LAG-3 expression on peripheral blood cells identifies patients with poorer outcomes after immune checkpoint blockade

Immune checkpoint blocking antibodies are a cornerstone in cancer treatment; however, they benefit only a subset of patients and biomarkers to guide immune checkpoint blockade (ICB) treatment choices are lacking. We designed this study to identify blood-based correlates of clinical outcome in ICB-treated patients. We performed immune profiling of 188 ICB--treated patients with melanoma using multiparametric flow cytometry to characterize immune cells in pretreatment peripheral blood. A supervised statistical learning approach was applied to a discovery cohort to classify phenotypes and determine their association with survival and treatment response. We identified three distinct immune phenotypes (immunotypes), defined in part by the presence of a LAG-3(+)CD8(+) T cell population. Patients with melanoma with a LAG(+) immunotype had poorer outcomes after ICB with a median survival of 22.2 months compared to 75.8 months for those with the LAG(-) immunotype (P = 0.031). An independent cohort of 94 ICB-treated patients with urothelial carcinoma was used for validation where LAG(+) immunotype was significantly associated with response (P = 0.007), survival (P < 0.001), and progression-free survival (P = 0.004). Multivariate Cox regression and stratified analyses further showed that the LAG(+) immunotype was an independent marker of outcome when compared to known clinical prognostic markers and previously described markers for the clinical activity of ICB, PD-L1, and tumor mutation burden. The pretreatment peripheral blood LAG(+) immunotype detects patients who are less likely to benefit from ICB and suggests a strategy for identifying actionable immune targets for further investigation.

Automated summary

Blood-based immune profiling was used to identify three distinct immune phenotypes associated with response to immune checkpoint blockade treatment in melanoma patients, with LAG(+) immunotype showing poorer outcomes. This LAG(+) immunotype was also validated to be significantly associated with treatment response and survival in an independent cohort of patients with urothelial carcinoma. The study suggests potential for using pretreatment LAG(+) immunotype as a marker for identifying patients less likely to benefit from immune checkpoint blockade and to guide further investigations of actionable immune targets.