Candidate role of ADAMTS2 in regulating keratinocyte apoptosis via indirect NF-κB modulation in life-threatening PD-1 inhibitor-induced TEN-like cutaneous toxicity

Abstract

Abstract Toxic epidermal necrolysis-like (TEN-like) immune-related cutaneous adverse event (ircAE) induced by programmed death 1 (PD-1) inhibitors is life-threatening; however, its pathogenesis remains unclear. This study aimed to dynamically characterize molecular signatures and identify potential pathogenic mediator(s) of TEN-like ircAE. Initial candidate mediators were identified through comparative analysis of bulk RNA sequencing data from distinct blood samples, coupled with a protein-protein interaction network. Subsequently, the potential pathogenic mediator(s), along with their primary cellular sources and corresponding effector events, were determined using quantitative PCR, tissue staining, single-cell RNA sequencing, and flow cytometry. Finally, validation was performed via in vitro cell experiments and in vivo rat models. By multiple comparisons among the sequencing data of progressive phase (Advanced stage), post-treatment recovery phase (Recovered stage), and matched controls (Control group) and following in vitro validation at the nucleic acid and protein levels, ADAMTS2 was identified as a promising candidate for further investigation. Subsequently, we showed that lesional fibroblasts were the primary cellular sources of ADAMTS2. Cultured human keratinocytes (HaCaT) were treated with supernatants from ADAMTS2-overexpressing fibroblasts (HDF-a), and the results showed that secreted ADAMTS2 promoted keratinocyte apoptosis via indirect inhibition of the NF-κB pathway. Furthermore, intradermal injection of an ADAMTS2-expressing plasmid in rats induced epidermal necrolysis-like lesions and keratinocyte apoptosis. Our study suggests that ADAMTS2 may serve as a candidate pathogenic mediator in PD-1 inhibitor-induced TEN-like ircAE. We have laid the groundwork for future studies on the pathogenesis and intervention targets of this life-threatening AE. These findings require validation with larger samples.