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If engagement of the innate immune system contributes to the mechanism of action, this could bode well for the use of CAR T cells in solid tumors, where T cells may not preferentially home to and persist at the sites of tumors as efficiently as they do in hematologic malignancies.
Several patients in CDCAR trials across institutions have experienced obtundation, seizures, aphasia, and mental status changes, which have all been reversible.
Some of these may be related to CRS, but whether this results from systemic cytokines crossing the blood-brain barrier and engaging cytokine receptors in the brain or from direct cytokine production in the central nervous system CNS is not clear.
Blinatumomab, a type of bispecific T-cell—engaging antibody BiTE that is a fusion protein between an anti-CD19 scFv and an anti-CD3 scFv, also has neurologic toxicity and seizures as its dose-limiting toxicity, even though it does not appear to control CNS disease.
It is interesting that blinatumomab has also been shown to cause MAS. B-cell aplasia is an expected on-target result of CDdirected therapies and has served as useful surrogate to determine the persistence and effectiveness of CDdirected CAR T cells.
Persistent B-cell aplasia could also result in an increased risk of infection even with replacement therapy. In an ideal setting, the CAR T cells would persist long enough to mediate definitive control of disease but then allow for recovery of normal B-cell and plasma cell recovery such that patients could be revaccinated.
As more patients are treated with CAR T cells directed to CD19, clinician investigators will need to establish straightforward algorithms for management of toxicities, including the optimal timing and dose of administration of cytokine blockade, corticosteroids, and immunoglobulin replacement.
However, suicide systems are still difficult to implement in all CAR T-cell trials, because many of the suicide systems are immunogenic eg, herpes simplex virus thymidine kinase or require intravenous administration of the suicide-inducing prodrug.
All investigators involved in CAR T-cell trials are acutely aware of the technical, regulatory, and financial challenges in manufacturing single-patient product lots.
One potential solution is to generate universal T-cell products from allogeneic donors, based on knockdown of the HLA genes coupled with enforced expression of nonclassical HLA molecules to avoid natural killer NK cell—mediated recognition and lysis.
One mandate of the guidance is for sponsors to attempt to define the active ingredient in the cell or gene therapy product.
For gene-modified T cells, there are multiple factors that contribute to the definition of the active ingredient: optimal vector, culture conditions, CAR design, cell type, and dose of that cell type.
However, the precise type of cell that is transduced may be important in defining the active ingredient as well.
Most investigators have focused on peripheral blood—derived T cells and subsets of these such as virus-specific T cells, central memory T cells, or cord blood—derived T cells.
Aside from defining the optimal cell product, there are 2 main hurdles in broadening the use of CAR-directed T cells beyond B-cell malignancies: target discovery and manufacturing on a wide scale.
Baylor has 2 open clinical trials targeting CD30 in Hodgkin disease, and the University of Cologne plans to treat patients with mycosis fungoides with CD30 CAR T cells encoding a CD28 domain with a deleted lck binding moiety, based on preclinical data that this reduces Tregs in the tumor microenvironment.
In the case of CDdirected CAR T cells, multisite trials are in the planning stages for several groups and now include involvement of the pharmaceutical and biotechnology industries as well as cooperative group networks.
This is an exciting time in the treatment strategies for all hematologic malignancies; a decade ago, few would have predicted that the promises of gene-modified cell therapies would be delivered by CAR T cells directed to aggressive hematologic malignancies such as adult and pediatric B-cell ALL.
Contribution: M. Conflict-of-interest disclosure: M. All authors have sponsored research grant support from Novartis. Sign In or Create an Account.
Sign In. Skip Nav Destination Content Menu. Close Abstract. Review of clinical data with CAR T cells in hematologic malignancies.
Future outlook. Article Navigation. Maus , Marcela V. This Site. Google Scholar. Stephan A. Grupp , Stephan A. David L.
Porter , David L. Carl H. June Carl H. Blood 17 : — Article history Submitted:. Connected Content. This is a companion to: Advances in the treatment of hematologic malignancies using immunoconjugates.
This is a companion to: Immunotoxins for leukemia. Cite Icon Cite. Figure 1. View large Download PPT. Figure 2. Table 1 CAR T-cell trials in hematologic malignancies.
Signaling domain. Other genes. Cytokine support. Number of patients. Persistence peak and duration. View Large. Gene transfer.
CAR signaling domain. The online version of this article contains a data supplement. The authors thank Anne Chew and Bruce Levine for constructive comments.
Durable complete responses in heavily pretreated patients with metastatic melanoma using T-cell transfer immunotherapy. Search ADS. Combinational targeting offsets antigen escape and enhances effector functions of adoptively transferred T cells in glioblastoma.
Anti-CDchimeric antigen receptors targeting B-cell precursor acute lymphoblastic leukemia. Receptor affinity and extracellular domain modifications affect tumor recognition by ROR1-specific chimeric antigen receptor T cells.
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