1
|
Gross G, Alkadieri S, Meir A, Itzhaki O, Aharoni-Tevet Y, Ben Yosef S, Zenab A, Shbiro L, Toren A, Yardeni T, Jacoby E. Improved CAR-T cell activity associated with increased mitochondrial function primed by galactose. Leukemia 2024; 38:1534-1540. [PMID: 38714877 DOI: 10.1038/s41375-024-02257-z] [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: 09/23/2023] [Revised: 04/13/2024] [Accepted: 04/15/2024] [Indexed: 05/21/2024]
Abstract
CD19 CAR-T cells have led to durable remissions in patients with refractory B-cell malignancies; nevertheless, most patients eventually relapse in the long term. Many interventions aimed at improving current products have been reported, with a subset of them focusing on a direct or indirect link to the metabolic state of the CAR-T cells. We assessed clinical products from an ongoing clinical trial utilizing CD19-28z CAR-T cells from patients with acute lymphoblastic leukemia. CAR-T clinical products leading to a complete response had significantly higher mitochondrial function (by oxygen consumption rate) irrespective of mitochondrial content. Next, we replaced the carbon source of the media from glucose to galactose to impact cellular metabolism. Galactose-containing media increased mitochondrial activity in CAR-T cells, and improved in in-vitro efficacy, without any consistent phenotypic change in memory profile. Finally, CAR-T cells produced in galactose-based glucose-free media resulted in increased mitochondrial activity. Using an in-vivo model of Nalm6 injected mice, galactose-primed CAR-T cells significantly improved leukemia-free survival compared to standard glucose-cultured CAR-T cells. Our results prove the significance of mitochondrial metabolism on CAR-T cell efficacy and suggest a translational pathway to improve clinical products.
Collapse
Affiliation(s)
- Golda Gross
- Cell Therapy Lab, Sheba Medical Center, Tel Hashomer, Israel
- Faculty of Medicinal & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Suha Alkadieri
- Cell Therapy Lab, Sheba Medical Center, Tel Hashomer, Israel
- Faculty of Medicinal & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Amilia Meir
- Cell Therapy Lab, Sheba Medical Center, Tel Hashomer, Israel
| | - Orit Itzhaki
- Ella Institute of Immuno-Oncology, Sheba Medical Center, Tel Hashomer, Israel
| | - Yarden Aharoni-Tevet
- Cell Therapy Lab, Sheba Medical Center, Tel Hashomer, Israel
- Faculty of Medicinal & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | | | - Angi Zenab
- Faculty of Medicinal & Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Bert Strassburger Metabolic Center for Preventive Medicine, Sheba Medical Center, Tel Hashomer, Israel
| | - Liat Shbiro
- Bert Strassburger Metabolic Center for Preventive Medicine, Sheba Medical Center, Tel Hashomer, Israel
| | - Amos Toren
- Faculty of Medicinal & Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Division of Pediatric Hematology and Oncology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Tal Yardeni
- Bert Strassburger Metabolic Center for Preventive Medicine, Sheba Medical Center, Tel Hashomer, Israel
| | - Elad Jacoby
- Cell Therapy Lab, Sheba Medical Center, Tel Hashomer, Israel.
- Faculty of Medicinal & Health Sciences, Tel Aviv University, Tel Aviv, Israel.
- Division of Pediatric Hematology and Oncology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel.
| |
Collapse
|
2
|
Rozenbaum M, Fluss R, Marcu-Malina V, Sarouk I, Meir A, Elitzur S, Zinger T, Jacob-Hirsch J, Saar EG, Rechavi G, Jacoby E. Genotoxicity Associated with Retroviral CAR Transduction of ATM-Deficient T Cells. Blood Cancer Discov 2024; 5:267-275. [PMID: 38747501 PMCID: PMC11215369 DOI: 10.1158/2643-3230.bcd-23-0268] [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: 12/20/2023] [Revised: 02/26/2024] [Accepted: 05/08/2024] [Indexed: 07/02/2024] Open
Abstract
Somatic variants in DNA damage response genes such as ATM are widespread in hematologic malignancies. ATM protein is essential for double-strand DNA break repair. Germline ATM deficiencies underlie ataxia-telangiectasia (A-T), a disease manifested by radiosensitivity, immunodeficiency, and predisposition to lymphoid malignancies. Patients with A-T diagnosed with malignancies have poor tolerance to chemotherapy or radiation. In this study, we investigated chimeric antigen receptor (CAR) T cells using primary T cells from patients with A-T (ATM-/-), heterozygote donors (ATM+/-), and healthy donors. ATM-/- T cells proliferate and can be successfully transduced with CARs, though functional impairment of ATM-/- CAR T-cells was observed. Retroviral transduction of the CAR in ATM-/- T cells resulted in high rates of chromosomal lesions at CAR insertion sites, as confirmed by next-generation long-read sequencing. This work suggests that ATM is essential to preserve genome integrity of CAR T-cells during retroviral manufacturing, and its lack poses a risk of chromosomal translocations and potential leukemogenicity. Significance: CAR T-cells are clinically approved genetically modified cells, but the control of genome integrity remains largely uncharacterized. This study demonstrates that ATM deficiency marginally impairs CAR T-cell function and results in high rates of chromosomal aberrations after retroviral transduction, which may be of concern in patients with DNA repair deficiencies.
Collapse
Affiliation(s)
- Meir Rozenbaum
- Cell Therapy Lab, Sheba Medical Center, Tel Hashomer, Israel.
| | - Reut Fluss
- Cancer Research Center, Sheba Medical Center, Tel Hashomer, Israel.
- Wohl Centre for Translational Medicine, Sheba Medical Center, Tel Hashomer, Israel.
| | | | - Ifat Sarouk
- National A-T Center, Pediatric Pulmonology Unit, The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, Israel.
| | - Amilia Meir
- Cell Therapy Lab, Sheba Medical Center, Tel Hashomer, Israel.
| | - Sarah Elitzur
- Department of Pediatric Hematology-Oncology, Schneider Children’s Medical Center, Petah Tikva, Israel.
- Faculty of Medicinal & Health Sciences, Tel Aviv University, Tel Aviv, Israel.
| | - Tal Zinger
- Cancer Research Center, Sheba Medical Center, Tel Hashomer, Israel.
| | - Jasmine Jacob-Hirsch
- Cancer Research Center, Sheba Medical Center, Tel Hashomer, Israel.
- Wohl Centre for Translational Medicine, Sheba Medical Center, Tel Hashomer, Israel.
| | - Efrat G. Saar
- Cancer Research Center, Sheba Medical Center, Tel Hashomer, Israel.
- Wohl Centre for Translational Medicine, Sheba Medical Center, Tel Hashomer, Israel.
| | - Gideon Rechavi
- Cancer Research Center, Sheba Medical Center, Tel Hashomer, Israel.
- Wohl Centre for Translational Medicine, Sheba Medical Center, Tel Hashomer, Israel.
- Faculty of Medicinal & Health Sciences, Tel Aviv University, Tel Aviv, Israel.
| | - Elad Jacoby
- Cell Therapy Lab, Sheba Medical Center, Tel Hashomer, Israel.
- Faculty of Medicinal & Health Sciences, Tel Aviv University, Tel Aviv, Israel.
- Division of Pediatric Hematology and Oncology, The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer, Israel.
| |
Collapse
|
3
|
Tian JS, Tay A. Progress on Electro-Enhancement of Cell Manufacturing. SMALL METHODS 2024; 8:e2301281. [PMID: 38059759 DOI: 10.1002/smtd.202301281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/09/2023] [Indexed: 12/08/2023]
Abstract
With the long persistence of complex, chronic diseases in society, there is increasing motivation to develop cells as living medicine to treat diseases ranging from cancer to wounds. While cell therapies can significantly impact healthcare, the shortage of starter cells meant that considerable raw materials must be channeled solely for cell expansion, leading to expensive products with long manufacturing time which can prevent accessibility by patients who either cannot afford the treatment or have highly aggressive diseases and cannot wait that long. Over the last three decades, there has been increasing knowledge on the effects of electrical modulation on proliferation, but to the best of the knowledge, none of these studies went beyond how electro-control of cell proliferation may be extended to enhance industrial scale cell manufacturing. Here, this review is started by discussing the importance of maximizing cell yield during manufacturing before comparing strategies spanning biomolecular/chemical/physical to modulate cell proliferation. Next, the authors describe how factors governing invasive and non-invasive electrical stimulation (ES) including capacitive coupling electric field may be modified to boost cell manufacturing. This review concludes by describing what needs to be urgently performed to bridge the gap between academic investigation of ES to industrial applications.
Collapse
Affiliation(s)
- Johann Shane Tian
- Department of Biomedical Engineering, National University of Singapore, Singapore, 117583, Singapore
| | - Andy Tay
- Department of Biomedical Engineering, National University of Singapore, Singapore, 117583, Singapore
- Institute for Health Innovation and Technology, National University of Singapore, Singapore, 117599, Singapore
- NUS Tissue Engineering Program, National University of Singapore, Singapore, 117510, Singapore
| |
Collapse
|
4
|
Chen X, Zhong S, Zhan Y, Zhang X. CRISPR-Cas9 applications in T cells and adoptive T cell therapies. Cell Mol Biol Lett 2024; 29:52. [PMID: 38609863 PMCID: PMC11010303 DOI: 10.1186/s11658-024-00561-1] [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: 12/04/2023] [Accepted: 03/15/2024] [Indexed: 04/14/2024] Open
Abstract
T cell immunity is central to contemporary cancer and autoimmune therapies, encompassing immune checkpoint blockade and adoptive T cell therapies. Their diverse characteristics can be reprogrammed by different immune challenges dependent on antigen stimulation levels, metabolic conditions, and the degree of inflammation. T cell-based therapeutic strategies are gaining widespread adoption in oncology and treating inflammatory conditions. Emerging researches reveal that clustered regularly interspaced palindromic repeats-associated protein 9 (CRISPR-Cas9) genome editing has enabled T cells to be more adaptable to specific microenvironments, opening the door to advanced T cell therapies in preclinical and clinical trials. CRISPR-Cas9 can edit both primary T cells and engineered T cells, including CAR-T and TCR-T, in vivo and in vitro to regulate T cell differentiation and activation states. This review first provides a comprehensive summary of the role of CRISPR-Cas9 in T cells and its applications in preclinical and clinical studies for T cell-based therapies. We also explore the application of CRISPR screen high-throughput technology in editing T cells and anticipate the current limitations of CRISPR-Cas9, including off-target effects and delivery challenges, and envisioned improvements in related technologies for disease screening, diagnosis, and treatment.
Collapse
Affiliation(s)
- Xiaoying Chen
- Department of Cardiology, Cardiovascular Institute of Zhengzhou University, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450003, China
| | - Shuhan Zhong
- Department of Hematology, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, 310003, China
| | - Yonghao Zhan
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450003, China.
| | - Xuepei Zhang
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450003, China.
| |
Collapse
|
5
|
Fried S, Shkury E, Itzhaki O, Sdayoor I, Yerushalmi R, Shem-Tov N, Danylesko I, Jacoby E, Shouval R, Kedmi M, Marcus R, Nagler A, Shimoni A, Avigdor A. Point-of-care anti-CD19 chimeric antigen receptor T-cell therapy for relapsed/refractory follicular lymphoma. Leuk Lymphoma 2023; 64:1956-1963. [PMID: 37565578 PMCID: PMC11023741 DOI: 10.1080/10428194.2023.2246611] [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: 05/25/2023] [Revised: 07/02/2023] [Accepted: 07/09/2023] [Indexed: 08/12/2023]
Abstract
Patients with relapsed/refractory follicular lymphoma (R/R-FL) often require multiple treatment lines. We performed a phase 1b/2 single-center clinical trial of autologous point-of-care anti-CD19 chimeric antigen receptor (CAR) T-cells in R/R-FL patients treated patients with ≥ 2 treatment lines. All 26 patients enrolled received CAR T-cell infusion at a median of 11 days after leukapheresis. Seventy-seven percent of patients had POD24. At enrollment, disease stage was III-IV in 85% of the patients, 77% had high-risk FLIPI score, and 77% had progressive disease. Grade III-IV cytokine release and immune effector cell-associated neurotoxicity syndromes occurred in 12% and 16% of the patients, respectively. Overall response rate at 1-month was 88%. The median follow-up was 15.4 months. One-year overall and progression-free survival were 100% and 63%, respectively. In conclusion, point-of-care CAR T-cell, manufactured within 11 days, induced a high response rate with an acceptable safety profile in patients with high-risk R/R-FL.
Collapse
Affiliation(s)
- Shalev Fried
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Eden Shkury
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Orit Itzhaki
- Ella Lemelbaum Institute for Immuno Oncology, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Inbal Sdayoor
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Ronit Yerushalmi
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Noga Shem-Tov
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Ivetta Danylesko
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Elad Jacoby
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Department of Pediatric Hematology-Oncology, Safra Children’s Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Roni Shouval
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Adult BMT Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
| | - Meirav Kedmi
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
- The Mina and Everard Goodman faculty of life sciences, Bar Ilan University, Ramat Gan, Israel
| | - Ronit Marcus
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Arnon Nagler
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Avichai Shimoni
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Abraham Avigdor
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| |
Collapse
|
6
|
Pessach I, Nagler A. Leukapheresis for CAR-T cell production and therapy. Transfus Apher Sci 2023; 62:103828. [PMID: 37838564 DOI: 10.1016/j.transci.2023.103828] [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] [Indexed: 10/16/2023]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is an effective, individualized immunotherapy, and novel treatment for hematologic malignancies. Six commercial CAR-T cell products are currently approved for lymphatic malignancies and multiple myeloma. In addition, an increasing number of clinical centres produce CAR-T cells on-site, which enable the administration of CAR-T cells on site. The CAR-T cell products are either fresh or cryopreserved. Manufacturing CAR-T cells is a complicated process that begins with leukapheresis to obtain T cells from the patient's peripheral blood. An optimal leukapheresis product is crucial step for a successful CAR-T cell therapy; therefore, it is imperative to understand the factors that may affect the quality or T cells. The leukapheresis for CAR-T cell production is well tolerated and safe for both paediatric and adult patients and CAR-Τ cell therapy presents high clinical response rate in many studies. CAR-T cell therapy is under continuous improvement, and it has transformed into an almost standard procedure in clinical haematology and stem cell transplantation facilities that provide both autologous and allogeneic stem cell transplantations. In patients suffering from advanced haematological malignancies, CAR-T cell therapy shows incredible antitumor efficacy. Even after a single infusion of autologous CD19-targeting CAR-T cells in patients with relapsed or refractory diffuse large B cell lymphoma (DLBCL) and acute lymphoblastic leukaemia (ALL), long lasting remission is observed, and a fraction of the patients are being cured. Future novel constructs are being developed with better T cell persistence and better expansion. New next-generation CAR-T cells are currently designed to avoid toxicities such as cytokine release syndrome and neurotoxicity.
Collapse
Affiliation(s)
- Ilias Pessach
- Hematology Department, Athens Medical Center, Athens, Greece
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Israel.
| |
Collapse
|
7
|
Li Y, Liu Y, Yang K, Jin L, Yang J, Huang S, Liu Y, Hu B, Liu R, Liu W, Liu A, Zheng Q, Zhang Y. Impact of ARID1A and TP53 mutations in pediatric refractory or relapsed mature B-Cell lymphoma treated with CAR-T cell therapy. Cancer Cell Int 2023; 23:281. [PMID: 37981695 PMCID: PMC10657579 DOI: 10.1186/s12935-023-03122-2] [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: 08/18/2023] [Accepted: 11/02/2023] [Indexed: 11/21/2023] Open
Abstract
BACKGROUND Chimeric antigen receptor (CAR)-T cell therapy has been used to treat pediatric refractory or relapsed mature B-cell non-Hodgkin lymphoma (r/r MB-NHL) with significantly improved outcomes, but a proportion of patients display no response or experience relapse after treatment. To investigate whether tumor-intrinsic somatic genetic alterations have an impact on CAR-T cell treatment, the genetic features and treatment outcomes of 89 children with MB-NHL were analyzed. METHODS 89 pediatric patients treated at multiple clinical centers of the China Net Childhood Lymphoma (CNCL) were included in this study. Targeted next-generation sequencing for a panel of lymphoma-related genes was performed on tumor samples. Survival rates and relapse by genetic features and clinical factors were analyzed. Survival curves were calculated using a log-rank (Mantel-Cox) test. The Wilcox sum-rank test and Fisher's exact test were applied to test for group differences. RESULTS A total of 89 driver genes with somatic mutations were identified. The most frequently mutated genes were TP53 (66%), ID3 (55%), and ARID1A (31%). The incidence of ARID1A mutation and co-mutation of TP53 and ARID1A was high in patients with r/r MB-NHL (P = 0.006; P = 0.018, respectively). CAR-T cell treatment significantly improved survival in r/r MB-NHL patients (P = 0.00081), but patients with ARID1A or ARID1A and TP53 co-mutation had poor survival compared to those without such mutations. CONCLUSION These results indicate that children with MB-NHL harboring ARID1A or TP53 and ARID1A co-mutation are insensitive to initial conventional chemotherapy and subsequent CAR-T cell treatment. Examination of ARID1A and TP53 mutation status at baseline might have prognostic value, and risk-adapted or more effective therapies should be considered for patients with these high-risk genetic alterations.
Collapse
Affiliation(s)
- Yang Li
- Molecular diagnostics laboratory, Beijing GoBroad Boren Hospital, Beijing, China
| | - Yang Liu
- Department of Pediatric Lymphoma, Beijing GoBroad Boren Hospital, Beijing, China
| | - Keyan Yang
- Molecular diagnostics laboratory, Beijing GoBroad Boren Hospital, Beijing, China
| | - Ling Jin
- Department of Hematology/Oncology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Jing Yang
- Department of Hematology/Oncology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Shuang Huang
- Department of Hematology/Oncology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Ying Liu
- Department of Pediatric Lymphoma, Beijing GoBroad Boren Hospital, Beijing, China
| | - Bo Hu
- Department of Pediatric Lymphoma, Beijing GoBroad Boren Hospital, Beijing, China
| | - Rong Liu
- Department of Hematology/Oncology, Capital institute of pediatric, Beijing, China
| | - Wei Liu
- Department of Hematology/Oncology, Zhengzhou Children's Hospital, Zhengzhou, China
| | - Ansheng Liu
- Department of Hematology/Oncology, Xian Children's Hospital, Xi'An, China
| | - Qinlong Zheng
- Molecular diagnostics laboratory, Beijing GoBroad Boren Hospital, Beijing, China.
| | - Yonghong Zhang
- Department of Pediatric Lymphoma, Beijing GoBroad Boren Hospital, Beijing, China.
| |
Collapse
|
8
|
Gross G, Alkadieri S, Meir A, Itzhaki O, Aharony-Tevet Y, Yosef SB, Zenab A, Shbiro L, Toren A, Yardeni T, Jacoby E. Improved CAR-T cell activity associated with increased mitochondrial function primed by galactose. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.09.23.559091. [PMID: 37808778 PMCID: PMC10557609 DOI: 10.1101/2023.09.23.559091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
CD19 CAR-T cells have led to durable remissions in patients with refractory B-cell malignancies; nevertheless, most patients eventually relapse in the long term. Many interventions aimed at improving current products have been reported, with a subset of them focusing on a direct or indirect link to the metabolic state of the CAR-T cells. We assessed clinical products from an ongoing clinical trial utilizing CD19-28z CAR-T cells from patients with acute lymphoblastic leukemia. CAR-T clinical products leading to a complete response had significantly higher mitochondrial function (by oxygen consumption rate) irrespective of mitochondrial content. Next, we replaced the carbon source of the media from glucose to galactose to impact cellular metabolism. Galactose-containing media increased mitochondrial activity in CAR-T cells, and improved in vitro efficacy, without any consistent phenotypic change in memory profile. Finally, CAR-T cells produced in galactose-based glucose-free media resulted in increased mitochondrial activity. Using an in vivo model of Nalm6 injected mice, galactose-primed CAR-T cells significantly improved leukemia-free survival compared to standard glucose-cultured CAR-T cells. Our results prove the significance of mitochondrial metabolism on CAR-T cell efficacy and suggest a translational pathway to improve clinical products.
Collapse
Affiliation(s)
- Golda Gross
- Cell Therapy Lab, Sheba Medical Center, Tel Hashomer, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Suha Alkadieri
- Cell Therapy Lab, Sheba Medical Center, Tel Hashomer, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amilia Meir
- Cell Therapy Lab, Sheba Medical Center, Tel Hashomer, Israel
| | - Orit Itzhaki
- Ella Institute of Immuno-Oncology, Sheba Medical Center, Tel Hashomer Israel
| | - Yarden Aharony-Tevet
- Cell Therapy Lab, Sheba Medical Center, Tel Hashomer, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Angi Zenab
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Bert Strassburger Metabolic Center for Preventive Medicine, Sheba Medical Center, Tel Hashomer, Israel
| | - Liat Shbiro
- Bert Strassburger Metabolic Center for Preventive Medicine, Sheba Medical Center, Tel Hashomer, Israel
| | - Amos Toren
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Pediatric Hematology and Oncology, The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer Israel
| | - Tal Yardeni
- Bert Strassburger Metabolic Center for Preventive Medicine, Sheba Medical Center, Tel Hashomer, Israel
| | - Elad Jacoby
- Cell Therapy Lab, Sheba Medical Center, Tel Hashomer, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Pediatric Hematology and Oncology, The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Tel Hashomer Israel
| |
Collapse
|
9
|
Ye X, Wu Y, Zhang H, Zhou Y, Dong J, Cai J. Rapid generation of CD19 CAR-T cells by minicircle DNA enables anti-tumor activity and prevents fatal CAR-B leukemia. Cancer Lett 2023:216278. [PMID: 37354981 DOI: 10.1016/j.canlet.2023.216278] [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: 07/21/2022] [Revised: 06/06/2023] [Accepted: 06/12/2023] [Indexed: 06/26/2023]
Abstract
Manufacturing chimeric antigen receptor (CAR)-T cellsusing viral vectors is expensive and time-consuming. In addition, during viral transduction, genes encoding CARs are randomly integrated into the genome, which can cause oncogenesis or produce devastating CARtumor cells. Here, using a virus-free and non-transgenic minicircle DNA (mcDNA) vector, we enabledthe rapid generation of CD19 CAR-T cells within two days. Furthermore, we demonstrated in vitro and in xenograft models that the antitumor effects of CD19 CAR-T cells produced by mcDNA are as effective as those produced by viral vectors. Finally, we showed that our manufacturing process avoids the production of fatal CARtumor cells. Taken together, we have provided a fast, effective, and therapeutically safe method for generating CD19 CAR-T cells for the treatment of leukemia.
Collapse
Affiliation(s)
- Xueshuai Ye
- Department of Surgery, Hebei Medical University, 361 East Zhongshan Road, Shijiazhuang, 050017, China
| | - Yongqiang Wu
- Gene Editing Research Center, Hebei University of Science and Technology, Shijiazhuang, 050000, China
| | - Haiqiang Zhang
- Department of Surgery, The Second Hospital of Hebei Medical University, 215 West Heping Road, Shijiazhuang, 050051, China
| | - Ye Zhou
- Department of Surgery, Hebei Medical University, 361 East Zhongshan Road, Shijiazhuang, 050017, China; Department of Oncology & Surgery, Hebei General Hospital, 348 West Heping Road, Shijiazhuang, 050051, China
| | - Jiantao Dong
- Department of Surgery, Hebei Medical University, 361 East Zhongshan Road, Shijiazhuang, 050017, China; Department of Oncology & Surgery, Hebei General Hospital, 348 West Heping Road, Shijiazhuang, 050051, China
| | - Jianhui Cai
- Department of Surgery, Hebei Medical University, 361 East Zhongshan Road, Shijiazhuang, 050017, China; Department of Oncology & Surgery, Hebei General Hospital, 348 West Heping Road, Shijiazhuang, 050051, China.
| |
Collapse
|
10
|
Ying Z, Xie Y, Zheng W, Liu W, Lin N, Tu M, Wang X, Ping L, Deng L, Zhang C, Wu M, Feng F, Du T, Tang Y, Su F, Guo Z, Li J, Song Y, Zhu J. Efficacy and safety of relmacabtagene autoleucel, an anti-CD19 chimeric antigen receptor T cell, in relapsed/refractory B-cell non-Hodgkin's lymphoma: 2-year results of a phase 1 trial. Bone Marrow Transplant 2023; 58:288-294. [PMID: 36477110 DOI: 10.1038/s41409-022-01888-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/11/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022]
Abstract
This study reported 2-year efficacy and safety of relma-cel in Chinese patients with relapsed/refractory (R/R) B-cell non-Hodgkin's lymphoma (B-NHL). In this phase 1 dose-escalating trial, patients received lymphodepleting chemotherapy for 3 days, followed by relma-cel as a single infusion in escalating dose levels (25 × 106, 50 × 106, 100 × 106, and 150 × 106 CAR-T cells). The endpoints included best objective response rate (ORR), best complete response rate (CRR), duration of response (DOR), progression-free survival (PFS), overall survival (OS), and safety. A total of 23 patients were enrolled, including 60.9% with diffuse large B-cell lymphoma and 26.1% with follicular lymphoma. Twenty patients were evaluable for efficacy, and the best ORR was 85.0% and the best CRR was 75.0%. With a median follow-up of 24.2 months, 6 patients died and 2 had progressive disease, the median DOR, PFS, and OS were all not reached. The 2-year PFS and OS rates were 60.0% and 70.0%, respectively. Any grade and grade ≥ 2 cytokine release syndrome occurred in 18.2% and 13.6% of patients, respectively. Only 1(4.5%) patient had grade 3 CRS lasting 13 days, which was resolved by tocilizumab. No grade ≥ 2 neurotoxicity events or treatment-related deaths occurred. Patients with R/R B-NHL treated with relma-cel achieved durable response with favorable safety profile.
Collapse
Affiliation(s)
- Zhitao Ying
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Yan Xie
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Wen Zheng
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Weiping Liu
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Ningjing Lin
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Meifeng Tu
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Xiaopei Wang
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Lingyan Ping
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Lijuan Deng
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Chen Zhang
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Meng Wu
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Feier Feng
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Tingting Du
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Yongjing Tang
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China
| | - Fang Su
- JW Therapeutics (Shanghai) Co., Ltd, Shanghai, 201210, China
| | - Ziyu Guo
- JW Therapeutics (Shanghai) Co., Ltd, Shanghai, 201210, China
| | - James Li
- JW Therapeutics (Shanghai) Co., Ltd, Shanghai, 201210, China
| | - Yuqin Song
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China.
| | - Jun Zhu
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142, China.
| |
Collapse
|
11
|
Systematic Review on CAR-T Cell Clinical Trials Up to 2022: Academic Center Input. Cancers (Basel) 2023; 15:cancers15041003. [PMID: 36831349 PMCID: PMC9954171 DOI: 10.3390/cancers15041003] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/29/2023] [Accepted: 01/31/2023] [Indexed: 02/08/2023] Open
Abstract
The development of Chimeric Antigen Receptor T cells therapy initiated by the United States and China is still currently led by these two countries with a high number of clinical trials, with Europe lagging in launching its first trials. In this systematic review, we wanted to establish an overview of the production of CAR-T cells in clinical trials around the world, and to understand the causes of this delay in Europe. We particularly focused on the academic centers that are at the heart of research and development of this therapy. We counted 1087 CAR-T cells clinical trials on ClinicalTrials.gov (Research registry ID: reviewregistry1542) on the date of 25 January 2023. We performed a global analysis, before analyzing the 58 European trials, 34 of which sponsored by academic centers. Collaboration between an academic and an industrial player seems to be necessary for the successful development and application for marketing authorization of a CAR-T cell, and this collaboration is still cruelly lacking in European trials, unlike in the leading countries. Europe, still far behind the two leading countries, is trying to establish measures to lighten the regulations surrounding ATMPs and to encourage, through the addition of fundings, clinical trials involving these treatments.
Collapse
|
12
|
Zhang DKY, Adu-Berchie K, Iyer S, Liu Y, Cieri N, Brockman JM, Neuberg D, Wu CJ, Mooney DJ. Enhancing CAR-T cell functionality in a patient-specific manner. Nat Commun 2023; 14:506. [PMID: 36720856 PMCID: PMC9889707 DOI: 10.1038/s41467-023-36126-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 01/16/2023] [Indexed: 02/02/2023] Open
Abstract
Patient responses to autologous CD19 chimeric antigen receptor (CAR) T-cell therapies are limited by insufficient and inconsistent cellular functionality. Here, we show that controlling the precise level of stimulation during T-cell activation to accommodate individual differences in the donor cells will dictate the functional attributes of CAR-T cell products. The functionality of CAR-T cell products, consisting of a diverse set of blood samples derived from healthy donors, acute lymphoblastic leukemia (ALL), and chronic lymphocytic lymphoma (CLL) patient samples, representing a range of patient health status, is tested upon culturing on artificial antigen-presenting cell scaffolds to deliver T-cell stimulatory ligands (anti-CD3/anti-CD28) at highly defined densities. A clear relationship is observed between the dose of stimulation, the phenotype of the T-cell blood sample prior to T-cell activation, and the functionality of the resulting CAR-T cell products. We present a model, based on this dataset, that predicts the precise stimulation needed to manufacture a desired CAR-T cell product, given the input T-cell attributes in the initial blood sample. These findings demonstrate a simple approach to enhance CAR-T functionality by personalizing the level of stimulation during T-cell activation to enable flexible manufacturing of more consistent and potent CAR-T cells.
Collapse
Affiliation(s)
- David K Y Zhang
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
- The Wyss Institute for Biologically Inspired Engineering, Harvard University, Cambridge, MA, USA
| | - Kwasi Adu-Berchie
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
- The Wyss Institute for Biologically Inspired Engineering, Harvard University, Cambridge, MA, USA
| | - Siddharth Iyer
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
- The Wyss Institute for Biologically Inspired Engineering, Harvard University, Cambridge, MA, USA
| | - Yutong Liu
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
- The Wyss Institute for Biologically Inspired Engineering, Harvard University, Cambridge, MA, USA
| | - Nicoletta Cieri
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Joshua M Brockman
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA
- The Wyss Institute for Biologically Inspired Engineering, Harvard University, Cambridge, MA, USA
| | - Donna Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Catherine J Wu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - David J Mooney
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, USA.
- The Wyss Institute for Biologically Inspired Engineering, Harvard University, Cambridge, MA, USA.
| |
Collapse
|
13
|
Alarcon Tomas A, Fein JA, Fried S, Flynn JR, Devlin SM, Fingrut WB, Anagnostou T, Alperovich A, Shah N, Fraint E, Lin RJ, Scordo M, Batlevi CL, Besser MJ, Dahi PB, Danylesko I, Giralt S, Imber BS, Jacoby E, Kedmi M, Nagler A, Palomba ML, Roshal M, Salles GA, Sauter C, Shem-Tov N, Shimoni A, Yahalom J, Yerushalmi R, Shah GL, Avigdor A, Perales MA, Shouval R. Outcomes of first therapy after CD19-CAR-T treatment failure in large B-cell lymphoma. Leukemia 2023; 37:154-163. [PMID: 36335261 PMCID: PMC9892211 DOI: 10.1038/s41375-022-01739-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 11/07/2022]
Abstract
Persistence or recurrence of large B-cell lymphoma after CD19-CAR-T is common, yet data guiding management are limited. We describe outcomes and features following CAR-T treatment failure. Of 305 adults who received CD19-CAR-T, 182 experienced disease recurrence or progression (1-year cumulative incidence 63% [95%CI: 57-69]). Of 52 post-CAR-T biopsies evaluated by flow cytometry, 49 (94%) expressed CD19. Subsequent anti-cancer treatment was administered in 135/182 (74%) patients with CAR-T treatment failure. Median OS from the first post-CAR-T treatment was 8 months (95%CI 5.6-11.0). Polatuzumab-, standard chemotherapy-, and lenalidomide-based treatments were the most common approaches after CAR-T. No complete responses (CRs) were observed with conventional chemotherapy, while CR rates exceeding 30% were seen following polatuzumab- or lenalidomide-based therapies. Factors associated with poor OS among patients treated post-CAR-T were pre-CAR-T bulky disease (HR 2.27 [1.10-4.72]), lack of response to CAR-T (2.33 [1.02-5.29]), age >65 years (HR 2.65 [1.49-4.73]) and elevated LDH at post-CAR-T treatment (HR 2.95 [1.61-5.38]). The presence of ≥2 of these factors was associated with inferior OS compared to ≤1 (56% vs. 19%). In this largest analysis to date of patients who progressed or relapsed after CD19-CAR-T, survival is poor, though novel agents such as polatuzumab and lenalidomide may have hold promise.
Collapse
Affiliation(s)
- Ana Alarcon Tomas
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Ph.D. Program in Signals Integration and Modulation in Biomedicine, Cell Therapy, and Translational Medicine, University of Murcia, Murcia, Spain
- Department of Hematology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Joshua A Fein
- University of Connecticut Medical Center, Farmington, CT, USA
| | - Shalev Fried
- Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
- Sackler School of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | - Jessica R Flynn
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sean M Devlin
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Warren B Fingrut
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Theodora Anagnostou
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, and 2. Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anna Alperovich
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- BMT and Cellular Therapy Department, Monter Cancer Center, Northshore University Hospital, Lake Success, NY, USA
| | - Nishi Shah
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ellen Fraint
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Division of Pediatric Hematology, Oncology, and Cellular Therapy, The Children's Hospital at Montefiore, Bronx, NY, USA
| | - Richard J Lin
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Michael Scordo
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Connie Lee Batlevi
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michal J Besser
- Sackler School of Medicine Tel-Aviv University, Tel-Aviv, Israel
- Ella Lemelbaum Institute for Immuno Oncology, Sheba Medical Center, Tel Hashomer, Israel
- Davidoff Center, Rabin Medical Center, Petach Tikva, Israel
| | - Parastoo B Dahi
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Ivetta Danylesko
- Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
- Sackler School of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | - Sergio Giralt
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Brandon S Imber
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Elad Jacoby
- Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
- Sackler School of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | - Meirav Kedmi
- Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
- Sackler School of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | - Arnon Nagler
- Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
- Sackler School of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | - M Lia Palomba
- Weill Cornell Medical College, New York, NY, USA
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mikhail Roshal
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gilles A Salles
- Weill Cornell Medical College, New York, NY, USA
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Craig Sauter
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Noga Shem-Tov
- Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
- Sackler School of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | - Avichai Shimoni
- Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
- Sackler School of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | - Joachim Yahalom
- Weill Cornell Medical College, New York, NY, USA
- Department of Medicine, Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ronit Yerushalmi
- Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
- Sackler School of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | - Gunjan L Shah
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Abraham Avigdor
- Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
- Sackler School of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | - Miguel-Angel Perales
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Weill Cornell Medical College, New York, NY, USA.
| | - Roni Shouval
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel.
- Weill Cornell Medical College, New York, NY, USA.
| |
Collapse
|
14
|
Fried S, Shouval R, Varda-Bloom N, Besser MJ, Yerushalmi R, Shem-Tov N, Danylesko I, Jacoby E, Teihman S, Itzhaki O, Fein JA, Kedmi M, Shimoni A, Nagler A, Avigdor A. Point-of-care CAR T-cell therapy as salvage strategy for out-of-specification tisagenlecleucel. Leuk Lymphoma 2022; 63:3385-3393. [PMID: 36111694 DOI: 10.1080/10428194.2022.2123232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Tisagenlecleucel (tisa-cel) is an anti-CD19 chimeric antigen receptor (CAR) T-cell therapy approved for patients with relapsed/refractory large B-cell lymphoma. Outcomes of patients with out-of-commercial specification (OOS) CAR T products are not well characterized. We therefore assessed 37 adult patients who underwent leukapheresis for tisa-cel therapy in a single center. In nine (24%) patients, manufactured tisa-cel was considered OOS. Three of them (33%) received tisa-cel after institutional review board approval; 2/9 (22%) did not receive tisa-cel due to disease progression; and 4/9 (44%) received academic point-of-care (POC) CAR T-cell as salvage therapy, at a median of 35 days following OOS notification. Three of those four patients achieved a complete response. In univariate analysis, risk factors for OOS were ≥ 4 prior therapies or previous bendamustine exposure. In conclusion, we report high OOS incidence of 24% in real-life setting. Forty-four percent of those patients received POC CAR T-cell as salvage therapy.
Collapse
Affiliation(s)
- Shalev Fried
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Roni Shouval
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel.,Adult BMT Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Nira Varda-Bloom
- Hematology Laboratory, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Michal J Besser
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel-Aviv, Israel.,Ella Lemelbaum Institute for Immuno Oncology, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Ronit Yerushalmi
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Noga Shem-Tov
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Ivetta Danylesko
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Elad Jacoby
- Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel.,Department of Pediatric Hematology-Oncology, Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Shlomit Teihman
- Hematology Laboratory, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Orit Itzhaki
- Ella Lemelbaum Institute for Immuno Oncology, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Joshua A Fein
- University of Connecticut Medical Center, Farmington, CT, USA
| | - Meirav Kedmi
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel.,The Mina and Everard Goodman faculty of life sciences, Bar Ilan University, Ramat Gan, Israel
| | - Avichai Shimoni
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Arnon Nagler
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Abraham Avigdor
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel
| |
Collapse
|
15
|
Bulsara S, Wu M, Wang T. Phase I CAR-T Clinical Trials Review. Anticancer Res 2022; 42:5673-5684. [PMID: 36456127 PMCID: PMC10132085 DOI: 10.21873/anticanres.16076] [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: 09/21/2022] [Revised: 10/14/2022] [Accepted: 10/24/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND/AIM Chimeric antigen receptor (CAR) T cells with tumor specificity are being increasingly investigated. Phase I trials are the first step of testing for safety of novel CAR-T therapy to determine the maximum tolerated dose (MTD). Several dose escalation methods have been developed over time including rule-based, model-based, and model-assisted designs. The goal of this project is to overview the phase I designs used in current CAR-T trials. MATERIALS AND METHODS We searched PubMed for peer-reviewed literature published between January 1, 2015 and December 31, 2021. The search was limited to human studies in the English language using the keywords "CAR-T phase I", "clinical trials", and "full text". RESULTS One hundred nine papers with at least partial phase I components were included for analysis. 31.2% of the trials used the traditional 3+3 or a variation of said design, and 60.6% did not mention the dose escalation design. The majority of the manuscripts (59.6%) did not report cohort size while 19.3% did not specify the timing of evaluation. Although most of the studies were registered with CT.gov, only 33.9% had any results submitted or posted to CT.gov These trends persisted even in manuscripts published in journals with high impact factors. CONCLUSION Standardizing the publication criteria and providing basic elements of phase I clinical trials are critical to ensure high quality of manuscripts. With the quick development and high costs of CAR-T cell therapy, adoption of advanced designs such as model-based and model-assisted should increase to improve efficiency of clinical trials.
Collapse
Affiliation(s)
- Shaun Bulsara
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, U.S.A
| | - Mengfen Wu
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, U.S.A
| | - Tao Wang
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, U.S.A.
| |
Collapse
|
16
|
Huang W, Li J, Liao MZ, Liu SN, Yu J, Jing J, Kotani N, Kamen L, Guelman S, Miles DR. Clinical Pharmacology Perspectives for Adoptive Cell Therapies in Oncology. Clin Pharmacol Ther 2022; 112:968-981. [PMID: 34888856 PMCID: PMC9786613 DOI: 10.1002/cpt.2509] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/24/2021] [Indexed: 12/30/2022]
Abstract
Adoptive cell therapies (ACTs) have shown transformative efficacy in oncology with five US Food and Drug Administration (FDA) approvals for chimeric antigen receptor (CAR) T-cell therapies in hematological malignancies, and promising activity for T cell receptor T-cell therapies in both liquid and solid tumors. Clinical pharmacology can play a pivotal role in optimizing ACTs, aided by modeling and simulation toolboxes and deep understanding of the underlying biological and immunological processes. Close collaboration and multilevel data integration across functions, including chemistry, manufacturing, and control, biomarkers, bioanalytical, and clinical science and safety teams will be critical to ACT development. As ACT is comprised of alive, polyfunctional, and heterogeneous immune cells, its overall physicochemical and pharmacological property is vastly different from other platforms/modalities, such as small molecule and protein therapeutics. In this review, we first describe the unique kinetics of T cells and the appropriate bioanalytical strategies to characterize cellular kinetics. We then assess the distinct aspects of clinical pharmacology for ACTs in comparison to traditional small molecule and protein therapeutics. Additionally, we provide a review for the five FDA-approved CAR T-cell therapies and summarize their properties, cellular kinetic characteristics, dose-exposure-response relationship, and potential baseline factors/variables in product, patient, and regimen that may affect the safety and efficacy. Finally, we probe into existing empirical and mechanistic quantitative techniques to understand how various modeling and simulation approaches can support clinical pharmacology strategy and propose key considerations to be incorporated and explored in future models.
Collapse
Affiliation(s)
- Weize Huang
- Genentech Inc.South San FranciscoCaliforniaUSA
| | - Junyi Li
- Genentech Inc.South San FranciscoCaliforniaUSA
| | | | | | - Jiajie Yu
- Genentech Inc.South San FranciscoCaliforniaUSA
| | - Jing Jing
- Genentech Inc.South San FranciscoCaliforniaUSA
| | - Naoki Kotani
- Genentech Inc.South San FranciscoCaliforniaUSA,Chugai Pharmaceutical Co., Ltd.TokyoJapan
| | - Lynn Kamen
- Genentech Inc.South San FranciscoCaliforniaUSA
| | | | | |
Collapse
|
17
|
Brezinger-Dayan K, Itzhaki O, Melnichenko J, Kubi A, Zeltzer LA, Jacoby E, Avigdor A, Shapira Frommer R, Besser MJ. Impact of cryopreservation on CAR T production and clinical response. Front Oncol 2022; 12:1024362. [PMID: 36276077 PMCID: PMC9582437 DOI: 10.3389/fonc.2022.1024362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 09/22/2022] [Indexed: 11/13/2022] Open
Abstract
Adoptive cell therapy with chimeric antigen receptor (CAR) T cells has become an efficient treatment option for patients with hematological malignancies. FDA approved CAR T products are manufactured in centralized facilities from fresh or frozen leukapheresis and the cryopreserved CAR T infusion product is shipped back to the patient. An increasing number of clinical centers produce CAR T cells on-site, which enables the use of fresh and cryopreserved PBMCs and CAR T cells. Here we determined the effect of cryopreservation on PBMCs and CD19 CAR T cells in a cohort of 118 patients treated with fresh CAR T cells and in several patients head-to-head. Cryopreserved PBMCs, obtained from leukapheresis products, contained less erythrocytes and T cells, but were sufficient to produce CAR T cells for therapy. There was no correlation between the recovery of PBMCs and the transduction efficacy, the number of CAR T cells obtained by the end of the manufacturing process, the in vitro reactivity, or the response rate to CAR T therapy. We could show that CAR T cells cryopreserved during the manufacturing process, stored and resumed expansion at a later time point, yielded sufficient cell numbers for treatment and led to complete remissions. Phenotype analysis including T cell subtypes, chemokine receptor and co-inhibitory/stimulatory molecules, revealed that fresh CAR T cells expressed significantly more TIM-3 and contained less effector T cells in comparison to their frozen counterparts. In addition, fresh CAR T infusion products demonstrated increased in vitro anti-tumor reactivity, however cryopreserved CAR T cells still showed high anti-tumor potency and specificity. The recovery of cryopreserved CAR T cells was similar in responding and non-responding patients. Although fresh CAR T infusion products exhibit higher anti-tumor reactivity, the use of frozen PBMCs as staring material and frozen CAR T infusion products seems a viable option, as frozen products still exhibit high in vitro potency and cryopreservation did not seem to affect the clinical outcome.
Collapse
Affiliation(s)
- Karin Brezinger-Dayan
- Ella Lemelbaum Institute for Immuno Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Orit Itzhaki
- Ella Lemelbaum Institute for Immuno Oncology, Sheba Medical Center, Ramat Gan, Israel
- *Correspondence: Michal J. Besser, ; Orit Itzhaki,
| | - Jenny Melnichenko
- Ella Lemelbaum Institute for Immuno Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Adva Kubi
- Ella Lemelbaum Institute for Immuno Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Li-at Zeltzer
- Ella Lemelbaum Institute for Immuno Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Elad Jacoby
- Division of Pediatric Hematology and Oncology, The Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Ramat Gan, Israel
- Department of Hematology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Abraham Avigdor
- Department of Bone Marrow Transplantation, Sheba Medical Center, Ramat Gan, Israel
| | | | - Michal J. Besser
- Ella Lemelbaum Institute for Immuno Oncology, Sheba Medical Center, Ramat Gan, Israel
- Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- *Correspondence: Michal J. Besser, ; Orit Itzhaki,
| |
Collapse
|
18
|
Characterizing piggyBat-a transposase for genetic modification of T cells. Mol Ther Methods Clin Dev 2022; 25:250-263. [PMID: 35474955 PMCID: PMC9018555 DOI: 10.1016/j.omtm.2022.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 03/17/2022] [Indexed: 11/21/2022]
Abstract
Chimeric antigen receptor (CAR) T cells targeting CD19 have demonstrated remarkable efficacy in the treatment of B cell malignancies. Current CAR T cell manufacturing protocols are complex and costly due to their reliance on viral vectors. Non-viral systems of genetic modification, such as with transposase and transposon systems, offer a potential streamlined alternative for CAR T cell manufacture and are currently being evaluated in clinical trials. In this study, we utilized the previously described transposase from the little brown bat, designated piggyBat, for production of CD19-specific CAR T cells. PiggyBat demonstrates efficient CAR transgene delivery, with a relatively low variability in integration copy number across a range of manufacturing conditions as well as a similar integration site profile to super-piggyBac transposon and viral vectors. PiggyBat-generated CAR T cells demonstrate CD19-specific cytotoxic efficacy in vitro and in vivo. These data demonstrate that alternative, naturally occurring DNA transposons can be efficiently re-tooled to be exploited in real-world applications.
Collapse
|
19
|
Inadvertent Transfer of Murine VL30 Retrotransposons to CAR-T Cells. ADVANCES IN CELL AND GENE THERAPY 2022; 2022. [PMID: 36081760 PMCID: PMC9450689 DOI: 10.1155/2022/6435077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
For more than a decade, genetically engineered autologous T-cells have been successfully employed as immunotherapy drugs for patients with incurable blood cancers. The active components in some of these game-changing medicines are autologous T-cells that express viral vector-delivered chimeric antigen receptors (CARs), which specifically target proteins that are preferentially expressed on cancer cells. Some of these therapeutic CAR expressing T-cells (CAR-Ts) are engineered via transduction with
-retroviral vectors (
-RVVs) produced in a stable producer cell line that was derived from murine PG13 packaging cells (ATCC CRL-10686). Earlier studies reported on the copackaging of murine virus-like 30S RNA (VL30) genomes with
-retroviral vectors generated in murine stable packaging cells. In an earlier study, VL30 mRNA was found to enhance the metastatic potential of human melanoma cells. These findings raise biosafety concerns regarding the possibility that therapeutic CAR-Ts have been inadvertently contaminated with potentially oncogenic VL30 retrotransposons. In this study, we demonstrated the presence of infectious VL30 particles in PG13 cell-conditioned media and observed the ability of these particles to deliver transcriptionally active VL30 genomes to human cells. Notably, VL30 genomes packaged by HIV-1-based vector particles transduced naïve human cells in culture. Furthermore, we detected the transfer and expression of VL30 genomes in clinical-grade CAR-T cells generated by transduction with PG13 cell-derived
-retroviral vectors. Our findings raise biosafety concerns regarding the use of murine packaging cell lines in ongoing clinical applications.
Collapse
|
20
|
Otegbeye F. Bench at Bedside Models Facilitate CAR-T Cell Supply Chain. Transplant Cell Ther 2022; 28:221-222. [PMID: 35523472 DOI: 10.1016/j.jtct.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Folashade Otegbeye
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA 98109.
| |
Collapse
|
21
|
Teoh J, Brown LF. Developing lisocabtagene maraleucel chimeric antigen receptor T-cell manufacturing for improved process, product quality and consistency across CD19+ hematologic indications. Cytotherapy 2022; 24:962-973. [DOI: 10.1016/j.jcyt.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 11/26/2022]
|
22
|
Beider K, Itzhaki O, Schachter J, Grushchenko-Polaq AH, Voevoda-Dimenshtein V, Rosenberg E, Ostrovsky O, Devillers O, Shapira Frommer R, Zeltzer LA, Toren A, Jacoby E, Shimoni A, Avigdor A, Nagler A, Besser MJ. Molecular and Functional Signatures Associated with CAR T Cell Exhaustion and Impaired Clinical Response in Patients with B Cell Malignancies. Cells 2022; 11:cells11071140. [PMID: 35406703 PMCID: PMC8997745 DOI: 10.3390/cells11071140] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/12/2022] [Accepted: 03/25/2022] [Indexed: 12/04/2022] Open
Abstract
Despite the high rates of complete remission following chimeric antigen receptor (CAR) T cell therapy, its full capacity is currently limited by the generation of dysfunctional CAR T cells. Senescent or exhausted CAR T cells possess poor targeting and effector functions, as well as impaired cell proliferation and persistence in vivo. Strategies to detect, prevent or reverse T cell exhaustion are therefore required in order to enhance the effectiveness of CAR T immunotherapy. Here we report that CD19 CAR T cells from non-responding patients with B cell malignancies show enrichment of CD8+ cells with exhausted/senescent phenotype and display a distinct transcriptional signature with dysregulation of genes associated with terminal exhaustion. Furthermore, CAR T cells from non-responding patients exhibit reduced proliferative capacity and decreased IL-2 production in vitro, indicating functional impairment. Overall, our work reveals potential mediators of resistance, paving the way to studies that will enhance the efficacy and durability of CAR T therapy in B cell malignancies.
Collapse
Affiliation(s)
- Katia Beider
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv 6997801, Israel; (K.B.); (A.H.G.-P.); (V.V.-D.); (E.R.); (O.O.); (O.D.); (A.S.); (A.A.)
| | - Orit Itzhaki
- Ella Lemelbaum Institute for Immuno Oncology, Chaim Sheba Medical Center, Tel Aviv 6997801, Israel; (O.I.); (J.S.); (R.S.F.); (L.-a.Z.)
| | - Jacob Schachter
- Ella Lemelbaum Institute for Immuno Oncology, Chaim Sheba Medical Center, Tel Aviv 6997801, Israel; (O.I.); (J.S.); (R.S.F.); (L.-a.Z.)
| | - Ania Hava Grushchenko-Polaq
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv 6997801, Israel; (K.B.); (A.H.G.-P.); (V.V.-D.); (E.R.); (O.O.); (O.D.); (A.S.); (A.A.)
| | - Valeria Voevoda-Dimenshtein
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv 6997801, Israel; (K.B.); (A.H.G.-P.); (V.V.-D.); (E.R.); (O.O.); (O.D.); (A.S.); (A.A.)
| | - Evgenia Rosenberg
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv 6997801, Israel; (K.B.); (A.H.G.-P.); (V.V.-D.); (E.R.); (O.O.); (O.D.); (A.S.); (A.A.)
| | - Olga Ostrovsky
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv 6997801, Israel; (K.B.); (A.H.G.-P.); (V.V.-D.); (E.R.); (O.O.); (O.D.); (A.S.); (A.A.)
| | - Olivia Devillers
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv 6997801, Israel; (K.B.); (A.H.G.-P.); (V.V.-D.); (E.R.); (O.O.); (O.D.); (A.S.); (A.A.)
| | - Ronnie Shapira Frommer
- Ella Lemelbaum Institute for Immuno Oncology, Chaim Sheba Medical Center, Tel Aviv 6997801, Israel; (O.I.); (J.S.); (R.S.F.); (L.-a.Z.)
| | - Li-at Zeltzer
- Ella Lemelbaum Institute for Immuno Oncology, Chaim Sheba Medical Center, Tel Aviv 6997801, Israel; (O.I.); (J.S.); (R.S.F.); (L.-a.Z.)
| | - Amos Toren
- Center for Pediatric Cell Therapy, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv 6997801, Israel; (A.T.); (E.J.)
| | - Elad Jacoby
- Center for Pediatric Cell Therapy, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv 6997801, Israel; (A.T.); (E.J.)
| | - Avichai Shimoni
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv 6997801, Israel; (K.B.); (A.H.G.-P.); (V.V.-D.); (E.R.); (O.O.); (O.D.); (A.S.); (A.A.)
| | - Abraham Avigdor
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv 6997801, Israel; (K.B.); (A.H.G.-P.); (V.V.-D.); (E.R.); (O.O.); (O.D.); (A.S.); (A.A.)
| | - Arnon Nagler
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv 6997801, Israel; (K.B.); (A.H.G.-P.); (V.V.-D.); (E.R.); (O.O.); (O.D.); (A.S.); (A.A.)
- Correspondence: (A.N.); (M.J.B.)
| | - Michal J. Besser
- Ella Lemelbaum Institute for Immuno Oncology, Chaim Sheba Medical Center, Tel Aviv 6997801, Israel; (O.I.); (J.S.); (R.S.F.); (L.-a.Z.)
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Correspondence: (A.N.); (M.J.B.)
| |
Collapse
|
23
|
Panowski SH, Srinivasan S, Tan N, Tacheva-Grigorova SK, Smith B, Mak Y, Ning H, Villanueva J, Wijewarnasuriya D, Lang S, Melton Z, Ghosh A, Dusseaux M, Galetto R, Heyen JR, Sai T, Van Blarcom TJ, Chaparro-Riggers J, Sasu BJ. Preclinical Development and Evaluation of Allogeneic CAR T Cells Targeting CD70 for the Treatment of Renal Cell Carcinoma. Cancer Res 2022; 82:2610-2624. [PMID: 35294525 DOI: 10.1158/0008-5472.can-21-2931] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 02/08/2022] [Accepted: 03/11/2022] [Indexed: 11/16/2022]
Abstract
CD70 is highly expressed in renal cell carcinoma (RCC), with limited expression in normal tissue, making it an attractive CAR T target for an immunogenic solid tumor indication. Here we generated and characterized a panel of anti-CD70 scFv-based CAR T cells. Despite the expression of CD70 on T cells, production of CAR T from a subset of scFvs with potent in vitro activity was achieved. Expression of CD70 CARs masked CD70 detection in cis and provide protection from CD70 CAR T-mediated fratricide. Two distinct classes of CAR T cells were identified with differing memory phenotype, activation status, and cytotoxic activity. Epitope mapping revealed that the two classes of CARs bind unique regions of CD70. CD70 CAR T cells displayed robust antitumor activity against RCC cell lines and patient-derived xenograft mouse models. Tissue cross-reactivity studies identified membrane staining in lymphocytes, thus matching the known expression pattern of CD70. In a cynomolgus monkey CD3-CD70 bispecific toxicity study, expected findings related to T cell activation and elimination of CD70-expressing cells were observed, including cytokine release and loss of cellularity in lymphoid tissues. Lastly, highly functional CD70 allogeneic CAR T cells were produced at large scale through elimination of the T cell receptor by TALEN-based gene editing. Taken together, these efficacy and safety data support the evaluation of CD70 CAR T cells for the treatment of RCC and has led to the advancement of an allogeneic CD70 CAR T candidate into phase I clinical trials.
Collapse
Affiliation(s)
| | | | - Nguyen Tan
- Allogene Therapeutics, South San Francisco, CA, United States
| | | | - Bryan Smith
- Allogene Therapeutics, South San Francisco, CA, United States
| | - Yvonne Mak
- Allogene Therapeutics, South San Francisco, CA, United States
| | - Hongxiu Ning
- Allogene Therapeutics, South San Francisco, CA, United States
| | | | | | - Shanshan Lang
- Allogene Therapeutics, South San Francisco, CA, United States
| | - Zea Melton
- Allogene Therapeutics, Inc., South San Francisco, CA, United States
| | - Adit Ghosh
- Allogene Therapeutics, South San Francisco, CA, United States
| | | | | | | | - Tao Sai
- Pfizer Inc, South San Francisco, CA, United States
| | | | | | - Barbra J Sasu
- Allogene Therapuetics Inc, South San Francisco, CA, United States
| |
Collapse
|
24
|
Garcia-Prieto CA, Villanueva L, Bueno-Costa A, Davalos V, González-Navarro EA, Juan M, Urbano-Ispizua Á, Delgado J, Ortiz-Maldonado V, del Bufalo F, Locatelli F, Quintarelli C, Sinibaldi M, Soler M, Castro de Moura M, Ferrer G, Urdinguio RG, Fernandez AF, Fraga MF, Bar D, Meir A, Itzhaki O, Besser MJ, Avigdor A, Jacoby E, Esteller M. Epigenetic Profiling and Response to CD19 Chimeric Antigen Receptor T-Cell Therapy in B-Cell Malignancies. J Natl Cancer Inst 2022; 114:436-445. [PMID: 34581788 PMCID: PMC8902331 DOI: 10.1093/jnci/djab194] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 07/11/2021] [Accepted: 09/22/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Chimeric antigen receptor (CAR) T cells directed against CD19 (CART19) are effective in B-cell malignancies, but little is known about the molecular factors predicting clinical outcome of CART19 therapy. The increasingly recognized relevance of epigenetic changes in cancer immunology prompted us to determine the impact of the DNA methylation profiles of CART19 cells on the clinical course. METHODS We recruited 114 patients with B-cell malignancies, comprising 77 patients with acute lymphoblastic leukemia and 37 patients with non-Hodgkin lymphoma who were treated with CART19 cells. Using a comprehensive DNA methylation microarray, we determined the epigenomic changes that occur in the patient T cells upon transduction of the CAR vector. The effects of the identified DNA methylation sites on clinical response, cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, event-free survival, and overall survival were assessed. All statistical tests were 2-sided. RESULTS We identified 984 genomic sites with differential DNA methylation between CAR-untransduced and CAR-transduced T cells before infusion into the patient. Eighteen of these distinct epigenetic loci were associated with complete response (CR), adjusting by multiple testing. Using the sites linked to CR, an epigenetic signature, referred to hereafter as the EPICART signature, was established in the initial discovery cohort (n = 79), which was associated with CR (Fisher exact test, P < .001) and enhanced event-free survival (hazard ratio [HR] = 0.36; 95% confidence interval [CI] = 0.19 to 0.70; P = .002; log-rank P = .003) and overall survival (HR = 0.45; 95% CI = 0.20 to 0.99; P = .047; log-rank P = .04;). Most important, the EPICART profile maintained its clinical course predictive value in the validation cohort (n = 35), where it was associated with CR (Fisher exact test, P < .001) and enhanced overall survival (HR = 0.31; 95% CI = 0.11 to 0.84; P = .02; log-rank P = .02). CONCLUSIONS We show that the DNA methylation landscape of patient CART19 cells influences the efficacy of the cellular immunotherapy treatment in patients with B-cell malignancy.
Collapse
Affiliation(s)
- Carlos A Garcia-Prieto
- Cancer and Leukemia Epigenetics and Biology Program (PEBCL), Josep Carreras Leukaemia Research Institute (IJC), Badalona, Spain
- Life Sciences Department, Barcelona Supercomputing Center (BSC), Barcelona, Spain
| | - Lorea Villanueva
- Cancer and Leukemia Epigenetics and Biology Program (PEBCL), Josep Carreras Leukaemia Research Institute (IJC), Badalona, Spain
| | - Alberto Bueno-Costa
- Cancer and Leukemia Epigenetics and Biology Program (PEBCL), Josep Carreras Leukaemia Research Institute (IJC), Badalona, Spain
| | - Veronica Davalos
- Cancer and Leukemia Epigenetics and Biology Program (PEBCL), Josep Carreras Leukaemia Research Institute (IJC), Badalona, Spain
| | | | - Manel Juan
- Department of Immunology, Hospital Clinic, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Álvaro Urbano-Ispizua
- Cancer and Leukemia Epigenetics and Biology Program (PEBCL), Josep Carreras Leukaemia Research Institute (IJC), Badalona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Hematology, University of Barcelona (UB), Barcelona, Spain
| | - Julio Delgado
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Cancer (CIBERONC), Madrid, Spain
| | | | - Francesca del Bufalo
- Department of Paediatric Haematology and Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Franco Locatelli
- Department of Paediatric Haematology and Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
- Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Concetta Quintarelli
- Department of Paediatric Haematology and Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Matilde Sinibaldi
- Department of Paediatric Haematology and Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marta Soler
- Cancer and Leukemia Epigenetics and Biology Program (PEBCL), Josep Carreras Leukaemia Research Institute (IJC), Badalona, Spain
| | - Manuel Castro de Moura
- Cancer and Leukemia Epigenetics and Biology Program (PEBCL), Josep Carreras Leukaemia Research Institute (IJC), Badalona, Spain
| | - Gerardo Ferrer
- Cancer and Leukemia Epigenetics and Biology Program (PEBCL), Josep Carreras Leukaemia Research Institute (IJC), Badalona, Spain
| | - Rocio G Urdinguio
- Nanomaterials and Nanotechnology Research Center (CINNCSIC), Health Research Institute of Asturias (ISPA), Institute of Oncology of Asturias (IUOPA), Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Department of Organisms and Systems Biology (BOS), University of Oviedo, Oviedo, Spain
| | - Agustin F Fernandez
- Nanomaterials and Nanotechnology Research Center (CINNCSIC), Health Research Institute of Asturias (ISPA), Institute of Oncology of Asturias (IUOPA), Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Department of Organisms and Systems Biology (BOS), University of Oviedo, Oviedo, Spain
| | - Mario F Fraga
- Nanomaterials and Nanotechnology Research Center (CINNCSIC), Health Research Institute of Asturias (ISPA), Institute of Oncology of Asturias (IUOPA), Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Department of Organisms and Systems Biology (BOS), University of Oviedo, Oviedo, Spain
| | - Diana Bar
- Division of Pediatric Hematology and Oncology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Amilia Meir
- Division of Pediatric Hematology and Oncology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Orit Itzhaki
- Ella Lemelbaum Institute for Immuno Oncology, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Michal J Besser
- Ella Lemelbaum Institute for Immuno Oncology, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Abraham Avigdor
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
| | - Elad Jacoby
- Division of Pediatric Hematology and Oncology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Manel Esteller
- Cancer and Leukemia Epigenetics and Biology Program (PEBCL), Josep Carreras Leukaemia Research Institute (IJC), Badalona, Spain
- Centro de Investigación Biomédica en Red de Cancer (CIBERONC), Madrid, Spain
- Institucio Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
- Physiological Sciences Department, School of Medicine and Health Sciences, University of Barcelona (UB), Spain
| |
Collapse
|
25
|
Jacoby E, Bielorai B, Hutt D, Itzhaki O, Adam E, Bar D, Besser MJ, Toren A. Parameters of long‐term response with
CD28
‐based
CD19 chimaeric antigen receptor‐modified
T cells in children and young adults with
B‐acute lymphoblastic leukaemia. Br J Haematol 2022; 197:475-481. [DOI: 10.1111/bjh.18105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/09/2022] [Accepted: 02/10/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Elad Jacoby
- Division of Pediatric Hematology and Oncology The Edmond and Lily Safra Children's Hospital, Sheba Medical Center Tel Hashomer Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Bella Bielorai
- Division of Pediatric Hematology and Oncology The Edmond and Lily Safra Children's Hospital, Sheba Medical Center Tel Hashomer Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Daphna Hutt
- Division of Pediatric Hematology and Oncology The Edmond and Lily Safra Children's Hospital, Sheba Medical Center Tel Hashomer Israel
| | - Orit Itzhaki
- Ella Institute of Immuno‐Oncology Sheba Medical Center Tel Hashomer Israel
| | - Etai Adam
- Division of Pediatric Hematology and Oncology The Edmond and Lily Safra Children's Hospital, Sheba Medical Center Tel Hashomer Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Diana Bar
- Division of Pediatric Hematology and Oncology The Edmond and Lily Safra Children's Hospital, Sheba Medical Center Tel Hashomer Israel
| | - Michal J. Besser
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
- Ella Institute of Immuno‐Oncology Sheba Medical Center Tel Hashomer Israel
| | - Amos Toren
- Division of Pediatric Hematology and Oncology The Edmond and Lily Safra Children's Hospital, Sheba Medical Center Tel Hashomer Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| |
Collapse
|
26
|
Kedmi M, Shouval R, Fried S, Bomze D, Fein J, Cohen Z, Danilesko I, Shem-Tov N, Yerushalmi R, Jacoby E, Besser M, Shimoni A, Nagler A, Avigdor A. Point-of-care anti-CD19 CAR T-cells for treatment of relapsed and refractory aggressive B cell lymphoma. Transplant Cell Ther 2022; 28:251-257. [PMID: 35218999 PMCID: PMC9519531 DOI: 10.1016/j.jtct.2022.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anti CD19 Chimeric Antigen Receptor (CAR) T-cell therapy has transformed the care of relapsed & refractory aggressive B cell Lymphoma. However, financial toxicity and manufacturing time represent barriers to its widespread implementation. OBJECTIVE Study applicability, toxicity, and efficacy of a locally produced autologous CD19-directed CAR-T cell product. METHODS We performed a phase 1b/2 clinical trial with a point-of-care (POC) CAR T-cell product that contains a CD28 costimulatory domain. Adult patients with aggressive B cell lymphoma or transformed low-grade lymphoma who received at least two prior regimens were eligible. RESULTS A total of 73 patients, with a median age of 49 years, met inclusion criteria. CAR-T production time from apheresis was 10 days (IQR 10-11), negating the need for bridging chemotherapy. Overall and complete response rates were 62.5% and 37.5%. Median progression-free and overall survival were 3.7 and 12.1 months, respectively. Overall and progression-free survival at 12 months were 52.1% (CI: 40.8%-66.5%) and 40% (CI: 30%-53.7%), respectively. Patients who achieved response had longer progression-free and overall survival. Grade 3-4 CRS was observed in 9.5% of the patients, and ICANS grade 3-4 in 21.9%. No deaths occurred due to CAR T-cell toxicity. Fifteen patients (20%) underwent allogeneic stem cell transplantation at a median time of 60 days post CAR T-cell therapy; 8 were alive at last follow-up. Of the six patients that underwent the transplant in complete response 2 deceased due to toxicity. CONCLUSIONS POC CAR-T cells are a feasible therapeutic option in aggressive B-cell lymphoma. They provide good efficacy while minimizing production time and the need for bridging therapy.
Collapse
Affiliation(s)
- Meirav Kedmi
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Israel; Sackler School of Medicine, Tel-Aviv University, Israel; The Mina & Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Israel.
| | - Roni Shouval
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Israel; Sackler School of Medicine, Tel-Aviv University, Israel; Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Weill Cornell Medical College, New York, NY
| | - Shalev Fried
- Sackler School of Medicine, Tel-Aviv University, Israel
| | - David Bomze
- Sackler School of Medicine, Tel-Aviv University, Israel
| | - Joshua Fein
- University of Connecticut Medical Center, Farmington, CT
| | - Zachary Cohen
- Sackler School of Medicine, Tel-Aviv University, Israel
| | - Ivetta Danilesko
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Israel; Sackler School of Medicine, Tel-Aviv University, Israel
| | - Noga Shem-Tov
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Israel; Sackler School of Medicine, Tel-Aviv University, Israel
| | - Ronit Yerushalmi
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Israel; Sackler School of Medicine, Tel-Aviv University, Israel
| | - Elad Jacoby
- Sackler School of Medicine, Tel-Aviv University, Israel; Division of Pediatric Hematology, Oncology and BMT, Chaim Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Tel Hashomer, Israel
| | - Michal Besser
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel-Aviv; Ella Lemelbaum Institute for Immuno Oncology, Chaim Sheba Medical Center, Israel
| | - Avichai Shimoni
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Israel; Sackler School of Medicine, Tel-Aviv University, Israel
| | - Arnon Nagler
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Israel; Sackler School of Medicine, Tel-Aviv University, Israel
| | - Abraham Avigdor
- Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Israel; Sackler School of Medicine, Tel-Aviv University, Israel
| |
Collapse
|
27
|
Buechner J, Caruana I, Künkele A, Rives S, Vettenranta K, Bader P, Peters C, Baruchel A, Calkoen FG. Chimeric Antigen Receptor T-Cell Therapy in Paediatric B-Cell Precursor Acute Lymphoblastic Leukaemia: Curative Treatment Option or Bridge to Transplant? Front Pediatr 2022; 9:784024. [PMID: 35145941 PMCID: PMC8823293 DOI: 10.3389/fped.2021.784024] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/02/2021] [Indexed: 01/02/2023] Open
Abstract
Chimeric antigen receptor T-cell therapy (CAR-T) targeting CD19 has been associated with remarkable responses in paediatric patients and adolescents and young adults (AYA) with relapsed/refractory (R/R) B-cell precursor acute lymphoblastic leukaemia (BCP-ALL). Tisagenlecleucel, the first approved CD19 CAR-T, has become a viable treatment option for paediatric patients and AYAs with BCP-ALL relapsing repeatedly or after haematopoietic stem cell transplantation (HSCT). Based on the chimeric antigen receptor molecular design and the presence of a 4-1BB costimulatory domain, tisagenlecleucel can persist for a long time and thereby provide sustained leukaemia control. "Real-world" experience with tisagenlecleucel confirms the safety and efficacy profile observed in the pivotal registration trial. Recent guidelines for the recognition, management and prevention of the two most common adverse events related to CAR-T - cytokine release syndrome and immune-cell-associated neurotoxicity syndrome - have helped to further decrease treatment toxicity. Consequently, the questions of how and for whom CD19 CAR-T could substitute HSCT in BCP-ALL are inevitable. Currently, 40-50% of R/R BCP-ALL patients relapse post CD19 CAR-T with either CD19- or CD19+ disease, and consolidative HSCT has been proposed to avoid disease recurrence. Contrarily, CD19 CAR-T is currently being investigated in the upfront treatment of high-risk BCP-ALL with an aim to avoid allogeneic HSCT and associated treatment-related morbidity, mortality and late effects. To improve survival and decrease long-term side effects in children with BCP-ALL, it is important to define parameters predicting the success or failure of CAR-T, allowing the careful selection of candidates in need of HSCT consolidation. In this review, we describe the current clinical evidence on CAR-T in BCP-ALL and discuss factors associated with response to or failure of this therapy: product specifications, patient- and disease-related factors and the impact of additional therapies given before (e.g., blinatumomab and inotuzumab ozogamicin) or after infusion (e.g., CAR-T re-infusion and/or checkpoint inhibition). We discuss where to position CAR-T in the treatment of BCP-ALL and present considerations for the design of supportive trials for the different phases of disease. Finally, we elaborate on clinical settings in which CAR-T might indeed replace HSCT.
Collapse
Affiliation(s)
- Jochen Buechner
- Department of Pediatric Hematology and Oncology, Oslo University Hospital, Oslo, Norway
| | - Ignazio Caruana
- Department of Paediatric Haematology, Oncology and Stem Cell Transplantation, University Hospital Würzburg, Würzburg, Germany
| | - Annette Künkele
- Department of Pediatric Oncology and Hematology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Susana Rives
- Department of Pediatric Hematology and Oncology, Hospital Sant Joan de Déu de Barcelona, Institut per la Recerca Sant Joan de Déu, Barcelona, Spain
| | - Kim Vettenranta
- University of Helsinki and Children's Hospital, University of Helsinki, Helsinki, Finland
| | - Peter Bader
- Division for Stem Cell Transplantation, Immunology and Intensive Care Medicine, Department for Children and Adolescents, University Hospital, Goethe University, Frankfurt, Germany
| | - Christina Peters
- St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
- St. Anna Children's Cancer Research Institute, Vienna, Austria
| | - André Baruchel
- Université de Paris et Institut de Recherche Saint-Louis (EA 35-18) and Hôpital Universitaire Robert Debré (APHP), Paris, France
| | - Friso G. Calkoen
- Department of Stem Cell Transplantation and Cellular Therapy, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| |
Collapse
|
28
|
Saini KS, Svane IM, Juan M, Barlesi F, André F. Manufacture of adoptive cell therapies at academic cancer centers: scientific, safety and regulatory challenges. Ann Oncol 2021; 33:6-12. [PMID: 34655734 DOI: 10.1016/j.annonc.2021.09.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/27/2021] [Accepted: 09/30/2021] [Indexed: 12/14/2022] Open
Affiliation(s)
- K S Saini
- Labcorp Drug Development Inc., Princeton, USA
| | - I M Svane
- National Center for Cancer Immune Therapy, Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - M Juan
- Department of Immunology, Hospital Clinic, IDIBAPS, Immunotherapy Platform Hospital Sant Joan de Déu, Universidad de Barcelona, Barcelona, Spain
| | - F Barlesi
- Department of Medical Oncology, Institut Gustave Roussy, Villejuif, France; Aix Marseille University, CNRS, INSERM, CRCM, Marseille, France
| | - F André
- Institut Gustave Roussy, INSERM UMR981, Université Paris Saclay, Paris, France.
| |
Collapse
|
29
|
Ernst M, Oeser A, Besiroglu B, Caro-Valenzuela J, Abd El Aziz M, Monsef I, Borchmann P, Estcourt LJ, Skoetz N, Goldkuhle M. Chimeric antigen receptor (CAR) T-cell therapy for people with relapsed or refractory diffuse large B-cell lymphoma. Cochrane Database Syst Rev 2021; 9:CD013365. [PMID: 34515338 PMCID: PMC8436585 DOI: 10.1002/14651858.cd013365.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Diffuse large B-cell lymphoma (DLBCL) is an aggressive cancer of the lymphatic system. About 30% to 40% of people with DLBCL experience relapse and 10% are refractory to first-line treatment usually consisting of R-CHOP chemotherapy. Of those eligible for second-line treatment, commonly consisting of salvage chemotherapy followed by autologous stem-cell transplantation (ASCT), around 50% experience relapse. With a median overall survival of less than six to 12 months, the prognosis of individuals who relapse or are refractory (r/r) to advanced lines of treatment or of those who are ineligible for ASCT, is very poor. With the introduction of chimeric antigen receptor (CAR) T-cell therapy, a novel treatment option for these people is available. OBJECTIVES To assess the benefits and harms of chimeric antigen receptor (CAR) T-cell therapy for people with relapsed or refractory (r/r) DLBCL. SEARCH METHODS An experienced information specialist performed a systematic database search for relevant articles on CENTRAL, MEDLINE and Embase until September 11th, 2020. We also searched trial registries and reference lists of identified studies up to this date. All search results were screened by two authors independently and a third author was involved in case of discrepancies. SELECTION CRITERIA We included prospectively planned trials evaluating CAR T-cell therapy for people with r/r DLBCL. We had planned to include randomised controlled trials (RCTs) and we flexibly adapted eligibility criteria to the most reliable study designs available. We excluded studies involving fewer than 10 participants with r/r DLBCL and studies with a proportion of participants with r/r DLBCL below 70%, unless data were reported separately for this subgroup. DATA COLLECTION AND ANALYSIS Two review authors extracted data and performed risk of bias ratings independently. A third author was involved in case of disagreements. As our search did not yield any completed RCTs, prospective controlled non-randomised studies of interventions (NRSIs) or prospective observational studies with a control group, we did not meta-analyse data and reported all results narratively. We adopted the GRADE approach to assess the certainty of the evidence for prioritised outcomes. MAIN RESULTS We identified 13 eligible uncontrolled studies evaluating a single or multiple arms of CAR T-cell therapies. We also identified 38 ongoing studies, including three RCTs. Ten studies are awaiting classification due to completion with no retrievable results data or insufficient data to justify inclusion. The mean number of participants enrolled, treated with CAR T-cell therapy and evaluated in the included studies were 79 (range 12 to 344; data unavailable for two studies), 61 (range 12 to 294; data unavailable for one study) and 52 (range 11 to 256), respectively. Most studies included people with r/r DLBCL among people with other haematological B-cell malignancies. Participants had received at least a median of three prior treatment lines (data unavailable for four studies), 5% to 50% had undergone ASCT (data unavailable for five studies) and, except for two studies, 3% to 18% had undergone allogenic stem-cell transplantation (data unavailable for eight studies). The overall risk of bias was high for all studies, in particular, due to incomplete follow-up and the absence of blinding. None of the included studies had a control group so that no adequate comparative effect measures could be calculated. The duration of follow-up varied substantially between studies, in particular, for harms. Our certainty in the evidence is very low for all outcomes. Overall survival was reported by eight studies (567 participants). Four studies reported survival rates at 12 months which ranged between 48% and 59%, and one study reported an overall survival rate of 50.5% at 24 months. The evidence is very uncertain about the effect of CAR T-cell therapy on overall survival. Two studies including 294 participants at baseline and 59 participants at the longest follow-up (12 months or 18 months) described improvements of quality of life measured with the EuroQol 5-Dimension 5-Level visual analogue scale (EQ-5D-5L VAS) or Function Assessment of Cancer Therapy-Lymphoma (FACT-Lym). The evidence is very uncertain about the effect of CAR T-cell therapy on quality of life. None of the studies reported treatment-related mortality. Five studies (550 participants) reported the occurrence of adverse events among participants, ranging between 99% and 100% for any grade adverse events and 68% to 98% for adverse events grade ≥ 3. In three studies (253 participants), 56% to 68% of participants experienced serious adverse events, while in one study (28 participants), no serious adverse events occurred. CAR T-cell therapy may increase the risk of adverse events and serious adverse events but the evidence is very uncertain about the exact risk. The occurrence of cytokine release syndrome (CRS) was reported in 11 studies (675 participants) under use of various grading criteria. Five studies reported between 42% and 100% of participants experiencing CRS according to criteria described in Lee 2014. CAR T-cell therapy may increase the risk of CRS but the evidence is very uncertain about the exact risk. Nine studies (575 participants) reported results on progression-free survival, disease-free survival or relapse-free survival. Twelve-month progression-free survival rates were reported by four studies and ranged between 44% and 75%. In one study, relapse-free survival remained at a rate of 64% at both 12 and 18 months. The evidence is very uncertain about the effect of CAR T-cell therapy on progression-free survival. Thirteen studies (620 participants) provided data on complete response rates. At six months, three studies reported complete response rates between 40% and 45%. The evidence is very uncertain about the effect of CAR T-cell therapy on complete response rates. AUTHORS' CONCLUSIONS The available evidence on the benefits and harms of CAR T-cell therapy for people with r/r DLBCL is limited, mainly because of the absence of comparative clinical trials. The results we present should be regarded in light of this limitation and conclusions should be drawn very carefully. Due to the uncertainty in the current evidence, a large number of ongoing investigations and a risk of substantial and potentially life-threatening complications requiring supplementary treatment, it is critical to continue evaluating the evidence on this new therapy.
Collapse
Affiliation(s)
- Moritz Ernst
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Annika Oeser
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Burcu Besiroglu
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Julia Caro-Valenzuela
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Ina Monsef
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Peter Borchmann
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Marius Goldkuhle
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| |
Collapse
|
30
|
Zhu H, Liu X. Advances of Tumorigenesis, Diagnosis at Early Stage, and Cellular Immunotherapy in Gastrointestinal Malignancies. Front Oncol 2021; 11:666340. [PMID: 34434889 PMCID: PMC8381364 DOI: 10.3389/fonc.2021.666340] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/19/2021] [Indexed: 01/10/2023] Open
Abstract
Globally, in 2018, 4.8 million new patients have a diagnosis of gastrointestinal (GI) cancers, while 3.4 million people died of such disorders. GI malignancies are tightly relevant to 26% of the world-wide cancer incidence and occupies 35% of all cancer-associated deaths. In this article, we principally investigated molecular and cellular mechanisms of tumorigenesis in five major GI cancers occurring at esophagus, stomach, liver, pancreas, and colorectal region that illustrate high morbidity in Eastern and Western countries. Moreover, through this investigation, we not only emphasize importance of the tumor microenvironment in development and treatment of malignant tumors but also identify significance of M2PK, miRNAs, ctDNAs, circRNAs, and CTCs in early detection of GI cancers, as well as systematically evaluate contribution of personalized precision medicine including cellular immunotherapy, new antigen and vaccine therapy, and oncolytic virotherapy in treatment of GI cancers.
Collapse
Affiliation(s)
- Haipeng Zhu
- Precision and Personalized Cancer Treatment Center, Division of Cancer Diagnosis & Therapy, Ciming Boao International Hospital, Boao Lecheng International Medical Tourism Pilot Zone, Qionghai, China.,Stem Cell and Biotherapy Technology Research Center, Xinxiang Medical College, Xinxiang, China
| | - Xiaojun Liu
- Division of Cellular & Biomedical Science, Ciming Boao International Hospital, Boao Lecheng International Medical Tourism Pilot Zone, Qionghai, China
| |
Collapse
|
31
|
Hernández-López A, Téllez-González MA, Mondragón-Terán P, Meneses-Acosta A. Chimeric Antigen Receptor-T Cells: A Pharmaceutical Scope. Front Pharmacol 2021; 12:720692. [PMID: 34489708 PMCID: PMC8417740 DOI: 10.3389/fphar.2021.720692] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/02/2021] [Indexed: 12/18/2022] Open
Abstract
Cancer is among the leading causes of death worldwide. Therefore, improving cancer therapeutic strategies using novel alternatives is a top priority on the contemporary scientific agenda. An example of such strategies is immunotherapy, which is based on teaching the immune system to recognize, attack, and kill malignant cancer cells. Several types of immunotherapies are currently used to treat cancer, including adoptive cell therapy (ACT). Chimeric Antigen Receptors therapy (CAR therapy) is a kind of ATC where autologous T cells are genetically engineered to express CARs (CAR-T cells) to specifically kill the tumor cells. CAR-T cell therapy is an opportunity to treat patients that have not responded to other first-line cancer treatments. Nowadays, this type of therapy still has many challenges to overcome to be considered as a first-line clinical treatment. This emerging technology is still classified as an advanced therapy from the pharmaceutical point of view, hence, for it to be applied it must firstly meet certain requirements demanded by the authority. For this reason, the aim of this review is to present a global vision of different immunotherapies and focus on CAR-T cell technology analyzing its elements, its history, and its challenges. Furthermore, analyzing the opportunity areas for CAR-T technology to become an affordable treatment modality taking the basic, clinical, and practical aspects into consideration.
Collapse
Affiliation(s)
- Alejandrina Hernández-López
- Laboratorio 7 Biotecnología Farmacéutica, Facultad de Farmacia, Universidad Autónoma Del Estado de Morelos, UAEM, Cuernavaca, Mexico
| | - Mario A. Téllez-González
- Laboratorio 7 Biotecnología Farmacéutica, Facultad de Farmacia, Universidad Autónoma Del Estado de Morelos, UAEM, Cuernavaca, Mexico
- Coordinación de Investigación, Centro Médico Nacional “20 de Noviembre” ISSSTE, Mexico city, Mexico
| | - Paul Mondragón-Terán
- Coordinación de Investigación, Centro Médico Nacional “20 de Noviembre” ISSSTE, Mexico city, Mexico
| | - Angélica Meneses-Acosta
- Laboratorio 7 Biotecnología Farmacéutica, Facultad de Farmacia, Universidad Autónoma Del Estado de Morelos, UAEM, Cuernavaca, Mexico
| |
Collapse
|
32
|
Razeghian E, Nasution MKM, Rahman HS, Gardanova ZR, Abdelbasset WK, Aravindhan S, Bokov DO, Suksatan W, Nakhaei P, Shariatzadeh S, Marofi F, Yazdanifar M, Shamlou S, Motavalli R, Khiavi FM. A deep insight into CRISPR/Cas9 application in CAR-T cell-based tumor immunotherapies. Stem Cell Res Ther 2021; 12:428. [PMID: 34321099 PMCID: PMC8317439 DOI: 10.1186/s13287-021-02510-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/12/2021] [Indexed: 12/15/2022] Open
Abstract
To date, two chimeric antigen receptors (CAR)-T cell products from autologous T cells have been approved by The United States Food and Drug Administration (FDA). The case-by-case autologous T cell generation setting is largely considered as a pivotal restraining cause for its large-scale clinical use because of the costly and prolonged manufacturing procedure. Further, activated CAR-T cells mainly express immune checkpoint molecules, including CTLA4, PD1, LAG3, abrogating CAR-T anti-tumor activity. In addition, CAR-T cell therapy potently results in some toxicity, such as cytokine releases syndrome (CRS). Therefore, the development of the universal allogeneic T cells with higher anti-tumor effects is of paramount importance. Thus, genome-editing technologies, in particular, clustered regularly interspaced short palindromic repeat (CRISPR)-Cas9 are currently being used to establish "off-the-shelf" CAR-T cells with robust resistance to immune cell-suppressive molecules. In fact, that simultaneous ablation of PD-1, T cell receptor alpha constant (TRAC or TCR), and also β-2 microglobulin (B2M) by CRISPR-Cas9 technique can support the manufacture of universal CAR-T cells with robust resistance to PD-L1. . Indeed, the ablation of β2M or TARC can severely hinder swift elimination of allogeneic T cells those express foreign HLA-I molecules, and thereby enables the generation of CAR-T cells from allogeneic healthy donors T cells with higher persistence in vivo. Herein, we will deliver a brief overview of the CAR-T cell application in the context of tumor immunotherapy. More importantly, we will discuss recent finding concerning the application of genome editing technologies for preparing universal CAR-T cells or cells that can effectively counter tumor escape, with a special focus on CRISPR-Cas9 technology.
Collapse
Affiliation(s)
- Ehsan Razeghian
- Human Genetics Division, Medical Biotechnology Department, National Institute of Genetics Engineering and Biotechnology (NIGEB), Tehran, Iran
| | | | - Heshu Sulaiman Rahman
- College of Medicine, University of Sulaimani, Sulaymaniyah, Iraq
- Department of Medical Laboratory Sciences, Komar University of Science and Technology, Sulaymaniyah, Iraq
| | - Zhanna R. Gardanova
- Department of Psychotherapy, Pirogov Russian National Research Medical University, 1 Ostrovityanova St, 117997 Moscow, Russia
| | - Walid Kamal Abdelbasset
- Department of Health and Rehabilitation Sciences, College of Applied Medical Sciences, Prince Sattam bin Abdulaziz University, Al Kharj, Saudi Arabia
- Department of Physical Therapy, Kasr Al-Aini Hospital, Cairo University, Giza, Egypt
| | - Surendar Aravindhan
- Department of Pharmacology, Saveetha Dental College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai, India
| | - Dmitry O. Bokov
- Institute of Pharmacy, Sechenov First Moscow State Medical University, 8 Trubetskaya St., bldg. 2, Moscow, 119991 Russian Federation
- Laboratory of Food Chemistry, Federal Research Center of Nutrition, Biotechnology and Food Safety, 2/14 Ustyinsky pr, Moscow, 109240 Russian Federation
| | - Wanich Suksatan
- Faculty of Nursing, HRH Princess Chulabhorn College of Medical Science, Chulabhorn Royal Academy, Bangkok, 10210 Thailand
| | - Pooria Nakhaei
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Siavash Shariatzadeh
- Department of Pharmacology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Faroogh Marofi
- Immunology Research Center (IRC), Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahboubeh Yazdanifar
- Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA USA
| | - Somayeh Shamlou
- Department of Applied Cell Sciences, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Roza Motavalli
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | |
Collapse
|
33
|
Yin Z, Zhang Y, Wang X. Advances in chimeric antigen receptor T-cell therapy for B-cell non-Hodgkin lymphoma. Biomark Res 2021; 9:58. [PMID: 34256851 PMCID: PMC8278776 DOI: 10.1186/s40364-021-00309-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/11/2021] [Indexed: 12/20/2022] Open
Abstract
B-cell non-Hodgkin lymphoma (B-NHL) is a group of heterogeneous disease which remains incurable despite developments of standard chemotherapy regimens and new therapeutic agents in decades. Some individuals could have promising response to standard therapy while others are unresponsive to standard chemotherapy or relapse after autologous hematopoietic stem-cell transplantation (ASCT), which indicates the necessity to develop novel therapies for refractory or relapsed B-NHLs. In recent years, a novel cell therapy, chimeric antigen receptor T-cell therapy (CAR-T), was invented to overcome the limitation of traditional treatments. Patients with aggressive B-NHL are considered for CAR-T cell therapy when they have progressive lymphoma after second-line chemotherapy, relapse after ASCT, or require a third-line therapy. Clinical trials of anti-CD19 CAR-T cell therapy have manifested encouraging efficacy in refractory or relapsed B-NHL. However, adverse effects of this cellular therapy including cytokine release syndrome, neurotoxicity, tumor lysis syndrome and on-target, off-tumor toxicities should attract our enough attention despite the great anti-tumor effects of CAR-T cell therapy. Although CAR-T cell therapy has shown remarkable results in patients with B-NHL, the outcomes of patients with B-NHL were inferior to patients with acute lymphoblastic leukemia. The inferior response rate may be associated with physical barrier of lymphoma, tumor microenvironment and low quality of CAR-T cells manufactured from B-NHL patients. Besides, some patients relapsed after anti-CD19 CAR-T cell therapy, which possibly were due to limited CAR-T cells persistence, CD19 antigen escape or antigen down-regulation. Quite a few new antigen-targeted CAR-T products and new-generation CAR-T, for example, CD20-targeted CAR-T, CD79b-targeted CAR-T, CD37-targeted CAR-T, multi-antigen-targeted CAR-T, armored CAR-T and four-generation CAR-T are developing rapidly to figure out these deficiencies.
Collapse
Affiliation(s)
- Zixun Yin
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, Shandong, China.,School of Medicine, Shandong University, Jinan, 250021, Shandong, China
| | - Ya Zhang
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, Shandong, China. .,School of Medicine, Shandong University, Jinan, 250021, Shandong, China. .,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250012, Shandong, China. .,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, 250021, Shandong, China. .,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, 250021, Shandong, China. .,National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, 251006, China.
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, Shandong, China. .,School of Medicine, Shandong University, Jinan, 250021, Shandong, China. .,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250012, Shandong, China. .,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, 250021, Shandong, China. .,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, 250021, Shandong, China. .,National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, 251006, China.
| |
Collapse
|
34
|
Nissani A, Lev-Ari S, Meirson T, Jacoby E, Asher N, Ben-Betzalel G, Itzhaki O, Shapira-Frommer R, Schachter J, Markel G, Besser MJ. Comparison of non-myeloablative lymphodepleting preconditioning regimens in patients undergoing adoptive T cell therapy. J Immunother Cancer 2021; 9:jitc-2020-001743. [PMID: 33990415 PMCID: PMC8127974 DOI: 10.1136/jitc-2020-001743] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 12/27/2022] Open
Abstract
Background Adoptive cell therapy with T cells genetically engineered to express a chimeric antigen receptor (CAR-T) or tumor-infiltrating T lymphocytes (TIL) demonstrates impressive clinical results in patients with cancer. Lymphodepleting preconditioning prior to cell infusion is an integral part of all adoptive T cell therapies. However, to date, there is no standardization and no data comparing different non-myeloablative (NMA) regimens. Methods In this study, we compared NMA therapies with different doses of cyclophosphamide or total body irradiation (TBI) in combination with fludarabine and evaluated bone marrow suppression and recovery, cytokine serum levels, clinical response and adverse events. Results We demonstrate that a cumulative dose of 120 mg/kg cyclophosphamide and 125 mg/m2 fludarabine (120Cy/125Flu) and 60Cy/125Flu preconditioning were equally efficient in achieving deep lymphopenia and neutropenia in patients with metastatic melanoma, whereas absolute lymphocyte counts (ALCs) and absolute neutrophil counts were significantly higher following 200 cGyTBI/75Flu-induced NMA. Thrombocytopenia was most profound in 120Cy/125Flu patients. 30Cy/75Flu-induced preconditioning in patients with acute lymphoblastic leukemia resulted in a minor ALC decrease, had no impact on platelet counts and did not yield deep neutropenia. Following cell infusion, 120Cy/125Flu patients with objective tumor response had significantly higher ALC and significant lower inflammatory indexes, such as neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR). Receiver-operating characteristics curve analysis 7 days after cell infusion was performed to determine the cut-offs, which distinguish between responding and non-responding patients in the 120Cy/125Flu cohort. NLR≤1.79 and PLR≤32.7 were associated with clinical response and overall survival. Cytokine serum levels did not associate with clinical response in patients with TIL. Patients in the 120Cy/125Flu cohort developed significantly more acute NMA-related adverse events, including thrombocytopenia, febrile neutropenia and cardiotoxicity, and stayed significantly longer in hospital compared with the 60Cy/125Flu and TBI/75Flu cohorts. Conclusions Bone marrow depletion and recovery were equally affected by 120Cy/125Flu and 60Cy/125Flu preconditioning; however, toxicity and consequently duration of hospitalization were significantly lower in the 60Cy/125Flu cohort. Patients in the 30Cy/75Flu and TBI/75Flu groups rarely developed NMA-induced adverse events; however, both regimens were not efficient in achieving deep bone marrow suppression. Among the regimens, 60Cy/125Flu preconditioning seems to achieve maximum effect with minimum toxicity.
Collapse
Affiliation(s)
- Abraham Nissani
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center at Tel Hashomer, Tel Hashomer, Israel
| | - Shaked Lev-Ari
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center at Tel Hashomer, Tel Hashomer, Israel
| | - Tomer Meirson
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center at Tel Hashomer, Tel Hashomer, Israel.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Elad Jacoby
- Division of Pediatric Hematology and Oncology, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center at Tel Hashomer, Tel Hashomer, Israel.,Department of Hematology, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Nethanel Asher
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center at Tel Hashomer, Tel Hashomer, Israel
| | - Guy Ben-Betzalel
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center at Tel Hashomer, Tel Hashomer, Israel
| | - Orit Itzhaki
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center at Tel Hashomer, Tel Hashomer, Israel
| | - Ronnie Shapira-Frommer
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center at Tel Hashomer, Tel Hashomer, Israel.,Oncology Division, Sheba Medical Center at Tel Hashomer, Tel Hashomer, Israel
| | - Jacob Schachter
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center at Tel Hashomer, Tel Hashomer, Israel
| | - Gal Markel
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center at Tel Hashomer, Tel Hashomer, Israel.,Deparment of Clinical Microbiology and Immunology, Tel Aviv University, Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Michal J Besser
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center at Tel Hashomer, Tel Hashomer, Israel .,Deparment of Clinical Microbiology and Immunology, Tel Aviv University, Sackler Faculty of Medicine, Tel Aviv, Israel
| |
Collapse
|
35
|
Owens K, Bozic I. Modeling CAR T-Cell Therapy with Patient Preconditioning. Bull Math Biol 2021; 83:42. [PMID: 33740142 DOI: 10.1007/s11538-021-00869-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 02/11/2021] [Indexed: 12/15/2022]
Abstract
The Federal Drug Administration approved the first Chimeric Antigen Receptor T-cell (CAR T-cell) therapies for the treatment of several blood cancers in 2017, and efforts are underway to broaden CAR T technology to address other cancer types. Standard treatment protocols incorporate a preconditioning regimen of lymphodepleting chemotherapy prior to CAR T-cell infusion. However, the connection between preconditioning regimens and patient outcomes is still not fully understood. Optimizing patient preconditioning plans and reducing the CAR T-cell dose necessary for achieving remission could make therapy safer. In this paper, we test treatment regimens consisting of sequential administration of chemotherapy and CAR T-cell therapy on a system of differential equations that models the tumor-immune interaction. We use numerical simulations of treatment plans from within the scope of current medical practice to assess the effect of preconditioning plans on the success of CAR T-cell therapy. Model results affirm clinical observations that preconditioning can be crucial for most patients, not just to reduce side effects, but to even achieve remission at all. We demonstrate that preconditioning plans using the same CAR T-cell dose and the same total concentration of chemotherapy can lead to different patient outcomes due to different delivery schedules. Results from sensitivity analysis of the model parameters suggest that making small improvements in the effectiveness of CAR T-cells in attacking cancer cells will significantly reduce the minimum dose required for successful treatment. Our modeling framework represents a starting point for evaluating the efficacy of patient preconditioning in the context of CAR T-cell therapy.
Collapse
Affiliation(s)
- Katherine Owens
- Department of Applied Mathematics, University of Washington, Seattle, WA, USA
| | - Ivana Bozic
- Department of Applied Mathematics, University of Washington, Seattle, WA, USA.
| |
Collapse
|
36
|
Weinstein-Marom H, Gross G, Levi M, Brayer H, Schachter J, Itzhaki O, Besser MJ. Genetic Modification of Tumor-Infiltrating Lymphocytes via Retroviral Transduction. Front Immunol 2021; 11:584148. [PMID: 33488585 PMCID: PMC7817656 DOI: 10.3389/fimmu.2020.584148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/24/2020] [Indexed: 11/24/2022] Open
Abstract
Adoptive T cell therapy (ACT) holds great promise for cancer treatment. One approach, which has regained wide interest in recent years, employs antitumor T cells isolated from tumor lesions ("tumor-infiltrating lymphocytes" or TIL). It is now appreciated that a considerable proportion of anti-melanoma TIL recognize new HLA-binding peptides resulting from somatic mutations, which occurred during tumor progression. The clinical efficacy of TIL can potentially be improved via their genetic modification, designed to enhance their survival, homing capacity, resistance to suppression, tumor killing ability and additional properties of clinical relevance. Successful implementation of such gene-based strategies critically depends on efficient and reproducible protocols for gene delivery into clinical TIL preparations. Here we describe an optimized protocol for the retroviral transduction of TIL. As the experimental system we employed anti-melanoma TIL cultures prepared from four patients, recombinant retrovirus encoding an anti-CD19 chimeric antigen receptor (CAR) as a model gene of interest and CD19+ and CD19- human cell lines serving as target cells. Transduction on day 7 of the rapid expansion protocol (REP) resulted in 69 ± 8% CAR positive TIL. Transduced, but not untransduced TIL, from the four patients responded robustly to CD19+, but not CD19- cell lines, as judged by substantial secretion of IFN-γ following co-culture. In light of the rekindled interest in antitumor TIL, this protocol can be incorporated into a broad range of gene-based approaches for improving the in-vivo survival and functionality of TIL in the clinical setting.
Collapse
Affiliation(s)
- Hadas Weinstein-Marom
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan, Israel
- Laboratory of Immunology, MIGAL-Galilee Research Institute, Kiryat Shmona, Israel
- Department of Biotechnology, Tel-Hai College, Upper Galilee, Israel
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gideon Gross
- Laboratory of Immunology, MIGAL-Galilee Research Institute, Kiryat Shmona, Israel
- Department of Biotechnology, Tel-Hai College, Upper Galilee, Israel
| | - Michal Levi
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Hadar Brayer
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Jacob Schachter
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Orit Itzhaki
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Michal J. Besser
- Ella Lemelbaum Institute for Immuno-Oncology, Sheba Medical Center, Ramat Gan, Israel
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
37
|
Hsieh EM, Rouce RH. Chimeric antigen receptor T cells for mature B-cell lymphoma and Burkitt lymphoma. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:487-493. [PMID: 33275669 PMCID: PMC7727550 DOI: 10.1182/hematology.2020000133] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has changed the landscape of immunotherapy for B-cell malignancies, including mature B-cell lymphomas. Although two CD19 CAR T-cell products have been commercially approved to treat relapsed/refractory B-cell lymphomas, outcomes in these patients remain inferior to those of patients with B-cell leukemia, regardless of therapy. Recent clinical studies and preclinical reports suggest that certain characteristics, such as the suppressive lymphoma tumor microenvironment and inferior endogenous T-cell fitness, may contribute to discrepant responses in these patients. In addition, these studies revealed that limited CAR T-cell persistence and tumor antigen escape, which also impact B-cell acute lymphoblastic leukemia, may play a more prominent role in lymphoma. Multiple promising strategies to overcome these barriers have advanced to clinical trials. In this review, we assess CAR T-cell therapies for pediatric relapsed/refractory mature B-cell lymphomas, potential obstacles diminishing antitumor activity and limiting CAR T-cell persistence, and current strategies to overcome these obstacles.
Collapse
MESH Headings
- Adolescent
- Burkitt Lymphoma/metabolism
- Burkitt Lymphoma/pathology
- Burkitt Lymphoma/therapy
- Humans
- Immunotherapy, Adoptive
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Male
- Precursor B-Cell Lymphoblastic Leukemia-Lymphoma/metabolism
- Precursor B-Cell Lymphoblastic Leukemia-Lymphoma/pathology
- Precursor B-Cell Lymphoblastic Leukemia-Lymphoma/therapy
- Receptors, Chimeric Antigen/therapeutic use
- Tumor Microenvironment
Collapse
Affiliation(s)
- Emily M. Hsieh
- Texas Children’s Cancer and Hematology Centers, Houston, TX; and
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX
| | - Rayne H. Rouce
- Texas Children’s Cancer and Hematology Centers, Houston, TX; and
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX
| |
Collapse
|
38
|
Anagnostou T, Riaz IB, Hashmi SK, Murad MH, Kenderian SS. Anti-CD19 chimeric antigen receptor T-cell therapy in acute lymphocytic leukaemia: a systematic review and meta-analysis. LANCET HAEMATOLOGY 2020; 7:e816-e826. [PMID: 33091355 DOI: 10.1016/s2352-3026(20)30277-5] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 08/10/2020] [Accepted: 08/14/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anti-CD19 chimeric antigen receptor (CAR) T-cell therapy has shown remarkable activity in patients with refractory or relapsed acute lymphocytic leukaemia. Various anti-CD19 CAR T-cell constructs have been trialled and responses vary widely among different studies. We aimed to systematically analyse the outcomes of patients with acute lymphocytic leukaemia treated with anti-CD19 CAR T cells and identify factors associated with differences in outcomes. METHODS We did a systematic review and meta-analysis of published and unpublished clinical trials that reported data on the outcomes of adult or paediatric patients that were treated with anti-CD19 CAR T cells for relapsed or refractory B-cell acute lymphocytic leukaemia, reported between Jan 1, 2012, and April 14, 2020. Studies with two patients or fewer were excluded and summary data were extracted from the reports. The primary outcome was the number of patients who had complete remission at any time after anti-CD19 CAR T-cell infusion. This study is not registered in PROSPERO. FINDINGS From 1160 studies, we identified 40 potentially appropriate studies, 35 (88%) of which met the eligibility criteria and were included in the final analysis (n=953 patients). The pooled complete remission was 80% (95% CI 75·5-84·8) and heterogeneity between studies was moderate (I2=56·96%). In the prespecified subgroup analyses, 195 (75% [95% CI 66·9-82·9, I2=35·22%]) of 263 patients in adult studies and 242 (81% [72·9-87·2, I2=54·45%]) of 346 patients in paediatric studies achieved complete remission, p=0·24. The pooled complete remission did not significantly differ with anti-CD19 CAR T-cell construct type or single-chain variable fragment clone, but was higher with autologous T-cell origin (727 [83%, 78·5-86·5, I2=44·34%] of 901 patients), compared with allogeneic T-cell origin (29 [55%, 30·6-79·0, I2=62·64%] of 52 patients; p=0·018). 242 (26% [95% CI 18·5-34·1]) of 854 patients developed grade 3 or worse cytokine release syndrome and 97 (12% [6·6-19·2]) of 532 developed grade 3 or worse neurotoxicity. There was no difference in the proportion of patients who achieved complete remission or who had cytokine release syndrome or neurotoxicity between different anti-CD19 CAR T-cell constructs. The risk of bias was assessed as low in 17 studies and moderate in 18 studies. INTERPRETATION The high response rates after anti-CD19 CAR T-cell therapy can be used to guide the use of therapy in patients with relapsed or refractory acute lymphocytic leukaemia. Comparison studies are required to further determine differences in efficacy between different anti-CD19 CAR T-cell constructs in the setting of relapsed or refractory acute lymphocytic leukaemia. FUNDING National Cancer Institute, National Comprehensive Cancer Network, Mayo Clinic K2R Research Pipeline, and Mayo Clinic Center for Individualized Medicine.
Collapse
Affiliation(s)
- Theodora Anagnostou
- Department of Medicine, Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Irbaz B Riaz
- Division of Haematology, Mayo Clinic, Rochester, MN, USA
| | - Shahrukh K Hashmi
- Division of Haematology, Mayo Clinic, Rochester, MN, USA; Oncology Centre, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | | | - Saad S Kenderian
- Division of Haematology, Mayo Clinic, Rochester, MN, USA; Department of Immunology, Mayo Clinic, Rochester, MN, USA; T-Cell Engineering, Mayo Clinic, Rochester, MN, USA; Department of Molecular Medicine, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
39
|
Nagler A. Update on chimeric antigen receptor – T cells (CAR-T) CD19 therapy: the Sheba experience. Hematol Transfus Cell Ther 2020. [DOI: 10.1016/j.htct.2020.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
40
|
Rozenbaum M, Meir A, Aharony Y, Itzhaki O, Schachter J, Bank I, Jacoby E, Besser MJ. Gamma-Delta CAR-T Cells Show CAR-Directed and Independent Activity Against Leukemia. Front Immunol 2020; 11:1347. [PMID: 32714329 PMCID: PMC7343910 DOI: 10.3389/fimmu.2020.01347] [Citation(s) in RCA: 128] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/27/2020] [Indexed: 12/16/2022] Open
Abstract
Autologous T cells engineered to express a chimeric antigen receptor (CAR) against the CD19 antigen are in the frontline of contemporary hemato-oncology therapies, leading to high remission rates in B-cell malignancies. Although effective, major obstacles involve the complex and costly individualized manufacturing process, and CD19 target antigen loss or modulation leading to resistant and relapse following CAR therapy. A potential solution for these limitations is the use of donor-derived γδT cells as a CAR backbone. γδT cells lack allogenecity and are safely used in haploidentical transplants. Moreover, γδT cells are known to mediate natural anti-tumor responses. Here, we describe a 14-day production process initiated from peripheral-blood mononuclear cells, leading to a median 185-fold expansion of γδ T cells with high purity (>98% CD3+ and >99% γδTCR+). CAR transduction efficacy of γδ T cells was equally high when compared to standard CAR-T cells (60.5 ± 13.2 and 65.3 ± 18.3%, respectively). CD19-directed γδCAR-T cells were effective against CD19+ cell lines in vitro and in vivo, showing cytokine production, direct target killing, and clearance of bone marrow leukemic cells in an NSG model. Multiple injections of γδCAR-T cells and priming of mice with zoledronate lead to enhanced tumor reduction in vivo. Unlike standard CD19 CAR-T cells, γδCAR-T cells were able to target CD19 antigen negative leukemia cells, an effect that was enhanced after priming the cells with zoledronate. In conclusion, γδCAR-T cell production is feasible and leads to highly pure and efficient effector cells. γδCAR-T cell may provide a promising platform in the allogeneic setting, and may target leukemic cells also after antigen loss.
Collapse
Affiliation(s)
- Meir Rozenbaum
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Ella Lemelbaum Institute for Immuno Oncology, Sheba Medical Center, Ramat Gan, Israel.,Center for Pediatric Cell Therapy, Sheba Medical Center, Tel Hashomer, Israel
| | - Amilia Meir
- Center for Pediatric Cell Therapy, Sheba Medical Center, Tel Hashomer, Israel
| | - Yarden Aharony
- Center for Pediatric Cell Therapy, Sheba Medical Center, Tel Hashomer, Israel
| | - Orit Itzhaki
- Ella Lemelbaum Institute for Immuno Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Jacob Schachter
- Ella Lemelbaum Institute for Immuno Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Ilan Bank
- Rheumatology Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Elad Jacoby
- Center for Pediatric Cell Therapy, Sheba Medical Center, Tel Hashomer, Israel.,Division of Pediatric Hematology and Oncology, Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Tel Hashomer, Israel.,Department of Pediatrics, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal J Besser
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Ella Lemelbaum Institute for Immuno Oncology, Sheba Medical Center, Ramat Gan, Israel.,Wohl Institute of Translational Medicine, Sheba Medical Center, Tel Aviv, Israel
| |
Collapse
|