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Dreyzin A, Rankin AW, Luciani K, Gavrilova T, Shah NN. Overcoming the challenges of primary resistance and relapse after CAR-T cell therapy. Expert Rev Clin Immunol 2024; 20:745-763. [PMID: 38739466 PMCID: PMC11180598 DOI: 10.1080/1744666x.2024.2349738] [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: 12/17/2023] [Accepted: 04/26/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION While CAR T-cell therapy has led to remarkable responses in relapsed B-cell hematologic malignancies, only 50% of patients ultimately have a complete, sustained response. Understanding the mechanisms of resistance and relapse after CAR T-cell therapy is crucial to future development and improving outcomes. AREAS COVERED We review reasons for both primary resistance and relapse after CAR T-cell therapies. Reasons for primary failure include CAR T-cell manufacturing problems, suboptimal fitness of autologous T-cells themselves, and intrinsic features of the underlying cancer and tumor microenvironment. Relapse after initial response to CAR T-cell therapy may be antigen-positive, due to CAR T-cell exhaustion or limited persistence, or antigen-negative, due to antigen-modulation on the target cells. Finally, we discuss ongoing efforts to overcome resistance to CAR T-cell therapy with enhanced CAR constructs, manufacturing methods, alternate cell types, combinatorial strategies, and optimization of both pre-infusion conditioning regimens and post-infusion consolidative strategies. EXPERT OPINION There is a continued need for novel approaches to CAR T-cell therapy for both hematologic and solid malignancies to obtain sustained remissions. Opportunities for improvement include development of new targets, optimally combining existing CAR T-cell therapies, and defining the role for adjunctive immune modulators and stem cell transplant in enhancing long-term survival.
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Affiliation(s)
- Alexandra Dreyzin
- Pediatric Oncology Branch, Center of Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
- Division of Pediatric Oncology, Children's National Hospital, Washington DC, USA
| | - Alexander W Rankin
- Pediatric Oncology Branch, Center of Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Katia Luciani
- School of Medicine, University of Limerick, Limerick, Ireland
| | | | - Nirali N Shah
- Pediatric Oncology Branch, Center of Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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2
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Jacobs R, Jacobson C. The treatment of follicular lymphoma with CD19-directed chimeric antigen receptor T-cell therapy. Front Oncol 2024; 14:1384600. [PMID: 38903716 PMCID: PMC11188288 DOI: 10.3389/fonc.2024.1384600] [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: 02/09/2024] [Accepted: 04/29/2024] [Indexed: 06/22/2024] Open
Abstract
Follicular lymphoma (FL) is the most common indolent non-Hodgkin lymphoma. Significant unmet need remains for patients with relapsed/refractory FL after ≥3 lines of prior therapy. While recent advancements have likely improved the survival of patients with FL, most patients will eventually relapse. The treatment of patients with FL after multiple relapses or those with refractory disease has historically led to lower overall response rates (ORR) and shorter progression-free survival (PFS) with each subsequent line of therapy. New treatments with high ORR and durable PFS are needed in this setting, particularly in patients that progress within 2 years of first line chemoimmunotherapy (POD24) and/or those refractory chemoimmunotherapy. Chimeric antigen receptor T-cell therapies targeting the B-cell antigen CD-19 have shown to be an efficacious treatment option for both heavily pretreated patients and/or patients with refractory FL, resulting in a high ORR and durable remissions.
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Affiliation(s)
- Ryan Jacobs
- Levine Cancer Institute, Charlotte, NC, United States
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3
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Gagelmann N, Bishop M, Ayuk F, Bethge W, Glass B, Sureda A, Pasquini MC, Kröger N. Axicabtagene Ciloleucel versus Tisagenlecleucel for Relapsed or Refractory Large B Cell Lymphoma: A Systematic Review and Meta-Analysis. Transplant Cell Ther 2024; 30:584.e1-584.e13. [PMID: 38281590 DOI: 10.1016/j.jtct.2024.01.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/28/2023] [Accepted: 01/23/2024] [Indexed: 01/30/2024]
Abstract
Axicabtagene ciloleucel (axi-cel) and tisagenlecleucel (tisa-cel) are CD19-directed chimeric antigen receptor T cell (CAR-T) therapies approved for relapsed/refractory aggressive large B cell lymphoma (LBCL). Significant costs and complex manufacturing underscore the importance of evidence-based counseling regarding the outcomes of these treatments. With the aim of examining the efficacy and safety of axi-cel versus tisa-cel in patients with relapsed/refractory aggressive LBCL, we performed a systematic literature search of comparative studies evaluating outcomes in relapsed/refractory aggressive LBCL after treatment with axi-cel or tisa-cel. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for response, progression-free survival (PFS), overall survival (OS), cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and hematotoxicity. Meta-analysis and meta-regression were used to generate summary statistics. A total of 2372 participants were included in the 8 studies in our analysis. The dropout rate between apheresis and infusion was 13% for axi-cel versus 18% for tisa-cel, and the median time from apheresis to infusion was 32 days versus 45 days. Axi-cel showed higher odds for a complete response (OR, 1.65; P < .001) and was associated with higher odds for PFS at 1 year after infusion (OR, .60; P < .001). OS appeared to be improved with axi-cel (OR, .84; 95% CI, .68 to 1.02; P = .08), whereas the cumulative incidence of nonrelapse mortality (NRM) was 11.5% for axi-cel versus 3.7% for tisa-cel (P = .002). The main predictors for survival were lactate dehydrogenase level, Eastern Cooperative Oncology Group Performance Status, and response to bridging, and axi-cel maintained superior efficacy even in elderly patients. In terms of safety, axi-cel was associated with significantly higher odds of any-grade CRS (OR, 3.23; P < .001), but not of grade ≥3 CRS (P = .92). Axi-cel was associated with significantly higher odds of severe ICANS grade ≥3 (OR, 4.03; P < .001). In terms of hematotoxicity, axi-cel was significantly associated with higher odds of severe neutropenia at 1 month after infusion (OR, 2.06; P = .003). As a result, axi-cel was associated with significantly greater resource utilization, including prolonged hospital stay, more frequent intensive care admission, and use of agents such as tocilizumab for toxicity management. We provide strong evidence of the greater efficacy of axi-cel versus tisa-cel in relapsed/refractory aggressive LBCL. The higher toxicity and NRM seen with axi-cel might not counterbalance the overall results, highlighting the need for timely intervention and careful selection of patients, balancing resource utilization and clinical benefit.
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Michael Bishop
- The David and Etta Jonas Center for Cellular Therapy, University of Chicago, Chicago, Illinois
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Bethge
- Department of Hematology and Oncology, University Hospital Tuebingen, Tuebingen, Germany
| | - Bertram Glass
- Department of Hematology and Cell Therapy, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Anna Sureda
- Bellvitge Institute for Biomedical Research, Universitat de Barcelona, Hematology Department, Institut Català d'Oncologia-Hospitalet, Barcelona, Spain
| | - Marcelo C Pasquini
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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4
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Galli E, Viscovo M, Fosso F, Pansini I, Di Cesare G, Iacovelli C, Maiolo E, Sorà F, Hohaus S, Sica S, Bellesi S, Chiusolo P. Unlocking Predictive Power: Quantitative Assessment of CAR-T Expansion with Digital Droplet Polymerase Chain Reaction (ddPCR). Int J Mol Sci 2024; 25:2673. [PMID: 38473919 DOI: 10.3390/ijms25052673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/16/2024] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
Flow cytometry (FCM) and quantitative PCR (qPCR) are conventional methods for assessing CAR-T expansion, while digital droplet PCR (ddPCR) is emerging as a promising alternative. We monitored CAR-T transcript expansion in 40 B-NHL patients post-infusion of CAR-T products (axi-cel; tisa-cel; and brexu-cel) with both His-Tag FCM and ddPCR techniques. Sensitivity and predictive capacity for efficacy and safety outcomes of ddPCR were analyzed and compared with FCM. A significant correlation between CAR-T counts determined by FCM and CAR transcripts assessed by ddPCR (p < 0.001) was observed. FCM revealed median CD3+CAR+ cell counts at 7, 14, and 30 days post-infusion with no significant differences. In contrast, ddPCR-measured median copies of CAR-T transcripts demonstrated significant lower copy numbers in tisa-cel recipients compared to the other products at day 7 and day 14. Patients with a peak of CAR transcripts at day 7 exceeding 5000 copies/microg gDNA, termed "good CAR-T expanders", were more likely to achieve a favorable response at 3 months (HR 10.79, 95% CI 1.16-100.42, p = 0.036). Good CAR-T expanders showed superior progression-free survival at 3, 6, and 12 months compared to poor CAR-T expanders (p = 0.088). Those reaching a peak higher than 5000 copies/microg gDNA were more likely to experience severe CRS and ICANS. DdPCR proves to be a practical method for monitoring CAR-T expansion, providing quantitative information that better predicts both treatment outcomes and toxicity.
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Affiliation(s)
- Eugenio Galli
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Marcello Viscovo
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Federica Fosso
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Ilaria Pansini
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giacomo Di Cesare
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Camilla Iacovelli
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Elena Maiolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Federica Sorà
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Stefan Hohaus
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Silvia Bellesi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Patrizia Chiusolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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5
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Fischer L, Grieb N, Born P, Weiss R, Seiffert S, Boldt A, Fricke S, Franz P, Heyn S, Kubasch AS, Baber R, Weidner H, Wang SY, Bach E, Hoffmann S, Ussmann J, Kirchberg J, Hell S, Schwind S, Metzeler KH, Herling M, Jentzsch M, Franke GN, Sack U, Reiche K, Köhl U, Platzbecker U, Vucinic V, Merz M. Cellular dynamics following CAR T cell therapy are associated with response and toxicity in relapsed/refractory myeloma. Leukemia 2024; 38:372-382. [PMID: 38184754 PMCID: PMC10844085 DOI: 10.1038/s41375-023-02129-y] [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: 09/28/2023] [Revised: 11/17/2023] [Accepted: 12/15/2023] [Indexed: 01/08/2024]
Abstract
B-cell maturation antigen (BCMA)-targeting chimeric antigen receptor (CAR) T cells revolutionized the treatment of relapsed/refractory multiple myeloma (RRMM). However, data on cellular (CAR) T cell dynamics and the association with response, resistance or the occurrence of cytokine release syndrome (CRS) are limited. Therefore, we performed a comprehensive flow cytometry analysis of 27 RRMM patients treated with Idecabtagene vicleucel (Ide-cel) to assess the expansion capacity, persistence and effects on bystander cells of BCMA-targeting CAR T cells. Additionally, we addressed side effects, like cytokine release syndrome (CRS) and cytopenia. Our results show that in vivo expansion of CD8+ CAR T cells is correlated to response, however persistence is not essential for durable remission in RRMM patients. In addition, our data provide evidence, that an increased fraction of CD8+ T cells at day of leukapheresis in combination with successful lymphodepletion positively influence the outcome. We show that patients at risk for higher-grade CRS can be identified already prior to lymphodepletion. Our extensive characterization contributes to a better understanding of the dynamics and effects of BCMA-targeting CAR T cells, in order to predict the response of individual patients as well as side effects, which can be counteracted at an early stage or even prevented.
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Affiliation(s)
- Luise Fischer
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Nora Grieb
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
- Innovation Center Computer Assisted Surgery (ICCAS), Leipzig, Germany
| | - Patrick Born
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Ronald Weiss
- Institute for Clinical Immunology, University Hospital of Leipzig, Leipzig, Germany
- Fraunhofer Institute for Cell Therapy and Immunology IZI, Leipzig, Germany
| | - Sabine Seiffert
- Institute for Clinical Immunology, University Hospital of Leipzig, Leipzig, Germany
| | - Andreas Boldt
- Institute for Clinical Immunology, University Hospital of Leipzig, Leipzig, Germany
| | - Stephan Fricke
- Fraunhofer Institute for Cell Therapy and Immunology IZI, Leipzig, Germany
| | - Paul Franz
- Fraunhofer Institute for Cell Therapy and Immunology IZI, Leipzig, Germany
| | - Simone Heyn
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Anne Sophie Kubasch
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Ronny Baber
- Institute for Laboratory Medicine Clinical Chemistry and Molecular Diagnostics, University Hospital Leipzig, Leipzig, Germany
- Leipzig Medical Biobank, University Leipzig, Leipzig, Germany
| | - Heike Weidner
- Bone Lab Dresden, University Hospital Dresden, Dresden, Germany
| | - Song Yau Wang
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Enrica Bach
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Sandra Hoffmann
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Jule Ussmann
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Janine Kirchberg
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Saskia Hell
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Sebastian Schwind
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Klaus H Metzeler
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Marco Herling
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Madlen Jentzsch
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Georg-Nikolaus Franke
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Ulrich Sack
- Institute for Clinical Immunology, University Hospital of Leipzig, Leipzig, Germany
| | - Kristin Reiche
- Fraunhofer Institute for Cell Therapy and Immunology IZI, Leipzig, Germany
| | - Ulrike Köhl
- Institute for Clinical Immunology, University Hospital of Leipzig, Leipzig, Germany
- Fraunhofer Institute for Cell Therapy and Immunology IZI, Leipzig, Germany
| | - Uwe Platzbecker
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Vladan Vucinic
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany
| | - Maximilian Merz
- Department of Hematology, Hemostaseology, Cellular Therapy and Infectiology, University Hospital of Leipzig, Leipzig, Germany.
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6
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Baguet C, Larghero J, Mebarki M. Early predictive factors of failure in autologous CAR T-cell manufacturing and/or efficacy in hematologic malignancies. Blood Adv 2024; 8:337-342. [PMID: 38052048 PMCID: PMC10788849 DOI: 10.1182/bloodadvances.2023011992] [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: 10/23/2023] [Revised: 11/21/2023] [Accepted: 11/21/2023] [Indexed: 12/07/2023] Open
Abstract
ABSTRACT Chimeric antigen receptor (CAR) T-cell therapies have shown significant benefits in the treatment of hematologic malignancies, such as B-cell acute lymphoblastic leukemia (B-ALL) and B-cell lymphoma. Despite the therapeutic advances offered by these innovative treatments, failures are still observed in 15% to 40% of patients with B-ALL and >50% of patients with B-cell lymphoma. Several hypotheses have emerged including CD19-negative or -positive relapses, low CAR T-cell activation and/or expansion in vivo, or T-cell exhaustion. To date, in the European Union, CAR T cells granted with marketing authorization are autologous and thus associated with a strong heterogeneity between products. Indeed, the manufacturing of a single batch requires cellular starting material collection by apheresis for each patient, with variable cellular composition, and then challenging pharmaceutical companies to standardize as much as possible the production process. In addition, these cost and time-consuming therapies are associated with a risk of manufacturing failure reaching 25%. Thus, there is a growing need to identify early risk factors of unsuccessful production and/or therapeutic escape. Quality of the apheresis product, pathology progression, as well as previous treatments have been reported as predictive factors of the variability in clinical response. The aim of this review is to report and discuss predictive factors that could help to anticipate the manufacturing success and clinical response.
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Affiliation(s)
- Clémentine Baguet
- Université Paris Cité, Assistance Publique – Hôpitaux de Paris, Hôpital Saint-Louis, Unité de Thérapie Cellulaire, Paris, France
| | - Jérôme Larghero
- Université Paris Cité, Assistance Publique – Hôpitaux de Paris, Hôpital Saint-Louis, Unité de Thérapie Cellulaire, Paris, France
- Université Paris Cité, Assistance Publique – Hôpitaux de Paris, Hôpital Saint-Louis, Centre MEARY de Thérapie Cellulaire et Génique, Paris, France
- INSERM, Centre d’investigation Clinique de Biothérapies CBT501, Paris, France
| | - Miryam Mebarki
- Université Paris Cité, Assistance Publique – Hôpitaux de Paris, Hôpital Saint-Louis, Unité de Thérapie Cellulaire, Paris, France
- INSERM, Centre d’investigation Clinique de Biothérapies CBT501, Paris, France
- Faculté de pharmacie, Université Paris Cité, Paris, France
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7
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Negishi S, Girsch JH, Siegler EL, Bezerra ED, Miyao K, Sakemura RL. Treatment strategies for relapse after CAR T-cell therapy in B cell lymphoma. Front Pediatr 2024; 11:1305657. [PMID: 38283399 PMCID: PMC10811220 DOI: 10.3389/fped.2023.1305657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/29/2023] [Indexed: 01/30/2024] Open
Abstract
Clinical trials of anti-CD19 chimeric antigen receptor T (CART19) cell therapy have shown high overall response rates in patients with relapsed/refractory B-cell malignancies. CART19 cell therapy has been approved by the US Food and Drug Administration for patients who relapsed less than 12 months after initial therapy or who are refractory to first-line therapy. However, durable remission of CART19 cell therapy is still lacking, and 30%-60% of patients will eventually relapse after CART19 infusion. In general, the prognosis of patients who relapse after CART19 cell therapy is poor, and various strategies to treat this patient population have been investigated extensively. CART19 failures can be broadly categorized by the emergence of either CD19-positive or CD19-negative lymphoma cells. If CD19 expression is preserved on the lymphoma cells, a second infusion of CART19 cells or reactivation of previously infused CART19 cells with immune checkpoint inhibitors can be considered. When patients develop CD19-negative relapse, targeting different antigens (e.g., CD20 or CD22) with CAR T cells, investigational chemotherapies, or hematopoietic stem cell transplantation are potential treatment options. However, salvage therapies for relapsed large B-cell lymphoma after CART19 cell therapy have not been fully explored and are conducted based on clinicians' case-by-case decisions. In this review, we will focus on salvage therapies reported to date and discuss the management of relapsed/refractory large B-cell lymphomas after CART19 cell therapy.
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Affiliation(s)
- Shuto Negishi
- Department of Hematology and Oncology, Konan Kosei Hospital, Konan, Japan
| | - James H. Girsch
- T Cell Engineering, Mayo Clinic, Rochester, MN, United States
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
- Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, United States
- Department of Molecular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Elizabeth L. Siegler
- T Cell Engineering, Mayo Clinic, Rochester, MN, United States
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Evandro D. Bezerra
- Department of Hematology and Oncology, Ohio State University, Columbus, OH, United States
| | - Kotaro Miyao
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - R. Leo Sakemura
- T Cell Engineering, Mayo Clinic, Rochester, MN, United States
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
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8
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Arcila ME, Patel U, Momeni-Boroujeni A, Yao J, Chan R, Chan J, Rijo I, Yu W, Chaves N, Patel H, Kakadiya S, Lachhander S, Senechal B, Riviere IC, Wang X, Sadelain M, Nafa K, Salazar P, Palomba L, Curran KJ, Park JH, Daniyan A, Borsu L. Validation of a High-Sensitivity Assay for Detection of Chimeric Antigen Receptor T-Cell Vectors Using Low-Partition Digital PCR Technology. J Mol Diagn 2023; 25:634-645. [PMID: 37330049 PMCID: PMC10488325 DOI: 10.1016/j.jmoldx.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 05/18/2023] [Accepted: 06/01/2023] [Indexed: 06/19/2023] Open
Abstract
Although in vivo engraftment, expansion, and persistence of chimeric antigen receptor (CAR) T cells are pivotal components of treatment efficacy, quantitative monitoring has not been implemented in routine clinical practice. We describe the development and analytical validation of a digital PCR assay for ultrasensitive detection of CAR constructs after treatment, circumventing known technical limitations of low-partitioning platforms. Primers and probes, designed for detection of axicabtagene, brexucabtagene, and Memorial Sloan Kettering CAR constructs, were employed to validate testing on the Bio-Rad digital PCR low-partitioning platform; results were compared with Raindrop, a high-partitioning system, as reference method. Bio-Rad protocols were modified to enable testing of DNA inputs as high as 500 ng. Using dual-input reactions (20 and 500 ng) and a combined analysis approach, the assay demonstrated consistent target detection around 1 × 10-5 (0.001%) with excellent specificity and reproducibility and 100% accuracy compared with the reference method. Dedicated analysis of 53 clinical samples received during validation/implementation phases showed the assay effectively enabled monitoring across multiple time points of early expansion (day 6 to 28) and long-term persistence (up to 479 days). CAR vectors were detected at levels ranging from 0.005% to 74% (vector versus reference gene copies). The highest levels observed in our cohort correlated strongly with the temporal diagnosis of grade 2 and 3 cytokine release syndrome diagnosis (P < 0.005). Only three patients with undetectable constructs had disease progression at the time of sampling.
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Affiliation(s)
- Maria E Arcila
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Utsav Patel
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amir Momeni-Boroujeni
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - JinJuan Yao
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Roger Chan
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joe Chan
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ivelise Rijo
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Wayne Yu
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nelio Chaves
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hina Patel
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Srushti Kakadiya
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean Lachhander
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Brigitte Senechal
- Cell Therapy and Cell Engineering Facility, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Isabelle C Riviere
- Cell Therapy and Cell Engineering Facility, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Xiuyan Wang
- Cell Therapy and Cell Engineering Facility, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michel Sadelain
- Cell Therapy and Cell Engineering Facility, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Khedoudja Nafa
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paulo Salazar
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lia Palomba
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kevin J Curran
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jae H Park
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anthony Daniyan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Laetitia Borsu
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
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9
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Rejeski K, Blumenberg V, Iacoboni G, Lopez-Corral L, Kharboutli S, Hernani R, Petrera A, Müller N, Hildebrand F, Frölich L, Karschnia P, Schmidt C, Cordas dos Santos DM, Piñana JL, Müller F, Martin AA, Dreyling M, von Bergwelt-Baildon M, Barba P, Subklewe M, Bücklein VL. Identifying Early Infections in the Setting of CRS With Routine and Exploratory Serum Proteomics and the HT10 Score Following CD19 CAR-T for Relapsed/Refractory B-NHL. Hemasphere 2023; 7:e858. [PMID: 37038465 PMCID: PMC10082278 DOI: 10.1097/hs9.0000000000000858] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 02/06/2023] [Indexed: 04/08/2023] Open
Abstract
Early fever after chimeric antigen receptor T-cell (CAR-T) therapy can reflect both an infection or cytokine release syndrome (CRS). Identifying early infections in the setting of CRS and neutropenia represents an unresolved clinical challenge. In this retrospective observational analysis, early fever events (day 0-30) were characterized as infection versus CRS in 62 patients treated with standard-of-care CD19.CAR-T for relapsed/refractory B-cell non-Hodgkin lymphoma. Routine serum inflammatory markers (C-reactive protein [CRP], interleukin-6 [IL-6], procalcitonin [PCT]) were recorded daily. Exploratory plasma proteomics were performed longitudinally in 52 patients using a multiplex proximity extension assay (Olink proteomics). Compared with the CRSonly cohort, we noted increased event-day IL-6 (median 2243 versus 64 pg/mL, P = 0.03) and particularly high PCT levels (median 1.6 versus 0.3 µg/L, P < 0.0001) in the patients that developed severe infections. For PCT, an optimal discriminatory threshold of 1.5 µg/L was established (area under the receiver operating characteristic curve [AUCROC] = 0.78). Next, we incorporated day-of-fever PCT levels with the patient-individual CAR-HEMATOTOX score. In a multicenter validation cohort (n = 125), we confirmed the discriminatory capacity of this so-called HT10 score for early infections at first fever (AUCROC = 0.87, P < 0.0001, sens. 86%, spec. 86%). Additionally, Olink proteomics revealed pronounced immune dysregulation and endothelial dysfunction in patients with severe infections as evidenced by an increased ANGPT2/1 ratio and an altered CD40/CD40L-axis. In conclusion, the high discriminatory capacity of the HT10 score for infections highlights the advantage of dynamic risk assessment and supports the incorporation of PCT into routine inflammatory panels. Candidate markers from Olink proteomics may further refine risk-stratification. If validated prospectively, the score will enable risk-adapted decisions on antibiotic use.
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10
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Xu H, Li N, Wang G, Cao Y. Predictive short/long-term efficacy biomarkers and resistance mechanisms of CD19-directed CAR-T immunotherapy in relapsed/refractory B-cell lymphomas. Front Immunol 2023; 14:1110028. [PMID: 37051246 PMCID: PMC10083339 DOI: 10.3389/fimmu.2023.1110028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/14/2023] [Indexed: 03/28/2023] Open
Abstract
Genetically modified T-cell immunotherapies are revolutionizing the therapeutic options for hematological malignancies, especially those of B-cell origin. Impressive efficacies of CD19-directed chimeric antigen receptor (CAR)-T therapy have been reported in refractory/relapsed (R/R) B-cell non-Hodgkin lymphoma (NHL) patients who were resistant to current standard therapies, with a complete remission (CR) rate of approximately 50%. At the same time, problems of resistance and relapse following CAR-T therapy have drawn growing attention. Recently, great efforts have been made to determine various factors that are connected to the responses and outcomes following CAR-T therapy, which may not only allow us to recognize those with a higher likelihood of responding and who could benefit most from the therapy but also identify those with a high risk of resistance and relapse and to whom further appropriate treatment should be administered following CAR-T therapy. Thus, we concentrate on the biomarkers that can predict responses and outcomes after CD19-directed CAR-T immunotherapy. Furthermore, the mechanisms that may lead to treatment failure are also discussed in this review.
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Affiliation(s)
- Hao Xu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, Hubei, China
| | - Ningwen Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, Hubei, China
| | - Gaoxiang Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, Hubei, China
- *Correspondence: Gaoxiang Wang, ; Yang Cao,
| | - Yang Cao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, Hubei, China
- *Correspondence: Gaoxiang Wang, ; Yang Cao,
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11
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CAR T-Cell Persistence Correlates with Improved Outcome in Patients with B-Cell Lymphoma. Int J Mol Sci 2023; 24:ijms24065688. [PMID: 36982764 PMCID: PMC10056741 DOI: 10.3390/ijms24065688] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has led to profound and durable tumor responses in a relevant subset of patients with relapsed/refractory (r/r) B-cell lymphomas. Still, some patients show insufficient benefit or relapse after CAR T-cell therapy. We performed a retrospective study to investigate the correlation between CAR T-cell persistence in the peripheral blood (PB) at 6 months, assessed by droplet digital PCR (ddPCR), with CAR T-cell treatment outcome. 92 patients with r/r B-cell lymphomas were treated with CD19-targeting CAR T-cell therapies at our institution between 01/2019–08/2022. Six months post-treatment, 15 (16%) patients had no detectable circulating CAR-T constructs by ddPCR. Patients with CAR T-cell persistence had a significantly higher CAR T-cell peak (5432 vs. 620 copies/ug cfDNA, p = 0.0096), as well as higher incidence of immune effector cell-associated neurotoxicity syndrome (37% vs. 7%, p = 0.0182). After a median follow-up of 8.5 months, 31 (34%) patients relapsed. Lymphoma relapses were less frequent among patients with CAR T-cell persistence (29% vs. 60%, p = 0.0336), and CAR T-cell persistence in the PB at 6 months was associated with longer progression-free survival (PFS) (HR 2.79, 95% CI: 1.09–7.11, p = 0.0319). Moreover, we observed a trend towards improved overall survival (OS) (HR 1.99, 95% CI: 0.68–5.82, p = 0.2092) for these patients. In our cohort of 92 B-cell lymphomas, CAR T-cell persistence at 6 months was associated with lower relapse rates and longer PFS. Moreover, our data confirm that 4-1BB-CAR T-cells have a longer persistence as compared to CD-28-based CAR T-cells.
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12
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Iovino L, Wu QV, Voutsinas J, Panaite L, Mullane E, Lynch RC, Ujjani C, Smith SD, Gopal AK, Till BG, Milano F, Chow V, Gauthier J, Turtle CJ, Maloney DG, Shadman M. Predictors of response to axicabtagene-ciloleucel CAR T cells in aggressive B cell lymphomas: A real-world study. J Cell Mol Med 2022; 26:5976-5983. [PMID: 36453136 PMCID: PMC9753434 DOI: 10.1111/jcmm.17550] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/06/2022] [Accepted: 07/29/2022] [Indexed: 12/03/2022] Open
Abstract
Chimeric antigen receptor T-cell (CAR T) therapy has shown promising efficacy in relapsed and refractory diffuse large B cell lymphoma (DLBCL). While most patients undergo CAR T infusion with active disease, the impact of some clinical variables, such as responsiveness to the pre-CAR T chemotherapy on the response to CAR T, is unknown. In this single-institution study, we studied the impact of several pre-CAR T variables on the post-CAR outcomes. Sixty patients underwent apheresis for axicabtagene-ciloleucel (axi-cel) and 42 of them (70.0%) had primary refractory disease. Bridging therapy between apheresis and lymphodepletion was given in 34 patients (56.7%). After axi-cel, the overall response rate was 63.3%. Responsiveness to the immediate pre-CAR T therapy did not show a significant association with response to axi-cel, progression-free (PFS) or overall (OS) survival. Multivariable analysis determined that bulky disease before lymphodepletion was independently associated with inferior outcomes, and patients that presented with high-burden disease unresponsive to immediate pre-CAR T therapy had a dismal outcome. This data supports proceeding with treatment in CAR T candidates regardless of their response to immediate pre-CAR T therapy. Interim therapeutic interventions should be considered in patients who have known risk factors for poor outcomes (bulky disease, high LDH).
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Affiliation(s)
- Lorenzo Iovino
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA
| | - Qian Vicky Wu
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA
| | - Jenna Voutsinas
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA
| | - Lorena Panaite
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Erin Mullane
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Ryan C. Lynch
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Chaitra Ujjani
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Stephen D. Smith
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Ajay K. Gopal
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Brian G. Till
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Filippo Milano
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Victor Chow
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Jordan Gauthier
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Cameron J. Turtle
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - David G. Maloney
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | - Mazyar Shadman
- Clinical Research DivisionFred Hutchinson Cancer Research CenterSeattleWashingtonUSA,Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
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13
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Higher doses of tisagenlecleucel are associated with improved outcomes: a report from the pediatric real-world CAR consortium. Blood Adv 2022; 7:541-548. [PMID: 35938863 PMCID: PMC9979765 DOI: 10.1182/bloodadvances.2022007246] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 06/03/2022] [Accepted: 06/03/2022] [Indexed: 11/20/2022] Open
Abstract
Remarkable complete response rates have been shown with tisagenlecleucel, a chimeric antigen receptor (CAR) T-cell therapy targeting CD19, in patients up to age 26 years with refractory/relapsed B-cell acute lymphoblastic leukemia; it is US Food and Drug Administration approved for this indication. Currently, patients receive a single dose of tisagenlecleucel across a wide dose range of 0.2 to 5.0 × 106 and 0.1 to 2.5 × 108 CAR T cells per kg for patients ≤50 and >50 kg, respectively. The effect of cell dose on survival and remission is not yet well established. Our primary goal was to determine if CAR T-cell dose affects overall survival (OS), event-free survival (EFS), or relapse-free-survival (RFS) in tisagenlecleucel recipients. Retrospective data were collected from Pediatric Real World CAR Consortium member institutions and included 185 patients infused with commercial tisagenlecleucel. The median dose of viable transduced CAR T cells was 1.7 × 106 CAR T cells per kg. To assess the impact of cell dose, we divided responders into dose quartiles: 0.134 to 1.300 × 106 (n = 48 [27%]), 1.301 to 1.700 × 106 (n = 46 [26%]), 1.701 to 2.400 × 106 (n = 43 [24%]), and 2.401 to 5.100 × 106 (n = 43 [24%]). OS, EFS, and RFS were improved in patients who received higher doses of tisagenlecleucel (P = .031, .0079, and .0045, respectively). Higher doses of tisagenlecleucel were not associated with increased toxicity. Because the current tisagenlecleucel package insert dose range remains broad, this work has implications in regard to targeting higher cell doses, within the approved dose range, to optimize patients' potential for long-standing remission.
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14
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Berger SC, Fehse B, Akyüz N, Geffken M, Wolschke C, Janson D, Gagelmann N, Luther M, Wichmann D, Frenzel C, Thayssen G, Alegiani A, Badbaran A, Zeschke S, Dierlamm J, Kröger N, Ayuk FA. Molecular monitoring of T-cell kinetics and migration in severe neurotoxicity after real-world CD19-specific chimeric antigen receptor T cell therapy. Haematologica 2022; 108:444-456. [PMID: 35950534 PMCID: PMC9890009 DOI: 10.3324/haematol.2022.281110] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Indexed: 02/03/2023] Open
Abstract
CD19-specific chimeric antigen receptor (CD19-CAR) T-cell therapies mediate durable responses in late-stage B-cell malignancies, but can be complicated by a potentially severe immune effector cell-associated neurotoxicity syndrome (ICANS). Despite broad efforts, the precise mechanisms of ICANS are not entirely known, and resistance to current ICANSdirected therapies (especially corticosteroids) has been observed. Recent data suggest that inflammatory cytokines and/or targeting of cerebral CD19-expressing pericytes can disrupt the blood-brain barrier and facilitate influx of immune cells, including CAR T cells. However, specific tools for CD19-CAR T-cell analysis within often minute samples of cerebrospinal fluid (CSF) are not broadly available. Here, we applied our recently developed digital polymerase chain reaction assays to monitor CD19-CAR T-cell kinetics in CSF and blood in real-world patients with neurotoxicity. Consistently, we observed a CAR T-cell enrichment within CSF in ICANS patients with further progressive accumulation despite intense corticosteroid- containing immuno-chemotherapies in a subset of patients with prolonged and therapy-resistant grade 3-4 neurotoxicity. We used next-generation T-cell receptor-b sequencing to assess the repertoire of treatment-refractory cells. Longitudinal analysis revealed a profound skewing of the T-cell receptor repertoire, which at least partly reflected selective expansion of infused T-cell clones. Interestingly, a major fraction of eventually dominating hyperexpanded T-cell clones were of non-CAR T-cell derivation. These findings hint to a role of therapy-refractory T-cell clones in severe ICANS development and prompt future systematic research to determine if CAR T cells may serve as 'door openers' and to further characterize both CAR-positive and non-CAR T cells to interrogate the transcriptional signature of these possibly pathologic T cells.
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Affiliation(s)
| | - Boris Fehse
- Department of Stem Cell Transplantation,Research Department Cell and Gene Therapy
| | | | | | | | | | | | | | | | | | - Guenther Thayssen
- Department of Neurology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany,°Current address: Department of Neurology with Stroke Unit, Asklepios Clinic Altona, Hamburg, Germany
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15
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Monfrini C, Stella F, Aragona V, Magni M, Ljevar S, Vella C, Fardella E, Chiappella A, Nanetti F, Pennisi M, Dodero A, Guidetti A, Corradini P, Carniti C. Phenotypic Composition of Commercial Anti-CD19 CAR T Cells Affects In Vivo Expansion and Disease Response in Patients with Large B-cell Lymphoma. Clin Cancer Res 2022; 28:3378-3386. [PMID: 35583610 PMCID: PMC9662896 DOI: 10.1158/1078-0432.ccr-22-0164] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/11/2022] [Accepted: 05/16/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE In clinical trials, the expansion and persistence of chimeric antigen receptor (CAR) T cells correlate with therapeutic efficacy. However, properties of CAR T cells that enable their in vivo proliferation have still to be consistently defined and the role of CAR T bag content has never been investigated in a real-life setting. EXPERIMENTAL DESIGN Residual cells obtained after washing 61 anti-CD19 CAR T product bags were analyzed to identify tisagenlecleucel/Tisa-cel and axicabtagene ciloleucel/Axi-cel phenotypic features associated with postinfusion CAR T-cell in vivo expansion and with response and survival. RESULTS While Tisa-cel was characterized by a significant enrichment in CAR+CD4+ T cells with central memory (P < 0.005) and effector (P < 0.005) phenotypes and lower rates of CAR+CD8+ with effector memory (P < 0.005) and naïve-like (P < 0.05) phenotypes as compared with Axi-cel, the two products displayed similar expansion kinetics. In vivo CAR T-cell expansion was influenced by the presence of CAR T with a CD8+ T central memory signature (P < 0.005) in both Tisa-cel and Axi-cel infusion products and was positively associated with response and progression-free survival (P < 0.05). CONCLUSIONS Our data indicate that despite the great heterogeneity of Tisa-cel and Axi-cel products, the differentiation status of the infused cells mediates CAR T-cell in vivo proliferation that is necessary for antitumor response.
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Affiliation(s)
- Chiara Monfrini
- Hematology Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | - Vanessa Aragona
- Hematology Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Martina Magni
- Hematology Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Silva Ljevar
- Department of Clinical Epidemiology and Trial Organization, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Cristina Vella
- Hematology Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | - Annalisa Chiappella
- Hematology Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Francesca Nanetti
- Hematology Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Martina Pennisi
- Hematology Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Anna Dodero
- Hematology Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Anna Guidetti
- Hematology Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy.,School of Medicine, Università degli Studi di Milano, Italy
| | - Paolo Corradini
- Hematology Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy.,School of Medicine, Università degli Studi di Milano, Italy.,Corresponding Author: Paolo Corradini, Fondazione IRCCS Istituto Nazionale Tumori and University of Milano, Medical Oncology, Via Venezian 1, Milano 20133, Italy. Phone: 0039-02-2390-2950; E-mail:
| | - Cristiana Carniti
- Hematology Division, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
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16
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Cellular kinetics: A clinical and computational review of CAR-T cell pharmacology. Adv Drug Deliv Rev 2022; 188:114421. [PMID: 35809868 DOI: 10.1016/j.addr.2022.114421] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/28/2022] [Accepted: 07/04/2022] [Indexed: 12/20/2022]
Abstract
To the extent that pharmacokinetics influence the effectiveness of nonliving therapeutics, so too do cellular kinetics influence the efficacy of Chimeric Antigen Receptor (CAR) -T cell therapy. Like conventional therapeutics, CAR-T cell therapies undergo a distribution phase upon administration. Unlike other therapeutics, however, this distribution phase is followed by subsequent phases of expansion, contraction, and persistence. The magnitude and duration of these phases unequivocally influence clinical outcomes. Furthermore, the "pharmacodynamics" of CAR-T cells is truly dynamic, as cells can rapidly become exhausted and lose their therapeutic efficacy. Mathematical models are among the translational tools commonly applied to assess, characterize, and predict the complex cellular kinetics and dynamics of CAR-T cells. Here, we provide a focused review of the cellular kinetics of CAR-T cells, the mechanisms underpinning their complexity, and the mathematical modeling approaches used to interrogate them.
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17
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Schubert ML, Berger C, Kunz A, Schmitt A, Badbaran A, Neuber B, Zeschke S, Wang L, Riecken K, Hückelhoven‑Krauss A, Müller I, Müller‑Tidow C, Dreger P, Kröger N, Ayuk F, Schmitt M, Fehse B. Comparison of single copy gene‑based duplex quantitative PCR and digital droplet PCR for monitoring of expansion of CD19‑directed CAR T cells in treated patients. Int J Oncol 2022; 60:48. [PMID: 35294040 PMCID: PMC8973917 DOI: 10.3892/ijo.2022.5338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/11/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Maria-Luisa Schubert
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), University Hospital Heidelberg, D‑69120 Heidelberg, Germany
| | - Carolina Berger
- Department of Stem Cell Transplantation, University Medical Centre Hamburg‑Eppendorf, D‑20246 Hamburg, Germany
| | - Alexander Kunz
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), University Hospital Heidelberg, D‑69120 Heidelberg, Germany
| | - Anita Schmitt
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), University Hospital Heidelberg, D‑69120 Heidelberg, Germany
| | - Anita Badbaran
- Department of Stem Cell Transplantation, University Medical Centre Hamburg‑Eppendorf, D‑20246 Hamburg, Germany
| | - Brigitte Neuber
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), University Hospital Heidelberg, D‑69120 Heidelberg, Germany
| | - Silke Zeschke
- Department of Stem Cell Transplantation, University Medical Centre Hamburg‑Eppendorf, D‑20246 Hamburg, Germany
| | - Lei Wang
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), University Hospital Heidelberg, D‑69120 Heidelberg, Germany
| | - Kristoffer Riecken
- Department of Stem Cell Transplantation, University Medical Centre Hamburg‑Eppendorf, D‑20246 Hamburg, Germany
| | - Angela Hückelhoven‑Krauss
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), University Hospital Heidelberg, D‑69120 Heidelberg, Germany
| | - Ingo Müller
- Department of Pediatric Hematology and Oncology, University Medical Centre Hamburg‑Eppendorf, D‑20246 Hamburg, Germany
| | - Carsten Müller‑Tidow
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), University Hospital Heidelberg, D‑69120 Heidelberg, Germany
| | - Peter Dreger
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), University Hospital Heidelberg, D‑69120 Heidelberg, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Centre Hamburg‑Eppendorf, D‑20246 Hamburg, Germany
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Centre Hamburg‑Eppendorf, D‑20246 Hamburg, Germany
| | - Michael Schmitt
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), University Hospital Heidelberg, D‑69120 Heidelberg, Germany
| | - Boris Fehse
- Department of Stem Cell Transplantation, University Medical Centre Hamburg‑Eppendorf, D‑20246 Hamburg, Germany
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18
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The Past, Present, and Future of Clinically Applied Chimeric Antigen Receptor-T-Cell Therapy. Pharmaceuticals (Basel) 2022; 15:ph15020207. [PMID: 35215319 PMCID: PMC8876595 DOI: 10.3390/ph15020207] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/31/2022] [Accepted: 02/06/2022] [Indexed: 12/13/2022] Open
Abstract
Immunotherapy represents the fourth pillar of cancer therapy after surgery, chemotherapy, and radiation. Chimeric antigen receptor (CAR)-T-cell therapy is an artificial immune cell therapy applied in clinical practice and is currently indicated for hematological malignancies, with cluster of differentiation 19 (CD19) as its target molecule. In this review, we discuss the past, present, and future of CAR-T-cell therapy. First, we summarize the various clinical trials that were conducted before the clinical application of CD19-targeted CAR-T-cell therapies began. Second, we discuss the accumulated real-world evidence and the barriers associated with applying clinical trials to clinical practices from the perspective of the quality and technical aspects. After providing an overview of all the moving parts involved in the production of CAR-T-cell products, we discuss the characteristics of immune cells (given that T cells are the raw materials for CAR-T-cell therapy) and elucidate the relationship between lifestyle, including diet and exercise, and immune cells. Finally, we briefly highlight future trends in the development of immune cell therapy. These advancements may help position CAR-T-cell therapy as a standard of care.
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19
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Clinical and Product Features Associated with Outcome of DLBCL Patients to CD19-Targeted CAR T-Cell Therapy. Cancers (Basel) 2021; 13:cancers13174279. [PMID: 34503088 PMCID: PMC8428364 DOI: 10.3390/cancers13174279] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 12/28/2022] Open
Abstract
Simple Summary Factors impacting the response to CAR T-cell therapies are not fully understood. In this monocentric prospective study, we describe the outcome of 60 patients with relapsed/refractory diffuse large B-cell lymphoma and transformed follicular lymphoma infused with CD19-directed CAR T-cell products, axicabtagene ciloleucel and tisagenlecleucel. We obtained a 40% complete metabolic response and a 27% partial metabolic response with a median progression-free survival of 3.1 months and a median of overall survival of 12.3 months. We also found that age-adjusted IPI at the time of infusion, product features, in vivo expansion, and CAR T-cell exhaustion phenotype were significatively associated with the efficacy of the CAR T-cell therapy. Abstract CD19-directed CAR T-cells have been remarkably successful in treating patients with relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL) and transformed follicular lymphoma (t-FL). In this cohort study, we treated 60 patients with axicabtagene ciloleucel or tisagenlecleucel. Complete and partial metabolic responses (CMR/PMR) were obtained in 40% and 23% of patients, respectively. After 6.9 months of median follow-up, median progression-free survival (mPFS) and overall survival (mOS) were estimated at 3.1 and 12.3 months, respectively. Statistical analyses revealed that CMR, PFS, and OS were all significantly associated with age-adjusted international prognostic index (aaIPI, p < 0.05). T-cell subset phenotypes in the apheresis product tended to correlate with PFS. Within the final product, increased percentages of both CD4 and CD8 CAR+ effector memory cells (p = 0.02 and 0.01) were significantly associated with CMR. Furthermore, higher CMR/PMR rates were observed in patients with a higher maximal in vivo expansion of CAR T-cells (p = 0.05) and lower expression of the LAG3 and Tim3 markers of exhaustion phenotype (p = 0.01 and p = 0.04). Thus, we find that aaIPI at the time of infusion, phenotype of the CAR T product, in vivo CAR T-cell expansion, and low levels of LAG3/Tim3 are associated with the efficacy of CAR T-cell therapy in DLBCL patients.
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