- treatment biopsies with multiplex immunofluorescence (mIF) using the Vectra platform, and analyzed images for marker expression and cellular location using HALO software. We designed multiple mIF panels with 6 markers per slide, 3 identifying TCL cells based on disease-specific phenotypes (e.g. CD4+PD1+CD8- for angioimmunoblastic TCL), pSTAT3,5, pS6, and a macrophage marker (CD68). Areas of TCL involvement within biopsy slides were manually defined during image analysis based on mIF and comparison to clinical immunohistochemistry. Differences in marker expressions were analyzed with the Wilcoxon test using the program R. Results: We analyzed 53 biopsies from 39 patients with high-quality mIF images, of which 17 were from lymph nodes and 36 were from extranodal sites. Of 39 patients, 13 were treated with RUX (9 biopsies pre-, 7 on, 4 post- treatment) and 26 with DUV (20 biopsies pre-, 6 on, 10 post- treatment). Median number of total TCL cells in pre-treatment biopsies was 1041 (range, 97-6463) and median TCL cell fraction within involved areas was 27.86% (range, 5.12-88.02%). Median macrophage fraction within involved areas was 5.92% (range, 2.89-11.88%). For either agent, response to treatment was not associated with: 1) quantity of macrophages (p=0.1 for responders vs non-responders to DUV, p=0.53 for RUX), 2) average distance between TCL cells and closest macrophage, 3) TCL cell fraction within involved areas, or 4) fraction of TCL cells expressing pSTAT3/5 (Figure). In contrast, pS6 expression in Conclusions: mIF is a feasible platform for biomarker discovery and translation in TCL, a set of lymphomas with heterogeneous immunophenotypes. pS6 expression in Citation Format: Paola Ghione, Alison Moskowitz, Priadarshini Kumar, Andrea Knezevic, Venkatraman Seshan, Eric Jacobsen, Jia Ruan, Johnathan Schatz, Sarah Noor, Patricia Myskowski, Helen Hancock, Theresa Davey, Obadi Obadi, Carlissa Onwasigwe, Nivetha Ganesan, Lauren Pomerantz, Christine Jarjies, Allison Sigler, Mark Geyer, Ariela Noy, David Straus, Natasha Galasso, Giorgio Inghirami, Steven Horwitz, David Weinstock, Travis Hollmann, Ahmet Dogan. Multispectral immunofluorescence identifies pS6 as a biomarker of intrinsic resistance to ruxolitinib in patients with relapsed/refractory T-cell lymphomas [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 4248.