scholarly journals Immunotherapy Using Chimeric Antigen Receptor-Engineered T Cells: A Novel Cellular Therapy with Important Implications for the Clinical Laboratory

2019 ◽  
Vol 65 (4) ◽  
pp. 519-529 ◽  
Author(s):  
Suzanne R Thibodeaux ◽  
Michael C Milone

Abstract BACKGROUND We have entered a new era of cancer therapy, with a number of immune-based therapies already used clinically as a standard of care. Adoptive cellular immunotherapy using T cells genetically modified with chimeric antigen receptors (CAR-T cells) represents a novel therapeutic approach. CAR-T cells have produced clinical responses in B-cell malignancies that are otherwise refractory to conventional therapies. Two CAR-T cell therapies obtained regulatory approval in 2017, with many more of these therapies under clinical development. CONTENT This review focuses on the current state of adoptive cellular immunotherapy, specifically CAR-T cells, in the clinic and how this therapy differs from traditional small molecule and biologic therapies. Areas in which the clinical laboratory is affected by these novel therapies are discussed. Opportunities for the clinical laboratory to help guide these therapies are also highlighted. SUMMARY The clinical laboratory will play an integral role in the care of patients undergoing adoptive cellular therapy with engineered T cells. There are many ways that this new therapeutic approach affects the clinical laboratory, and the clinical laboratory will likely play a critical role in managing patients that are treated with CAR-T cell therapy.

Cancers ◽  
2020 ◽  
Vol 12 (3) ◽  
pp. 567 ◽  
Author(s):  
Susana Pascoal ◽  
Benjamin Salzer ◽  
Eva Scheuringer ◽  
Andrea Wenninger-Weinzierl ◽  
Caterina Sturtzel ◽  
...  

Chimeric antigen receptor (CAR) T cells have proven to be a powerful cellular therapy for B cell malignancies. Massive efforts are now being undertaken to reproduce the high efficacy of CAR T cells in the treatment of other malignancies. Here, predictive preclinical model systems are important, and the current gold standard for preclinical evaluation of CAR T cells are mouse xenografts. However, mouse xenograft assays are expensive and slow. Therefore, an additional vertebrate in vivo assay would be beneficial to bridge the gap from in vitro to mouse xenografts. Here, we present a novel assay based on embryonic zebrafish xenografts to investigate CAR T cell-mediated killing of human cancer cells. Using a CD19-specific CAR and Nalm-6 leukemia cells, we show that live observation of killing of Nalm-6 cells by CAR T cells is possible in zebrafish embryos. Furthermore, we applied Fiji macros enabling automated quantification of Nalm-6 cells and CAR T cells over time. In conclusion, we provide a proof-of-principle study that embryonic zebrafish xenografts can be used to investigate CAR T cell-mediated killing of tumor cells. This assay is cost-effective, fast, and offers live imaging possibilities to directly investigate CAR T cell migration, engagement, and killing of effector cells.


2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 10001-10001
Author(s):  
Jing Pan ◽  
Jing Pan ◽  
Biping Deng ◽  
Zhuojun Ling ◽  
Weiliang Song ◽  
...  

10001 Background: Despite the success of chimeric antigen receptor T cell therapy in B cell malignances, there is currently no proved CAR T treatment for T cell neoplasms. We provide first evidence support the use of donor derived CAR T cells in T cell leukemia. Methods: In this phase 1 trial, CD7 CAR T cells were manufactured with T cells from prior SCT prior to a single infusion at doses of 5 × 105 or 1 × 106 (± 30%) cells per kilogram of body weight. donors, or from new donors who were HLA-matched or haploidentical, via leukopheresis and transduced with a lentiviral vector which carries a CD7 CAR construct. The primary endpoint was safety. Short-term efficacy was also assessed. Results: Results of 20 enrolled patients who received infusion are reported. Of 20 patients, 12 received previous HSCT-donor derived CAR T cells and 8 received fresh haplo-identical donor derived CAR T cells and plan to received transplantation as consolidation after remission.Adverse events included grade 3-4 hematologic toxicity in all (100%), grade 3-4 and grade 1-2 cytokine release syndrome in 2 (10%) and in 18 (90%), grade 1 neurotoxicity in 3 (15%), grade 1-2 graft-versus-host disease in 12 (60%), and grade 1 viral activation in 3 (15%) patients. Nineteen (95%) patients had a response, including 18 (90%) with complete remission and 1 (5%) with partial remission. Of 19 responders, 7 were bridged to SCT and remained minimal residual disease (MRD)-negative until last visit; 12 were followed up at a medium of 4.4 months, among whom 9 remained MRD-negative, 1 had a relapse, 1 discontinued for other treatment, and 1 died of pulmonary fungal infection at 5.5 months. CAR cells mostly persisted beyond 3 months. Patient CD7-positive healthy T cells were depleted, while CD7-negative T cells increased. Conclusions: We report the initial toxicity profile and anti-leukemia activity of a donor-derived CD7-targeted cellular immunotherapy for patients with relapsed or refractory T-ALL. (Funded by the National Key R&D program; ChiCTR.org number, ChiCTR2000034762). Clinical trial information: ChiCTR2000034762. [Table: see text]


2020 ◽  
Vol 21 (19) ◽  
pp. 7222
Author(s):  
Ashley R. Sutherland ◽  
Madeline N. Owens ◽  
C. Ronald Geyer

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.


2021 ◽  
Vol 12 ◽  
Author(s):  
Mikel Etxebeste-Mitxeltorena ◽  
Inés del Rincón-Loza ◽  
Beatriz Martín-Antonio

Adoptive cellular immunotherapy using chimeric antigen receptor (CAR)-modified T cells and Natural Killer (NK) cells are common immune cell sources administered to treat cancer patients. In detail, whereas CAR-T cells induce outstanding responses in a subset of hematological malignancies, responses are much more deficient in solid tumors. Moreover, NK cells have not shown remarkable results up to date. In general, immune cells present high plasticity to change their activity and phenotype depending on the stimuli they receive from molecules secreted in the tumor microenvironment (TME). Consequently, immune cells will also secrete molecules that will shape the activities of other neighboring immune and tumor cells. Specifically, NK cells can polarize to activities as diverse as angiogenic ones instead of their killer activity. In addition, tumor cell phagocytosis by macrophages, which is required to remove dying tumor cells after the attack of NK cells or CAR-T cells, can be avoided in the TME. In addition, chemotherapy or radiotherapy treatments can induce senescence in tumor cells modifying their secretome to a known as “senescence-associated secretory phenotype” (SASP) that will also impact the immune response. Whereas the SASP initially attracts immune cells to eliminate senescent tumor cells, at high numbers of senescent cells, the SASP becomes detrimental, impacting negatively in the immune response. Last, CAR-T cells are an attractive option to overcome these events. Here, we review how molecules secreted in the TME by either tumor cells or even by immune cells impact the anti-tumor activity of surrounding immune cells.


2021 ◽  
Vol 9 (7) ◽  
pp. e002723
Author(s):  
Kedar Kirtane ◽  
Hany Elmariah ◽  
Christine H Chung ◽  
Daniel Abate-Daga

While immune checkpoint inhibitors (ICIs) have ushered in major changes in standards of care for many solid tumor malignancies, primary and acquired resistance is common. Insufficient antitumor T cells, inadequate function of these cells, and impaired formation of memory T cells all contribute to resistance mechanisms to ICI. Adoptive cellular therapy (ACT) is a form of immunotherapy that is rapidly growing in clinical investigation and has the potential to overcome these limitations by its ability to augment the number, specificity, and reactivity of T cells against tumor tissue. ACT has revolutionized the treatment of hematologic malignancies, though the use of ACT in solid tumor malignancies is still in its early stages. There are currently three major modalities of ACT: tumor-infiltrating lymphocytes (TILs), genetically engineered T-cell receptors (TCRs), and chimeric antigen receptor (CAR) T cells. TIL therapy involves expansion of a heterogeneous population of endogenous T cells found in a harvested tumor, while TCRs and CAR T cells involve expansion of a genetically engineered T-cell directed toward specific antigen targets. In this review, we explore the potential of ACT as a treatment modality against solid tumors, discuss their advantages and limitations against solid tumor malignancies, discuss the promising therapies under active investigation, and examine future directions for this rapidly growing field.


2016 ◽  
Vol 44 (2) ◽  
pp. 349-355 ◽  
Author(s):  
Lynsey M. Whilding ◽  
Sabari Vallath ◽  
John Maher

Immunotherapy of cancer using chimeric antigen receptor (CAR) T-cells is a rapidly expanding field. CARs are fusion molecules that couple the binding of a tumour-associated cell surface target to the delivery of a tailored T-cell activating signal. Re-infusion of such genetically engineered T-cells to patients with haematological disease has demonstrated unprecedented response rates in Phase I clinical trials. However, such successes have not yet been observed using CAR T-cells against solid malignancies and this is, in part, due to a lack of safe tumour-specific targets. The αvβ6 integrin is strongly up-regulated in multiple solid tumours including those derived from colon, lung, breast, cervix, ovaries/fallopian tube, pancreas and head and neck. It is associated with poorer prognosis in several cancers and exerts pro-tumorigenic activities including promotion of tumour growth, migration and invasion. By contrast, physiologic expression of αvβ6 is largely restricted to wound healing. These attributes render this epithelial-specific integrin a highly attractive candidate for targeting using immunotherapeutic strategies such as CAR T-cell adoptive immunotherapy. This mini-review will discuss the role and expression of αvβ6 in cancer, as well as its potential as a therapeutic target.


Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 1334-1334 ◽  
Author(s):  
David T Teachey ◽  
Simon F. Lacey ◽  
Pamela A Shaw ◽  
J Joseph Melenhorst ◽  
Noelle V. Frey ◽  
...  

Abstract CAR T cells with anti-CD19 specificity have demonstrated considerable promise against highly refractory hematologic malignancies. Dramatic responses with complete remission rates as high as 90% have been reported in patients (pts) with relapsed/refractory ALL treated with CTL019 (Maude et al., NEJM 2014). Marked in vivo CAR T cell proliferation (100 to 100,000x) leads to improved efficacy but can be associated with adverse events, including cytokine release syndrome (CRS). To better understand manifestations of CRS, we studied clinical, laboratory, and biomarker data of 39 children and 12 adults with relapsed/refractory ALL treated with anti-CD19 CAR T cells. T cells were lentivirally transduced with a CAR composed of anti-CD19 single chain variable fragment/4-1BB/CD3 (Porter, NEJM 2011). 43 cytokines, chemokines, and soluble receptors (collectively termed cytokines hereafter) were serially measured, using Luminex bead array. Other biomarkers were tested in a CLIA/CAP certified lab. 48 of 51 pts developed grade 1-5 CRS (CRS1-5) (see Table). Most pts developed mild (grade 1-2) to moderate (grade 3) CRS (34/51). 14 pts developed severe (grade 4-5) CRS (12 grade 4, 2 adults with grade 5). 21 pts were treated with the IL-6 inhibitor tocilizumab, and most had rapid marked clinical improvement in CRS evidenced by quick resolution of fever and weaning of vasoactive medications. We found peak levels of 24 cytokines, including IFNg, IL6, IL8, sIL2Ra, sgp130, sIL6R, MCP1, MIP1a, and GM-CSF during the first month after CTL019 infusion were highly associated with CRS4-5 compared to CRS0-3, significant by the Holm-Bonferroni adjusted p-value. Analyzing cytokines from the first 3 days after infusion, sent before patients developed severe CRS, only 2 cytokines, sgp130 and IFNg, were strongly associated with later development of severe CRS (p<0.001) and significant by Holm-Bonferroni. With a 3 variable regression model, found by forward selection, we accurately predicted which pts developed severe CRS using IFNg, sgp130, and IL1Ra (PPV 75%, NPV 94%, sensitivity 86%, specificity 89%, AUC=0.93). For the pediatric cohort, the modeling was even more accurate; a combination of IFNg, IL13, and MIP1a had PPV 92%, NPV 100%, sensitivity 100%, and specificity 96% (AUC=0.98). In the pediatric cohort only, a bone marrow aspirate was collected immediately prior to infusion. We found disease burden was associated with CRS severity but did not improve the predictive accuracy of the models over the cytokines alone. A combination of sgp130, IFNg and disease burden yielded PPV 77%, NPV 96%, sensitivity 91%, and specificity 88% (AUC 0.95). We are validating our models in an additional cohort and will present those data. The 1-month peak of several clinical laboratory tests were strongly associated with severe CRS, including CRP, ferritin, LDH, AST, and BUN; however, they were not predictive of severe CRS. Some of these, including CRP, had a good NPV for early prediction but none had a good PPV. We hypothesized and demonstrated that children with severe CRS develop clinical and laboratory manifestations similar to macrophage activation syndrome (MAS)/hemophagocytic syndrome (HLH), including hyperferritinemia (>10,000ng/ml), splenomegaly, and hypofibrinogenemia. Of the tested cytokines, 18 have been previously studied in children with HLH. We found a near identical pattern of cytokines differentially elevated in HLH also elevated in pts with CRS4-5 compared with CRS0-3. IL6, sIL6R, and sgp130 were markedly elevated in pts with CRS4-5; this IL6 cytokine pattern, along with the pronounced response to tocilizumab, establishes that IL6 trans-signaling is clinically relevant. These data represent the largest and most comprehensive profiling of the clinical and laboratory manifestations of CAR T cell related CRS and provide novel insights into CRS biology. They represent the first data that can accurately predict which pts treated with CAR T cells have a high probability of becoming critically ill. These data have direct therapeutic relevance and may guide future cytokine directed therapy. The first 4 authors contributed equally. Table 1. CRS grading Gr1 Supportive care only Gr2 IV therapies +/- hospitalization. Gr3 Hypotension requiring IV fluids or low-dose vasoactives or hypoxemia requiring oxygen, CPAP, or BIPAP. Gr4 Hypotension requiring high-dose vasoactives or hypoxemia requiring mechanical ventilation. Gr 5 Death Disclosures Teachey: Novartis: Research Funding. Off Label Use: tocilizumab. Lacey:Novartis: Research Funding. Shaw:Novartis: Research Funding. Melenhorst:Novartis: Research Funding. Frey:Novartis: Research Funding. Maude:Novartis: Consultancy, Research Funding. Aplenc:Sigma Tau: Consultancy. Chen:Novartis: Research Funding. Gonzalez:Novartis: Research Funding. Pequignot:Novartis: Research Funding. Rheingold:Endo: Other: Husband's employer, has equity interest; Novartis: Consultancy. June:Novartis: Research Funding; University of Pennsylvania: Patents & Royalties: financial interests due to intellectual property and patents in the field of cell and gene therapy. Conflicts of interest are managed in accordance with University of Pennsylvania policy and oversight. Porter:Novartis: Patents & Royalties, Research Funding; Genentech: Other: Spouse Employment. Grupp:Novartis: Research Funding.


2020 ◽  
Vol 38 (15_suppl) ◽  
pp. 3034-3034 ◽  
Author(s):  
Yajing Zhang

3034 Background: Chimeric antigen receptor T (CAR T) cells targeting CD19 have been used to achieve breakthroughs in the treatment of hematological malignancies, however, a high recurrence rate is the main obstacle to durable remission following CAR T cell therapy. Methods: As an open-label and single-arm phase I/IIa trial (ClinicalTrials.gov number, NCT03097770), we screened 99 patients with r/r B-NHL—including DLBCL, PMBCL, CLL/SLL, MCL, TFL and FL—according to the 2008 WHO Classification of Tumors of Hematopoietic and Lymphoid Tissue, and a total of 87 patients received an infusion of one dose tandem CD19/CD20 CAR-engineered T cells on day 0 in the range of 0.5×106-10×106 cells per kilogram of body weight after conditioning chemotherapy. The primary objective was to evaluate the safety and tolerability of CAR T cells. Efficacy, progression-free survival (PFS) and overall survival (OS) were evaluated as secondary objectives. Our clinical trials is registered with ClinicalTrials.gov, NCT03097770. Safety was assessed by CTCAE Version 5.0, and clinical response by PET-CT referred to standard international criteria. The trial remains open, and recruitment to extension cohorts with alternative endpoints is underway. Results: Between May 11, 2017, and Jan 31, 2020, 99 patients were enrolled and 87 received tandem CD19/CD20 CAR-engineered T cells across phases I/IIa. As of the cutoff date, 74 assessable patients were followed up for a median of 13.5 months (IQR 33.2 - 3.3), 62 (84%) had an objective response, and 55 (74%) had a complete response. The median progression-free survival and overall survival were all not reached. Cytokine release syndrome (CRS) occurred in 62 patients (71%), with 61% grade 1 or 2 and 10% grade 3 or more. CAR-T-cell-related encephalopathy syndrome (CRES) of grade 3 occurred in 2 patients (2%) . Three treatment-related deaths (2 in pulmonary infection and 1 in deposition of CART cells in pulmonary alveoli). Conclusions: In this study, optimized tandem CD19/CD20 CAR-engineered T cells induced a potent and durable anti-tumour response with controllable CRS and CRES. Clinical trial information: NCT03097770 .


2019 ◽  
Vol 17 (3.5) ◽  
pp. YIA19-005
Author(s):  
Saul J. Priceman ◽  
Stephen J. Forman ◽  
◽  
◽  

Repairing defects in antitumor immunity has been a longstanding challenge in prostate cancer, and in recent years cellular immunotherapy has emerged as a promising approach for controlling advanced disease. To date, therapies including tumor vaccine and adoptive T-cell immunotherapy have made remarkable headway in solid cancers. Several validated prostate-specific tumor antigens are available as targets for T-cell therapy, including prostate stem cell antigen (PSCA), which is overexpressed in metastatic disease. We are in late-stage preclinical development of PSCA-specific chimeric antigen receptor (CAR)-engineered T cells with plans to initiate a clinical trial early 2019 for the treatment of metastatic castration-resistant prostate cancer. Immune checkpoint pathways, including the programmed cell death protein-1 (PD-1) and the cytotoxic T lymphocyte-associated protein-4 (CTLA4), have emerged as critical drivers of immunosuppression in solid cancers, by limiting both adaptive antitumor immunity as well as adoptive T-cell therapies. Unfortunately in prostate cancer, checkpoint inhibition has led to underwhelming responses, likely due to the low mutational load and immunologically “cold” tumor microenvironment. We hypothesize that antitumor activity of PSCA-CAR T cells will elicit checkpoint pathways that dampen antitumor immune responses and reduce overall clinical outcomes. Herein, we utilize an shRNA approach to knockdown checkpoint receptors as a rational combinatorial strategy that targets checkpoint pathways to improve overall therapy with PSCA-CAR T cells for metastatic prostate cancer. We have successfully developed a multiple shRNA knockdown approach to simultaneously disrupt 3 pathways that may hamper CAR T-cell activity in the tumor. These CAR T cells with shRNA knockdown of checkpoint receptors will be directly compared with checkpoint pathway inhibitor antibody therapies in xenograft models of prostate cancer, with the hope that next generation CARs will resist this break on the immune system in solid tumors.


2020 ◽  
Vol 14 (4) ◽  
pp. 312-323
Author(s):  
Romeo G. Mihăilă

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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