Hematologic Malignancies: Plasma Cell Disorders

2017 ◽  
pp. 561-568 ◽  
Author(s):  
Madhav V. Dhodapkar ◽  
Ivan Borrello ◽  
Adam D. Cohen ◽  
Edward A. Stadtmauer
Keyword(s):  
Bone Marrow ◽  
T Cells ◽  
Monoclonal Antibodies ◽  
T Cell ◽  
Cell Surface ◽  
Plasma Cell ◽  
Antigen Specificity ◽  
Immune Effector ◽  
Car T Cells ◽  
Car T

Multiple myeloma (MM) is a plasma cell malignancy characterized by the growth of tumor cells in the bone marrow. Properties of the tumor microenvironment provide both potential tumor-promoting and tumor-restricting properties. Targeting underlying immune triggers for evolution of tumors as well as direct attack of malignant plasma cells is an emerging focus of therapy for MM. The monoclonal antibodies daratumumab and elotuzumab, which target the plasma cell surface proteins CD38 and SLAMF7/CS1, respectively, particularly when used in combination with immunomodulatory agents and proteasome inhibitors, have resulted in high response rates and improved survival for patients with relapsed and refractory MM. A number of other monoclonal antibodies are in various stages of clinical development, including those targeting MM cell surface antigens, the bone marrow microenvironment, and immune effector T cells such as antiprogrammed cell death protein 1 antibodies. Bispecific preparations seek to simultaneously target MM cells and activate endogenous T cells to enhance efficacy. Cellular immunotherapy seeks to overcome the limitations of the endogenous antimyeloma immune response through adoptive transfer of immune effector cells with MM specificity. Allogeneic donor lymphocyte infusion can be effective but can cause graft-versus-host disease. The most promising approach appears to be genetically modified cellular therapy, in which T cells are given novel antigen specificity through expression of transgenic T-cell receptors (TCRs) or chimeric antigen receptors (CARs). CAR T cells against several different targets are under investigation in MM. Infusion of CD19-targeted CAR T cells following salvage autologous stem cell transplantation (SCT) was safe and extended remission duration in a subset of patients with relapsed/refractory MM. CAR T cells targeting B-cell maturation antigen (BCMA) appear most promising, with dramatic remissions seen in patients with highly refractory disease in three ongoing trials. Responses are associated with degree of CAR T-cell expansion/persistence and often toxicity, including cytokine release syndrome (CRS) and neurotoxicity. Ongoing and future studies are exploring correlates of response, ways to mitigate toxicity, and “universal” CAR T cells.

scholarly journals Analysis of T lymphocytes after bone marrow transplantation using monoclonal antibodies

Blood ◽  
1982 ◽  
Vol 60 (3) ◽  
pp. 578-582 ◽  
Author(s):  
R Fox ◽  
R McMillan ◽  
W Spruce ◽  
P Tani ◽  
D Mason
Keyword(s):  
Bone Marrow ◽  
T Cells ◽  
Monoclonal Antibodies ◽  
Bone Marrow Transplantation ◽  
T Cell ◽  
Cell Surface ◽  
Marrow Transplantation ◽  
T Cell Subsets ◽  
Clinically Significant ◽  
Abnormal Ratio

Abstract Using monoclonal antibodies to cell surface antigens and fluorescent cell sorter analysis, we studied peripheral blood lymphocyte subsets after bone marrow transplantation (BMT). In 13 patients studied 3 mo or more after BMT, the ratio of T-cell subsets defined by antibodies OKT4 and OKT8 was reversed (OKT4/OK%8 = 0.7 +/- 0.3) in comparison to normal volunteers or bone marrow donors (ratio OKT4/OKT8 = 1.7 +/- 0.4) (p less than 0.001). This reversed ratio persisted for up to 3 yr after BMT. In contrast to a previous report, presence of an abnormal ratio of T-cell subsets did not correlate with clinically significant graft- versus-host disease (GVHD). In agreement with a previous study, (26% +/- 8%; less than 4% in normals (p less than 0.001) and antibody OKT10 reactive cells (39% +/- 20% versus 10% +/- 4%) (p less than 0.01), suggesting in vivo activation. However, their PBL did not react with antibody B3/25 (antitransferrin receptor), a marker found on normal PBL after in vitro activation by mitogens (BMT patients less than 5%; normal PBL T cells plus PHA 45% +/- 11%). These results demonstrate that BMT patients have: (A) an abnormal ratio of T-cell subsets in the presence or absence of clinically significant GVDH disease so that these measurements were not useful in monitoring patients; (B) an increased number of T cells with cell surface phenotype (OKT8+, Ia+, OKT10+, B3/25-) that is distinct from normals but similar to patients with infectious mononucleosis or acquired hypogammaglobulinemia.

scholarly journals Immunotherapeutic Targeting of TSLPR with Chimeric Antigen Receptor T Cells in AML

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 2789-2789
Author(s):  
Lindsey F Call ◽  
Sommer Castro ◽  
Thao T. Tang ◽  
Cynthia Nourigat-Mckay ◽  
LaKeisha Perkins ◽  
...  
Keyword(s):  
Bone Marrow ◽  
T Cells ◽  
Cell Surface ◽  
Peripheral Blood ◽  
Surface Expression ◽  
Cell Surface Expression ◽  
Car T Cells ◽  
Car T

Abstract Adoptive transfer of T cells engineered to express chimeric antigen receptors (CARs) has achieved impressive outcomes in the treatment of refractory/relapsed B-ALL, providing potentially curative treatment options for these patients. The use of CAR T in AML, however, is still in its infancy with limitations due to the innate heterogeneity associated with AML and the lack of AML-specific targets for therapeutic development. The CRLF2 gene encodes for thymic stromal lymphopoietin receptor (TSLPR) and has previously been shown to be highly upregulated in a subset of children and adults with B-ALL. Targeting TSLPR with CAR T cells demonstrates potent anti-leukemia activity against TSLPR-positive B-ALL (PMID 26041741). Through Target Pediatric AML (TpAML), we profiled the transcriptome of nearly 3000 children and young adults with AML and identified CRLF2 (TSLPR) to be highly expressed in a subset of AML, including the majority of AML harboring KM2TA (aka MLL) fusions. TSLPR cell surface expression was validated in primary patient samples using flow cytometry, which showed uniform expression of TSLPR on AML blasts. Given that TSLPR is expressed in AML with confirmed cell surface expression, we developed TSLPR-directed CAR T for preclinical evaluation in AML. We generated a TSLPR-directed CAR using the single-chain variable fragment (scFv) derived from an anti-TSLPR binder (clone 3G1, MD Anderson), IgG4 spacer and 41-BB/CD3zeta signaling domains. The in vitro cytotoxicity of TSLPR CAR T cells was evaluated against the REH-1 cell line and primary AML specimens. TSLPR CAR T cells demonstrated anti-leukemia activity against REH-1 as well as against primary AML specimens. To evaluate the in vivo efficacy of TSLPR CAR T cells, we developed a patient-derived xenograft (PDX) model using bone marrow cells from a TSLPR-positive patient. These cells provided a robust model system to evaluate the in vivo activity of TSLPR CAR T cells, as they produced an aggressive leukemia in humanized NSG-SGM3 mice. The PDX generated from these cells died within 2 months of transplant with significant leukemia infiltration into the bone marrow, liver, and spleen. In the in vivo study, the leukemia burden was assessed by flow cytometric analysis of AML cells in the peripheral blood and bone marrow aspirates following treatment with unmodified control or TSLPR CAR T cells given at 10x10 6 T cells per mouse. After CAR T treatment, we detected a significant decrease in leukemia infiltration into the peripheral blood and bone marrow in the CAR T-treated mice compared to mice that received unmodified T cells. In this study, we report that similar to B-ALL, CRLF2 (TSLPR) is overexpressed in a subset of AML, providing a strategy to eliminate AML cells with CAR T cell therapy. We validated the cell surface expression of TSLPR and showed that the expression is uniform across AML specimens. We further demonstrate that CAR T cells targeting TSLPR were effective in eliminating AML cells in vitro and in vivo. Given that TSLPR is highly expressed in the KMT2A-rearranged AML, a subtype that is associated with poor outcomes, TSLPR-directed CAR T cells represent a promising immunotherapy for this high-risk AML subset. Disclosures Pardo: Hematologics, Inc.: Current Employment.

scholarly journals CD19 CAR-T Cell Therapy in Children with Relapsed and Refractory B-ALL

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 1737-1737
Author(s):  
Olga Molostova ◽  
Larisa Shelikhova ◽  
Yakov Muzalevsky ◽  
Alexey Kazachenok ◽  
Rimma Khismatullina ◽  
...  
Keyword(s):  
Bone Marrow ◽  
T Cells ◽  
T Cell ◽  
Point Of Care ◽  
Mitigation Strategy ◽  
T Cell Therapy ◽  
Car T Cells ◽  
Car T Cell Therapy ◽  
Car T

Abstract Introduction CD19 CAR-T is a highly effective therapy among children with relapsed/refractory B-ALL. The optimal approach to delivery of this therapy and the best post-remission strategy remain to be established. We have tested in a prospective academic trial CD19 CAR-T cells manufactured at the point-of-care based on the automatic bioreactor platform. Based on the results of the first part of the trial, a toxicity mitigation strategy with conditional split dosing and refined post-remission therapy based on allogeneic HSCT was implemented. We report here the results of toxicity mitigation strategy approach as well as the long-term outcome with regard to the HSCT consolidation. Patients and methods A total of 57 pts with relapsed/refractory B-ALL were screened, 54 pts were included in the trial, and additional 3 pts were eligible for compassionate use of CD19 CAR-T cell therapy. The CliniMACS Prodigy T-cell transduction process with lentiviral second generation CD19.4-1BB zeta vector (Lentigen, Miltenyi Biotec) was used for CAR-T manufacturing. All patients received prophylactic tocilizumab before CAR-T cells infusion. In the first part of trial 33 pts received lymphodepleting chemotherapy containing cyclophosphamide (750 mg/m2) and fludarabine (120 mg/m2), CAR-T cells was administered in dose-escalating regimen (0.1, 0.5, 1, and 3х10 6/kg b.w.). After the interim analysis, treatment scheme was modified to adapt the lymphodepletion therapy and the starting CAR-T dose to the leukemia burden. Twenty-four consecutive pts were divided into "low leukemia burden" (n=10) and "highleukemia burden" (n=14) groups, based on the threshold of 15% leukemic cells in the bone marrow. Patients with low leukemia burden received the same lymphodepletion chemotherapy as in the first part of the trial, and a single fixed dose of CAR-T cells at 1x10 6/kg b.w. Patients with high leukemia burden received an escalated lymphodepletion (fludarabine 120 mg/m 2, cyclophosphamide 750 mg/m 2, cytarabine 900 mg/m 2, etoposide 450 mg/m 2, dexamethasone 30 mg/m 2) and a divided dose of CAR-T. Day 0 CAR-T dose was set at 0.1 x10 6/kg. The second dose of 0.9x10 6/kg b.w. was administered between day 7 and day 14 if the following criteria were met: bone marrow leukemia burden by flow cytometry < 15% and CRS and/or ICANS grade within 3 previous days does not exceed grade 2. Results Thirty patients included in the first part of the trial, were evaluable for response at day 28, and 27 (90%) of them had MRD-negative remission. Interim analysis showed that grade 3-5 CRS and neurotoxicity were associated exclusively with large leukemia burden (>15% blasts in the bone marrow) at the enrollment (p=0,003). With the risk-adapted strategy (part 2 of the trial), 8 patients (80%) with low leukemic burden achieved CR at day 28, and all patients (100%) with high leukemic burden achieved complete remission on day 28. In the high burden cohort 4 patients received the second CAR-T infusion, while the remaining 10 patients did not receive second dose due to either toxicity grade ³2 (4 pts), or persistence of >15% blast cells in bone marrow (6 pts). There were no cases of grade IV-V toxicity among patients with high leukemia burden, Table 1. For all patients the median follow-up for survivors was 490 days (287-1193), the cumulative incidence of relapse after initial response was 69.6%, median time to relapse was 250 days (58-696). HSCT during the CR was performed in 15 patients. The median time between first CAR-T infusion and HSCT was 96 days (41-292). Three patients (20%) relapsed early after HSCT (88, 114 and 155 days). Event-free and overall survival for the total cohort was 19.6% and 56.4%, respectively. Among the 34 pts, who did not receive HSCT in CR after CAR-T therapy, EFS and OS were 14.7% and 55.7%. Among the 15 pts, who received HSCT as consolidation, EFS and OS were 86.1% and 80%, p-value for HSCT vs no HSCT 0.125 (OS) and 0.0001 (EFS). Conclusion Low doses of non-cryopreserved CAR-T cells (0.1*10 6/kg), manufactured at the point-of-care, demonstrated high efficacy in patients with high initial leukemia burden, as well as favorable profile of life-threatening toxicity. The proposed risk-adapted strategy of CAR-T dosing allows to achieve high remission rate in all patients (with high and low leukemic mass). HSCT is likely to be a necessary modality for consolidation and long-term maintenance of remission after CAR-T therapy among a majority of patients with advanced B-ALL. Figure 1 Figure 1. Disclosures Maschan: Miltenyi Biotec: Speakers Bureau.

scholarly journals Allogeneic CAR-T Cell Therapy for Treatment of Relapse after Allo-HSCT in Patients with Refractory CML Lymphoid Blast Crisis: Significance of HLA Matched Donor/Patient Pair in the Safety/Efficacy of CAR-T Cell Therapy

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 4275-4275 ◽  
Author(s):  
Kai Sun ◽  
Xuejun Zhang ◽  
Zhen Wang ◽  
Yuqing Chen ◽  
Lei Zhang ◽  
...  
Keyword(s):  
Bone Marrow ◽  
T Cells ◽  
T Cell ◽  
Cell Therapy ◽  
Blast Crisis ◽  
T Cell Therapy ◽  
Car T Cells ◽  
Car T Cell ◽  
Car T Cell Therapy ◽  
Car T

Abstract Introduction: CD19-specific CAR-T cells have shown promise in the treatment of relapsed or refractory Ph+ ALL. It remains to be established whether allogeneic CAR-T cells have clinical activity in patients with relapsed CML lymphoid blast crisis with a history of allo-HSCT. Here we report our experience in two cases of allogeneic CAR-T cell therapy for treatment of relapse after allo-HSCT in patients with refractory CML lymphoid blast crisis. Methods: For manufacture of allogeneic CAR-T cells, peripheral blood mononuclear cells were collected from the same stem cell donor. Lentiviral construction and generation of CAR-T cells, clinical protocol design, assessment and management of cytokine release syndrome (CRS), were performed as described in our previous report (Leukemia. 2017;31:2587-2593). Fludarabine and cyclophosphamide had been administered for lymphocyte depletion before allogeneic CAR-T cells infusion. Patients: Patient 1 was a 52-year-old woman with refractory CML lymphoid blast crisis, who had a relapse after undergoing allo-HSCT from her daughter (HLA-10/10). Her initial examinations of peripheral blood and bone marrow were consistent with the diagnosis of CML lymphoid blast crisis. Cytogenetics and molecular analysis confirmed the presence of t(9;22)(q34;q11) and BCR-ABL1 210 fusion protein. In February 2017, examination of bone marrow revealed a further increase of lymphoblasts to 83.2%. In addition, ABL1 kinase mutations (Y253H and E255K/V) were identified. The patient underwent HLA 10/10-matched allo-HSCT without acute GVHD. A remission with a negative test for BCR-ABL1 210 and 99.62% donor chimerism had been achieved, then she had a lymphoblastic relapse occurred 2 months after allo-HSCT. Consistently, BCR-ABL1 210 turned positive, and chimerism analysis showed 67.4% donor chimerism. 3 weeks after relapse, allogeneic CAR-T cells were infused at the dose of 5×106 /kg CD19-specific CAR-T cells. Patient 2 was a 39-year-old male patient with relapsed CML lymphoid blast crisis with a history of allo-HSCT. He had received a diagnosis of CML chronic phase 7 years earlier. Bone marrow revealed a karyotype of 46, XY, t(3;9;22)(q27;q34;q11) and BCR-ABL mRNA transcript. From April 2011 to September 2012, the patient was treated with nilotinib. In September 2012, bone marrow examination revealed 78% lymphoblasts, thus the diagnosis of CML lymphoid blast crisis was established. In December 2012, the patient underwent HLA 7/10-matched sibling allo-HSCT (from his brother) without evidence of GVHD and maintained CR for 2 years. In December 2014, the patient developed bone marrow relapse (lymphoblast 9.5%) and extramedullary leukemia (testicular involvement) harboring the BCR-ABL-T315I mutation. During 2014 to 2018, the patient received multiple courses of CIKs, HDMTX and DLI, but failed to achieve CR. In March 2018, the patient received healthy donor derived allogeneic CAR19 T cells (2×105/kg) therapy. Result: Before CAR-T cells infusion, both patients with refractory CML lymphoid blast crisis had a relapse after successful allo-HSCT. Approximately 1 month after CAR-T cells infusion, a persistent morphologic remission, a recovering BM, and complete absence of BCR-ABL mRNA transcripts confirmed morphologic and molecular remission in both patients. Consistent with this, flow cytometry could not detect blasts or CD19+ B lineage cells. Patient 1 did not experience toxicities and allogeneic CAR-T cell therapy was well tolerated. Patient 2 developed severe CRS (Gr 4) including high-grade fevers (>40°C), hypotension, hypoxia, mental status changes, and seizures. These episodes ran for approximately 1 week before they were halted by treatment with steroids plus tocilizumab, and plasma exchange. The toxicity of allogeneic CAR-T cells is correlated with high levels of IL-6, IFN-γ, TNF-a, and CRP. Conclusion: The clinical outcomes from these 2 patients demonstrate the in vivo efficacy of allogeneic CD19-targeted T cells to induce clinical, morphology and molecular remissions as well as B cell aplasia in adults with relapsed CML lymphoid blast crisis with a history of allo-HSCT. The efficacy of allogeneic CAR-T cell therapy may not always be related to the risk of severe CRS. The degree of HLA matching may have a major impact on the prevention of CRS after allogeneic CAR-T cell therapy. Fully HLA-matched-pair may increase the safety and efficacy of the allogeneic CAR-T cell therapy. Disclosures No relevant conflicts of interest to declare.

scholarly journals CAR2.0 Therapy for the Management of Post-Transplantation Relapse of B-Cell Acute Lymphoblastic Leukemia

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 7-7
Author(s):  
Rui Zhang ◽  
Juan Xiao ◽  
Zhouyang Liu ◽  
Yuan Sun ◽  
Sanfang Tu ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Flow Cytometry ◽  
T Cells ◽  
T Cell ◽  
Lymphoblastic Leukemia ◽  
Car T Cells ◽  
Car T Cell ◽  
Car T ◽  
Cell Acute Lymphoblastic Leukemia

BACKGROUND: Allogeneic haematopoietic stem cell transplantation (allo-HCT) is a standard treatment for relapsed/refractory B-cell acute lymphoblastic leukemia (r/r B-ALL). However ~30-40% of patients (pts) still relapse after HCT. We report a cohort of 20 r/rB-ALL pts, who relapsed after HCT, and enrolled in the CAR2.0 study receiving one or two types of CAR-T cells targeting various B-ALL antigens. METHOD: Pts with r/r B-ALL who relapsed after allo-HCT and did not have significant active comorbiditeis, were enrolled in the study. The target antigens were determined based on immunostaining of each pt's leukemia cells, and CAR-T infusions included a single, or a combination of CAR-Ts targeting the following antigens: CD19, CD22, CD123 and CD38. T cells were collected from pts (N=4) or their allogeneic donors (N=16) and transduced with an apoptosis-inducible, safety-engineered lentiviral CAR with the following intracellular signaling domains: CD28/CD27/CD3ζ-iCasp9 (4SCAR). Pts received cyclophosphamide/fludarabine lymphodepleting therapy before infusion of 0.2-5.8x106 CAR-T/kg per infusion. In addition to disease response, we carefully monitored the quality of apheresis cells, efficiency of gene transfer, T cell proliferation rate, CAR-T infusion dose, and the CAR-T copy number in peripheral blood. RESULTS: Among the 20 enrolled pts, 11 were <18 years of age, and 7 were BCR- ABL (P190) positive. Before CAR-T treatment, 7 pts had ≤grade 2 active graft-versus-host disease (GVHD), and 13 pts received chemotherapy or targeted therapy after their relapse post HCT. Six pts had extramedullary relapse and 2 of them also had bone marrow relapse. The tumor burden in bone marrow ranged from minimal residual disease (MRD) negative to 66% of blasts, based on flow cytometry before CAR-T therapy. Five pts had >10% blasts in bone marrow, 8 pts had <3% blasts, and 7 pts had MRD negative bone marrow (summarized in the Table below). Based on the GVHD history, chimerism state and the available T-cell sources, 16 pts used allogeneic HCT donor T-cells for CAR-T preparation. All pts were full donor chimeras prior to CAR-T infusion, except one pt who had 41% donor cells in bone marrow. Eleven pts received a single CD19 CAR-T infusion, with a mean dose of 1.6x106 CAR-T/kg, and ten achieved an MRD remission and one had progressive disease (PD) within 60 days by flow cytometry. The remaining 9 pts received 2 CAR-Ts (CD19 plus CD22, CD123 or CD38 CAR-Ts) given on the same day, and resulted in 8 CR and 1 PD within 60 days. After CAR-T infusion, no cytokine release syndrome (CRS) was observed in 8 pts, and 12 pts experienced CRS of grade 1, which was consistent with the previously described low toxicity profile of the 4SCAR design. Acute GVHD ≤ grade 2 developed in 5 pts within one month following CAR-T cell infusion but all responded well to supportive care and/or cyclosporine infusion. The 2 pts who developed PD after CAR-T infusion included the one with 41% donor chimerism and had grade 2 GVHD and active infections before CAR-T infusion. The other pt with PD following CAR-T had severe bone marrow suppression, low leukocyte count, infections and was transfusion dependent before enrollment. This emphasizes the need for controlling comorbidities before infusion of CAR-T cells. In summary, total 18 patients (90%) achieved negative MRD remission within 2 months of therapy with acceptable CRS. Four pts relapsed (after being in remission for 3 months) and 14 pts are in continued remission, 6 of which for > 1 year. None of these 20 pts received a second HCT after CAR-T infusion. GVHD developed in 5/16 (31%) pts after donor source CAR-T cell infusion within one month, but all responded well to treatment. CONCLUSION: This study focuses on CAR-T cell therapy following relapse after HCT. While the expanded study is ongoing, we present results of the first 20 pts. Use of donor-derived or recipient-derived CAR-T products in pts who relapsed after allo-HCT is well tolerated and it may prolong life expectancy of these pts while maintaining good quality of life. Table Disclosures No relevant conflicts of interest to declare.

scholarly journals Local Manufacture of CD19 CAR-T Cells Using an Automated Closed-System: Robust Manufacturing and High Clinical Efficacy with Low Toxicities

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 2625-2625
Author(s):  
Olga Molostova ◽  
Larisa Shelikhova ◽  
Dina Schneider ◽  
Rimma Khismatullina ◽  
Yakov Muzalevsky ◽  
...  
Keyword(s):  
Bone Marrow ◽  
T Cells ◽  
T Cell ◽  
Brain Edema ◽  
Transmembrane Domain ◽  
Lymphoblastic Leukemia ◽  
Car T Cells ◽  
Car T Cell ◽  
Car T ◽  
Grade Iii

Introduction CD19 CAR-T cell products were recently approved as therapy for B-lineage malignancies. We initiated an IIT trial where manufacture of CAR-T cells was performed locally using a unique CD19 CAR with potent anti-leukemic effects. Patients and methods A total of 37 pts with relapsed/refractory B-acute lymphoblastic leukemia (12 female, 25 male, median age 10 y) were screened, 27 pts were enrolled for a trial, 10 were eligible for compassionate use of CD19 CAR-T cell therapy. Sixteen patients had relapsed B-ALL after haploidentical HSCT, 19 pts refractory relapse, 2 induction failure, 13 patients had previous blinatumomab infusion. Eighteen patients had >20% blast cells, median bone marrow leukemia burden for patients with full blown disease was 89%, 19 pts had minimal residual disease (MRD) >0.1% in BM, 3 had skeletal involvement with multiple mass lesions, one had CNS involvement. The CliniMACS Prodigy T cell transduction (TCT) process was used to produce CD19 CAR-T cells. The automated production included CD4/CD8 selection, CD3/CD28 stimulation with MACS GMP T Cell TransAct and transduced with lentiviral vector expressing the CD19CAR gene (second generation CD19.4-1BB zeta with alternate transmembrane domain derived from the TNF superfamily) (Lentigen, Miltenyi Biotec company). T cells were expansion over 10 days in the presence of serum-free TexMACS GMP Medium supplemented with MACS GMP IL-7 and IL-15. Final product was administered without cryopreservation to the patients after fludarabine/cyclophosphamide preconditioning. All patients received prophylactic tocilizumab at 8mg/kg before CAR-T cell infusion. Patients did not receive HSCT as consolidation after CAR-T therapy. Results Thirty-five manufacturing cycles were successful. Median transduction efficacy was 60% (20-80). Median expansion of T cells was x 46 (18-51). CD4:CD8 ratio in the final product was 0.73. The cell products were administered at a dose of 3*106/kg of CAR-T cells in 4 pts, 1*106/kg in 9 pts, 0.5*106/kg in 14 pts, 0.1*106/kg in 8 pts. Two patients received 0.1*106/kg of CAR-T cells produced from haploidentical donors. The cytokine release syndrome (CRS) occurred in 22 (59%) pts and was mostly mild and moderate: grade I - 15 pts, grade II- 4 pts, grade III - 2 pt, grade IV - 1 pt. CAR-T cell related encephalopathy occurred in 15 (40%). Grade I-II neurotoxicity developed in 10 pts, grade III - in 2 pt, grade IV - 1 pt, grade V - 2 pt. In one patient with grade V neurotoxicity concomitant K. pneumonia encephalitis was documented. Severe (grade 3-5) CRS and neurotoxicity were associated exclusively with large leukemia burden (>20% in the bone marrow) at enrollment, p=0,002. Thirty-one patient was evaluable for response at day 28. Four pts had persistent leukemia. In 27 (87%) cases Flow MRD-negative remission was achieved. Disease relapse after initial response was registered in 9 (33%) cases (7 patients had CD19 negative, 2 had CD19 positive relapse). At the moment of reporting, 10 patients have died (3 due to sepsis, 1 due to brain edema, 1 due to brain edema and K. pneumonia encephalitis, 5 due to progression of disease or relapse). Twenty-seven pts are alive, 19 in complete remission with a median follow up of 223 days (41-516 days). Conclusion CliniMACS Prodigy TCT process is a robust CAR-T cell manufacturing platform that enables rapid and flexible provision of CAR-T cells to patients in need. Significant toxicity of CD19 CAR-T cells was associated exclusively with high leukemia burden at enrollment. In the absence of HSCT consolidation relapse rate exceeds 30%. Disclosures Schneider: Lentigen Technology, A Miltenyi Biotec Company: Employment. Preussner:Miltenyi Biotec: Employment. Rauser:Miltenyi Biotec: Employment. Orentas:Lentigen Technology Inc., a Miltenyi Biotec Company: . Dropulic:Lentigen Technology, A Miltenyi Biotec Company: Employment. Maschan:Miltenyi Biotec: Other: lecture fee.

scholarly journals Chimeric Antigen Receptors/Genetically Modified T-Cells

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. SCI-37-SCI-37 ◽  
Author(s):  
James N. Kochenderfer
Keyword(s):  
Bone Marrow ◽  
T Cells ◽  
T Cell ◽  
B Cell ◽  
Dose Level ◽  
Plasma Cells ◽  
Cell Therapies ◽  
Car T Cells ◽  
Car T ◽  
Fourth Dose

Multiple myeloma (MM) is a usually incurable malignancy of plasma cells. While the therapy of MM has improved greatly in the past 15 years, therapies with novel mechanisms of action are needed for MM. Allogeneic stem cell transplantation has been shown to have a potent anti-myeloma effect, and allogeneic donor lymphocyte infusions can cause remissions of MM. These results from allogeneic transplantation show that MM can be vulnerable to cellular immunotherapies, but allogeneic transplants have substantial rates of mortality and morbidity. Anti-CD19 CAR T cells have been shown to have powerful activity against B-cell malignancies. The success of anti-CD19 CAR T cells against B-cell malignancies has motivated investigators to develop genetically-modified T-cell therapies for MM. CD19 has been targeted as a therapy for multiple myeloma. A clinical trial of anti-CD19 CAR T cells for MM is underway. Part of the rationale for targeting CD19 is that CD19 might be expressed on a myeloma stem cell, which might be a mature B cell. The NY-ESO antigen has been targeted by human-leukocyte-antigen-restricted T cells in a clinical trial enrolling MM patients. B-cell maturation antigen (BCMA) is expressed by most cases of MM. We conducted the first-in-humans clinical trial of CAR T cells targeting BCMA at the National Cancer Institute. T cells expressing the CAR used in this work (CAR-BCMA) specifically recognized BCMA-expressing cells. Twelve patients received CAR-BCMA T cells on this dose-escalation trial. Among the 6 patients treated on the lowest two dose levels, limited anti-myeloma activity and mild toxicity occurred. On the third dose level, one patient obtained a very good partial remission. Two patients were treated on the fourth dose level of 9x106 CAR+T cells/kg bodyweight. Before treatment, the first patient on the fourth dose level had chemotherapy-resistant MM making up 90% of bone marrow cells. After treatment, bone marrow plasma cells became undetectable by flow cytometry, and the patient's MM entered a stringent complete remission that lasted for 17 weeks before relapse. The second patient on the fourth dose level had chemotherapy-resistant MM with 80% bone marrow plasma cells before treatment. Twenty-eight weeks after this patient received CAR-BCMA T-cells, bone marrow plasma cells were undetectable by flow cytometry, and the serum monoclonal protein had decreased by >95%. Both patients treated on the fourth dose level had toxicity consistent with cytokine-release syndrome including fever, hypotension, and dyspnea. Both patients also had prolonged cytopenias. In summary, our findings demonstrated strong anti-myeloma activity of CAR-BCMA T cells. One of the best attributes of the CAR T-cell field is that there are multiple avenues for improving CAR T-cell therapies. New CAR designs are being tested. Any part of the CAR might be improved including development of new fully-human single chain variable fragments (scFv) for the antigen-recognition component of the CAR, testing different hinge and transmembrane domains, and defining the optimal costimulatory moieties. Another avenue for improving CAR T-cell therapies is improving T-cell culture methods. Optimizing clinical application of CAR T cells, especially enhancing toxicity management, is another important avenue of improving CAR T-cell therapies. Finally, identifying new CAR target antigens is a critically important area of CAR research. In summary, genetically-modified T cells hold great promise to make a profound improvement in the therapy of multiple myeloma. Disclosures Kochenderfer: bluebird bio: Patents & Royalties, Research Funding; Kite Pharma: Patents & Royalties, Research Funding.

CAR T Cells and Other Cellular Therapies for Multiple Myeloma: 2018 Update

2018 ◽  
pp. e6-e15 ◽  
Author(s):  
Adam D. Cohen
Keyword(s):  
T Cells ◽  
T Cell ◽  
Residual Disease ◽  
Checkpoint Inhibitors ◽  
Antigen Specificity ◽  
Cell Repertoire ◽  
Cellular Therapies ◽  
Car T Cells ◽  
Car T Cell ◽  
Car T

Cellular therapies are a rapidly evolving approach to myeloma treatment, which bring a unique mechanism of action with the potential to overcome drug resistance and induce long-term remissions. Two primary approaches are being studied: non–gene-modified strategies, which rely on the endogenous anti-myeloma T-cell repertoire, and gene-modified strategies, which introduce a new T-cell receptor (TCR) or a chimeric antigen receptor (CAR) to confer novel antigen specificity. CAR T cells show the greatest activity to date. Multiple antigen targets, including B-cell maturation antigen (BCMA), CD19, CD38, CD138, and SLAMF7, are being explored for myeloma, and BCMA has emerged as the most promising. Preliminary data from four phase I studies of BCMA CAR T cells, each using a different CAR construct, that involved 90 evaluable patients with relapsed/refractory disease have been reported. These data show response rates of 60% to 100%, including minimal residual disease (MRD)-negative complete remissions, at effective doses (> 108 CAR-positive cells) after lymphodepleting conditioning. Response durability has been more variable, likely related to differences in CAR T-cell products, lymphodepleting regimens, patient selection criteria, and/or underlying biology/prognostic factors. In the two most recent studies, however, most patients remained progression free with median follow-up time of 6 to 10 months; some ongoing remissions lasted more than 1 year. Toxicities are similar to those from CD19 CAR T cells and include cytokine release syndrome and neurotoxicity that is reversible but can be severe. Multiple BCMA CAR T-cell studies are ongoing. Future directions include combinations with immunomodulatory drugs, checkpoint inhibitors, or other CAR T cells, as well as use of gene-edited cellular products to enhance the safety and efficacy of this approach.

scholarly journals Modular Chimeric Antigen Receptor Systems for Universal CAR T Cell Retargeting

2020 ◽  
Vol 21 (19) ◽  
pp. 7222
Author(s):  
Ashley R. Sutherland ◽  
Madeline N. Owens ◽  
C. Ronald Geyer
Keyword(s):  
T Cells ◽  
T Cell ◽  
Cell Activity ◽  
Cellular Immunotherapy ◽  
Antigen Receptors ◽  
Antigen Specificity ◽  
Precise Control ◽  
Car T Cells ◽  
Multiple Antigen ◽  
Car T

The engineering of T cells through expression of chimeric antigen receptors (CARs) against tumor-associated antigens (TAAs) has shown significant potential for use as an anti-cancer therapeutic. The development of strategies for flexible and modular CAR T systems is accelerating, allowing for multiple antigen targeting, precise programming, and adaptable solutions in the field of cellular immunotherapy. Moving beyond the fixed antigen specificity of traditional CAR T systems, the modular CAR T technology splits the T cell signaling domains and the targeting elements through use of a switch molecule. The activity of CAR T cells depends on the presence of the switch, offering dose-titratable response and precise control over CAR T cells. In this review, we summarize developments in universal or modular CAR T strategies that expand on current CAR T systems and open the door for more customizable T cell activity.

scholarly journals Overcoming Heterogeneity of Antigen Expression for Effective CAR T Cell Targeting of Cancers

Cancers ◽  
2020 ◽  
Vol 12 (5) ◽  
pp. 1075 ◽  
Author(s):  
Sareetha Kailayangiri ◽  
Bianca Altvater ◽  
Malena Wiebel ◽  
Silke Jamitzky ◽  
Claudia Rossig
Keyword(s):  
T Cells ◽  
T Cell ◽  
Cell Surface ◽  
Antigen Expression ◽  
T Cell Therapy ◽  
Major Mechanism ◽  
Car T Cells ◽  
Car T Cell ◽  
Combination Strategies ◽  
Car T

Chimeric antigen receptor (CAR) gene-modified T cells (CAR T cells) can eradicate B cell malignancies via recognition of surface-expressed B lineage antigens. Antigen escape remains a major mechanism of relapse and is a key barrier for expanding the use of CAR T cells towards solid cancers with their more diverse surface antigen repertoires. In this review we discuss strategies by which cancers become amenable to effective CAR T cell therapy despite heterogeneous phenotypes. Pharmaceutical approaches have been reported that selectively upregulate individual target antigens on the cancer cell surface to sensitize antigen-negative subclones for recognition by CARs. In addition, advanced T cell engineering strategies now enable CAR T cells to interact with more than a single antigen simultaneously. Still, the choice of adequate targets reliably and selectively expressed on the cell surface of tumor cells but not normal cells, ideally by driving tumor growth, is limited, and even dual or triple antigen targeting is unlikely to cure most solid tumors. Innovative receptor designs and combination strategies now aim to recruit bystander cells and alternative cytolytic mechanisms that broaden the activity of CAR-engineered T cells beyond CAR antigen-dependent tumor cell recognition.

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