Bridging therapy with axicabtagene ciloleucel for large B-cell lymphoma: results from the US Lymphoma CAR-T Consortium

ABSTRACT

During the manufacturing period of autologous chimeric antigen receptor (CAR) T-cell therapy, patients may experience a decline in their condition due to cancer progression. In this study, we investigated the impact of bridging therapy (BT) on the outcome of patients with relapsed/refractory large B-cell lymphoma who received antilymphoma treatment between leukapheresis and axicabtagene ciloleucel (axi-cel) infusion. We conducted our analysis using data from the multicenter US Lymphoma CAR-T Consortium, with a median follow-up of 33 months (range, 4.3-42.1). Out of the 298 patients who underwent leukapheresis, 275 patients received axi-cel. A total 52% of patients (n = 143) who received BT had a higher baseline risk profile than patients who did not receive BT, and these patients, as a group, had inferior outcomes compared with those who did not receive BT. However, after propensity score matching between the 2 groups, there were no statistically significant differences in overall response rate (77% vs 87%; P = .13), complete response rate (58% vs 70%; P = .1), progression-free survival (hazard ratio [HR], 1.25; P = .23), and overall survival (HR, 1.39; P=.09) between the BT group and the no-BT group, respectively. Analyzing the effects of BT in the whole cohort that underwent leukapheresis regardless of receiving axi-cel (intention-to-treat analysis) showed similar results. Radiation BT resulted in outcomes similar to those observed with nonradiation BT. Our findings suggest that BT may be safe without a significant impact on long-term survival for patients who require disease stabilization during the manufacturing period. Moreover, our results suggest that there is no clear advantage to using radiation-based BT over nonradiation-based BT.

Allogeneic transplant following CAR T-cell therapy for large B-cell lymphoma

Allogeneic hematopoietic cell transplantation (alloHCT) can potentially salvage large B-cell lymphoma (LBCL) patients experiencing treatment failure after chimeric antigen receptor T-cell therapy (CAR T). Nonetheless, data on the efficacy and toxicities of alloHCT after receipt of CAR T are limited. We report a multicenter retrospective study assessing the safety, toxicities, and outcomes of alloHCT in LBCL patients following CAR T failure. Eighty-eight patients with relapsed, refractory LBCL received an alloHCT following anti-CD19 CAR T failure. The median number of lines of therapy between CAR T infusion and alloHCT was one (range, 0-7). Low intensity conditioning was used in 77% (n=68) and peripheral blood was the most common graft source (86%, n=76). The most common donor types were matched unrelated donor (39%), followed by haploidentical (30%) and matched related donor (26%). Median follow-up of survivors was 15 months (range, 1-72). One-year overall survival, progression-free survival, and graft-versus-host disease-free relapse-free survival were 59%, 45%, and 39% respectively. One-year non-relapse mortality and progression/relapse were 22% and 33% respectively. On multivariate analysis, <2 lines of intervening therapy between CAR T and alloHCT and complete response at time of alloHCT were associated with better outcomes. In conclusion, alloHCT after CAR T failure can provide durable remissions in a subset of patients.

539 Phase 1 study of mRNA-2752, a lipid nanoparticle encapsulating mRNAs encoding human OX40L/IL-23/IL-36γ, for intratumoral (ITu) injection +/- durvalumab in advanced solid tumors and lymphoma

Background

mRNA-2752 is a novel mRNA-based therapeutic agent encoding OX40L T cell co-stimulator, IL-23 and IL-36γ pro-inflammatory cytokines. Preclinical data demonstrate synergy in combination with PD-L1 blockade.

Methods

This study evaluated the safety and efficacy of ITu mRNA-2752 administered Q2W up to 7 doses as monotherapy (Arm A) or in combination with the PD-L1 inhibitor durvalumab (Arm B) in patients (pts) with palpable tumors or tumors accessible with image guidance. Biomarker analyses included IHC of immune markers, whole transcriptome assessments, and protein evaluations of IL-23, IL-36γ and pro-inflammatory cytokines in pre- and post-treatment tumor biopsies and plasma. A PK/PD model was built to capture the IL-23 serum concentrations at the Q2W regimen to predict the exposure at the QW regimen to support an exploratory cohort.

Results

As of 08April 2021, 49 pts were treated: Arm A (n=19) and Arm B (n=30) at doses ranging from 0.25 to 8mg Q2W. Treatment emergent adverse events (TEAEs) occurring in ≥ 10% of pts included Gr 1/2 injection site erythema/pain/swelling, fever, chills, fatigue, AST/ALT increase, lumbar myalgia, and maculopapular rash. One DLT of cytokine release syndrome was seen at the 8mg dose in Arm B. A squamous-cell bladder cancer and DLBCL have achieved confirmed PRs on Arm B, ongoing for 23 and 16 cycles, respectively. Biomarker analyses show increased IL-23 and IL-36γ protein expression, and their respective downstream cytokines IL-22 and IL-6, in tumor and plasma 6–24h after dosing; most cytokines assessed were elevated after treatment. Increased IFNγ and TNFα in tumor and plasma, sustained increases in interferon response genes including PD-L1 and markers of T cell infiltration, and activation in the TME (particularly in pts achieving a PR) indicate pro-inflammatory treatment effects with mRNA-2752 +/- durvalumab. PK/PD modeling showed the Cmax of IL-23 serum concentration of mRNA-2752 at 8mg approached a plateau, and simulations showed increasing the dosing frequency from Q2W to QW vs. dose increase may have a greater effect on increasing drug exposure.

Conclusions

ITu mRNA-2752 is safe and tolerable when combined with durvalumab. The recommended dose for expansion is 8mg mRNA-2752. Analyses of tumor and plasma biomarkers suggest a sustained treatment effect that includes elevated IFNγ, TNFα, and PD-L1 levels, providing rationale for combination therapy. Enrollment is ongoing in expansion cohorts of TNBC, urothelial cancer, lymphoma, immune-checkpoint refractory melanoma and NSCLC. PK/PD modeling supports QW dosing which is being explored in cutaneous melanoma in the neoadjuvant setting.

Trial Registration

NCT03739931

References

Hewitt SL, Bai A, Bailey D et al. Durable anticancer immunity from intratumoral administration of IL-23, IL-36γ, and OX40L mRNAs. Sci Transl Med. 2019;11(477):1–15.

Ethics Approval

The study was approved by the respective participating Institution’s Ethics Board and conducted in accordance with the International Council for Harmonisation harmonised tripartite guideline E6(R1): Good Clinical Practice and all applicable government regulations.

Consent

Written informed consent was obtained from the patient for publication of this abstract and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.

Standard-of-Care Axicabtagene Ciloleucel for Relapsed or Refractory Large B-Cell Lymphoma: Results From the US Lymphoma CAR T Consortium

PURPOSE

Axicabtagene ciloleucel (axi-cel) is an autologous CD19-directed chimeric antigen receptor (CAR) T-cell therapy approved for relapsed/refractory large B-cell lymphoma (LBCL) on the basis of the single-arm phase II ZUMA-1 trial, which showed best overall and complete response rates in infused patients of 83% and 58%, respectively. We report clinical outcomes with axi-cel in the standard-of-care (SOC) setting for the approved indication.

PATIENTS AND METHODS

Data were collected retrospectively from all patients with relapsed/refractory LBCL who underwent leukapheresis as of September 30, 2018, at 17 US institutions with the intent to receive SOC axi-cel. Toxicities were graded and managed according to each institution's guidelines. Responses were assessed as per Lugano 2014 classification.

RESULTS

Of 298 patients who underwent leukapheresis, 275 (92%) received axi-cel therapy. Compared with the registrational ZUMA-1 trial, 129 patients (43%) in this SOC study would not have met ZUMA-1 eligibility criteria because of comorbidities at the time of leukapheresis. Among the axi-cel-treated patients, grade ≥ 3 cytokine release syndrome and neurotoxicity occurred in 7% and 31%, respectively. Nonrelapse mortality was 4.4%. Best overall and complete response rates in infused patients were 82% (95% CI, 77% to 86%) and 64% (95% CI, 58% to 69%), respectively. At a median follow-up of 12.9 months from the time of CAR T-cell infusion, median progression-free survival was 8.3 months (95% CI, 6.0 to15.1 months), and median overall survival was not reached. Patients with poor Eastern Cooperative Oncology Group performance status of 2-4 and elevated lactate dehydrogenase had shorter progression-free and overall survival on univariable and multivariable analysis.

CONCLUSION

The safety and efficacy of axi-cel in the SOC setting in patients with relapsed/refractory LBCL was comparable to the registrational ZUMA-1 trial.

Ibrutinib Dose Adherence and Therapeutic Efficacy in Non-Hodgkin Lymphoma: A Single-Center Experience

BACKGROUND

As oral targeted agents, such as ibrutinib, become more widely used, understanding the impact of suboptimal dosing on overall survival (OS) and progression-free survival (PFS) outside of clinical trials is imperative.

PATIENTS AND METHODS

Data on ibrutinib discontinuation, dose reductions, and treatment interruptions were collected on 170 non-Hodgkin lymphoma and chronic lymphocytic leukemia (CLL; n = 115, 64%) patients treated with ibrutinib at a single institution. Ibrutinib dose adherence was calculated as the proportion of days in which ibrutinib was administered out of the total number of days ibrutinib was prescribed in the first 8 weeks. Kaplan-Meier curves and log-rank tests were used to compare conditional survival outcomes beyond 8 weeks in patients with ≥ 80% dose adherence and patients with < 80% dose adherence.

RESULTS

Median OS among those who discontinued therapy for progression was poor (n = 51, 1.7 months; 95% confidence interval, 0.3-3.7). Lower dose adherence (< 80%) was associated with significantly worse PFS (P = .002) and OS (P = .021). However, among CLL patients, lower dose adherence was only associated with worse PFS (P = .043). Patients with early dose reductions had significantly worse PFS (P = .004) and OS (P = .014). Patients with dose interruptions lasting > 1 week had worse PFS (P = .047) but not OS (P = .577).

CONCLUSION

In this observational study, non-Hodgkin lymphoma and CLL patients experienced poor outcomes after discontinuing ibrutinib for disease progression. The inferior survival related to suboptimal dose adherence of ibrutinib was predominantly due to early dose reduction. These data confirm poor survival in CLL and lymphoma patients alike after ibrutinib discontinuation, and support recommendations for full dose at treatment initiation.

Axicabtagene Ciloleucel CAR T-Cell Therapy in Refractory Large B-Cell Lymphoma

BACKGROUND

In a phase 1 trial, axicabtagene ciloleucel (axi-cel), an autologous anti-CD19 chimeric antigen receptor (CAR) T-cell therapy, showed efficacy in patients with refractory large B-cell lymphoma after the failure of conventional therapy.

METHODS

In this multicenter, phase 2 trial, we enrolled 111 patients with diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, or transformed follicular lymphoma who had refractory disease despite undergoing recommended prior therapy. Patients received a target dose of 2×106 anti-CD19 CAR T cells per kilogram of body weight after receiving a conditioning regimen of low-dose cyclophosphamide and fludarabine. The primary end point was the rate of objective response (calculated as the combined rates of complete response and partial response). Secondary end points included overall survival, safety, and biomarker assessments.

RESULTS

Among the 111 patients who were enrolled, axi-cel was successfully manufactured for 110 (99%) and administered to 101 (91%). The objective response rate was 82%, and the complete response rate was 54%.With a median follow-up of 15.4 months, 42% of the patients continued to have a response, with 40% continuing to have a complete response. The overall rate of survival at 18 months was 52%. The most common adverse events of grade 3 or higher during treatment were neutropenia (in 78% of the patients), anemia (in 43%), and thrombocytopenia (in 38%). Grade 3 or higher cytokine release syndrome and neurologic events occurred in 13% and 28% of the patients, respectively. Three of the patients died during treatment. Higher CAR T-cell levels in blood were associated with response.

CONCLUSIONS

In this multicenter study, patients with refractory large B-cell lymphoma who received CAR T-cell therapy with axi-cel had high levels of durable response, with a safety profile that included myelosuppression, the cytokine release syndrome, and neurologic events. (Funded by Kite Pharma and the Leukemia and Lymphoma Society Therapy Acceleration Program; ZUMA-1 ClinicalTrials.gov number, NCT02348216 .).

Abstract CT047: SD-101, a novel intratumoral class C CpG-ODN, given with low-dose radiation in patients with untreated low-grade B-cell lymphoma: interim results of a phase I trial

Prior studies have shown preliminary clinical efficacy in combining CPG-ODN with radiation therapy (XRT) to patients with indolent B-cell lymphoma. We report Phase 1 data of combination XRT and SD-101, a synthetic class C CPG-ODN, selected for strong induction of type I interferon.

Methods: This dose-escalation Phase I trial (3+3 design) enrolled patients with untreated indolent B-cell lymphoma. The primary endpoints were safety and alpha-interferon-gene induction. Secondary endpoints included efficacy assessment using Cheson (1999) criteria and quantification of changes in tumor-infiltrating lymphocytes. Patients had a single lesion treated with XRT (2 Gy daily X 2 days) followed by weekly intratumoral SD-101 × 5 doses. Pharmacodynamic assessment included flow cytometry assessment of T-cell infiltrates in a FNA sample of the treated tumor and RT-PCR RNA assay of whole blood to assess induction of alpha-interferon genes. Efficacy assessment included imaging (CT at 3, 6, and every 6 months thereafter).

Results: As of 23 Dec 2015, 13 patients total were enrolled and treated with SD-101 doses of 1, 2, 4 or 8 mg/dose. There were no dose limiting toxicities. Twelve patients received all planned doses of XRT and SD-101. One patient (8 mg) withdrew consent for treatment after receiving 1 SD-101 dose due to Grade 2 confusion and flu-like symptoms. The most common adverse events (AEs) (decreasing frequency) were chills, malaise, myalgia, fatigue, headache, pyrexia, and nausea, typically resolving within 48 hours. One serious AE occurred (Grade 3 Pulmonary Embolism (4 mg)) which was incidental and asymptomatic. There were 2 dose delays due to an AE (Grade 3 neutropenia) in the same patient (8 mg) that resolved without treatment. The other AE was Grade 3 malaise reported in 2 patients (8 mg). At study Day 90, a reduction of the product of diameters in treated tumors occurred in 12 patients (median -45.3%; range [-87, +100]) and in non-treated tumors occurred in 11 patients (median -8.1%; range [-48, +45]). An induction of alpha-interferon genes occurred at all dose levels with similar level of induction. At the treated site, regulatory T-cells (T Regs) were reduced in 8 of 10 patients (average decrease 22.3 + 9.5%) at Day 8. There was an average reduction of 83.3 + 9.9% in follicular T helper cells (Tfh) at Day 8 (n = 9 with baseline Tfh).

Conclusions: SD-101 combined with radiation therapy showed preliminary abscopal anti-tumor activity and was well tolerated. A maximum tolerated dose has not yet been reached at the doses explored. Target engagement of the TLR-9 receptor (induction of interferon-alpha genes) was observed across all dose groups. A decrease in the proportion of T Regs and Tfh cells suggests modulation of their inhibitory effects and tumor growth promoting effects, respectively. The study is currently enrolling 2 expansion cohorts at 1 mg and 8 mg.

Citation Format: Ronald Levy, Nancy Bartlett, Jonathan Friedberg, Patrick Reagan, Leo Gordon, Craig Bergman, Robert Coffman, Robert Janssen, Albert Candia, Michael Khodadoust, Matthew Frank, Steven Long, Debra Czerwinski, Michael Chu, Holbrook Kohrt. SD-101, a novel intratumoral class C CpG-ODN, given with low-dose radiation in patients with untreated low-grade B-cell lymphoma: interim results of a phase I trial. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr CT047.

Approach to diagnosis and treatment of hypercalcemia in a patient with malignancy

Hypercalcemia is a common complication of malignancy and portends a worse prognosis. It causes a variety of symptoms in patients, which can range from confusion and polyuria to coma and death. There are 4 broad mechanistic categories to classify hypercalcemia of malignancy: local osteolysis secondary to metastatic cancer or multiple myeloma, excess parathyroid-related hormone, excess 1,25-dihydroxyvitamin D production, and ectopic parathyroid hormone production. Volume expansion with normal saline solution and treatment with intravenous bisphosphonates to decrease osteoclast-mediated bone destruction are effective initial therapies. Calcitonin, gallium nitrate, and corticosteroids can serve as adjunctive therapies. Denosumab is an attractive therapeutic option for refractory cases of hypercalcemia, although more data are required before this therapy can be recommended.

Activation of the transcription factor, nuclear factor kappa-B, during the estrous cycle and early pregnancy in the pig

Establishment and maintenance of pregnancy in the pig involves intricate communication between the developing conceptuses and the maternal endometrium. This process occurs during trophoblast elongation which is spaciotemporally associated with conceptus synthesis and release of IL1B concomitant with pregnancy-specific endometrial up-regulation of IL-1 receptors, providing the potential for activation of the transcription factor, NFKB. The objective of the current investigation was to determine changes in expression and cellular localization of NFKB and associated factors during the estrous cycle and early pregnancy in the pig. In situ hybridization was used to localize changes in PGR, ESR1, and TNFRSF11A during the peri-implantation period. Quantitative RT-PCR was utilized to demonstrate gene expression changes for NFKB1, RELA, TNFRSF11A, TLR4, NFKBIA and NFKBIB. Transcription factor ELISA demonstrated an overall increase in RELA during the peri-implantation period in both cyclic and pregnant gilts. While the presence of TNFSF11A and TLR4 were both detected, TLR4 expression changes were temporally associated with NFKB expression and activation. Collectively, these data demonstrate that NFKB activation may occur during the period of uterine receptivity in both the cyclic and pregnant endometrium.

Chemosensory responses to CO2 in multiple brain stem nuclei determined using a voltage-sensitive dye in brain slices from rats

We used epifluorescence microscopy and a voltage-sensitive dye, di-8-ANEPPS, to study changes in membrane potential during hypercapnia with or without synaptic blockade in chemosensory brain stem nuclei: the locus coeruleus (LC), the nucleus of the solitary tract, lateral paragigantocellularis nucleus, raphé pallidus, and raphé obscurus and, in putative nonchemosensitive nuclei, the gigantocellularis reticular nucleus and the spinotrigeminal nucleus. We studied the response to hypercapnia in LC cells to evaluate the performance characteristics of the voltage-sensitive dye. Hypercapnia depolarized many LC cells and the voltage responses to hypercapnia were diminished, but not eradicated, by synaptic blockade (there were intrinsically CO2-sensitive cells in the LC). The voltage response to hypercapnia was substantially diminished after inhibiting fast Na+ channels with tetrodotoxin. Thus action potential-related activity was responsible for most of the optical signal that we detected. We systematically examined CO2 sensitivity among cells in brain stem nuclei to test the hypothesis that CO2 sensitivity is a ubiquitous phenomenon, not restricted to nominally CO2 chemosensory nuclei. We found intrinsically CO2 sensitive neurons in all the nuclei that we examined; even the nonchemosensory nuclei had small numbers of intrinsically CO2 sensitive neurons. However, synaptic blockade significantly altered the distribution of CO2-sensitive cells in all of the nuclei so that the cellular response to CO2 in more intact preparations may be difficult to predict based on studies of intrinsic neuronal activity. Thus CO2-sensitive neurons are widely distributed in chemosensory and nonchemosensory nuclei and CO2 sensitivity is dependent on inhibitory and excitatory synaptic activity even within brain slices. Neuronal CO2 sensitivity important for the behavioral response to CO2 in intact animals will thus be determined as much by synaptic mechanisms and patterns of connectivity throughout the brain as by intrinsic CO2 sensitivity.

'Common sense and a thick hide'. Physicians providing care to their own family members

OBJECTIVE

To determine how frequently physicians treat their relatives in 17 categories of care, their reasons for deciding to treat, and their level of comfort with this practice.

DESIGN

Mailed survey.

SETTING

Rural, suburban, and urban practices in Oregon.

SUBJECTS

Two thousand fourteen physicians in the following specialties: general practice, family practice, general internal medicine, general surgery, orthopedic surgery, obstetrics/gynecology, and pediatric medicine.

RESULTS

One thousand two hundred ninety-two questionnaires (64%) were returned. Minor prescribing was done most frequently, followed by routine pediatric care, physical examinations, and minor surgery. All other forms of care occurred rarely, and there appears to be a gradient based on the level of complexity, seriousness, and potential for conflict with privacy. In general, older, male, and rural physicians provided more services to family members than their younger, female, and urban counterparts. General and family practitioners performed the most family care; general internists, the least. The most important reasons for providing care were convenience for the patient and request from relatives. Providers were most comfortable providing care to their children and least comfortable providing care to their grandparents.

CONCLUSIONS

There is a wide range of practice, depending on the nature of the care and provider characteristics. Physicians report treating their own family members rarely and face significant dilemmas when doing so.