1
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Liu J, Chen H, Guo C, Li J, Li M, Zhao M, Fu Z, Zhang Z, Li F, Zhao X, Yang L, Wang L, Lv Q, Zhang Y. Sulforaphane activates CD8 + T cells antitumor response through IL-12RB2/MMP3/FasL-induced MDSCs apoptosis'. J Immunother Cancer 2024; 12:e007983. [PMID: 38296593 PMCID: PMC10831471 DOI: 10.1136/jitc-2023-007983] [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] [Accepted: 12/04/2023] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Extensive attention has been given to the role of myeloid-derived suppressor cells (MDSCs) in driving tumor progression and treatment failure. Preclinical studies have identified multiple agents that eliminate MDSCs. However, none have been authorized in the cliniccal ues due to the safety reasons. In the present study, we investigated the efficacy and mechanism of sulforaphane (SFN) to eliminate MDSCs in the tumor microenvironment (TME). METHODS We monitored SFN effect on tumor growth and the percents or apoptosis of immune cell subsets in mice models bearing LLC or B16 cells. Flow cytometry, quantitative reverse transcription-PCR, immunohistochemistry, ELISA, immunofluorescence, imaging flow cytometry and western blot were performed to validate the role of SFN on MDSCs function in vivo and in vitro. RNA sequencing was then used to interrogate the mechanisms of how SFN regulated MDSCs function. Tumor xenograft models were established to evaluate the involvement of IL-12RB2/MMP3/FasL induced MDSCs apoptosis in vivo. We verified the effect of SFN on MDSCs and CD8+ T cells in the blood samples from a phase I clinical trial (KY-2021-0350). RESULTS In this study, we elucidated that SFN liberated CD8+ T-cell antitumor ability by reducing MDSCs abundance, leading to repressed tumor growth. SFN treatment suppressed MDSCs accumulation in the peripheral blood and tumor sites of mice, but had no effect on the bone marrow. Mechanistically, SFN activates IL-12RB2, which stimulates the MMP3/FasL signaling cascade to trigger caspase 3 cleavage and induce apoptosis in MDSCs. Clinically, SFN treatment eliminates peripheral MDSCs and increases the percentage and activation of CD8+ T cells. CONCLUSIONS Collectively, we uncovered the role of SFN in eliminating MDSCs to emancipate CD8+ T cells through IL-12RB2/MMP3/FasL induced apoptosis, thus providing a strategy for targeting MDSCs to control tumors and improve clinical efficacy.
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Affiliation(s)
- Jinyan Liu
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Huanan Chen
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Department of Medical Record Management and Statistics, Shandong Provincial, Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Caijuan Guo
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jieyao Li
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Miaomiao Li
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ming Zhao
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ziyi Fu
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Zhen Zhang
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Feng Li
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Xuan Zhao
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Li Yang
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Liping Wang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Quanjun Lv
- Department of Nutrition and Food Hygiene, College of Public Health, and the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yi Zhang
- Biotherapy Center and Cancer Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- State Key Laboratory of Esophageal Cancer Prevention & and Treatment, Zhengzhou, Henan, China
- School of Life Sciences, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
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2
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McNerney KO, Moskop A, Winestone LE, Baggott C, Talano JA, Schiff D, Rossoff J, Modi A, Verneris MR, Laetsch TW, Schultz L. Practice Preferences for Consolidative Hematopoietic Stem Cell Transplantation Following Tisagenlecleucel in Children and Young Adults with B Cell Acute Lymphoblastic Leukemia. Transplant Cell Ther 2024; 30:75.e1-75.e11. [PMID: 37816472 DOI: 10.1016/j.jtct.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/26/2023] [Accepted: 10/04/2023] [Indexed: 10/12/2023]
Abstract
Treatment with tisagenlecleucel (tisa-cel) achieves excellent complete remission rates in children and young adults with relapsed or refractory B cell acute lymphoblastic leukemia (B-ALL), but approximately 50% maintain long-term remission. Consolidative hematopoietic stem cell transplantation (cHSCT) is a potential strategy to reduce relapse risk, but it carries substantial short- and long-term toxicities. Additionally, several strategies for management of B cell recovery (BCR) and next-generation sequencing (NGS) positivity post-tisa-cel exist, without an accepted standard. We hypothesized that practice preferences surrounding cHSCT, as well as management of BCR and NGS positivity, varies across tisa-cel-prescribing physicians and sought to characterize current practice preferences. A survey focusing on preferences regarding the use of cHSCT, management of BCR, and NGS positivity was distributed to physicians who prescribe tisa-cel for children and young adults with B-ALL. Responses were collected from August 2022 to April 2023. Fifty-nine unique responses were collected across 43 institutions. All respondents prescribed tisa-cel for children and young adults. The clinical focus of respondents was HSCT in 71%, followed by leukemia/lymphoma in 24%. For HSCT-naive patients receiving tisa-cel, 57% of respondents indicated they made individualized decisions for cHSCT based on patient factors, whereas 22% indicated they would avoid cHSCT and 21% indicated they would pursue cHSCT when feasible. Certain factors influenced >50% of respondents towards recommending cHSCT (either an increased likelihood of recommending or always recommending), including preinfusion disease burden >25%, primary refractory B-ALL, M3 bone marrow following reinduction for relapse, KMT2A-rearranged B-ALL, history of blinatumomab nonresponse, and HSCT-naive status. Most respondents indicated they would pursue HSCT for HSCT-naive, total body irradiation (TBI) recipients with BCR before 6 months post-tisa-cel or with NGS positivity at 1 or 3 months post-tisa-cel, although there was variability in responses regarding whether to proceed to HSCT directly or provide intervening therapy prior to HSCT. Fewer respondents recommended HSCT for BCR or NGS positivity in patients with a history of HSCT, in noncandidates for TBI, and in patients with trisomy 21. The results of this survey indicate there exists significant practice variability regarding the use of cHSCT, as well as interventions for post-tisa-cel BCR or NGS positivity. These results highlight areas in which ongoing clinical trials could inform more standardized practice.
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Affiliation(s)
- Kevin O McNerney
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Amy Moskop
- Division of HematologyOncologyBlood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, Wisconsin
| | - Lena E Winestone
- Division of Allergy, Immunology, and BMT, Department of Pediatrics, University of California San Francisco Benioff Children's Hospitals, San Francisco, California; UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Christina Baggott
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Julie-An Talano
- Division of HematologyOncologyBlood and Marrow Transplantation, Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, Wisconsin
| | - Deborah Schiff
- Department of Pediatric Hematology and Oncology, Rady Children's Hospital, San Diego, California
| | - Jenna Rossoff
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Arunkumar Modi
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Michael R Verneris
- University of Colorado School of Medicine, Children's Hospital of Colorado, Aurora, Colorado
| | - Theodore W Laetsch
- Department of Pediatrics and Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Oncology, Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Liora Schultz
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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3
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Puckrin R, Jamani K, Jimenez-Zepeda VH. Long-term survivorship care after CAR-T cell therapy. Eur J Haematol 2024; 112:41-50. [PMID: 37767547 DOI: 10.1111/ejh.14100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/29/2023] [Indexed: 09/29/2023]
Abstract
While cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome are well-recognized acute toxicities of chimeric antigen receptor (CAR) T cell therapy, these complications have become increasingly manageable by protocolized treatment algorithms incorporating the early administration of tocilizumab and corticosteroids. As CAR-T cell therapy expands to new disease indications and the number of long-term survivors steadily increases, there is growing recognition of the need to appropriately evaluate and manage the late effects of CAR-T cell therapy, including late-onset or persistent neurotoxicity, prolonged cytopenias, delayed immune reconstitution and infections, subsequent malignancies, organ dysfunction, psychological distress, and fertility implications. In this review, we provide a practical approach to the long-term survivorship care of the CAR-T cell recipient, with a focus on the optimal strategies to address the common and challenging late complications affecting this unique population.
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Affiliation(s)
- Robert Puckrin
- Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Kareem Jamani
- Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Victor H Jimenez-Zepeda
- Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
- Arnie Charbonneau Cancer Research Institute, University of Calgary, Calgary, Alberta, Canada
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4
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Pieters R, Mullighan CG, Hunger SP. Advancing Diagnostics and Therapy to Reach Universal Cure in Childhood ALL. J Clin Oncol 2023; 41:5579-5591. [PMID: 37820294 PMCID: PMC10730082 DOI: 10.1200/jco.23.01286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/24/2023] [Accepted: 08/10/2023] [Indexed: 10/13/2023] Open
Abstract
Systemic combination chemotherapy and intrathecal chemotherapy markedly increased the survival rate of children with ALL. In the past two decades, the use of minimal (measurable) residual disease (MRD) measurements early in therapy improved risk group stratification with subsequent treatment intensifications for patients at high risk of relapse, and enabled a reduction of treatment for low-risk patients. The recent development of more sensitive MRD technologies may further affect risk stratification. Molecular genetic profiling has led to the discovery of many new subtypes and their driver genetic alterations. This increased our understanding of the biological basis of ALL, improved risk classification, and enabled implementation of precision medicine. In the past decade, immunotherapies, including bispecific antibodies, antibody-drug conjugates, and cellular therapies directed against surface proteins, led to more effective and less toxic therapies, replacing intensive chemotherapy courses and allogeneic stem-cell transplantation in patients with relapsed and refractory ALL, and are now being tested in newly diagnosed patients. It has taken 50-60 years to increase the cure rate in childhood ALL from 0% to 90% by stepwise improvements in chemotherapy. This review provides an overview of how the developments over the past 10-15 years mentioned above have significantly changed the diagnostic and treatment approach in ALL, and discusses how the integrated use of molecular and immunotherapeutic insights will very likely direct efforts to cure those children with ALL who are not cured today, and improve the quality of life for survivors who should have decades of life ahead. Future efforts must focus on making effective, yet very expensive, new technologies and therapies available to children with ALL worldwide.
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Affiliation(s)
- Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Charles G. Mullighan
- Department of Pathology and Hematological Malignancies Program, Comprehensive Cancer Center, St Jude Children's Research Hospital, Memphis, TN
| | - Stephen P. Hunger
- Division of Oncology, Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
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5
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Epperly R, Shah NN. Long-term follow-up of CD19-CAR T-cell therapy in children and young adults with B-ALL. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:77-83. [PMID: 38066902 PMCID: PMC10727115 DOI: 10.1182/hematology.2023000422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The tremendous successes of CD19-directed CAR T cells in children and young adults with B-cell acute lymphoblastic leukemia (B-ALL) has led to the more widespread use of this important treatment modality. With an ability to induce remission and potentially lead to long-term survival in patients with multiply relapsed/chemotherapy refractory disease, more children are now receiving this therapy with the hope of inducing a long-term durable remission (with or without consolidative hematopoietic cell transplantation). While overcoming the acute toxicities was critical to its broad implementation, the emerging utilization requires close evaluation of subacute and delayed toxicities alongside a consideration of late effects and issues related to survivorship following CAR T cells. In this underexplored area of toxicity monitoring, this article reviews the current state of the art in relationship to delayed toxicities while highlighting areas of future research in the study of late effects in children and young adults receiving CAR T cells.
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Affiliation(s)
- Rebecca Epperly
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Bethesda, MD
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6
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Molina JC. Leveraging health care technology to improve health outcomes and reduce outcome disparities in AYA leukemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:573-580. [PMID: 38066875 PMCID: PMC10727055 DOI: 10.1182/hematology.2023000510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Significant improvements have occurred for adolescent and young adult (AYA) B-cell acute lymphoblastic leukemia (B-ALL) patients following the widespread adoption of "pediatric-inspired" treatment regimens for AYA patients cared for in adult oncology settings. However, for AYA patients, aged 15 to 39, an outcomes gap remains in B-ALL, necessitating the incorporation of novel therapies into up-front treatment regimens. As a result, clinical trial enrollment remains the current standard of care for AYA B-ALL across disease subtypes when available and accessible. Currently, several up-front trials are looking to incorporate the use of inotuzumab, blinatumomab, and chimeric antigen receptor T-cell therapy into existing chemotherapy backbones for AYA patients, as well as tyrosine kinase inhibitors for both Philadelphia-positive (Ph+) and Ph-like B-ALL. In addition to ongoing attempts to improve up-front treatments by incorporating immunotherapy and targeted approaches, the increased use of next generation sequencing for measurable residual disease evaluation has led to superior risk-stratification and a decreased need to pursue consolidative hematopoietic stem cell transplantation during the first complete remission for many patients.
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Affiliation(s)
- John C. Molina
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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7
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McClory SE, Maude SL. The Current State of Chimeric Antigen Receptor T Cell Therapy for B Lymphoblastic Leukemia. Hematol Oncol Clin North Am 2023; 37:1041-1052. [PMID: 37500380 DOI: 10.1016/j.hoc.2023.06.003] [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: 07/29/2023]
Abstract
Over the past decade, CAR T cell therapy has transformed the treatment of relapsed or refractory B-ALL in children and adults. CD19-directed CAR T cells can induce complete remissions in a large majority of patients with B-ALL, and up to half of these patients will go on to maintain durable remissions. However, significant challenges remain for patients who relapse or do not respond. This review will discuss the history of CAR T cell therapy for B-ALL, the treatment considerations for CAR T cell recipients, and current clinical trials and future directions for CAR T cell therapy in B-ALL.
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Affiliation(s)
- Susan E McClory
- Division of Oncology, Cancer Immunotherapy Program, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Shannon L Maude
- Division of Oncology, Cancer Immunotherapy Program, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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8
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Cummins K, Gill S. Chimeric Antigen Receptor T Cells in Acute Myeloid Leukemia. Hematol Oncol Clin North Am 2023; 37:1125-1147. [PMID: 37442676 DOI: 10.1016/j.hoc.2023.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
Up to 30% of patients with acute myeloid leukemia (AML) who undergo chimeric antigen receptor (CAR) T-cell therapy have evidence of response, although trials are highly heterogeneous. These responses are rarely deep or durable. CD123, CD33, and CLL-1 have emerged as the most common targets for CAR T cells in AML. CAR T cells against myeloid antigens cause myeloablation as well as cytokine release syndrome, although neurotoxicity is rarely seen. Future efforts should focus on AML-specific antigen discovery or engineering, and on further enhancing the activity of CAR T cells.
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Affiliation(s)
- Katherine Cummins
- Peter MacCallum Cancer Centre, University of Melbourne, 305 Grattan Street, Melbourne, VIC 3000, Australia
| | - Saar Gill
- Division of Hematology-Oncology, University of Pennsylvania Perelman School of Medicine, 8-101 Smilow Center for Translational Research, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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9
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Garg S, Ni W, Griffin JD, Sattler M. Chimeric Antigen Receptor T Cell Therapy in Acute Myeloid Leukemia: Trials and Tribulations. Hematol Rep 2023; 15:608-626. [PMID: 37987319 PMCID: PMC10660693 DOI: 10.3390/hematolrep15040063] [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: 07/18/2023] [Revised: 08/01/2023] [Accepted: 11/08/2023] [Indexed: 11/22/2023] Open
Abstract
Acute myeloid leukemia (AML) is a heterogeneous hematological malignancy that is often associated with relapse and drug resistance after standard chemotherapy or targeted therapy, particularly in older patients. Hematopoietic stem cell transplants are looked upon as the ultimate salvage option with curative intent. Adoptive cell therapy using chimeric antigen receptors (CAR) has shown promise in B cell malignancies and is now being investigated in AML. Initial clinical trials have been disappointing in AML, and we review current strategies to improve efficacy for CAR approaches. The extensive number of clinical trials targeting different antigens likely reflects the genetic heterogeneity of AML. The limited number of patients reported in multiple early clinical studies makes it difficult to draw conclusions about CAR safety, but it does suggest that the efficacy of this approach in AML lags behind the success observed in B cell malignancies. There is a clear need not only to improve CAR design but also to identify targets in AML that show limited expression in normal myeloid lineage cells.
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Affiliation(s)
- Swati Garg
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA; (W.N.); (J.D.G.); (M.S.)
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Wei Ni
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA; (W.N.); (J.D.G.); (M.S.)
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - James D. Griffin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA; (W.N.); (J.D.G.); (M.S.)
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Martin Sattler
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA; (W.N.); (J.D.G.); (M.S.)
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
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10
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Lamble AJ, Moskop A, Pulsipher MA, Maude SL, Summers C, Annesley C, Baruchel A, Gore L, Amrolia P, Shah N. INSPIRED Symposium Part 2: Prevention and Management of Relapse Following Chimeric Antigen Receptor T Cell Therapy for B Cell Acute Lymphoblastic Leukemia. Transplant Cell Ther 2023; 29:674-684. [PMID: 37689393 DOI: 10.1016/j.jtct.2023.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/30/2023] [Indexed: 09/11/2023]
Abstract
Although CD19-directed chimeric antigen receptor (CAR) T cell therapy (CAR-T) for relapsed/refractory B cell acute lymphoblastic leukemia (B-ALL) has been transformative in inducing and sustaining remission, relapse rates remain unacceptably high, with approximately 50% of children and young adults experiencing relapse within the first year postinfusion. Emerging strategies to extend the durability of remission involve the use of prognostic biomarkers to identify those at high risk of relapse or incorporate strategies aimed to enhancing functional CAR T cell persistence. Nonetheless, with antigen loss/down-regulation or evolution to lineage switch as major mechanisms of relapse, optimizing single antigen targeting alone is insufficient. Here, with a focus on relapse prevention strategies, including postinfusion surveillance and treatment approaches being explored to optimize post-CAR-T management (eg, combinatorial antigen targeting strategies, preemptive hematopoietic cell transplantation), we review the current state of the art in the prevention and management of post CAR-T relapse. We highlight the advancements in the field and identify gaps in the literature to guide future research in optimizing the prevention and management of post-CAR-T relapse in children and young adults with B-ALL.
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Affiliation(s)
- Adam J Lamble
- Division of Hematology/Oncology, University of Washington, Seattle Children's Hospital, Seattle, Washington.
| | - Amy Moskop
- Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, Wisconsin
| | - Michael A Pulsipher
- Division of Hematology and Oncology, Intermountain Primary Children's Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah
| | - Shannon L Maude
- Division of Oncology, Cell Therapy and Transplant Section, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Corinne Summers
- Division of Hematology/Oncology, University of Washington, Seattle Children's Hospital, Seattle, Washington; Fred Hutchinson Cancer Center, Seattle, Washington
| | - Colleen Annesley
- Division of Hematology/Oncology, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - André Baruchel
- Pediatric Hematology Department, Robert Debré University Hospital, AP-HP and Université Paris Cité, Paris, France
| | - Lia Gore
- Pediatric Hematology/Oncology/BMT-CT, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| | - Persis Amrolia
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - Nirali Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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11
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Myers RM, Jacoby E, Pulsipher MA, Pasquini MC, Grupp SA, Shah NN, Laetsch TW, Curran KJ, Schultz LM. INSPIRED Symposium Part 1: Clinical Variables Associated with Improved Outcomes for Children and Young Adults treated with Chimeric Antigen Receptor T cells for B cell Acute Lymphoblastic Leukemia. Transplant Cell Ther 2023; 29:598-607. [PMID: 37481241 PMCID: PMC11031134 DOI: 10.1016/j.jtct.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/16/2023] [Indexed: 07/24/2023]
Abstract
Chimeric antigen receptor (CAR) T cell therapy (CAR-T) targeting the CD19 antigen on B cell acute lymphoblastic leukemia (B-ALL) has transitioned from a highly investigational therapy with limited access to a commercial therapy with established toxicities, response and survival rates, and access in numerous countries. With more than a decade of clinical study and 5 years of commercial access, data showing associations with success and failure have emerged. To address functional limitations of CAR-T and overcome constrained sample sizes when studying single-trial or single-center data, collaborative groups, including the Pediatric Real World CAR Consortium, the CAR-Multicenter Analysis, the Center for International Blood and Marrow Transplant Research, and the International BFM Study Group, among others, have been retrospectively interrogating the amassed clinical experience. The high patient numbers and varied clinical experiences compiled by these groups have defined clinical variables impacting CAR-T outcomes. Here we review published CAR-T trials and consortium/collaborative outcomes to establish variables associated with optimal response to CAR-T in children and young adults with B-ALL. We focus on findings with clinical relevance that have emerged, including data implicating pretreatment disease burden, presence of extramedullary disease, nonresponse to prior CD19 antigen targeting (blinatumomab therapy), CAR T cell dose, and fludarabine pharmacokinetics as factors impacting post-CAR-T survival. Additionally, we address the role of collaborative efforts going forward in guiding clinical practice evolution and further optimizing post-CAR-T outcomes.
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Affiliation(s)
- Regina M Myers
- Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elad Jacoby
- Division of Pediatric Hematology, Oncology and BMT, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
| | - Michael A Pulsipher
- Intermountain Primary Children's Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah
| | - Marcelo C Pasquini
- Medical College of Wisconsin/Center for International Blood and Marrow Transplant Research, Milwaukee, Wisconsin
| | - Stephan A Grupp
- Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Theodore W Laetsch
- Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kevin J Curran
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Liora M Schultz
- Department of Pediatrics, Division of Hematology and Oncology, Stanford University School of Medicine, Palo Alto, California, USA.
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12
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Maese LD, Pulsipher MA. Blinatumomab Conundrum in Low-Risk Relapsed B-Cell ALL. J Clin Oncol 2023; 41:4087-4092. [PMID: 37311171 DOI: 10.1200/jco.23.00594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/03/2023] [Accepted: 04/28/2023] [Indexed: 06/15/2023] Open
Abstract
The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. BACKGROUND The Children's Oncology Group (COG) AALL1331 trial demonstrated improved survival and less toxicity in children with high-/intermediate-risk relapsed ALL receiving blinatumomab compared with intensive chemotherapy before hematopoietic stem-cell transplant (HSCT). The low-risk arm of AALL1331 compared addition of three cycles of blinatumomab to chemotherapy alone, but a survival improvement was not noted. Secondary analyses showed improvement in disease-free survival (DFS) and overall survival (OS) of low-risk patients with bone marrow disease ± extramedullary (EM) involvement (4-year DFS 72.7% ± 5.8% v 53.7% ± 6.7%; 4-year OS 97.1% ± 2.1% v 84.8% ± 4.8%), but failed to show an advantage with blinatumomab for patients with isolated EM relapse. Of note, DFS of isolated CNS (iCNS) relapse was worse than previous studies at 24% on both arms, likely because of decreases in CNS-intensive therapy compared with previous approaches and inadequacy of blinatumomab for controlling CNS disease. CASE Our case of late isolated CNS B-cell ALL relapse outlines challenges for clinicians attempting to decrease toxicity and avoid HSCT: (1) defining of low risk appropriately, (2) attempting to reduce the treatment burden of past protocols, and (3) understanding approach and timing of cranial irradiation. APPROACH Although AALL1331 therapy without blinatumomab leads to excellent survival in patients with isolated testicular relapse, we recommend a modified AALL02P2 backbone of chemotherapy with 1,800 cGy cranial radiotherapy for patients with late iCNS relapse. Future studies integrating chimeric antigen receptor T cells, which have better CNS penetration, may help decrease the intensive treatment burden for patients with late iCNS recurrence.
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Affiliation(s)
- Luke D Maese
- Intermountain Primary Children's Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
| | - Michael A Pulsipher
- Intermountain Primary Children's Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
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Worel N, Holbro A, Vrielink H, Ootjers C, Le Poole K, Beer-Wekking I, Rintala T, Lozano M, Bonig H. A guide to the collection of T-cells by apheresis for ATMP manufacturing-recommendations of the GoCART coalition apheresis working group. Bone Marrow Transplant 2023; 58:742-748. [PMID: 37024570 DOI: 10.1038/s41409-023-01957-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/03/2023] [Accepted: 03/13/2023] [Indexed: 04/08/2023]
Abstract
Autologous chimeric antigen receptor-modified T-cells (CAR-T) provide meaningful benefit for otherwise refractory malignancies. As clinical indications for CAR-T cells are expanding, hospitals hitherto not active in the field of immune effector cell therapy will need to build capacity and expertise. The GoCART Coalition seeks to disseminate knowledge and skills to facilitate the introduction of CAR-T cells and to standardize management and documentation of CAR-T cell recipients, in order to optimize outcomes and to be able to benchmark clinical results against other centers. Apheresis generates the starting material for CAR-T cell manufacturing. This guide provides some initial suggestions for patient's apheresis readiness and performance to collect starting material and should thus facilitate the implementation of a CAR-T-starting material apheresis facility. It cannot replace, of course, the extensive training needed to perform qualitative apheresis collections in compliance with national and international regulations and assess their cellular composition and biological safety.
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Affiliation(s)
- Nina Worel
- Department for Transfusion Medicine and Cell Therapy, Medical University of Vienna, Vienna, Austria.
| | - Andreas Holbro
- Regional Blood Transfusion Service, Swiss Red Cross, Basel, Switzerland
- Division of Hematology, University Hospital Basel and University Basel, Basel, Switzerland
- Innovation Focus Cell Therapies, University Hospital Basel, Basel, Switzerland
| | - Hans Vrielink
- Department for Transfusion Medicine, Sanquin Blood Supply, Amsterdam, The Netherlands
| | - Claudia Ootjers
- Department of Hematology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Kaatje Le Poole
- Department for Transfusion Medicine, Sanquin Blood Supply, Amsterdam, The Netherlands
| | - Ingrid Beer-Wekking
- Department of Hematology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Miquel Lozano
- Apheresis and Cellular Therapy Unit, Department of Hemotherapy and Hemostasis, University Clinic Hospital, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Halvard Bonig
- Institute for Transfusion Medicine and Immunohematology, Goethe University, Frankfurt a.M., Germany
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
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