Axicabtagene Ciloleucel CAR T-Cell Therapy in Refractory Large B-Cell Lymphoma

Nanomedicines for cardiovascular diseases: Lessons learned and pathways forward

Cardiovascular diseases (CVDs) are vital causes of global mortality. Apart from lifestyle intervention like exercise for high-risk groups or patients at early period, various medical interventions such as percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery have been clinically used to reduce progression and prevalence of CVDs. However, invasive surgery risk and severe complications still contribute to ventricular remodeling, even heart failure. Innovations in nanomedicines have fueled impressive medical advances, representing a CVD therapeutic alternative. Currently, clinical translation of nanomedicines from bench to bedside continues to suffer unpredictable biosafety and orchestrated behavior mechanism, which, if appropriately addressed, might pave the way for their clinical implementation in the future. While state-of-the-art advances in CVDs nanomedicines are widely summarized in this review, the focus lies on urgent preclinical concerns and is transitioned to the ongoing clinical trials including stem cells-based, extracellular vesicles (EV)-based, gene, and Chimeric Antigen Receptor T (CAR T) cell therapy whose clinically applicable potential in CVD therapy will hopefully provide first answers. Overall, this review aims to provide a concise but comprehensive understanding of perspectives and challenges of CVDs nanomedicines, especially from a clinical perspective.

A comprehensive review on targeting diverse immune cells for anticancer therapy: Beyond immune checkpoint inhibitors

Although immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment, primary resistance and acquired resistance continue to limit their efficacy for many patients. To address resistance and enhance the anti-tumor activity within the tumor immune microenvironment (TIME), numerous therapeutic strategies targeting both innate and adaptive immune cells have emerged. These include combination therapies with ICIs, chimeric antigen receptor T-cell (CAR-T), chimeric antigen receptor macrophages (CAR-Ms) or chimeric antigen receptor natural killer cell (CAR-NK) therapy, colony stimulating factor 1 receptor (CSF1R) inhibitors, dendritic cell (DC) vaccines, toll-like receptor (TLR) agonists, cytokine therapies, and chemokine inhibition. These approaches underscore the significant potential of the TIME in cancer treatment. This article provides a comprehensive and up-to-date review of the mechanisms of action of various innate and adaptive immune cells within the TIME, as well as the therapeutic strategies targeting each immune cell type, aiming to deepen the understanding of their therapeutic potential.

Cellular therapies in rheumatic and musculoskeletal diseases

A substantial proportion of patients diagnosed with rheumatologic and musculoskeletal diseases (RMDs) exhibit resistance to conventional therapies or experience recurrent symptoms. These diseases, which include autoimmune disorders such as multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosus, are marked by the presence of autoreactive B cells that play a critical role in their pathogenesis. The persistence of these autoreactive B cells within lymphatic organs and inflamed tissues impairs the effectiveness of B-cell-depleting monoclonal antibodies like rituximab. A promising therapeutic approach involves using T cells genetically engineered to express chimeric antigen receptors (CARs) that target specific antigens. This strategy has demonstrated efficacy in treating B-cell malignancies by achieving long-term depletion of malignant and normal B cells. Preliminary data from patients with RMDs, particularly those with lupus erythematosus and dermatomyositis, suggest that CAR T-cells targeting CD19 can induce rapid and sustained depletion of circulating B cells, leading to complete clinical and serological responses in cases that were previously unresponsive to conventional therapies. This review will provide an overview of the current state of preclinical and clinical studies on the use of CAR T-cells and other cellular therapies for RMDs. Additionally, it will explore potential future applications of these innovative treatment modalities for managing patients with refractory and recurrent manifestations of these diseases.

Protection of CD33-modified hematopoietic stem cell progeny from CD33-directed CAR T cells in rhesus macaques

ABSTRACT

The treatment of monogenetic disorders, such as hemoglobinopathies and lysosomal storage diseases, has markedly improved with the advent of cell and gene therapies, particularly allogeneic or gene-modified autologous stem cell transplantations. However, therapeutic efficacy is reliant on maintaining engraftment above a critical threshold. To maintain such engraftment levels, we and others have pursued approaches to shield edited cells from antibody or chimeric antigen receptor (CAR) T-cell-mediated selection. Here, we focused on CD33, which is expressed early on hematopoietic stem and progenitor cells (HSPCs) as well as on myeloid progenitors. Rhesus macaques were engrafted with HSPCs edited to ablate CD33 using either CRISPR/CRISPR-associated protein 9 or adenine base editor. Both editing strategies showed similar post-transplant recovery kinetics and yielded equivalent levels of engraftment. We then created a V-set domain-specific CAR construct (CAR33), validated its functionality in vitro, and treated both animals with autologous CAR33 T cells. CAR33 T cells expanded after infusion and caused specific depletion of CD33WT but not CD33null progeny, leading to a transient enrichment for gene-edited cells in the blood. No depletion was seen in the bone marrow stem cell compartment with CD34+CD90+ HSCs expressing lower levels of CD33 in comparison to monocytes. Thus, we show proof of concept and safety of an epitope editing-based enrichment/protection strategy in macaques.

Outcome of high-grade B-cell lymphoma compared with other large B-cell lymphoma after CAR-T rescue: a DESCAR-T LYSA study

ABSTRACT

High-grade B-cell lymphoma (HGBL) with MYC and BCL2 and/or BCL6 rearrangements (double hit [HGBL-DH] or triple hit [HGBL-TH]) or not otherwise specified (HGBL-NOS) are considered to be more aggressive diseases among large B-cell lymphomas (LBCLs). CD19-targeting chimeric antigen receptor (CAR) T cells have changed the prognosis of chemoresistant LBCL. Clinical and pathological data of patients treated for relapsed/refractory LBCL or HGBL in third line or more, all characterized by fluorescence in situ hybridization, were collected from the French DESCAR-T registry. Between January 2018 and November 2022, a total of 228 patients were included across 14 centers, 73 with HGBL (28 HGBL-DH MYC-BCL2, 14 HGBL-TH, 8 HGBL-DH MYC-BCL6, and 23 HGBL-NOS) and 155 with non-HGBL. The median follow-up was 18.5 months (95% confidence interval [CI], 14.3-23.4) from the date of infusion. Progression-free survival and overall survival (OS) were not significantly different between HGBL and non-HGBL, at 3.2 months (95% CI, 2.8-6.0) vs 4.5 months (95% CI, 3.1-8.7; P = .103) and 15.4 months (95% CI, 5.6-32.4) vs 18.3 months (95% CI, 8.5 to not reached), respectively. From the date of eligibility, the median OS was inferior for patients with HGBL-TH/DH MYC-BCL2 at 6.6 months vs 18.5 months for HGBL-NOS vs 13.6 months for HGBL-DH MYC-BCL6 vs 11.8 months for LBCL (P = .037). However, patients who received infusion presented the same outcome. CAR T-cell therapy used in third line or more seems to overcome the poor prognosis of HGBL subtypes, especially in HGBL-TH/DH MYC-BCL2. This observation supports considering the potential benefit of using CAR T cells earlier in disease course.

A novel NFKB1 agonist remodels tumor microenvironment and activates dendritic cells to promote anti-tumor immunity in colorectal cancer

BACKGROUND

The immunosuppressive nature of the tumor microenvironment (TME) and the existence of cancer stem cells (CSCs) present significant hurdles in tumor therapy. The identification of therapeutic agents that can target both CSCs and the TME could be a potential approach to overcome treatment resistance.

METHODS

We conducted an in vivo chemical screen to identify F1929-1458, which is capable of eliciting an organism-wide response to destroy stem cell tumors in Drosophila. We then performed functional validation using a mouse colorectal cancer graft tumor model established with the CT26 cell line characterized by its high content of CSCs. Single-cell sequencing was employed to analyze alterations in the TME. Small molecule pull-down mass spectrometry, cellular thermal shift assay, drug affinity experiment, and molecular docking were utilized to identify the target of F1929-1458. An in vitro co-culture system was applied to establish that the damage-associated molecular patterns (DAMPs) released by the tumor cells are accountable for the activation of dendritic cells (DCs).

RESULTS

We demonstrated that F1929-1458 treatment enhanced T cell infiltration and T cell mediated tumor regression, its anti-tumor effect was nullified in nude mice and was abolished after anti-CD3 neutralizing antibody treatment. We found that F1929-1458 binds NFKB1 to activate the NF-κB signaling pathway in tumor cells. The activation further elicits cellular stress, causing tumor cells to release DAMPs (HMGB1-gDNA complex, ATP, and OxLDL). These DAMPs, in turn, stimulate the cGAS-STING and NLRP3 inflammasome pathways in DCs, resulting in the generation of type I IFNs and IL-1β. These cytokines facilitate the maturation of DCs and antigen presentation, ultimately enhancing T cell-mediated anti-tumor immunity. Additionally, we showed that the combination of F1929-1458 and the anti-PD-1 antibody exhibited a synergistic anti-tumor effect.

CONCLUSION

Our study identified a novel NFKB1 agonist that promotes anti-tumor immunity by remodeling the TME and activating DCs and that may provide a new way to overcome resistance to current anti-tumor immunotherapy in colorectal cancer.

A current view of the pathogenesis and treatment of primary cutaneous diffuse large B cell lymphoma - leg type

Primary cutaneous diffuse large B cell lymphoma, leg type (PCDLBCL-LT) is an aggressive B cell extranodal variant of lymphoma present in the skin, typically without evidence of extra cutaneous spread at the time of diagnosis. PCDLBCL-LT accounts for 20% of all primary cutaneous B cell lymphomas (CBCL) and 5% of all primary cutaneous lymphomas (PCL). It is more common in the elderly (median age 75 years). The disease commonly manifests as rapidly-growing red to bluish often ulcerating, nodular tumors, plaques or violaceous nodules on one or both lower extremities. Only 10% to 15% of lesions develop in other areas. A prognosis of PCDLBCL-LT is poor, with a 5-year survival rate of 40 to 50%. The first-line treatment of PCDLBCL-LT includes immunochemotherapy, most commonly R-CHOP (rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, prednisone). In the case of a solitary lesion, excision or radiotherapy should be considered. Many patients demonstrate cutaneous relapses (70%) or systemic dissemination (50%). Recent studies have reported the use of Bruton's tyrosine-kinase (BTK) inhibitors, BCL2 inhibitors, immunomodulatory drugs and immune check-point inhibitors in treating relapsed or refractory patients. The study summarizes the current view of the pathogenesis, diagnosis and treatment of PCDLBCL-LT, including genetic abnormalities and novel targeted drugs.

A collagenase nanogel backpack improves CAR-T cell therapy outcomes in pancreatic cancer

Chimeric antigen receptor (CAR) T cell therapy has revolutionized the treatment of haematological malignancies. Challenges in overcoming physical barriers however greatly limit CAR-T cell efficacy in solid tumours. Here we show that an approach based on collagenase nanogel generally improves the outcome of T cell-based therapies, and specifically of CAR-T cell therapy. The nanogels are created by cross-linking collagenase and subsequently modifying them with a CXCR4 antagonist peptide. These nanogels can bind CAR-T cells via receptor-ligand interaction, resulting in cellular backpack delivery systems. The nanogel backpacks modulate tumoural infiltration and localization of CAR-T cells by surmounting physical barriers and disrupting chemokine-mediated CAR-T cell imprisonment, thereby addressing their navigation deficiency within solid tumours. Our approach offers a promising strategy for pancreatic cancer therapy and holds potential for advancing CAR-T cell therapy towards clinical applications.

Next-generation immunotherapeutic approaches for blood cancers: Exploring the efficacy of CAR-T and cancer vaccines

Recent advancements in immunotherapy, particularly Chimeric antigen receptor (CAR)-T cell therapy and cancer vaccines, have significantly transformed the treatment landscape for leukemia. CAR-T cell therapy, initially promising in hematologic cancers, faces notable obstacles in solid tumors due to the complex and immunosuppressive tumor microenvironment. Challenges include the heterogeneous immune profiles of tumors, variability in antigen expression, difficulties in therapeutic delivery, T cell exhaustion, and reduced cytotoxic activity at the tumor site. Additionally, the physical barriers within tumors and the immunological camouflage used by cancer cells further complicate treatment efficacy. To overcome these hurdles, ongoing research explores the synergistic potential of combining CAR-T cell therapy with cancer vaccines and other therapeutic strategies such as checkpoint inhibitors and cytokine therapy. This review describes the various immunotherapeutic approaches targeting leukemia, emphasizing the roles and interplay of cancer vaccines and CAR-T cell therapy. In addition, by discussing how these therapies individually and collectively contribute to tumor regression, this article aims to highlight innovative treatment paradigms that could enhance clinical outcomes for leukemia patients. This integrative approach promises to pave the way for more effective and durable treatment strategies in the oncology field. These combined immunotherapeutic strategies hold great promise for achieving more complete and lasting remissions in leukemia patients. Future research should prioritize optimizing treatment sequencing, personalizing therapeutic combinations based on individual patient and tumor characteristics, and developing novel strategies to enhance T cell persistence and function within the tumor microenvironment. Ultimately, these efforts will advance the development of more effective and less toxic immunotherapeutic interventions, offering new hope for patients battling this challenging disease.

Hypogammaglobulinemia in Children Receiving Targeted Immunotherapies for B Lineage Malignancies: Practical Guidance for Assessment and Management

Hypogammaglobulinemia is a well-defined risk factor for infection. B-cell-directed immunotherapies given in addition to conventional chemotherapy are now core elements of effective therapy for children with B lymphoid malignancies. These therapies are associated with depletion of normal B cells and consequent hypogammaglobulinemia. This review summarizes the current state of knowledge regarding the mechanism, incidence, and clinical outcomes related to hypogammaglobulinemia in children with mature B-cell non-Hodgkin lymphoma and B-cell acute lymphoblastic leukemia, as well as provides practical guidance for laboratory monitoring and considerations for immunoglobulin replacement therapy.

T-Cell Senescence: Unlocking the Tumor Immune "Dark Box" - A Multidimensional Analysis from Mechanism to Tumor Immunotherapeutic Intervention

Immunosenescence is the dysfunction of the immune system that occurs with age, a process that is complex and characterized by several features, of which T-cell senescence is one of the key manifestations. In the tumor microenvironment, senescent T cells lead to the inability of tumor cells to be effectively eliminated, triggering immunosuppression, which in turn affects the efficacy of immunotherapy. This is a strong indication that T-cell senescence significantly weakens the immune function of the body, making individuals, especially elderly patients with cancer, more vulnerable to cancer attacks. Despite the many challenges, T-cell senescence is important as a potential therapeutic target. This review provides insights into the molecular mechanisms of T-cell senescence and its research advances in patients with cancer, especially in older adults, and systematically analyzes potential intervention strategies, including molecular mechanism-based interventions, the use of immune checkpoint inhibitors, and CAR-T cell therapy. It is hoped that this will establish a theoretical framework for T-cell senescence in the field of tumor immunology and provide a scientific and prospective reference basis for subsequent in-depth research and clinical practice on senescent T cells.

Complex neural-immune interactions shape glioma immunotherapy

Rich neural-immune interactions in the central nervous system (CNS) shape its function and create a unique immunological microenvironment for immunotherapy in CNS malignancies. Far from the now-debunked concept of CNS "immune privilege," it is now understood that unique immunological niches and constant immune surveillance of the brain contribute in multifaceted ways to brain health and robustly influence immunotherapy approaches for CNS cancers. Challenges include immune-suppressive and neurotoxicity-promoting crosstalk between brain, immune, and tumor cells. Developing effective immunotherapies for cancers of the nervous system will require a deeper understanding of these neural-immune-malignant cell interactions. Here, we review progress and challenges in immunotherapy for gliomas of the brain and spinal cord in light of these unique neural-immune interactions and highlight future work needed to optimize promising immunotherapies for gliomas.

An Implantable Double-Layered Spherical Scaffold Depositing Gene and Cell Agents to Facilitate Collaborative Cancer Immunotherapy

Gene therapies and adoptive cell therapy (ACT) are promising strategies for cancer immunotherapy. Referring to their different mechanisms, the combination of these two might result in a strategy with potential collaborative and compensatory effects. However, it is challenging to combine gene therapies and ACT that work in a proper logical order. Here, we developed a double-layered spherical scaffold (DLS) to codeliver mRNA and T cells and constructed an implantable hydrogel formulation, named the GD-920 scaffold. With a diameter of 7 mm, this scaffold loaded primary T cells in the inner layer and the Bim mRNA nanocomplex in the outer layer. While maintaining their bioactivities, GD-920 released gene and cell payloads in a controllable and sequential manner. The mRNA complex from the outer layer was first released and induced immunogenic tumor cell death. The produced antigens then migrated into the scaffold with dendritic cells, triggering a tumor-specific immune response. Finally, activated T cells released by the inner layer attacked the tumor tissue via massive infiltration. We showed that in situ implantation of the GD-920 scaffold is capable of effectively inhibiting tumor growth and is far more potent than that of control scaffolds containing a single payload. Our results demonstrated the outstanding potential of this DLS in combining gene and cell therapeutic approaches to cancer immunotherapy.

Progress, Applications and Prospects of CRISPR-Based Genome Editing Technology in Gene Therapy for Cancer and Sickle Cell Disease

The advent of genome-editing technologies, particularly the RNA-guided the clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated system (Cas) 9, which originates from prokaryotic CRISPR/Cas adaptive immune mechanisms, has revolutionized molecular biology. Renowned for its simplicity, cost-effectiveness, and capacity for multiplexed gene editing, CRISPR/Cas9 has emerged as the most versatile and widely adopted genome-editing platform. Its applications span fundamental research, biotechnology, medicine, and therapeutics. This review highlights recent advancements in CRISPR-based technologies, focusing on CRISPR/Cas9, CRISPR/Cas12a, and CRISPR/Cas12f. It emphasizes precision editing methods like base editing and prime editing, which enable targeted nucleotide changes without double-strand breaks. The specificity of these tools, including on-target accuracy and off-target risks, is critically evaluated. Additionally, recent preclinical and clinical efforts to treat diseases such as cancer and sickle cell disease using CRISPR are summarized. Finally, the challenges and future directions of CRISPR-mediated gene therapy are discussed, emphasizing its potential to integrate with other molecular approaches to address unmet medical needs.

Allogeneic Chimeric Antigen Receptor T-Cell Products Cemacabtagene Ansegedleucel/ALLO-501 in Relapsed/Refractory Large B-Cell Lymphoma: Phase I Experience From the ALPHA2/ALPHA Clinical Studies

PURPOSE

Off-the-shelf, allogeneic CD19 chimeric antigen receptor (CAR) T-cell products may improve access to treatment versus autologous ones. We report the phase I experience of the allogeneic CD19 CAR T-cell product cemacabtagene ansegedleucel (cema-cel) and its predecessor, ALLO-501, in CD19 CAR T-naïve patients with relapsed/refractory large B-cell lymphoma (R/R LBCL).

METHODS

In the ALPHA2/ALPHA studies, the safety and efficacy of allogeneic CD19 CAR T cells were evaluated in CD19 CAR T treatment-naïve patients with R/R LBCL. Patients received healthy donor-derived, human leukocyte antigen-unmatched cema-cel/ALLO-501 following a 3-day lymphodepletion regimen of fludarabine (30 mg/m2 once daily), cyclophosphamide (300 or 500 mg/m2 once daily), and escalating doses of the anti-CD52 monoclonal antibody, ALLO-647.

RESULTS

As of September 26, 2024, 33 CD19 CAR T-naïve patients with LBCL (median age, 66 years; median number of previous therapies, 3) received allogeneic CAR T cells. CAR T-cell expansion was observed following infusion, with persistence observed up to 4 months. The overall and complete response (CR) rates were 58% and 42%, respectively; the median duration of response in patients with a CR was 23.1 months. The most common treatment-emergent adverse events were hematologic toxicities. No cases of graft-versus-host disease, immune effector cell-associated neurotoxicity syndrome, or grade ≥3 cytokine release syndrome were reported.

CONCLUSION

Allogeneic CD19 CAR T cells demonstrated promising overall and durable CR rates with a manageable safety profile in CD19 CAR T-naïve patients with R/R LBCL, supporting additional evaluation of cema-cel in patients with LBCL.

Prognostic Factors and Effect Modifiers in Patients With Relapse or Refractory Diffuse Large B-Cell Lymphoma After Two Lines of Therapy: A Systematic Literature and Expert Clinical Review

OBJECTIVES

The objective of this systematic literature review (SLR) combined with expert clinical review was to identify and rank prognostic factors and effect measure modifiers (EMMs) systematically and comprehensively in patients with relapsed or refractory (R/R) diffuse large B-cell lymphoma (DLBCL) who initiate treatment after ≥ 2 prior lines of therapy (LoTs; 3L+ R/R DLBCL).

METHODS

We performed an SLR of studies published between 2016 and 2021 and extracted study characteristics, prognostic factors, and EMMs. This was followed by clinical review and ranking of findings by subject matter experts using questionnaires, follow-up interviews, and quantitative ranking.

RESULTS

Across 46 included studies, the SLR identified 36 prognostic factors significantly associated with ≥ 1 clinical outcome. Based on subject matter expert ranking of the SLR-derived list, the five most important prognostic variables in descending order are: early chemo-immunotherapy failure, Eastern Cooperative Oncology Group performance status, refractory to last LoT, number of prior LoTs, and double- or triple-hit lymphoma.

CONCLUSIONS

This SLR and expert clinical review is the first to provide a comprehensive assessment of prognostic factors for 3L+ R/R DLBCL. No statistically significant EMMs were identified. This robust multi-method approach can assist in selecting prognostic variables for comparative analyses between real-world studies and clinical trials.

Enhanced CAR T-Cell Therapy for Lymphoma after Previous Failure

BACKGROUND

Chimeric antigen receptor (CAR) T cells targeting CD19 have transformed the treatment of B-cell cancers, but many patients do not have long-term remission. We designed an anti-CD19 enhanced (armored) CAR T-cell product (huCART19-IL18) that secretes interleukin-18 to enhance antitumor activity.

METHODS

In this study, we assessed the safety, feasibility, and preliminary efficacy of huCART19-IL18 in patients with relapsed or refractory lymphoma after previous anti-CD19 CAR T-cell therapy. Using a 3-day manufacturing process, we administered huCART19-IL18-positive cells in doses ranging from 3×106 to 3×108.

RESULTS

A total of 21 patients received huCART19-IL18. Cytokine release syndrome occurred in 62% of the patients (47% with grade 1 or 2), and immune effector-cell-associated neurotoxicity syndrome occurred in 14% (all grade 1 or 2). No unexpected adverse events were observed. Robust CAR T-cell expansion was detected across all dose levels. At 3 months after infusion, a complete or partial response was seen in 81% of the patients (90% confidence interval [CI], 62 to 93) and a complete response in 52% (90% CI, 33 to 71). With a median follow-up of 17.5 months (range, 3 to 34), the median duration of response was 9.6 months (90% CI, 5.5 to not reached).

CONCLUSIONS

In this small study, huCART19-IL18 had a safety profile consistent with other CAR T-cell treatments and showed promising efficacy at low cell doses in patients with lymphoma after the failure of previous anti-CD19 CAR T-cell therapy. (ClinicalTrials.gov number, NCT04684563.).

Targeting inflammation with chimeric antigen receptor macrophages using a signal switch

Chimeric antigen receptor (CAR) T-cell immunotherapy has shown great success in clinical cancer, bringing hope to apply CAR strategies to other clinical settings. Here we developed a CAR macrophage (CAR-M) that recognizes the major inflammatory molecule tumour necrosis factor (TNF) and activates an intracellular IL-4 signalling pathway, thereby programming engineered macrophages for an anti-inflammatory function. CAR-M therapy has exhibited efficacy in mouse models of both acute and chronic inflammatory diseases. In kidney ischaemia reperfusion injury (IRI), infused CAR-Ms switched to an anti-inflammatory phenotype in inflamed kidney and attenuated kidney IRI. The anti-inflammatory phenotype of infused CAR-Ms switched off during the recovery phase of kidney IRI, coinciding with the disappearance of TNF. In Adriamycin-induced nephropathy, a model of chronic inflammatory disease, infused CAR-Ms maintained an anti-inflammatory phenotype for several weeks in response to sustained high levels of TNF and improved kidney function and structure. CAR-Ms also effectively reduced tissue injury in another organ, the liver. Human anti-TNF CAR-Ms exhibit anti-inflammatory phenotype and function in response to TNF. The CAR-M design, using signal switching, holds promise for the treatment of a broad range of acute and chronic inflammatory diseases.

From concept to cure: The evolution of CAR-T cell therapy

Chimeric antigen receptor (CAR)-T cell therapy has revolutionized cancer immunotherapy in the 21st century, providing innovative solutions and life-saving therapies for previously untreatable diseases. This approach has shown remarkable success in treating various hematological malignancies and is now expanding into clinical trials for solid tumors, such as prostate cancer and glioblastoma, as well as infectious and autoimmune diseases. CAR-T cell therapy involves harvesting a patient's T cells, genetically engineering them with viral vectors to express CARs targeting specific antigens and reinfusing the modified cells into the patient. These CAR-T cells function independently of major histocompatibility complex (MHC) antigen presentation, selectively identifying and eliminating target cells. This review highlights the key milestones in CAR-T cell evolution, from its invention to its clinical applications. It outlines the historical timeline leading to the invention of CAR-T cells, discusses the major achievements that have transformed them into a breakthrough therapy, and addresses remaining challenges, including high manufacturing costs, limited accessibility, and toxicity issues such as cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome. Additionally, the review explores future directions and advances in the field, such as developing next-generation CAR-T cells aiming to maximize efficacy, minimize toxicity, and broaden therapeutic applications.

High-dimensional temporal mapping of CAR T cells reveals phenotypic and functional remodeling during manufacturing

Despite the notable success of chimeric antigen receptor (CAR) T cell therapies in hematological malignancies, clinical outcomes remain variable, making it critical to understand how manufacturing influences product composition and function. We developed a 36-marker spectral flow cytometry panel enabling integrated profiling of phenotypic, metabolic, and functional attributes across CAR T cell production. Mid-expansion products (day 5) retained stem-like, metabolically active CD4+ Th1 subsets with high proliferative capacity, whereas prolonged culture (day 10) enriched terminally differentiated CD8+ Tc1 cells and NK-like T cell populations. CAR+ and CAR- T cells showed similar differentiation trajectories, suggesting that culture conditions may have a larger impact on phenotypic remodeling than CAR integration. Upon antigen encounter and restimulation, day 5 and day 10 products showed comparable cytotoxicity, while differing in their activation and checkpoint profiles. Cryopreservation modestly affected stem cell memory, activation, and metabolic markers but preserved overall phenotype and cytotoxic function. These findings establish a high-dimensional framework for mapping CAR T cell dynamics to support manufacturing optimization and next-generation cell therapy design.

Two-stage CD8+ CAR T-cell differentiation in patients with large B-cell lymphoma

Advancements in chimeric antigen receptor (CAR) T-cell therapy for treating diffuse large B-cell lymphoma (DLBCL) have been limited by an incomplete understanding of CAR T-cell differentiation in patients. Here, we show via single-cell, multi-modal, and longitudinal analyses, that CD8+ CAR T cells from DLBCL patients successfully treated with axicabtagene ciloleucel undergo two distinct waves of clonal expansion in vivo. The first wave is dominated by an exhausted-like effector memory phenotype during peak expansion (day 8-14). The second wave is dominated by a terminal effector phenotype during the post-peak persistence period (day 21-28). Importantly, the two waves have distinct ontogeny from the infusion product and are biologically uncoupled. Precursors of the first wave exhibit more effector-like signatures, whereas precursors of the second wave exhibit more stem-like signatures. We demonstrate that CAR T-cell expansion and persistence are mediated by clonally, phenotypically, and ontogenically distinct CAR T-cell populations that serve complementary clinical purposes.

Variance in development of early and late cardiotoxicities in patients with lymphoma and myeloma receiving CAR T-cell therapies

Cardiovascular adverse events (CVAEs) are recognized complications of chimeric antigen receptor (CAR) T-cell therapies. However, data are lacking regarding subtypes of adverse events that develop in patients with different malignancies, and little is known about the timeframe in which different cardiotoxicities are most likely to occur post-CAR T-cell therapies. In this study, 211 patients, including 138 lymphoma patients and 66 myeloma patients who received CAR T-cell therapies were retrospectively identified. Of these, 42 patients (19.9%) developed CVAEs post-treatment. Myeloma patients predominantly experienced heart failure while lymphoma patients predominantly experienced arrhythmia. Severe CVAEs were observed even at >12 months post-treatment. Lower baseline global longitudinal strain was significantly associated with development of post-CAR T-cell therapy CVAEs in both lymphoma and myeloma patients. These findings highlight the spectra of post-CAR T-cell cardiotoxicities in lymphoma and myeloma patients and the importance of echocardiography for pretreatment risk stratification and long-term surveillance.

Impacts of ageing on the efficacy of CAR-T cell therapy

Chimeric antigen receptor T cells recognizing CD19 (19CAR-T) cell therapy has achieved robust clinical efficacy when treating some hematological malignancies, but which patient subgroups benefit mostly remains elusive. Here we summarized the data of 541 patients from 30 clinical trials who underwent 19 CAR-T therapy and analyzed the different clinical responses between young (<44 years), middle-aged (45-59 years) and elderly (>60 years) patients and found that the young patients showed a higher level of complete response (CR) rate. Therefore, we then summarize the advances of studies focusing on the effects of age on anti-tumor efficacy of CAR-T therapy and analyze the reasons for the low CR rate after CAR-T cell therapy in elderly patients with tumors, aiming to provide hints for oncologists to select the most suitable candidate for this cancer immunotherapy.

Feasibility of Intratumoral Administration With EPHB4-CAR-T Cells for the Treatment of Oral Squamous Cell Carcinoma

Oral squamous cell carcinoma (OSCC) represents the most common type of oral cancer, and its prognosis remains poor. In this study, we found that almost OSCC cases showed high Ephrin type-B receptor 4 (EPHB4) expression that was mainly localized on the membrane of tumor cells. Therefore, EPHB4 represents a potential target of chimeric antigen receptor (CAR) T cell therapy for OSCC treatment. Because the oral cavity can be directly accessed, local administration of CAR-T cells is feasible for treating OSCC. In this study, we investigated the efficacy of intratumoral injection of EPHB4-specific CAR-T cells in OSCC using xenograft models. To evaluate the anti-tumor effect, the SAS OSCC cell line or an OSCC patient-derived xenograft (PDX) tumor was subcutaneously implanted into NOD SCID gamma mice, and EPHB4-CAR-T cells were intratumorally injected twice. As expected, administration of CAR-T cells suppressed tumor growth of both SAS cells and PDX tumor. EPHB4 expression in tumor tissues was attenuated by CAR-T cell treatment, which was accompanied by a reduction in tumor area and accumulation of CAR-T cells. Our findings suggest that intratumoral injection of EPHB4-CAR-T cells represents a potential therapeutic strategy for OSCC.

CAR T-cell therapy landscape in pediatric, adolescent and young adult oncology - A comprehensive analysis of clinical trials

Chimeric Antigen Receptor (CAR) T-cell therapy has emerged as a transformative approach in cancer treatment, particularly for hematologic malignancies. This therapy involves the genetic modification of patients' T-cells to target specific tumor antigens, bypassing the traditional MHC-TCR-mediated recognition. This innovation marks a significant step toward personalized medicine and precision oncology. In the pediatric, adolescent, and young adult (P-AYA) populations, Tisagenlecleucel (Kymriah®) exemplifies the success of CAR T-cell therapy, demonstrating significant efficacy in treating relapsed or refractory acute lymphoblastic leukemia (r/r ALL). However, the development of CAR T-cell therapies for P-AYA patients has not progressed as rapidly as for adults, with only one FDA approval for pediatric applications compared to six for adults up to 2024. Several challenges hinder the development of pediatric CAR T-cell therapies, including complex production logistics, limited clinical site access, restrictive patient eligibility criteria, and financial constraints, necessitating more effective incentives for pediatric oncology drug development independent of adult indications. To assess the current landscape of CAR T-cell therapy in P-AYA oncology, we conducted a comprehensive review of clinical trials registered on ClinicalTrials.gov up to May 2024. Our analysis included 77 trials exclusively targeting the P-AYA population from an initial pool of 40,690 studies filtered by age, dates, and specific criteria related to CAR T-cell interventions in cancer therapy. We found that 45 % of these trials originated from the USA and 30 % from China. The data retrieved from these trials provided insights into various aspects, including histological categories, antigenic targets, CAR-T generations, costimulatory domains, manufacturing processes, geographical distribution, and funding sources. This review highlighted a predominant focus on hematologic malignancies, particularly B-cell acute lymphoblastic leukemia (B-ALL), with significant attention to dual antigen targeting (CD19 and CD22) to address resistance mechanisms. Emerging targets such as GD2 for solid tumors and B7-H3 for various cancers also showed promise. Additionally, most trials still utilize second-generation CAR-T constructs with 4-1BB costimulatory domains, reflecting a conservative approach in pediatric populations. Our findings underscore the disparity in CAR T-cell therapy development between pediatric and adult populations, driven by distinct biological, ethical, and economic considerations. Pediatric cancers require specialized treatments tailored to the unique biology and genetic makeup of pediatric oncology. However, research and drug development have historically focused less on pediatric needs. Despite legislative efforts to promote pediatric oncology drug development, significant gaps remain. Clinical trials for P-AYA populations face challenges in patient enrollment, trial design, and funding, often relying on academic and non-profit institutions. Addressing these barriers is critical for advancing CAR T-cell therapy in pediatric oncology, improving outcomes, and ensuring equitable access to innovative treatments for these vulnerable populations. This review aims to inform future research and policy decisions, promoting advancements in CAR T-cell therapy for P-AYA cancer patients.

Engineering TCR-controlled fuzzy logic into CAR T cells enhances therapeutic specificity

Chimeric antigen receptor (CAR) T cell immunotherapy represents a breakthrough in the treatment of hematological malignancies, but poor specificity has limited its applicability to solid tumors. By contrast, natural T cells harboring T cell receptors (TCRs) can discriminate between neoantigen-expressing cancer cells and self-antigen-expressing healthy tissues but have limited potency against tumors. We used a high-throughput platform to systematically evaluate the impact of co-expressing a TCR and CAR on the same CAR T cell. While strong TCR-antigen interactions enhanced CAR activation, weak TCR-antigen interactions actively antagonized their activation. Mathematical modeling captured this TCR-CAR crosstalk in CAR T cells, allowing us to engineer dual TCR/CAR T cells targeting neoantigens (HHATL8F/p53R175H) and human epithelial growth factor receptor 2 (HER2) ligands, respectively. These T cells exhibited superior anti-cancer activity and minimal toxicity against healthy tissue compared with conventional CAR T cells in a humanized solid tumor mouse model. Harnessing pre-existing inhibitory crosstalk between receptors, therefore, paves the way for the design of more precise cancer immunotherapies.

Impact of Real-World Clinical Factors on an Analysis of the Cost-Effectiveness of "Immediate CAR-T" Versus "Late CAR-T" as Second-Line Treatment for DLBCL Patients

While chimeric antigen receptor (CAR-T) targeting CD19 as second-line therapy for diffuse large B cell lymphoma (DLBCL) is a promising strategy, the high costs and limited access to CAR-T pose significant challenges. When assessing the cost-effectiveness of CAR-T, we need to consider not only individual outcomes but also how to effectively integrate CAR-T into the overall treatment approach for relapsed DLBCL. We conducted a cost-effective analysis for patients with DLBCL in early relapse or primary refractory, to compare "immediate CAR-T," which proceeds directly to CAR-T, and "late CAR-T," which initially aims at ASCT and quickly switches to third-line CAR-T if non-responsive. The primary analysis used a patient age of 60 years, and it also examined variations from 40 to 70 years. The analysis was performed for both Japanese and US settings using a Markov model incorporating life expectancy in both countries, with extensive sensitivity analysis including factors such as age, the choice of CAR-T (lisocabtagene maraleucel or axicabtagene ciloleucel), and the opportunity to receive third-line CAR-T, to reflect real-world situations. The length of a Markov cycle was defined to be 1 month, and patients in the model were assumed to age 1 year every 12 Markov cycles. The analysis was made over a lifetime horizon, and the outcome was measured based on incremental cost-effectiveness ratio (ICER), with willingness-to-pay (WTP) thresholds of ¥7,500,000 and $150,000 per quality-adjusted life years (QALY) in Japan and the US, respectively, with an annual discount rate of 3%. Compared with "late CAR-T," the "immediate CAR-T" strategy gained QALYs of 0.97 and 0.89 with an incremental cost of ¥5,998,354 and $88,440 in Japan and the US, respectively. The ICERs were ¥6,170,058/QALY in Japan and $99,596/QALY in the US. In the probabilistic sensitivity analysis for patients aged 60, "immediate CAR-T" was cost-effective in 54.8% and 61.7% of the 10,000 Monte Carlo iterations in Japan and the US, respectively. Sensitivity analyses showed that "immediate CAR-T" was not cost-effective when patients were over 68.4 in Japan, when the standardized mortality ratio of CAR-T and ASCT survivors was close, and when utility during treatment-free remission was low. Incorporating various clinical factors, the analysis showed that "immediate CAR-T" is more cost-effective than "late CAR-T." However, this conclusion should be interpreted with caution, as the ICERs were very close to the WTP thresholds, and the results were highly sensitive to parameter changes.

Clinical development of immuno-oncology therapeutics

Immuno-oncology (IO) is one of the fastest growing therapeutic areas within oncology. IO agents work indirectly via the host's adaptive and innate immune system to recognize and eradicate tumor cells. Despite checkpoint inhibitors being only introduced to the market since 2011, they have become the second most approved product category. Current Food and Drug Administration (FDA)-approved classes of IO agents include: immune checkpoint inhibitors (ICIs), chimeric antigen receptor T-cell therapy (CAR-T), bi-specific T-cell engager (BiTE) antibody therapy, T-cell receptor (TCR) engineered T cell therapy, tumor-infiltrating lymphocyte (TIL) therapy, cytokine therapy, cancer vaccine therapy, and oncolytic virus therapy. Cancer immunotherapy has made progress in multiple cancer types including melanoma, non-small cell lung cancer (NSCLC), renal cell carcinoma (RCC), and urothelial carcinoma; however, several cancers remain refractory to immunotherapy. Future directions of IO include exploration in the neoadjuvant/perioperative setting, combination strategies, and optimizing patient selection through improved biomarkers.

Unravelling the modified T cell receptor through Gen-Next CAR T cell therapy in Glioblastoma: Current status and future challenges

PURPOSE

Despite current technological advancements in the treatment of glioma, immediate alleviation of symptoms can be catered by therapeutic modalities, including surgery, chemotherapy, and combinatorial radiotherapy that exploit aberrations of glioma. Additionally, a small number of target antigens, their heterogeneity, and immune evasion are the potential reasons for developing targeted therapies. This oncologic milestone has catalyzed interest in developing immunotherapies against Glioblastoma to improve overall survival and cure patients with high-grade glioma. The next-gen CAR-T Cell therapy is one of the effective immunotherapeutic strategies in which autologous T cells have been modified to express receptors against GBM and it modulates cytotoxicity.

METHODS

In this review article, we examine preclinical and clinical outcomes, and limitations as well as present cutting-edge techniques to improve the function of CAR-T cell therapy and explore the possibility of combination therapy.

FINDINGS

To date, several CAR T-cell therapies are being evaluated in clinical trials for GBM and other brain malignancies and multiple preclinical studies have demonstrated encouraging outcomes.

IMPLICATIONS

CAR-T cell therapy represents a promising therapeutic paradigm in the treatment of solid tumors but a few limitations include, the blood-brain barrier (BBB), antigen escape, tumor microenvironment (TME), tumor heterogeneity, and its plasticity that suppresses immune responses weakens the ability of this therapy. Additional investigation is required that can accurately identify the targets and reflect the similar architecture of glioblastoma, thus optimizing the efficiency of CAR-T cell therapy; allowing for the selection of patients most likely to benefit from immuno-based treatments.

Lymphodepletion chemotherapy in chimeric antigen receptor-engineered T (CAR-T) cell therapy in lymphoma

The development of chimeric antigen receptor (CAR) T-cells, engineered from peripheral T-lymphocytes of a patient with lymphoma, in order to specifically target tumor cells, has been a revolution in adoptive cell therapy (ACT). As outlined in this review, ACT was initiated by hematopoietic cell transplantation (HSCT) and re-injection of interleukin-boosted tumor-infiltrating lymphocytes (TIL). The innovative venture of genetically modifying autologous peripheral T-cells to target them to cell-surface tumoral antigens through an antibody-derived structure (i.e. independent of major histocompatibility antigen presentation, physiologically necessary for T-cell activation), and intracytoplasmic T-cell costimulatory peptides, via a novel membrane CAR, has been an outstanding breakthrough. Here, focusing on B-cell hematological malignancies and mostly non-Hodgkin lymphoma, attention is brought to the importance of providing an optimal microenvironment for such therapeutic cells to proliferate and positively develop anti-tumoral cytotoxicity. This, perhaps paradoxically, implies a pre-infusion step of deep lymphopenia and deregulation of immunosuppressive mechanisms enhanced by tumoral cells. Fludarabine and cyclophosphamide appear to be the most efficient lymphodepletive drugs in this context, dosage being of importance, as will be illustrated by a thorough literature review.

Site-specific analysis of extranodal involvement in large B-cell lymphoma reveals distinct efficacy with chimeric antigen receptor T-cell therapy

Over 60% of relapsed/refractory large B-cell lymphoma (R/R LBCL) patients treated with chimeric antigen receptor (CAR) T-cells experience progressive disease. The impact of site-specific extranodal involvement on CAR-T outcomes has not been fully elucidated. This multicenter study included 516 R/R LBCL patients infused with CD19-targeted CAR T-cells; 177 (34%) had only-nodal (N), 66 (13%) only-extranodal (E) and 273 (53%) nodal and extranodal (NE) disease at time of CAR T-cells. The NE cohort included more patients with a poor performance status and high tumor burden. In the multivariable analysis, the NE group had a shorter progression-free survival (PFS) (HR 1.27 [95%CI 0.98-1.64], p = 0.07) and overall survival (HR 1.41 [95%CI 1.05-1.88], p = 0.02) compared to N. Conversely, we did not identify efficacy differences between N and E patients. A higher number of extranodal sites and specific organ involvement (liver, adrenal glands, pancreas), were associated with shorter PFS. Finally, extranodal involvement increased at time of relapse, displaying heterogeneous individual site clearance rates. In conclusion, patients with concomitant nodal and extranodal involvement at time of CAR-T had worse outcomes, but this cohort harbored high-risk baseline characteristics. An increasing number of extranodal sites and certain disease locations were associated with lower CAR-T efficacy.

Advancing Allogeneic NK Cell Immunotherapy through Microfluidic Gene Delivery

Chimeric antigen receptor (CAR)-T cell therapy has revolutionized cancer treatment, yet challenges such as manufacturing complexity, high costs, and safety concerns have spurred the development of alternatives like CAR-natural killer (NK) cell immunotherapies. CAR-NK cell therapies provide innate cytotoxicity with antigen-independent targeting, reducing safety risks while improving therapeutic efficacy. However, efficient genomic engineering and large-scale production of allogeneic NK cells remain significant obstacles. To address these challenges, a novel microfluidic gene delivery platform is developed, the Y-hydroporator, designed for allogeneic NK cell immunotherapy. This platform features a Y-shaped microchannel where NK cells experience rapid hydrodynamic stretching near the stagnation point, creating transient membrane discontinuities that facilitate the uptake of exogenous cargo. The Y-hydroporator achieves high delivery and transfection efficiency, processing ≈2 × 106 cells min-1 while maintaining long-term cell viability (>89%) and functionality. Using this platform, human primary CAR-NK cells and NKG2A-knockout NK cells are successfully generated by delivering anti-CD19 CAR mRNA and CRISPR/Cas9 ribonucleoproteins, respectively. These engineered NK cells demonstrated enhanced cytotoxicity, underscoring the potential of the Y-hydroporator as a transformative tool for advancing allogeneic NK cell-based immunotherapies.

Novel strategies to manage CAR-T cell toxicity

The immune-related adverse events associated with chimeric antigen receptor (CAR)-T cell therapy result in substantial morbidity as well as considerable cost to the health-care system, and can limit the use of these treatments. Current therapeutic strategies to manage immune-related adverse events include interleukin-6 receptor (IL-6R) blockade and corticosteroids. However, because these interventions do not always address the side effects, nor prevent progression to higher grades of adverse events, new approaches are needed. A deeper understanding of the cell types involved, and their associated signalling pathways, cellular metabolism and differentiation states, should provide the basis for alternative strategies. To preserve treatment efficacy, cytokine-mediated toxicity needs to be uncoupled from CAR-T cell function, expansion, long-term persistence and memory formation. This may be achieved by targeting CAR or independent cytokine signalling axes transiently, and through novel T cell engineering strategies, such as low-affinity CAR-T cells, reversible on-off switches and versatile adaptor systems. We summarize the current management of cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome, and review T cell- and myeloid cell-intrinsic druggable targets and cellular engineering strategies to develop safer CAR-T cells.

Safety and clinical efficacy of Relmacabtagene autoleucel (relma-cel) for systemic lupus erythematosus: a phase 1 open-label clinical trial

Background

Systemic lupus erythematosus (SLE) is a classic systemic autoimmune disease mediated by autoantibodies. Chimeric antigen receptor T (CAR-T) cell therapy, known for its success in cancer, has shown promise in achieving durable B cell depletion and long-term remission in SLE. Relmacabtagene autoleucel (relma-cel) is the second anti-CD19 CAR-T product approved for marketing by the National Medical Products Administration (NMPA) in China and demonstrates its long-term efficacy in relapsed/refractory (r/r) large B cell lymphoma (LBCL). We report the results from a phase I open-label clinical trial of relma-cel in treating patients with moderately to severely active SLE.

Methods

Eligible patients were aged 18-70 years, a ≥6-month history of SLE, and the disease had to remain active after at least 2 months of stable SLE standard treatment prior to screening. We evaluated four dose levels (DL) of relma-cel in a dose-escalation scheme: total dose of 25 × 106, 50 × 106, 75 × 106, and 100 × 106 anti-CD19 CAR-T cells. All patients received lymphodepletion chemotherapy with fludarabine and cyclophosphamide. The primary endpoints were the incidence of dose-limiting toxicities (DLTs) and adverse events (AEs). Secondary endpoints included the evaluation of standard cellular pharmacokinetic parameters, the SLE Responder Index (SRI) response rate, and changes from baseline in the Safety of Estrogens in Lupus Erythematosus National Assessment-Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI), British Isles Lupus Assessment Group 2004 (BILAG-2004) and Physician's Global Assessment (PGA) scores post-treatment. This trial is registered with ClinicalTrials.gov, NCT05765006.

Findings

Between March 28, 2023 and April 8, 2024, a total of 12 patients were screened for study inclusion, of whom 8 patients were enrolled and assigned to different dose levels: 25 × 106 cells (n = 3), 50 × 106 cells (n = 2), 75 × 106 cells (n = 2), and 100 × 106 cells (n = 1). No DLT was observed. The most common AEs included cytopenia (n = 8, 100%), cytokine release syndrome (CRS) (n = 7, 88%) and hypogammaglobulinemia (n = 5, 63%). No Grade 3 or higher immune effector cell-associated hematotoxicity (ICAHT) occurred. No cases of immune effector cell-associated neurotoxicity syndrome (ICANS) were reported. CRS was predominantly grade 1, characterized mainly by mild fever and muscle soreness. A rare severe adverse event, immune effector cell-associated hemophagocytic lymphohistiocytosis-like syndrome (IEC-HS), was observed in one patient. The median time to reach maximum CAR-T cell expansion (Cmax) was 9.5 days (range: 8-22 days). The median Cmax was 18.74 CD3+CAR+ cells/μL (range: 7.94-228.36) by flow cytometry and 81766.5 copies/μg DNA (range: 50,979-1,140,893) by quantitative real-time PCR (qPCR). In all patients treated with relma-cel, CD19+ B cells in peripheral blood were almost completely depleted within 11-15 days and gradually recovered within 2-6 months. All patients achieved SRI response. Four patients achieved Definition of Remission in SLE (DORIS) remission criteria and seven patients reached the Lupus Low Disease Activity State (LLDAS) criteria within 1-4 months following relma-cel infusion.

Interpretation

This study preliminarily demonstrated that relma-cel is an effective and safe CAR-T product for the treatment of patients with moderately to severely active SLE, providing valuable clinical insights into the management of rare complications. Further studies with larger sample sizes are warranted.

Funding

National Natural Science Foundation of China.

Chimeric antigen receptor T cell therapy in octogenarians with B cell lymphoma: a real-world US multicenter collaborative study

Older patients with lymphoma are typically underrepresented in clinical trials with chimeric antigen receptor T cell (CAR T) therapy. In this multicenter, observational study we aimed to assess the safety and efficacy of standard CD19 CAR T in patients 80 years of age or older. At total of 88 patients, median age 82 (range, 80-89) years, were included. Diffuse large B cell lymphoma (DLBCL) (N = 60, 68.2%) represented the most common histology. Patients were treated mostly with axicabtagene ciloleucel (N = 41, 46.6%) followed by lisocabtagene maraleucel (N = 25, 28.4%). Cytokine release syndrome (CRS) (any grade) was seen in 68 (77.3%) and 51 (58%) developed immune effector cell-associated neurotoxicity syndrome (ICANS). Incidence of grade 3-4 CRS and ICANS were 7.4% and 31.4%, respectively. For patients with DLBCL/tFL, the 1-year NRM, relapse, PFS, and OS were 11.6%, 40.8%, 47.6%, and 61.2%, respectively. We conclude that CAR T is feasible and effective in patients 80 years or older with B cell lymphomas. These patients must be provided the opportunity to be evaluated for this curative approach.

Hypomagnesemia in lymphoma patients receiving CAR T therapy correlates with immune dysfunction and decreased survival

BACKGROUND

Hypomagnesemia has been correlated with inferior outcomes in patients with large B cell lymphoma (LBCL) undergoing stem cell transplants. As T-cell and myeloid cell dysfunction have been associated with low magnesium conditions, we investigated whether serum magnesium (Mg) levels could predict clinical outcomes in LBCL patients who received chimeric antigen receptor T-cell therapy.

METHODS

Patients with LBCL who received axi-cel under the ZUMA-1 trial or as FDA approved therapy at Mayo Clinic were examined. Serum samples were obtained at specified time points and cytokine analysis was performed. Single cell RNA sequencing was performed on peripheral blood mononuclear cells. The Student T-test, Kruskal Wallis, or Fisher's Exact Tests were used to compare differences in demographics across Mg levels. Survival curves were plotted using the Kaplan-Meier methodology and compared using the Wilcoxon test.

RESULTS

We found that hypomagnesemia before lymphodepletion chemotherapy predicted inferior progression-free and overall survival in the pivotal study ZUMA-1 (NCT02348216). These results were validated in an independent cohort of LBCL patients receiving axicabtagene ciloleucel (axi-cel) at Mayo Clinic. Hypomagnesemia correlated with increased inflammatory serum markers and cytokine levels including ferritin, IL-6, IL1Ra, IL-8, and MIP1a. scRNAseq analysis unveiled altered immune interactions between monocytes and T cells with a concordant immune suppressive transcriptome.

CONCLUSIONS

Hypomagnesemia at the time of CAR-T infusion is associated with an unfavorable inflammatory profile and decreased response and survival in LBCL patients receiving axi-cel. These findings suggest a potentially actionable prognostic factor for patients with large cell lymphoma undergoing CAR-T.

CD22 CAR-T cells secreting CD19 T-cell engagers for improved control of B-cell acute lymphoblastic leukemia progression

BACKGROUND

CD19-directed cancer immunotherapies, based on engineered T cells bearing chimeric antigen receptors (CARs, CAR-T cells) or the systemic administration of bispecific T cell-engaging (TCE) antibodies, have shown impressive clinical responses in relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL). However, more than half of patients relapse after CAR-T or TCE therapy, with antigen escape or lineage switching accounting for one-third of disease recurrences. To minimize tumor escape, dual-targeting CAR-T cell therapies simultaneously targeting CD19 and CD22 have been developed and validated both preclinically and clinically.

METHODS

We have generated the first dual-targeting strategy for B-cell malignancies based on CD22 CAR-T cells secreting an anti-CD19 TCE antibody (CAR-STAb-T) and conducted a comprehensive preclinical characterization comparing its therapeutic potential in B-ALL with that of previously validated dual-targeting CD19/CD22 tandem CAR cells (TanCAR-T cells) and co-administration of two single-targeting CD19 and CD22 CAR-T cells (pooled CAR-T cells).

RESULTS

We demonstrate that CAR-STAb-T cells efficiently redirect bystander T cells, resulting in higher cytotoxicity of B-ALL cells than dual-targeting CAR-T cells at limiting effector:target ratios. Furthermore, when antigen loss was replicated in a heterogeneous B-ALL cell model, CAR-STAb T cells induced more potent and effective cytotoxic responses than dual-targeting CAR-T cells in both short- and long-term co-culture assays, reducing the risk of CD19-positive leukemia escape. In vivo, CAR-STAb-T cells also controlled leukemia progression more efficiently than dual-targeting CAR-T cells in patient-derived xenograft mouse models under T cell-limiting conditions.

CONCLUSIONS

CD22 CAR-T cells secreting CD19 T-cell engagers show an enhanced control of B-ALL progression compared with CD19/CD22 dual CAR-based therapies, supporting their potential for clinical testing.

Foxp3 confers long-term efficacy of chimeric antigen receptor-T cells via metabolic reprogramming

The tumor microenvironment, characterized by low oxygen tension and scarce nutrients, impairs chimeric antigen receptor (CAR)-T cell metabolism, leading to T cell exhaustion and dysfunction. Notably, Foxp3 confers a metabolic advantage to regulatory T cells under such restrictive conditions. Exploiting this property, we generated CAR-TFoxp3 cells by co-expressing Foxp3 with a third-generation CAR construct. The CAR-TFoxp3 cells exhibited distinct metabolic reprogramming, marked by downregulated aerobic glycolysis and oxidative phosphorylation coupled with upregulated lipid metabolism. This metabolic shift was driven by Foxp3's interaction with dynamin-related protein 1. Crucially, CAR-TFoxp3 cells did not acquire regulatory T cell immunosuppressive functions but instead demonstrated enhanced antitumor potency and reduced expression of exhaustion markers via Foxp3-mediated adaptation. The potent antitumor effect and absence of immunosuppression were confirmed in a humanized immune system mouse model. Our findings establish a metabolic reprogramming-based strategy to enhance CAR-T cell adaptability within the hostile tumor microenvironment while preserving therapeutic efficacy.

Revolutionizing immunotherapy: The next frontier in CAR T-cell engineering

Chimeric Antigen Receptor (CAR) T-cell therapy has emerged as a groundbreaking immunotherapy, offering new hope for cancer treatment, particularly in hematologic malignancies. This review explores the development of CAR T-cell therapy from its first-generation design, which laid the foundational structure, to advanced fifth-generation CARs that integrate sophisticated synthetic biology. Each generation of CARs has introduced critical improvements, such as the incorporation of costimulatory domains, dual signaling pathways, and cytokine release mechanisms to enhance T-cell activation, persistence, and efficacy. Current applications of CAR T-cell therapy have seen significant success in treating cancers like acute lymphoblastic leukemia and diffuse large B-cell lymphoma, with several therapies gaining regulatory approval. However, challenges persist in targeting solid tumors due to the immunosuppressive tumor microenvironment and antigen heterogeneity. Ongoing clinical trials and research are focused on overcoming these barriers through next-generation CAR designs, novel antigen targets, and combination therapies. The review highlights recent advancements, emerging targets, and the potential of CAR T-cell therapy to revolutionize cancer treatment, paving the way for more effective and personalized approaches.

Cell-based immunotherapies for solid tumors: advances, challenges, and future directions

Cell-based immunotherapies, including CAR-T, CAR-NK, and TCR-T therapies, represent a transformative approach to cancer treatment by offering precise targeting of tumor cells. Despite their success in hematologic malignancies, these therapies encounter significant challenges in treating solid tumors, such as antigen heterogeneity, immunosuppressive tumor microenvironments, limited cellular infiltration, off-target toxicity, and difficulties in manufacturing scalability. CAR-T cells have demonstrated exceptional efficacy in blood cancers but face obstacles in solid tumors, whereas CAR-NK cells offer reduced graft-versus-host disease but encounter similar barriers. TCR-T cells expand the range of treatable cancers by targeting intracellular antigens but require meticulous antigen selection to prevent off-target effects. Alternative therapies like TIL, NK, and CIK cells show promise but require further optimization to enhance persistence and overcome immunosuppressive barriers. Manufacturing complexity, high costs, and ensuring safety and efficacy remain critical challenges. Future advancements in gene editing, multi-antigen targeting, synthetic biology, off-the-shelf products, and personalized medicine hold the potential to address these issues and expand the use of cell-based therapies. Continued research and innovation are essential to improving safety, efficacy, and scalability, ultimately leading to better patient outcomes.

Strategies to overcome tumour relapse caused by antigen escape after CAR T therapy

Chimeric antigen receptor (CAR) T cell therapy has revolutionized the treatment of B cell and plasma cell malignancies, and numerous promising targets against solid tumours are being explored. Despite their initial therapeutic success in hematological cancers, relapse occurs in a significant fraction of patients, highlighting the need for further innovations in advancing CAR T cell therapy. Tumour antigen heterogeneity and acquired tumour resistance leading to antigen escape (antigen loss/downregulation) have emerged as a crucial factor contributing to immune escape and CAR T cell resistance, particularly in the case of solid tumours with only limited success achieved to date. In this review, we discuss mechanisms of tumour relapse in CAR T cell therapy and the promising strategies that are under development to overcome multiple resistance mechanisms, thereby reducing outgrowth of antigen escape variants. Specifically, we emphasize the importance of designing clinical translational strategies to enhance CAR T cell crosstalk with host immune cells, eliciting endogenous antitumour immune responses through antigen/epitope spreading, which offers a genuine solution to the limitations of targeting tumour antigen heterogeneity in solid tumours with monospecific T cell therapies.

The Improving Outcomes in Relapsed-Refractory Diffuse Large B Cell Lymphoma: The Role of CAR T-Cell Therapy

OPINION STATEMENT

Diffuse large B cell lymphoma, not otherwise specified (DLBCL-NOS) is the most common aggressive lymphoma and can be cured with CHOP-R immunochemotherapy in 60% of cases. The second-line therapy includes salvage regimens followed by autologous stem cell transplantation (ASCT), which offers a cure to a minority of patients due to limitations in efficacy and eligibility. These data present the unmet need in the field, and this review article focuses on how second-generation chimeric antigen receptor T (CAR T) cell therapy targeting CD19 antigen may improve the outcomes with relapsed/refractory DLBCL. In heavily pretreated patients, who have dismal outcomes with conventional therapy, all three approved products-tisangenlecleucel (tisa-cel), axicabtagene ciloleucel (axi-cel), and lisocabtagene maraleucel (liso-cel) have shown durable, unprecedented complete responses with the potential for cure. When compared to salvage regimens and ASCT as the standard of care, axi-cel and liso-cel, unlike tisa-cel, have demonstrated superiority in long-term control. In ASCT-ineligible r/r DLBCL, liso-cel has shown a favourable benefit-risk ratio. Regarding safety, two adverse events of interest have emerged: cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome, both of which are manageable. Real-world evidence reflects the results of pivotal trials while favouring axi-cel in heavily pretreated patients, albeit with higher toxicity. The main barrier to the implementation of this treatment modality is the cost associated with the process of CAR T therapy, along with complications and reimbursement issues. However, the barriers can be overcome, and CAR T therapy has the potential to become the standard of care in relapsed/refractory DLBCL. Furthermore, with advances in the scientific engineering of CAR products and the understanding of novel treatment modalities currently being tested in clinical trials, we believe that targeted cellular therapy will become the future of relapsed/refractory DLBCL treatment.

A 6-tsRNA signature for early detection, treatment response monitoring, and prognosis prediction in diffuse large B cell lymphoma

Diffuse large B-cell lymphoma (DLBCL) presents considerable clinical challenges due to its aggressive nature and diverse clinical progression. New molecular biomarkers are urgently needed for outcome prediction. We analyzed blood samples from DLBCL patients and healthy individuals using short, non-coding RNA sequencing. A classifier based on six tsRNAs was developed through random forest and primary component analysis. This classifier, established using Cox proportional hazards modeling with repeated 10-fold cross-validation on an internal cohort of 100 samples analyzed using RT-qPCR, effectively identified high-risk patients with significantly lower overall survival compared to low-risk patients (Hazard ratio: 6.657, 95%CI 2.827-15.68, P = 0.0006). Validation in an external cohort of 160 samples using RT-qPCR confirmed the classifier's robust performance. High-risk status was strongly associated with disease histological subtype, stage, and International Prognostic Index scores. Integration of the classifier into the IPI model enhanced the precision and consistency of prognostic predictions. A dynamic study revealed that patients experiencing a 1.06-fold decrease after one therapy cycle (early molecular response) exhibited better treatment outcomes and prognosis. Furthermore, the 6-tsRNA signature accurately differentiated healthy individuals from DLBCL (AUC 0.882, 95%CI 0.826-0.939). These findings underscore the potential of the identified 6-tsRNA profile as a biomarker for monitoring treatment effectiveness and predicting DLBCL outcomes.

Expanding horizons of cancer immunotherapy: hopes and hurdles

Background

Tumor displays various forms of tumor heterogeneity including immune heterogeneity that allow cancer cells to survive during conventional anticancer drug interventions. Thus, there is a strong rationale for overcoming anticancer drug resistance by employing the components of immune cells. Using the immune system to target tumor cells has revolutionized treatment. Recently, significant progress has been achieved at preclinical and clinical levels to benefit cancer patients.

Approach

A review of literature from the past ten years across PubMed, Scopus, and Web of Science focused on immunotherapy strategies. These include immune checkpoint inhibitors (ICIs), tumor-infiltrating lymphocyte therapy, antibody-drug conjugates (ADCs), cancer vaccines, CAR T-cell therapy, and the role of the gut microbiome.

Conclusion

While immunotherapy outcomes have improved, particularly for tumor types such as melanoma and non-small cell lung cancer (NSCLC), challenges persist regarding predictive biomarker identification and better management. Ongoing research on modifiers of immune function like gut microbiome-derived metabolites, next-generation ADCs, and new classes of biologics is warranted. Overall, continued investigation toward optimizing synergistic immunotherapeutic combinations through strategic drug delivery systems is imperative for preclinical and clinical success in cancer patients.

Cytokine Release Syndrome and Neurotoxicity Following CD19 CAR-T in B-Cell Lymphoma

Chimeric antigen receptor T cell (CAR-T) therapy is an effective treatment for relapsed-refractory large B-cell lymphoma (LBCL). However, toxicities, particularly cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS), remain significant concerns. Analyze temporal trends, risk factors, and associations between these toxicities and their severity. In this registry study by the Center for International Blood and Marrow Transplant Research, we studied CRS and ICANS in 1916 LBCL patients treated with commercial CAR-T therapies (axicabtagene ciloleucel 74.9%, tisagenlecleucel 25.1%) between 2018 and 2020. Outcomes include development of CRS/ICANS, timing and severity according to ASTC grading, overall survival (OS). Risk factors were assessed using Cox proportional hazards model. Among patients developing CRS (75.2%), 11.3% had grade ≥3 CRS. Among patients developing ICANS (43.5%), 47.7% had grade ≥3 ICANS. Among patients developing CRS, severe CRS rates decreased from 14.0% in 2018 to 9.2% in 2020 (P< .01). However, the proportion of severe ICANS in patients who developed ICANS remained statistically unchanged (41.5% in 2018 to 53.7% in 2020, P= .10). CRS and ICANS were correlated: 57.1% of patients with CRS also experienced ICANS, and CRS was reported in 97.5% of ICANS cases, suggesting a potential continuum between toxicities. Axicabtagene ciloleucel was associated with higher risk of any grade CRS (OR, 4.6; 95% CI, 3.65 to 5.81) and ICANS (OR, 5.85; 95% CI, 4.48 to 7.64) as well as early and severe forms of both complications. Older age, lower performance status, and elevated lactate dehydrogenase levels prior to infusion also variably predicted these toxicities. In a landmark analysis starting 30 days postinfusion, patients with severe CRS or severe ICANS had shorter OS compared to those without these toxicities. High grades of CRS improved over time likely related to earlier intervention, development of ICANS is intrinsically related with CRS. These findings underscore the need for effective strategies to mitigate these toxicities and improve CAR-T safety.

Novel humanized CD19-CAR-T (Now talicabtagene autoleucel, Tali-cel™) cells in relapsed/ refractory pediatric B-acute lymphoblastic leukemia- an open-label single-arm phase-I/Ib study

Chimeric Antigen Receptor-T (CAR-T) cell therapy is effective for relapsed/refractory B-acute lymphoblastic leukemia (r/r B-ALL) but is not universally available. We developed a novel humanized CD19-directed CAR-T (HCAR19) approved for Phase 1/1b/2 trials. Patients aged 3-25 years were enrolled with r/r B-ALL and ineligible for allogeneic stem cell transplant. Lymphodepletion utilized standard-dose fludarabine and cyclophosphamide. A 3 + 3 design testing 3 dose-ranges was used to determine Phase-2 Dose (P2D): Dose-A, 1 × 106 HCAR19 cells/kg, Dose-B, 3-5 × 106/kg, and Dose-C, 10-15 × 106/kg. Primary endpoint was overall response rate (ORR) at day-30 on bone-marrow flow-cytometry. From May-2021 to September-2023 12 patients [median age-14 (range: 5-24) years] were enrolled with median bone marrow blasts 19.5% at screening. Cytokine release syndrome occurred in 10 (83%) patients, predominantly Grades 1-2, and Grade-2 immune-cell associated neurotoxicity (ICANS) in 1. All patients had Grade-3 cytopenia. ORR was 91.7% (11/12), complete response (CR) in 8 (66.7%) and partial response in 3 (25%). Seven of 8 CRs were at Dose-levels B and C, all of which were sustained till 12 months follow-up. Patients who received dose levels below 3 × 106/kg, or did not achieve CR, had early loss of response or rapid progression. HCAR19 demonstrated safety, manageable toxicity, and durable remissions. and P2D was determined as 5-10 × 106 HCAR19-cells/kg. CLINICAL TRIAL REGISTRATION: The study is registered in the Clinical Trials Registry- India (CTRI/2021/05/033348 and CTRI/2023/03/050689).