Impact of Bridging Chemotherapy on Clinical Outcomes of CD19 CAR T Therapy in Relapse/Refractory Diffuse Large B- Cell Lymphoma in Real World Experience

Background: Autologous chimeric antigen receptor (CAR) T cell therapy has shown to be effective in relapsed or refractory (R/R) diffuse large B cell lymphoma (DLBCL) but requires in real world and in Europe at least a 4 weeks period of cell processing. During this "bridging period", patients are vulnerable to disease progression and complications. We sought to characterize bridging therapy strategies. Methods: We performed a retrospective review of patients (pts) with R/R DLBCL treated with commercialized CD19 CAR T cells, either Axicabtagene Ciloleucel (Yescarta) or tisagenlecleucel (Kymriah). Bridging therapy (BT) was defined by any therapy given from enrolment to cell infusion. We divided bridging therapy in 2 groups: high intensity BT (HI, including chemotherapy+/-immunotherapy) and low intensity BT (LI, including monoclonal antibodies rituximab, brentuximab, dexamethasone, lenalidomide). We evaluated toxicity (cytokine releasing syndrome (CRS), CAR-related encephalopathy syndrome (CRES), infections) and efficacy (OS, PFS) after infusion according to the intensity of the BT. Results: 46 pts were enrolled for commercialized CAR T cells (Kymriah n=25, Yescarta n=21) including R/R DLBCL (n=35), TFL (n=5) or PMBL (n=6) between June 2018 and April 2019. The median age was 57 (IQR, 42 to 64). Number of pts with aaIPI > 2 was 20. The median number of previous lines was 3 (range 3-5), including 15 autologous stem cell transplants and 2 allotransplants. Median time between enrollment and infusion, and between collection and infusion were 59 (35 to 118) and 40 (32 to 90) days, respectively. Overall, 30 (65%) pts received a HI and 16 (35%) a LI or no bridging therapy. Median number of BT cycles was 2 (range, 1-4). 13 patients had various regimen because of uncontrolled disease. Pts receiving HI presented at enrollment with more elevated LDH (60% vs 31%), more involved extranodal sites (n> 2, 32% vs 0%), higher IPI (>2, 77% vs 43%, p=.049), and higher total metabolic tumor volume (TMTV) measured on FDG PET/CT (median, 90 vs 10, p=.002). After BT, 44 pts were infused. 2 pts died before infusion because of a pulmonary infection (n=1) and a lymphoma progression (n=1), both in the HI group. At infusion response evaluation showed that 25 (57%) pts progressed during BT, without difference in the HI or the LI groups (61 % vs 50%). Median TMTV in HI and LI was 95 (10 -256) vs 18 (8 - 44), respectively. After CAR T infusion, 14 pts (32%) developed an infectious disease (7 in the LI group, 7 in the HI group, p=0.31). Median duration of neutropenia (PNN < 1000) was 8 days, 7 in the LI and 9 in the HI (p= 0.21). In the LI and HI groups, 11 and 19 pts developed a CRS (0 grade 3-4), 1 and 11 pts developed a CRES (1 and 3 grade 3-4), respectively. The HI/LI did not impact the occurrence of CRS (p=1.00) but that of CRES (p=0.03). Pts with abnormal LDH (p=0.02), high number of courses (p=0.03) or PS>0 (p=0.049) had a higher risk of CRS, whereas patients with high IPI (p=0.03), and high values of CRP (P=0.02) or decreased albumin levels (p=0.008) had a higher risk of CRES. After CAR T cells infusion, with a median follow up of 5.7 months, the median PFS was not reached in the LI group, and was of 3 months in the HI group (p=0.06). The median OS was not reached in the LI group, and was of 12.5 months in the HI group (p=0.09). In multivariate analyses, IPI was predictor of better PFS, whereas low IPI and TMTV were predictors of better OS. No evidence of any effect of intensity of the BT on OS or PFS was observed in these multivariate analyses. Conclusion: The type of bridging therapies was very heterogeneous. Its intensity was closely related to tumor burden at enrolment. There was no significant difference in terms of efficacy between the HI and LI groups, but a higher frequency of CRES in the HI group. Disclosures Paillassa: Janssen: Other: Bibliography board with young hematologists. Di Blasi:Novartis: Honoraria. Thieblemont:Roche: Honoraria, Research Funding; Gilead: Honoraria; Novartis: Honoraria; Kyte: Honoraria; Janssen: Honoraria; Celgene: Honoraria; Cellectis: Membership on an entity's Board of Directors or advisory committees.

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Clinical Response of CD19 CAR-T Cells (relmacabtagene autoleucel, relma-cel) in Adults with Heavily-Pre-Treated Relapsed/Refractory (r/r) Large B-Cell Lymphoma in China

Blood ◽

10.1182/blood-2020-136038 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 39-40

Author(s):

Jun Zhu ◽

Zhitao Ying ◽

Yuqin Song ◽

Haiyan Yang ◽

Ye Guo ◽

...

Keyword(s):

T Cells ◽

Cell Lymphoma ◽

B Cell Lymphoma ◽

High Dose ◽

Private Company ◽

Car T Cells ◽

Large B Cell Lymphoma ◽

Car T ◽

Grade 3 ◽

Large B Cell

Currently, no CAR-T product has been approved for use in China despite having hundreds of active CAR-T trials. Relma-cel (JWCAR029) is a CAR-T product with a CAR construct comprised of a binding domain, derived from a murine CD19-specific mAb (FMC63), a CD3ζ activation domain, and a 4-1BB costimulatory domain, and manufactured in China with a commercial-ready, highly automated, single train process to select, activate, transduce and expand both CD4 and CD8 cells to a wide range of doses with consistent product attributes. Relma-cel was evaluated in the first prospective, single-arm, multi-center, pivotal study (RELIANCE Trial) of CAR-T therapy conducted under Chinese IND to support an NMPA-accepted BLA submission in r/r large B-cell lymphoma (LBCL) (NCT 04089215) and the preliminary results are presented herein. Eligible adult patients had measurable, histologically confirmed r/r LBCL, failed at least 2 prior therapies, including anthracycline and anti-CD20 agents, and not had allogeneic transplant within 90 days or primary CNS lymphoma. Patients were randomized to receive either 100×106 (low dose) or 150×106 (high dose) CAR+ T cells as a single infusion following fludarabine 25 mg/m2 & cyclophosphamide 250 mg/m2 daily×3 as lymphodepletion. Patients were evaluated for efficacy (Lugano criteria, 2014), safety (CRS by Lee 2014, and all other events by CTCAE v4.03), and PK (by qPCR and flow cytometry). The protocol pre-specified and regulatory authority-agreed primary endpoint was 3 month ORR by landmark analysis to exclude a 3-month 20% ORR (Michael, 2017). Secondary endpoints included best overall response rate (BOR), duration of response (DOR), progression free survival (PFS), overall survival (OS), frequency/severity of AEs and CAR-T cell expansion. Investigators adjudicated disease response and progression based on imaging studies, pathology and clinical data; a sensitivity analysis was also conducted using an independent review committee adjudication. Between May 2018 and Dec 2019, 69 patients were screened, and 59 enrolled and treated with relma-cel, with median age of 56.0 years (18-75), 59.3% ECOG 1-2, and included several LBCL subtypes (DLBCL NOS 69.5%, TFL 15.3%, DHL/THL 5.1%, and PMBCL 6.8%) and nearly all with poor risk disease (81.4% treatment refractory, 45.8% ≥3 lines of prior therapies, 42.4% requiring bridging therapy, 39% IPI≥3). The median doses administered in low and high dose groups were 99.7×106 (range, 80.1-101.3) and 150.0×106 (range, 120.0-156.4) CAR+ T cells, respectively. Among the 58 efficacy evaluable patients, the primary analysis demonstrated a 3 month ORR of 58.6% (95% CI, 44.9-71.4) (the excluded patient had product that did not meet viability threshold criterion, but achieved CR at D29 that is ongoing for >1 year). As of Jun 17, 2020 data cut-off, BOR was 75.9% (95% CI, 62.8-86.1) with CR rate of 51.7% (95% CI, 38.2-65.1). With a median follow-up of 8.9 months, median OS were not reached, and 6 month DOR, PFS and OS were 60.0%, 54.2% and 90.8%, respectively. No improvement in efficacy outcomes was observed in the high dose group. Of 59 treated patients, grade ≥3 AEs occurring in >5% of patients were cytokine release syndrome (CRS), febrile neutropenia and lung infection (all, 5.1%). Grade ≥3 lab abnormalities in >10% of patients were neutrophil count decreased (30.5%), white blood cell count decreased (13.6%), leukopenia (10.2%) and neutropenia (10.2%). The rates of CRS, neurotoxicity (NT), death, and the use of tocilizumab/steroids are shown in Table 1. All events of CRS and NT resolved except for 1 patient with grade 4 CRS ongoing at the time of death as the result of sepsis at day 8. As of data cut off, no cases of severe cytopenia or severe infections occurred beyond 30 days of infusion. The two dose groups did not differ significantly in PK parameters (see Table 1). The RELIANCE Trial provided the first demonstration of licensure-quality CAR-T manufacturing and clinical trial data generation in r/r patients originating in China. These results with relma-cel demonstrate similar preliminary response rates and PK profiles while providing the potential for an improved toxicity profile in heavily-pre-treated patients with r/r DLBCL having poor risk features relative to other CD19-specific CAR-Ts approved in the US and EU. Figure Disclosures Zhang: JW Therapeutics (Shanghai) Co. Ltd: Current Employment, Current equity holder in private company. Yang:JW Therapeutics (Shanghai) Co. Ltd: Current Employment, Current equity holder in private company. Zhou:JW Therapeutics (Shanghai) Co. Ltd: Current Employment, Current equity holder in private company. Zheng:JW Therapeutics (Shanghai) Co. Ltd: Current Employment, Current equity holder in private company.

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Chimeric Antigen Receptor-Engineered T-Cells - A New Way and Era for Lymphoma Treatment

Recent Patents on Anti-Cancer Drug Discovery ◽

10.2174/1574892814666191022164641 ◽

2020 ◽

Vol 14 (4) ◽

pp. 312-323

Author(s):

Romeo G. Mihăilă

Keyword(s):

T Cells ◽

T Cell ◽

Response Rate ◽

Cell Lymphoma ◽

B Cell Lymphoma ◽

Car T Cells ◽

Future Developments ◽

Car T Cell ◽

Large B Cell Lymphoma ◽

Car T

Background: Patients with refractory or relapsed diffuse large B-cell lymphoma have a poor prognosis with the current standard of care. Objective: Chimeric Antigen Receptor T-cells (CAR T-cells) are functionally reprogrammed lymphocytes, which are able to recognize and kill tumor cells. The aim of this study is to make progress in this area. Method: A mini-review was achieved using the articles published in Web of Science and PubMed in the last year and the new patents were made in this field. Results: The responses to CAR T-cell products axicabtagene ciloleucel and tisagenlecleucel are promising; the objective response rate can reach up to 83%, and the complete response rate ranges between 40 and 58%. About half of the patients may have serious side effects, such as cytokine release syndrome and neurotoxicity. Current and future developments include the improvement of CAR T-cell expansion and polyfunctionality, the combined use of CAR T-cells with a fusion protein between interferon and an anti-CD20 monoclonal antibody, with checkpoint inhibitors or small molecule sensitizers that have apoptotic-regulatory effects. Furthermore, the use of IL-12-expressing CAR T-cells, an improved technology for the production of CAR T-cells based on targeted nucleases, the widespread use of allogeneic CAR T-cells or universal CAR T-cells obtained from genetically engineered healthy donor T-cells are future developments actively considered. Conclusion: CAR T-cell therapy significantly improved the outcome of patients with relapsed or refractory diffuse large B-cell lymphoma. The advances in CAR T-cells production technology will improve the results and enable the expansion of this new immunotherapy.

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Contrasting results with second-line CAR T cells in large B cell lymphoma

Nature Reviews Clinical Oncology ◽

10.1038/s41571-021-00598-7 ◽

2022 ◽

Author(s):

Diana Romero

Keyword(s):

T Cells ◽

B Cell ◽

Cell Lymphoma ◽

B Cell Lymphoma ◽

Second Line ◽

Car T Cells ◽

Large B Cell Lymphoma ◽

Car T ◽

Large B Cell

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More on Anti-CD19 CAR T Cells in CNS Diffuse Large-B-Cell Lymphoma

New England Journal of Medicine ◽

10.1056/nejmc1712460 ◽

2017 ◽

Vol 377 (21) ◽

pp. 2101-2102 ◽

Cited By ~ 4

Keyword(s):

T Cells ◽

B Cell ◽

Cell Lymphoma ◽

B Cell Lymphoma ◽

Car T Cells ◽

Large B Cell Lymphoma ◽

Car T ◽

Large B Cell

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Fatal late-onset CAR T-cell–mediated encephalitis after axicabtagene-ciloleucel in a patient with large B-cell lymphoma

Blood Advances ◽

10.1182/bloodadvances.2021004889 ◽

2021 ◽

Vol 5 (19) ◽

pp. 3789-3793

Author(s):

Susanne Jung ◽

Jochen Greiner ◽

Stephanie von Harsdorf ◽

Pavle Popovic ◽

Roland Moll ◽

...

Keyword(s):

T Cells ◽

T Cell ◽

B Cell ◽

Cell Lymphoma ◽

B Cell Lymphoma ◽

Car T Cells ◽

Car T Cell ◽

Large B Cell Lymphoma ◽

Car T ◽

Large B Cell

Abstract Treatment with CD19-directed (CAR) T cells has evolved as a standard of care for multiply relapsed or refractory large B-cell lymphoma (r/r LBCL). A common side effect of this treatment is the immune effector cell–associated neurotoxicity syndrome (ICANS). Severe ICANS can occur in up to 30% to 40% of patients treated with axicabtagene-ciloleucel (axi-cel), usually within the first 4 weeks after administration of the dose and usually responding well to steroids. We describe a case of progressive central neurotoxicity occurring 9 months after axi-cel infusion in a patient with r/r LBCL who had undergone a prior allogeneic hematopoietic cell transplant. Despite extensive systemic and intrathecal immunosuppression, neurological deterioration was inexorable and eventually fatal within 5 months. High CAR T-cell DNA copy numbers and elevated levels of interleukin-1 (IL-1) and IL-6 were found in the cerebral spinal fluid as clinical symptoms emerged, and CAR T-cell brain infiltration was observed on autopsy, suggesting that CAR T cells played a major pathogenetic role. This case of unexpected, devastating, late neurotoxicity warrants intensified investigation of neurological off-target effects of CD19-directed CAR T cells and highlights the need for continuous monitoring for late toxicities in this vulnerable patient population.

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Case Report: Combined Intravenous Infusion and Local Injection of CAR-T Cells Induced Remission in a Relapsed Diffuse Large B-Cell Lymphoma Patient

Frontiers in Immunology ◽

10.3389/fimmu.2021.665230 ◽

2021 ◽

Vol 12 ◽

Author(s):

Linhui Hu ◽

Fan Wu ◽

Huiping Wang ◽

Weiwei Zhu ◽

Juan Wang ◽

...

Keyword(s):

T Cells ◽

B Cell ◽

Intravenous Infusion ◽

Cell Lymphoma ◽

B Cell Lymphoma ◽

Local Injection ◽

Car T Cells ◽

Large B Cell Lymphoma ◽

Car T ◽

Large B Cell

Relapsed diffuse large B-cell lymphoma (DLBCL) is a disease with a poor prognosis. Recent clinical trials results showed chimeric antigen receptor (CAR) T cell therapy has a promising role in treating relapsed DLBCL. Unfortunately, patients with extranodal lesions respond poorly to CAR-T cells administered intravenously. Herein, we evaluated the efficacy and safety of a new treatment strategy of CAR-T cells, combining intravenous infusion with local injection of CAR-T cells, in a relapsed DLBCL patient with extranodal lesions. The patient achieved durable remission and without severe adverse effects after CAR-T cells treatment. During the follow-up period of one year, the patient remained in good condition. In conclusion, combining intravenous injection with a local injection for CAR-T cell is a feasible strategy for relapsed DLBCL patients with extranodal lesions.

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