- Research note
- Open Access
Tumour associated lymphocytes in the pleural effusions of patients with mesothelioma express high levels of inhibitory receptors
© The Author(s) 2018
- Received: 29 October 2018
- Accepted: 26 November 2018
- Published: 5 December 2018
Pleural effusion (PE) is a common feature of malignant pleural mesothelioma. These effusions typically contain lymphocytes and malignant cells. We postulated that the PE would be a source of lymphocytes for analysis of tumor immune milieu. The aim of this study was to compare the phenotype and T cell receptor usage of pleural effusion T cells with paired concurrently drawn peripheral blood lymphocytes. We used multi-parameter flow cytometry and high-throughput T cell receptor sequencing to analyse peripheral blood and pleural effusion mononuclear cells.
Both CD8+ and CD4+ T cells from effusion showed increased expression of T cell inhibitory receptors PD-1, LAG-3 and Tim-3 compared to blood. Comprehensive T cell receptor sequencing on one of the patients showed a discordant distribution of clonotypes in the antigen-experienced (PD-1+) compartment between effusion and blood, suggesting an enrichment of antigen specific clonotypes in the effusion, with potential as an immunological response biomarker.
- Pleural effusion
- T cell receptor
Malignant mesothelioma originates from mesothelial cells lining the pleura. Most patients have a history of asbestos exposure, present with advanced disease and receive palliative chemotherapy only. The median survival for patients treated with cisplatin and pemetrexed is around 12 months  and most patients die from their disease.
The success of immunotherapy targeting checkpoint inhibitory T cell receptors in a variety of cancer types, has seen the anti-tumour immune response re-emerge as a promising prognostic marker, therapeutic target and a potential biomarker of response for cancer immunotherapy . Such therapies are under clinical investigation for the treatment of patients with mesothelioma , and understanding T cell responses in these patients is crucial for improving the efficacy of immunotherapy.
The prognostic significance of tumour infiltrating lymphocytes (TILs) is established for many cancer types including mesothelioma . Longitudinal characterisation of T cell phenotype and T cell receptor (TCR) usage at the tumour site could help us to understand how to promote effective anti-tumour immunity. However, serial analysis of immune changes at the tumour site is rarely feasible in clinical practice as tumour biopsies are invasive. Malignant pleural effusions (PE), a recurrent and common complication of mesothelioma, are regularly drained as a palliative measure and can be sampled serially . PE is an abnormal accumulation of fluid in the pleural space with T lymphocytes the predominant immune cells . Given that malignant PE are intimately associated with mesothelioma, they form an important part of the local tumour environment and as such, immune events in the PE may serve as surrogate markers of the intratumoural milieu. We characterized T cell phenotype in PE and peripheral blood in 9 patients with mesothelioma, and compared the T cell repertoire between PE and peripheral blood of a selected patient.
Materials and methods
Sample collection and processing
This study was approved by the site Human Research Ethics Committee and the patient provided written informed consent for collection and analysis of biological samples. Blood was collected into a heparinized Vacutainer® (BD Diagnostics) and peripheral blood mononuclear cells (PBMC) isolated according to manufacturer’s instructions. A 50 ml PE sample was collected. Ficoll density centrifugation was used to isolate PE mononuclear cells (PEMC). Cells were stored in liquid nitrogen until analysis.
The nine participants in the current study had a histologically or cytologically confirmed diagnosis of malignant pleural mesothelioma. Participants could have any stage or duration of disease; prior treatment with chemotherapy or radiotherapy was allowed. Effusions from patients with prior talc pleurodesis or pleural infection were excluded from this study.
Thawed cells were labelled with antibodies: CD14-APC-eFluor®780 (61D3), CD19-APC-eFluor®780 (HIB19), LAG-3-PE (3DS223H) (eBioscience); CD45-BUV395 (HI30), CD3-BV510 (UCHT1), CD4-BV711 (OKT4), CD8a-FITC (RPA-T8), PD-1-PerCP-Cy5.5 (EH12.2H7), PD-1-PECy7 (EH12.2H7), Tim-3-APC (F38-232), CD45RA-BV785 (HI100) (BioLegend). Dead cells were excluded using Viability Dye eFluor™780 (ThermoFisher). Samples were acquired on a LSR Fortessa (BD Biosciences) and analyzed using FlowJov10 (Treestar).
Cells were sorted on CD3, CD4, CD8 and PD-1 expression with a BD Influx™ (BD Biosciences). DNA was extracted from sorted cells using QIAmp DNA Kit (Qiagen). DNA sequences were amplified with a Human TCRβ ImmunoSeq Kit (Adaptive Biotechnologies). Sequencing was performed on a MiSeq (MS-102-3001, Illumina) and data was analyzed using the Adaptive ImmunoSeq suite. Each TCR clonotype is defined as a unique TCRβ nucleotide sequence. Differential abundance of T cell clones were compared as previously described . The diversity of each sample was assigned a clonality score , whereby each score varied from 0 (each clone appearing once) to 1 (monoclonal sample).
Malignant effusions have proportionately more T cells that express inhibitory receptors, compared to blood
Patient characteristics at the point when effusion and blood samples were taken
Age (at sample date)
Sample time from diagnosis (days)
Indwelling pleural catheter (IPC)/thoracentesis
Effusion vol. (ml)
Cell concentration in effusion (× 107/100 ml)
Malignant effusions have diverse TCR repertoires compared to blood
We examined the T cell repertoire by sequencing the TCRβ chain in T cells from PE and matched peripheral blood. As PD-1 was the most abundantly expressed T cell inhibitory receptor in our PE samples compared with blood, T cell subsets were further sorted into CD4+PD-1+ and CD8+PD-1+ populations. We performed high throughput TCRseq in CD4+, CD4+PD-1+, CD8+ and CD8+PD-1+ T cells derived from matched PE and peripheral blood. This was performed in a single participant (patient 9 in Table 1), who had no prior treatment that might alter the TCR repertoire, and was selected on the basis of sample availability.
When we examined the PD-1+ subsets, the clonality scores in the blood were similarly higher than the effusion (Fig. 2d). The number of differentially expressed CD8+PD-1+ clones in each compartment were similar to the CD8+ analysis (Fig. 2e). Interestingly, the highly dominant CD8+ T cell clone in this patient’s blood was not present in the CD8+PD-1+ PBMCs, suggesting this patient had an antecedent infection independent of the pleural space. Importantly, the number of differentially expressed CD4+ T cell clones in each compartment was higher in the CD4+PD-1+ analysis compared to the CD4+ analysis (27 vs. 3; Fig. 2f). There were marked clonotypic expansions in CD4+PD-1+ population that were not evident in the bulk CD4+ population, showing that some differences were only observed after fine analysis of clonal frequency associated with phenotype.
Tumour biopsies from patients with mesothelioma are difficult to obtain, can cause significant morbidity, and are usually only taken once at diagnosis unless a subsequent surgical resection is performed. Thus, serial collection of malignant PE provides a unique opportunity to analyze dynamic events adjacent to the tumour microenvironment over time. A recent study by Aaerts et al. showed that the cellular composition of malignant PE over time is dynamic and influenced by response to treatment . While this study was limited to a small group of patients, ongoing longitudinal studies will determine if PE T cells behave similarly to TILs and peripheral blood lymphocytes during disease progression and immunotherapy. Our data suggest that PE T cells, like TILs, exhibit an exhausted phenotype characterized by increased expression of inhibitory markers as compared with peripheral blood T cells. In line with this, previous studies have demonstrated increased expression of PD-1 and Tim-3 on CD4+ and CD8+ T cells in PE compared with matched blood in patients with mesothelioma [11, 12] and lung cancer [13–15], suggesting that T cells in the PE more closely approximate TILs than do T cells in peripheral blood. Of note, the expression of co-inhibitory markers on TILs has been shown to correlate with response to immunotherapy , supporting the potential for PE T cells to provide predictive information longitudinally.
We examined the T cell repertoire from PE and blood in a single patient using TCRseq. CD4+ and CD8+ TCR repertoires were diverse in the PE, suggesting minimal T cell expansion in the PE of this patient. This contrasts oligoclonal T cell expansion observed in ascites derived from patients with ovarian cancer . We observed a more restricted TCR repertoire in effusion CD4+PD-1+ T cells compared to CD4+ T cells, similar to previous studies studying PD-1+ TILs [9, 18]. In depth analysis of CD4+PD-1+ T cells also uncovered more differentially expressed TCR clones in the effusion, suggesting that focusing on PD-1+ T cells might yield important insight into the immunological milieu.
PD-1+ T cells is a population of interest to understand the relationship between T cells in the peripheral blood, PE and tumour. As we reported the findings from a single patient, it remains to be seen if TCR repertoire in the PE is equally diverse in other patients with mesothelioma, or if the repertoire changes after different therapies. The specificity of T cells in the effusion is still to be determined, as is their ability to recognize tumour antigens.
The study was limited by small patient numbers, especially with one patient for the TCR analysis. Tumour biopsies were unavailable for a comprehensive comparison of inhibitory receptor expression and TCR diversity between all compartments.
JCh and AM performed experiments, wrote, and edited the main manuscript text. AM, ACo, JC, MW, ACh prepared figures. BN collected human samples. JC, WL, BR, YL provided intellectual input into manuscript. AN, RL and AM provided input into study design and experimental setup. All authors read and approved the final manuscript.
We acknowledge the facilities, and the scientific and technical assistance of the Australian Microscopy & Microanalysis Research Facility at the Centre for Microscopy, Characterisation & Analysis University of Western Australia, a facility funded by the University, State and Commonwealth Governments. The authors also acknowledge Justin Leon and Cynthia Gregory for sample collection and processing.
The authors declare that they have no competing interests.
Consent for publication
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Ethics approval and consent to participate
This study was approved by the Sir Charles Gairdner Hospital Human Research Ethics Committee and the patient provided written informed consent for collection and analysis of biological samples.
We acknowledge funding from Cancer Council Western Australia, Raine Foundation, University of Western Australia, US Department of Defence, the Australian Science and Industry Endowment Fund, Insurance Commission of Western Australia and the National Health and Medical Research Council.
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