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Dagar G, Gupta A, Masoodi T, Nisar S, Merhi M, Hashem S, Chauhan R, Dagar M, Mirza S, Bagga P, Kumar R, Akil ASAS, Macha MA, Haris M, Uddin S, Singh M, Bhat AA. Harnessing the potential of CAR-T cell therapy: progress, challenges, and future directions in hematological and solid tumor treatments. J Transl Med 2023; 21:449. [PMID: 37420216 PMCID: PMC10327392 DOI: 10.1186/s12967-023-04292-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/21/2023] [Indexed: 07/09/2023] Open
Abstract
Traditional cancer treatments use nonspecific drugs and monoclonal antibodies to target tumor cells. Chimeric antigen receptor (CAR)-T cell therapy, however, leverages the immune system's T-cells to recognize and attack tumor cells. T-cells are isolated from patients and modified to target tumor-associated antigens. CAR-T therapy has achieved FDA approval for treating blood cancers like B-cell acute lymphoblastic leukemia, large B-cell lymphoma, and multiple myeloma by targeting CD-19 and B-cell maturation antigens. Bi-specific chimeric antigen receptors may contribute to mitigating tumor antigen escape, but their efficacy could be limited in cases where certain tumor cells do not express the targeted antigens. Despite success in blood cancers, CAR-T technology faces challenges in solid tumors, including lack of reliable tumor-associated antigens, hypoxic cores, immunosuppressive tumor environments, enhanced reactive oxygen species, and decreased T-cell infiltration. To overcome these challenges, current research aims to identify reliable tumor-associated antigens and develop cost-effective, tumor microenvironment-specific CAR-T cells. This review covers the evolution of CAR-T therapy against various tumors, including hematological and solid tumors, highlights challenges faced by CAR-T cell therapy, and suggests strategies to overcome these obstacles, such as utilizing single-cell RNA sequencing and artificial intelligence to optimize clinical-grade CAR-T cells.
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Affiliation(s)
- Gunjan Dagar
- Department of Medical Oncology (Lab.), Dr. BRAIRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, 110029, India
| | - Ashna Gupta
- Department of Medical Oncology (Lab.), Dr. BRAIRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, 110029, India
| | - Tariq Masoodi
- Laboratory of Cancer Immunology and Genetics, Sidra Medicine, Doha, Qatar
| | - Sabah Nisar
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Maysaloun Merhi
- National Center for Cancer Care and Research, Hamad Medical Corporation, 3050, Doha, Qatar
| | - Sheema Hashem
- Department of Human Genetics, Sidra Medicine, Doha, Qatar
| | - Ravi Chauhan
- Department of Medical Oncology (Lab.), Dr. BRAIRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, 110029, India
| | - Manisha Dagar
- Shiley Eye Institute, University of California San Diego, San Diego, CA, USA
| | - Sameer Mirza
- Department of Chemistry, College of Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Puneet Bagga
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Rakesh Kumar
- School of Biotechnology, Shri Mata Vaishno Devi University, Katra, Jammu and Kashmir, 182320, India
| | - Ammira S Al-Shabeeb Akil
- Department of Human Genetics-Precision Medicine in Diabetes, Obesity and Cancer Program, Sidra Medicine, P.O. Box 26999, Doha, Qatar
| | - Muzafar A Macha
- Watson-Crick Centre for Molecular Medicine, Islamic University of Science and Technology, Pulwama, Jammu and Kashmir, India
| | - Mohammad Haris
- Center for Advanced Metabolic Imaging in Precision Medicine, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Laboratory Animal Research Center, Qatar University, Doha, Qatar
| | - Shahab Uddin
- Laboratory Animal Research Center, Qatar University, Doha, Qatar.
- Translational Research Institute, Academic Health System, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar.
| | - Mayank Singh
- Department of Medical Oncology (Lab.), Dr. BRAIRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, 110029, India.
| | - Ajaz A Bhat
- Department of Human Genetics-Precision Medicine in Diabetes, Obesity and Cancer Program, Sidra Medicine, P.O. Box 26999, Doha, Qatar.
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Zam W, Assaad A. Chimeric antigen receptor T-cells (CARs) in cancer treatment. Curr Mol Pharmacol 2021; 15:532-546. [PMID: 34382510 DOI: 10.2174/1874467214666210811150255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/27/2021] [Accepted: 05/17/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cancer is one of the leading causes of death worldwide. Chemotherapy, radiation therapy, and stem cell transplantation were the main cancer treatment approaches for several years but due to their limited effectiveness, there was a constant search for new therapeutic approaches. Cancer immunotherapy that utilizes and enhances the normal capacity of the patient's immune system was used to fight against cancer. Genetically engineered T-cells that express chimeric antigen receptors (CARs) showed remarkable anti-tumor activity against hematologic malignancies and is now being investigated in a variety of solid tumors. The use of this therapy in the last few years has been successful, achieving a great success in improving the quality of life and prolonging the survival time of patients with a reduction in remission rates. However, many challenges still need to be resolved in order for this technology to gain widespread adoption. <P> Objective: This review summarizes various experimental approaches towards the use of CAR T-cells in hematologic malignancies and solid tumors. <P> Conclusion: Finally, we address the challenges posed by CAR T-cells and discuss strategies for improving the performance of these T cells in fighting cancers.
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Affiliation(s)
- Wissam Zam
- Department of Analytical and Food Chemistry, Faculty of Pharmacy, Al-Wadi International University, Homs. Syrian Arab Republic
| | - Amany Assaad
- 2. Department of Analytical and Food Chemistry, Faculty of Pharmacy,Tartous University, Tartous. Syrian Arab Republic
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Antitumor Potency of an Anti-CD19 Chimeric Antigen Receptor T-Cell Therapy, Lisocabtagene Maraleucel in Combination With Ibrutinib or Acalabrutinib. J Immunother 2021; 43:107-120. [PMID: 31899702 PMCID: PMC7144752 DOI: 10.1097/cji.0000000000000307] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Supplemental Digital Content is available in the text. Chimeric antigen receptor (CAR) T-cell therapy is a promising treatment for patients with CD19+ B-cell malignancies. Combination strategies that improve CAR T-cell potency, limit tumor environment–mediated immune dysfunction, and directly reduce tumor burden may increase the potential for durable clinical benefit of CAR T-cell therapy. Lisocabtagene maraleucel (liso-cel) is a product therapy candidate being tested in patients with relapsed/refractory non-Hodgkin lymphoma or chronic lymphocytic leukemia. This study assessed the in vitro and in vivo functionality of CAR T cells transduced to express the anti-CD19 CAR of liso-cel in combination with ibrutinib or acalabrutinib. In prolonged stimulation assays, the presence of ibrutinib or acalabrutinib improved the CAR T-cell effector function. RNA-Seq analysis and surface marker profiling of these CAR T cells treated with ibrutinib but not acalabrutinib revealed gene expression changes consistent with skewing toward a memory-like, type 1 T-helper, Bruton tyrosine kinase phenotype. Ibrutinib or acalabrutinib improved CD19+ tumor clearance and prolonged survival of tumor-bearing mice when used in combination with CAR T cells. A combination of the defined cell product therapy candidate, liso-cel, with ibrutinib or acalabrutinib is an attractive approach that may potentiate the promising clinical responses already achieved in CD19+ B-cell malignancies with each of these single agents.
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Griggio V, Perutelli F, Salvetti C, Boccellato E, Boccadoro M, Vitale C, Coscia M. Immune Dysfunctions and Immune-Based Therapeutic Interventions in Chronic Lymphocytic Leukemia. Front Immunol 2020; 11:594556. [PMID: 33312177 PMCID: PMC7708380 DOI: 10.3389/fimmu.2020.594556] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/14/2020] [Indexed: 01/01/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is a B-cell malignancy characterized by a wide range of tumor-induced alterations, which affect both the innate and adaptive arms of the immune response, and accumulate during disease progression. In recent years, the development of targeted therapies, such as the B-cell receptor signaling inhibitors and the Bcl-2 protein inhibitor venetoclax, has dramatically changed the treatment landscape of CLL. Despite their remarkable anti-tumor activity, targeted agents have some limitations, which include the development of drug resistance mechanisms and the inferior efficacy observed in high-risk patients. Therefore, additional treatments are necessary to obtain deeper responses and overcome drug resistance. Allogeneic hematopoietic stem cell transplantation (HSCT), which exploits immune-mediated graft-versus-leukemia effect to eradicate tumor cells, currently represents the only potentially curative therapeutic option for CLL patients. However, due to its potential toxicities, HSCT can be offered only to a restricted number of younger and fit patients. The growing understanding of the complex interplay between tumor cells and the immune system, which is responsible for immune escape mechanisms and tumor progression, has paved the way for the development of novel immune-based strategies. Despite promising preclinical observations, results from pilot clinical studies exploring the safety and efficacy of novel immune-based therapies have been sometimes suboptimal in terms of long-term tumor control. Therefore, further advances to improve their efficacy are needed. In this context, possible approaches include an earlier timing of immunotherapy within the treatment sequencing, as well as the possibility to improve the efficacy of immunotherapeutic agents by administering them in combination with other anti-tumor drugs. In this review, we will provide a comprehensive overview of main immune defects affecting patients with CLL, also describing the complex networks leading to immune evasion and tumor progression. From the therapeutic standpoint, we will go through the evolution of immune-based therapeutic approaches over time, including i) agents with broad immunomodulatory effects, such as immunomodulatory drugs, ii) currently approved and next-generation monoclonal antibodies, and iii) immunotherapeutic strategies aiming at activating or administering immune effector cells specifically targeting leukemic cells (e.g. bi-or tri-specific antibodies, tumor vaccines, chimeric antigen receptor T cells, and checkpoint inhibitors).
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Affiliation(s)
- Valentina Griggio
- University Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy.,Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Francesca Perutelli
- University Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy.,Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Chiara Salvetti
- University Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy.,Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Elia Boccellato
- University Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy.,Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Mario Boccadoro
- University Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy.,Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Candida Vitale
- University Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy.,Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Marta Coscia
- University Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy.,Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
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Bouziana S, Bouzianas D. Exploring the Dilemma of Allogeneic Hematopoietic Cell Transplantation after Chimeric Antigen Receptor T Cell Therapy: To Transplant or Not? Biol Blood Marrow Transplant 2020; 26:e183-e191. [DOI: 10.1016/j.bbmt.2020.04.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 01/14/2023]
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Vitale C, Strati P. CAR T-Cell Therapy for B-Cell non-Hodgkin Lymphoma and Chronic Lymphocytic Leukemia: Clinical Trials and Real-World Experiences. Front Oncol 2020; 10:849. [PMID: 32670869 PMCID: PMC7326110 DOI: 10.3389/fonc.2020.00849] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/29/2020] [Indexed: 12/13/2022] Open
Abstract
Chimeric antigen receptor-modified (CAR) T cells targeting CD19 have revolutionized the treatment of relapsed or refractory aggressive B-cell lymphomas, and their use has increased the cure rate for these cancers from 10 to 40%. Two second-generation anti-CD19 CAR T-cell products, axicabtagene ciloleucel and tisagenlecleucel, have been approved for use in patients, and the approval of a third product, lisocabtagene maraleucel, is expected in 2020. The commercial availability of the first two products has facilitated the development of real-world experience in treating relapsed or refractory aggressive B-cell lymphomas, shed light on anti-CD19 CAR T-cell products' feasibility in trial-ineligible patients, and raised the need for strategies to mitigate the adverse effects associated with anti-CD19 CAR T-cell therapy, such as cytokine release syndrome, neurotoxicity, and cytopenia. In addition, promising clinical data supporting the use of anti-CD19 CAR T-cell therapy in patients with indolent B-cell lymphomas or chronic lymphocytic leukemia have recently become available, breaking the paradigm that these conditions are not curable. Multiple clinical CAR T-cell therapy-based trials are ongoing. These include studies comparing CAR T-cell therapy to autologous stem cell transplantation or investigating their use at earlier stages of disease, novel combinations, and novel constructs. Here we provide a thorough review on the use of the anti-CD19 CAR T-cell products axicabtagene ciloleucel, tisagenlecleucel and lisocabtagene maraleucel in patients with indolent or aggressive B-cell lymphoma or with chronic lymphocytic leukemia, and present novel CAR T cell-based approaches currently under investigation in these disease settings.
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Affiliation(s)
- Candida Vitale
- University Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino and Department of Molecular Biotechnology and Health Sciences, University of Torino, Turin, Italy
| | - Paolo Strati
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Bair SM, Porter DL. Accelerating chimeric antigen receptor therapy in chronic lymphocytic leukemia: The development and challenges of chimeric antigen receptor T-cell therapy for chronic lymphocytic leukemia. Am J Hematol 2019; 94:S10-S17. [PMID: 30861173 DOI: 10.1002/ajh.25457] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 12/27/2022]
Abstract
Studies of chimeric antigen receptor (CAR) T-cell therapy in chronic lymphocytic leukemia (CLL) have demonstrated the potential to produce deep remissions-and possibly cures-in some patients with heavily pretreated, high-risk, relapsed, and refractory disease. Unfortunately, most clinical trials of CAR T cells in CLL report complete responses only in the minority of patients, although recent studies have begun to elucidate the factors most predictive of response. These studies have suggested strategies for optimizing CAR T-cell fitness as well as the pre-existing host immune response, approaches that will likely lead to improvements in the efficacy of CAR T cells in CLL. Treating patients earlier in the course of their disease or using combination therapies with CAR T cells may further enhance efficacy. In this review, we summarize the existing literature on CAR T cell therapy in CLL, discuss mechanisms of response and resistance, and describe challenges facing the field.
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Affiliation(s)
- Steven M. Bair
- Cell Therapy and Transplant Program, Division of Hematology‐Oncology, Perelman School of Medicine and Abramson Cancer CenterUniversity of Pennsylvania Philadelphia Pennsylvania
| | - David L. Porter
- Cell Therapy and Transplant Program, Division of Hematology‐Oncology, Perelman School of Medicine and Abramson Cancer CenterUniversity of Pennsylvania Philadelphia Pennsylvania
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Wu M, Zhang L, Zhang H, Ning J, Tu S, He Y, Li Y. CD19 chimeric antigen receptor-redirected T cells combined with epidermal growth factor receptor pathway substrate 8 peptide-derived dendritic cell vaccine in leukemia. Cytotherapy 2019; 21:659-670. [PMID: 31031152 DOI: 10.1016/j.jcyt.2019.03.313] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/21/2019] [Accepted: 03/28/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Chimeric antigen receptor (CAR)-T cell therapy opens a new era for cancer treatment. However, in prolonged follow-up, relapse has emerged as one of the major obstacles. Dendritic cell (DC) vaccination is a promising treatment to eradicate tumor cells and prevent relapse. The epidermal growth factor receptor (EGFR) pathway substrate 8 (Eps8) gene is involved in regulating cancer progression and is considered an attractive target for specific cancer immunotherapy. The purpose of this study was to explore a combinatorial therapy using CAR-T cells and a DC vaccine such as Eps8-DCs to increase leukemia treatment efficacy. METHODS We pulsed DCs with Eps8-derived peptides to generate Eps8-DCs, engineered T cells to express a second-generation CAR specific for CD19, and analyzed the effects of the Eps8-DCs on the in vitro expansion, phenotype and effector functions of the CD19 CAR-T cells. RESULTS The Eps8-DCs significantly reduced the activation-induced cell death and enhanced the proliferative potential of CAR-T cells during in vitro expansion. In addition, the expanded T cells co-cultured with the Eps8-DCs exhibited an increased percentage of central memory T cells (Tcms) and a decreased percentage of effector memory T cells (Tems). The Eps8-DCs enhanced CD19 CAR-T cell immune functions, including cytokine production, CD107a degranulation activity and cytotoxicity. DISCUSSION This study demonstrates that Eps8-DCs exert synergistic effect on CD19 targeting CAR-T cells and paves the way for clinical trials using the combination of DC vaccination and engineered T cells in relapsed leukemia.
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Affiliation(s)
- Meirong Wu
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Litian Zhang
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Hanzhen Zhang
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Jingxuan Ning
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China; Department of Hematology, Yuncheng Central Hospital, Shanxi Medical University, Yuncheng, China
| | - Sanfang Tu
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yanjie He
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yuhua Li
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China.
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Thomas X, Paubelle E. Tisagenlecleucel-T for the treatment of acute lymphocytic leukemia. Expert Opin Biol Ther 2018; 18:1095-1106. [DOI: 10.1080/14712598.2018.1533951] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Xavier Thomas
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud Hospital, Pierre Bénite, France
| | - Etienne Paubelle
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud Hospital, Pierre Bénite, France
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Zhao Z, Chen Y, Francisco NM, Zhang Y, Wu M. The application of CAR-T cell therapy in hematological malignancies: advantages and challenges. Acta Pharm Sin B 2018; 8:539-551. [PMID: 30109179 PMCID: PMC6090008 DOI: 10.1016/j.apsb.2018.03.001] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 01/26/2018] [Accepted: 02/18/2018] [Indexed: 02/07/2023] Open
Abstract
Chimeric antigen receptor T cell (CAR-T cell) therapy is a novel adoptive immunotherapy where T lymphocytes are engineered with synthetic receptors known as chimeric antigen receptors (CAR). The CAR-T cell is an effector T cell that recognizes and eliminates specific cancer cells, independent of major histocompatibility complex molecules. The whole procedure of CAR-T cell production is not well understood. The CAR-T cell has been used predominantly in the treatment of hematological malignancies, including acute lymphoblastic leukemia, chronic lymphocytic leukemia, lymphoma, and multiple myeloma. Solid tumors including melanoma, breast cancer and sarcoma offer great promise in CAR-T cell research and development. CD19 CAR-T cell is most commonly used, and other targets, including CD20, CD30, CD38 and CD138 are being studied. Although this novel therapy is promising, there are several disadvantages. In this review we discuss the applications of CAR-T cells in different hematological malignancies, and pave a way for future improvement on the effectiveness and persistence of these adoptive cell therapies.
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Affiliation(s)
- Zijun Zhao
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China
| | - Yu Chen
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China
| | | | - Yuanqing Zhang
- School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou 510006, China
| | - Minhao Wu
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China
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11
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Porter D, Frey N, Wood PA, Weng Y, Grupp SA. Grading of cytokine release syndrome associated with the CAR T cell therapy tisagenlecleucel. J Hematol Oncol 2018; 11:35. [PMID: 29499750 PMCID: PMC5833070 DOI: 10.1186/s13045-018-0571-y] [Citation(s) in RCA: 276] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 02/09/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Anti-CD19 CAR T cell therapy has demonstrated high response rates in patients with relapsed or refractory (r/r) B cell malignancies but is associated with significant toxicity. Cytokine release syndrome (CRS) is the most significant complication associated with CAR T cell therapy, and it is critical to have a reproducible and easy method to grade CRS after CAR T cell infusions. DISCUSSION The Common Terminology Criteria for Adverse Events scale is inadequate for grading CRS associated with cellular therapy. Clinical experience with the anti-CD19 CAR T cell therapy tisagenlecleucel at the University of Pennsylvania (Penn) was used to develop the Penn grading scale for CRS. The Penn grading scale depends on easily accessible clinical features; does not rely on location of care or quantitation of supportive care; assigns grades to guide CRS management; distinguishes between mild, moderate, severe, and life-threatening CRS; and applies to both early-onset and delayed-onset CRS associated with T cell therapies. Clinical data from 55 pediatric patients with r/r B cell acute lymphoblastic leukemia and 42 patients with r/r chronic lymphocytic lymphoma treated with tisagenlecleucel were used to demonstrate the current application of the Penn grading scale. CONCLUSION We show that the Penn grading scale provides reproducible CRS grading that can be useful to guide therapy and that can be applied across clinical trials and treatment platforms.
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Affiliation(s)
- David Porter
- Division of Hematology-Oncology, Blood and Marrow Transplantation and Cellular Therapy Program, Perelman School of Medicine and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA.
| | - Noelle Frey
- Division of Hematology-Oncology, Blood and Marrow Transplantation and Cellular Therapy Program, Perelman School of Medicine and Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Yanqiu Weng
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Stephan A Grupp
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.,Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, 3501 Civic Center Blvd. CTRB 3006, Philadelphia, PA, 19104, USA
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12
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Marin-Acevedo JA, Soyano AE, Dholaria B, Knutson KL, Lou Y. Cancer immunotherapy beyond immune checkpoint inhibitors. J Hematol Oncol 2018; 11:8. [PMID: 29329556 PMCID: PMC5767051 DOI: 10.1186/s13045-017-0552-6] [Citation(s) in RCA: 135] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 12/28/2017] [Indexed: 12/17/2022] Open
Abstract
Malignant cells have the capacity to rapidly grow exponentially and spread in part by suppressing, evading, and exploiting the host immune system. Immunotherapy is a form of oncologic treatment directed towards enhancing the host immune system against cancer. In recent years, manipulation of immune checkpoints or pathways has emerged as an important and effective form of immunotherapy. Agents that target cytotoxic T lymphocyte-associated molecule-4 (CTLA-4), programmed cell death receptor-1 (PD-1), and programmed cell death ligand-1 (PD-L1) are the most widely studied and recognized. Immunotherapy, however, extends beyond immune checkpoint therapy by using new molecules such as chimeric monoclonal antibodies and antibody drug conjugates that target malignant cells and promote their destruction. Genetically modified T cells expressing chimeric antigen receptors are able to recognize specific antigens on cancer cells and subsequently activate the immune system. Native or genetically modified viruses with oncolytic activity are of great interest as, besides destroying malignant cells, they can increase anti-tumor activity in response to the release of new antigens and danger signals as a result of infection and tumor cell lysis. Vaccines are also being explored, either in the form of autologous or allogenic tumor peptide antigens, genetically modified dendritic cells that express tumor peptides, or even in the use of RNA, DNA, bacteria, or virus as vectors of specific tumor markers. Most of these agents are yet under development, but they promise to be important options to boost the host immune system to control and eliminate malignancy. In this review, we have provided detailed discussion of different forms of immunotherapy agents other than checkpoint-modifying drugs. The specific focus of this manuscript is to include first-in-human phase I and phase I/II clinical trials intended to allow the identification of those drugs that most likely will continue to develop and possibly join the immunotherapeutic arsenal in a near future.
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Affiliation(s)
| | - Aixa E Soyano
- Department of Hematology and Oncology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Bhagirathbhai Dholaria
- Department of Hematology and Oncology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
- Current address: Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Keith L Knutson
- Department of Immunology, Mayo Clinic, Jacksonville, FL, USA
| | - Yanyan Lou
- Department of Hematology and Oncology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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Turtle CJ, Hanafi LA, Berger C, Hudecek M, Pender B, Robinson E, Hawkins R, Chaney C, Cherian S, Chen X, Soma L, Wood B, Li D, Heimfeld S, Riddell SR, Maloney DG. Immunotherapy of non-Hodgkin's lymphoma with a defined ratio of CD8+ and CD4+ CD19-specific chimeric antigen receptor-modified T cells. Sci Transl Med 2017; 8:355ra116. [PMID: 27605551 DOI: 10.1126/scitranslmed.aaf8621] [Citation(s) in RCA: 769] [Impact Index Per Article: 109.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 07/21/2016] [Indexed: 12/20/2022]
Abstract
CD19-specific chimeric antigen receptor (CAR)-modified T cells have antitumor activity in B cell malignancies, but factors that affect toxicity and efficacy have been difficult to define because of differences in lymphodepletion and heterogeneity of CAR-T cells administered to individual patients. We conducted a clinical trial in which CD19 CAR-T cells were manufactured from defined T cell subsets and administered in a 1:1 CD4(+)/CD8(+) ratio of CAR-T cells to 32 adults with relapsed and/or refractory B cell non-Hodgkin's lymphoma after cyclophosphamide (Cy)-based lymphodepletion chemotherapy with or without fludarabine (Flu). Patients who received Cy/Flu lymphodepletion had increased CAR-T cell expansion and persistence, and higher response rates [50% complete remission (CR), 72% overall response rate (ORR)] than patients who received Cy-based lymphodepletion without Flu (8% CR, 50% ORR). The CR rate in patients treated with Cy/Flu at the maximally tolerated dose was 64% (82% ORR; n = 11). Cy/Flu minimized the effects of an immune response to the murine single-chain variable fragment component of the CAR, which limited CAR-T cell expansion and clinical efficacy in patients who received Cy-based lymphodepletion without Flu. Severe cytokine release syndrome (sCRS) and grade ≥3 neurotoxicity were observed in 13 and 28% of all patients, respectively. Serum biomarkers, one day after CAR-T cell infusion, correlated with subsequent sCRS and neurotoxicity. Immunotherapy with CD19 CAR-T cells in a defined CD4(+)/CD8(+) ratio allowed identification of correlative factors for CAR-T cell expansion, persistence, and toxicity, and facilitated optimization of lymphodepletion that improved disease response and overall and progression-free survival.
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Affiliation(s)
- Cameron J Turtle
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA. Department of Medicine, University of Washington, Seattle, WA 98109, USA.
| | - Laïla-Aïcha Hanafi
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Carolina Berger
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA. Department of Medicine, University of Washington, Seattle, WA 98109, USA
| | - Michael Hudecek
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Barbara Pender
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Emily Robinson
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Reed Hawkins
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Colette Chaney
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Sindhu Cherian
- Department of Laboratory Medicine, University of Washington, Seattle, WA 98109, USA
| | - Xueyan Chen
- Department of Laboratory Medicine, University of Washington, Seattle, WA 98109, USA
| | - Lorinda Soma
- Department of Laboratory Medicine, University of Washington, Seattle, WA 98109, USA
| | - Brent Wood
- Department of Laboratory Medicine, University of Washington, Seattle, WA 98109, USA
| | - Daniel Li
- Juno Therapeutics, Seattle, WA 98109, USA
| | - Shelly Heimfeld
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Stanley R Riddell
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA. Department of Medicine, University of Washington, Seattle, WA 98109, USA
| | - David G Maloney
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA. Department of Medicine, University of Washington, Seattle, WA 98109, USA
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14
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Chimeric antigen receptor T-cells for B-cell malignancies. Transl Res 2017; 187:59-82. [PMID: 28719798 DOI: 10.1016/j.trsl.2017.06.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/18/2017] [Accepted: 06/23/2017] [Indexed: 12/27/2022]
Abstract
The adoptive transfer of T-lymphocytes modified to express chimeric antigen receptors (CAR-Ts) has produced impressive clinical responses among patients with B-cell malignancies. This has led to a rapid expansion in the number of clinical trials over the past several years. Although CD19-specific CAR-Ts are the most extensively evaluated, CAR-Ts specific for other B-cell-associated targets have also shown promise. However, despite this success, toxicities associated with CAR-T administration remain a significant concern. There continues to be substantial heterogeneity among CAR-T products, and differences in both CAR designs and CAR-T production strategies can substantially affect clinical outcomes. Ongoing clinical studies will further elucidate these differences and many other innovative approaches are being evaluated at the preclinical level. In this review, we will discuss the background and rationale for the use of CAR-Ts, provide an overview of advances in the field, and examine the application of CAR-Ts to the treatment of B-cell malignancies, including a summary of clinical trials published to date.
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15
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Wegner A. Chimeric antigen receptor T cells for the treatment of cancer and the future of preclinical models for predicting their toxicities. Immunotherapy 2017; 9:669-680. [DOI: 10.2217/imt-2017-0028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Chimeric antigen receptor T-cell therapy has achieved highly promising results in clinical trials, particularly in B-cell malignancies. However, reports of serious adverse events including a number of patient deaths have raised concerns about safety of this treatment. Presently available preclinical models are not designed for predicting toxicities seen in human patients. Besides choosing the right animal model, careful considerations must be taken in chimeric antigen receptor T-cell design and the amount of T cells infused. The development of more sophisticated in vitro models and humanized mouse models for preclinical modeling and toxicity tests will help us to improve the design of clinical trials in cancer immunotherapy.
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Affiliation(s)
- Anja Wegner
- Department of Research Oncology, King's College London, Guy's Hospital Campus, Great Maze Pond, London, SE1 9RT, UK
- Institute of Immunity & Transplantation, University College London, Royal Free Hospital, Roland Hill Street, London, NW3 2PF, UK
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16
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Hay KA, Turtle CJ. Chimeric Antigen Receptor (CAR) T Cells: Lessons Learned from Targeting of CD19 in B-Cell Malignancies. Drugs 2017; 77:237-245. [PMID: 28110394 PMCID: PMC5603178 DOI: 10.1007/s40265-017-0690-8] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Adoptive immunotherapy with chimeric antigen receptor-modified (CAR)-T cells is a rapidly growing therapeutic approach to treating patients with refractory cancer, with over 100 clinical trials in various malignancies in progress. The enthusiasm for CAR-T cells has been driven by the clinical success of CD19-targeted CAR-T cell therapy in B-cell acute lymphoblastic leukemia, and the promising data in B-cell non-Hodgkin's lymphoma and chronic lymphocytic leukemia. Despite the success of targeting CD19 with CAR-T cells in early clinical studies, many challenges remain to improve outcomes, reduce toxicity, and determine the appropriate settings for CAR-T cell immunotherapy. Reviewing the lessons learned thus far in CD19 CAR-T cell trials and how some of these challenges may be overcome will help guide the development of CAR-T cell therapy for malignancies of B-cell origin, as well as for other hematopoietic and non-hematopoietic cancers.
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MESH Headings
- Antigens, CD19/immunology
- Humans
- Immunotherapy
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Lymphoma, Non-Hodgkin/drug therapy
- Lymphoma, Non-Hodgkin/immunology
- Precursor B-Cell Lymphoblastic Leukemia-Lymphoma/drug therapy
- Precursor B-Cell Lymphoblastic Leukemia-Lymphoma/immunology
- Receptors, Antigen, T-Cell/immunology
- T-Lymphocytes/immunology
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Affiliation(s)
- Kevin A Hay
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave., Seattle, WA, 98109, USA.
| | - Cameron J Turtle
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave., Seattle, WA, 98109, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
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17
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Shank BR, Do B, Sevin A, Chen SE, Neelapu SS, Horowitz SB. Chimeric Antigen Receptor T Cells in Hematologic Malignancies. Pharmacotherapy 2017; 37:334-345. [PMID: 28079265 DOI: 10.1002/phar.1900] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patients with B-cell hematologic malignancies who progress through first- or second-line chemotherapy have a poor prognosis. Early clinical trials with autologous anti-CD19 chimeric antigen receptor (CAR) T cells have demonstrated promising results for patients who have relapsed or refractory disease. Lymphodepleting conditioning regimens, including cyclophosphamide, fludarabine, pentostatin, bendamustine, interleukin-2, and total body irradiation, are often administered before the infusion of CAR T cells, allowing for greater T-cell expansion. The major toxicity associated with CAR T-cell infusions is cytokine release syndrome (CRS), a potentially life-threatening systemic inflammatory disorder. The quick onset and progression of CRS require rapid detection and intervention to reduce treatment-related mortality. Management with tocilizumab can help ameliorate the symptoms of severe CRS, allowing steroids, which diminish the expansion and persistence of CAR T cells, to be reserved for tocilizumab-refractory patients. Other toxicities of CAR T-cell therapy include neutropenia and/or febrile neutropenia, infection, tumor lysis syndrome, neurotoxicity and nausea/vomiting. A review of patients' medications is imperative to eliminate medications that may contribute to treatment-related toxicities. Studies are ongoing to help optimize patient selection, preparation, safety, and management of individuals receiving CAR T cells. Long-term follow-up will help establish the place of CAR T cells in therapy.
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Affiliation(s)
- Brandon R Shank
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bryan Do
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adrienne Sevin
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sheree E Chen
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sattva S Neelapu
- Division of Cancer Medicine, Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sandra B Horowitz
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
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18
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Huguet F, Tavitian S. Emerging biological therapies to treat acute lymphoblastic leukemia. Expert Opin Emerg Drugs 2016; 22:107-121. [DOI: 10.1080/14728214.2016.1257606] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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