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Pearson AD, Rossig C, Mackall C, Shah NN, Baruchel A, Reaman G, Ricafort R, Heenen D, Bassan A, Berntgen M, Bird N, Bleickardt E, Bouchkouj N, Bross P, Brownstein C, Cohen SB, de Rojas T, Ehrlich L, Fox E, Gottschalk S, Hanssens L, Hawkins DS, Horak ID, Taylor DH, Johnson C, Karres D, Ligas F, Ludwinski D, Mamonkin M, Marshall L, Masouleh BK, Matloub Y, Maude S, McDonough J, Minard-Colin V, Norga K, Nysom K, Pappo A, Pearce L, Pieters R, Pule M, Quintás-Cardama A, Richardson N, Schüßler-Lenz M, Scobie N, Sersch MA, Smith MA, Sterba J, Tasian SK, Weigel B, Weiner SL, Zwaan CM, Lesa G, Vassal G. Paediatric Strategy Forum for medicinal product development of chimeric antigen receptor T-cells in children and adolescents with cancer: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2021; 160:112-133. [PMID: 34840026 DOI: 10.1016/j.ejca.2021.10.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/13/2021] [Indexed: 12/30/2022]
Abstract
The seventh multi-stakeholder Paediatric Strategy Forum focused on chimeric antigen receptor (CAR) T-cells for children and adolescents with cancer. The development of CAR T-cells for patients with haematological malignancies, especially B-cell precursor acute lymphoblastic leukaemia (BCP-ALL), has been spectacular. However, currently, there are scientific, clinical and logistical challenges for use of CAR T-cells in BCP-ALL and other paediatric malignancies, particularly in acute myeloid leukaemia (AML), lymphomas and solid tumours. The aims of the Forum were to summarise the current landscape of CAR T-cell therapy development in paediatrics, too identify current challenges and future directions, with consideration of other immune effector modalities and ascertain the best strategies to accelerate their development and availability to children. Although the effect is of limited duration in about half of the patients, anti-CD19 CAR T-cells produce high response rates in relapsed/refractory BCP-ALL and this has highlighted previously unknown mechanisms of relapse. CAR T-cell treatment as first- or second-line therapy could also potentially benefit patients whose disease has high-risk features associated with relapse and failure of conventional therapies. Identifying patients with very early and early relapse in whom CAR T-cell therapy may replace haematopoietic stem cell transplantation and be definitive therapy versus those in whom it provides a more effective bridge to haematopoietic stem cell transplantation is a very high priority. Development of approaches to improve persistence, either by improving T cell fitness or using more humanised/fully humanised products and co-targeting of multiple antigens to prevent antigen escape, could potentially further optimise therapy. Many differences exist between paediatric B-cell non-Hodgkin lymphomas (B-NHL) and BCP-ALL. In view of the very small patient numbers with relapsed lymphoma, careful prioritisation is needed to evaluate CAR T-cells in children with Burkitt lymphoma, primary mediastinal B cell lymphoma and other NHL subtypes. Combination trials of alternative targets to CD19 (CD20 or CD22) should also be explored as a priority to improve efficacy in this population. Development of CD30 CAR T-cell immunotherapy strategies in patients with relapsed/refractory Hodgkin lymphoma will likely be most efficiently accomplished by joint paediatric and adult trials. CAR T-cell approaches are early in development for AML and T-ALL, given the unique challenges of successful immunotherapy actualisation in these diseases. At this time, CD33 and CD123 appear to be the most universal targets in AML and CD7 in T-ALL. The results of ongoing or planned first-in-human studies are required to facilitate further understanding. There are promising early results in solid tumours, particularly with GD2 targeting cell therapies in neuroblastoma and central nervous system gliomas that represent significant unmet clinical needs. Further understanding of biology is critical to success. The comparative benefits of autologous versus allogeneic CAR T-cells, T-cells engineered with T cell receptors T-cells engineered with T cell receptor fusion constructs, CAR Natural Killer (NK)-cell products, bispecific T-cell engager antibodies and antibody-drug conjugates require evaluation in paediatric malignancies. Early and proactive academia and multi-company engagement are mandatory to advance cellular immunotherapies in paediatric oncology. Regulatory advice should be sought very early in the design and preparation of clinical trials of innovative medicines, for which regulatory approval may ultimately be sought. Aligning strategic, scientific, regulatory, health technology and funding requirements from the inception of a clinical trial is especially important as these are very expensive therapies. The model for drug development for cell therapy in paediatric oncology could also involve a 'later stage handoff' to industry after early development in academic hands. Finally, and very importantly, strategies must evolve to ensure appropriate ease of access for children who need and could potentially benefit from these therapies.
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Affiliation(s)
| | - Claudia Rossig
- University Children´s Hospital Muenster, Pediatric Hematology and Oncology, Germany
| | - Crystal Mackall
- Department of Pediatrics and Medicine, Stanford University, Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford, CA, USA
| | - Nirali N Shah
- Pediatric Oncology Branch, National Cancer Institute, USA
| | - Andre Baruchel
- Hôpital Universitaire Robert Debré (APHP) and Université de Paris, France
| | | | | | | | | | - Michael Berntgen
- Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Dominik Karres
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | - Franca Ligas
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | | | | | - Lynley Marshall
- The Royal Marsden Hospital and the Institute of Cancer Research, London, UK
| | | | | | - Shannon Maude
- Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, USA
| | | | - Veronique Minard-Colin
- Department of Pediatric and Adolescent Oncology, INSERM U1015, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Koen Norga
- Antwerp University Hospital, Paediatric Committee of the European Medicines Agency, Federal Agency for Medicines and Health Products, Belgium
| | | | | | | | - Rob Pieters
- Princess Maxima Center for Pediatric Oncology, Netherlands
| | | | | | | | - Martina Schüßler-Lenz
- Chair of CAT (Committee for Advanced Therapies), European Medicines Agency (EMA), Amsterdam, Netherlands; Paul-Ehrlich-Institut, Germany
| | | | | | | | - Jaroslav Sterba
- University Hospital Brno, Masaryk University, Brno, Czech Republic
| | - Sarah K Tasian
- Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, USA
| | | | | | - Christian Michel Zwaan
- Princess Maxima Center for Pediatric Oncology, Netherlands; Haematological Malignancies Co-Chair Innovative Therapies for Children with Cancer Consortium (ITCC), Europe; Erasmus University Medical Center Rotterdam, Netherlands
| | - Giovanni Lesa
- Paediatric Medicines Office, Scientific Evidence Generation Department, Human Medicines Division, European Medicines Agency (EMA), Amsterdam, Netherlands
| | - Gilles Vassal
- ACCELERATE, Europe; Department of Pediatric and Adolescent Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
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Gofshteyn JS, Shaw PA, Teachey DT, Grupp SA, Maude S, Banwell B, Chen F, Lacey SF, Melenhorst JJ, Edmonson MJ, Panzer J, Barrett DM, McGuire JL. Neurotoxicity after CTL019 in a pediatric and young adult cohort. Ann Neurol 2018; 84:537-546. [PMID: 30178481 DOI: 10.1002/ana.25315] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 06/27/2018] [Accepted: 08/21/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To characterize the incidence and clinical characteristics of neurotoxicity in the month following CTL019 infusion in children and young adults, to define the relationship between neurotoxicity and cytokine release syndrome (CRS), and to identify predictive biomarkers for development of neurotoxicity following CTL019 infusion. METHODS We analyzed data on 51 subjects, 4 to 22 years old, who received CTL019, a chimeric antigen receptor-modified T-cell therapy against CD19, between January 1, 2010 and December 1, 2015 through a safety/feasibility clinical trial (NCT01626495) at our institution. We recorded incidence of significant neurotoxicity (encephalopathy, seizures, and focal deficits) and CRS, and compared serum cytokine levels in the first month postinfusion between subjects who did and did not develop neurotoxicity. RESULTS Neurotoxicity occurred in 23 of 51 subjects (45%, 95% confidence interval = 31-60%) and was positively associated with higher CRS grade (p < 0.0001) but was not associated with demographic characteristics or prior oncologic treatment history. Serum interleukin (IL)-2, IL-15, soluble IL-4, and hepatocyte growth factor concentrations were higher in subjects with neurotoxicity than those with isolated CRS. Differences in peak levels of select cytokines including IL-12 and soluble tumor necrosis factor receptor-1 within the first 3 days were seen in subjects with neurotoxicity. INTERPRETATION Neurotoxicity is common after CTL019 infusion in children and young adults, and is associated with higher CRS grade. Differences in serum cytokine profiles between subjects with neurotoxicity and those with isolated CRS suggest unique pathophysiological mechanisms. Serum cytokine profiles in the first 3 days postinfusion may help identify children and young adults at risk for neurotoxicity, and may provide a foundation for investigation into potential mitigation strategies. Ann Neurol 2018;84:537-546.
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Affiliation(s)
| | - Pamela A Shaw
- Division of Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - David T Teachey
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Stephan A Grupp
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Shannon Maude
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Brenda Banwell
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Fang Chen
- Division of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Simon F Lacey
- Division of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jan J Melenhorst
- Division of Pathology and Laboratory Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - MacKenzie J Edmonson
- Division of Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jessica Panzer
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David M Barrett
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer L McGuire
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
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Levine B, Maude S, Zheng Z, Shaw P, Ambrose D, Aplenc R, Barker C, Barrett D, Brogdon J, Callahan C, Chen F, Chew A, Suhoski Davis M, Fesnak A, Finklestein J, Frey N, Lacey S, Lamontagne A, Lewitt L, Loew A, Marcucci K, Melenhorst J, Motley L, Mudambi M, Nazimuddin F, O'Rourke M, Porter D, Rheingold S, Scholler J, Tayor C, White C, Wood P, Young R, Teachey D, June C, Grupp S. Durable Remissions with Control of Cytokine Release Syndrome (CRS) Using T Cells Expressing CD19 Targeted Chimeric Antigen Receptor (CAR) CTL019 to Treat Relapsed/Refractory (R/R) Acute Lymphoid Leukemia (ALL). Cytotherapy 2016. [DOI: 10.1016/j.jcyt.2016.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
The field of adoptive cell transfer includes chimeric antigen receptor (CAR) engineered T cells, constructs that emerged from basic research into principles of immunology and have transformed into clinically effective therapies for haematological malignancies. T cells engineered to express these artificial receptors hold great promise, but also carry significant risk. While permanent genetic modification of mature T cells appears safe, modulating their in vivo function is difficult, partly because the robust response can trigger other arms of the immune system. Suicide systems and toxicity management with cytokine blockade or signal transduction modulators have emerged as a new frontier in this field, a far cry from early problems getting CAR T cells to work at all. Currently, clinical trials in patients with relapsed or refractory B cell malignancies treated with CD19-specific CAR T cells have induced durable remissions in adults and children. Results from these trials indicate that more work needs to be done to understand biomarkers of efficacy, the role of T cell persistence and how to integrate this care into standard practice. Cell therapy will not be a 'one size fits all' class of medicine, and here we will discuss the development of this therapy and important questions for its future.
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Affiliation(s)
- Shannon Maude
- Abramson Cancer Center and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David M Barrett
- Abramson Cancer Center and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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