CN113893338A

CN113893338A - Application of CD38 CAR-T cells in acute myelopathy of chronic myelocytic leukemia

Info

Publication number: CN113893338A
Application number: CN202111297618.5A
Authority: CN
Inventors: 唐晓文; 俞磊; 吴德沛; 戴海萍; 崔庆亚; 崔巍; 尹佳; 康立清
Original assignee: First Affiliated Hospital of Suzhou University; Shanghai Unicar Therapy Bio Medicine Technology Co Ltd
Current assignee: First Affiliated Hospital of Suzhou University; Shanghai Unicar Therapy Bio Medicine Technology Co Ltd
Priority date: 2021-11-04
Filing date: 2021-11-04
Publication date: 2022-01-07
Also published as: WO2023078023A1

Abstract

The invention discloses an application of CD38 CAR-T cells in acute myelopathy of chronic myelocytic leukemia, which is characterized in that the application is CD38 CAR-T cells, and the total infusion dose is as follows: (0.5-2.0). times.10⁷In terms of/kg. The invention treats acute myelopathy of chronic myelocytic leukemia by infusing CD38 CAR-T cells, overcomes the defects of drug resistance of conventional treatment means including Tyrosine Kinase Inhibitor (TKI), chemotherapy and the like, improves the clinical curative effect of patients with acute myelopathy of chronic myelocytic leukemia, and improves the possibility of relieving and transiting the patients to allogeneic hematopoietic stem cell transplantation.

Description

Application of CD38 CAR-T cells in acute myelopathy of chronic myelocytic leukemia

Technical Field

The invention relates to the technical field of biology, in particular to application of CD38 CAR-T cells in acute myelopathy of chronic granulocytic leukemia.

Background

Chronic Myelogenous Leukemia (CML) is a malignant disease of hematopoietic stem cells that is mainly characterized by myelogenous hyperplasia, accounting for 15% -20% of adult leukemias. 95% of CML patients are Philadelphia (Ph) chromosome positive, where the long arm of chromosome 9 (9q34) and the long arm of chromosome 22 (22q11) are translocated to each other to form a shorter than normal chromosome 22, i.e., t (9; 22) (q 34; q11), thereby producing the BCR-ABL fusion gene. Patients in the chronic phase of CML, if untreated, typically progress to the accelerated phase of CML (AP-CML) or the acute phase of CML (BP-CML) within 3 to 5 years.

About 5-10% of CML patients will develop AP-CML or BP-CML due to TKI resistance, and the acute phase is the terminal phase of CML, similar to acute leukemia. 2/3 in BP-CML patients is acute myelopathy, and BP-CML patients progress rapidly, have extremely poor prognosis and often die within months, and have median survival period less than 12 months. At present, BP-CML patients have limited treatment methods, and TKI replacement, TKI combined chemotherapy, TKI combined demethylation medicine and salvage hematopoietic stem cell transplantation treatment can be selected. The response rate of single TKI treatment is low, the treatment response of the TKI combined demethylation drug is not obviously improved, the TKI combined chemotherapy often has obvious treatment-related toxic and side effects, and the treatment response is obviously lower than that of acute myeloid leukemia. The above treatments rarely allow patients to obtain molecular relief, and the possibility of disease re-development exists in a short period; if the patient does not obtain molecular relief to rescue the hematopoietic stem cell transplantation, the recurrence rate after transplantation is high and the survival time is very short. The CML acute change is divided into acute stranguria change and acute myelopathy, and the prognosis of a patient with the CML acute myelopathy is worse; therefore, a new therapeutic approach for treating acute myelopathy of CML needs to be explored urgently, so that the limitations of the existing treatment are overcome, and more patients benefit.

Chimeric antigen receptor T cell (CAR-T) cell therapy has made breakthrough progress in B-lineage hematological malignancies and has met with great success. CAR-T, however, is slow to develop in the treatment of myeloid hematological malignancies, the main reasons include: myeloid tumors lack ideal antigen targets, resulting in CAR-T cells that cannot effectively eliminate tumor cells and are prone to off-target effects; can not break through the microenvironment of the immunosuppressive tumor of the myeloid leukemia. Therefore, CAR-T cell therapy for myeloid leukemia is also a difficult and hot point in the current therapeutic research.

The pathobiology of BP-CML involves a variety of pathways, including genetic and epigenetic aberrations, among others. It has been shown that TKI is unable to clear CML Leukemic Stem Cells (LSCs) and is the pathophysiological basis for acute changes in CML. Clearing LSC is hoped for cure of BP-CML. LSC is present in CD34+ CD 38-and CD34+ CD38+ or CD 34-cells, and it has been proved that CD34-CD38+ cells are leukemia initiating cells and play an important role in the development, progression and transformation of leukemia. In both of these patients, the leukemia cells expressed CD34 and CD38 at the time of onset, but after acute myelopoiesis, the leukemia cells still expressed CD38, but not CD 34. We envision that CD38 is the antigen target and that CD38 is eliminated⁺CML acute myelogenous leukemia cells explore a new treatment method for TKI and chemotherapy-resistant CML acute myelogenous patients.

CD38 is a glycoprotein with exoenzyme function, widely expressed in plasma cells, other lymphocytes and myeloid tumor cells, and not expressed in normal hematopoietic stem cells. CD 38-targeted CAR-T cells have been shown to be highly effective in clinical studies for the treatment of multiple myeloma. Meanwhile, the CD38 monoclonal antibody (Daratumumab) has encouraging curative effect on treating multiple myeloma and has better safety and mild hematologic toxicity. Compared with Daratumumab, CD38 CAR-T is a living drug, can be expanded in vivo, and has stronger curative effect persistence without increasing curative toxicity.

Thus, in view of the expression of CD38, but not CD34, in CML acute myelogenous patients, combined with the successful use of CD38 CAR-T cells in multiple myeloma, CD38 CAR-T cell therapy can be used in CML acute myelogenous TKI and chemotherapy-resistant patients to eliminate CD 38-positive myeloid leukemia cells and improve disease status.

Disclosure of Invention

In order to overcome the defects of the prior art, the invention aims to provide the application of the CD38 CAR-T cells in acute myelopathy of chronic myelogenous leukemia. The application overcomes the drug resistance problem of TKI and chemotherapy, and has no obvious toxic and side effects.

In order to realize the purpose of the invention, the adopted technical scheme is as follows:

the use of CD38 CAR-T cells in acute myelogenous leukemia, wherein the CD38 CAR-T cells are infused with a total dose of: (0.5-2.0). times.10⁷And/kg, the infusion is carried out in 3 days according to 20 percent, 30 percent and 50 percent of the total infusion dose.

In a preferred embodiment of the invention, the source of the CD38 CAR-T cells is autologous cells of the patient.

In a preferred embodiment of the present invention, the subject is a patient with acute myelogenous leukemia.

In a preferred embodiment of the present invention, the chronic myelogenous leukemia patients with acute myelogenous changes have a combination of TKI and chemotherapy resistance.

The invention has the beneficial effects that:

the application is applied to patients with acute myelopathy of chronic myelogenous leukemia and TKI and chemotherapy resistance, and the innovation point is that the CD38 CAR-T is applied for treatment. CAR-T cells can be continuously expanded under the stimulation of tumor cells, tumor cells can be continuously killed, drug resistance in the prior art is overcome, CD38 is used as a treatment target, CD38 is not expressed in normal HSC, and severe pancytopenia is avoided.

Drawings

FIG. 1 shows the trend of BCR/ABL fusion gene changes after CD38 CAR-T treatment case 2 of the present invention;

FIG. 2 shows the morphological and ABL kinase region mutation changes after CD38 CAR-T treatment of case 1 and case 2 in accordance with the present invention;

FIG. 3 shows the residual lesion changes in leukemia after CD38 CAR-T treatment of case 1 and case 2 in accordance with the present invention.

Detailed Description

The working principle of the present invention is further explained below with reference to specific implementation cases.

Case 1:

33 year old men, in 2018, had a low fever in outpatient clinic for diagnosis due to progressive dizziness and asthenia, and have been examined for blood with normal leucocytes 375X 10⁹Per L, platelet count 65X 10⁹L; bone marrow elephant: 9.5 percent of original children; leukemia immunophenotyping showed: 6.9% of the naive population, myeloid expression; the BCR-ABL fusion gene is positive, and is definitely diagnosed as CML. The medicine is administered with imatinib 0.4g for oral administration once a day, and is automatically stopped due to low blood platelet. After 1 month, the bone marrow was reviewed: BCR-ABL: 75.57%, CBF beta/MYH 11 positive, ABL kinase region mutation negative, and treating with dasatinib instead. In 4 months of 2018, peripheral blood primary immature cells are rechecked for 40 percent and are diagnosed as acute myelogenous change of chronic myelocytic leukemia, and chemotherapy is carried out by a scheme of combining demethoxydaunorubicin with cytarabine (IA) 4-26 times; bone perforation morphology 1% was rechecked in months 2018-6, chromosome 46, XY, t (9; 22) (q 34; q11) [1 ]]/46，XY，t(7；12)(q22.p15)[1]/46，XY[1]CBF β/MYH 11: 6.37%, BCR-ABL: 489.60 percent. 2018-6-12 for IA-regimen chemotherapy, 2018-7 for bone puncture, MRD 1X 10 in morphological remission^-3CBF beta/MYH 11 negative, BCR-ABL 0.601%. 2018-7-20 is administered with IA chemotherapy again, 9-3 times of small dose of arabinoside chemotherapy, and 2 courses of chemotherapy. 2018-12 bone puncture shows ABL kinase zone mutation E255K positive, which is changed into bonatinib treatment. Then, negative was periodically checked. The doctor of our department sees the fever again in 12 days 3 and 12 in 2020.

Physical examination: the traditional Chinese medicine composition has the advantages of being clear in mind, free of anemia appearance, free of swelling of superficial lymph nodes of the whole body, free of mucosa ulcer in the oral cavity, free of tenderness in sternum, clear in lung auscultation respiratory sound, free of rale, arrhythmia and free of pathological noise. The abdomen is soft, there is no tenderness and pain, there is no pain in the liver and spleen, there is no edema in the lower limbs.

Auxiliary inspection: conventional leukocyte of blood 91.79X 10⁹L, blood platelet 12 function10⁹And L. Bone marrow elephant: morphogen was 47% (fig. 2); leukemia immunophenotyping: naive cells 85.9%, myeloid expression (fig. 3), CD38+ 95.7%; chromosome: 46, XY, t (9; 22); ABL kinase region mutations: T315I positive (fig. 2); gene mutation: RUNX1, WT1, ABL (T315I) positive; CBF beta/MYH 11: 1.02%, BCR-ABL: 21.40 percent.

Treatment: the CML acute myelopathy can be clearly diagnosed by combining case data and auxiliary examination results. The patient is diagnosed with CML2, and is still subjected to acute myelopoiesis on the basis of successively replacing various TKIs (imatinib, dasatinib and boratinib) and combining multiple chemotherapies (IA, small dose of cytarabine and the like for 6 times), and the existence of various TKIs and combined chemotherapies for drug resistance is considered. Thus, patients received autologous CD38 CAR-T cell therapy with a total number of infused cells of 1X 10⁷And/kg, 20%, 30%, 50% of the total amount is returned in 3 days.

The curative effect is as follows: blood was routinely returned gradually to normal 1 week after CD38 CAR-T cell infusion. And (3) rechecking bone marrow: complete remission (fig. 2); MRD < 2.7X 10^-4(FIG. 3); CBF beta/MYH 11 turns negative; BCR-ABL 0%; T315I was negative (fig. 3).

Case 2:

a34-year-old male suffers from abdominal distension and pain in the left upper abdomen in 2019, and the local hospital is diagnosed due to the discomfort of the left upper abdomen, and the blood examination is shown conventionally: white blood cell count 403X 10⁹/L, hemoglobin 98g/L, platelet count 268X 10⁹L; bone marrow morphology: chronic myelogenous leukemia (chronic stage), with hyperactive proliferation of nucleated cells, 97% of granulocytes; bone marrow biopsy: bone marrow hyperplasia is active, and the proportion of grain systems is obviously increased; leukemia immunophenotyping: 1.8% of naive cell population, myeloid expression; BCR-ABL (P210): and (4) positive. The patient was diagnosed with chronic myelogenous leukemia (chronic phase) and was given an oral once daily treatment of 0.4g of imatinib. Bone marrow was rechecked in 2019 for 5 months, and bone marrow morphology: the proliferation of the granule system is active, accounting for 75 percent; BCR-ABL quantification: 26.97 percent. Progressive decrease of platelets occurred in 7 months in 2019, bone marrow was rechecked, bone marrow morphology: 41% of original children; chromosome: 46 XY, t (9; 22) (q 34; q 11); gene mutation: CEBPA single mutation, ABL kinase domain mutation: E255K mutation. The acute myelogenous leukemia is diagnosed as chronic granulocytic leukemia, and the acute myelogenous leukemia is changed into dasatinibAnd (5) continuing targeted therapy. 2019-08-06 plus IA regimen for chemotherapy. 2019-11-15 for bone puncture reexamination: the proliferation of nucleated cells is active, and the primary cells account for 3.6 percent; leukemia immunophenotyping: 4.7% of the naive cell population was analyzed for myeloid expression; chromosome: 46 XY, t (9; 22) (q 34; q11) [5 ]]/46， XY[5](ii) a 13.37 percent of BCR-ABL and 29.63 percent of peripheral blood BCR-ABL, and the treatment is continued by using nilotinib. 2019-12-14 is treated by adding interferon and nilotinib, and 2019-12-31 is used for leukemia immunophenotyping, which indicates that 8.1% of naive cell populations are expressed in a marrow system, and the disease control is considered to be poor, so that the treatment is changed from 2020-01-04 to boratinib, and 2020-01-16 is used for rechecking the marrow, and the marrow morphology: 2.5% of the original children; leukemia immunophenotyping: 39.9 percent; chromosome: 46 XY, t (9; 22) (q 34; q11) [9 ]]/46， idm，del(7)(q21)，inv(16)(p23q22)[1](ii) a 77.3% of BCR-ABL (bone marrow), 69.7% of BCR-ABL (blood) and 94% of BCR-ABL-FISH. Second-generation sequencing: PHF6 mutation was positive (39%). 2020-01-20 continue nilotinib in combination with interferon therapy. 2020-1-31 are admitted to the hospital for further treatment.

Physical examination: the traditional Chinese medicine composition has the advantages of being clear in mind, free of anemia appearance, free of swelling of systemic superficial lymph nodes, free of tenderness in sternum, clear in lung auscultation respiratory sound, free of harmony, arrhythmia and free of pathological noise. The abdomen is soft, there is no tenderness and pain, the spleen is accessible under the ribs, and there is no edema in both lower limbs.

Auxiliary inspection: line 2020-1-20 bone marrow examination, bone marrow morphology: hemorrhagia, 13.5% of primary (fig. 2); and (3) immune typing: analysis of 26.3% naive cells, myeloid expression (FIG. 3), 94.9% CD 38; FISH: BCR-ABL positive 90%. Bone marrow BCR-ABL 42.76%, peripheral blood BCR-ABL quantitative range 18.7% -34.8%. ABL kinase region mutations: E255K (fig. 2).

Treatment: combining case data and auxiliary examination results, the patient is diagnosed with acute myelopathy of chronic granulocytic leukemia, and is treated by multiple TKIs (dasatinib, nilotinib and boratinib) and interferons in sequence, the BCR-ABL fusion gene level remains high, and the disease is not morphologically relieved. Lines 2020-2-12 DAC + HAAG regimen chemotherapy, no effect. Thus, after patient and family consent were obtained, the patients received autologous CD38 CAR-T therapy with a total number of infused cells of 1X 10⁷In terms of total amount of20%, 30% and 50% are returned in 3 days.

The curative effect is as follows: bone marrow was reviewed in the second half month of CD38 CAR-T, bone marrow morphology: mitigation (fig. 2); MRD: 2.7% (16302 cells analyzed) (fig. 3); chromosome: normal karyotype; bone marrow BCR/ABL 0%. ABL kinase region mutations: negative (fig. 2). The patient obtains molecular and MRD negative relief, and creates favorable conditions for further allogeneic hematopoietic stem cell transplantation. Then, the haplotype allogeneic hematopoietic stem cell transplantation is successfully carried out, regular follow-up is carried out after the transplantation till now, the bone marrow is rechecked, the bone marrow morphology indicates that the BCR/ABL fusion gene of the bone marrow and peripheral blood is continuously negative in remission (figure 1), and the bone marrow and peripheral blood are continuously survived for 1 year and 8 months without diseases.

Claims

Use of CD38 CAR-T cells in acute myeloid leukemia, wherein said use is CD38 CAR-T cells, and wherein the total dose infused is: (0.5-2.0). times.10⁷And/kg, the infusion is carried out in 3 days according to 20 percent, 30 percent and 50 percent of the total infusion dose.
2. The use of CD38 CAR-T cells in chronic myelogenous leukemia acute myelopathy according to claim 1, wherein the source of CD38 CAR-T cells is autologous cells of the patient.
3. The use of a CD38 CAR-T cell according to claim 1, wherein the subject is a patient with chronic myelogenous leukemia acute myelogenous change.
4. The use of CD38 CAR-T cells according to claim 1, wherein the patient has combined TKI and chemotherapy resistance.