1
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Ma L, Zhang K, Xu J, Wang J, Jiang T, Du X, Zhang J, Huang J, Ren F, Liu D, Xue W, Kan D, Yao M, Liang Y, Jason-Sun H. Building a novel TRUCK by harnessing the endogenous IFN-gamma promoter for cytokine expression. Mol Ther 2024; 32:2728-2740. [PMID: 38879754 DOI: 10.1016/j.ymthe.2024.06.017] [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: 12/25/2023] [Revised: 04/22/2024] [Accepted: 06/14/2024] [Indexed: 06/27/2024] Open
Abstract
Despite the remarkable success of chimeric antigen receptor (CAR) T therapy in hematological malignancies, its efficacy in solid tumors remains limited. Cytokine-engineered CAR T cells offer a promising avenue, yet their clinical translation is hindered by the risks associated with constitutive cytokine expression. In this proof-of-concept study, we leverage the endogenous interferon (IFN)-γ promoter for transgenic interleukin (IL)-15 expression. We demonstrate that IFN-γ expression is tightly regulated by T cell receptor signaling. By introducing an internal ribosome entry site IL15 into the 3' UTR of the IFN-γ gene via homology directed repair-mediated knock-in, we confirm that IL-15 expression can co-express with IFN-γ in an antigen stimulation-dependent manner. Importantly, the insertion of transgenes does not compromise endogenous IFN-γ expression. In vitro and in vivo data demonstrate that IL-15 driven by the IFN-γ promoter dramatically improves CAR T cells' antitumor activity, suggesting the effectiveness of IL-15 expression. Last, as a part of our efforts toward clinical translation, we have developed an innovative two-gene knock-in approach. This approach enables the simultaneous integration of CAR and IL-15 genes into TRAC and IFN-γ gene loci using a single AAV vector. CAR T cells engineered to express IL-15 using this approach demonstrate enhanced antitumor efficacy. Overall, our study underscores the feasibility of utilizing endogenous promoters for transgenic cytokines expression in CAR T cells.
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MESH Headings
- Interferon-gamma/metabolism
- Promoter Regions, Genetic
- Humans
- Animals
- Mice
- Immunotherapy, Adoptive/methods
- Interleukin-15/genetics
- Interleukin-15/metabolism
- Receptors, Chimeric Antigen/genetics
- Receptors, Chimeric Antigen/metabolism
- Receptors, Chimeric Antigen/immunology
- T-Lymphocytes/metabolism
- T-Lymphocytes/immunology
- Genetic Vectors/genetics
- Cell Line, Tumor
- Transgenes
- Cytokines/metabolism
- Receptors, Antigen, T-Cell/genetics
- Receptors, Antigen, T-Cell/metabolism
- Xenograft Model Antitumor Assays
- Gene Expression
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Affiliation(s)
- Liya Ma
- Shenzhen Celconta Life Science Co. Ltd., Shenzhen, Guangdong, China
| | - Kaiwen Zhang
- Shenzhen Celconta Life Science Co. Ltd., Shenzhen, Guangdong, China
| | - Jian Xu
- Shenzhen Celconta Life Science Co. Ltd., Shenzhen, Guangdong, China
| | - Jian Wang
- Shenzhen Celconta Life Science Co. Ltd., Shenzhen, Guangdong, China
| | - Ting Jiang
- Shenzhen Celconta Life Science Co. Ltd., Shenzhen, Guangdong, China
| | - Xiaolong Du
- Shenzhen Celconta Life Science Co. Ltd., Shenzhen, Guangdong, China
| | - Jiaxin Zhang
- Shenzhen Celconta Life Science Co. Ltd., Shenzhen, Guangdong, China
| | - Jing Huang
- Shenzhen Celconta Life Science Co. Ltd., Shenzhen, Guangdong, China
| | - Fengyi Ren
- Shenzhen Celconta Life Science Co. Ltd., Shenzhen, Guangdong, China
| | - Dong Liu
- Shenzhen Celconta Life Science Co. Ltd., Shenzhen, Guangdong, China
| | - Weiwei Xue
- Shenzhen Celconta Life Science Co. Ltd., Shenzhen, Guangdong, China
| | - Dongxu Kan
- Shenzhen Celconta Life Science Co. Ltd., Shenzhen, Guangdong, China
| | - Mengjiao Yao
- Shenzhen Celconta Life Science Co. Ltd., Shenzhen, Guangdong, China
| | - Yutian Liang
- Shenzhen Celconta Life Science Co. Ltd., Shenzhen, Guangdong, China
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2
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De Philippis C, Giacomel A, Pensato U, Pinton C, Taurino D, Mannina D, Mariotti J, Sarina B, Marcheselli S, Timofeeva I, Capizzuto R, Santoro A, Bramanti S. Late-onset relapsing neurotoxicity after Brexucabtagene autoleucel associated with high chimeric antigen receptor T cells in cerebrospinal fluid. Cytotherapy 2024:S1465-3249(24)00822-3. [PMID: 39152952 DOI: 10.1016/j.jcyt.2024.07.015] [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: 05/21/2024] [Revised: 07/22/2024] [Accepted: 07/28/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND AIMS Mounting evidence suggests that persistent cell expansion is the main driver for both efficacy and toxicity of chimeric antigen receptor (CAR) T-cell therapy. Hereby, we describe a case of delayed recurrent neurotoxicity associated with late CAR T-cells re-expansion. CASE DESCRIPTION A 44-year-old man suffering from mantle cell lymphoma received brexu-cel. After infusion, he developed grade 2 cytokine release syndrome. On day +11, grade 3 neurotoxicity was reported and high-dose methylprednisolone was started with a complete resolution of neurological manifestations. On day +30, he experienced a late-onset CAR T-cell toxicity associated with CAR T-cell re-expansion. The patient was treated with tocilizumab and dexamethasone, with resolution of symptoms. On day +58, he was readmitted for new onset of neurotoxicity. Notably, a new CAR T-cell expansion was observed, with an unexpectedly elevated cerebrospinal fluid/blood ratio. The patient was promptly treated with dexamethasone and then escalated to high-dose methylprednisolone and anakinra, with resolution of his neurologic condition noted. CONCLUSIONS CAR T-cell-related neurotoxicity usually has an early monophasic course. To our knowledge, this is the first case of late-onset, recurrent neurotoxicity. Moreover, an elevated level of cerebrospinal fluid CAR T cells was observed, which may suggest that the delayed neurotoxicity was primarily caused by the brain infiltration of CAR T cells rather than driven by cytokine-mediated neuroinflammation.
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Affiliation(s)
| | - Arianna Giacomel
- IRCCS Humanitas Research Hospital, Humanitas Cancer Center, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Umberto Pensato
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IRCCS Humanitas Research Hospital, Milan, Italy
| | - Chiara Pinton
- IRCCS Humanitas Research Hospital, Humanitas Cancer Center, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Daniela Taurino
- IRCCS Humanitas Research Hospital, Humanitas Cancer Center, Milan, Italy
| | - Daniele Mannina
- IRCCS Humanitas Research Hospital, Humanitas Cancer Center, Milan, Italy
| | - Jacopo Mariotti
- IRCCS Humanitas Research Hospital, Humanitas Cancer Center, Milan, Italy
| | - Barbara Sarina
- IRCCS Humanitas Research Hospital, Humanitas Cancer Center, Milan, Italy
| | | | - Inna Timofeeva
- IRCCS Humanitas Research Hospital, Humanitas Cancer Center, Milan, Italy
| | - Rossana Capizzuto
- IRCCS Humanitas Research Hospital, Humanitas Cancer Center, Milan, Italy
| | - Armando Santoro
- IRCCS Humanitas Research Hospital, Humanitas Cancer Center, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Stefania Bramanti
- IRCCS Humanitas Research Hospital, Humanitas Cancer Center, Milan, Italy
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3
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Pensato U, Pondrelli F, de Philippis C, Asioli GM, Crespi A, Buizza A, Mannina D, Casadei B, Maffini E, Straffi L, Marcheselli S, Zinzani PL, Bonifazi F, Guarino M, Bramanti S. Primary vs. pre-emptive anti-seizure medication prophylaxis in anti-CD19 CAR T-cell therapy. Neurol Sci 2024; 45:4007-4014. [PMID: 38512531 PMCID: PMC11255041 DOI: 10.1007/s10072-024-07481-0] [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: 02/16/2024] [Accepted: 03/17/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Seizures may occur in up to 30% of non-Hodgkin lymphoma patients who received anti-CD19 CAR T-cell therapy, yet the optimal anti-seizure medication (ASM) prevention strategy has not been thoroughly investigated. METHODS Consecutive patients affected by refractory non-Hodgkin lymphoma who received anti-CD19 CAR T-cells were included. Patients were selected and assessed using similar internal protocols. ASM was started either as a primary prophylaxis (PP-group) before CAR T-cells infusion or as a pre-emptive therapy (PET-group) only upon the onset of neurotoxicity development. RESULTS One hundred fifty-six patients were included (PP-group = 88, PET-group = 66). Overall, neurotoxicity and severe neurotoxicity occurred in 45 (29%) and 20 (13%) patients, respectively, equally distributed between the two groups. Five patients experienced epileptic events (PET-group = 3 [4%]; PP-group = 2 [2%]). For all the PET-group patients, seizure/status epilepticus occurred in the absence of overt CAR-T-related neurotoxicity, whereas patients in the PP-group experienced brief seizures only in the context of critical neurotoxicity with progressive severe encephalopathy. ASMs were well-tolerated by all patients, even without titration. No patients developed epilepsy or required long-term ASMs. CONCLUSION Our data suggest that both primary and pre-emptive anti-seizure prophylaxis are safe and effective in anti-CD19 CAR T-cell recipients. Clinical rationale suggests a possible more favourable profile of primary prophylaxis, yet no definitive conclusion of superiority between the two ASM strategies can be drawn from our study.
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Affiliation(s)
- Umberto Pensato
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy.
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Federica Pondrelli
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Chiara de Philippis
- BMT and Cell Therapy Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Gian Maria Asioli
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Alessandra Crespi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Alessandro Buizza
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Daniele Mannina
- BMT and Cell Therapy Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Beatrice Casadei
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli", Bologna, Italy
| | - Enrico Maffini
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli", Bologna, Italy
| | - Laura Straffi
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Simona Marcheselli
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Pier Luigi Zinzani
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli", Bologna, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Università Di Bologna, Bologna, Italy
| | - Francesca Bonifazi
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli", Bologna, Italy
| | - Maria Guarino
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Stefania Bramanti
- BMT and Cell Therapy Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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4
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Shimomura M, Tanaka M, Kobayashi Y, Izumo H, Tateishi Y, Mizoguchi Y, Kawaguchi H, Okada S, Karakawa S. A Pediatric Case of B Cell Precursor ALL With Blinatumomab-associated Encephalopathy. J Pediatr Hematol Oncol 2024:00043426-990000000-00464. [PMID: 39008535 DOI: 10.1097/mph.0000000000002925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 06/28/2024] [Indexed: 07/17/2024]
Abstract
Blinatumomab is a CD3/CD19-directed bispecific T-cell engager used to treat relapsed or refractory B-cell precursor acute lymphoblastic leukemia (BCP-ALL). Although blinatumomab has shown efficacy, it can cause serious adverse events, including cytokine release syndrome and neurological events. Among the neurological events, encephalopathy is rare, and knowledge is lacking. Herein, we present a pediatric case of blinatumomab-associated encephalopathy that initially presented with refractory convulsions and later developed into a cerebral infarction. The patient experienced prolonged paralysis and increased brain damage.
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Affiliation(s)
- Maiko Shimomura
- Department of Pediatrics, Hiroshima University Hospital, Hiroshima, Japan
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5
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Olejarz W, Sadowski K, Szulczyk D, Basak G. Advancements in Personalized CAR-T Therapy: Comprehensive Overview of Biomarkers and Therapeutic Targets in Hematological Malignancies. Int J Mol Sci 2024; 25:7743. [PMID: 39062986 PMCID: PMC11276786 DOI: 10.3390/ijms25147743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 07/12/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Chimeric antigen receptor T-cell (CAR-T) therapy is a novel anticancer therapy using autologous or allogeneic T-cells. To date, six CAR-T therapies for specific B-cell acute lymphoblastic leukemia (B-ALL), non-Hodgkin lymphomas (NHL), and multiple myeloma (MM) have been approved by the Food and Drug Administration (FDA). Significant barriers to the effectiveness of CAR-T therapy include cytokine release syndrome (CRS), neurotoxicity in the case of Allogeneic Stem Cell Transplantation (Allo-SCT) graft-versus-host-disease (GVHD), antigen escape, modest antitumor activity, restricted trafficking, limited persistence, the immunosuppressive microenvironment, and senescence and exhaustion of CAR-Ts. Furthermore, cancer drug resistance remains a major problem in clinical practice. CAR-T therapy, in combination with checkpoint blockades and bispecific T-cell engagers (BiTEs) or other drugs, appears to be an appealing anticancer strategy. Many of these agents have shown impressive results, combining efficacy with tolerability. Biomarkers like extracellular vesicles (EVs), cell-free DNA (cfDNA), circulating tumor (ctDNA) and miRNAs may play an important role in toxicity, relapse assessment, and efficacy prediction, and can be implicated in clinical applications of CAR-T therapy and in establishing safe and efficacious personalized medicine. However, further research is required to fully comprehend the particular side effects of immunomodulation, to ascertain the best order and combination of this medication with conventional chemotherapy and targeted therapies, and to find reliable predictive biomarkers.
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Affiliation(s)
- Wioletta Olejarz
- Department of Biochemistry and Pharmacogenomics, Faculty of Pharmacy, Medical University of Warsaw, 02-097 Warsaw, Poland;
- Centre for Preclinical Research, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Karol Sadowski
- Department of Biochemistry and Pharmacogenomics, Faculty of Pharmacy, Medical University of Warsaw, 02-097 Warsaw, Poland;
- Centre for Preclinical Research, Medical University of Warsaw, 02-097 Warsaw, Poland
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-097 Warsaw, Poland;
| | - Daniel Szulczyk
- Chair and Department of Biochemistry, The Medical University of Warsaw, 02-097 Warsaw, Poland;
| | - Grzegorz Basak
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-097 Warsaw, Poland;
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6
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Schlegel LS, Werbrouck C, Boettcher M, Schlegel P. Universal CAR 2.0 to overcome current limitations in CAR therapy. Front Immunol 2024; 15:1383894. [PMID: 38962014 PMCID: PMC11219820 DOI: 10.3389/fimmu.2024.1383894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 06/03/2024] [Indexed: 07/05/2024] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapy has effectively complemented the treatment of advanced relapsed and refractory hematological cancers. The remarkable achievements of CD19- and BCMA-CAR T therapies have raised high expectations within the fields of hematology and oncology. These groundbreaking successes are propelling a collective aspiration to extend the reach of CAR therapies beyond B-lineage malignancies. Advanced CAR technologies have created a momentum to surmount the limitations of conventional CAR concepts. Most importantly, innovations that enable combinatorial targeting to address target antigen heterogeneity, using versatile adapter CAR concepts in conjunction with recent transformative next-generation CAR design, offer the promise to overcome both the bottleneck associated with CAR manufacturing and patient-individualized treatment regimens. In this comprehensive review, we delineate the fundamental prerequisites, navigate through pivotal challenges, and elucidate strategic approaches, all aimed at paving the way for the future establishment of multitargeted immunotherapies using universal CAR technologies.
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Affiliation(s)
- Lara Sophie Schlegel
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Coralie Werbrouck
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Michael Boettcher
- Department of Pediatric Surgery, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Patrick Schlegel
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Department of Pediatric Hematology and Oncology, Westmead Children’s Hospital, Sydney, NSW, Australia
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7
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Szlasa W, Dybko J. Current status of bispecific antibodies and CAR-T therapies in multiple myeloma. Int Immunopharmacol 2024; 134:112043. [PMID: 38733817 DOI: 10.1016/j.intimp.2024.112043] [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: 02/05/2024] [Revised: 03/28/2024] [Accepted: 04/05/2024] [Indexed: 05/13/2024]
Abstract
Multiple myeloma (MM), a malignancy of plasma cells, is an incurable disease that is characterized by the neoplastic proliferation of plasma cells leading to extensive skeletal destruction. This includes osteolytic lesions, osteopenia, and pathologic fractures. MM is clinically manifested through bone pain, renal insufficiency, hypercalcemia, anemia, and recurrent infections. Its prevalence and the need for effective treatment underscore the importance of this research. Recent advancements in MM therapy have been significant, particularly with the integration of daratumumab into first-line treatments. The use of daratumumab in regimens such as DRD (Daratumumab, Revlimid, Dexamethasone) and D-RVd (Daratumumab, Lenalidomide, Bortezomib, Dexamethasone) represents a paradigm shift in the treatment landscape. GRIFFIN and CASSIOPEIA trials have highlighted the efficacy of these regimens, particularly in prolonging progression-free survival and deepening patient responses. The shift from older regimens like MPV (Melphalan, Prednisone, Velcade) to more effective ones like DRD and RVD has been pivotal in treatment strategies. This review also focuses on the potential of Chimeric Antigen Receptor T-cell therapy and bispecific antibodies in MM. CAR-T therapy, which has shown success in other hematological malignancies, is being explored for its ability to specifically target MM cells. The latest clinical trials and research findings are analyzed to evaluate the efficacy and challenges of CAR-T therapy in MM. Additionally, the role of bispecific antibodies, which are designed to bind both cancer cells and T cells, is explored. These antibodies offer a unique mechanism that could complement the effects of CAR-T therapy.
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Affiliation(s)
- Wojciech Szlasa
- Lower Silesia Centre for Oncology, Pulmonology and Hematology in Wrocław, 53-439 Wroclaw, Poland; Medical University Hospital, Borowska 213, 50-556, Wrocław, Poland; Department of Molecular and Cellular Biology, Faculty of Pharmacy, Wroclaw Medical University, Wroclaw, Poland
| | - Jarosław Dybko
- Lower Silesia Centre for Oncology, Pulmonology and Hematology in Wrocław, 53-439 Wroclaw, Poland; Department of Oncology and Hematology, Wroclaw University of Science and Technology, 50-370 Wrocław, Poland.
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8
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Storci G, De Felice F, Ricci F, Santi S, Messelodi D, Bertuccio SN, Laprovitera N, Dicataldo M, Rossini L, De Matteis S, Casadei B, Vaglio F, Ursi M, Barbato F, Roberto M, Guarino M, Asioli GM, Arpinati M, Cortelli P, Maffini E, Tomassini E, Tassoni M, Cavallo C, Iannotta F, Naddeo M, Tazzari PL, Dan E, Pellegrini C, Guadagnuolo S, Carella M, Sinigaglia B, Pirazzini C, Severi C, Garagnani P, Kwiatkowska KM, Ferracin M, Zinzani PL, Bonafè M, Bonifazi F. CAR+ extracellular vesicles predict ICANS in patients with B cell lymphomas treated with CD19-directed CAR T cells. J Clin Invest 2024; 134:e173096. [PMID: 38833312 PMCID: PMC11245152 DOI: 10.1172/jci173096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 05/24/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUNDPredicting immune effector cell-associated neurotoxicity syndrome (ICANS) in patients infused with CAR T cells is still a conundrum. This complication, thought to be consequent to CAR T cell activation, arises a few days after infusion, when circulating CAR T cells are scarce and specific CAR T cell-derived biomarkers are lacking.METHODSCAR+ extracellular vesicle (CAR+EV) release was assessed in human CD19.CAR T cells cocultured with CD19+ target cells. A prospective cohort of 100 patients with B cell lymphoma infused with approved CD19.CAR T cell products was assessed for plasma CAR+EVs as biomarkers of in vivo CD19.CAR T cell activation. Human induced pluripotent stem cell-derived (iPSC-derived) neural cells were used as a model for CAR+EV-induced neurotoxicity.RESULTSIn vitro release of CAR+EVs occurs within 1 hour after target engagement. Plasma CAR+EVs are detectable 1 hour after infusion. A concentration greater than 132.8 CAR+EVs/μL at hour +1 or greater than 224.5 CAR+EVs/μL at day +1 predicted ICANS in advance of 4 days, with a sensitivity and a specificity outperforming other ICANS predictors. ENO2+ nanoparticles were released by iPSC-derived neural cells upon CAR+EV exposure and were increased in plasma of patients with ICANS.CONCLUSIONPlasma CAR+EVs are an immediate signal of CD19.CAR T cell activation, are suitable predictors of neurotoxicity, and may be involved in ICANS pathogenesis.TRIAL REGISTRATIONNCT04892433, NCT05807789.FUNDINGLife Science Hub-Advanced Therapies (financed by Health Ministry as part of the National Plan for Complementary Investments to the National Recovery and Resilience Plan [NRRP]: E.3 Innovative health ecosystem for APC fees and immunomonitoring).
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Affiliation(s)
- Gianluca Storci
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco De Felice
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Francesca Ricci
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Spartaco Santi
- IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Institute of Molecular Genetics, National Research Council of Italy, Bologna, Italy
| | - Daria Messelodi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | | | - Michele Dicataldo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Lucrezia Rossini
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | | | - Beatrice Casadei
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesca Vaglio
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Margherita Ursi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Francesco Barbato
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Marcello Roberto
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Maria Guarino
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Mario Arpinati
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pietro Cortelli
- Department of Biomedical and Neuromotor Sciences, Bellaria Hospital, Università di Bologna, Bologna, Italy
- IRCCS Institute of Neurological Sciences of Bologna, Bellaria Hospital, Bologna, Italy
| | - Enrico Maffini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Enrica Tomassini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marta Tassoni
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Carola Cavallo
- Laboratory Ramses, Research & Innovation Technology Department, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | - Maria Naddeo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | | | - Elisa Dan
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | | | - Matteo Carella
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | | | - Chiara Pirazzini
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | | | - Paolo Garagnani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | | | - Manuela Ferracin
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Pier Luigi Zinzani
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Università di Bologna, Istituto di Ematologia "Seràgnoli," Bologna, Italy
| | - Massimiliano Bonafè
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
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9
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Ciccone R, Quintarelli C, Camera A, Pezzella M, Caruso S, Manni S, Ottaviani A, Guercio M, Del Bufalo F, Quadraccia MC, Orlando D, Di Cecca S, Sinibaldi M, Aurigemma M, Iaffaldano L, Sarcinelli A, D'Amore ML, Ceccarelli M, Nazio F, Marabitti V, Giorda E, Pezzullo M, De Stefanis C, Carai A, Rossi S, Alaggio R, Del Baldo G, Becilli M, Mastronuzzi A, De Angelis B, Locatelli F. GD2-Targeting CAR T-cell Therapy for Patients with GD2+ Medulloblastoma. Clin Cancer Res 2024; 30:2545-2557. [PMID: 38551501 PMCID: PMC11145172 DOI: 10.1158/1078-0432.ccr-23-1880] [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: 06/21/2023] [Revised: 01/03/2024] [Accepted: 03/27/2024] [Indexed: 06/04/2024]
Abstract
PURPOSE Medulloblastoma (MB), the most common childhood malignant brain tumor, has a poor prognosis in about 30% of patients. The current standard of care, which includes surgery, radiation, and chemotherapy, is often responsible for cognitive, neurologic, and endocrine side effects. We investigated whether chimeric antigen receptor (CAR) T cells directed toward the disialoganglioside GD2 can represent a potentially more effective treatment with reduced long-term side effects. EXPERIMENTAL DESIGN GD2 expression was evaluated on primary tumor biopsies of MB children by flow cytometry. GD2 expression in MB cells was also evaluated in response to an EZH2 inhibitor (tazemetostat). In in vitro and in vivo models, GD2+ MB cells were targeted by a CAR-GD2.CD28.4-1BBζ (CAR.GD2)-T construct, including the suicide gene inducible caspase-9. RESULTS GD2 was expressed in 82.68% of MB tumors. The SHH and G3-G4 subtypes expressed the highest levels of GD2, whereas the WNT subtype expressed the lowest. In in vitro coculture assays, CAR.GD2 T cells were able to kill GD2+ MB cells. Pretreatment with tazemetostat upregulated GD2 expression, sensitizing GD2dimMB cells to CAR.GD2 T cells cytotoxic activity. In orthotopic mouse models of MB, intravenously injected CAR.GD2 T cells significantly controlled tumor growth, prolonging the overall survival of treated mice. Moreover, the dimerizing drug AP1903 was able to cross the murine blood-brain barrier and to eliminate both blood-circulating and tumor-infiltrating CAR.GD2 T cells. CONCLUSIONS Our experimental data indicate the potential efficacy of CAR.GD2 T-cell therapy. A phase I/II clinical trial is ongoing in our center (NCT05298995) to evaluate the safety and therapeutic efficacy of CAR.GD2 therapy in high-risk MB patients.
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Affiliation(s)
- Roselia Ciccone
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Concetta Quintarelli
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Antonio Camera
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Michele Pezzella
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simona Caruso
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simona Manni
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessio Ottaviani
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marika Guercio
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesca Del Bufalo
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Maria Cecilia Quadraccia
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Domenico Orlando
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Stefano Di Cecca
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Matilde Sinibaldi
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Mariasole Aurigemma
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Laura Iaffaldano
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrea Sarcinelli
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Maria Luisa D'Amore
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Manuela Ceccarelli
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesca Nazio
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Veronica Marabitti
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Ezio Giorda
- Research Laboratories, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marco Pezzullo
- Research Laboratories, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Andrea Carai
- Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sabrina Rossi
- Department of Laboratories, Pathology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rita Alaggio
- Department of Laboratories, Pathology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giada Del Baldo
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marco Becilli
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Angela Mastronuzzi
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Biagio De Angelis
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Franco Locatelli
- Department of Onco-Haematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
- Department of Life Sciences and Public Health, Catholic University of the Sacred Heart, Rome, Italy
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10
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Ferreri CJ, Bhutani M. Mechanisms and management of CAR T toxicity. Front Oncol 2024; 14:1396490. [PMID: 38835382 PMCID: PMC11148294 DOI: 10.3389/fonc.2024.1396490] [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: 03/05/2024] [Accepted: 05/07/2024] [Indexed: 06/06/2024] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapies have dramatically improved treatment outcomes for patients with relapsed or refractory B-cell acute lymphoblastic leukemia, large B-cell lymphoma, follicular lymphoma, mantle cell lymphoma, and multiple myeloma. Despite unprecedented efficacy, treatment with CAR T cell therapies can cause a multitude of adverse effects which require monitoring and management at specialized centers and contribute to morbidity and non-relapse mortality. Such toxicities include cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, neurotoxicity distinct from ICANS, immune effector cell-associated hemophagocytic lymphohistiocytosis-like syndrome, and immune effector cell-associated hematotoxicity that can lead to prolonged cytopenias and infectious complications. This review will discuss the current understanding of the underlying pathophysiologic mechanisms and provide guidelines for the grading and management of such toxicities.
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Affiliation(s)
- Christopher J Ferreri
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health Wake Forest University School of Medicine, Charlotte, NC, United States
| | - Manisha Bhutani
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health Wake Forest University School of Medicine, Charlotte, NC, United States
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11
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Strongyli E, Evangelidis P, Sakellari I, Gavriilaki M, Gavriilaki E. Change in Neurocognitive Function in Patients Who Receive CAR-T Cell Therapies: A Steep Hill to Climb. Pharmaceuticals (Basel) 2024; 17:591. [PMID: 38794161 PMCID: PMC11123727 DOI: 10.3390/ph17050591] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/01/2024] [Accepted: 05/02/2024] [Indexed: 05/26/2024] Open
Abstract
Immunotherapy with chimeric antigen receptor T (CAR-T) cell therapies has brought substantial improvement in clinical outcomes in patients with relapsed/refractory B cell neoplasms. However, complications such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) limit the therapeutic efficacy of this treatment approach. ICANS can have a broad range of clinical manifestations, while various scoring systems have been developed for its grading. Cognitive decline is prevalent in CAR-T therapy recipients including impaired attention, difficulty in item naming, and writing, agraphia, and executive dysfunction. In this review, we aim to present the diagnostic methods and tests that have been used for the recognition of cognitive impairment in these patients. Moreover, up-to-date data about the duration of cognitive impairment symptoms after the infusion are presented. More research on the risk factors, pathogenesis, preventive measures, and therapy of neurocognitive impairment is crucial for better outcomes for our patients.
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Affiliation(s)
- Evlampia Strongyli
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (E.S.); (I.S.)
| | - Paschalis Evangelidis
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
| | - Ioanna Sakellari
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (E.S.); (I.S.)
| | - Maria Gavriilaki
- 1st Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Eleni Gavriilaki
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (E.S.); (I.S.)
- Second Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
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12
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von dem Borne PA, Kemps-Mols BM, de Wreede LC, van Beek AA, Snijders TJF, van Lammeren D, Tijmensen J, Sijs-Szabó A, Oudshoorn MA, Halkes CJM, van Balen P, Marijt WAE, Tjon JML, Vermaat JSP, Veelken H. The degree of HLA matching determines the incidence of cytokine release syndrome and associated nonrelapse mortality in matched related and unrelated allogeneic stem cell transplantation with post-transplant cyclophosphamide. Leuk Lymphoma 2024:1-11. [PMID: 38710017 DOI: 10.1080/10428194.2024.2344060] [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: 11/01/2023] [Accepted: 04/12/2024] [Indexed: 05/08/2024]
Abstract
Cytokine release syndrome (CRS) occurs frequently after haplo-identical allogeneic stem cell transplantation (alloSCT) with post-transplant cyclophosphamide (PTCy), increasing nonrelapse mortality (NRM) and decreasing survival. Data on CRS in HLA-matched alloSCT are limited and effects of specific HLA-mismatches on CRS development unknown. We hypothesized that in HLA-matched alloSCT increasing degrees of HLA-mismatching influence CRS incidence, NRM and survival. Retrospective analysis of 126 HLA-matched PTCy-alloSCT patients showed that higher degrees of HLA-mismatching significantly increased CRS incidence (26%, 75% and 90% CRS with 12/12, 10/10 and 9/10 matched donors, respectively). Maximum temperature during CRS increased with higher HLA-mismatch. Specific associations between HLA-mismatches and CRS could be determined. Grade 2 CRS and CRS-induced grade 3 fever were associated with significantly increased NRM (p < 0.001 and p = 0.003, respectively) and inferior survival (p < 0.001 and p = 0.005, respectively). NRM was mainly caused by disease conditions that may be considered CRS-induced inflammatory responses (encephalopathy, cryptogenic organizing pneumonia and multi-organ failure).
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Affiliation(s)
| | - Berit M Kemps-Mols
- Department of Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Liesbeth C de Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Adriaan A van Beek
- Department of Immunology, Leiden University Medical Center, Leiden, the Netherlands
| | - Tjeerd J F Snijders
- Department of Hematology, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | - Janneke Tijmensen
- Department of Hematology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Aniko Sijs-Szabó
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mirjam A Oudshoorn
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Peter van Balen
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - W A Erik Marijt
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jennifer M L Tjon
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Joost S P Vermaat
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hendrik Veelken
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
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13
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Katsin M, Shman T, Migas A, Lutskovich D, Serada Y, Khalankova Y, Kostina Y, Dubovik S. Case report: Rapid resolution of grade IV ICANS after first line intrathecal chemotherapy with methotrexate, cytarabine and dexamethasone. Front Immunol 2024; 15:1380451. [PMID: 38765003 PMCID: PMC11099209 DOI: 10.3389/fimmu.2024.1380451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/22/2024] [Indexed: 05/21/2024] Open
Abstract
Corticosteroid therapy is the mainstay of immune effector cell-associated neurotoxicity syndrome (ICANS) management, although its use has been associated with worse overall survival (OS) and progression-free survival (PFS) after chimeric antigen receptor T-cell (CAR-T cell) therapy. Many options are being investigated for prophylaxis and management. Accumulating evidence supports the use of intrathecal (IT) chemotherapy for the management of high-grade ICANS. Here, we describe a case of a patient with stage IV Primary mediastinal B-cell lymphoma (PMBCL) successfully treated with IT methotrexate, cytarabine, and dexamethasone as first-line therapy for CD19 CAR-T cell-associated grade IV ICANS. The stable and rapid resolution of ICANS to grade 0 allowed us to discontinue systemic corticosteroid use, avoiding CAR-T cells ablation and ensuring preservation of CAR-T cell function. The described patient achieved a complete radiologic and clinical response to CD19 CAR-T cell therapy and remains disease-free after 9 months. This case demonstrates a promising example of how IT chemotherapy could be used as first-line treatment for the management of high-grade ICANS.
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Affiliation(s)
- Mikalai Katsin
- Department of Hematology, Vitebsk Regional Clinical Cancer Centre, Vitebsk, Belarus
| | - Tatsiana Shman
- Laboratory of Genetic Biotechnologies, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Alexandr Migas
- Laboratory of Genetic Biotechnologies, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Dzmitry Lutskovich
- Laboratory of Genetic Biotechnologies, Belarusian Research Center for Pediatric Oncology, Hematology and Immunology, Minsk, Belarus
| | - Yuliya Serada
- Department of Hematology, Vitebsk Regional Clinical Cancer Centre, Vitebsk, Belarus
| | - Yauheniya Khalankova
- Department of Hematology, Vitebsk Regional Clinical Cancer Centre, Vitebsk, Belarus
| | - Yuliya Kostina
- Department of Hematology, Vitebsk Regional Clinical Cancer Centre, Vitebsk, Belarus
| | - Simon Dubovik
- Laboratory of Molecular Diagnostics and Biotechnology, Institute of Bioorganic Chemistry of the National Academy of Sciences of Belarus, Minsk, Belarus
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14
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Johnson NM, Koumpouras F. Chimeric antigen receptors: "CARs" in the fast lane for rheumatology. Curr Opin Rheumatol 2024; 36:176-183. [PMID: 38517338 PMCID: PMC11224568 DOI: 10.1097/bor.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
PURPOSE OF REVIEW Recent advances in hematology-oncology have pioneered cell-mediated elimination of pathologic B-cell populations employing chimeric antigen receptor (CAR) T cells. In this review, we discuss recent adoption of CAR-T treatment for severe refractory autoimmune disease. We highlight unique aspects of the autoimmune model and review current clinical data regarding treatment of rheumatologic disease. RECENT FINDINGS To date, several CAR-Ts are FDA approved for Multiple Myeloma and B-cell malignancies and have demonstrated extraordinary clinical responses in refractory disease. Realizing the central role of B-cells in certain autoimmune diseases, CAR-T is now being explored for achieving drug-free remission induction, and potentially cure, of several rheumatologic diseases. The largest experience to date in the field of autoimmunity, building off the University Hospital Erlangen groups' earlier success treating a single patient with CD19-CAR in severe refractory SLE, Mackensen et al. enrolled five patients in a compassionate use program. Following autologous CD19-CAR T infusion, they demonstrated drug-free clinical and laboratory remission for at least 12 months in all five patients, with reconstitution of B cells expressing a naïve phenotype. SUMMARY CAR-T treatment has shown striking drug-free responses in severe lupus and other autoimmune diseases, creating a need for further exploration and development.
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Affiliation(s)
- Nathan M Johnson
- Depatment of Internal Medicine, Yale New-Haven Hospital, Yale School of Medicine
| | - Fotios Koumpouras
- Section of Rheumatology, Allergy & Immunology, Department of Internal Medicine, Yale School of Medicine, New Haven Conn
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15
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Kim SJ, Yoon SE, Kim WS. Current Challenges in Chimeric Antigen Receptor T-cell Therapy in Patients With B-cell Lymphoid Malignancies. Ann Lab Med 2024; 44:210-221. [PMID: 38205527 PMCID: PMC10813822 DOI: 10.3343/alm.2023.0388] [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: 09/30/2023] [Revised: 11/18/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
Chimeric antigen receptor (CAR) T-cell therapy is a promising immunotherapy based on genetically engineered T cells derived from patients. The introduction of CAR T-cell therapy has changed the treatment paradigm of patients with B-cell lymphoid malignancies. However, challenging issues including managing life-threatening toxicities related to CAR T-cell infusion and resistance to CAR T-cell therapy, leading to progression or relapse, remain. This review summarizes the issues with currently approved CAR T-cell therapies for patients with relapsed or refractory B-cell lymphoid malignancies, including lymphoma and myeloma. We focus on unique toxicities after CAR T-cell therapy, such as cytokine-related events and hematological toxicities, and the mechanisms underlying post-CAR T-cell failure.
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Affiliation(s)
- Seok Jin Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University School of Medicine, Seoul, Korea
- CAR T-cell Therapy Center, Samsung Comprehensive Cancer Center, Seoul, Korea
| | - Sang Eun Yoon
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- CAR T-cell Therapy Center, Samsung Comprehensive Cancer Center, Seoul, Korea
| | - Won Seog Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University School of Medicine, Seoul, Korea
- CAR T-cell Therapy Center, Samsung Comprehensive Cancer Center, Seoul, Korea
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16
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Li Y, Hu Z, Li Y, Wu X. Charting new paradigms for CAR-T cell therapy beyond current Achilles heels. Front Immunol 2024; 15:1409021. [PMID: 38751430 PMCID: PMC11094207 DOI: 10.3389/fimmu.2024.1409021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 04/18/2024] [Indexed: 05/18/2024] Open
Abstract
Chimeric antigen receptor-T (CAR-T) cell therapy has made remarkable strides in treating hematological malignancies. However, the widespread adoption of CAR-T cell therapy is hindered by several challenges. These include concerns about the long-term and complex manufacturing process, as well as efficacy factors such as tumor antigen escape, CAR-T cell exhaustion, and the immunosuppressive tumor microenvironment. Additionally, safety issues like the risk of secondary cancers post-treatment, on-target off-tumor toxicity, and immune effector responses triggered by CAR-T cells are significant considerations. To address these obstacles, researchers have explored various strategies, including allogeneic universal CAR-T cell development, infusion of non-activated quiescent T cells within a 24-hour period, and in vivo induction of CAR-T cells. This review comprehensively examines the clinical challenges of CAR-T cell therapy and outlines strategies to overcome them, aiming to chart pathways beyond its current Achilles heels.
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Affiliation(s)
- Ying Li
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhenhua Hu
- Department of Health and Nursing, Nanfang College of Sun Yat-sen University, Guangzhou, China
| | - Yuanyuan Li
- Zhongshan Institute for Drug Discovery, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Zhongshan, China
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Xiaoyan Wu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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17
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Xu MY, Zeng N, Liu CQ, Sun JX, An Y, Zhang SH, Xu JZ, Zhong XY, Ma SY, He HD, Hu J, Xia QD, Wang SG. Enhanced cellular therapy: revolutionizing adoptive cellular therapy. Exp Hematol Oncol 2024; 13:47. [PMID: 38664743 PMCID: PMC11046957 DOI: 10.1186/s40164-024-00506-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 03/31/2024] [Indexed: 04/28/2024] Open
Abstract
Enhanced cellular therapy has emerged as a novel concept following the basis of cellular therapy. This treatment modality applied drugs or biotechnology to directly enhance or genetically modify cells to enhance the efficacy of adoptive cellular therapy (ACT). Drugs or biotechnology that enhance the killing ability of immune cells include immune checkpoint inhibitors (ICIs) / antibody drugs, small molecule inhibitors, immunomodulatory factors, proteolysis targeting chimera (PROTAC), oncolytic virus (OV), etc. Firstly, overcoming the inhibitory tumor microenvironment (TME) can enhance the efficacy of ACT, which can be achieved by blocking the immune checkpoint. Secondly, cytokines or cytokine receptors can be expressed by genetic engineering or added directly to adoptive cells to enhance the migration and infiltration of adoptive cells to tumor cells. Moreover, multi-antigen chimeric antigen receptors (CARs) can be designed to enhance the specific recognition of tumor cell-related antigens, and OVs can also stimulate antigen release. In addition to inserting suicide genes into adoptive cells, PROTAC technology can be used as a safety switch or degradation agent of immunosuppressive factors to enhance the safety and efficacy of adoptive cells. This article comprehensively summarizes the mechanism, current situation, and clinical application of enhanced cellular therapy, describing potential improvements to adoptive cellular therapy.
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Affiliation(s)
- Meng-Yao Xu
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Na Zeng
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Chen-Qian Liu
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Jian-Xuan Sun
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Ye An
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Si-Han Zhang
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Jin-Zhou Xu
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Xing-Yu Zhong
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Si-Yang Ma
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Hao-Dong He
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Jia Hu
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China
| | - Qi-Dong Xia
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China.
| | - Shao-Gang Wang
- Department and Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1095 Jiefang Avenue, Wuhan, 430030, China.
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18
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Ritmeester-Loy SA, Draper IH, Bueter EC, Lautz JD, Zhang-Wong Y, Gustafson JA, Wilson AL, Lin C, Gafken PR, Jensen MC, Orentas R, Smith SEP. Differential protein-protein interactions underlie signaling mediated by the TCR and a 4-1BB domain-containing CAR. Sci Signal 2024; 17:eadd4671. [PMID: 38442200 PMCID: PMC10986860 DOI: 10.1126/scisignal.add4671] [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: 06/13/2022] [Accepted: 01/09/2024] [Indexed: 03/07/2024]
Abstract
Cells rely on activity-dependent protein-protein interactions to convey biological signals. For chimeric antigen receptor (CAR) T cells containing a 4-1BB costimulatory domain, receptor engagement is thought to stimulate the formation of protein complexes similar to those stimulated by T cell receptor (TCR)-mediated signaling, but the number and type of protein interaction-mediating binding domains differ between CARs and TCRs. Here, we performed coimmunoprecipitation mass spectrometry analysis of a second-generation, CD19-directed 4-1BB:ζ CAR (referred to as bbζCAR) and identified 128 proteins that increased their coassociation after target engagement. We compared activity-induced TCR and CAR signalosomes by quantitative multiplex coimmunoprecipitation and showed that bbζCAR engagement led to the activation of two modules of protein interactions, one similar to TCR signaling that was more weakly engaged by bbζCAR as compared with the TCR and one composed of TRAF signaling complexes that was not engaged by the TCR. Batch-to-batch and interindividual variations in production of the cytokine IL-2 correlated with differences in the magnitude of protein network activation. Future CAR T cell manufacturing protocols could measure, and eventually control, biological variation by monitoring these signalosome activation markers.
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Affiliation(s)
- Samuel A. Ritmeester-Loy
- Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle, WA 98101, USA
| | - Isabella H. Draper
- Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle, WA 98101, USA
| | - Eric C. Bueter
- Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle, WA 98101, USA
| | - Jonathan D Lautz
- Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle, WA 98101, USA
| | - Yue Zhang-Wong
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, Seattle, WA 98101, USA
| | - Joshua A. Gustafson
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, Seattle, WA 98101, USA
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, WA 98101 USA
| | - Ashley L. Wilson
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, Seattle, WA 98101, USA
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, WA 98101 USA
| | - Chenwei Lin
- Proteomics and Metabolomics Facility, Fred Hutchinson Cancer Center, Seattle, WA 98101, USA
| | - Philip R. Gafken
- Proteomics and Metabolomics Facility, Fred Hutchinson Cancer Center, Seattle, WA 98101, USA
| | - Michael C. Jensen
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, Seattle, WA 98101, USA
- Seattle Children’s Therapeutics, Seattle Children’s Research Institute, Seattle, WA 98101 USA
- Department of Pediatrics, University of Washington, Seattle, WA 98101, USA
| | - Rimas Orentas
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, Seattle, WA 98101, USA
- Department of Pediatrics, University of Washington, Seattle, WA 98101, USA
| | - Stephen E. P. Smith
- Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle, WA 98101, USA
- Department of Pediatrics, University of Washington, Seattle, WA 98101, USA
- Graduate Program in Neuroscience, University of Washington, Seattle, WA 98101, USA
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19
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Asioli GM, Castioni CA, Zinzani PL, Casadio MC, Pierucci E, Casadei B, Spinardi L, Pellegrini C, Bonafé M, Maffini E, Guarino M, Cortelli P, Bonifazi F. Intracranial pressure management in fulminant cerebral oedema after CAR T-cell therapy: Not all is lost! Br J Haematol 2024; 204:1109-1113. [PMID: 38111196 DOI: 10.1111/bjh.19270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 12/05/2023] [Accepted: 12/08/2023] [Indexed: 12/20/2023]
Affiliation(s)
- Gian Maria Asioli
- UOC Clinica Neurologica - Rete Neurologica Metropolitana (NEUROMET), IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Carlo Alberto Castioni
- UOC Anestesia e Rianimazione, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Pier Luigi Zinzani
- Istituto di Ematologia "Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Maria Chiara Casadio
- Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Elisabetta Pierucci
- Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Beatrice Casadei
- Istituto di Ematologia "Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Luca Spinardi
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cinzia Pellegrini
- Istituto di Ematologia "Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Massimiliano Bonafé
- Istituto di Ematologia "Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Enrico Maffini
- Istituto di Ematologia "Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maria Guarino
- UOC Clinica Neurologica - Rete Neurologica Metropolitana (NEUROMET), IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Pietro Cortelli
- UOC Clinica Neurologica - Rete Neurologica Metropolitana (NEUROMET), IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Francesca Bonifazi
- Istituto di Ematologia "Seràgnoli", IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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20
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Billingsley MM, Gong N, Mukalel AJ, Thatte AS, El-Mayta R, Patel SK, Metzloff AE, Swingle KL, Han X, Xue L, Hamilton AG, Safford HC, Alameh MG, Papp TE, Parhiz H, Weissman D, Mitchell MJ. In Vivo mRNA CAR T Cell Engineering via Targeted Ionizable Lipid Nanoparticles with Extrahepatic Tropism. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2024; 20:e2304378. [PMID: 38072809 DOI: 10.1002/smll.202304378] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/16/2023] [Indexed: 03/16/2024]
Abstract
With six therapies approved by the Food and Drug Association, chimeric antigen receptor (CAR) T cells have reshaped cancer immunotherapy. However, these therapies rely on ex vivo viral transduction to induce permanent CAR expression in T cells, which contributes to high production costs and long-term side effects. Thus, this work aims to develop an in vivo CAR T cell engineering platform to streamline production while using mRNA to induce transient, tunable CAR expression. Specifically, an ionizable lipid nanoparticle (LNP) is utilized as these platforms have demonstrated clinical success in nucleic acid delivery. Though LNPs often accumulate in the liver, the LNP platform used here achieves extrahepatic transfection with enhanced delivery to the spleen, and it is further modified via antibody conjugation (Ab-LNPs) to target pan-T cell markers. The in vivo evaluation of these Ab-LNPs confirms that targeting is necessary for potent T cell transfection. When using these Ab-LNPs for the delivery of CAR mRNA, antibody and dose-dependent CAR expression and cytokine release are observed along with B cell depletion of up to 90%. In all, this work conjugates antibodies to LNPs with extrahepatic tropism, evaluates pan-T cell markers, and develops Ab-LNPs capable of generating functional CAR T cells in vivo.
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Affiliation(s)
| | - Ningqiang Gong
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Alvin J Mukalel
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Ajay S Thatte
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Rakan El-Mayta
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Savan K Patel
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Ann E Metzloff
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Kelsey L Swingle
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Xuexiang Han
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Lulu Xue
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Alex G Hamilton
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Hannah C Safford
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Mohamad-Gabriel Alameh
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Tyler E Papp
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Hamideh Parhiz
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Drew Weissman
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Michael J Mitchell
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Institute for Immunology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Institute for Regenerative Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Penn Institute for RNA Innovation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
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21
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Ghilardi G, Paruzzo L, Svoboda J, Chong EA, Shestov AA, Chen L, Cohen IJ, Gabrielli G, Nasta SD, Porazzi P, Landsburg DJ, Gerson JN, Carter J, Barta SK, Yelton R, Pajarillo R, Patel V, White G, Ballard HJ, Weber E, Napier E, Chong ER, Fraietta JA, Garfall AL, Porter DL, Milone MC, O’Connor R, Schuster SJ, Ruella M. Bendamustine lymphodepletion before axicabtagene ciloleucel is safe and associates with reduced inflammatory cytokines. Blood Adv 2024; 8:653-666. [PMID: 38113468 PMCID: PMC10839610 DOI: 10.1182/bloodadvances.2023011492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/27/2023] [Accepted: 11/27/2023] [Indexed: 12/21/2023] Open
Abstract
ABSTRACT Lymphodepletion (LD) is an integral component of chimeric antigen receptor T-cell (CART) immunotherapies. In this study, we compared the safety and efficacy of bendamustine (Benda) to standard fludarabine/cyclophosphamide (Flu/Cy) LD before CD19-directed, CD28-costimulated CART axicabtagene ciloleucel (axi-cel) for patients with large B-cell lymphoma (LBCL) and follicular lymphoma (FL). We analyzed 59 patients diagnosed with LBCL (n = 48) and FL (n = 11) consecutively treated with axi-cel at the University of Pennsylvania. We also analyzed serum samples for cytokine levels and metabolomic changes before and after LD. Flu/Cy and Benda demonstrated similar efficacy, with complete remission rates of 51.4% and 50.0% (P = .981), respectively, and similar progression-free and overall survivals. Any-grade cytokine-release syndrome occurred in 91.9% of patients receiving Flu/Cy vs 72.7% of patients receiving Benda (P = .048); any-grade neurotoxicity after Flu/Cy occurred in 45.9% of patients and after Benda in 18.2% of patients (P = .031). In addition, Flu/Cy was associated with a higher incidence of grade ≥3 neutropenia (100% vs 54.5%; P < .001), infections (78.4% vs 27.3%; P < .001), and neutropenic fever (78.4% vs 13.6%; P < .001). These results were confirmed both in patients with LBCL and those with FL. Mechanistically, patients with Flu/Cy had a greater increase in inflammatory cytokines associated with neurotoxicity and reduced levels of metabolites critical for redox balance and biosynthesis. This study suggests that Benda LD may be a safe alternative to Flu/Cy for CD28-based CART CD19-directed immunotherapy with similar efficacy and reduced toxicities. Benda is associated with reduced levels of inflammatory cytokines and increased anabolic metabolites.
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Affiliation(s)
- Guido Ghilardi
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Luca Paruzzo
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
- Department of Oncology, University of Turin, Turin, Italy
| | - Jakub Svoboda
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Eise A. Chong
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Alexander A. Shestov
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Linhui Chen
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ivan J. Cohen
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Giulia Gabrielli
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin, Italy
| | - Sunita D. Nasta
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Patrizia Porazzi
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Daniel J. Landsburg
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - James N. Gerson
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jordan Carter
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Stefan K. Barta
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Rebecca Yelton
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Raymone Pajarillo
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Vrutti Patel
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Griffin White
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Hatcher J. Ballard
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Elizabeth Weber
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ellen Napier
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Emeline R. Chong
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Joseph A. Fraietta
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
| | - Alfred L. Garfall
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - David L. Porter
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Michael C. Milone
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Roderick O’Connor
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stephen J. Schuster
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Marco Ruella
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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22
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Ligon JA, Ramakrishna S, Ceppi F, Calkoen FGJ, Diorio C, Davis KL, Jacoby E, Gottschalk S, Schultz LM, Capitini CM. INSPIRED Symposium Part 4B: Chimeric Antigen Receptor T Cell Correlative Studies-Established Findings and Future Priorities. Transplant Cell Ther 2024; 30:155-170. [PMID: 37863355 DOI: 10.1016/j.jtct.2023.10.012] [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: 10/03/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 10/22/2023]
Abstract
Chimeric antigen receptor (CAR) T cell therapy has revolutionized the treatment of B cell malignancies, with multiple CAR T cell products approved for numerous indications by regulatory agencies worldwide. However, significant work remains to be done to enhance these treatments. In March 2023, a group of experts in CAR T cell therapy assembled at the National Institutes of Health in Bethesda, Maryland at the Insights in Pediatric CAR T Cell Immunotherapy: Recent Advances and Future Directions (INSPIRED) Symposium to identify key areas for research for the coming years. In session 4B, correlative studies to be incorporated into future clinical trials and real-world settings were discussed. Active areas of research identified included (1) optimizing CAR T cell product manufacturing; (2) ensuring adequate lymphodepletion prior to CAR T cell administration; (3) overcoming immunoregulatory cells and tumor stroma present in the tumor microenvironment, particularly in solid tumors; (4) understanding tumor intrinsic properties that lead to CAR T cell immunotherapy resistance; and (5) uncovering biomarkers predictive of treatment resistance, treatment durability, or immune-related adverse events. Here we review the results of previously published clinical trials and real-world studies to summarize what is currently known about each of these topics. We then outline priorities for future research that we believe will be important for improving our understanding of CAR T cell therapy and ultimately leading to better outcomes for patients.
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Affiliation(s)
- John A Ligon
- Department of Pediatrics, Division of Hematology/Oncology, University of Florida, Gainesville, Florida; University of Florida Health Cancer Center, Gainesville, Florida.
| | - Sneha Ramakrishna
- Stanford Center for Cancer Cell Therapy, Stanford University School of Medicine, Stanford, California; Department of Pediatrics, Stanford University, Stanford, California
| | - Francesco Ceppi
- Division of Pediatrics, Department of Woman-Mother-Child, Pediatric Hematology-Oncology Unit, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Friso G J Calkoen
- Division of Pediatric Oncology, Princess Maxima Center, Utrecht, The Netherlands
| | - Caroline Diorio
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kara L Davis
- Stanford Center for Cancer Cell Therapy, Stanford University School of Medicine, Stanford, California; Department of Pediatrics, Stanford University, Stanford, California
| | - Elad Jacoby
- Pediatric Hemato-Oncology, Sheba Medical Center and Tel Aviv University, Tel Aviv, Israel
| | - Stephen Gottschalk
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Liora M Schultz
- Stanford Center for Cancer Cell Therapy, Stanford University School of Medicine, Stanford, California; Department of Pediatrics, Stanford University, Stanford, California
| | - Christian M Capitini
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
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23
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Pensato U, de Philippis C, Mannina D, Taurino D, Sarina B, Mariotti J, Villa F, Costantini E, Marcheselli S, Bramanti S. Frontal Lobe Status Epilepticus Related to CAR T-Cell Therapy Responsive to Anakinra. Can J Neurol Sci 2024:1-3. [PMID: 38234097 DOI: 10.1017/cjn.2024.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Affiliation(s)
- Umberto Pensato
- IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Chiara de Philippis
- BMT and Cell Therapy Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Daniele Mannina
- BMT and Cell Therapy Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Daniela Taurino
- BMT and Cell Therapy Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Barbara Sarina
- BMT and Cell Therapy Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Jacopo Mariotti
- BMT and Cell Therapy Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Milan, Italy
| | | | | | | | - Stefania Bramanti
- BMT and Cell Therapy Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Milan, Italy
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24
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Pinto SN, Krenciute G. The Mechanisms of Altered Blood-Brain Barrier Permeability in CD19 CAR T-Cell Recipients. Int J Mol Sci 2024; 25:644. [PMID: 38203814 PMCID: PMC10779697 DOI: 10.3390/ijms25010644] [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: 11/30/2023] [Revised: 12/31/2023] [Accepted: 01/02/2024] [Indexed: 01/12/2024] Open
Abstract
Cluster of differentiation 19 (CD19) chimeric antigen receptor (CAR) T cells are a highly effective immunotherapy for relapsed and refractory B-cell malignancies, but their utility can be limited by the development of immune effector cell-associated neurotoxicity syndrome (ICANS). The recent discovery of CD19 expression on the pericytes in the blood-brain barrier (BBB) suggests an important off-target mechanism for ICANS development. In addition, the release of systemic cytokines stimulated by the engagement of CD19 with the CAR T cells can cause endothelial activation and decreased expression of tight junction molecules, further damaging the integrity of the BBB. Once within the brain microenvironment, cytokines trigger a cytokine-specific cascade of neuroinflammatory responses, which manifest clinically as a spectrum of neurological changes. Brain imaging is frequently negative or nonspecific, and treatment involves close neurologic monitoring, supportive care, interleukin antagonists, and steroids. The goal of this review is to inform readers about the normal development and microstructure of the BBB, its unique susceptibility to CD19 CAR T cells, the role of individual cytokines on specific elements of the brain's microstructural environment, and the clinical and imaging manifestations of ICANS. Our review will link cellular pathophysiology with the clinical and radiological manifestations of a complex clinical entity.
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Affiliation(s)
- Soniya N. Pinto
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA
| | - Giedre Krenciute
- Department of Bone Marrow Transplantation & Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA;
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25
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Ren X, Zhang G, Li G, Wang Y. Chimeric antigen receptor T-cell therapy-induced nervous system toxicity: a real-world study based on the FDA Adverse Event Reporting System database. BMC Cancer 2024; 24:10. [PMID: 38166723 PMCID: PMC10762809 DOI: 10.1186/s12885-023-11753-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Nervous system toxicity (NST) is one of the most frequent and dangerous side effects of chimeric antigen receptor T-cell (CAR-T) therapy, which is an effective treatment for related tumors in most relapsed/refractory (r/r) hematologic malignancies. Current clinical trial data do not fully reflect the real-world situation. Therefore, this study evaluated the NST of CAR-T therapy using the FDA Adverse Event Reporting System (FAERS). METHODS Data were retrieved from FAERS for the period from January 1, 2017 to March 31, 2023. Disproportionality analysis and Bayesian analysis were used for data mining. The reporting odds ratio (ROR) for NST with 95% confidence interval (CI) was calculated for each CAR-T product. The time to onset (TTO) and clinical outcomes due to CAR-T therapy-associated NST were assessed. RESULTS Overall, 6946 cases of NST associated with CAR-T therapy were identified. The patients had a median age of 61 years (interquartile range [IQR]: 47-69 years). Significant signals were observed for all CAR-T products (ROR: 2.19, 95% CI: 2.13-2.44). Anti-CD19 CAR-T products showed a higher NST signal than anti-B cell maturation antigen (BCMA) CAR-T products (ROR025 2.13 vs. 1.98). Brexucabtagene autoleucel (ROR: 3.17, 95% CI: 2.90-3.47) and axicabtagene ciloleucel (ROR: 2.92, 95% CI: 2.81-3.03) had the two highest NST signals. For the preferred term "brain edema," the highest signals were obtained for CD28 CAR-T products. The median TTO of NST for all CAR-T products was 7 days (IQR: 3-17 days). The proportion of death, life-threatening and hospitalization adverse events associated with NST was 20.06%, 7.21%, and 32.70%, respectively. The proportion of death outcomes was higher in patients treated with tisagenlecleucel (30.36%) than in those treated with other CAR-T products, except ciltacabtagene autoleucel (P < 0.001). The proportion of hospitalizations was significantly higher for lisocabtagene maraleucel-associated NST (53.85%) than for other drugs, except for ciltacabtagene autoleucel (P < 0.001). CONCLUSIONS NST is more closely associated with anti-CD19 CAR-Ts and CAR-Ts containing CD28. Serious NST (brain oedema) is likely to occur with CAR-Ts that contain CD28. CAR-T-related NST warrants greater attention owing to the high proportion of serious adverse events and delayed NST.
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Affiliation(s)
- Xiayang Ren
- Department of Pharmacy, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Guanmin Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Pharmacy, Peking University Cancer Hospital & Institute, Beijing, China
| | - Guohui Li
- Department of Pharmacy, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China.
| | - Yanfeng Wang
- Department of Comprehensive Oncology, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China.
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Yeung CCS, Woolston DW, Wu V, Voutsinas JM, Basom R, Davis C, Hirayama AV, Naresh KN. Abnormal bone marrow findings in patients following treatment with chimeric antigen receptor-T cell therapy. Eur J Haematol 2024; 112:111-121. [PMID: 37526606 DOI: 10.1111/ejh.14068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Bone marrow (BM) assessment after CAR-T cell immunotherapy infusion is not routinely performed to monitor adverse events such as cytopenias, hemophagocytic lymphohistiocytosis, or infections. Our institution has performed BM biopsies as part of CAR-T cell treatment protocols, encompassing pre- and post-treatment time points and during long-term follow-up. METHODS We conducted a systematic retrospective review of BM abnormalities observed in samples from 259 patients following CAR-T cell immunotherapy. We correlated BM pathology findings with mortality, relapse/residual disease, and laboratory values. RESULTS At a median of 35.5 days post-CAR-T infusion, 25.5% showed severe marrow hypocellularity, and 6.2% showed serous atrophy, and peripheral blood cytopenias corroborated these observations. Marrow features associated with reduced disease burden post-CAR-T infusion include increased lymphocytes seen in 16 patients and an increase of macrophages or granulomatous response seen in 25 patients. However, a 100-day landmark analysis also showed increased marrow histiocytes were associated with lower survival (median OS 6.0 vs. 21.4 months, p = .026), as was grade 2-3 marrow reticulin (18 patients) (median OS 12.5 vs. 24.2 months, p = .034). CONCLUSIONS These data represent the first systematic observations of BM changes in patients receiving CAR-T cell immunotherapy.
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Affiliation(s)
- Cecilia C S Yeung
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - David W Woolston
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Vicky Wu
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Jenna M Voutsinas
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Ryan Basom
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Chris Davis
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Alexandre V Hirayama
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Kikkeri N Naresh
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
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Fenton GA, Dean EA. Exacerbations of Persistent Neurotoxicity following Axicabtagene Ciloleucel in a Patient with Relapsed/Refractory Diffuse Large B-Cell Lymphoma: A Case Report. Case Rep Oncol 2024; 17:75-81. [PMID: 38196817 PMCID: PMC10776132 DOI: 10.1159/000535426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 11/20/2023] [Indexed: 01/11/2024] Open
Abstract
Introduction Neurological toxicity following chimeric antigen receptor T-cell infusion, termed immune cell-associated neurotoxicity syndrome (ICANS), is a common and limiting factor in the expansion of this promising treatment modality. While refractory cases of ICANS have been reported in clinical trials, there is limited description of these presentations and their associated treatment. The use of predictive biomarkers and risk stratification tools offer a means of identifying patients with higher likelihood of developing ICANS; however, their discriminatory sensitivity has been shown to vary depending on disease type. Case Presentation In this case report, we present the clinical course of a patient with diffuse large B-cell lymphoma treated with axicabtagene ciloleucel who developed a nonsinusoidal pattern of severe neurotoxicity refractory to steroid treatment, and we evaluate the predictive value of commonly used biomarkers and risk scores in assessing the likelihood of her presentation. Conclusion In assessing the efficacy of these scores in the context of our patient's pattern of severe neurotoxicity exacerbations, we aim to provide valuable clinical insight to better manage refractory ICANS and ultimately improve patient outcomes.
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Affiliation(s)
- Graeme A. Fenton
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Erin A. Dean
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL, USA
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Mannan A, Kakkar C, Dhiman S, Singh TG. Advancing the frontiers of adaptive cell therapy: A transformative mechanistic journey from preclinical to clinical settings. Int Immunopharmacol 2023; 125:111095. [PMID: 37875038 DOI: 10.1016/j.intimp.2023.111095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/08/2023] [Accepted: 10/17/2023] [Indexed: 10/26/2023]
Abstract
Although the concept of using the patient's immune system to combat cancer has been around for a while, it is only in recent times that substantial progress has been achieved in this field. Over the last ten years, there has been a significant advancement in the treatment of cancer through immune checkpoint blockade. This treatment has been approved for multiple types of tumors. Another approach to modifying the immune system to detect tumor cells and fight them off is adaptive cell therapy (ACT). This therapy involves using T cells that have been modified with either T cell receptors (TCR) or chimeric antigen receptors (CAR) to target the tumor cells. ACT has demonstrated encouraging outcomes in different types of tumors, and clinical trials are currently underway worldwide to enhance this form of treatment. This review focuses on the advancements that have been made in ACT from preclinical to clinical settings till now.
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Affiliation(s)
- Ashi Mannan
- Chitkara College of Pharmacy, Chitkara University, Rajpura, 140401, Punjab, India.
| | - Chirag Kakkar
- Chitkara College of Pharmacy, Chitkara University, Rajpura, 140401, Punjab, India.
| | - Sonia Dhiman
- Chitkara College of Pharmacy, Chitkara University, Rajpura, 140401, Punjab, India.
| | - Thakur Gurjeet Singh
- Chitkara College of Pharmacy, Chitkara University, Rajpura, 140401, Punjab, India.
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Giardino Torchia ML, Moody G. DIALing-up the preclinical characterization of gene-modified adoptive cellular immunotherapies. Front Immunol 2023; 14:1264882. [PMID: 38090585 PMCID: PMC10713823 DOI: 10.3389/fimmu.2023.1264882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/27/2023] [Indexed: 12/18/2023] Open
Abstract
The preclinical characterization of gene modified adoptive cellular immunotherapy candidates for clinical development often requires the use of mouse models. Gene-modified lymphocytes (GML) incorporating chimeric antigen receptors (CAR) and T-cell receptors (TCR) into immune effector cells require in vivo characterization of biological activity, mechanism of action, and preclinical safety. Typically, this characterization involves the assessment of dose-dependent, on-target, on-tumor activity in severely immunocompromised mice. While suitable for the purpose of evaluating T cell-expressed transgene function in a living host, this approach falls short in translating cellular therapy efficacy, safety, and persistence from preclinical models to humans. To comprehensively characterize cell therapy products in mice, we have developed a framework called "DIAL". This framework aims to enable an end-to-end understanding of genetically engineered cellular immunotherapies in vivo, from infusion to tumor clearance and long-term immunosurveillance. The acronym DIAL stands for Distribution, Infiltration, Accumulation, and Longevity, compartmentalizing the systemic attributes of gene-modified cellular therapy and providing a platform for optimization with the ultimate goal of improving therapeutic efficacy. This review will discuss both existent and emerging examples of DIAL characterization in mouse models, as well as opportunities for future development and optimization.
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Affiliation(s)
| | - Gordon Moody
- Cell Therapy Unit, Oncology Research, AstraZeneca, Gaithersburg, MD, United States
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30
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Palomo M, Moreno-Castaño AB, Salas MQ, Escribano-Serrat S, Rovira M, Guillen-Olmos E, Fernandez S, Ventosa-Capell H, Youssef L, Crispi F, Nomdedeu M, Martinez-Sanchez J, De Moner B, Diaz-Ricart M. Endothelial activation and damage as a common pathological substrate in different pathologies and cell therapy complications. Front Med (Lausanne) 2023; 10:1285898. [PMID: 38034541 PMCID: PMC10682735 DOI: 10.3389/fmed.2023.1285898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
The endothelium is a biologically active interface with multiple functions, some of them common throughout the vascular tree, and others that depend on its anatomical location. Endothelial cells are continually exposed to cellular and humoral factors, and to all those elements (biological, chemical, or hemodynamic) that circulate in blood at a certain time. It can adapt to different stimuli but this capability may be lost if the stimuli are strong enough and/or persistent in time. If the endothelium loses its adaptability it may become dysfunctional, becoming a potential real danger to the host. Endothelial dysfunction is present in multiple clinical conditions, such as chronic kidney disease, obesity, major depression, pregnancy-related complications, septic syndromes, COVID-19, and thrombotic microangiopathies, among other pathologies, but also in association with cell therapies, such as hematopoietic stem cell transplantation and treatment with chimeric antigen receptor T cells. In these diverse conditions, evidence suggests that the presence and severity of endothelial dysfunction correlate with the severity of the associated disease. More importantly, endothelial dysfunction has a strong diagnostic and prognostic value for the development of critical complications that, although may differ according to the underlying disease, have a vascular background in common. Our multidisciplinary team of women has devoted many years to exploring the role of the endothelium in association with the mentioned diseases and conditions. Our research group has characterized some of the mechanisms and also proposed biomarkers of endothelial damage. A better knowledge would provide therapeutic strategies either to prevent or to treat endothelial dysfunction.
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Affiliation(s)
- Marta Palomo
- Hemostasis and Erythropathology Laboratory, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, Institut de Recerca August Pi Sunyer, University of Barcelona, Barcelona, Spain
- Hematology External Quality Assessment Laboratory, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Ana Belén Moreno-Castaño
- Hemostasis and Erythropathology Laboratory, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, Institut de Recerca August Pi Sunyer, University of Barcelona, Barcelona, Spain
| | - María Queralt Salas
- Hematopoietic Stem Cell Transplantation Unit, Hematology Department, Institute of Cancer and Blood Diseases, Hospital Clínic de Barcelona, Institut de Recerca August Pi Sunyer, Barcelona, Spain
| | - Silvia Escribano-Serrat
- Hemostasis and Erythropathology Laboratory, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, Institut de Recerca August Pi Sunyer, University of Barcelona, Barcelona, Spain
| | - Montserrat Rovira
- Hematopoietic Stem Cell Transplantation Unit, Hematology Department, Institute of Cancer and Blood Diseases, Hospital Clínic de Barcelona, Institut de Recerca August Pi Sunyer, Barcelona, Spain
| | - Elena Guillen-Olmos
- Department of Nephrology and Kidney Transplantation, Hospital Clínic de Barcelona, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), University of Barcelona, Barcelona, Spain
| | - Sara Fernandez
- Medical Intensive Care Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Lina Youssef
- BCNatal – Barcelona Center for Maternal Fetal and Neonatal Medicine, Hospital Clínic de Barcelona and Hospital Sant Joan de Déu, Institut de Recerca August Pi Sunyer, University of Barcelona, Barcelona, Spain
- Josep Carreras Leukaemia Research Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Fatima Crispi
- BCNatal – Barcelona Center for Maternal Fetal and Neonatal Medicine, Hospital Clínic de Barcelona and Hospital Sant Joan de Déu, Institut de Recerca August Pi Sunyer, University of Barcelona, Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
| | - Meritxell Nomdedeu
- Hemostasis and Hemotherapy Department, Institute of Cancer and Blood Diseases, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Julia Martinez-Sanchez
- Hemostasis and Erythropathology Laboratory, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, Institut de Recerca August Pi Sunyer, University of Barcelona, Barcelona, Spain
| | - Blanca De Moner
- Hemostasis and Erythropathology Laboratory, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, Institut de Recerca August Pi Sunyer, University of Barcelona, Barcelona, Spain
- Josep Carreras Leukaemia Research Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Maribel Diaz-Ricart
- Hemostasis and Erythropathology Laboratory, Centre de Diagnòstic Biomèdic, Hospital Clínic de Barcelona, Institut de Recerca August Pi Sunyer, University of Barcelona, Barcelona, Spain
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Dowling MR, Turtle CJ. ICANS prophylaxis: potentially transformative but elusive. Blood Adv 2023; 7:6782-6784. [PMID: 37962875 PMCID: PMC10692280 DOI: 10.1182/bloodadvances.2023011027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open
Affiliation(s)
- Mark R Dowling
- Clinical Haematology Peter MacCallum Cancer Centre and Royal Melbourne Hospital, and the Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne VIC 3052, Australia
| | - Cameron J Turtle
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Camperdown NSW 2050, Australia
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Mauget M, Lemercier S, Houot R, Manson G. Immune effector cell-associated acute stroke: A novel entity? Eur J Cancer 2023; 194:113352. [PMID: 37852043 DOI: 10.1016/j.ejca.2023.113352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 10/20/2023]
Affiliation(s)
- Matteo Mauget
- Department of Hematology, University Hospital of Rennes, Rennes, France; Infectious Diseases and Intensive Care Unit, University Hospital of Rennes, Rennes France
| | - Sophie Lemercier
- Department of Neurology, University Hospital of Rennes, Rennes, France
| | - Roch Houot
- Department of Hematology, University Hospital of Rennes, Rennes, France; INSERM, U1236, Rennes, France
| | - Guillaume Manson
- Department of Hematology, University Hospital of Rennes, Rennes, France.
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Callahan C, Haas L, Smith L. CAR-T cells for pediatric malignancies: Past, present, future and nursing implications. Asia Pac J Oncol Nurs 2023; 10:100281. [PMID: 38023730 PMCID: PMC10661550 DOI: 10.1016/j.apjon.2023.100281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 07/30/2023] [Indexed: 12/01/2023] Open
Abstract
The treatment landscape for pediatric cancers over the last 11 years has undergone a dramatic change, especially with relapsed and refractory B-cell acute lymphoblastic leukemia (ALL), due to the introduction of chimeric antigen receptor-T (CAR-T) cell therapy. Because of the success of CAR-T cell therapy in patients with relapsed and refractory B-cell ALL, this promising therapy is undergoing trials in multiple other pediatric malignancies. This article will focus on the introduction of CAR-T cell therapy in pediatric B-cell ALL and discuss past and current trials. We will also discuss trials for CAR-T cell therapy in other pediatric malignancies. This information was gathered through a comprehensive literature review along with using first hand institutional experience. Due to the potential severe toxicities related to CAR-T cell therapy, safe practices and monitoring are key. These authors demonstrate that nurses have a profound responsibility in preparing and caring for patients and families, monitoring and managing side effects in these patients, ensuring that study guidelines are followed, and providing continuity for patients, families, and referring providers. Education of nurses is crucial for improved patient outcomes.
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Affiliation(s)
- Colleen Callahan
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Lauren Haas
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Laura Smith
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, USA
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34
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Li T, Luo R, Su L, Lv F, Mei L, Yu Y. Advanced Materials and Delivery Systems for Enhancement of Chimeric Antigen Receptor Cells. SMALL METHODS 2023; 7:e2300880. [PMID: 37653606 DOI: 10.1002/smtd.202300880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/12/2023] [Indexed: 09/02/2023]
Abstract
Chimeric antigen receptor (CAR) cell therapy is a great success and breakthrough in immunotherapy. However, there are still lots of barriers to its wide use in clinical, including long time consumption, high cost, and failure against solid tumors. For these challenges, researches are deplored to explore CAR cells to more appliable products in clinical. This minireview focuses on the advanced non-viral materials for CAR-T transfection ex vivo with better performance, delivery systems combined with other therapy for enhancement of CAR-T therapy in solid tumors. In addition, the targeted delivery platform for CAR cells in vivo generation as a breakthrough technology as its low cost and convenience. In the end, the prospective direction and future of CAR cell therapy are discussed.
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Affiliation(s)
- Tingxuan Li
- Tianjin Key Laboratory of Biomedical Materials, Key Laboratory of Biomaterials and Nanotechnology for Cancer Immunotherapy, Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, 300192, P. R. China
| | - Ran Luo
- Tianjin Key Laboratory of Biomedical Materials, Key Laboratory of Biomaterials and Nanotechnology for Cancer Immunotherapy, Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, 300192, P. R. China
| | - Lina Su
- Department of Pharmacy, Qujing Medical College, Qujing, Yunnan, 655000, P. R. China
| | - Feng Lv
- Tianjin Key Laboratory of Biomedical Materials, Key Laboratory of Biomaterials and Nanotechnology for Cancer Immunotherapy, Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, 300192, P. R. China
| | - Lin Mei
- Tianjin Key Laboratory of Biomedical Materials, Key Laboratory of Biomaterials and Nanotechnology for Cancer Immunotherapy, Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, 300192, P. R. China
- Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, Hunan, 410013, P. R. China
| | - Yongkang Yu
- Tianjin Key Laboratory of Biomedical Materials, Key Laboratory of Biomaterials and Nanotechnology for Cancer Immunotherapy, Institute of Biomedical Engineering, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, 300192, P. R. China
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Rosen RS, Yang JH, Peña JS, Schloss R, Yarmush ML. An in vitro model of the macrophage-endothelial interface to characterize CAR T-cell induced cytokine storm. Sci Rep 2023; 13:18835. [PMID: 37914765 PMCID: PMC10620221 DOI: 10.1038/s41598-023-46114-y] [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: 02/17/2023] [Accepted: 10/27/2023] [Indexed: 11/03/2023] Open
Abstract
Chimeric Antigen Receptor (CAR) T-cell therapy is a highly effective treatment for B-cell malignancies but limited in use due to clinically significant hyperinflammatory toxicities. Understanding the pathophysiologic mechanisms which mediate these toxicities can help identify novel management strategies. Here we report a novel in vitro model of the macrophage-endothelial interface to study the effects of CAR T-cell-induced cytokine storm. Using this model, we demonstrate that macrophage-mediated inflammation is regulated by endothelial cell activity. Furthermore, endothelial inflammation occurs independently of macrophages following exposure to CAR T-cell products and the induced endothelial inflammation potentiates macrophage-mediated inflammatory signaling, leading to a hyperinflammatory environment. While corticosteroids, the current gold standard of care, attenuate the resulting macrophage inflammatory signaling, the endothelial activity remains refractory to this treatment strategy. Utilizing a network model, coupled to in vitro secretion profiling, we identified STAT3 programming as critical in regulating this endothelial behavior. Lastly, we demonstrate how targeting STAT3 activity can abrogate endothelial inflammation and attenuate this otherwise hyperinflammatory environment. Our results demonstrate that endothelial cells play a central role in the pathophysiology of CAR T-cell toxicities and targeting the mechanisms driving the endothelial response can guide future clinical management.
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Affiliation(s)
- Robert S Rosen
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Jason H Yang
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA
- Center for Emerging and Re-Emerging Pathogens, Rutgers New Jersey Medical School, Newark, NJ, USA
- Department of Microbiology, Biochemistry and Molecular Genetics, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Juan S Peña
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA
| | - Rene Schloss
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA.
| | - Martin L Yarmush
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA
- Center for Engineering in Medicine, Massachusetts General Hospital, Boston, MA, USA
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Yang Z, Wang Y. Clinical development of chimeric antigen receptor-T cell therapy for hematological malignancies. Chin Med J (Engl) 2023; 136:2285-2296. [PMID: 37358555 PMCID: PMC10538902 DOI: 10.1097/cm9.0000000000002549] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Indexed: 06/27/2023] Open
Abstract
ABSTRACT Cellular therapies have revolutionized the treatment of hematological malignancies since their conception and rapid development. Chimeric antigen receptor (CAR)-T cell therapy is the most widely applied cellular therapy. Since the Food and Drug Administration approved two CD19-CAR-T products for clinical treatment of relapsed/refractory acute lymphoblastic leukemia and diffuse large B cell lymphoma in 2017, five more CAR-T cell products were subsequently approved for treating multiple myeloma or B cell malignancies. Moreover, clinical trials of CAR-T cell therapy for treating other hematological malignancies are ongoing. Both China and the United States have contributed significantly to the development of clinical trials. However, CAR-T cell therapy has many limitations such as a high relapse rate, adverse side effects, and restricted availability. Various methods are being implemented in clinical trials to address these issues, some of which have demonstrated promising breakthroughs. This review summarizes developments in CAR-T cell trials and advances in CAR-T cell therapy.
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Affiliation(s)
- Zhihuan Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Tianjin Key Laboratory of Cell Therapy for Blood Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300020, China
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37
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Scherer LD, Rouce RH. Targeted cellular therapy for treatment of relapsed or refractory leukemia. Best Pract Res Clin Haematol 2023; 36:101481. [PMID: 37612000 DOI: 10.1016/j.beha.2023.101481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 08/25/2023]
Abstract
While the mainstay of treatment for high-risk or relapsed, refractory leukemia has historically revolved around allogeneic hematopoietic stem cell transplant (allo-HSCT), targeted immunotherapies have emerged as a promising therapeutic option, especially given the poor prognosis of patients who relapse after allo-HSCT. Novel cellular immunotherapies that harness the cytotoxic abilities of the immune system in a targeted manner (often called "adoptive" cell therapy), have changed the way we treat r/r hematologic malignancies and continue to change the treatment landscape given the rapid evolution of these powerful, yet sophisticated precision therapies that often offer a less toxic alternative to conventional salvage therapies. Importantly, adoptive cell therapy can be allo-HSCT-enabling or a therapeutic option for patients in whom transplantation has failed or is contraindicated. A solid understanding of the core concepts of adoptive cell therapy is necessary for stem cell transplant physicians, nurses and ancillary staff given its proximity to the transplant field as well as its inherent complexities that require specific expertise in compliant manufacturing, clinical application, and risk mitigation. Here we will review use of targeted cellular therapy for the treatment of r/r leukemia, focusing on chimeric antigen receptor T-cells (CAR T-cells) given the remarkable sustained clinical responses leading to commercial approval for several hematologic indications including leukemia, with brief discussion of other promising investigational cellular immunotherapies and special considerations for sustainability and scalability.
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Affiliation(s)
- Lauren D Scherer
- Texas Children's Cancer Center, USA; Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, USA
| | - Rayne H Rouce
- Texas Children's Cancer Center, USA; Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, USA.
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Pinto SN, Liu CSJ, Nelson MD, Bluml S, Livingston D, Tamrazi B. Neuroimaging of complications arising after CD19 chimeric antigen receptor T-cell therapy: A review. J Neuroimaging 2023; 33:703-715. [PMID: 37327044 DOI: 10.1111/jon.13138] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/17/2023] Open
Abstract
Chimeric antigen receptor (CAR) T cells targeting the CD19 (cluster of differentiation 19) cell surface glycoprotein have emerged as a highly effective immunologic therapy in patients with relapsed or refractory B-cell malignancies. The engagement of CAR T cells with CD19 on the surface of neoplastic B cells causes a systemic cytokine release, which can compromise the blood-brain barrier and cause an immune effector cell-associated neurotoxicity syndrome (ICANS). In a small proportion of ICANS patients who demonstrate neuroimaging abnormalities, certain distinct patterns have been recognized, including signal changes in the thalami, external capsule, and brainstem, the subcortical and/or periventricular white matter, the splenium of the corpus callosum, and the cerebellum. On careful review of the underlying pathophysiology of ICANS, we noticed that these changes closely mirror the underlying blood-brain barrier disruption and neuroinflammatory and excitotoxic effects of the offending cytokines released during ICANS. Furthermore, other uncommon complications of CD19 CAR T-cell therapy such as posterior reversible encephalopathy syndrome, ocular complications, and opportunistic fungal infections can be catastrophic if not diagnosed in a timely manner, with neuroimaging playing a significant role in management. In this narrative review, we will summarize the current literature on the spectrum of neuroimaging findings in ICANS, list appropriate differential diagnoses, and explore the imaging features of other uncommon central nervous system complications of CD19 CAR T-cell therapy using illustrative cases from two tertiary care institutions.
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Affiliation(s)
- Soniya N Pinto
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Chia-Shang J Liu
- Division of Neuroradiology, Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Marvin D Nelson
- Division of Neuroradiology, Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Stefan Bluml
- Division of Neuroradiology, Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - David Livingston
- Resident, Department of Radiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Benita Tamrazi
- Division of Neuroradiology, Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
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Gavriilaki E, Mallouri D, Bousiou Z, Demosthenous C, Vardi A, Dolgyras P, Batsis I, Stroggyli E, Karvouni P, Masmanidou M, Gavriilaki M, Bouinta A, Bitsianis S, Kapravelos N, Bitzani M, Vasileiadou G, Yannaki E, Sotiropoulos D, Papagiannopoulos S, Kazis D, Kimiskidis V, Anagnostopoulos A, Sakellari I. Molecular and Clinical Characteristics of Different Toxicity Rates in Anti-CD19 Chimeric Antigen Receptor T Cells: Real-World Experience. Cancers (Basel) 2023; 15:4253. [PMID: 37686529 PMCID: PMC10487155 DOI: 10.3390/cancers15174253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
Commercially available anti-CD19 chimeric antigen receptor T cells (CARΤ cells) have offered long-term survival to a constantly expanding patient population. Given that novel toxicities including cytokine release syndrome (CRS) and neurotoxicity (ICANS) have been observed, we aimed to document the safety and toxicity of this treatment in a real-world study. We enrolled 31 adult patients referred to our center for CAR T therapy. Tisagenlecleucel was infused in 12 patients, axicabtagene ciloleucel in 14, and brexucabtagene autoleucel in 5. Cytokine release syndrome was noted in 26 patients while neurotoxicity was observed in 7. Tocilizumab was administered for CRS in 18 patients, along with short-term, low-dose steroid administration in one patient who developed grade III CRS and, subsequently, grade I ICANS. High-dose steroids, along with anakinra and siltuximab, were administered in only two MCL patients. With a median follow-up time of 13.4 months, nine patients were then in CR. The progression-free (PFS) and overall survival (OS) rates were 41.2% and 88.1% at one year, respectively. MCL diagnosis, which coincides with the administration of brexucabtagene autoleucel, was the only factor to be independently associated with poor OS (p < 0.001); meanwhile, increased LDH independently predicted PFS (p = 0.027).In addition, CRP at day 14 was associated with a poor OS (p = 0.001). Therefore, our real-world experience confirmed that commercial CAR T therapy can be administered with minimal toxicity.
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Affiliation(s)
- E. Gavriilaki
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
- Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - D. Mallouri
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - Z. Bousiou
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - C. Demosthenous
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - A. Vardi
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - P. Dolgyras
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - I. Batsis
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - E. Stroggyli
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - P. Karvouni
- Medical School, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - M. Masmanidou
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - M. Gavriilaki
- 1st Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (M.G.); (V.K.)
| | - A. Bouinta
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - S. Bitsianis
- Department of Surgery, G. Papanicolaou Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - N. Kapravelos
- 1st Intensive Care Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (N.K.); (G.V.)
| | - M. Bitzani
- 2nd Intensive Care Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (M.B.); (S.P.)
| | - G. Vasileiadou
- 1st Intensive Care Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (N.K.); (G.V.)
| | - E. Yannaki
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - D. Sotiropoulos
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - S. Papagiannopoulos
- 2nd Intensive Care Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (M.B.); (S.P.)
| | - D. Kazis
- 3rd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - V. Kimiskidis
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
- 1st Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (M.G.); (V.K.)
| | - A. Anagnostopoulos
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
| | - I. Sakellari
- Hematology Department and Bone Marrow Transplant (BMT) Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece; (D.M.); (Z.B.); (C.D.); (A.V.); (P.D.); (I.B.); (E.S.); (M.M.); (A.B.); (E.Y.); (D.S.); (A.A.); (I.S.)
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Heo BY, Lee MW, Choi S, Jung Y, Pham TTD, Jang Y, Park JH, Kang S, Koh JS, Jo DY, Kwon J, Song IC. Autoimmune Limbic Encephalitis in Patients with Hematologic Malignancies after Haploidentical Hematopoietic Stem Cell Transplantation with Post-Transplant Cyclophosphamide. Cells 2023; 12:2049. [PMID: 37626859 PMCID: PMC10453524 DOI: 10.3390/cells12162049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/05/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Autoimmune limbic encephalitis (LE) is a rare, but devastating complication of allogeneic hematopoietic stem cell transplantation (HSCT). There is currently limited evidence describing the risk factors, laboratory features, and underlying mechanisms of this neurologic adverse event. We retrospectively reviewed available clinical, imaging, and laboratory data from adult patients with hematological malignancies who underwent haploidentical HSCT with post-transplant cyclophosphamide (PTCy) at Chungnam National University Hospital from June 2016 to May 2020. Patients who developed LE were compared to those who did not based on clinical assessment, serum inflammatory biomarkers, and reconstitution of various T cell populations. Of 35 patients, 4 developed LE. There were no differences in patient demographics, donor demographics, or treatment conditions between patients that did and did not develop LE. Overall, patients with LE had worse clinical outcomes and overall survival than those without. In addition, they tended to have higher markers of systemic inflammation in the early post-transplant period, including fever, C-reactive protein (CRP), and cytokines. Remarkably, baseline interleukin-6 levels before HSCT were found to be higher in patients who developed LE than those who did not. In addition, analysis of T cell subsets showed impaired expansion of CD25+FOXP3+ regulatory T (Treg) cells in LE compared to non-LE patients despite appropriate reconstitution of the total CD4+ T cell population. Patients that developed LE within the first 30 days of HSCT were likely to have high serum IL-6 among other inflammatory cytokines coupled with suppression of regulatory T cell differentiation. Further work is needed on the mechanisms underlying impaired Treg expansion following HSCT and potential therapies.
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Affiliation(s)
- Bu Yeon Heo
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Myung-Won Lee
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munwha-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Suyoung Choi
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Yunju Jung
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Thi Thuy Duong Pham
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Yunseon Jang
- Translational Immunology Institute, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Jung-Hyun Park
- Translational Immunology Institute, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Sora Kang
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munwha-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Jeong Suk Koh
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munwha-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Deog-Yeon Jo
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munwha-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Jaeyul Kwon
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Translational Immunology Institute, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Ik-Chan Song
- Department of Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Brain Korea 21 FOUR Project for Medical Science, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Department of Internal Medicine, College of Medicine, Chungnam National University, 282 Munwha-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Translational Immunology Institute, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
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Nouri Y, Weinkove R, Perret R. An In Vitro Model to Assess CRS Potential of CAR T Cells Using a Tumor Cell Line and Autologous Monocytes. Curr Protoc 2023; 3:e864. [PMID: 37606421 DOI: 10.1002/cpz1.864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
Chimeric antigen receptor (CAR) T cell therapy is an engineered cell therapy where T cells are isolated and genetically modified to contain a synthetic CAR with specificity to a tumor cell antigen. Upon antigen binding, the CAR T cell will initiate signaling cascades that result in lysis of the associated tumor cell. Cytokine release syndrome (CRS) is the primary toxicity associated with CAR T cell therapy and remains a prominent safety issue with currently available commercial products. CRS is driven by interaction of the CAR T cells with endogenous monocytes and macrophages, which can lead to immune cell overactivation and an increase in certain cytokines to supraphysiological levels. Identifying the potential of any given CAR construct to drive toxicities in vivo should be assessed in preclinical models prior to human trials. While there are in vivo mouse models available for this purpose, these are often complex xenograft models available in few centers. Thus, there is a need to develop an in vitro assay for measuring the CRS potential of CAR T cells. The assay described here is a preclinical tool for assessing the propensity of any given CAR construct to produce potentially CRS-driving cytokines following tumor cell and monocyte interactions. This article provides a detailed protocol for target cell preparation and isolation of monocytes from peripheral blood mononuclear cells (PBMCs) autologous to the CAR T cells, as well as protocols for seeding the three cell types in a co-culture assay and collecting/analyzing the cytokines produced via an ELISA or multiplex bead array. © 2023 The Authors. Current Protocols published by Wiley Periodicals LLC. Basic Protocol 1: Preparation of K562 target cells Basic Protocol 2: Isolation of monocytes from autologous PBMCs Basic Protocol 3: Seeding of CAR T cells, monocytes, and K562 cells in 96-well plates Basic Protocol 4: Analysis of co-culture supernatants by single-cytokine ELISA Alternate Protocol: Analysis of co-culture supernatants by multiplex cytokine bead array.
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Affiliation(s)
- Yasmin Nouri
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
- Department of Pathology and Molecular Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Robert Weinkove
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
- Department of Pathology and Molecular Medicine, University of Otago Wellington, Wellington, New Zealand
- Te Rerenga Ora Blood and Cancer Centre, Te Whatu Ora Health New Zealand Capital Coast & Hutt Valley, Wellington, New Zealand
| | - Rachel Perret
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
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Saleki K, Mohamadi MH, Alijanizadeh P, Rezaei N. Neurological adverse effects of chimeric antigen receptor T-cell therapy. Expert Rev Clin Immunol 2023; 19:1361-1383. [PMID: 37578341 DOI: 10.1080/1744666x.2023.2248390] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Chimeric antigen receptor (CAR) T-cell is among the most prevalent approaches that act by directing T-cells toward cancer; however, they need to be optimized to minimize side effects and maximize efficacy before being used as standard treatment for malignancies. Neurotoxicity associated with CAR T-cell therapy has been well-documented in recent works. AREAS COVERED In this regard, two established syndromes exist. Immune effector cell-associated neurotoxicity syndrome (ICANS), previously called cytokine release encephalopathy syndrome (CRES), is a neuropsychiatric condition which can occur after therapy by immune effector cells (IEC) and T-lymphocytes utilizing treatments. Another syndrome is cytokine release syndrome (CRS), which may overlap with ICANS. EXPERT OPINION ICANS clinical manifestations include cerebral edema, mild lethargy, aphasia, and seizures. Notably, ICANS is associated with changes to EEG and neuroradiological findings. Therefore, it is necessary to make a timely and accurate diagnosis of neurological complications of CAR T-cells by clinical presentations, neuroimaging, and EEG. Since neurological events by different CAR T-cell products are heterogeneous, guides should be developed according to each product. Here, we provide an updated review of general information on CAR T-cell therapies and applications, neurological syndromes associated with their use, and risk factors contributing to ICANS.
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Affiliation(s)
- Kiarash Saleki
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran
- USERN Office, Babol University of Medical Sciences, Babol, Iran
- Department of e-Learning, Virtual School of Medical Education and Management, Shahid Beheshti University of Medical Sciences(SBMU), Tehran, Iran
| | | | - Parsa Alijanizadeh
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran
- USERN Office, Babol University of Medical Sciences, Babol, Iran
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
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Alsalem AN, Scarffe LA, Briemberg HR, Aaroe AE, Harrison RA. Neurologic Complications of Cancer Immunotherapy. Curr Oncol 2023; 30:5876-5897. [PMID: 37366923 DOI: 10.3390/curroncol30060440] [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: 05/05/2023] [Revised: 06/07/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023] Open
Abstract
Immunotherapy has revolutionized cancer treatment over the past decade. As it is increasingly introduced into routine clinical practice, immune-related complications have become more frequent. Accurate diagnosis and treatment are essential, with the goal of reduced patient morbidity. This review aims to discuss the various clinical manifestations, diagnosis, treatments, and prognosis of neurologic complications associated with the use of immune checkpoint inhibitors, adoptive T-cell therapies, and T-cell redirecting therapies. We also outline a suggested clinical approach related to the clinical use of these agents.
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Affiliation(s)
- Aseel N Alsalem
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
| | - Leslie A Scarffe
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
| | - Hannah R Briemberg
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
| | - Ashley E Aaroe
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Rebecca A Harrison
- Division of Neurology, University of British Columbia, Vancouver, BC V6T 2B5, Canada
- Division of Medical Oncology, BC Cancer, University of British Columbia, Vancouver, BC V5Z 4E6, Canada
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Gatto L, Ricciotti I, Tosoni A, Di Nunno V, Bartolini S, Ranieri L, Franceschi E. CAR-T cells neurotoxicity from consolidated practice in hematological malignancies to fledgling experience in CNS tumors: fill the gap. Front Oncol 2023; 13:1206983. [PMID: 37397356 PMCID: PMC10312075 DOI: 10.3389/fonc.2023.1206983] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/05/2023] [Indexed: 07/04/2023] Open
Abstract
Chimeric antigen receptor (CAR-T) therapy has marked a paradigm shift in the treatment of hematological malignancies and represent a promising growing field also in solid tumors. Neurotoxicity is a well-recognized common complication of CAR-T therapy and is at the forefront of concerns for CAR-based immunotherapy widespread adoption, as it necessitates a cautious approach. The non-specific targeting of the CAR-T cells against normal tissues (on-target off-tumor toxicities) can be life-threatening; likewise, immune-mediate neurological symptoms related to CAR-T cell induced inflammation in central nervous system (CNS) must be precociously identified and recognized and possibly distinguished from non-specific symptoms deriving from the tumor itself. The mechanisms leading to ICANS (Immune effector Cell-Associated Neurotoxicity Syndrome) remain largely unknown, even if blood-brain barrier (BBB) impairment, increased levels of cytokines, as well as endothelial activation are supposed to be involved in neurotoxicity development. Glucocorticoids, anti-IL-6, anti-IL-1 agents and supportive care are frequently used to manage patients with neurotoxicity, but clear therapeutic indications, supported by high-quality evidence do not yet exist. Since CAR-T cells are under investigation in CNS tumors, including glioblastoma (GBM), understanding of the full neurotoxicity profile in brain tumors and expanding strategies aimed at limiting adverse events become imperative. Education of physicians for assessing individualized risk and providing optimal management of neurotoxicity is crucial to make CAR-T therapies safer and adoptable in clinical practice also in brain tumors.
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Affiliation(s)
- Lidia Gatto
- Department of Oncology, Azienda Unità Sanitaria Locale (AUSL) Bologna, Bologna, Italy
| | - Ilaria Ricciotti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Alicia Tosoni
- Nervous System Medical Oncology Department, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Vincenzo Di Nunno
- Department of Oncology, Azienda Unità Sanitaria Locale (AUSL) Bologna, Bologna, Italy
| | - Stefania Bartolini
- Nervous System Medical Oncology Department, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Lucia Ranieri
- Nervous System Medical Oncology Department, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Enrico Franceschi
- Nervous System Medical Oncology Department, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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Santomasso BD, Gust J, Perna F. How I treat unique and difficult-to-manage cases of CAR T-cell therapy-associated neurotoxicity. Blood 2023; 141:2443-2451. [PMID: 36877916 PMCID: PMC10329188 DOI: 10.1182/blood.2022017604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/01/2023] [Accepted: 02/17/2023] [Indexed: 03/08/2023] Open
Abstract
With growing indications for chimeric antigen receptor (CAR) T-cell therapy, toxicity profiles are evolving. There is an urgent and unmet need of approaches to optimally manage emerging adverse events that extend beyond the standard paradigm of cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome (ICANS). Although management guidelines exist for ICANS, there is little guidance on how to approach patients with neurologic comorbidities, and how to manage rare neurotoxicity presentations, such as CAR T-cell therapy-related cerebral edema, severe motor complications or late-onset neurotoxicity. In this study, we present 3 scenarios of patients treated with CAR T cells who develop unique types of neurotoxicity, and we describe an approach for the evaluation and management based on experience because objective data are limited. The goal of this study is to develop an awareness of emerging and unusual complications, discuss treatment approaches, and help institutions and health care providers establish frameworks to navigate how to best address unusual neurotoxicities to ultimately improve patient outcomes.
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Affiliation(s)
- Bianca D. Santomasso
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Juliane Gust
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, WA
- Seattle Children's Research Institute Center for Integrative Brain Research, Seattle, WA
| | - Fabiana Perna
- Division of Hematology/Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
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Pensato U, Amore G, Muccioli L, Sammali S, Rondelli F, Rinaldi R, D'Angelo R, Nicodemo M, Mondini S, Sambati L, Asioli GM, Rossi S, Santoro R, Cretella L, Ferrari S, Spinardi L, Faccioli L, Fanti S, Paccagnella A, Pierucci E, Casadei B, Pellegrini C, Zinzani PL, Bonafè M, Cortelli P, Bonifazi F, Guarino M. CAR t-cell therapy in BOlogNa-NEUrotoxicity TReatment and Assessment in Lymphoma (CARBON-NEUTRAL): proposed protocol and results from an Italian study. J Neurol 2023; 270:2659-2673. [PMID: 36869888 DOI: 10.1007/s00415-023-11595-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVE To investigate neurotoxicity clinical and instrumental features, incidence, risk factors, and early and long-term prognosis in lymphoma patients who received CAR T-cell therapy. METHODS In this prospective study, consecutive refractory B-cell non-Hodgkin lymphoma patients who received CAR T-cell therapy were included. Patients were comprehensively evaluated (neurological examination, EEG, brain MRI, and neuropsychological test) before and after (two and twelve months) CAR T-cells. From the day of CAR T-cells infusion, patients underwent daily neurological examinations to monitor the development of neurotoxicity. RESULTS Forty-six patients were included in the study. The median age was 56.5 years, and 13 (28%) were females. Seventeen patients (37%) developed neurotoxicity, characterized by encephalopathy frequently associated with language disturbances (65%) and frontal lobe dysfunction (65%). EEG and brain FDG-PET findings also supported a predominant frontal lobe involvement. The median time at onset and duration were five and eight days, respectively. Baseline EEG abnormalities predicted ICANS development in the multivariable analysis (OR 4.771; CI 1.081-21.048; p = 0.039). Notably, CRS was invariably present before or concomitant with neurotoxicity, and all patients who exhibited severe CRS (grade ≥ 3) developed neurotoxicity. Serum inflammatory markers were significantly higher in patients who developed neurotoxicity. A complete neurological resolution following corticosteroids and anti-cytokines monoclonal antibodies was reached in all patients treated, except for one patient developing a fatal fulminant cerebral edema. All surviving patients completed the 1-year follow-up, and no long-term neurotoxicity was observed. CONCLUSIONS In the first prospective Italian real-life study, we presented novel clinical and investigative insights into ICANS diagnosis, predictive factors, and prognosis.
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Affiliation(s)
- Umberto Pensato
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italia
- Department of Neurology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Giulia Amore
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italia
| | - Lorenzo Muccioli
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italia
| | - Susanna Sammali
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italia
| | - Francesca Rondelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Italia, Sant'Orsola Hospital, Via Giuseppe Massarenti 9, Bologna, Italia
| | - Rita Rinaldi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Italia, Sant'Orsola Hospital, Via Giuseppe Massarenti 9, Bologna, Italia
| | - Roberto D'Angelo
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Italia, Sant'Orsola Hospital, Via Giuseppe Massarenti 9, Bologna, Italia
| | - Marianna Nicodemo
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Italia, Sant'Orsola Hospital, Via Giuseppe Massarenti 9, Bologna, Italia
| | - Susanna Mondini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Italia, Sant'Orsola Hospital, Via Giuseppe Massarenti 9, Bologna, Italia
| | - Luisa Sambati
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Italia, Sant'Orsola Hospital, Via Giuseppe Massarenti 9, Bologna, Italia
| | - Gian Maria Asioli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Italia, Sant'Orsola Hospital, Via Giuseppe Massarenti 9, Bologna, Italia
| | - Simone Rossi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Italia, Sant'Orsola Hospital, Via Giuseppe Massarenti 9, Bologna, Italia
| | - Rossella Santoro
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Italia, Sant'Orsola Hospital, Via Giuseppe Massarenti 9, Bologna, Italia
| | - Lucia Cretella
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Italia, Sant'Orsola Hospital, Via Giuseppe Massarenti 9, Bologna, Italia
| | - Susy Ferrari
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Italia, Sant'Orsola Hospital, Via Giuseppe Massarenti 9, Bologna, Italia
| | - Luca Spinardi
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Faccioli
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Stefano Fanti
- Nuclear Medicine Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Paccagnella
- Nuclear Medicine Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Elisabetta Pierucci
- Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Beatrice Casadei
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Cinzia Pellegrini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Pier Luigi Zinzani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Massimiliano Bonafè
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pietro Cortelli
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italia
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Italia, Sant'Orsola Hospital, Via Giuseppe Massarenti 9, Bologna, Italia
| | | | - Maria Guarino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Italia, Sant'Orsola Hospital, Via Giuseppe Massarenti 9, Bologna, Italia.
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Bompaire F, Birzu C, Bihan K, Desestret V, Fargeot G, Farina A, Joubert B, Leclercq D, Nichelli L, Picca A, Tafani C, Weiss N, Psimaras D, Ricard D. Advances in treatments of patients with classical and emergent neurological toxicities of anticancer agents. Rev Neurol (Paris) 2023; 179:405-416. [PMID: 37059646 DOI: 10.1016/j.neurol.2023.03.015] [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: 03/09/2023] [Revised: 03/18/2023] [Accepted: 03/21/2023] [Indexed: 04/16/2023]
Abstract
The neurotoxicity associated to the anticancer treatments has received a growing body of interest in the recent years. The development of innovating therapies over the last 20years has led to the emergence of new toxicities. Their diagnosis and management can be challenging in the clinical practice and further research is warranted to improve the understanding of their pathogenic mechanisms. Conventional treatments as radiation therapy and chemotherapy are associated to well-known and under exploration emerging central nervous system (CNS) and peripheral nervous system (PNS) toxicities. The identification of the risk factors and a better understanding of their pathogeny through a "bench to bedside and back again" approach, are the first steps towards the development of toxicity mitigation strategies. New imaging techniques and biological explorations are invaluable for their diagnosis. Immunotherapies have changed the cancer treatment paradigm from tumor cell centered to immune modulation towards an efficient anticancer immune response. The use of the immune checkpoints inhibitors (ICI) and chimeric antigen receptor (CAR-T cells) lead to an increase in the incidence of immune-mediated toxicities and new challenges in the neurological patient's management. The neurological ICI-related adverse events (n-irAE) are rare but potentially severe and may present with both CNS and PNS involvement. The most frequent and well characterized, from a clinical and biological standpoint, are the PNS phenotypes: myositis and polyradiculoneuropathy, but the knowledge on CNS phenotypes and their treatments is expanding. The n-irAE management requires a good balance between dampening the autoimmune toxicity without impairing the anticancer immunity. The adoptive cell therapies as CAR-T cells, a promising anticancer strategy, trigger cellular activation and massive production of proinflammatory cytokines inducing frequent and sometime severe toxicity known as cytokine release syndrome and immune effector cell-associated neurologic syndrome. Their management requires a close partnership between oncologist-hematologists, neurologists, and intensivists. The oncological patient's management requires a multidisciplinary clinical team (oncologist, neurologist and paramedical) as well as a research team leading towards a better understanding and a better management of the neurological toxicities.
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Affiliation(s)
- Flavie Bompaire
- Service de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France; UMR 9010 Centre Borelli, Université Paris-Saclay, École Normale Supérieure Paris-Saclay, CNRS, Service de Santé des Armées, Université Paris Cité, Inserm, Saclay, France; OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France
| | - Cristina Birzu
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Service de Neurologie 2-Mazarin, Sorbonne Université, Paris, France
| | - Kevin Bihan
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; AP-HP, Service de Pharmacologie, Centre Régional de Pharmacovigilance, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Inserm, CIC-1901, Sorbonne Universités, Paris, France
| | - Virginie Desestret
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Service de Neurocognition et Neuro-ophtalmologie, Hospices Civils de Lyon, Hôpital Neurologique Pierre-Wertheimer, Lyon, France; Centre de Référence Maladies Rares pour les Syndromes Neurologiques Paranéoplasiques et les Encéphalites Auto-Immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL-CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France
| | - Guillaume Fargeot
- AP-HP, Service de Neurologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Antonio Farina
- Centre de Référence Maladies Rares pour les Syndromes Neurologiques Paranéoplasiques et les Encéphalites Auto-Immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL-CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France; Service de Neurologie, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Bastien Joubert
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Centre de Référence Maladies Rares pour les Syndromes Neurologiques Paranéoplasiques et les Encéphalites Auto-Immunes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France; MeLiS, UCBL-CNRS UMR 5284, Inserm U1314, Université Claude-Bernard Lyon 1, Lyon, France; Service de Neurologie, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Delphine Leclercq
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; AP-HP, Service de Neuroradiologie, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Sorbonne Universités, Paris, France
| | - Lucia Nichelli
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; AP-HP, Service de Neuroradiologie, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Sorbonne Universités, Paris, France
| | - Alberto Picca
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Service de Neurologie 2-Mazarin, Sorbonne Université, Paris, France
| | - Camille Tafani
- Service de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France; OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France
| | - Nicolas Weiss
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; Dipartimento di Neuroscienze, Psicologia, Area del Farmaco e Salute del Bambino. Università di Firenze, Firenze, Italy; AP-HP, Service de Soins Intensifs en Neurologie, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Sorbonne Universités, Paris, France; École du Val-de-Grâce, Service de Santé des Armées, Paris, France
| | - Dimitri Psimaras
- OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles-Foix, Service de Neurologie 2-Mazarin, Sorbonne Université, Paris, France
| | - Damien Ricard
- Service de Neurologie, Hôpital d'Instruction des Armées Percy, Service de Santé des Armées, Clamart, France; UMR 9010 Centre Borelli, Université Paris-Saclay, École Normale Supérieure Paris-Saclay, CNRS, Service de Santé des Armées, Université Paris Cité, Inserm, Saclay, France; OncoNeuroTox Group: Center for Patients with Neurological Complications of Oncologic Treatments, Hôpitaux Universitaires Pitié-Salpêtrière - Charles-Foix et Hôpital d'Instruction des Armées Percy, Paris, France; École du Val-de-Grâce, Service de Santé des Armées, Paris, France.
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Xiao X, Cheng Y, Zheng X, Fang Y, Zhang Y, Sun R, Tian Z, Sun H. Bispecific NK-cell engager targeting BCMA elicits stronger antitumor effects and produces less proinflammatory cytokines than T-cell engager. Front Immunol 2023; 14:1113303. [PMID: 37114050 PMCID: PMC10126364 DOI: 10.3389/fimmu.2023.1113303] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/27/2023] [Indexed: 04/29/2023] Open
Abstract
Bispecific antibodies have attracted more attention in recent years for the treatment of tumors, in which most of them target CD3, which mediates the killing of tumor cells by T cells. However, T-cell engager may cause serious side effects, including neurotoxicity and cytokine release syndrome. More safe treatments are still needed to address unmet medical needs, and NK cell-based immunotherapy is a safer and more effective way to treat tumors. Our study developed two IgG-like bispecific antibodies with the same configuration: BT1 (BCMA×CD3) attracted T cells and tumor cells, while BK1 (BCMA×CD16) attracted NK cells and tumor cells. Our study showed that BK1 mediated NK cell activation and upregulated the expression of CD69, CD107a, IFN-γ and TNF. In addition, BK1 elicited a stronger antitumor effect than BT1 both in vitro and in vivo. Combinatorial treatment (BK1+BT1) showed a stronger antitumor effect than either treatment alone, as indicated by in vitro experiments and in vivo murine models. More importantly, BK1 induced fewer proinflammatory cytokines than BT1 both in vitro and in vivo. Surprisingly, BK1 reduced cytokine production in the combinatorial treatment, suggesting the indispensable role of NK cells in the control of cytokine secretion by T cells. In conclusion, our study compared NK-cell engagers and T-cell engagers targeting BCMA. The results indicated that NK-cell engagers were more effective with less proinflammatory cytokine production. Furthermore, the use of NK-cell engagers in combinatorial treatment helped to reduce cytokine secretion by T cells, suggesting a bright future for NK-cell engagers in clinical settings.
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Affiliation(s)
- Xinghui Xiao
- Hefei National Research Center for Physical Sciences at Microscale, The CAS Key Laboratory of Innate Immunity and Chronic Disease, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Institute of Immunology, University of Science and Technology of China, Hefei, China
| | - Ying Cheng
- Hefei National Research Center for Physical Sciences at Microscale, The CAS Key Laboratory of Innate Immunity and Chronic Disease, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Institute of Immunology, University of Science and Technology of China, Hefei, China
| | - Xiaodong Zheng
- Hefei National Research Center for Physical Sciences at Microscale, The CAS Key Laboratory of Innate Immunity and Chronic Disease, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Institute of Immunology, University of Science and Technology of China, Hefei, China
| | - Yuhang Fang
- Hefei National Research Center for Physical Sciences at Microscale, The CAS Key Laboratory of Innate Immunity and Chronic Disease, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Institute of Immunology, University of Science and Technology of China, Hefei, China
| | - Yu Zhang
- Hefei National Research Center for Physical Sciences at Microscale, The CAS Key Laboratory of Innate Immunity and Chronic Disease, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Institute of Immunology, University of Science and Technology of China, Hefei, China
| | - Rui Sun
- Hefei National Research Center for Physical Sciences at Microscale, The CAS Key Laboratory of Innate Immunity and Chronic Disease, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Institute of Immunology, University of Science and Technology of China, Hefei, China
| | - Zhigang Tian
- Hefei National Research Center for Physical Sciences at Microscale, The CAS Key Laboratory of Innate Immunity and Chronic Disease, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Institute of Immunology, University of Science and Technology of China, Hefei, China
- Hefei TG ImmunoPharma Corporation Limited, Hefei, China
| | - Haoyu Sun
- Hefei National Research Center for Physical Sciences at Microscale, The CAS Key Laboratory of Innate Immunity and Chronic Disease, School of Basic Medical Sciences, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Institute of Immunology, University of Science and Technology of China, Hefei, China
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Cole K, Al-Kadhimi Z, Talmadge JE. Highlights into historical and current immune interventions for cancer. Int Immunopharmacol 2023; 117:109882. [PMID: 36848790 PMCID: PMC10355273 DOI: 10.1016/j.intimp.2023.109882] [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: 12/30/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 03/01/2023]
Abstract
Immunotherapy is an additional pillar when combined with traditional standards of care such as chemotherapy, radiotherapy, and surgery for cancer patients. It has revolutionized cancer treatment and rejuvenated the field of tumor immunology. Several types of immunotherapies, including adoptive cellular therapy (ACT) and checkpoint inhibitors (CPIs), can induce durable clinical responses. However, their efficacies vary, and only subsets of cancer patients benefit from their use. In this review, we address three goals: to provide insight into the history of these approaches, broaden our understanding of immune interventions, and discuss current and future approaches. We highlight how cancer immunotherapy has evolved and discuss how personalization of immune intervention may address present limitations. Cancer immunotherapy is considered a recent medical achievement and in 2013 was selected as the "Breakthrough of the Year" by Science. While the breadth of immunotherapeutics has been rapidly expanding, to include the use of chimeric antigen receptor (CAR) T-cell therapy and immune checkpoint inhibitor (ICI) therapy, immunotherapy dates back over 3000 years. The expansive history of immunotherapy, and related observations, have resulted in several approved immune therapeutics beyond the recent emphasis on CAR-T and ICI therapies. In addition to other classical forms of immune intervention, including human papillomavirus (HPV), hepatitis B, and the Mycobacterium bovis Bacillus Calmette-Guérin (BCG) tuberculosis vaccines, immunotherapies have had a broad and durable impact on cancer therapy and prevention. One classic example of immunotherapy was identified in 1976 with the use of intravesical administration of BCG in patients with bladder cancer; resulting in a 70 % eradication rate and is now standard of care. However, a greater impact from the use of immunotherapy is documented by the prevention of HPV infections that are responsible for 98 % of cervical cancer cases. In 2020, the World Health Organization (WHO) estimated that 341,831 women died from cervical cancer [1]. However, administration of a single dose of a bivalent HPV vaccine was shown to be 97.5 % effective in preventing HPV infections. These vaccines not only prevent cervical squamous cell carcinoma and adenocarcinoma, but also oropharyngeal, anal, vulvar, vaginal, and penile squamous cell carcinomas. The breadth, response and durability of these vaccines can be contrasted with CAR-T-cell therapies, which have significant barriers to their widespread use including logistics, manufacturing limitations, toxicity concerns, financial burden and lasting remissions observed in only 30 to 40 % of responding patients. Another, recent immunotherapy focus are ICIs. ICIs are a class of antibodies that can increase the immune responses against cancer cells in patients. However, ICIs are only effective against tumors with a high mutational burden and are associated with a broad spectrum of toxicities requiring interruption of administration and/or administration corticosteroids; both of which limit immune therapy. In summary, immune therapeutics have a broad impact worldwide, utilizing numerous mechanisms of action and when considered in their totality are more effective against a broader range of tumors than initially considered. These new cancer interventions have tremendous potential notability when multiple mechanisms of immune intervention are combined as well as with standard of care modalities.
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Affiliation(s)
- Kathryn Cole
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Zaid Al-Kadhimi
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE 68198, USA; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - James E Talmadge
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE 68198, USA; Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE 68198-5950, USA; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA.
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Moreno-Castaño AB, Fernández S, Ventosa H, Palomo M, Martinez-Sanchez J, Ramos A, Ortiz-Maldonado V, Delgado J, Fernández de Larrea C, Urbano-Ispizua A, Penack O, Nicolás JM, Téllez A, Escolar G, Carreras E, Fernández-Avilés F, Castro P, Diaz-Ricart M. Characterization of the endotheliopathy, innate-immune activation and hemostatic imbalance underlying CAR-T cell toxicities: laboratory tools for an early and differential diagnosis. J Immunother Cancer 2023; 11:jitc-2022-006365. [PMID: 37045474 PMCID: PMC10106034 DOI: 10.1136/jitc-2022-006365] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Chimeric antigen receptor (CAR)-T cell-based immunotherapy constitutes a revolutionary advance for treatment of relapsed/refractory hematological malignancies. Nevertheless, cytokine release and immune effector cell-associated neurotoxicity syndromes are life-threatening toxicities in which the endothelium could be a pathophysiological substrate. Furthermore, differential diagnosis from sepsis, highly incident in these patients, is challenging. Suitable laboratory tools could be determinant for their appropriate management. METHODS Sixty-two patients treated with CAR-T cell immunotherapy for hematological malignancies (n=46 with CD19-positive diseases, n=16 with multiple myeloma) were included. Plasma samples were obtained: before CAR-T cell infusion (baseline); after 24-48 hours; at suspicion of any toxicity onset and 24-48 hours after immunomodulatory treatment. Biomarkers of endothelial dysfunction (soluble vascular cell adhesion molecule 1 (sVCAM-1), soluble TNF receptor 1 (sTNFRI), thrombomodulin (TM), soluble suppression of tumorigenesis-2 factor (ST2), angiopoietin-2 (Ang-2)), innate immunity activation (neutrophil extracellular traps (NETs), soluble C5b-9 (sC5b-9)) and hemostasis/fibrinolysis (von Willebrand Factor antigen (VWF:Ag), ADAMTS-13 (A13), α2-antiplasmin (α2-AP), plasminogen activator inhibitor-1 antigen (PAI-1 Ag)) were measured and compared with those in cohorts of patients with sepsis and healthy donors. RESULTS Patients who developed CAR-T cell toxicities presented increased levels of sVCAM-1, sTNFRI and ST2 at the clinical onset versus postinfusion values. Twenty-four hours after infusion, ST2 levels were good predictors of any CAR-T cell toxicity, and combination of ST2, Ang-2 and NETs differentiated patients requiring intensive care unit admission from those with milder clinical presentations. Association of Ang-2, NETs, sC5b-9, VWF:Ag and PAI-1 Ag showed excellent discrimination between severe CAR-T cell toxicities and sepsis. CONCLUSIONS This study provides relevant contributions to the current knowledge of the CAR-T cell toxicities pathophysiology. Markers of endotheliopathy, innate immunity activation and hemostatic imbalance appear as potential laboratory tools for their prediction, severity and differential diagnosis.
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Affiliation(s)
- Ana Belen Moreno-Castaño
- Hemostasis and Erythropathology Laboratory, Hematopathology, Pathology Department, Biomedical Diagnostic Center (CDB), Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain
| | - Sara Fernández
- Intensive Care Unit, Clinical Institute of Medicine and Dermatology (ICMID), Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Helena Ventosa
- Intensive Care Unit, Clinical Institute of Medicine and Dermatology (ICMID), Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Marta Palomo
- Hematology External Quality Assessment Laboratory, Biomedical Diagnostic Center (CDB), Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Alex Ramos
- Institut de Recerca Contra la Leucèmia Josep Carreras, Campus Clínic, Barcelona, Spain
| | - Valentín Ortiz-Maldonado
- Hematology Department, Clinical Institute of Hematologic and Oncologic Diseases (ICMHO), Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Julio Delgado
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain
- Hematology Department, Clinical Institute of Hematologic and Oncologic Diseases (ICMHO), Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Carlos Fernández de Larrea
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain
- Hematology Department, Clinical Institute of Hematologic and Oncologic Diseases (ICMHO), Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Alvaro Urbano-Ispizua
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain
- Hematology Department, Clinical Institute of Hematologic and Oncologic Diseases (ICMHO), Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Olaf Penack
- Hematology Department, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - J M Nicolás
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain
- Intensive Care Unit, Clinical Institute of Medicine and Dermatology (ICMID), Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Adrian Téllez
- Intensive Care Unit, Clinical Institute of Medicine and Dermatology (ICMID), Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Gines Escolar
- Hemostasis and Erythropathology Laboratory, Hematopathology, Pathology Department, Biomedical Diagnostic Center (CDB), Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain
| | - Enric Carreras
- Fundación Josep Carreras contra la Leucemia, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | - Francesc Fernández-Avilés
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain
- Hematology Department, Clinical Institute of Hematologic and Oncologic Diseases (ICMHO), Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Pedro Castro
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain
- Intensive Care Unit, Clinical Institute of Medicine and Dermatology (ICMID), Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Maribel Diaz-Ricart
- Hemostasis and Erythropathology Laboratory, Hematopathology, Pathology Department, Biomedical Diagnostic Center (CDB), Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic de Barcelona, Barcelona, Spain
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