TCR sequencing is superior to clinical score evaluation in assessing clearance of the malignant T-cell clones and resiquimod is associated with maturation of circulating DCs. (A) Although in many patients, clinical scores improved following reduction of the malignant T cell clone, at least 3 patients (1, 5, and 11) still had clinically evident disease despite near-complete eradication of malignant T cells. The percentage malignant clone and clinical CAILS scores for patients 1 and 5 are shown. (B) Likewise, improvement in clinical score did not necessarily reflect depletion of malignant T cells. Results for patients 6 are shown, in whom the percentage and absolute number of malignant T cells increased despite a clinically improving examination. (C) Residual inflammation on clinical examination is more reflective of benign T-cell activation than the presence of malignant T cells. The CAIL clinical scores at 12 weeks, the percentage of benign T and NK cells making the indicated cytokines, and the percentage of malignant clonal T cells are shown together for patients 1, 5, and 6. In patients 1 and 5, activation of benign T cells was evident despite near-complete eradication of the malignant T-cell clone, suggesting benign T cells were producing the inflammation measured by clinical CAILS scores. In patient 6, low cytokine production by benign T cells was associated with an improving clinical score but an increasing burden of malignant T cells. (D) CD80 expression is increased on circulating CD11c⁺ myeloid-derived DCs during periods of topical resiquimod use. PBMCs were isolated from peripheral blood at the indicated time points and expression of CD80 on CD11c⁺ DC was assessed by flow cytometry. Periods when patients were applying resiquimod gel are indicated. Representative results from 2 patients are shown; a similar pattern of DC maturation was observed in 4/8 patients tested. (E) Resiquimod further enhanced DC maturation in vitro. PBMCs isolated from blood at the indicated time points were incubated overnight in 10 µg/mL resiquimod and surface expression of CD80 on CD11c⁺ DCs was assessed by flow cytometry.