Locoregional delivery of IL-13Rα2-targeting CAR-T cells in recurrent high-grade glioma: a phase 1 trial

Chimeric antigen receptor T cell (CAR-T) therapy is an emerging strategy to improve treatment outcomes for recurrent high-grade glioma, a cancer that responds poorly to current therapies. Here we report a completed phase I trial evaluating IL-13Rα2-targeted CAR-T cells in 65 patients with recurrent high-grade glioma, the majority being recurrent glioblastoma (rGBM). Primary objectives were safety and feasibility, maximum tolerated dose/maximum feasible dose and a recommended phase 2 dose plan. Secondary objectives included overall survival, disease response, cytokine dynamics and tumor immune contexture biomarkers. This trial evolved to evaluate three routes of locoregional T cell administration (intratumoral (ICT), intraventricular (ICV) and dual ICT/ICV) and two manufacturing platforms, culminating in arm 5, which utilized dual ICT/ICV delivery and an optimized manufacturing process. Locoregional CAR-T cell administration was feasible and well tolerated, and as there were no dose-limiting toxicities across all arms, a maximum tolerated dose was not determined. Probable treatment-related grade 3+ toxicities were one grade 3 encephalopathy and one grade 3 ataxia. A clinical maximum feasible dose of 200 × 106 CAR-T cells per infusion cycle was achieved for arm 5; however, other arms either did not test or achieve this dose due to manufacturing feasibility. A recommended phase 2 dose will be refined in future studies based on data from this trial. Stable disease or better was achieved in 50% (29/58) of patients, with two partial responses, one complete response and a second complete response after additional CAR-T cycles off protocol. For rGBM, median overall survival for all patients was 7.7 months and for arm 5 was 10.2 months. Central nervous system increases in inflammatory cytokines, including IFNγ, CXCL9 and CXCL10, were associated with CAR-T cell administration and bioactivity. Pretreatment intratumoral CD3 T cell levels were positively associated with survival. These findings demonstrate that locoregional IL-13Rα2-targeted CAR-T therapy is safe with promising clinical activity in a subset of patients. ClinicalTrials.gov Identifier: NCT02208362 .

Targeting Wnt signaling for improved glioma immunotherapy

Introduction

Despite aggressive standard-of-care therapy, including surgery, radiation, and chemotherapy, glioblastoma recurrence is almost inevitable and uniformly lethal. Activation of glioma-intrinsic Wnt/β-catenin signaling is associated with a poor prognosis and the proliferation of glioma stem-like cells, leading to malignant transformation and tumor progression. Impressive results in a subset of cancers have been obtained using immunotherapies including anti-CTLA4, anti-PD-1, and anti-PD-L1 or chimeric antigen receptor (CAR) T cell therapies. However, the heterogeneity of tumors, low mutational burden, single antigen targeting, and associated antigen escape contribute to non-responsiveness and potential tumor recurrence despite these therapeutic efforts. In the current study, we determined the effects of the small molecule, highly specific Wnt/CBP (CREB Binding Protein)/β-catenin antagonist ICG-001, on glioma tumor cells and the tumor microenvironment (TME)-including its effect on immune cell infiltration, blood vessel decompression, and metabolic changes.

Methods

Using multiple glioma patient-derived xenografts cell lines and murine tumors (GL261, K-Luc), we demonstrated in vitro cytostatic effects and a switch from proliferation to differentiation after treatment with ICG-001.

Results

In these glioma cell lines, we further demonstrated that ICG-001 downregulated the CBP/β-catenin target gene Survivin/BIRC5-a hallmark of Wnt/CBP/β-catenin inhibition. We found that in a syngeneic mouse model of glioma (K-luc), ICG-001 treatment enhanced tumor infiltration by CD3+ and CD8+ cells with increased expression of the vascular endothelial marker CD31 (PECAM-1). We also observed differential gene expression and induced immune cell infiltration in tumors pretreated with ICG-001 and then treated with CAR T cells as compared with single treatment groups or when ICG-001 treatment was administered after CAR T cell therapy.

Discussion

We conclude that specific Wnt/CBP/β-catenin antagonism results in pleotropic changes in the glioma TME, including glioma stem cell differentiation, modulation of the stroma, and immune cell activation and recruitment, thereby suggesting a possible role for enhancing immunotherapy in glioma patients.

Engineered IL13 variants direct specificity of IL13Rα2-targeted CAR T cell therapy

IL13Rα2 is an attractive target due to its overexpression in a variety of cancers and rare expression in healthy tissue, motivating expansion of interleukin 13 (IL13)-based chimeric antigen receptor (CAR) T cell therapy from glioblastoma into systemic malignancies. IL13Rα1, the other binding partner of IL13, is ubiquitously expressed in healthy tissue, raising concerns about the therapeutic window of systemic administration. IL13 mutants with diminished binding affinity to IL13Rα1 were previously generated by structure-guided protein engineering. In this study, two such variants, termed C4 and D7, are characterized for their ability to mediate IL13Rα2-specific response as binding domains for CAR T cells. Despite IL13Rα1 and IL13Rα2 sharing similar binding interfaces on IL13, mutations to IL13 that decrease binding affinity for IL13Rα1 did not drastically change binding affinity for IL13Rα2. Micromolar affinity to IL13Rα1 was sufficient to pacify IL13-mutein CAR T cells in the presence of IL13Rα1-overexpressing cells in vitro. Interestingly, effector activity of D7 CAR T cells, but not C4 CAR T cells, was demonstrated when cocultured with IL13Rα1/IL4Rα-coexpressing cancer cells. While low-affinity interactions with IL13Rα1 did not result in observable toxicities in mice, in vivo biodistribution studies demonstrated that C4 and D7 CAR T cells were better able to traffic away from IL13Rα1+ lung tissue than were wild-type (WT) CAR T cells. These results demonstrate the utility of structure-guided engineering of ligand-based binding domains with appropriate selectivity while validating IL13-mutein CARs with improved selectivity for application to systemic IL13Rα2-expressing malignancies.

Abstract CT541A: Oncolytic viral reshaping of the tumor microenvironment to promote CAR T cell therapy for glioblastoma

The combination of chimeric antigen receptor (CAR) T cell therapy, which delivers large numbers of tumor reactive T cells, and oncolytic viral therapy, causing activation of host immune responses, is an attractive approach for improving outcomes for patients with glioblastoma (GBM). Here we present data from two independent phase I clinical trials evaluating IL13Rα2-targeted CAR therapy (NCT02208362) and C134 oncolytic viral (OV) therapy (NCT03657576) for the treatment of recurrent GBM (rGBM), along with preclinical studies supporting the utility of combining these two therapies. For NCT02208362, locoregional delivery of IL13Rα2-targeted CAR T cells were evaluated in heavily pretreated patients with rGBM. Interrogating biomarkers of clinical response revealed that levels of intratumoral T cells prior to treatment were positively associated with overall survival; furthermore, two patients who achieved a complete response had the highest levels of intratumoral CD3+ T cells pre-therapy. These findings suggest that therapeutic strategies which increase endogenous immune infiltrates could augment CAR T cell mediated responses. For NCT03657576, intratumoral delivery of C134, a herpes simplex virus (HSV-1) that has been genetically engineered to safely replicate and kill glioma tumor cells, is also being evaluated for treatment of rGBM. We report findings from a patient treated intratumorally with 1 × 106 pfu of C134. At 6-7 weeks post treatment this patient had MRI changes that suggested possible recurrence or pseudoprogression, and therefore underwent resection with biopsy assessment. Evaluation of virus-treated areas showed increased immune infiltrates as compared to untreated tumor sites, suggesting that C134 activated host immune responses. These clinical findings provide the rationale for evaluating a combination therapy of C134 OV and IL13Rα2-CAR T cells to potentially reshape the tumor microenvironment (TME) and enhance CAR therapy. In orthotopic GBM models in nude mice, we show that co-treatment with the two agents gave no adverse reaction, and more notably pre-treatment with C134 re-shaped the TME by increasing immune cell infiltrates and enhanced the efficacy of sub-therapeutic doses of CAR T cell therapy delivered either intraventricularly or intratumorally. Ongoing preclinical studies aim to provide detailed phenotypic analysis, as well as a mechanistic understanding of this combination approach to support the potential benefit of a soon to be opened combination trial evaluating C134 and IL13Rα2-CAR T cells. In this clinical trial in patients with IL13Rα2+ rGBM and anaplastic astrocytoma, increasing doses of intratumorally administered C134 will be followed by dual intracranial intratumoral and intraventricular administration of IL13Rα2-targeted CAR T cell therapy.

Citation Format: Christine E. Brown, Agata Xella, Jonathan C. Hibbard, Vanessa Salvary, Brenda Aguilar, Jamie Wagner, Bruce Dezube, Knut Niss, Lynn Bayless, James Edinger, Jianmei Leavenworth, Stephen J. Forman, Behnam Badie, James M. Markert, Kevin A. Cassady. Oncolytic viral reshaping of the tumor microenvironment to promote CAR T cell therapy for glioblastoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT541A.

LIBERTI: A SMART study in plastic surgery

BACKGROUND/AIMS

Laser treatment of burns scars is considered by some providers to be standard of care. However, there is little evidence-based research as to the true benefit. A number of factors hinder evaluation of the benefit of laser treatment. These include significant heterogeneity in patient response and possible delayed effects from the laser treatment. Moreover, laser treatments are often provided sequentially using different types of equipment and settings, so there are effectively a large number of overall treatment options that need to be compared. We propose a trial capable of coping with these issues and that also attempts to take advantage of the heterogeneous response in order to estimate optimal treatment plans personalized to each individual patient. It will be the first large-scale randomized trial to compare the effectiveness of laser treatments for burns scars and, to our knowledge, the very first example of the utility of a Sequential Multiple Assignment Randomized Trial in plastic surgery.

METHODS

We propose using a Sequential Multiple Assignment Randomized Trial design to investigate the effect of various permutations of laser treatment on hypertrophic burn scars. We will compare and test hypotheses regarding laser treatment effects at a general population level. Simultaneously, we hope to use the data generated to discover possible beneficial personalized treatment plans, tailored to individual patient characteristics.

RESULTS

We show that the proposed trial has good power to detect laser treatment effect at the overall population level, despite comparing a large number of treatment combinations. The trial will simultaneously provide high-quality data appropriate for estimating precision-medicine treatment rules. We detail population-level comparisons of interest and corresponding sample size calculations. We provide simulations to suggest the power of the trial to detect laser effect and also the possible benefits of personalization of laser treatment to individual characteristics.

CONCLUSION

We propose, to our knowledge, the first use of a Sequential Multiple Assignment Randomized Trial in surgery. The trial is rigorously designed so that it is reasonably straightforward to implement and powered to answer general overall questions of interest. The trial is also designed to provide data that are suitable for the estimation of beneficial precision-medicine treatment rules that depend both on individual patient characteristics and on-going real-time patient response to treatment.

Accelerating high-dimensional clustering with lossless data reduction

MOTIVATION

For cluster analysis, high-dimensional data are associated with instability, decreased classification accuracy and high-computational burden. The latter challenge can be eliminated as a serious concern. For applications where dimension reduction techniques are not implemented, we propose a temporary transformation which accelerates computations with no loss of information. The algorithm can be applied for any statistical procedure depending only on Euclidean distances and can be implemented sequentially to enable analyses of data that would otherwise exceed memory limitations.

RESULTS

The method is easily implemented in common statistical software as a standard pre-processing step. The benefit of our algorithm grows with the dimensionality of the problem and the complexity of the analysis. Consequently, our simple algorithm not only decreases the computation time for routine analyses, it opens the door to performing calculations that may have otherwise been too burdensome to attempt.

AVAILABILITY AND IMPLEMENTATION

R, Matlab and SAS/IML code for implementing lossless data reduction is freely available in the Appendix.

CONTACT

obrienj@hms.harvard.edu.

Maintaining muscle protein anabolism after a metabolic stress: role of dextrose vs. amino acid availability

The effect of chronic hypocaloric parenteral infusions of amino acids (AA) vs. dextrose (D) on protein homeostasis after a generalized metabolic stress was examined. Multicatheterized mongrel dogs were metabolically challenged by a 4-day fast and then administered a 4-day intravenous infusion of saline (S, n = 8), D (n = 8), or isocaloric AA (n = 7). Although nitrogen balance (g.kg.1.day-1) was similarly negative with S (-0.37 +/- 0.05), D (-0.28 +/- 0.03), and AA (-0.37 +/- 0.04) during the fasting period, it was less negative (P < or = 0.05) with AA (-0.06 +/- 0.04) than with D (-0.20 +/- 0.03) or S (-0.23 +/- 0.04) during nutrient infusion. AA resulted in net hindlimb uptake and D in net hindlimb release of essential AA (570 +/- 261 vs. -248 +/- 59 nmol.kg-1.min-1). Whereas S and D infusions led to net hindlimb muscle protein loss (-37 +/- 24 and -89 +/- 33 micrograms.kg-1.min-1, respectively, P < or = 0.05 vs. AA), parenteral AA resulted in net deposition (169 +/- 62 micrograms.kg-1.min-1) as measured using L-[ring-2H5]phenylalanine. Thus hypocaloric parenteral D infusion after a metabolic stress does not favor nitrogen conservation, because net whole body nitrogen loss, skeletal muscle protein catabolism, and hindlimb AA release were not blunted compared with S infusion. Conversely, hypocaloric AA infusion preserves whole body and muscle protein stores.

Estrogen-mediated induction of rat prolactin gene transcription requires the formation of a chromatin loop between the distal enhancer and proximal promoter regions

Rat PRL (rPRL) gene transcription is controlled by proteins that interact with two DNA elements located in the 5'-upstream regulatory region. These elements, the distal enhancer and the proximal promoter, are separated by nearly 1500 bp of DNA. Induction of rPRL transcription by the estrogen 17 beta-estradiol (E2) is conferred through the estrogen response element located in the distal enhancer. To activate transcription, the estrogen-estrogen receptor complex must "communicate" with RNA polymerase II located at the proximal promoter. Using a novel nuclear ligation assay, it is shown that estrogen treatment of rat pituitary GH3 cells stimulates the formation of chromatin loops between the distal enhancer and proximal promoter of the rPRL gene, juxtaposing these two transcriptional control regions. The formation of these chromatin loops was observed in both the endogenous rPRL gene and in a rPRL-Tn5 minichromosome. Induction of rPRL and rPRL-Tn5 expression by E2 was reduced by coincubation of cells with the antiestrogen 4-hydroxytamoxifen. Likewise, 4-hydroxytamoxifen was found to block the E2-induced formation of chromatin loops between the distal and proximal regions. Concurrent treatment with the synthetic glucocorticoid dexamethasone reduced the E2-induced transcription rate of the rPRL and rPRL-Tn5 gene to near basal levels. Similarly, dexamethasone treatment inhibited the ability of E2 to enhance the formation of the chromatin loops. These data suggest that the activation of rPRL gene transcription by E2 involves the stabilization of a chromatin loop that facilitates protein-protein interactions between transcription factors that are associated with the distal enhancer and the proximal promoter.