Clonal Large Granular Lymphocyte (LGL) Expansion Associated with Dasatinib Therapy.
Authors: Mustjoki Satu , Laurinolli Tuisku , Ekblom Marja , Rauhala Auvo , Sinisalo Marjatta , Almqvist Anders , Koivunen Elli , Lundan Tuija , Ebeling Freja , Koskenvesa Perttu , Hjorth-Hansen Henrik , Arstila Petteri , Stenke Leif , Steegmann Juan Luis , Hoglund Martin , Simonsson Bengt , Shah Neil , Paquette Ronald , Porkka Kimmo 
Published: October 2019

Abstract
In addition to therapeutic efficacy in imatinib-resistant BCR-ABL positive malignancies, dasatinib may have off-target immunomodulatory effects by inhibiting kinases (e.g. SRCs, c-KIT) in immune effector cells. In a proportion of patients, dasatinib treatment is associated with non-infectious pleural effusions and panniculitis, which may reflect aberrant immune reactivity. Here we describe a marked expansion of clonal LGL lymphocytes in blood among 11 BCR-ABL positive patients on dasatinib therapy (5 CML CP, 1 CML AP, 1 CML BC, 4 Ph+ALL). All patients were previously exposed to imatinib without similar changes in lymphocyte count or morphology. The median time to LGL lymphocytosis was 2 months from the start of dasatinib (range 1–8 months). It developed abruptly, with a peak lymphocyte count of 4–20 ×109/L, and was often preceded by low-grade fever. In all evaluable cases, lymphocyte counts normalized after drug discontinuation. By immunophenotyping, 6 patients had a CD3/CD8+ cytotoxic T-cell phenotype and 4 patients had a CD56+ NK-cell phenotype. The LGL lymphocytes were BCR-ABL negative. All CD3-positive cases had a clonal rearrangement of TCR gamma/delta genes by PCR; clonality was not detected in samples prior to dasatinib therapy (n=3). In TCR beta gene repertoire assay, oligoclonal patterns were seen in selected genes. All patients with HLA data had the A2 allele (n=8). Dasatinib-related complications were common: pleural effusions and/or pulmonary infiltrates (n=8), modest CMV reactivation (n=5), severe colitis (n=5), which developed after appearance of LGL lymphocytosis. Immunophenotyping was available from 2 patients with pleural effusions: in both cases the majority of cells were CD3+CD8+ T-cells and no leukemic cells were detected. TCR gamma assay was done from one patient sample and it showed similar clonal pattern as in peripheral blood. However, despite frequent side-effects, response to dasatinib treatment was very good in all cases, including complete molecular responses in 5 advanced phase patients. Transient clonal LGL lymphocytosis has been described in few patient cases with a primary herpesvirus infection. Our patients share striking pheno/genotypic similarities with LGL leukemia, in which an antigen driven expansion of LGLs precedes the occurrence of oncogenic events. However, in our patients LGL lymphocytosis appeared to be a benign phenomenon. We postulate that by virtue of inhibition of key non-BCR-ABL kinases, dasatinib induces a reversible state of autoimmune-like reactivity upon antigen challenge in a proportion of patients with a distinct genetic and/or environmental background. The aberrant immune response may also result in enhanced anti-leukemic control driven by the cytotoxic T/NK LGL cells. Dasatinib could be a valuable tool in uncovering the pathogenesis of LGL lymphoproliferation, putatively related to mutations in kinases targeted by the drug.