Optimum Imatinib Exposure Have Possibility of Leading to Appropriate Immune Response after Imatinib Discontinuation in CML Patients

Introduction: Imatinib, the first tyrosine kinase inhibitor (TKI), has dramatically improved the prognosis of chronic myeloid leukemia (CML) patients. Recently, many trials of TKI discontinuation revealed that approximately 40% to 60% of CML patients who treated long time TKI therapy reached the treatment free remission (TFR), thus now TFR is proposed as one of the goals in CML treatment. Achieving deep molecular response (DMR) by TKI therapy is a minimum requirement of challenge to TKI discontinuation in CML patient, actually CML patients with molecular residual disease (MRD) showed worse consequence than undetectable MRD (IJH 2017). On the other hand, it was known that some patients have continued TFR with detectable BCR-ABL fusion gene, these patients hadn't shown indubitable molecular relapse while BCR-ABL⁺ malignant cells continued to exist for prolonged time. We hypothesized that the malignant cells were eliminated by host immune systems in these fluctuated patients. Here, we focused on T-cell response, so we analyzed T-cell related markers to identify biomarkers that can predict patients which can continue TFR or not in Japanese CML patients. Furthermore, we confirmed the action of imatinib for T-cell response in vitro.

Methods: Japanese CML patients treated with imatinib for at least three years and confirmed in DMR for at least two years were eligible. Patients who received other TKI or stem cell transplantations were excluded. Patients were re-confirmed in MR4.5 before discontinue imatinib and they were sampled peripheral blood at pre- and 1, 3 months after stopping imatinib (figure 1). Peripheral blood mononuclear cells (PBMCs) were subjected to staining with T-cell markers and analyzed by mass cytometry and flowcytometry. Plasma were subjected to detecting Imatinib trough concentrations. Purchased PBMCs of healthy individuals were cultured and analyzed by flowcytometry in vitro assay.

Results: Samples of 68 CML patients were analyzed. We classified these CML patients into two groups (Non-retreatment and Retreatment groups) by clinical courses after stopping imatinib (figure 2). Frequency of CD4⁺ T cells and CD8⁺ T cells in CD3⁺ T cells were no difference between both groups. FoxP3⁺CD4⁺ regulatory T cells (Treg) were also no difference between both groups, but kinetics of Treg, especially Fraction II (Fr.II : FoxP3^hiCD45RA^-) of Treg from Pre-stopping imatinib to 1 month after stopping imatinib significantly increased in non-retreatment groups. Kinetics of Treg / CD8⁺ T cells ratio also significantly increased in non-retreatment groups, and predicted curve made by these kinetics of each groups were significant (figure 3). The expression of PD-1 or other suppressive co-stimulatory molecules in CD8⁺ T cells of non-retreatment groups at after stopping imatinib had tendency to decrease. Phosphorylated LCK in CD8⁺ T cells of non-retreatment groups at after stopping imatinib had tendency to increase. Next, we did in vitro assay to confirm the effect of pre-treatment of imatinib in imatinib free T cells. Pre-treatment of imatinib suppressed the proliferations of Treg Fr.II after TCR stimulation dose dependently, but not CD8⁺ T cells (figure 4). Frequency of phosphorylated LCK in Treg Fr.II increased after TCR stimulation even if pre-treated imatinib at reasonable dose, but didn't increased under the condition of high dose imatinib.

Conclusion: Treg population and Treg / CD8⁺ T cells ratio in PBMCs elevated after stopping imatinib in non-retreatment groups of CML patients. Population of CD8⁺ T cells showed no differences in two groups but CD8⁺ T cells were tending to activate after stopping imatinib in non-retreatment groups. These data indicate that the kinetics of Treg after stopping imatinib connect with the immune response of imatinib discontinued CML patients. In vitro data indicate that Treg were more sensitive for imatinib treatment than CD8⁺ T cells, so kinetics of Treg may possibly become the biomarker of ability of immune responses. Our data suggested that optimum imatinib exposure induce appropriate immune responses leading good prognosis, and excess imatinib exposure induce exhaust immune responses leading poor prognosis.

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