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Identification of Pathogenic Immune Cell Subsets Associated With Checkpoint Inhibitor–Induced Myocarditis

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Zhu, Han, Galdos, Francisco X., Lee, Daniel, Waliany, Sarah, Huang, Yuhsin Vivian, Ryan, Julia, Dang, Katherine, Neal, Joel W. +9 more·2022·Circulation
DOI 10.1161/circulationaha.121.056730PMC PMC9397491
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Abstract

Background: Immune checkpoint inhibitors (ICIs) are monoclonal antibodies used to activate the immune system against tumor cells. Despite therapeutic benefits, ICIs have the potential to cause immune-related adverse events such as myocarditis, a rare but serious side effect with up to 50% mortality in affected patients. Histologically, patients with ICI myocarditis have lymphocytic infiltrates in the heart, implicating T cell–mediated mechanisms. However, the precise pathological immune subsets and molecular changes in ICI myocarditis are unknown. Methods: To identify immune subset(s) associated with ICI myocarditis, we performed time-of-flight mass cytometry on peripheral blood mononuclear cells from 52 individuals: 29 patients with autoimmune adverse events (immune-related adverse events) on ICI, including 8 patients with ICI myocarditis, and 23 healthy control subjects. We also used multiomics single-cell technology to immunophenotype 30 patients/control subjects using single-cell RNA sequencing, single-cell T-cell receptor sequencing, and cellular indexing of transcriptomes and epitopes by sequencing with feature barcoding for surface marker expression confirmation. To correlate between the blood and the heart, we performed single-cell RNA sequencing/T-cell receptor sequencing/cellular indexing of transcriptomes and epitopes by sequencing on MRL/Pdcd1 −/− (Murphy Roths large/programmed death-1–deficient) mice with spontaneous myocarditis. Results: Using these complementary approaches, we found an expansion of cytotoxic CD8 + T effector cells re-expressing CD45RA (Temra CD8 + cells) in patients with ICI myocarditis compared with control subjects. T-cell receptor sequencing demonstrated that these CD8 + Temra cells were clonally expanded in patients with myocarditis compared with control subjects. Transcriptomic analysis of these Temra CD8 + clones confirmed a highly activated and cytotoxic phenotype. Longitudinal study demonstrated progression of these Temra CD8 + cells into an exhausted phenotype 2 months after treatment with glucocorticoids. Differential expression analysis demonstrated elevated expression levels of proinflammatory chemokines (CCL5/CCL4/CCL4L2) in the clonally expanded Temra CD8 + cells, and ligand receptor analysis demonstrated their interactions with innate immune cells, including monocytes/macrophages, dendritic cells, and neutrophils, as well as the absence of key anti-inflammatory signals. To complement the human study, we performed single-cell RNA sequencing/T-cell receptor sequencing/cellular indexing of transcriptomes and epitopes by sequencing in Pdcd1 −/− mice with spontaneous myocarditis and found analogous expansions of cytotoxic clonal effector CD8 + cells in both blood and hearts of such mice compared with controls. Conclusions: Clonal cytotoxic Temra CD8 + cells are significantly increased in the blood of patients with ICI myocarditis, corresponding to an analogous increase in effector cytotoxic CD8 + cells in the blood/hearts of Pdcd1 −/− mice with myocarditis. These expanded effector CD8 + cells have unique transcriptional changes, including upregulation of chemokines CCL5/CCL4/CCL4L2, which may serve as attractive diagnostic/therapeutic targets for reducing life-threatening cardiac immune-related adverse events in ICI-treated patients with cancer.

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  • Expansion of CD8+ T cells was observed in PBMC of patients with ICI myocarditis.

    “Expansion of CD8 + T cells was also observed in the PBMC of patients with ICI myocarditis”

    From Autoimmune Myocarditis, Old Dogs and New Tricks. (2024) · cites this paper as [83]

    The Results report an increase in Temra CD8+ cells in the peripheral blood of patients with ICI myocarditis. They also report no significant difference in overall CD8+ T-cell proportions, so the claim is supported for a CD8+ subset, not CD8+ T cells generally. (LLM, conf=0.88)

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Cited by

Sorted by citations

Authors
Zhu, H., Galdos, F. X., Lee, D., Waliany, S., Huang, Y. V., Ryan, J., Dang, K., Neal, J. W., Wakelee, H. A., Reddy, S. A., Srinivas, S., Lin, L.-L., Witteles, R. M., Maecker, H. T., Davis, M. M., Nguyen, P. K., & Wu, S. M.
Affiliations
  • Stanford Medicine (US)
  • Stanford Cardiovascular Institute (US)
  • Stanford University (US)
  • Cornell University (US)
  • University of California, Santa Barbara (US)
  • Sanofi (United States) (US)
  • Howard Hughes Medical Institute (US)
ORCID
Venue
Circulation
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2022-07-26
Volume
146
Issue
4
Pages
316-335
ISSN
  • 0009-7322 (ISSN-L)
  • 1524-4539
DOI
10.1161/circulationaha.121.056730
PMC
PMC9397491
OpenAlex
W4283704197
Cited by
192
References
8
Citations by year
2026: 53 · 2025: 56 · 2024: 47 · 2023: 29 · 2022: 6 · 2021: 1
FWCI
14.86
Type
journal article
Language
en
Open access
Locations
  • Circulation (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Heart, Lung, and Blood Institute (F32HL149188, K08HL161405)
  • National Cancer Institute (P30CA124435)
  • National Institute of General Medical Sciences (RM1GM131981)
  • U.S. National Library of Medicine (DP1LM012179)
Topics
  • Health Sciences › Medicine › Oncology › Cancer Immunotherapy and Biomarkers
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Viral Infections and Immunology Research
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Fibrosis and Remodeling
Keywords
immune checkpoint inhibitors, immune-related adverse events, myocarditis, CD8+ T cells, TEMRA cells, T cell exhaustion, clonal expansion, T cell receptor repertoire, chemokines, RANTES, carbon tetrachloride, monocytes, dendritic cells, neutrophils, PDCD1
MeSH terms
Antineoplastic Agents, Immunological, Animals, Epitopes, Antineoplastic Agents, Humans, Leukocytes, Mononuclear, Longitudinal Studies, Myocarditis, Mice

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