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Guo Z, Ding Y, Wang M, Zhai Q, Liu J, Du Q. Comparing the Differences in Adverse Events among Chimeric Antigen Receptor T-Cell Therapies: A Real-World Pharmacovigilance Study. Pharmaceuticals (Basel) 2024; 17:1025. [PMID: 39204130 PMCID: PMC11359317 DOI: 10.3390/ph17081025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 07/28/2024] [Accepted: 08/01/2024] [Indexed: 09/03/2024] Open
Abstract
In this study, we compared the similarities and differences in adverse events (AEs) among CAR T-cell products through signal mining via the FDA Adverse Event Reporting System (FAERS) and identified unknown AEs to provide a reference for safe clinical medication. Data from the FAERS database spanning from the fourth quarter of 2017 to the first quarter of 2024 were extracted. Signals were identified using the reporting odds ratio (ROR) method and the Medicines and Healthcare Products Regulatory Agency (MHRA) method. A total of 11,386 AE reports related to six CAR T-cell products were selected. The top three categories of AEs reported were nervous system disorders, immune system disorders, and general disorders and administration site conditions. However, there were variations in the AE spectra among the different CAR T-cell products. The BCMA-targeting drugs idecabtagene vicleucel (Ide-cel) and ciltacabtagene autoleucel (Cilta-cel) were found to be associated with parkinsonism, which were not observed in CD19-targeting drugs. Tisagenlecleucel (Tisa-cel) and axicabtagene ciloleucel (Axi-cel) exhibited cerebrovascular accident-related AEs, graft versus host disease, and abnormal coagulation indices. Cilta-cel was associated with cerebral hemorrhage, intracranial hemorrhage, cranial nerve disorder, and facial nerve disorder. Cardiopulmonary toxicity, including hypoxia, tachypnoea, cardiorenal syndrome, and hypotension, exhibited strong signal intensities and considerable overlap with CRS. The number of positive signals for cardiopulmonary toxicity associated with drugs targeting CD-19 is greater. Clinicians should assess patients prior to medication and closely monitor their vital signs, mental status, and laboratory parameters during treatment.
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Affiliation(s)
- Zihan Guo
- Department of Pharmacy, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (Z.G.); (Y.D.); (M.W.); (Q.Z.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yunlan Ding
- Department of Pharmacy, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (Z.G.); (Y.D.); (M.W.); (Q.Z.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Mengmeng Wang
- Department of Pharmacy, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (Z.G.); (Y.D.); (M.W.); (Q.Z.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qing Zhai
- Department of Pharmacy, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (Z.G.); (Y.D.); (M.W.); (Q.Z.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Jiyong Liu
- Department of Pharmacy, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (Z.G.); (Y.D.); (M.W.); (Q.Z.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qiong Du
- Department of Pharmacy, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (Z.G.); (Y.D.); (M.W.); (Q.Z.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
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2
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Bhatla T, Cooper S, Hogan LE. Low-risk relapsed acute lymphoblastic leukemia in children and young adults: what have we learnt and what's next? Leuk Lymphoma 2024:1-7. [PMID: 38861360 DOI: 10.1080/10428194.2024.2362408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 05/27/2024] [Indexed: 06/13/2024]
Abstract
While outcomes for newly diagnosed children with acute lymphoblastic leukemia (ALL) have improved over the last few decades, 10-15% will relapse. Outcomes for those children with relapse remains a challenge, with 5-year overall survival of approximately 35-60%. Large cooperative group trials have identified factors associated with favorable (low risk, LR) outcome at relapse, including later relapse, B-cell phenotype, isolated extramedullary relapse and a good response to initial re-induction therapy. Contemporary therapeutic regimens are aimed at improving outcomes, while decreasing toxicity. A main focus of current research involves how immunotherapy can be best incorporated with cytotoxic chemotherapy to improve survival in relapsed ALL. Here we review therapeutic strategies for LR relapse, including review of recently completed and ongoing trials.
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Affiliation(s)
- Teena Bhatla
- Children's Hospital of New Jersey at Newark Beth Israel, Newark, NJ, USA
| | - Stacy Cooper
- Department of Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - Laura E Hogan
- Department of Pediatrics, Stony Brook Children's, Stony Brook, NY, USA
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3
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Locatelli F, del Bufalo F, Quintarelli C. Allogeneic chimeric antigen receptor T cells for children with relapsed/refractory B-cell precursor acute lymphoblastic leukemia. Haematologica 2024; 109:1689-1699. [PMID: 38832424 PMCID: PMC11141659 DOI: 10.3324/haematol.2023.284604] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 02/01/2024] [Indexed: 06/05/2024] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has emerged as a breakthrough cancer therapy over the past decade. Remarkable outcomes in B-cell lymphoproliferative disorders and multiple myeloma have been reported in both pivotal trials and real-word studies. Traditionally, the use of a patient's own (autologous) T cells to manufacture CAR products has been the standard practice. Nevertheless, this approach has some drawbacks, including manufacturing delays, dependence on the functional fitness of the patient's T cells, which can be compromised by both the disease and prior therapies, and contamination of the product with blasts. A promising alternative is offered by the development of allogeneic CAR-cell products. This approach has the potential to yield more efficient drug products and enables the use of effector cells with negligible alloreactive potential and a significant CAR-independent antitumor activity through their innate receptors (i.e., natural killer cells, γδ T cells and cytokine induced killer cells). In addition, recent advances in genome editing tools offer the potential to overcome the primary challenges associated with allogeneic CAR T-cell products, namely graft-versus-host disease and host allo-rejection, generating universal, off-the-shelf products. In this review, we summarize the current pre-clinical and clinical approaches based on allogeneic CAR T cells, as well as on alternative effector cells, which represent exciting opportunities for multivalent approaches and optimized antitumor activity.
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Affiliation(s)
- Franco Locatelli
- Department of Hematology/Oncology, Cell and Gene Therapy – IRCCS, Bambino Gesù Children’s Hospital, Rome
- Catholic University of the Sacred Heart, Department of Life Sciences and Public Health, Rome
| | - Francesca del Bufalo
- Department of Hematology/Oncology, Cell and Gene Therapy – IRCCS, Bambino Gesù Children’s Hospital, Rome
| | - Concetta Quintarelli
- Department of Hematology/Oncology, Cell and Gene Therapy – IRCCS, Bambino Gesù Children’s Hospital, Rome
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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4
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Goldberg L, Haas ER, Urak R, Vyas V, Pathak KV, Garcia-Mansfield K, Pirrotte P, Singhal J, Figarola JL, Aldoss I, Forman SJ, Wang X. Immunometabolic Adaptation of CD19-Targeted CAR T Cells in the Central Nervous System Microenvironment of Patients Promotes Memory Development. Cancer Res 2024; 84:1048-1064. [PMID: 38315779 PMCID: PMC10984768 DOI: 10.1158/0008-5472.can-23-2299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/16/2023] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
Metabolic reprogramming is a hallmark of T-cell activation, and metabolic fitness is fundamental for T-cell-mediated antitumor immunity. Insights into the metabolic plasticity of chimeric antigen receptor (CAR) T cells in patients could help identify approaches to improve their efficacy in treating cancer. Here, we investigated the spatiotemporal immunometabolic adaptation of CD19-targeted CAR T cells using clinical samples from CAR T-cell-treated patients. Context-dependent immunometabolic adaptation of CAR T cells demonstrated the link between their metabolism, activation, differentiation, function, and local microenvironment. Specifically, compared with the peripheral blood, low lipid availability, high IL15, and low TGFβ in the central nervous system microenvironment promoted immunometabolic adaptation of CAR T cells, including upregulation of a lipolytic signature and memory properties. Pharmacologic inhibition of lipolysis in cerebrospinal fluid led to decreased CAR T-cell survival. Furthermore, manufacturing CAR T cells in cerebrospinal fluid enhanced their metabolic fitness and antileukemic activity. Overall, this study elucidates spatiotemporal immunometabolic rewiring of CAR T cells in patients and demonstrates that these adaptations can be exploited to maximize the therapeutic efficacy of CAR T cells. SIGNIFICANCE The spatiotemporal immunometabolic landscape of CD19-targeted CAR T cells from patients reveals metabolic adaptations in specific microenvironments that can be exploited to maximize the therapeutic efficacy of CAR T cells.
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Affiliation(s)
- Lior Goldberg
- Department of Hematology and Hematopoietic Cell Transplantation, T Cell Therapeutics Research Laboratories, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
- Department of Pediatrics, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Eric R. Haas
- Department of Hematology and Hematopoietic Cell Transplantation, T Cell Therapeutics Research Laboratories, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
- Ionic Cytometry Solutions, Cambridge, MA 02141, USA
| | - Ryan Urak
- Department of Hematology and Hematopoietic Cell Transplantation, T Cell Therapeutics Research Laboratories, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Vibhuti Vyas
- Department of Hematology and Hematopoietic Cell Transplantation, T Cell Therapeutics Research Laboratories, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Khyatiben V. Pathak
- Integrated Mass Spectrometry Shared Resource, City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA
- Cancer & Cell Biology Division, Translational Genomics Research Institute, Phoenix, AZ 85004 USA
| | - Krystine Garcia-Mansfield
- Integrated Mass Spectrometry Shared Resource, City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA
- Cancer & Cell Biology Division, Translational Genomics Research Institute, Phoenix, AZ 85004 USA
| | - Patrick Pirrotte
- Integrated Mass Spectrometry Shared Resource, City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA
- Cancer & Cell Biology Division, Translational Genomics Research Institute, Phoenix, AZ 85004 USA
| | - Jyotsana Singhal
- Division of Diabetes and Metabolic Diseases Research, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - James L. Figarola
- Division of Diabetes and Metabolic Diseases Research, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, T Cell Therapeutics Research Laboratories, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Stephen J. Forman
- Department of Hematology and Hematopoietic Cell Transplantation, T Cell Therapeutics Research Laboratories, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Xiuli Wang
- Department of Hematology and Hematopoietic Cell Transplantation, T Cell Therapeutics Research Laboratories, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
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5
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Aldoss I, Clark MC, Wang X, Forman SJ. Leveraging CD19CAR T cells early in the treatment of older patients with B-ALL: are we there yet? Leuk Lymphoma 2024; 65:440-448. [PMID: 38179704 DOI: 10.1080/10428194.2023.2298712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/19/2023] [Indexed: 01/06/2024]
Abstract
Older adults (≥55 years old) with B-cell acute lymphoblastic leukemia (B-ALL) have dismal outcomes with standard chemotherapy as the result of low treatment efficacy and considerable risks for treatment-related morbidity and mortality. There has been a recent success with the introduction of novel therapies, such as blinatumomab and inotuzumab, in the frontline therapeutic paradigm in older adults with B-ALL. However, these agents have their own challenges including the limited durability of remission, the need for additional concurrent chemotherapy and the prolonged course of treatment, and limited efficacy in the setting of extramedullary disease. Here, we hypothesize that the incorporation of chimeric antigen receptor (CAR) T cell therapy as a consolidation treatment in older adults with B-cell ALL in their first complete remission is the ideal setting to advance treatment outcomes by reducing treatment toxicity, enhancing remission durability, and expanding the use of this effective therapy in this age population.
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Affiliation(s)
- Ibrahim Aldoss
- Hematological Malignancies Research Institute, Duarte, CA, USA
- Gehr Family Center for Leukemia Research, Duarte, CA, USA
- Department of Hematology/Hematopoietic Cell Transplantation, Duarte, CA, USA
| | - Mary Caroline Clark
- Hematological Malignancies Research Institute, Duarte, CA, USA
- Department of Clinical and Translational Project Development, Duarte, CA, USA
| | - Xiuli Wang
- Hematological Malignancies Research Institute, Duarte, CA, USA
- T Cell Therapeutic Research Laboratories, City of Hope, Duarte, CA, USA
| | - Stephen Joel Forman
- Hematological Malignancies Research Institute, Duarte, CA, USA
- Department of Hematology/Hematopoietic Cell Transplantation, Duarte, CA, USA
- T Cell Therapeutic Research Laboratories, City of Hope, Duarte, CA, USA
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6
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Devine KJ, Trivedi H, Reilly AF. B-Lymphoblastic Lymphoma in Children: A Case Series From a Single Institution. J Pediatr Hematol Oncol 2024; 46:e254-e258. [PMID: 38408123 PMCID: PMC10956661 DOI: 10.1097/mph.0000000000002828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/18/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Pediatric B-lymphoblastic lymphoma is an uncommon subtype of non-Hodgkin lymphoma. Studies regarding the biology, clinical course, and approach to relapse are limited. OBSERVATIONS We present a series of children with B-lymphoblastic lymphoma to describe the clinical course at diagnosis and relapse as well as the role of tumor cytogenetics, immunotherapy, and hematopoietic stem cell transplant. CONCLUSIONS The prognostic significance of cytogenetic changes in B-lymphoblastic lymphoma is not well described but may offer improved risk stratification. Immunotherapy may offer salvage options for relapsed disease and can serve as a bridge to transplant.
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Affiliation(s)
- Kaitlin J. Devine
- Division of Oncology, The Children’s Hospital of Philadelphia
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Hirva Trivedi
- Division of Oncology, The Children’s Hospital of Philadelphia
| | - Anne F. Reilly
- Division of Oncology, The Children’s Hospital of Philadelphia
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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7
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Murphy L, Aldoss I. Blinatumomab improves outcomes for pediatric patients with low-risk B-cell acute lymphoblastic leukemia in first marrow relapse. Transl Pediatr 2024; 13:530-534. [PMID: 38590377 PMCID: PMC10998983 DOI: 10.21037/tp-23-521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 12/29/2023] [Indexed: 04/10/2024] Open
Affiliation(s)
- Lindsey Murphy
- Department of Pediatrics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, Gehr Family Center for Leukemia Research, City of Hope National Medical Center, Duarte, CA, USA
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8
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Levstek L, Janžič L, Ihan A, Kopitar AN. Biomarkers for prediction of CAR T therapy outcomes: current and future perspectives. Front Immunol 2024; 15:1378944. [PMID: 38558801 PMCID: PMC10979304 DOI: 10.3389/fimmu.2024.1378944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapy holds enormous potential for the treatment of hematologic malignancies. Despite its benefits, it is still used as a second line of therapy, mainly because of its severe side effects and patient unresponsiveness. Numerous researchers worldwide have attempted to identify effective predictive biomarkers for early prediction of treatment outcomes and adverse effects in CAR T cell therapy, albeit so far only with limited success. This review provides a comprehensive overview of the current state of predictive biomarkers. Although existing predictive metrics correlate to some extent with treatment outcomes, they fail to encapsulate the complexity of the immune system dynamics. The aim of this review is to identify six major groups of predictive biomarkers and propose their use in developing improved and efficient prediction models. These groups include changes in mitochondrial dynamics, endothelial activation, central nervous system impairment, immune system markers, extracellular vesicles, and the inhibitory tumor microenvironment. A comprehensive understanding of the multiple factors that influence therapeutic efficacy has the potential to significantly improve the course of CAR T cell therapy and patient care, thereby making this advanced immunotherapy more appealing and the course of therapy more convenient and favorable for patients.
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Affiliation(s)
| | | | | | - Andreja Nataša Kopitar
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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9
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Knight E T, Oluwole O, Kitko C. The Implementation of Chimeric Antigen Receptor (CAR) T-cell Therapy in Pediatric Patients: Where Did We Come From, Where Are We Now, and Where are We Going? Clin Hematol Int 2024; 6:96-115. [PMID: 38817691 PMCID: PMC11108586 DOI: 10.46989/001c.94386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 02/13/2024] [Indexed: 06/01/2024] Open
Abstract
CD19-directed Chimeric Antigen Receptor (CAR) T-cell therapy has revolutionized the treatment of patients with B-cell acute lymphoblastic leukemia (B-ALL). Somewhat uniquely among oncologic clinical trials, early clinical development occurred simultaneously in both children and adults. In subsequent years however, the larger number of adult patients with relapsed/refractory (r/r) malignancies has led to accelerated development of multiple CAR T-cell products that target a variety of malignancies, resulting in six currently FDA-approved for adult patients. By comparison, only a single CAR-T cell therapy is approved by the FDA for pediatric patients: tisagenlecleucel, which is approved for patients ≤ 25 years with refractory B-cell precursor ALL, or B-cell ALL in second or later relapse. Tisagenlecleucel is also under evaluation in pediatric patients with relapsed/refractory B-cell non-Hodgkin lymphoma, but is not yet been approved for this indication. All the other FDA-approved CD19-directed CAR-T cell therapies available for adult patients (axicabtagene ciloleucel, brexucabtagene autoleucel, and lisocabtagene maraleucel) are currently under investigations among children, with preliminary results available in some cases. As the volume and complexity of data continue to grow, so too does the necessity of rapid assimilation and implementation of those data. This is particularly true when considering "atypical" situations, e.g. those arising when patients do not precisely conform to the profile of those included in pivotal clinical trials, or when alternative treatment options (e.g. hematopoietic stem cell transplantation (HSCT) or bispecific T-cell engagers (BITEs)) are also available. We have therefore developed a relevant summary of the currently available literature pertaining to the use of CD19-directed CAR-T cell therapies in pediatric patients, and sought to provide guidance for clinicians seeking additional data about specific clinical situations.
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Affiliation(s)
| | - Olalekan Oluwole
- Medicine Hematology and Oncology, Vanderbilt University Medical Center
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10
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Bagley SJ, Binder ZA, Lamrani L, Marinari E, Desai AS, Nasrallah MP, Maloney E, Brem S, Lustig RA, Kurtz G, Alonso-Basanta M, Bonté PE, Goudot C, Richer W, Piaggio E, Kothari S, Guyonnet L, Guerin CL, Waterfall JJ, Mohan S, Hwang WT, Tang OY, Logun M, Bhattacharyya M, Markowitz K, Delman D, Marshall A, Wherry EJ, Amigorena S, Beatty GL, Brogdon JL, Hexner E, Migliorini D, Alanio C, O'Rourke DM. Repeated peripheral infusions of anti-EGFRvIII CAR T cells in combination with pembrolizumab show no efficacy in glioblastoma: a phase 1 trial. NATURE CANCER 2024; 5:517-531. [PMID: 38216766 DOI: 10.1038/s43018-023-00709-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 12/13/2023] [Indexed: 01/14/2024]
Abstract
We previously showed that chimeric antigen receptor (CAR) T-cell therapy targeting epidermal growth factor receptor variant III (EGFRvIII) produces upregulation of programmed death-ligand 1 (PD-L1) in the tumor microenvironment (TME). Here we conducted a phase 1 trial (NCT03726515) of CAR T-EGFRvIII cells administered concomitantly with the anti-PD1 (aPD1) monoclonal antibody pembrolizumab in patients with newly diagnosed, EGFRvIII+ glioblastoma (GBM) (n = 7). The primary outcome was safety, and no dose-limiting toxicity was observed. Secondary outcomes included median progression-free survival (5.2 months; 90% confidence interval (CI), 2.9-6.0 months) and median overall survival (11.8 months; 90% CI, 9.2-14.2 months). In exploratory analyses, comparison of the TME in tumors harvested before versus after CAR + aPD1 administration demonstrated substantial evolution of the infiltrating myeloid and T cells, with more exhausted, regulatory, and interferon (IFN)-stimulated T cells at relapse. Our study suggests that the combination of CAR T cells and PD-1 inhibition in GBM is safe and biologically active but, given the lack of efficacy, also indicates a need to consider alternative strategies.
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Affiliation(s)
- Stephen J Bagley
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Zev A Binder
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Center for Cellular Immunotherapies, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- GBM Translational Center of Excellence, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lamia Lamrani
- Clinical Immunology Laboratory, Institut Curie, Paris, France
- INSERM U932, PSL University, Immunity and Cancer, Institut Curie Research Center, Paris, France
- Parker Institute for Cancer Immunotherapy, San Francisco, CA, USA
| | - Eliana Marinari
- Agora Cancer Research Center, Lausanne, Switzerland
- Center for Translational Research in Onco-Hematology, University of Geneva, Geneva, Switzerland
- Swiss Cancer Center Léman, Lausanne and Geneva, Geneva, Switzerland
- Department of Oncology, University Hospital of Geneva, Geneva, Switzerland
| | - Arati S Desai
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - MacLean P Nasrallah
- GBM Translational Center of Excellence, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Eileen Maloney
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Steven Brem
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- GBM Translational Center of Excellence, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert A Lustig
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Goldie Kurtz
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Michelle Alonso-Basanta
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Pierre-Emmanuel Bonté
- INSERM U932, PSL University, Immunity and Cancer, Institut Curie Research Center, Paris, France
| | - Christel Goudot
- INSERM U932, PSL University, Immunity and Cancer, Institut Curie Research Center, Paris, France
| | - Wilfrid Richer
- INSERM U932, PSL University, Immunity and Cancer, Institut Curie Research Center, Paris, France
- Department of Translational Research, PSL Research University, Institut Curie Research Center, Paris, France
| | - Eliane Piaggio
- INSERM U932, PSL University, Immunity and Cancer, Institut Curie Research Center, Paris, France
| | - Shawn Kothari
- Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, USA
| | - Lea Guyonnet
- Cytometry Platform, CurieCoreTech, Institut Curie, Paris, France
| | - Coralie L Guerin
- Cytometry Platform, CurieCoreTech, Institut Curie, Paris, France
| | - Joshua J Waterfall
- Department of Translational Research, PSL Research University, Institut Curie Research Center, Paris, France
- INSERM U830, PSL University, Institut Curie Research Cente, Paris, France
| | - Suyash Mohan
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Wei-Ting Hwang
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Oliver Y Tang
- GBM Translational Center of Excellence, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Meghan Logun
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Center for Cellular Immunotherapies, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- GBM Translational Center of Excellence, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Meghna Bhattacharyya
- GBM Translational Center of Excellence, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Kelly Markowitz
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Devora Delman
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Amy Marshall
- Center for Cellular Immunotherapies, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - E John Wherry
- Parker Institute for Cancer Immunotherapy, San Francisco, CA, USA
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Institute for Immunology and Immune Health, Cambridge, MA, USA
| | - Sebastian Amigorena
- INSERM U932, PSL University, Immunity and Cancer, Institut Curie Research Center, Paris, France
| | - Gregory L Beatty
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- GBM Translational Center of Excellence, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Elizabeth Hexner
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Denis Migliorini
- Agora Cancer Research Center, Lausanne, Switzerland
- Center for Translational Research in Onco-Hematology, University of Geneva, Geneva, Switzerland
- Swiss Cancer Center Léman, Lausanne and Geneva, Geneva, Switzerland
- Department of Oncology, University Hospital of Geneva, Geneva, Switzerland
| | - Cecile Alanio
- Clinical Immunology Laboratory, Institut Curie, Paris, France.
- INSERM U932, PSL University, Immunity and Cancer, Institut Curie Research Center, Paris, France.
- Parker Institute for Cancer Immunotherapy, San Francisco, CA, USA.
| | - Donald M O'Rourke
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Center for Cellular Immunotherapies, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- GBM Translational Center of Excellence, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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11
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Ren Y, Liang H, Huang Y, Miao Y, Li R, Qiang J, Wu L, Qi J, Li Y, Xia Y, Huang L, Wang S, Kong X, Zhou Y, Zhang Q, Zhu G. Key candidate genes and pathways in T lymphoblastic leukemia/lymphoma identified by bioinformatics and serological analyses. Front Immunol 2024; 15:1341255. [PMID: 38464517 PMCID: PMC10920334 DOI: 10.3389/fimmu.2024.1341255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/08/2024] [Indexed: 03/12/2024] Open
Abstract
T-cell acute lymphoblastic leukemia (T-ALL)/T-cell lymphoblastic lymphoma (T-LBL) is an uncommon but highly aggressive hematological malignancy. It has high recurrence and mortality rates and is challenging to treat. This study conducted bioinformatics analyses, compared genetic expression profiles of healthy controls with patients having T-ALL/T-LBL, and verified the results through serological indicators. Data were acquired from the GSE48558 dataset from Gene Expression Omnibus (GEO). T-ALL patients and normal T cells-related differentially expressed genes (DEGs) were investigated using the online analysis tool GEO2R in GEO, identifying 78 upregulated and 130 downregulated genes. Gene Ontology (GO) and protein-protein interaction (PPI) network analyses of the top 10 DEGs showed enrichment in pathways linked to abnormal mitotic cell cycles, chromosomal instability, dysfunction of inflammatory mediators, and functional defects in T-cells, natural killer (NK) cells, and immune checkpoints. The DEGs were then validated by examining blood indices in samples obtained from patients, comparing the T-ALL/T-LBL group with the control group. Significant differences were observed in the levels of various blood components between T-ALL and T-LBL patients. These components include neutrophils, lymphocyte percentage, hemoglobin (HGB), total protein, globulin, erythropoietin (EPO) levels, thrombin time (TT), D-dimer (DD), and C-reactive protein (CRP). Additionally, there were significant differences in peripheral blood leukocyte count, absolute lymphocyte count, creatinine, cholesterol, low-density lipoprotein, folate, and thrombin times. The genes and pathways associated with T-LBL/T-ALL were identified, and peripheral blood HGB, EPO, TT, DD, and CRP were key molecular markers. This will assist the diagnosis of T-ALL/T-LBL, with applications for differential diagnosis, treatment, and prognosis.
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Affiliation(s)
- Yansong Ren
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Haoyue Liang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yali Huang
- Clinical Laboratory of Zhengning County People's Hospital, Qingyang, Gansu, China
| | - Yuyang Miao
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin Geriatrics Institute, Tianjin, China
| | - Ruihua Li
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin Geriatrics Institute, Tianjin, China
| | - Junlian Qiang
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin Geriatrics Institute, Tianjin, China
| | - Lihong Wu
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin Geriatrics Institute, Tianjin, China
| | - Jinfeng Qi
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin Geriatrics Institute, Tianjin, China
| | - Ying Li
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin Geriatrics Institute, Tianjin, China
| | - Yonghui Xia
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Lunhui Huang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Shoulei Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Xiaodong Kong
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin Geriatrics Institute, Tianjin, China
| | - Yuan Zhou
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Qiang Zhang
- Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin Geriatrics Institute, Tianjin, China
| | - Guoqing Zhu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
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12
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Agrawal V, Murphy L, Pourhassan H, Pullarkat V, Aldoss I. Optimizing CAR-T cell therapy in adults with B-cell acute lymphoblastic leukemia. Eur J Haematol 2024; 112:236-247. [PMID: 37772976 DOI: 10.1111/ejh.14109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/12/2023] [Accepted: 09/14/2023] [Indexed: 09/30/2023]
Abstract
Chimeric antigen receptor T-cell (CAR-T) therapy has demonstrated unprecedented success in the treatment of various hematologic malignancies including relapsed or refractory (R/R) B-cell acute lymphoblastic leukemia (B-ALL). Currently, there are two FDA-approved CD19-directed CAR-T cell products for the treatment of adults with R/R B-ALL. Despite high remission rates following CD19 CAR-T cell therapy in R/R B-ALL, remission durability remains limited in most adult patients, with relapse observed frequently in the absence of additional consolidation therapy. Furthermore, the burden of CAR-T cell toxicity remains significant in adults with R/R B-ALL and further limits the wide utilization of this effective therapy. In this review, we discuss patient and disease factors that are linked to CAR-T cell therapy outcomes in R/R B-ALL and strategies to optimize durability of response to reduce relapse and mitigate toxicity in the adult population. We additionally discuss future approaches being explored to maximize the benefit of CAR-T in adults with B-ALL.
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Affiliation(s)
- Vaibhav Agrawal
- Department of Hematology and Hematopoietic Cell Transplantation, Gehr Family Center for Leukemia Research, City of Hope National Medical Center, Duarte, California, USA
| | - Lindsey Murphy
- Department of Pediatrics, City of Hope National Medical Center, Duarte, California, USA
| | - Hoda Pourhassan
- Department of Hematology and Hematopoietic Cell Transplantation, Gehr Family Center for Leukemia Research, City of Hope National Medical Center, Duarte, California, USA
| | - Vinod Pullarkat
- Department of Hematology and Hematopoietic Cell Transplantation, Gehr Family Center for Leukemia Research, City of Hope National Medical Center, Duarte, California, USA
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, Gehr Family Center for Leukemia Research, City of Hope National Medical Center, Duarte, California, USA
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13
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Liu Y, Li Y, Yu Z, Wang R, Jing Y. Sequential autologous CAR-T and allogeneic CAR-T therapy successfully treats central nervous system involvement relapsed/refractory ALL: a case report and literature review. Front Oncol 2024; 14:1341682. [PMID: 38322417 PMCID: PMC10845664 DOI: 10.3389/fonc.2024.1341682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/02/2024] [Indexed: 02/08/2024] Open
Abstract
Background The central nervous system (CNS) is the most common site of extramedullary invasion in acute lymphoblastic leukemia (ALL), and involvement of the CNS is often associated with relapse, refractory disease, and poor prognosis. Chimeric antigen receptor-T (CAR-T) cell therapy, a promising modality in cancer immunotherapy, has demonstrated significant advantages in the treatment of hematological malignancies. However, due to associated adverse reactions such as nervous system toxicity, the safety and efficacy of CAR-T cell therapy in treating CNSL remains controversial, with limited reports available. Case report Here, we present the case of a patient with confirmed B-ALL who experienced relapse in both bone marrow (BM) and cerebrospinal fluid (CSF) despite multiple cycles of chemotherapy and intrathecal injections. The infusion of autologous CD19 CAR-T cells resulted in complete remission (CR) in both BM and CSF for 40 days. However, the patient later experienced a relapse in the bone marrow. Subsequently, allogeneic CD19 CAR-T cells derived from her brother were infused, leading to another achievement of CR in BM. Significantly, only grade 1 cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) events were detected during the treatment period and showed improvement with symptomatic management. During subsequent follow-up, the patient achieved a disease-free survival of 5 months and was successfully bridged to hematopoietic stem cell transplantation. Conclusion Our study provides support for the argument that CNS involvement should not be deemed an absolute contraindication to CAR-T cell therapy. With the implementation of suitable management and treatment strategies, CAR-T therapy can proficiently target tumor cells within the CNS. This treatment option may be particularly beneficial for relapsed or refractory patients, as well as those with central nervous system involvement who have shown limited response to conventional therapies. Additionally, CAR-T cell therapy may serve as a valuable bridge to allogeneic hematopoietic stem cell transplantation (allo-HSCT) in these patients.
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Affiliation(s)
| | | | | | | | - Yu Jing
- Medical School of Chinese PLA, Department of Hematology in the Fifth Medical Center of PLA General Hospital, Beijing, China
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14
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Yoon JH, Lee S. Diagnostic and therapeutic advances in adults with acute lymphoblastic leukemia in the era of gene analysis and targeted immunotherapy. Korean J Intern Med 2024; 39:34-56. [PMID: 38225824 PMCID: PMC10790045 DOI: 10.3904/kjim.2023.407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/03/2023] [Accepted: 12/23/2023] [Indexed: 01/17/2024] Open
Abstract
Acute lymphoblastic leukemia (ALL) is one of the most rapidly changing hematological malignancies with advanced understanding of the genetic landscape, detection methods of minimal residual disease (MRD), and the development of immunotherapeutic agents with good clinical outcomes. The annual incidence of adult ALL in Korea is 300-350 patients per year. The WHO classification of ALL was revised in 2022 to reflect the molecular cytogenetic features and suggest new adverse- risk subgroups, such as Ph-like ALL and ETP-ALL. We continue to use traditional adverse-risk features and cytogenetics, with MRD-directed post-remission therapy including allogeneic hematopoietic cell transplantation. However, with the introduction of novel agents, such as ponatinib, blinatumomab, and inotuzumab ozogamicin incorporated into frontline therapy, good MRD responses have been achieved, and overall survival outcomes are improving. Accordingly, some clinical trials have suggested a possible era of chemotherapy-free or transplantation-free approaches in the near future. Nevertheless, relapse of refractory ALL still occurs, and some poor ALL subtypes, such as Ph-like ALL and ETP-ALL, are unsolved problems for which novel agents and treatment strategies are needed. In this review, we summarize the currently applied diagnostic and therapeutic practices in the era of advanced genetic analysis and targeted immunotherapies in United States and Europe and introduce real-world Korean data.
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Affiliation(s)
- Jae-Ho Yoon
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok Lee
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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15
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Winestone LE, Bhojwani D, Ghorashian S, Muffly L, Leahy AB, Chao K, Steineck A, Rössig C, Lamble A, Maude SL, Myers R, Rheingold SR. INSPIRED Symposium Part 4A: Access to CAR T Cell Therapy in Unique Populations with B Cell Acute Lymphoblastic Leukemia. Transplant Cell Ther 2024; 30:56-70. [PMID: 37821078 DOI: 10.1016/j.jtct.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/06/2023] [Accepted: 10/06/2023] [Indexed: 10/13/2023]
Abstract
The approval of tisagenlecleucel (tisa-cel) for use in children with B cell acute lymphoblastic leukemia (B-ALL) was based on the phase 2 ELIANA trial, a global registration study. However, the ELIANA trial excluded specific subsets of patients facing unique challenges and did not include a sufficient number of patients to adequately evaluate outcomes in rare subpopulations. Since the commercialization of tisa-cel, data have become available that support therapeutic indications beyond the specific cohorts previously eligible for chimeric antigen receptor (CAR) T cells targeted to CD19 (CD19 CAR-T) therapy on the registration clinical trial. Substantial real-world data and aggregate clinical trial data have addressed gaps in our understanding of response rates, longer-term efficacy, and toxicities associated with CD19 CAR-T in special populations and rare clinical scenarios. These include patients with central nervous system relapsed disease, who were excluded from ELIANA and other early CAR-T trials owing to concerns about risk of neurotoxicity that have not been born out. There is also interest in the use of CD19 CAR-T for very-high-risk patients earlier in the course of therapy, such as patients with persistent minimal residual disease after 2 cycles of upfront chemotherapy and patients with first relapse of B-ALL. However, these indications are not specified on the label for tisa-cel and historically were not included in eligibility criteria for most clinical trials; data addressing these populations are needed. Populations at high risk of relapse, including patients with high-risk cytogenetic lesions, infants with B-ALL, patients with trisomy 21, and young adults with B-ALL, also may benefit from earlier treatment with CD19 CAR-T. It is important to prospectively study patient-reported outcomes given the differential toxicity expected between CD19 CAR-T and the historic standard of care, hematopoietic cell transplantation. Now that CD19 CAR-T therapy is commercially available, studies evaluating potential access disparities created by this very expensive novel therapy are increasingly pressing.
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Affiliation(s)
- Lena E Winestone
- Division of Allergy, Immunology, and BMT, Department of Pediatrics, UCSF Benioff Children's Hospitals, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California.
| | - Deepa Bhojwani
- Division of Pediatric Hematology-Oncology, Children's Hospital Los Angeles, Norris Comprehensive Cancer Center and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Sara Ghorashian
- Haematology Department, Great Ormond Street Hospital, London UK, Developmental Biology and Cancer, UCL-Great Ormond Street Institute of Child Health, University College London, London United Kingdom
| | - Lori Muffly
- Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford University, Stanford, California
| | - Allison Barz Leahy
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karen Chao
- Division of Hematology, Oncology, Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Angela Steineck
- MACC Fund Center for Cancer and Blood Disorders, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Claudia Rössig
- University Children's Hospital Muenster, Pediatric Hematology and Oncology, Muenster, Germany; Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Adam Lamble
- Division of Hematology and Oncology, Seattle Children's Hospital, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Shannon L Maude
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Regina Myers
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan R Rheingold
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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16
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McNerney KO, Hsieh EM, Shalabi H, Epperly R, Wolters PL, Hill JA, Gardner R, Talleur AC, Shah NN, Rossoff J. INSPIRED Symposium Part 3: Prevention and Management of Pediatric Chimeric Antigen Receptor T Cell-Associated Emergent Toxicities. Transplant Cell Ther 2024; 30:38-55. [PMID: 37821079 PMCID: PMC10842156 DOI: 10.1016/j.jtct.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/06/2023] [Accepted: 10/06/2023] [Indexed: 10/13/2023]
Abstract
Chimeric antigen receptor (CAR) T cell (CAR-T) therapy has emerged as a revolutionary cancer treatment modality, particularly in children and young adults with B cell malignancies. Through clinical trials and real-world experience, much has been learned about the unique toxicity profile of CAR-T therapy. The past decade brought advances in identifying risk factors for severe inflammatory toxicities, investigating preventive measures to mitigate these toxicities, and exploring novel strategies to manage refractory and newly described toxicities, infectious risks, and delayed effects, such as cytopenias. Although much progress has been made, areas needing further improvements remain. Limited guidance exists regarding initial administration of tocilizumab with or without steroids and the management of inflammatory toxicities refractory to these treatments. There has not been widespread adoption of preventive strategies to mitigate inflammation in patients at high risk of severe toxicities, particularly children. Additionally, the majority of research related to CAR-T toxicity prevention and management has focused on adult populations, with only a few pediatric-specific studies published to date. Given that children and young adults undergoing CAR-T therapy represent a unique population with different underlying disease processes, physiology, and tolerance of toxicities than adults, it is important that studies be conducted to evaluate acute, delayed, and long-term toxicities following CAR-T therapy in this younger age group. In this pediatric-focused review, we summarize key findings on CAR-T therapy-related toxicities over the past decade, highlight emergent CAR-T toxicities, and identify areas of greatest need for ongoing research.
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Affiliation(s)
- Kevin O McNerney
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Emily M Hsieh
- Pediatric Hematology/Oncology, Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Norris Comprehensive Cancer Center, Keck School of Medicine of USC, Los Angeles, California
| | - Haneen Shalabi
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Rebecca Epperly
- Department of Bone Marrow Transplant, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Pamela L Wolters
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Joshua A Hill
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Rebecca Gardner
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Aimee C Talleur
- Department of Bone Marrow Transplant, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jenna Rossoff
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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17
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Pieters R, Mullighan CG, Hunger SP. Advancing Diagnostics and Therapy to Reach Universal Cure in Childhood ALL. J Clin Oncol 2023; 41:5579-5591. [PMID: 37820294 PMCID: PMC10730082 DOI: 10.1200/jco.23.01286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/24/2023] [Accepted: 08/10/2023] [Indexed: 10/13/2023] Open
Abstract
Systemic combination chemotherapy and intrathecal chemotherapy markedly increased the survival rate of children with ALL. In the past two decades, the use of minimal (measurable) residual disease (MRD) measurements early in therapy improved risk group stratification with subsequent treatment intensifications for patients at high risk of relapse, and enabled a reduction of treatment for low-risk patients. The recent development of more sensitive MRD technologies may further affect risk stratification. Molecular genetic profiling has led to the discovery of many new subtypes and their driver genetic alterations. This increased our understanding of the biological basis of ALL, improved risk classification, and enabled implementation of precision medicine. In the past decade, immunotherapies, including bispecific antibodies, antibody-drug conjugates, and cellular therapies directed against surface proteins, led to more effective and less toxic therapies, replacing intensive chemotherapy courses and allogeneic stem-cell transplantation in patients with relapsed and refractory ALL, and are now being tested in newly diagnosed patients. It has taken 50-60 years to increase the cure rate in childhood ALL from 0% to 90% by stepwise improvements in chemotherapy. This review provides an overview of how the developments over the past 10-15 years mentioned above have significantly changed the diagnostic and treatment approach in ALL, and discusses how the integrated use of molecular and immunotherapeutic insights will very likely direct efforts to cure those children with ALL who are not cured today, and improve the quality of life for survivors who should have decades of life ahead. Future efforts must focus on making effective, yet very expensive, new technologies and therapies available to children with ALL worldwide.
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Affiliation(s)
- Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Charles G. Mullighan
- Department of Pathology and Hematological Malignancies Program, Comprehensive Cancer Center, St Jude Children's Research Hospital, Memphis, TN
| | - Stephen P. Hunger
- Division of Oncology, Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
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18
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Talleur AC, Naik S, Gottschalk S. Preventing relapse after CD19 CAR T-cell therapy for pediatric ALL: the role of transplant and enhanced CAR T cells. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:91-96. [PMID: 38066941 PMCID: PMC10727085 DOI: 10.1182/hematology.2023000424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
CD19-specific chimeric antigen receptor (CAR) T-cell therapy has become an integral part of our treatment armamentarium for pediatric patients with relapsed or refractory B-cell acute lymphoblastic leukemia (B-ALL). However, despite initial remission rates of greater than 80%, durable remission occurs in only 40% to 50% of patients. In this review we summarize our current knowledge of the role of consolidative hematopoietic cell transplantation in the management of pediatric patients who achieved a minimal residual disease-negative complete response post CD19 CAR T-cell therapy. In addition, we review approaches to enhance effector function CD19 CAR T cells, focusing on how to improve persistence and prevent the emergence of CD19- B-ALL blasts.
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Affiliation(s)
- Aimee C Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN
| | - Swati Naik
- Department of Bone Marrow Transplantation and Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN
| | - Stephen Gottschalk
- Department of Bone Marrow Transplantation and Cellular Therapy, St Jude Children's Research Hospital, Memphis, TN
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19
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Epperly R, Giordani VM, Mikkilineni L, Shah NN. Early and Late Toxicities of Chimeric Antigen Receptor T-Cells. Hematol Oncol Clin North Am 2023; 37:1169-1188. [PMID: 37349152 PMCID: PMC10592597 DOI: 10.1016/j.hoc.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
As chimeric antigen receptor (CAR) T-cell therapy is increasingly integrated into clinical practice across a range of malignancies, identifying and treating inflammatory toxicities will be vital to success. Early experiences with CD19-targeted CAR T-cell therapy identified cytokine release syndrome and neurotoxicity as key acute toxicities and led to unified initiatives to mitigate the influence of these complications. In this section, we provide an update on the current state of CAR T-cell-related toxicities, with an emphasis on emerging acute toxicities affecting additional organ systems and considerations for delayed toxicities and late effects.
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Affiliation(s)
- Rebecca Epperly
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, 262 Danny Thomas Place, MS 1130, Memphis, TN 38105, USA
| | - Victoria M Giordani
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Building 10, Room 1W-3750, 9000 Rockville Pike MSC 1104, Bethesda, MD 20892, USA; Pediatric Hematology/Oncology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Lekha Mikkilineni
- Blood and Marrow Transplantation & Cellular Therapy, Stanford University, Palo Alto, CA, USA; Stanford School of Medicine, 300 Pasteur Drive, Room H0101, Stanford, CA 94305, USA
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Building 10, Room 1W-3750, 9000 Rockville Pike MSC 1104, Bethesda, MD 20892, USA.
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20
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Song KW, Scott BJ, Lee EQ. Neurotoxicity of Cancer Immunotherapies Including CAR T Cell Therapy. Curr Neurol Neurosci Rep 2023; 23:827-839. [PMID: 37938472 DOI: 10.1007/s11910-023-01315-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 11/09/2023]
Abstract
PURPOSE OF REVIEW To outline the spectrum of neurotoxicity seen with approved immunotherapies and in pivotal clinical trials including immune checkpoint inhibitors, chimeric antigen receptor T-cell therapy, vaccine therapy, and oncolytic viruses. RECENT FINDINGS There has been an exponential growth in new immunotherapies, which has transformed the landscape of oncology treatment. With more widespread use of cancer immunotherapies, there have also been advances in characterization of its associated neurotoxicity, research into potential underlying mechanisms, and development of management guidelines. Increasingly, there is also mounting interest in long-term neurologic sequelae. Neurologic complications of immunotherapy can impact every aspect of the central and peripheral nervous system. Early recognition and treatment are critical. Expanding indications for immunotherapy to solid and CNS tumors has led to new challenges, such as how to reliably distinguish neurotoxicity from disease progression. Our evolving understanding of immunotherapy neurotoxicity highlights important areas for future research and the need for novel immunomodulatory therapeutics.
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Affiliation(s)
- Kun-Wei Song
- Department of Neurology, Stanford University School of Medicine, 453 Quarry Rd, 2nd Floor, Stanford, CA, 94305, USA.
| | - Brian J Scott
- Department of Neurology, Stanford University School of Medicine, 453 Quarry Rd, 2nd Floor, Stanford, CA, 94305, USA
| | - Eudocia Q Lee
- Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, 450 Brookline Avenue, Boston, MA, 02215, USA
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21
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Andrew EC, Hughes D, Gilsenan M, Mignone C, Khaw SL, Wang SS. Severe persistent neurotoxicity associated with CAR T therapy in children. Br J Haematol 2023; 203:651-655. [PMID: 37528536 DOI: 10.1111/bjh.19015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/20/2023] [Indexed: 08/03/2023]
Abstract
CD19-directed chimeric antigen receptor (CAR) T-cell therapy is an important therapy for relapsed or refractory acute lymphoblastic leukaemia, but its use carries the risk of immune effector cell-associated neurotoxicity syndrome (ICANS). In children, severe ICANS is almost universally reported in association with cytokine release syndrome and is reversible. We describe two cases of severe, intractable neurotoxicity following CAR T-cell therapy in children with pre-existing central nervous system (CNS) vulnerabilities. The cases were atypical in their delayed onset and independence from cytokine release syndrome and did not respond to standard therapies.
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Affiliation(s)
- Eden C Andrew
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - David Hughes
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Maddie Gilsenan
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Cristina Mignone
- Medical Imaging Department, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Seong Lin Khaw
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Stacie Shiqi Wang
- Children's Cancer Centre, Royal Children's Hospital, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
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22
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Lamble AJ, Moskop A, Pulsipher MA, Maude SL, Summers C, Annesley C, Baruchel A, Gore L, Amrolia P, Shah N. INSPIRED Symposium Part 2: Prevention and Management of Relapse Following Chimeric Antigen Receptor T Cell Therapy for B Cell Acute Lymphoblastic Leukemia. Transplant Cell Ther 2023; 29:674-684. [PMID: 37689393 DOI: 10.1016/j.jtct.2023.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/30/2023] [Indexed: 09/11/2023]
Abstract
Although CD19-directed chimeric antigen receptor (CAR) T cell therapy (CAR-T) for relapsed/refractory B cell acute lymphoblastic leukemia (B-ALL) has been transformative in inducing and sustaining remission, relapse rates remain unacceptably high, with approximately 50% of children and young adults experiencing relapse within the first year postinfusion. Emerging strategies to extend the durability of remission involve the use of prognostic biomarkers to identify those at high risk of relapse or incorporate strategies aimed to enhancing functional CAR T cell persistence. Nonetheless, with antigen loss/down-regulation or evolution to lineage switch as major mechanisms of relapse, optimizing single antigen targeting alone is insufficient. Here, with a focus on relapse prevention strategies, including postinfusion surveillance and treatment approaches being explored to optimize post-CAR-T management (eg, combinatorial antigen targeting strategies, preemptive hematopoietic cell transplantation), we review the current state of the art in the prevention and management of post CAR-T relapse. We highlight the advancements in the field and identify gaps in the literature to guide future research in optimizing the prevention and management of post-CAR-T relapse in children and young adults with B-ALL.
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Affiliation(s)
- Adam J Lamble
- Division of Hematology/Oncology, University of Washington, Seattle Children's Hospital, Seattle, Washington.
| | - Amy Moskop
- Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, Wisconsin
| | - Michael A Pulsipher
- Division of Hematology and Oncology, Intermountain Primary Children's Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah
| | - Shannon L Maude
- Division of Oncology, Cell Therapy and Transplant Section, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Corinne Summers
- Division of Hematology/Oncology, University of Washington, Seattle Children's Hospital, Seattle, Washington; Fred Hutchinson Cancer Center, Seattle, Washington
| | - Colleen Annesley
- Division of Hematology/Oncology, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - André Baruchel
- Pediatric Hematology Department, Robert Debré University Hospital, AP-HP and Université Paris Cité, Paris, France
| | - Lia Gore
- Pediatric Hematology/Oncology/BMT-CT, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| | - Persis Amrolia
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - Nirali Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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23
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Saleh K, Pasquier F, Bigenwald C, De Botton S, Ribrag V, Castilla-Llorente C. CAR T-Cells for the Treatment of B-Cell Acute Lymphoblastic Leukemia. J Clin Med 2023; 12:6883. [PMID: 37959347 PMCID: PMC10647582 DOI: 10.3390/jcm12216883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 10/22/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
B-cell acute lymphoblastic leukemia (B-ALL) is the most common subtype of acute leukemia in the pediatric population. The prognosis and treatment of B-ALL have dramatically improved over the past decade with the adoption of intensive and prolonged combination chemotherapy regimens. The advent of novel immunologic agents such as blinatumomab and inotuzumab has changed the treatment landscape of B-ALL. However, patients have continued to relapse, raising the need for novel therapies. Chimeric antigen receptor (CAR) T-cells have achieved a milestone in the treatment of B-ALL. Two CD19-targeting CAR T-cells were approved by the Food and Drug Administration and the European Medicines Agency for the treatment of relapsed and/or refractory B-ALL. In this review, we review the available data regarding CD19-targeting CAR T-cells with their safety profile as well as the mechanism of resistance to these agents and the way to overcome this resistance.
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Affiliation(s)
- Khalil Saleh
- International Department, Gustave Roussy Cancer Campus, 94800 Villejuif, France;
| | - Florence Pasquier
- Department of Hematology, Gustave Roussy Cancer Campus, 94800 Villejuif, France; (F.P.); (C.B.); (S.D.B.); (V.R.)
| | - Camille Bigenwald
- Department of Hematology, Gustave Roussy Cancer Campus, 94800 Villejuif, France; (F.P.); (C.B.); (S.D.B.); (V.R.)
| | - Stéphane De Botton
- Department of Hematology, Gustave Roussy Cancer Campus, 94800 Villejuif, France; (F.P.); (C.B.); (S.D.B.); (V.R.)
| | - Vincent Ribrag
- Department of Hematology, Gustave Roussy Cancer Campus, 94800 Villejuif, France; (F.P.); (C.B.); (S.D.B.); (V.R.)
- Département D’innovation Thérapeutique et D’essais Précoces (DITEP), Gustave Roussy Cancer Campus, 94800 Villejuif, France
| | - Cristina Castilla-Llorente
- Department of Hematology, Gustave Roussy Cancer Campus, 94800 Villejuif, France; (F.P.); (C.B.); (S.D.B.); (V.R.)
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24
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Epperly R, Shulkin BL, Bag AK, Cheng C, Inaba H, Lucas JT, Naik S, Triplett BM, Gottschalk S, Talleur AC. CD19 CAR T-cell therapy demonstrates activity against extramedullary disease in pediatric patients with B-ALL. Blood Adv 2023; 7:6320-6324. [PMID: 37595052 PMCID: PMC10589782 DOI: 10.1182/bloodadvances.2023010461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/18/2023] [Accepted: 08/10/2023] [Indexed: 08/20/2023] Open
Affiliation(s)
- Rebecca Epperly
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN
| | - Barry L. Shulkin
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, TN
| | - Asim K. Bag
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, TN
| | - Cheng Cheng
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN
| | - Hiroto Inaba
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | - John T. Lucas
- Department of Radiation Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Swati Naik
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN
| | - Brandon M. Triplett
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN
| | - Stephen Gottschalk
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN
| | - Aimee C. Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN
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25
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Myers RM, Jacoby E, Pulsipher MA, Pasquini MC, Grupp SA, Shah NN, Laetsch TW, Curran KJ, Schultz LM. INSPIRED Symposium Part 1: Clinical Variables Associated with Improved Outcomes for Children and Young Adults treated with Chimeric Antigen Receptor T cells for B cell Acute Lymphoblastic Leukemia. Transplant Cell Ther 2023; 29:598-607. [PMID: 37481241 PMCID: PMC11031134 DOI: 10.1016/j.jtct.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/16/2023] [Indexed: 07/24/2023]
Abstract
Chimeric antigen receptor (CAR) T cell therapy (CAR-T) targeting the CD19 antigen on B cell acute lymphoblastic leukemia (B-ALL) has transitioned from a highly investigational therapy with limited access to a commercial therapy with established toxicities, response and survival rates, and access in numerous countries. With more than a decade of clinical study and 5 years of commercial access, data showing associations with success and failure have emerged. To address functional limitations of CAR-T and overcome constrained sample sizes when studying single-trial or single-center data, collaborative groups, including the Pediatric Real World CAR Consortium, the CAR-Multicenter Analysis, the Center for International Blood and Marrow Transplant Research, and the International BFM Study Group, among others, have been retrospectively interrogating the amassed clinical experience. The high patient numbers and varied clinical experiences compiled by these groups have defined clinical variables impacting CAR-T outcomes. Here we review published CAR-T trials and consortium/collaborative outcomes to establish variables associated with optimal response to CAR-T in children and young adults with B-ALL. We focus on findings with clinical relevance that have emerged, including data implicating pretreatment disease burden, presence of extramedullary disease, nonresponse to prior CD19 antigen targeting (blinatumomab therapy), CAR T cell dose, and fludarabine pharmacokinetics as factors impacting post-CAR-T survival. Additionally, we address the role of collaborative efforts going forward in guiding clinical practice evolution and further optimizing post-CAR-T outcomes.
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Affiliation(s)
- Regina M Myers
- Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elad Jacoby
- Division of Pediatric Hematology, Oncology and BMT, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
| | - Michael A Pulsipher
- Intermountain Primary Children's Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah
| | - Marcelo C Pasquini
- Medical College of Wisconsin/Center for International Blood and Marrow Transplant Research, Milwaukee, Wisconsin
| | - Stephan A Grupp
- Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Theodore W Laetsch
- Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kevin J Curran
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Liora M Schultz
- Department of Pediatrics, Division of Hematology and Oncology, Stanford University School of Medicine, Palo Alto, California, USA.
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26
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Sun S, Ding Z, Gao L, Hammock BD, Huang X, Xu ZP, Wang X, Cheng Q, Mo F, Shi W, Xie S, Liu A, Li H, Yang X, Lu X. A dendritic/tumor fusion cell vaccine enhances efficacy of nanobody-based CAR-T cells against solid tumor. Theranostics 2023; 13:5099-5113. [PMID: 37771772 PMCID: PMC10526666 DOI: 10.7150/thno.84946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023] Open
Abstract
Background: Chimeric antigen receptor (CAR) T-cell therapy is practical in treating cancers of hematopoietic origin, but of that in solid tumors compromises efficacy for the loss of the antigen recognized by the CAR. However, dendritic cell (DC)/tumor fusion vaccines present a spectrum of known or unknown tumor antigens to stimulate T cell expansion and enhanced T cell response. Developing a new strategy of enhanced nanobody-based CAR-T (Nb-CAR-T) cells antitumor activity by DC/tumor fusion vaccines stimulation would provide guidance for more effective CAR-T cell therapies. Methods: Considering the therapeutic potential of nanobody (Nb), we first screened EGFRvIII Nb, then constructed and verified the function of EGFRvIII Nb-CAR-T cells in vitro and in vivo. We further combined DC/tumor fusion vaccines to boost EGFRvIII Nb-CAR-T cells antitumor effect, which was evaluated in vitro Nb-CAR-T cell function and in the tumor-bearing xenograft mouse models. Results: We had for the first time successfully selected EGFRvIII Nb for the generation of the novel EGFRvIII Nb-CAR-T cells. Importantly, our results suggested that DC/tumor fusion vaccines stimulate Nb-CAR-T cells response not only in improving T cell proliferation, T cell activation, cytokine secretion and tumor-specific cytotoxicity in vitro, but also significantly reducing tumor burden, prolonging survival and improving Nb-CAR-T cells infiltration. Conclusions: We have innovatively shown that DC/tumor fusion vaccines significantly enhance the efficacy of Nb-CAR-T cells against solid tumors. This new strategy has provided a promising therapeutic platform for promoting the clinical treatment of CAR-T cells therapy.
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Affiliation(s)
- Shuyang Sun
- College of Stomatology/ Hospital of Stomatology/ School of Basic Medical Sciences/ Guangxi Key Laboratory of Nanobody Research/ Guangxi Nanobody Engineering Research Center/ Laboratory Animal Center/ Pharmaceutical College/ Affiliated Tumor Hospital, Guangxi Medical University, Nanning, 530021, China
| | - Ziqiang Ding
- College of Stomatology/ Hospital of Stomatology/ School of Basic Medical Sciences/ Guangxi Key Laboratory of Nanobody Research/ Guangxi Nanobody Engineering Research Center/ Laboratory Animal Center/ Pharmaceutical College/ Affiliated Tumor Hospital, Guangxi Medical University, Nanning, 530021, China
| | - Li Gao
- College of Stomatology/ Hospital of Stomatology/ School of Basic Medical Sciences/ Guangxi Key Laboratory of Nanobody Research/ Guangxi Nanobody Engineering Research Center/ Laboratory Animal Center/ Pharmaceutical College/ Affiliated Tumor Hospital, Guangxi Medical University, Nanning, 530021, China
| | - Bruce D. Hammock
- UCD Comprehensive Cancer Center, Department of Entomology and Nematology, University of California, Davis, CA 95616, USA
| | - Xianing Huang
- College of Stomatology/ Hospital of Stomatology/ School of Basic Medical Sciences/ Guangxi Key Laboratory of Nanobody Research/ Guangxi Nanobody Engineering Research Center/ Laboratory Animal Center/ Pharmaceutical College/ Affiliated Tumor Hospital, Guangxi Medical University, Nanning, 530021, China
| | - Zhi Ping Xu
- Australian Institute for Bioengineering and Nanotechnology, University of Queensland, Brisbane, QLD 4072, Australia
| | - Xuan Wang
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Qihong Cheng
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Fengzhen Mo
- College of Stomatology/ Hospital of Stomatology/ School of Basic Medical Sciences/ Guangxi Key Laboratory of Nanobody Research/ Guangxi Nanobody Engineering Research Center/ Laboratory Animal Center/ Pharmaceutical College/ Affiliated Tumor Hospital, Guangxi Medical University, Nanning, 530021, China
| | - Wei Shi
- College of Stomatology/ Hospital of Stomatology/ School of Basic Medical Sciences/ Guangxi Key Laboratory of Nanobody Research/ Guangxi Nanobody Engineering Research Center/ Laboratory Animal Center/ Pharmaceutical College/ Affiliated Tumor Hospital, Guangxi Medical University, Nanning, 530021, China
| | - Shenxia Xie
- College of Stomatology/ Hospital of Stomatology/ School of Basic Medical Sciences/ Guangxi Key Laboratory of Nanobody Research/ Guangxi Nanobody Engineering Research Center/ Laboratory Animal Center/ Pharmaceutical College/ Affiliated Tumor Hospital, Guangxi Medical University, Nanning, 530021, China
| | - Aiqun Liu
- College of Stomatology/ Hospital of Stomatology/ School of Basic Medical Sciences/ Guangxi Key Laboratory of Nanobody Research/ Guangxi Nanobody Engineering Research Center/ Laboratory Animal Center/ Pharmaceutical College/ Affiliated Tumor Hospital, Guangxi Medical University, Nanning, 530021, China
| | - Haixia Li
- College of Stomatology/ Hospital of Stomatology/ School of Basic Medical Sciences/ Guangxi Key Laboratory of Nanobody Research/ Guangxi Nanobody Engineering Research Center/ Laboratory Animal Center/ Pharmaceutical College/ Affiliated Tumor Hospital, Guangxi Medical University, Nanning, 530021, China
| | - Xiaomei Yang
- College of Stomatology/ Hospital of Stomatology/ School of Basic Medical Sciences/ Guangxi Key Laboratory of Nanobody Research/ Guangxi Nanobody Engineering Research Center/ Laboratory Animal Center/ Pharmaceutical College/ Affiliated Tumor Hospital, Guangxi Medical University, Nanning, 530021, China
| | - Xiaoling Lu
- College of Stomatology/ Hospital of Stomatology/ School of Basic Medical Sciences/ Guangxi Key Laboratory of Nanobody Research/ Guangxi Nanobody Engineering Research Center/ Laboratory Animal Center/ Pharmaceutical College/ Affiliated Tumor Hospital, Guangxi Medical University, Nanning, 530021, China
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27
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Maese LD, Pulsipher MA. Blinatumomab Conundrum in Low-Risk Relapsed B-Cell ALL. J Clin Oncol 2023; 41:4087-4092. [PMID: 37311171 DOI: 10.1200/jco.23.00594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/03/2023] [Accepted: 04/28/2023] [Indexed: 06/15/2023] Open
Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. BACKGROUND The Children's Oncology Group (COG) AALL1331 trial demonstrated improved survival and less toxicity in children with high-/intermediate-risk relapsed ALL receiving blinatumomab compared with intensive chemotherapy before hematopoietic stem-cell transplant (HSCT). The low-risk arm of AALL1331 compared addition of three cycles of blinatumomab to chemotherapy alone, but a survival improvement was not noted. Secondary analyses showed improvement in disease-free survival (DFS) and overall survival (OS) of low-risk patients with bone marrow disease ± extramedullary (EM) involvement (4-year DFS 72.7% ± 5.8% v 53.7% ± 6.7%; 4-year OS 97.1% ± 2.1% v 84.8% ± 4.8%), but failed to show an advantage with blinatumomab for patients with isolated EM relapse. Of note, DFS of isolated CNS (iCNS) relapse was worse than previous studies at 24% on both arms, likely because of decreases in CNS-intensive therapy compared with previous approaches and inadequacy of blinatumomab for controlling CNS disease. CASE Our case of late isolated CNS B-cell ALL relapse outlines challenges for clinicians attempting to decrease toxicity and avoid HSCT: (1) defining of low risk appropriately, (2) attempting to reduce the treatment burden of past protocols, and (3) understanding approach and timing of cranial irradiation. APPROACH Although AALL1331 therapy without blinatumomab leads to excellent survival in patients with isolated testicular relapse, we recommend a modified AALL02P2 backbone of chemotherapy with 1,800 cGy cranial radiotherapy for patients with late iCNS relapse. Future studies integrating chimeric antigen receptor T cells, which have better CNS penetration, may help decrease the intensive treatment burden for patients with late iCNS recurrence.
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Affiliation(s)
- Luke D Maese
- Intermountain Primary Children's Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
| | - Michael A Pulsipher
- Intermountain Primary Children's Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
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28
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Holland EM, Yates B, Steinberg SM, Yuan CM, Wang HW, Annesley C, Shalabi H, Stroncek D, Fry TJ, Krueger J, Jacoby E, Hsieh E, Bhojwani D, Gardner RA, Maude SL, Shah NN. Chimeric Antigen Receptor T Cells as Salvage Therapy for Post-Chimeric Antigen Receptor T Cell Failure. Transplant Cell Ther 2023; 29:574.e1-574.e10. [PMID: 37394115 PMCID: PMC10529970 DOI: 10.1016/j.jtct.2023.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/09/2023] [Accepted: 06/28/2023] [Indexed: 07/04/2023]
Abstract
Outcomes for post-chimeric antigen receptor (CAR) T cell therapy (CART) relapse are poor. The utilization of a unique CAR T cell construct for post-CART failure is increasing, but this approach is not well described. In this study, with CART-A the first unique CAR T cell construct received and CART-B the second, the primary objective was to characterize outcomes following CART-B. Secondary objectives included evaluating safety and toxicity with sequential CART infusions; investigating the impact of potential factors, such as antigen modulation and interval therapy, on CART-B response; and characterizing long-term outcomes in patients receiving multiple CARTs. This was a retrospective review (NCT03827343) of children and young adults with B cell acute lymphoblastic leukemia (B-ALL) undergoing CART therapy who received at least 2 unique CART constructs, excluding interim CART reinfusions of the same product. Of 135 patients, 61 (45.1%) received 2 unique CART constructs, including 13 who received >2 CARTs over time. Patients included in this analysis received 14 distinct CARTs targeting CD19 and/or CD22. The median age at CART-A was 12.6 years (range, 3.3 to 30.4 years). The median time from CART-A to CART-B was 302 days (range, 53 to 1183 days). CART-B targeted a different antigen than CART-A in 48 patients (78.7%), owing primarily to loss of CART-A antigen target. The rate of complete remission (CR) was lower with CART-B (65.5%; 40 of 61) than with CART-A (88.5%; 54 of 61; P = .0043); 35 of 40 (87.5%) CART-B responders had CART-B targeting a different antigen than CART-A. Among the 21 patients with a partial response or nonresponse to CART-B, 8 (38.1%) received CART-B with the same antigen target as CART-A. Of 40 patients with CART-B complete response (CR), 29 (72.5%) relapsed. For the 21 patients with evaluable data, the relapse immunophenotype was antigennegative in 3 (14.3%), antigendim in 7 (33.3%), antigenpositive in 10 (47.6%), and lineage switch in 1 (4.8%). The median relapse-free survival following CART-B CR was 9.4 months (95% confidence interval [CI], 6.1 to 13.2 months), and overall survival was 15.0 months (95% CI, 13.0 to 22.7 months). Given the limited salvage options for post-CART relapse, identifying optimizing strategies for CART-B is critical. We raise awareness about the emerging use of CART for post-CART failure and highlight clinical implications accompanying this paradigm shift.
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Affiliation(s)
- Elizabeth M Holland
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Bonnie Yates
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Seth M Steinberg
- Biostatistics and Data Management Section, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Constance M Yuan
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Hao-Wei Wang
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Colleen Annesley
- Division of Hematology and Oncology University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Haneen Shalabi
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - David Stroncek
- Center for Cellular Engineering, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Terry J Fry
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland; University of Colorado Anschutz Medical Campus and Center for Cancer and Blood Disorders, Children's Hospital of Colorado, Aurora, Colorado
| | - Joerg Krueger
- Bone Marrow Transplant/Cell Therapy Section, Division of Hematology/Oncology, SickKids, Toronto, Ontario, Canada
| | - Elad Jacoby
- Pediatric Hemato-Oncology, Sheba Medical Center and Tel Aviv University, Tel Aviv, Israel
| | - Emily Hsieh
- Hematology/Oncology, Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Deepa Bhojwani
- Hematology/Oncology, Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Rebecca A Gardner
- Division of Hematology and Oncology University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Shannon L Maude
- Division of Oncology, Cell Therapy and Transplant Section, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
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29
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Xia Y, Sun T, Li G, Li M, Wang D, Su X, Ye J, Ji C. Spatial single cell analysis of tumor microenvironment remodeling pattern in primary central nervous system lymphoma. Leukemia 2023; 37:1499-1510. [PMID: 37120690 PMCID: PMC10317840 DOI: 10.1038/s41375-023-01908-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 05/01/2023]
Abstract
To determine the overall tumor microenvironment (TME), characteristics, and transition mechanisms in primary central nervous system lymphoma (PCNSL), we performed spatial transcriptomics and matched the corresponding single-cell sequencing data of PCNSL patients. We found that tumor cells may achieve a "TME remodeling pattern" through an "immune pressure-sensing model", in which they could choose to reshape the TME into a barrier environment or a cold environment according to the immune pressure. A key FKBP5+ tumor subgroup was found to be responsible for pushing tumors into the barrier environment, which provides a possible way to evaluate the stage of PCNSL. The specific mechanism of the TME remodeling pattern and the key molecules of the immune pressure-sensing model were identified through the spatial communication analysis. Finally, we discovered the spatial and temporal distributions and variation characteristics of immune checkpoint molecules and CAR-T target molecules in immunotherapy. These data clarified the TME remodeling pattern of PCNSL, provided a reference for its immunotherapy, and provided suggestions for the TME remodeling mechanism of other cancers.
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Affiliation(s)
- Yuan Xia
- Department of Hematology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, 250012, PR China
| | - Tao Sun
- Department of Hematology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, 250012, PR China
- Shandong Key Laboratory of Immunohematology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, 250012, PR China
| | - Guosheng Li
- Department of Hematology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, 250012, PR China
- Shandong Key Laboratory of Immunohematology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, 250012, PR China
| | - Mingying Li
- Department of Hematology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, 250012, PR China
| | - Dongmei Wang
- Department of Hematology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, 250012, PR China
| | - Xiuhua Su
- Department of Hematology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, 250012, PR China
| | - Jingjing Ye
- Department of Hematology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, 250012, PR China.
- Shandong Key Laboratory of Immunohematology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, 250012, PR China.
| | - Chunyan Ji
- Department of Hematology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, 250012, PR China.
- Shandong Key Laboratory of Immunohematology, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, 250012, PR China.
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30
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Talleur AC, Pui CH, Karol SE. What is Next in Pediatric B-cell Precursor Acute Lymphoblastic Leukemia. LYMPHATICS 2023; 1:34-44. [PMID: 38269058 PMCID: PMC10804398 DOI: 10.3390/lymphatics1010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Cure rates now exceed 90% in many contemporary trials for children with B-cell acute lymphoblastic leukemia (ALL). However, treatment remains suboptimal and therapy is toxic for all patients. New treatment options potentially offer the chance to reduce both treatment resistance and toxicity. Here, we review recent advances in ALL diagnostics, chemotherapy, and immunotherapy. In addition to describing recently published results, we also attempt to project the impact of these new developments into the future to imagine what B-ALL therapy may look like in the next few years.
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Affiliation(s)
- Aimee C Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Seth E Karol
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
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31
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Santomasso BD, Gust J, Perna F. How I treat unique and difficult-to-manage cases of CAR T-cell therapy-associated neurotoxicity. Blood 2023; 141:2443-2451. [PMID: 36877916 PMCID: PMC10329188 DOI: 10.1182/blood.2022017604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/01/2023] [Accepted: 02/17/2023] [Indexed: 03/08/2023] Open
Abstract
With growing indications for chimeric antigen receptor (CAR) T-cell therapy, toxicity profiles are evolving. There is an urgent and unmet need of approaches to optimally manage emerging adverse events that extend beyond the standard paradigm of cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome (ICANS). Although management guidelines exist for ICANS, there is little guidance on how to approach patients with neurologic comorbidities, and how to manage rare neurotoxicity presentations, such as CAR T-cell therapy-related cerebral edema, severe motor complications or late-onset neurotoxicity. In this study, we present 3 scenarios of patients treated with CAR T cells who develop unique types of neurotoxicity, and we describe an approach for the evaluation and management based on experience because objective data are limited. The goal of this study is to develop an awareness of emerging and unusual complications, discuss treatment approaches, and help institutions and health care providers establish frameworks to navigate how to best address unusual neurotoxicities to ultimately improve patient outcomes.
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Affiliation(s)
- Bianca D. Santomasso
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Juliane Gust
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, WA
- Seattle Children's Research Institute Center for Integrative Brain Research, Seattle, WA
| | - Fabiana Perna
- Division of Hematology/Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
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32
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Velasco R, Mussetti A, Villagrán-García M, Sureda A. CAR T-cell-associated neurotoxicity in central nervous system hematologic disease: Is it still a concern? Front Neurol 2023; 14:1144414. [PMID: 37090983 PMCID: PMC10117964 DOI: 10.3389/fneur.2023.1144414] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 03/06/2023] [Indexed: 04/25/2023] Open
Abstract
Chimeric antigen receptor (CAR) T-cell systemic immunotherapy has revolutionized how clinicians treat several refractory and relapsed hematologic malignancies. Due to its peculiar mechanism of action, CAR T-cell-based therapy has enlarged the spectrum of neurological toxicities. CAR T-cell-associated neurotoxicity-initially defined as CAR T-cell-related encephalopathy syndrome (CRES) and currently coined within the acronym ICANS (immune effector cell-associated neurotoxicity syndrome)-is perhaps the most concerning toxicity of CAR T-cell therapy. Importantly, hematologic malignancies (especially lymphoid malignancies) may originate in or spread to the central nervous system (CNS) in the form of parenchymal and/or meningeal disease. Due to the emergence of deadly and neurological adverse events, such as fatal brain edema in some patients included in early CAR T-cell trials, safety concerns for those with CNS primary or secondary infiltration arose and contributed to the routine exclusion of individuals with pre-existing or active CNS involvement from pivotal trials. However, based primarily on the lack of evidence, it remains unknown whether CNS involvement increases the risk and/or severity of CAR T-cell-related neurotoxicity. Given the limited treatment options available for patients once they relapse with CNS involvement, it is of high interest to explore the role of novel clinical strategies including CAR T cells to treat leukemias/lymphomas and myeloma with CNS involvement. The purpose of this review was to summarize currently available neurological safety data of CAR T-cell-based immunotherapy from the clinical trials and real-world experiences in adult patients with CNS disease due to lymphoma, leukemia, or myeloma. Increasing evidence supports that CNS involvement in hematologic disease should no longer be considered per se as an absolute contraindication to CAR T-cell-based therapy. While the incidence may be high, severity does not appear to be impacted significantly by pre-existing CNS status. Close monitoring by trained neurologists is recommended.
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Affiliation(s)
- Roser Velasco
- Neuro-Oncology Unit, Department of Neurology, Hospital Universitari de Bellvitge-Institut Català d'Oncologia, Barcelona, Spain
- Department of Cell Biology, Physiology and Immunology, Institute of Neurosciences, Cerdanyola del Vallés, Spain
| | - Alberto Mussetti
- Department of Hematology, Catalan Institute of Oncology, Hospital Duran i Reynals, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Macarena Villagrán-García
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, Hospices Civils de Lyon, Hôpital Neurologique, Bron. UMR MeLiS team SynatAc, INSERM1314/CNRS5284, Lyon, France
| | - Anna Sureda
- Department of Hematology, Catalan Institute of Oncology, Hospital Duran i Reynals, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- Medicine Department, Universitat de Barcelona, Barcelona, Spain
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33
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Aldoss I, Shah BD, Park JH, Muffly L, Logan AC, Brown P, Stock W, Jabbour EJ. Sequencing antigen-targeting antibodies and cellular therapies in adults with relapsed/refractory B-cell acute lymphoblastic leukemia. Am J Hematol 2023; 98:666-680. [PMID: 36691748 DOI: 10.1002/ajh.26853] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/15/2022] [Accepted: 01/17/2023] [Indexed: 01/25/2023]
Abstract
The recent approvals of four CD19-or CD22-targeted therapies for B-cell acute lymphoblastic leukemia (B-ALL) have transformed the treatment of relapsed/refractory (r/r) disease. Adults with r/r B-ALL are usually eligible for all options, but there are no studies directly comparing these agents, and the treating physician must decide which to select. Each therapy has notable activity as a single agent but has limitations in particular settings, and the optimal choice varies. These therapies can be complementary and used either sequentially or concomitantly. Here, we review the current landscape of antigen-targeted therapies for r/r B-ALL and discuss considerations for their use.
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Affiliation(s)
- Ibrahim Aldoss
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Bijal D Shah
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Jae H Park
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lori Muffly
- Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford University, Stanford, California, USA
| | - Aaron C Logan
- Division of Hematology/Oncology, University of California San Francisco Helen Diller Comprehensive Cancer Center, San Francisco, California, USA
| | | | - Wendy Stock
- Comprehensive Cancer Research Center, University of Chicago Medicine, Chicago, Illinois, USA
| | - Elias J Jabbour
- Division of Cancer Medicine, Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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34
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Gao Z, Lian Y, Ti J, Ren R, Ma L. Therapeutic efficacy and infectious complications of CD19-targeted chimeric antigen receptor-modified T cell immunotherapy. Anticancer Drugs 2023; 34:551-557. [PMID: 36728516 PMCID: PMC9997630 DOI: 10.1097/cad.0000000000001485] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 11/14/2022] [Indexed: 02/03/2023]
Abstract
Lymphocyte depletion chemotherapy CD19-targeted chimeric antigen receptor-modified T (CAR-T) cell immunotherapy is an innovative approach for the treatment of refractory or relapsed B-cell malignancies. This method also has the occurrence of infection, and there has been no systematic analysis of infectious complications. In our study, we intend to analyze the infection in patients between day 0 and day 90 by analyzing the data of 40 patients who received CD19 CAR-T cell therapy collected in our hospital. We assessed risk factors for infection before and after treatment using Poisson and Cox regression, respectively. A cohort study was used, including patients with acute lymphocytic leukemia, chronic lymphocytic leukemia and non-Hodgkin's lymphoma. 40 patients were infected for the first time occurred at a median of 6 days after CAR-T cell infusion, and 8 (20%) had 10 infections within 28 days after CAR-T cell infusion, on days 29 and 29. The infection density between 90 days was lower at 0.67. This resulted in an infection density of 1.19 infections per 100 days. Two patients (5%) developed invasive fungal infections and two patients (5%) developed life-threatening or fatal infections. In an adjusted model for baseline characteristics, patients with ALL, ≥4 prior antitumor regimens, and receiving the highest CAR-T cell dose had higher infection densities at 28 days. The incidence of infection was comparable to that observed in clinical trials of salvage associated with infection after CAR-T cell infusion.
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Affiliation(s)
- Zhilin Gao
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yu Lian
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Juanjuan Ti
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Ruirui Ren
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Liangming Ma
- Department of Hematology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
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35
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Kopmar NE, Cassaday RD. How I prevent and treat central nervous system disease in adults with acute lymphoblastic leukemia. Blood 2023; 141:1379-1388. [PMID: 36548957 PMCID: PMC10082377 DOI: 10.1182/blood.2022017035] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/28/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
The central nervous system (CNS) is the most important site of extramedullary disease in adults with acute lymphoblastic leukemia (ALL). Although CNS disease is identified only in a minority of patients at the time of diagnosis, subsequent CNS relapses (either isolated or concurrent with other sites) occur in some patients even after the delivery of prophylactic therapy targeted to the CNS. Historically, prophylaxis against CNS disease has included intrathecal (IT) chemotherapy and radiotherapy (RT), although the latter is being used with decreasing frequency. Treatment of a CNS relapse usually involves intensive systemic therapy and cranial or craniospinal RT along with IT therapy and consideration of allogeneic hematopoietic cell transplant. However, short- and long-term toxicities can make these interventions prohibitively risky, particularly for older adults. As new antibody-based immunotherapy agents have been approved for relapsed/refractory B-cell ALL, their use specifically for patients with CNS disease is an area of keen interest not only because of the potential for efficacy but also concerns of unique toxicity to the CNS. In this review, we discuss data-driven approaches for these common and challenging clinical scenarios as well as highlight how recent findings potentially support the use of novel immunotherapeutic strategies for CNS disease.
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Affiliation(s)
- Noam E. Kopmar
- Division of Hematology, Department of Medicine, University of Washington School of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Ryan D. Cassaday
- Division of Hematology, Department of Medicine, University of Washington School of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
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36
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Wang T, Tang Y, Cai J, Wan X, Hu S, Lu X, Xie Z, Qiao X, Jiang H, Shao J, Yang F, Ren H, Cao Q, Qian J, Zhang J, An K, Wang J, Luo C, Liang H, Miao Y, Ma Y, Wang X, Ding L, Song L, He H, Shi W, Xiao P, Yang X, Yang J, Li W, Zhu Y, Wang N, Gu L, Chen Q, Tang J, Yang JJ, Cheng C, Leung W, Chen J, Lu J, Li B, Pui CH. Coadministration of CD19- and CD22-Directed Chimeric Antigen Receptor T-Cell Therapy in Childhood B-Cell Acute Lymphoblastic Leukemia: A Single-Arm, Multicenter, Phase II Trial. J Clin Oncol 2023; 41:1670-1683. [PMID: 36346962 PMCID: PMC10419349 DOI: 10.1200/jco.22.01214] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/10/2022] [Accepted: 09/21/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We determined the safety and efficacy of coadministration of CD19- and CD22-chimeric antigen receptor (CAR) T cells in patients with refractory disease or high-risk hematologic or isolated extramedullary relapse of B-acute lymphoblastic leukemia. PATIENTS AND METHODS This phase II trial enrolled 225 evaluable patients age ≤ 20 years between September 17, 2019, and December 31, 2021. We first conducted a safety run-in stage to determine the recommended dose. After interim analysis of the first 30 patients treated (27 at the recommended dose) showing that the treatment was safe and effective, the study enrolled additional patients according to the study design. RESULTS Complete remission was achieved in 99.0% of the 194 patients with refractory leukemia or hematologic relapse, all negative for minimal residual disease. Their overall 12-month event-free survival (EFS) was 73.5% (95% CI, 67.3 to 80.3). Relapse occurred in 43 patients (24 with CD19+/CD22+ relapse, 16 CD19-/CD22+, one CD19-/CD22-, and two unknown). Consolidative transplantation and persistent B-cell aplasia at 6 months were associated with favorable outcomes. The 12-month EFS was 85.0% (95% CI, 77.2 to 93.6) for the 78 patients treated with transplantation and 69.2% (95% CI, 60.8 to 78.8) for the 116 nontransplanted patients (P = .03, time-dependent covariate Cox model). All 25 patients with persistent B-cell aplasia at 6 months remained in remission at 12 months. The 12-month EFS for the 20 patients with isolated testicular relapse was 95.0% (95% CI, 85.9 to 100), and for the 10 patients with isolated CNS relapse, it was 68.6% (95% CI, 44.5 to 100). Cytokine release syndrome developed in 198 (88.0%) patients, and CAR T-cell neurotoxicity in 47 (20.9%), resulting in three deaths. CONCLUSION CD19-/CD22-CAR T-cell therapy achieved relatively durable remission in children with relapsed or refractory B-acute lymphoblastic leukemia, including those with isolated or combined extramedullary relapse. [Media: see text].
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Affiliation(s)
- Tianyi Wang
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanjing Tang
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiaoyang Cai
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinyu Wan
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shaoyan Hu
- Department of Hematology/Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Xiaoxi Lu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Zhiwei Xie
- Department of Pediatrics, Anhui Medical University Second Affiliated Hospital, Anhui, China
| | - Xiaohong Qiao
- Department of Pediatrics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hui Jiang
- Department of Hematology/Oncology, Shanghai Children's Hospital, Shanghai, China
| | - Jingbo Shao
- Department of Hematology/Oncology, Shanghai Children's Hospital, Shanghai, China
| | - Fan Yang
- Department of Hematology/Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Hong Ren
- Department of Pediatric Intensive Care Unit, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qing Cao
- Department of Infectious Diseases, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Juan Qian
- Department of Pediatric Intensive Care Unit, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian Zhang
- Department of Pediatric Intensive Care Unit, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kang An
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianmin Wang
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chengjuan Luo
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huanhuan Liang
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Miao
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yani Ma
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiang Wang
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lixia Ding
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lili Song
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hailong He
- Department of Hematology/Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Wenhua Shi
- Department of Hematology/Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Peifang Xiao
- Department of Hematology/Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Xiaomin Yang
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Yang
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenjie Li
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiping Zhu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Ningling Wang
- Department of Pediatrics, Anhui Medical University Second Affiliated Hospital, Anhui, China
| | - Longjun Gu
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qimin Chen
- Department of Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingyan Tang
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun J. Yang
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN
| | - Cheng Cheng
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - Wing Leung
- Department of Pediatrics, University of Hong Kong, Hong Kong SAR, China
| | - Jing Chen
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Lu
- Department of Hematology/Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Benshang Li
- Department of Hematology/Oncology, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ching-Hon Pui
- Departments of Oncology, Pathology, and Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
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Jabbour E, Short NJ, Jain N, Haddad FG, Welch MA, Ravandi F, Kantarjian H. The evolution of acute lymphoblastic leukemia research and therapy at MD Anderson over four decades. J Hematol Oncol 2023; 16:22. [PMID: 36927623 PMCID: PMC10018889 DOI: 10.1186/s13045-023-01409-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/09/2023] [Indexed: 03/18/2023] Open
Abstract
Progress in the research and therapy of adult acute lymphoblastic leukemia (ALL) is accelerating. This analysis summarizes the data derived from the clinical trials conducted at MD Anderson between 1985 and 2022 across ALL subtypes. In Philadelphia chromosome-positive ALL, the addition of BCR::ABL1 tyrosine kinase inhibitors (TKIs) to intensive chemotherapy since 2000, improved outcomes. More recently, a chemotherapy-free regimen with blinatumomab and ponatinib resulted in a complete molecular remission rate of 85% and an estimated 3-year survival rate of 90%, potentially reducing the role of, and need for allogeneic stem cell transplantation (SCT) in remission. In younger patients with pre-B Philadelphia chromosome-negative ALL, the integration of blinatumomab and inotuzumab into the frontline therapy has improved the estimated 3-year survival rate to 85% across all risk categories. Our future strategy is to evaluate the early integration of both immunotherapy agents, inotuzumab and blinatumomab, with low-dose chemotherapy (dose-dense mini-Hyper-CVD-inotuzumab-blinatumomab) into the frontline setting followed by CAR T cells consolidation in high-risk patients, without any further maintenance therapy. In older patients, using less intensive chemotherapy (mini-Hyper-CVD) in combination with inotuzumab and blinatumomab has improved the 5-year survival rate to 50%. Among patients ≥ 65-70 years, the mortality in complete remission (CR) is still high and is multifactorial (old age, death in CR with infections, development of myelodysplastic syndrome or acute myeloid leukemia). A chemotherapy-free regimen with inotuzumab and blinatumomab is being investigated. The assessment of measurable residual disease (MRD) by next-generation sequencing (NGS) is superior to conventional assays, with early MRD negativity by NGS being associated with the best survival. We anticipate that the future therapy in B-ALL will involve less intensive and shorter chemotherapy regimens in combination with agents targeting CD19 (blinatumomab), CD20, and CD22 (inotuzumab). The optimal timing and use of CAR T cells therapy may be in the setting of minimal disease, and future trials will assess the role of CAR T cells as a consolidation among high-risk patients to replace allogeneic SCT. In summary, the management of ALL has witnessed significant progress during the past four decades. Novel combination regimens including newer-generation BCR::ABL1 TKIs and novel antibodies are questioning the need and duration of intensive chemotherapy and allogeneic SCT.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX, 77030, USA.
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX, 77030, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX, 77030, USA
| | - Fadi G Haddad
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX, 77030, USA
| | - Mary Alma Welch
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX, 77030, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX, 77030, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX, 77030, USA
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38
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Myers RM, Shah NN, Pulsipher MA. How I use risk factors for success or failure of CD19 CAR T cells to guide management of children and AYA with B-cell ALL. Blood 2023; 141:1251-1264. [PMID: 36416729 PMCID: PMC10082355 DOI: 10.1182/blood.2022016937] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 11/24/2022] Open
Abstract
By overcoming chemotherapeutic resistance, chimeric antigen receptor (CAR) T cells facilitate deep, complete remissions and offer the potential for long-term cure in a substantial fraction of patients with chemotherapy refractory disease. However, that success is tempered with 10% to 30% of patients not achieving remission and over half of patients treated eventually experiencing relapse. With over a decade of experience using CAR T cells in children, adolescents, and young adults (AYA) to treat relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL) and 5 years since the first US Food and Drug Administration approval, data defining the nuances of patient-specific risk factors are emerging. With the commercial availability of 2 unique CD19 CAR T-cell constructs for B-ALL, in this article, we review the current literature, outline our approach to patients, and discuss how individual factors inform strategies to optimize outcomes in children and AYA receiving CD19 CAR T cells. We include data from both prospective and recent large retrospective studies that offer insight into understanding when the risks of CAR T-cell therapy failure are high and offer perspectives suggesting when consolidative hematopoietic cell transplantation or experimental CAR T-cell and/or alternative immunotherapy should be considered. We also propose areas where prospective trials addressing the optimal use of CAR T-cell therapy are needed.
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Affiliation(s)
- Regina M. Myers
- Division of Oncology, Cell Therapy and Transplant Section, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Nirali N. Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Michael A. Pulsipher
- Division of Hematology and Oncology, Intermountain Primary Children’s Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
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39
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Newman H, Li Y, Liu H, Myers RM, Tam V, DiNofia A, Wray L, Rheingold SR, Callahan C, White C, Baniewicz D, Winestone LE, Kadauke S, Diorio C, June CH, Getz KD, Aplenc R, Teachey DT, Maude SL, Grupp SA, Bona K, Leahy AB. Impact of poverty and neighborhood opportunity on outcomes for children treated with CD19-directed CAR T-cell therapy. Blood 2023; 141:609-619. [PMID: 36351239 PMCID: PMC9979709 DOI: 10.1182/blood.2022017866] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/08/2022] [Accepted: 09/25/2022] [Indexed: 11/11/2022] Open
Abstract
Children living in poverty experience excessive relapse and death from newly diagnosed acute lymphoblastic leukemia (ALL). The influence of household poverty and neighborhood social determinants on outcomes from chimeric antigen receptor (CAR) T-cell therapy for relapsed/refractory (r/r) leukemia is poorly described. We identified patients with r/r CD19+ ALL/lymphoblastic lymphoma treated on CD19-directed CAR T-cell clinical trials or with commercial tisagenlecleucel from 2012 to 2020. Socioeconomic status (SES) was proxied at the household level, with poverty exposure defined as Medicaid-only insurance. Low-neighborhood opportunity was defined by the Childhood Opportunity Index. Among 206 patients aged 1 to 29, 35.9% were exposed to household poverty, and 24.9% had low-neighborhood opportunity. Patients unexposed to household poverty or low-opportunity neighborhoods were more likely to receive CAR T-cell therapy with a high disease burden (>25%), a disease characteristic associated with inferior outcomes, as compared with less advantaged patients (38% vs 30%; 37% vs 26%). Complete remission (CR) rate was 93%, with no significant differences by household poverty (P = .334) or neighborhood opportunity (P = .504). In multivariate analysis, patients from low-opportunity neighborhoods experienced an increased hazard of relapse as compared with others (P = .006; adjusted hazard ratio [HR], 2.3; 95% confidence interval [CI], 1.3-4.1). There was no difference in hazard of death (P = .545; adjusted HR, 1.2; 95% CI, 0.6-2.4). Among children who successfully receive CAR T-cell therapy, CR and overall survival are equitable regardless of proxied SES and neighborhood opportunity. Children from more advantaged households and neighborhoods receive CAR T-cell therapy with a higher disease burden. Investigation of multicenter outcomes and access disparities outside of clinical trial settings is warranted.
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Affiliation(s)
- Haley Newman
- Division of Oncology and Cancer Immunotherapy Program, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Yimei Li
- Division of Oncology and Cancer Immunotherapy Program, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Childhood Cancer Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Hongyan Liu
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Regina M. Myers
- Division of Oncology and Cancer Immunotherapy Program, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Vicky Tam
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Amanda DiNofia
- Division of Oncology and Cancer Immunotherapy Program, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Childhood Cancer Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Lisa Wray
- Division of Oncology and Cancer Immunotherapy Program, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Childhood Cancer Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Susan R. Rheingold
- Division of Oncology and Cancer Immunotherapy Program, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Childhood Cancer Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Colleen Callahan
- Division of Oncology and Cancer Immunotherapy Program, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Claire White
- Division of Oncology and Cancer Immunotherapy Program, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Diane Baniewicz
- Division of Oncology and Cancer Immunotherapy Program, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Lena E. Winestone
- Division of Allergy, Immunology, and Blood & Marrow Transplant, Department of Pediatrics, UCSF Benioff Children’s Hospitals, San Francisco, CA
| | - Stephan Kadauke
- Division of Transfusion Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Caroline Diorio
- Division of Oncology and Cancer Immunotherapy Program, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Carl H. June
- Parker Institute for Cancer Immunotherapy, University of Pennsylvania, Philadelphia, PA
| | - Kelly D. Getz
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Richard Aplenc
- Division of Oncology and Cancer Immunotherapy Program, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Childhood Cancer Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - David T. Teachey
- Division of Oncology and Cancer Immunotherapy Program, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Childhood Cancer Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Shannon L. Maude
- Division of Oncology and Cancer Immunotherapy Program, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Childhood Cancer Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Stephan A. Grupp
- Division of Oncology and Cancer Immunotherapy Program, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Childhood Cancer Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Kira Bona
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Boston Children’s Hospital, Boston, MA
- Department of Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Allison Barz Leahy
- Division of Oncology and Cancer Immunotherapy Program, Children’s Hospital of Philadelphia, Philadelphia, PA
- Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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40
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Dargenio M, Bonifacio M, Chiaretti S, Vitale A, Fracchiolla NS, Papayannidis C, Giglio F, Salutari P, Audisio E, Scappini B, Zappasodi P, Defina M, Forghieri F, Scattolin AM, Todisco E, Lunghi M, Guolo F, Del Principe MI, Annunziata M, Lazzarotto D, Cedrone M, Pasciolla C, Imovilli A, Tanasi I, Trappolini S, Cerrano M, La Starza R, Krampera M, Di Renzo N, Candoni A, Pizzolo G, Ferrara F, Foà R. Incidence, treatment and outcome of central nervous system relapse in adult acute lymphoblastic leukaemia patients treated front-line with paediatric-inspired regimens: A retrospective multicentre Campus ALL study. Br J Haematol 2023; 200:440-450. [PMID: 36335916 PMCID: PMC10098932 DOI: 10.1111/bjh.18537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/08/2022]
Abstract
Within the Campus ALL network we analyzed the incidence, characteristics, treatment and outcome of a central nervous system (CNS) relapse in 1035 consecutive adult acute lymphoblastic leukemia (ALL) patients treated frontline with pediatric-inspired protocols between 2009 and 2020. Seventy-one patients (6.8%) experienced a CNS recurrence, more frequently in T- (28/278; 10%) than in B-ALL (43/757; 5.7%) (p = 0.017). An early CNS relapse-< 12 months from diagnosis-was observed in 41 patients. In multivariate analysis, risk factors for early CNS relapse included T-cell phenotype (p = <0.001), hyperleucocytosis >100 × 109 /L (p<0.001) and male gender (p = 0.015). Treatment was heterogeneous, including chemotherapy, radiotherapy, intrathecal therapy and novel agents. A complete remission (CR) was obtained in 39 patients (55%) with no differences among strategies. After CR, 26 patients underwent an allogenic transplant, with a significant overall survival benefit compared to non-transplanted patients (p = 0.012). After a median observation of 8 months from CNS relapse, 23 patients (32%) were alive. In multivariate analysis, the time to CNS relapse was the strongest predictor of a lower 2-year post-relapse survival (p<0.001). In conclusion, in adult ALL the outcome after a CNS relapse remains very poor. Effective CNS prophylaxis remains the best approach and allogenic transplant should be pursued when possible.
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Affiliation(s)
- Michelina Dargenio
- Ospedale Vito Fazzi, Unità Operativa di Ematologia e Trapianto, Lecce, Italy
| | - Massimiliano Bonifacio
- Dipartimento di Medicina, Sezione di Ematologia, Università e Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Sabina Chiaretti
- Divisione di Ematologia, Dipartimento di Medicina Traslazionale e di Precisione, Università Sapienza, Rome, Italy
| | - Antonella Vitale
- Divisione di Ematologia, Dipartimento di Medicina Traslazionale e di Precisione, Università Sapienza, Rome, Italy
| | | | - Cristina Papayannidis
- IRCCS Azienda Ospedaliero-Universitaria, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Fabio Giglio
- Ospedale San Raffaele, Unità Operativa di Ematologia, Milan, Italy
| | - Prassede Salutari
- Unità Operativa Complessa di Ematologia, Ospedale Civile Spirito Santo, Pescara, Italy
| | - Ernesta Audisio
- Dipartimento di Ematologia e Oncologia, AO Città della Salute e della Scienza, Torino, Italy
| | | | - Patrizia Zappasodi
- Unità Operativa di Ematologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marzia Defina
- Unità Operativa Complessa di Ematologia, AOUS, Università di Siena, Siena, Italy
| | - Fabio Forghieri
- Unità Operativa Complessa di Ematologia, AOU Policlinico, Modena, Italy
| | | | - Elisabetta Todisco
- Unità Operativa Ematologia, Istituto Europeo di Oncologia (IEO), Milan, Italy
| | - Monia Lunghi
- Divisione di Ematologia, Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, Novara, Italy
| | - Fabio Guolo
- Clinica Ematologica, Dipartimento di Medicina Interna, Università degli Studi di Genova, Genoa, Italy.,Dipartimento di Oncologia e Ematologia, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Mario Annunziata
- Unità Operativa Complessa di Ematologia, AORN Cardarelli, Naples, Italy
| | - Davide Lazzarotto
- Clinica ematologica e centro trapianti, Azienda sanitaria universitaria Friuli Centrale, Udine, Italy
| | - Michele Cedrone
- Unità Operativa Complessa di Ematologia, Ospedale San Giovanni Addolorata, Rome, Italy
| | - Crescenza Pasciolla
- Unità Operativa di Ematologia, IRCCS Istituto Tumori Giovanni Paolo II, Bari, Italy
| | | | - Ilaria Tanasi
- Dipartimento di Medicina, Sezione di Ematologia, Università e Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Marco Cerrano
- Unità Operativa di Ematologia, Presidio Molinette-AOU Città della Salute e della Scienza, Torino, Italy
| | - Roberta La Starza
- Sezione di Ematologia e Trapianto, Università degli Studi di Perugia, A.O. Perugia, Italy
| | - Mauro Krampera
- Dipartimento di Medicina, Sezione di Ematologia, Università e Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Nicola Di Renzo
- Ospedale Vito Fazzi, Unità Operativa di Ematologia e Trapianto, Lecce, Italy
| | - Anna Candoni
- Unità Operativa Complessa di Ematologia, AORN Cardarelli, Naples, Italy
| | - Giovanni Pizzolo
- Dipartimento di Medicina, Sezione di Ematologia, Università e Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Felicetto Ferrara
- Dipartimento di Biomedicina e Prevenzione, Università degli studi Tor Vergata, Rome, Italy
| | - Robin Foà
- Divisione di Ematologia, Dipartimento di Medicina Traslazionale e di Precisione, Università Sapienza, Rome, Italy
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41
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Dean EA, Peters KR, Adams CB, Hiemenz JW. Pattern of brexucabtagene autoleucel-related neurotoxicity on magnetic resonance imaging of the brain in a patient with relapsed/refractory B-cell acute lymphoblastic leukemia and prior leptomeningeal disease. Radiol Case Rep 2023; 18:1093-1098. [PMID: 36660565 PMCID: PMC9842530 DOI: 10.1016/j.radcr.2022.12.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 12/21/2022] [Indexed: 01/08/2023] Open
Abstract
Immune effector cell-associated neurotoxicity syndrome (ICANS) secondary to chimeric antigen receptor T-cell therapy is common in adult patients with relapsed/refractory (R/R) B-cell acute lymphoblastic leukemia (ALL), but imaging findings during neurologic toxicity and their meaning have yet to be systematically described in this patient population. Brexucabtagene autoleucel (brexu-cel) is a CD19-directed autologous T-cell immunotherapy for the treatment of adult patients with R/R B-cell ALL that can enter the central nervous system. We present a case of an adult patient with R/R B-cell ALL and prior leptomeningeal disease who developed neurologic toxicity and new findings on magnetic resonance imaging of the brain while receiving brexu-cel. We interpret the patient's neuroimaging studies within clinical context to differentiate ICANS from active treatment of residual leukemia.
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Affiliation(s)
- Erin A. Dean
- Division of Hematology and Oncology, Department of Medicine, University of Florida, 1515 SW Archer Rd, Gainesville, FL, 32610, USA,Corresponding author.
| | - Keith R. Peters
- Department of Radiology, University of Florida, Gainesville, FL, USA
| | - Carolyn B. Adams
- Division of Hematology and Oncology, Department of Pharmacy, University of Florida, Gainesville, FL, USA
| | - John W. Hiemenz
- Division of Hematology and Oncology, Department of Medicine, University of Florida, 1515 SW Archer Rd, Gainesville, FL, 32610, USA
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42
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Shakirova A, Karpov T, Komarova Y, Lepik K. In search of an ideal template for therapeutic genome editing: A review of current developments for structure optimization. Front Genome Ed 2023; 5:1068637. [PMID: 36911237 PMCID: PMC9992834 DOI: 10.3389/fgeed.2023.1068637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/08/2023] [Indexed: 02/24/2023] Open
Abstract
Gene therapy is a fast developing field of medicine with hundreds of ongoing early-stage clinical trials and numerous preclinical studies. Genome editing (GE) now is an increasingly important technology for achieving stable therapeutic effect in gene correction, with hematopoietic cells representing a key target cell population for developing novel treatments for a number of hereditary diseases, infections and cancer. By introducing a double strand break (DSB) in the defined locus of genomic DNA, GE tools allow to knockout the desired gene or to knock-in the therapeutic gene if provided with an appropriate repair template. Currently, the efficiency of methods for GE-mediated knock-in is limited. Significant efforts were focused on improving the parameters and interaction of GE nuclease proteins. However, emerging data suggests that optimal characteristics of repair templates may play an important role in the knock-in mechanisms. While viral vectors with notable example of AAVs as a donor template carrier remain the mainstay in many preclinical trials, non-viral templates, including plasmid and linear dsDNA, long ssDNA templates, single and double-stranded ODNs, represent a promising alternative. Furthermore, tuning of editing conditions for the chosen template as well as its structure, length, sequence optimization, homology arm (HA) modifications may have paramount importance for achieving highly efficient knock-in with favorable safety profile. This review outlines the current developments in optimization of templates for the GE mediated therapeutic gene correction.
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Affiliation(s)
- Alena Shakirova
- RM Gorbacheva Research Institute of Pediatric Oncology, Hematology and Transplantation, Pavlov University, Saint Petersburg, Russia
| | - Timofey Karpov
- RM Gorbacheva Research Institute of Pediatric Oncology, Hematology and Transplantation, Pavlov University, Saint Petersburg, Russia.,Peter the Great St. Petersburg Polytechnic University, Saint Petersburg, Russia
| | - Yaroslava Komarova
- RM Gorbacheva Research Institute of Pediatric Oncology, Hematology and Transplantation, Pavlov University, Saint Petersburg, Russia
| | - Kirill Lepik
- RM Gorbacheva Research Institute of Pediatric Oncology, Hematology and Transplantation, Pavlov University, Saint Petersburg, Russia
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43
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Thastrup M, Duguid A, Mirian C, Schmiegelow K, Halsey C. Central nervous system involvement in childhood acute lymphoblastic leukemia: challenges and solutions. Leukemia 2022; 36:2751-2768. [PMID: 36266325 PMCID: PMC9712093 DOI: 10.1038/s41375-022-01714-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 09/17/2022] [Accepted: 09/22/2022] [Indexed: 11/10/2022]
Abstract
Delivery of effective anti-leukemic agents to the central nervous system (CNS) is considered essential for cure of childhood acute lymphoblastic leukemia. Current CNS-directed therapy comprises systemic therapy with good CNS-penetration accompanied by repeated intrathecal treatments up to 26 times over 2-3 years. This approach prevents most CNS relapses, but is associated with significant short and long term neurotoxicity. Despite this burdensome therapy, there have been no new drugs licensed for CNS-leukemia since the 1960s, when very limited anti-leukemic agents were available and there was no mechanistic understanding of leukemia survival in the CNS. Another major barrier to improved treatment is that we cannot accurately identify children at risk of CNS relapse, or monitor response to treatment, due to a lack of sensitive biomarkers. A paradigm shift in treating the CNS is needed. The challenges are clear - we cannot measure CNS leukemic load, trials have been unable to establish the most effective CNS treatment regimens, and non-toxic approaches for relapsed, refractory, or intolerant patients are lacking. In this review we discuss these challenges and highlight research advances aiming to provide solutions. Unlocking the potential of risk-adapted non-toxic CNS-directed therapy requires; (1) discovery of robust diagnostic, prognostic and response biomarkers for CNS-leukemia, (2) identification of novel therapeutic targets combined with associated investment in drug development and early-phase trials and (3) engineering of immunotherapies to overcome the unique challenges of the CNS microenvironment. Fortunately, research into CNS-ALL is now making progress in addressing these unmet needs: biomarkers, such as CSF-flow cytometry, are now being tested in prospective trials, novel drugs are being tested in Phase I/II trials, and immunotherapies are increasingly available to patients with CNS relapses. The future is hopeful for improved management of the CNS over the next decade.
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Affiliation(s)
- Maria Thastrup
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Alasdair Duguid
- Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, UK
| | - Christian Mirian
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Protein Research, Proteomics Program, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Christina Halsey
- Wolfson Wohl Cancer Research Centre, School of Cancer Sciences, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
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44
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Xiao J, Zhang T, Gao F, Zhou Z, Shu G, Zou Y, Yin G. Natural Killer Cells: A Promising Kit in the Adoptive Cell Therapy Toolbox. Cancers (Basel) 2022; 14:cancers14225657. [PMID: 36428748 PMCID: PMC9688567 DOI: 10.3390/cancers14225657] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/13/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022] Open
Abstract
As an important component of the innate immune system, natural killer (NK) cells have gained increasing attention in adoptive cell therapy for their safety and efficacious tumor-killing effect. Unlike T cells which rely on the interaction between TCRs and specific peptide-MHC complexes, NK cells are more prone to be served as "off-the-shelf" cell therapy products due to their rapid recognition and killing of tumor cells without MHC restriction. In recent years, constantly emerging sources of therapeutic NK cells have provided flexible options for cancer immunotherapy. Advanced genetic engineering techniques, especially chimeric antigen receptor (CAR) modification, have yielded exciting effectiveness in enhancing NK cell specificity and cytotoxicity, improving in vivo persistence, and overcoming immunosuppressive factors derived from tumors. In this review, we highlight current advances in NK-based adoptive cell therapy, including alternative sources of NK cells for adoptive infusion, various CAR modifications that confer different targeting specificity to NK cells, multiple genetic engineering strategies to enhance NK cell function, as well as the latest clinical research on adoptive NK cell therapy.
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Affiliation(s)
- Jiani Xiao
- Department of Pathology, School of Basic Medical Sciences, Xiangya Hospital, Central South University, Changsha 410000, China
| | - Tianxiang Zhang
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06511, USA
| | - Fei Gao
- Department of Pathology, School of Basic Medical Sciences, Xiangya Hospital, Central South University, Changsha 410000, China
| | - Zhengwei Zhou
- Department of Pathology, School of Basic Medical Sciences, Xiangya Hospital, Central South University, Changsha 410000, China
| | - Guang Shu
- Department of Pathology, School of Basic Medical Sciences, Xiangya Hospital, Central South University, Changsha 410000, China
| | - Yizhou Zou
- Department of Immunology, School of Basic Medicine, Central South University, Changsha 410000, China
- Correspondence: (Y.Z.); (G.Y.)
| | - Gang Yin
- Department of Pathology, School of Basic Medical Sciences, Xiangya Hospital, Central South University, Changsha 410000, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410000, China
- Correspondence: (Y.Z.); (G.Y.)
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45
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Zhang N, Shao J, Li H, Zhu J, Xia M, Chen K, Jiang H. Humanized CD19-directed CAR-T Cell Therapy in Pediatric Relapsed/Refractory Acute Lymphoblastic Leukemia With CNSL or Neurological Comorbidity. J Immunother 2022; 45:396-406. [PMID: 36018262 PMCID: PMC9528944 DOI: 10.1097/cji.0000000000000437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 06/30/2022] [Indexed: 11/25/2022]
Abstract
Chimeric antigen receptor T cell (CAR-T) therapy has breakthrough potential for relapsed/refractory (R/R) acute lymphoblastic leukemia (ALL). However, because of the risk for neurotoxicity, trials usually exclude patients with central nervous system leukemia (CNSL) or active neurological comorbidities (NC). Here, we evaluated the efficacy and neurotoxicity of humanized CD19-directed CAR-T therapy for R/R ALL with CNSL or NC. Of 12 enrolled patients, 4 had CNSL with bone marrow (BM) or testicular recurrence, 3 had BM relapses with NC, and 5 had BM relapse without NC. Bridging chemotherapy was performed for high tumor burden before CAR-T therapy. Patients with CNSL or BM relapse with NC or without NC experienced 100% complete remission. Tumor burden reduction did not occur in 1 patient with NC, who developed grade 5 neurotoxicity before BM assessment, and one patient with CNSL developed leukoencephalopathy. Severe cytokine release syndrome and neurotoxicity developed in 0% with CNSL, 33.3% with BM relapse and NC, and 0% without NC. CAR-T cells expanded in the cerebrospinal fluid (CSF) of all patients with no difference among CNSL, BM with NC, or no NC (respective median percentages among lymphocyte: 33.7%, 48.2% and 34.5%, P =0.899; respective median concentrations: 0.82, 2.21, and 0.46/μL, P =0.719). Median CSF CAR-T cell duration was 5.5 (3-9) months with CNSL and 3 (2-3) months without CNSL ( P =0.031). CAR-T can be given safely and effectively to pediatric patients with R/R ALL with CNSL or NC who have near-normal neurological status. High tumor burden may confer increased risk for severe neurotoxicity.
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Affiliation(s)
- Na Zhang
- Department of Hematology and Oncology
| | | | - Hong Li
- Department of Hematology and Oncology
| | | | - Min Xia
- Department of Clinical Laboratory, Shanghai Children’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Kai Chen
- Department of Hematology and Oncology
| | - Hui Jiang
- Department of Hematology and Oncology
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46
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Ragoonanan D, Sheikh IN, Gupta S, Khazal SJ, Tewari P, Petropoulos D, Li S, Mahadeo KM. The Evolution of Chimeric Antigen Receptor T-Cell Therapy in Children, Adolescents and Young Adults with Acute Lymphoblastic Leukemia. Biomedicines 2022; 10:biomedicines10092286. [PMID: 36140387 PMCID: PMC9496125 DOI: 10.3390/biomedicines10092286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 08/05/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Chimeric antigen receptor T-cell (CAR T) therapy is a revolutionary treatment for pediatric, adolescent and young adult patients (AYA) with relapsed/refractory B-cell acute lymphoblastic leukemia. While the landscape of immunotherapy continues to rapidly evolve, widespread use of CAR T therapy is limited and many questions remain regarding the durability of CAR T therapy, methods to avoid CAR T therapy resistance and the role of consolidative stem cell transplant. Modified strategies to develop effective and persistent CAR T cells at lower costs and decreased toxicities are warranted. In this review we present current indications, limitations and future directions of CAR T therapy for ALL in the pediatric and AYA population.
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Affiliation(s)
- Dristhi Ragoonanan
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence: (D.R.); (I.N.S.)
| | - Irtiza N. Sheikh
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence: (D.R.); (I.N.S.)
| | - Sumit Gupta
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sajad J. Khazal
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Priti Tewari
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Demetrios Petropoulos
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Shulin Li
- Department of Pediatrics Research, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Kris M. Mahadeo
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Shalabi H, Qin H, Su A, Yates B, Wolters PL, Steinberg SM, Ligon JA, Silbert S, DéDé K, Benzaoui M, Goldberg S, Achar S, Schneider D, Shahani SA, Little L, Foley T, Molina JC, Panch S, Mackall CL, Lee DW, Chien CD, Pouzolles M, Ahlman M, Yuan CM, Wang HW, Wang Y, Inglefield J, Toledo-Tamula MA, Martin S, Highfill SL, Altan-Bonnet G, Stroncek D, Fry TJ, Taylor N, Shah NN. CD19/22 CAR T cells in children and young adults with B-ALL: phase 1 results and development of a novel bicistronic CAR. Blood 2022; 140:451-463. [PMID: 35605184 PMCID: PMC9353146 DOI: 10.1182/blood.2022015795] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/03/2022] [Indexed: 11/20/2022] Open
Abstract
Remission durability following single-antigen targeted chimeric antigen receptor (CAR) T-cells is limited by antigen modulation, which may be overcome with combinatorial targeting. Building upon our experiences targeting CD19 and CD22 in B-cell acute lymphoblastic leukemia (B-ALL), we report on our phase 1 dose-escalation study of a novel murine stem cell virus (MSCV)-CD19/CD22-4-1BB bivalent CAR T-cell (CD19.22.BBζ) for children and young adults (CAYA) with B-cell malignancies. Primary objectives included toxicity and dose finding. Secondary objectives included response rates and relapse-free survival (RFS). Biologic correlatives included laboratory investigations, CAR T-cell expansion and cytokine profiling. Twenty patients, ages 5.4 to 34.6 years, with B-ALL received CD19.22.BBζ. The complete response (CR) rate was 60% (12 of 20) in the full cohort and 71.4% (10 of 14) in CAR-naïve patients. Ten (50%) developed cytokine release syndrome (CRS), with 3 (15%) having ≥ grade 3 CRS and only 1 experiencing neurotoxicity (grade 3). The 6- and 12-month RFS in those achieving CR was 80.8% (95% confidence interval [CI]: 42.4%-94.9%) and 57.7% (95% CI: 22.1%-81.9%), respectively. Limited CAR T-cell expansion and persistence of MSCV-CD19.22.BBζ compared with EF1α-CD22.BBζ prompted laboratory investigations comparing EF1α vs MSCV promoters, which did not reveal major differences. Limited CD22 targeting with CD19.22.BBζ, as evaluated by ex vivo cytokine secretion and leukemia eradication in humanized mice, led to development of a novel bicistronic CD19.28ζ/CD22.BBζ construct with enhanced cytokine production against CD22. With demonstrated safety and efficacy of CD19.22.BBζ in a heavily pretreated CAYA B-ALL cohort, further optimization of combinatorial antigen targeting serves to overcome identified limitations (www.clinicaltrials.gov #NCT03448393).
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Affiliation(s)
| | | | | | | | | | - Seth M Steinberg
- Biostatistics and Data Management Section, Center for Cancer Research (CCR), National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD
| | - John A Ligon
- Pediatric Oncology Branch and
- Division of Hematology/Oncology, Department of Pediatrics, University of Florida, Gainesville, FL
| | - Sara Silbert
- Pediatric Oncology Branch and
- Center for Cancer and Blood Disorders, Children's National Hospital, Washington, DC
| | | | - Mehdi Benzaoui
- Pediatric Oncology Branch and
- Université Montpellier, Institut de Génétique Moléculaire de Montpellier, CNRS, Montpellier, France
| | | | - Sooraj Achar
- Laboratory of Integrative Cancer Immunology, CCR, NCI, NIH, Bethesda, MD
| | | | - Shilpa A Shahani
- Pediatric Oncology Branch and
- Department of Pediatrics, City of Hope, Duarte, CA
| | | | | | | | - Sandhya Panch
- Center for Cellular Engineering, Department of Transfusion Medicine, NIH Clinical Center, Bethesda, MD
- Department of Hematology, Seattle Cancer Care Alliance, University of Washington, Seattle, WA
| | - Crystal L Mackall
- Pediatric Oncology Branch and
- Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, CA
- Department of Pediatrics and
- Department of Medicine, Stanford University, Stanford, CA
| | - Daniel W Lee
- Pediatric Oncology Branch and
- Department of Pediatric Hematology/Oncology, Department of Pediatrics, University of Virginia, Charlottesville, VA
- University of Virginia Cancer Center, Charlottesville, VA
| | | | | | - Mark Ahlman
- Radiology and Imaging Sciences, NIH Clinical Center, Bethesda, MD
| | | | - Hao-Wei Wang
- Laboratory of Pathology, CCR, NCI, NIH, Bethesda, MD
| | - Yanyu Wang
- Applied Developmental Research Directorate, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Jon Inglefield
- Applied Developmental Research Directorate, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Mary Anne Toledo-Tamula
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research, NCI, Frederick MD; and
| | | | - Steven L Highfill
- Center for Cellular Engineering, Department of Transfusion Medicine, NIH Clinical Center, Bethesda, MD
| | | | - David Stroncek
- Center for Cellular Engineering, Department of Transfusion Medicine, NIH Clinical Center, Bethesda, MD
| | - Terry J Fry
- Pediatric Oncology Branch and
- University of Colorado Anschutz Medical Campus and Center for Cancer and Blood Disorders, Children's Hospital of Colorado, Aurora, CO
| | - Naomi Taylor
- Pediatric Oncology Branch and
- Université Montpellier, Institut de Génétique Moléculaire de Montpellier, CNRS, Montpellier, France
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48
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Talleur AC, Myers R, Annesley C, Shalabi H. Chimeric Antigen Receptor T-cell Therapy: Current Status and Clinical Outcomes in Pediatric Hematologic Malignancies. Hematol Oncol Clin North Am 2022; 36:701-727. [PMID: 35780062 DOI: 10.1016/j.hoc.2022.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Chimeric antigen receptor T-cell (CART) therapy has transformed the treatment paradigm for pediatric patients with relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL), with complete remission rates in key pivotal CD19-CART trials ranging from 65% to 90%. Alongside this new therapy, new toxicity profiles and treatment limitations have emerged, necessitating toxicity consensus grading systems, cooperative group trials, and novel management approaches. This review highlights the results of key clinical trials of CART for pediatric hematologic malignancies, discusses the most common toxicities seen to date, and elucidates challenges, opportunities, and areas of active research to optimize this therapy.
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Affiliation(s)
- Aimee C Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, 262 Danny Thomas Place, MS1130, Memphis, TN 38105, USA
| | - Regina Myers
- Division of Oncology, Children's Hospital of Philadelphia, Office 2568A, 3500 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Colleen Annesley
- Seattle Children's Research Institute, 4800 Sand Point Way NE, M/S MB8.501, Seattle, WA 98145-5005, USA
| | - Haneen Shalabi
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Building 10, Room 1W-5750, 9000 Rockville Pike, Bethesda, MD 20892-1104, USA.
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49
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Li Y, Hwang WT, Maude SL, Teachey DT, Frey NV, Myers RM, Barz Leahy A, Liu H, Porter DL, Grupp SA, Shaw PA. Statistical considerations for analyses of time-to-event endpoints in oncology clinical trials: Illustrations with CAR-T immunotherapy studies. Clin Cancer Res 2022; 28:3940-3949. [PMID: 35838646 DOI: 10.1158/1078-0432.ccr-22-0560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/06/2022] [Accepted: 07/13/2022] [Indexed: 11/16/2022]
Abstract
Chimeric antigen receptor T-cell (CAR-T) therapy is an exciting development in the field of cancer immunology and has received a lot of interest in recent years. Many time-to-event (TTE) endpoints related to relapse, disease progression, and remission are analyzed in CAR-T studies to assess treatment efficacy. Definitions of these TTE endpoints are not always consistent, even for the same outcomes (e.g., progression-free survival), which often stems from analysis choices regarding which events to consider as part of the composite endpoint, censoring or competing risk in the analysis. Subsequent therapies such as hematopoietic stem cell transplantation are common but are not treated the same in different studies. Standard survival analysis methods are commonly applied to TTE analyses but often without full consideration of the assumptions inherent in the chosen analysis. We highlight two important issues of TTE analysis that arise in CAR-T studies, as well as in other settings in oncology: the handling of competing risks and assessing the association between a time-varying (post-infusion) exposure and the TTE outcome. We review existing analytical methods, including the cumulative incidence function and regression models for analysis of competing risks, and landmark and time-varying covariate analysis for analysis of post-infusion exposures. We clarify the scientific questions that the different analytical approaches address and illustrate how the application of an inappropriate method could lead to different results using data from multiple published CAR-T studies. Codes for implementing these methods in standard statistical software are provided.
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Affiliation(s)
- Yimei Li
- University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Wei-Ting Hwang
- University of Pennsylvania, Philadelphia, PA, United States
| | - Shannon L Maude
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - David T Teachey
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Noelle V Frey
- University of Pennsylvania, Philadelphia, United States
| | - Regina M Myers
- Children's Hospital of Philadelphia, Philadelphia, United States
| | | | - Hongyan Liu
- Children's Hospital of Philadelphia, United States
| | - David L Porter
- University of Pennsylvania, Philadelphia, PA, United States
| | - Stephan A Grupp
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Pamela A Shaw
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
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50
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Cao XY, Li JJ, Lu PH, Liu KY. Efficacy and safety of CD19 CAR-T cell therapy for acute lymphoblastic leukemia patients relapsed after allogeneic hematopoietic stem cell transplantation. Int J Hematol 2022; 116:315-329. [PMID: 35737192 DOI: 10.1007/s12185-022-03398-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/30/2022] [Accepted: 05/30/2022] [Indexed: 10/17/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an effective therapy for B-cell acute lymphoblastic leukemia (B-ALL). Although allo-HSCT can be curative for some B-ALL patients, relapse still occurs in some patients following allo-HSCT. Conventional chemotherapies show poor efficacy in B-ALL patients who have relapsed following allo-HSCT. In the past decade, chimeric antigen receptor T-cell (CAR-T) therapy has shown to be efficacious for B-ALL patients. In particular, autologous CD19 CAR-T therapy results in a high remission rate. However, there are challenges in the use of CD19 CAR-T therapy for B-ALL patients who have relapsed following allo-HSCT, including the selection of CAR-T cell source for manufacturing, post-CAR-T graft-versus-host disease (GVHD) risk, maintenance of long-term efficacy after remission through CAR-T therapy, and whether a consolidative second transplant is needed. In this review, we describe the current status of CAR-T therapy for B-ALL patients who have relapsed following allo-HSCT, the advantages and disadvantages of various CAR-T cell sources, the characteristics and management of GVHD following CAR-T therapy, and the risk factors that may affect long-term efficacy.
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Affiliation(s)
- Xing-Yu Cao
- Hebei Yanda Lu Daopei Hospital, Langfang, Hebei, China.,Beijing Lu Daopei Institute of Hematology, Beijing, China
| | - Jing-Jing Li
- Hebei Yanda Lu Daopei Hospital, Langfang, Hebei, China.,Beijing Lu Daopei Institute of Hematology, Beijing, China
| | - Pei-Hua Lu
- Hebei Yanda Lu Daopei Hospital, Langfang, Hebei, China. .,Beijing Lu Daopei Institute of Hematology, Beijing, China.
| | - Kai-Yan Liu
- Beijing Lu Daopei Institute of Hematology, Beijing, China. .,Peking University People's Hospital, Beijing, China.
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