Lenalidomide Treatment Restores In Vivo T Cell Activity in Relapsed/Refractory FL and DLBCL
Authors: Menard Cedric , Dulong Joelle , Nguyen Tien Tuan , Bescher Nadège , Latour Maelle , Bézier Isabelle , Loisel Séverine , Houot Roch , Lamy Thierry , Morschhauser Franck , Tarte Karin 
Published: April 2021

Abstract
The immunostimulatory properties of lenalidomide have been mostly described in vitro while in vivo studies performed in multiple myeloma or chronic lymphocytic leukemia have reported a poorly characterized T-cell activation. A better understanding of lenalidomide kinetics and mechanisms of action is mandatory to optimize its combination with other immunotherapeutic agents in particular for the treatment of non Hodgkin lymphomas.
We undertook a thorough immune monitoring of patients enrolled in the French multicenter clinical trial GALEN (ClinicalTrials.gov: NCT01582776) addressing the tolerance and efficacy of the association of lenalidomide and obinutuzumab, a glycoengineered type II anti-CD20 monoclonal antibody, in relapsed/refractory B-cell lymphomas. A 1-week interval between the start of lenalidomide and the first infusion of obinutuzumab was planned, allowing an assessment of the effect of lenalidomide alone on immune-related parameters separately from the combinatorial therapy. Serial blood samples were collected in 44 patients (16 DLBCL and 28 FL) to investigate T, B, NK, and myeloid subsets. In addition, in vitro functional assays were designed to address T cell functional features (proliferation, immune synapse, activity of regulatory T cells (Treg)).
In the context of the association with obinutuzumab, we first checked that CD20 expression was not affected on circulating malignant and normal B cells (p=0.43 and 0.8; respectively). Interestingly, upon 1 week of lenalidomide treatment, normal B cells, unlike malignant B cells, upregulated MHC class II (p&lt;0.001 versus 0.16; respectively) while both increased the expression of the costimulatory molecule CD86 (p=0.001 and 0.002; respectively). More importantly, the T-cell capacity to mount a functional immune synapse with malignant B cells was restored in 5/6 relapsed/refractory patients (p&lt;0.001) and we confirmed that this stood true for 6 FL patients at diagnosis (p&lt;0.001). In addition, T cell proliferation was strongly increased in vivo as measured by Ki67 staining (p&lt;0.001) but also upon TCR stimulation ex vivo (p=0.002). This immunostimulatory effect could not be ascribed to a blockade of Treg inhibitory potential by lenalidomide as effector T-cell proliferation was similarly enhanced upon in vitro Treg depletion before and after lenalidomide treatment (p=0.02). In addition, T-cell activation was associated with a reshaping of memory T-cell distribution with the central memory subset dropping in favor of effector cells (p&lt;0.001 and 0.002 respectively). This restoration of T-cell functions was paralleled by the induction of activation markers on T cells such as HLA-DR, CD137, PD-1, and Tim-3 (p&lt;0.001 for all markers). Finally, immune stimulation was not confined to T cells as NK cells also upregulated CD137 (p&lt;0.001) but not PD-1 (p=0.53) expression. We also investigated the myeloid compartment including circulating MDSC and monocytes, both being putative precursors of tumor-associated macrophages. Within 1 week of lenalidomide, patients experienced a decrease of monocytes subsets count and an upregulation of the activation marker and Fcg receptor CD64 (p=0.006). Of note, preliminary experiments showed that, at least in some cases, in vitro exposure of macrophages to lenalidomide could enhance anti-CD20-mediated phagocytosis of tumor cells. Some of these immunological parameters were transiently modulated and returned to baseline levels upon lenalidomide washout but others were restored long term in particular the immune synapse score and memory T cell counts.
We herein report for the first time early in vivo T cell activation by lenalidomide in relapse FL/DLBCL through a detailed phenotypic analysis strengthened by innovative functional assays. The study of T cells heterogeneity at the transcriptomic level is underway and the correlation of these immunomodulatory properties with clinical data is also currently being addressed. Our results will help build new and more relevant lenalidomide-based immunotherapeutic approaches. (This study was supported by research grants from Celgene and Roche companies)

Disclosures
Menard: Celgene: Consultancy; Astra Zeneca: Membership on an entity's Board of Directors or advisory committees; BMS: Consultancy. Lamy: Roche: Consultancy, Honoraria. Morschhauser: Roche: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; Bristol-Myers Squibb: Consultancy, Honoraria; Celgene: Consultancy, Honoraria; Servier: Consultancy; Gilead: Consultancy. Tarte: Celgene: Consultancy, Research Funding; Novimmune: Research Funding; Roche: Consultancy.