Exploratory mass cytometry analysis reveals immunophenotypes of cancer treatment-related pneumonitis

Reviewer #1 (Public Review):

Cytotoxic agents and immune checkpoint inhibitors are the most commonly used and efficacious treatments for lung cancers. However their use brings two significant pulmonary side-effects; namely Pneumocystis jirovecii infection and resultant pneumonia (PCP), and interstitial lung disease (ILD). To observe the potential immunological drivers of these adverse events, Yanagihara et al. analysed and compared cells present in the bronchoalveolar lavage of three patient groups (PCP, cytotoxic drug-induced ILD [DI-ILD], and ICI-associated ILD [ICI-ILD]) using mass cytometry (64 markers). In PCP, they observed an expansion of the CD16+ T cell population, with the highest CD16+ T proportion (97.5%) in a fatal case, whilst in ICI-ILD, they found an increase in CD57+ CD8+ T cells expressing immune checkpoints (TIGIT+ LAG3+ TIM-3+ PD-1+), FCRL5+ B cells, and CCR2+ CCR5+ CD14+ monocytes. Given the fatal case, the authors also assessed for, and found, a correlation between CD16+ T cells and disease severity in PCP, postulating that this may be owing to endothelial destruction. Although n numbers are relatively small (n=7-9 in each cohort; common numbers for CyTOF papers), the authors use a wide panel (n=65) and two clustering methodologies giving greater strength to the conclusions. The differential populations discovered using one or two of the analytical methods are robust: whole population shifts with clear and significant clustering. These data are an excellent resource for clinical disease specialists and pan-disease immunologists, with a broad and engaging contextual discussion about what they could mean.

Strengths:
• The differences in immune cells in BAL in these specific patient subgroups is relatively unexplored.
• This is an observational study, with no starting hypothesis being tested.
• Two analytical methods are used to cluster the data.
• A relatively wide panel was used (64 markers), with particular strength in the alpha beta T cells and B cells.
• Relevant biomarkers, beta-D-glucan and KL-6 were also analysed
• Appropriate statistics were used throughout.
• Numbers are low (7 cases of PCP, 9 of DI-ILD, and 9 of ICI-ILD) but these are difficult samples to collect and so in relative terms, and considering the use of CyTOF, these are good numbers.
• Beta-D-glucan shows potential as a biomarker for PCP (as previously reported) whilst KL-6 shows potential as a biomarker for ICI-ILD (not reported before). Interestingly, KL-6 was not seen to be increased in DI-ILD patients.
• Despite the relatively low n numbers and lack of matching there are some clear differentials. The CD4/CD8+CD16+HLA-DR+CXCR3+CD14- T cell result is striking - up in PCP (with EM CD4s significantly down) - whilst the CD8 EMRA population is clear in ICI-ILD and 'non-exhausted' CD4s, with lower numbers of EMRA CD8s in DI-ILD.
• The authors identify 17/31 significantly differentiated clusters of myeloid cells, eg CD11bhi CD11chi CD64+ CD206+ alveolar macrophages with HLA-DRhi in PCP.
• With respect to B cells, the authors found that FCRL5+ B cells were more abundant in patients with ICI-ILD compared to those with PCP and DI-ILD, suggesting these FCRL5+ B cells may have a role in irAE.
• One patient's extreme CD16+ T cell (97.5% positive) and death, led the authors to consider CD16+ T cells as an indicator of disease severity in PCP. This was then tested and found to be correct.
• Authors discuss results in context of literature leading them to suggest that CD16+ T cells may target endothelial cells and wonder if anti-complement therapy may be efficacious in PCP.
• Great discussion on auto-reactive T cell clones where the authors suggest that in ICI-ILD CD8s may react against healthy lung, driving ILD.
• An observation of CXCR3 in different CD8 populations in ICI-ILD and PCP lead the authors to hypothesise on the chemoattractants in the microenvironment.
• Excellent point suggesting CD57 may not always be a marker of senescence on T cells - reflective of growing change within the community.
• Well considered suggestion that FCRL5+ B cells may be involved in ICI-ILD driven autoimmunity.
• The authors discuss the main weaknesses in the discussion and stress that the findings detailed in the paper "demonstrate a correlation rather than proof of causation".
• Figures and legends are clear and pleasing to the eye.

Weaknesses:
• This is an observational study, with no starting hypothesis being tested.
• Only patients who were able to have a lavage taken have been recruited.
• One set of analysis wasn't carried out for one subgroup (ICI-ILD) as PD1 expression was negative owing to the use of nivolumab.
• Some immune cell subsets wouldn't be picked up with the markers and gating strategies used; e.g. NK cells.
• Some immune cells would be disproportionately damaged by the storage, thawing and preparation of the samples; e.g. granulocytes.
• Numbers are low (7 cases of PCP, 9 of DI-ILD, and 9 of ICI-ILD), sex, age and adverse event matching wasn't performed, and treatment regimen are varied and 'suspected' (suggesting incomplete clinical data) - but these are difficult samples to collect. These numbers drop further for some analyses e.g. T cell clustering owing to factors such as low cell number.
• The disease comparisons are with each other, there is no healthy control.
• Samples are taken at one time point.
• The discussion on probably the stand out result - the CD16+ T cells in PCP - relies on two papers - leading to a slightly skewed emphasis on one paper on CD16+ cells in COVID. There are other papers out there that have observed CD16+ T cells in other conditions. It is also worth being in mind that given the markers used, these CD16+ T cell may be gamma deltas.
• The discussion on ICI patient consistently showing increased PD1, could have been greater, as given the ICI is targeting PD1, one would expect the opposite as commented on, and observed, in the methods section.

Reviewer #2 (Public Review):

Yanagihara and colleagues investigated the immune cell composition of bronchoalveolar lavage fluid (BALF) samples in a cohort of patients with malignancy undergoing chemotherapy and with with lung adverse reactions including Pneumocystis jirovecii pneumonia (PCP) and immune-checkpoint inhibitors (ICIs) or cytotoxic drug induced interstitial lung diseases (ILDs). Using mass cytometry, their aim was to characterize the cellular and molecular changes in BAL to improve our understanding of their pathogenesis and identify potential biomarkers and therapeutic targets. In this regard, the authors identify a correlation between CD16 expression in T cells and the severity of PCP and an increased infiltration of CD57+ CD8+ T cells expressing immune checkpoints and FCLR5+ B cells in ICI-ILD patients.

The conclusions of this paper are mostly well supported by data, but some aspects of the data analysis need to be clarified and extended.

1. The authors should elaborate on why different set of markers were selected for each analysis step. E.g., Different set of markers were used for UMAP, CITRUS and viSNE in the T cell and myeloid analysis.

2. The authors should state if a normality test for the distribution of the data was performed. If not, non-parametric tests should be used.

3. The authors should explore the correlation between CD16 intensity and the CTCAE grade in T cell subsets such as EMRA CD8 T cells, effector memory CD4, etc as identified in Figure 1B.

4. The authors could use CITRUS to better assess the B cell compartment.

Reviewer #3 (Public Review):

The authors collected BALF samples from lung cancer patients newly diagnosed with PCP, DI-ILD or ICI-ILD. CyTOF was performed on these samples, using two different panels (T-cell and B-cell/myeloid cell panels). Results were collected, cleaned-up, manually gated and pre-processed prior to visualisation with manifold learning approaches t-SNE (in the form of viSNE) or UMAP, and analysed by CITRUS (hierarchical clustering followed by feature selection and regression) for population identification - all using Cytobank implementation - in an attempt to identify possible biomarkers for these disease states. By comparing cell abundances from CITRUS results and qualitative inspection of a small number of marker expressions, the authors claimed to have identified an expansion of CD16+ T-cell population in PCP cases and an increase in CD57+ CD8+ T-cells, FCRL5+ B-cells and CCR2+ CCR5+ CD14+ monocytes in ICI-ILD cases.

By the authors' own admission, there is an absence of healthy donor samples and, perhaps as a result of retrospective experimental design, also an absence of pre-treatment samples. The entire analysis effectively compares three yet-established disease states with no common baseline - what really constitutes a "biomarker" in such cases? The introduction asserts that "y characterizing the cellular and molecular changes in BAL from patients with these complications, we aim to improve our understanding of their pathogenesis and identify potential therapeutic targets" (lines 82-84). Given these obvious omissions, no real "changes" have been studied in the paper. These are very limited comparisons among three, and only these three, states.

Even assuming more thorough experimental design, the data analysis is unfortunately too shallow and has not managed to explore the wealth of information that could potentially be extracted from the results. CITRUS is accessible and convenient, but also make a couple of big assumptions which could affect data analysis - 1) Is it justified to concatenate all FCS files to analyse the data in one batch / small batches? Could there be batch effects or otherwise other biological events that could confuse the algorithm? 2) With a relatively small number of samples, and after internal feature selection of CITRUS, is the regression model suitable for population identification or would it be too crude and miss out rare populations? There are plenty of other established methods that could be used instead. Have those methods been considered?

Colouring t-SNE or UMAP (e.g. Figure 6C) plots by marker expression is useful for quick identification of cell populations but it is not a quantitative analysis. In a CyTOF analysis like this, it is common to work out fold changes of marker expressions between conditions. It is inadequate to judge expression levels and infer differences simply by looking at colours.

The relatively small number of samples also mean that most results presented in the paper are not statistical significant. Whilst it is understandable that it is not always possible to collect a large number of patient samples for studies like this, having several entire major figures showing "n.s." (e.g. Figures 3A, 4B and 5C), together with limitations in the comparisons themselves and inadequate analysis, make the observations difficult to be convincing, and even less so for the single fatal PCP case where N = 1.

It would also be good scientific practice to show evidence of sample data quality control. Were individual FCS files examined? Did the staining work? Some indication of QC would also be great.

This dataset generated and studied by the authors have the potential to address the question they set out to answer and thus potentially be useful for the field. However, in the current state of presentation, more evidence and more thorough data analysis are needed to draw any conclusions, or correlations, as the authors would like to frame them.