US20150202286A1 - Toxicity Management for Anti-Tumor Activity of CARs - Google Patents

Toxicity Management for Anti-Tumor Activity of CARs Download PDF

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US20150202286A1
US20150202286A1 US14/410,659 US201314410659A US2015202286A1 US 20150202286 A1 US20150202286 A1 US 20150202286A1 US 201314410659 A US201314410659 A US 201314410659A US 2015202286 A1 US2015202286 A1 US 2015202286A1
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cytokine
patient
cells
cell
therapy
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Carl H. June
Bruce L. Levine
Michael D. Kalos
Stephan Grupp
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Childrens Hospital of Philadelphia CHOP
University of Pennsylvania Penn
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Publication of US20150202286A1 publication Critical patent/US20150202286A1/en
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Assigned to THE CHILDREN'S HOSPITAL OF PHILADELPHIA reassignment THE CHILDREN'S HOSPITAL OF PHILADELPHIA ASSIGNMENT OF ASSIGNORS INTEREST (SEE DOCUMENT FOR DETAILS). Assignors: GRUPP, Stephan
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Definitions

  • ALL acute lymphocytic leukemia
  • Chimeric antigen receptor modified T cells targeting lineage-specific antigens CD19 and CD20 have been reported to be effective in adults with CLL and B-cell lymphomas (Till et al., 2008, Blood 112:2261-71; Kochenderfer et al., 2010, Blood 116:4099-102; Brentjens et al., 2011, Blood 118:4817-28; Porter et al., 2011, N Engl J Med 365:725-33; Kalos et al., 2011, Science Translational Medicine 3:95ra73; Savoldo et al., 2011, J Clin Invest 121:1822-5).
  • CAR T cells on ALL blasts a more immature leukemia with a more rapid progression, have not been fully investigated.
  • compositions and methods for treatment of cancer using CARs and addressing toxicity of the CARs.
  • the present invention addresses this need.
  • the invention provides a method of treating a patient having a disease, disorder or condition associated with an elevated expression of a tumor antigen.
  • the method comprises administering a first-line therapy and a second-line therapy to a patient in need thereof, wherein the first line therapy comprises administering to the patient an effective amount of a cell genetically modified to express a CAR, wherein the CAR comprises an antigen binding domain, a transmembrane domain, and an intracellular signaling domain.
  • cytokine levels in the patient are monitored to determine the appropriate type of second-line therapy to be administered to the patient and the appropriate second-line therapy is administered to the patient in need thereof.
  • an increase in the level of a cytokine identifies a type of cytokine inhibitory therapy to be administered to the patient in need thereof.
  • the cytokine is selected from the group consisting of IL-1 ⁇ , IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, IL-13, IL-15, IL-17, IL-1Ra, IL-2R, IFN- ⁇ , IFN- ⁇ , MIP-1 ⁇ , MIP-1 ⁇ , MCP-1, TNF ⁇ , GM-CSF, G-CSF, CXCL9, CXCL10, CXCR factors, VEGF, RANTES, EOTAXIN, EGF, HGF, FGF- ⁇ , CD40, CD40L, ferritin, and any combination thereof.
  • the cytokine inhibitory therapy is selected from the group consisting of a small interfering RNA (siRNA), a microRNA, an antisense nucleic acid, a ribozyme, an expression vector encoding a transdominant negative mutant, an antibody, a peptide, a small molecule, a cytokine inhibitory drug, and any combination thereof.
  • siRNA small interfering RNA
  • microRNA an antisense nucleic acid
  • a ribozyme an expression vector encoding a transdominant negative mutant
  • an antibody a peptide
  • a small molecule a cytokine inhibitory drug
  • the cytokine levels are monitored by detecting the protein level of the cytokine in a biological sample from the patient.
  • the cytokine levels are monitored by detecting the nucleic acid level of the cytokine in a biological sample from the patient.
  • the invention provides a method of reducing or avoiding an adverse effect associated with the administration of a cell genetically modified to express a CAR, wherein the CAR comprises an antigen binding domain, a transmembrane domain, and an intracellular signaling domain, the method comprising monitoring the levels of a cytokine in a patient to determine the appropriate type of cytokine therapy to be administered to the patient and administering the appropriate cytokine therapy to the patient.
  • an increase in the level of a cytokine identifies a type of cytokine inhibitory therapy to be administered to the patient.
  • the cytokine is selected from the group consisting of IL-1 ⁇ , IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, IL-13, IL-15, IL-17, IL-1Ra, IL-2R, IFN- ⁇ , IFN- ⁇ , MIP-1 ⁇ , MIP-1 ⁇ , MCP-1, TNF ⁇ , GM-CSF, G-CSF, CXCL9, CXCL10, CXCR factors, VEGF, RANTES, EOTAXIN, EGF, HGF, FGF- ⁇ , CD40, CD40L, ferritin, and any combination thereof.
  • the cytokine inhibitory therapy is selected from the group consisting of a small interfering RNA (siRNA), a microRNA, an antisense nucleic acid, a ribozyme, an expression vector encoding a transdominant negative mutant, an intracellular antibody, a peptide, a small molecule, a cytokine inhibitory drug, and any combination thereof.
  • siRNA small interfering RNA
  • microRNA an antisense nucleic acid
  • a ribozyme an expression vector encoding a transdominant negative mutant
  • an intracellular antibody a peptide, a small molecule, a cytokine inhibitory drug, and any combination thereof.
  • the cytokine levels are monitored by detecting the protein level of the cytokine in a biological sample from the patient.
  • the cytokine levels are monitored by detecting the nucleic acid level of the cytokine in a biological sample from the patient.
  • FIG. 1 is an image demonstrating serum cytokine levels in four different patients. All patients exhibited cytokine release, including IL-6.
  • FIG. 2 is an image depicting serum cytokines plotted in a representative patient. The patient was critically ill on days 5 to 7, and only began to improve following tocilizumab administration.
  • FIG. 3 is an image demonstrating that antibody interventions do not impact CART 19 cellular functionality as measured for markers of T cell activity (perforin and IFN- ⁇ ).
  • FIG. 4 is a series of images depicting clinical responses.
  • FIG. 4A shows two children with multiply-relapsed chemotherapy-refractory CD19+ B cell precursor acute lymphoblastic leukemia who were treated with CTL019 cells, infused on Day 0. Changes in serum lactate dehydrogenase (LDH) and body temperature after CTL019 infusion, with maximum temperature per 24 hour period demarcated with circles.
  • LDH serum lactate dehydrogenase
  • CHOP-100 was given methylprednisolone starting on day 5 at 2 mg/kg/day, tapered to off by day 12. On the morning of day 7, etanercept was given 0.8 mg/kg ⁇ 1. At 6 pm in the evening of day 7, tocilizumab 8 mg/kg ⁇ 1 was administered.
  • FIG. 4B shows serum cytokines and inflammatory markers measured at frequent time points after CTL019 infusion. Cytokine values are shown using a semi-logarithmic plot with fold-change from baseline.
  • Baseline (Day 0 pre-infusion) values (pg/ml serum) for each analyte were (CHOP-100, CHOP-101): IL1- ⁇ : (0.9, 0.2); IL-6: (4.3, 1.9); TNF- ⁇ : (1.5, 0.4); IL2R ⁇ : (418.8, 205.7); IL-2: (0.7, 0.4); IL-10 (9.9, 2.3); IL1R ⁇ : (43.9, 27.9).
  • FIG. 4C shows changes in circulating absolute neutrophil count (ANC), absolute lymphocyte count (ALC) and white blood cell (WBC) count.
  • ALC absolute lymphocyte count
  • WBC white blood cell
  • FIG. 5 is a series of imaged depicting expansion and visualization of CTL019 cells in peripheral blood, bone marrow and CSF.
  • FIG. 5A shows flow cytometric analysis of peripheral blood stained with antibodies to detect CD3 and the anti-CD19 CAR. Depicted are the percent of CD3 cells expressing the CAR in CHOP-100 and CHOP-101.
  • FIG. 5B shows the presence of CTL019 T cells in peripheral blood, bone marrow, and CSF by quantitative real-time PCR. Genomic DNA was isolated from whole blood, bone marrow aspirates and CSF collected at serial time points before and after CTL019 infusion.
  • FIG. 5A shows flow cytometric analysis of peripheral blood stained with antibodies to detect CD3 and the anti-CD19 CAR. Depicted are the percent of CD3 cells expressing the CAR in CHOP-100 and CHOP-101.
  • FIG. 5B shows the presence of CTL019 T cells in peripheral blood, bone marrow, and CSF by quantitative real-time PCR. Geno
  • FIG. 5C shows flow cytometric detection of CTL019 cells in CSF collected from CHOP-100 and CHOP-101.
  • FIG. 5D shows images of activated large granular lymphocytes in Wright-stained smears of the peripheral blood and cytospins of the CSF.
  • FIG. 6 is an image showing CD19 expression at baseline and at relapse in CHOP-101. Bone marrow samples from CHOP-101 were obtained prior to CTL019 infusion and at time of relapse 2 months later. Mononuclear cells isolated from marrow samples were stained for CD45, CD34 and CD19 and analyzed on an Accuri C6 flow cytometer. After gating on live cells, the blast gate (CD45+SSC low) was subgated on CD34+ cells and histograms generated for CD19 expression. Division line represents threshold for the same gating on isotype controls.
  • Pre-therapy blasts have a range of distribution of CD19, with a small population of very dim staining cells seen as the tail of the left histogram at 102 on the X-axis.
  • the relapse sample does not have any CD19 positive blasts.
  • Analysis of CD19 expression on the pre-treatment blast population revealed a small population of CD19 dim or negative cells.
  • the mean fluorescence intensity (MFI) of this small population of cells was 187 (left panel), similar to the MFI of the anti-CD19-stained relapsed blast cells (201, right panel).
  • Pre-therapy marrow sample was hypocellular with 10% blasts and relapse marrowsample was normocellular with 68% blasts, accounting for differences in events available for acquisition.
  • FIG. 7 is an image showing induction of remission in bone marrow in CHOP-101 on day+23 after CTL019 infusion.
  • FIG. 8 is an image depicting in vivo expansion and persistence of CTL019 cells in blood.
  • the number of white blood cells (WBC), CD3+ T cells, and CTL019 cells in blood is shown for CHOP-100 and CHOP-101. Cell numbers are shown on a semi-logarithmic plot.
  • FIG. 9 is a series of images demonstrating that subjects had an elimination of CD19 positive cells in bone marrow and blood within 1 month after CTL019 infusion.
  • FIG. 9A shows persistent B cell aplasia in CHOP-100.
  • the top panel shows a predominant population of leukemic blast cells in bone marrow aspirated from CHOP-100 expressing CD19 and CD20 on day+6. This population is absent at day+23 and 6 months.
  • FIG. 9B shows B cell aplasia and emergence of CD19 escape variant cells in CHOP-101. Flow cytometric analysis of bone marrow aspirates from CHOP-101 stained with anti-CD45, CD34 and CD19.
  • FIG. 10 is a graph depicting the levels of ferritin present in the patient following receipt of CAR T cells.
  • FIG. 11 is a graph depicting the levels of myoglobin present in the patient following receipt of CAR T cells.
  • FIG. 12 is a graph depicting the levels of plasminogen activator inhibitor-1 (PAI-1) present in the patient following receipt of CART cells.
  • PAI-1 plasminogen activator inhibitor-1
  • the invention relates to compositions and methods for treating cancer including but not limited to hematologic malignancies and solid tumors.
  • the invention also encompasses methods of treating and preventing certain types of cancer, including primary and metastatic cancer, as well as cancers that are refractory or resistant to conventional chemotherapy.
  • the methods comprise administering to a patient in need of such treatment or prevention a therapeutically or prophylactically effective amount of a T cell transduced to express a chimeric antigen receptor (CAR).
  • CARs are molecules that combine antibody-based specificity for a desired antigen (e.g., tumor antigen) with a T cell receptor-activating intracellular domain to generate a chimeric protein that exhibits a specific anti-tumor cellular immune activity.
  • the invention encompasses methods of managing certain cancers (e.g., preventing or prolonging their recurrence, or lengthening the time of remission) by evaluating the profile of soluble factors in patients post T cell infusion.
  • the profile of soluble factors includes evaluation of a cytokine profile.
  • cytokine profile indicates an increase in a particular cytokine post T cell infusion compared to pre T cell infusion
  • a skilled artisan can elect to administer to the patient in need of such management an effective amount of a cytokine inhibitory compound or a pharmaceutically acceptable salt, solvate, hydrate, stereoisomer, clathrate, or pro drug thereof to manage the elevated levels of the cytokine post T cell infusion.
  • the present invention is partly based on the discovery that the identify of a unique combination of factors whose modulation from baseline or pre-existing levels at baseline can help track T cell activation, target activity, and potential harmful side effects following CAR T cell infusion in order to help manage the treatment of the cancer.
  • Exemplary factors include but are not limited to IL-1 ⁇ , IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, IL-13, IL-15, IL-17, IL-1Ra, IL-2R, IFN- ⁇ , IFN- ⁇ , MIP-1 ⁇ , MIP-1 ⁇ , MCP-1, TNF ⁇ , GM-CSF, G-CSF, CXCL9, CXCL10, CXCR factors, VEGF, RANTES, EOTAXIN, EGF, HGF, FGF- ⁇ , CD40, CD40L, ferritin, and the like.
  • the present invention relates to a strategy of adoptive cell transfer of T cells transduced to express a chimeric antigen receptor (CAR) in combination with toxicity management, where a profile of soluble factors from a post T cell infusion patient is generated and a therapy directed against the elevated soluble factor is carried out in order to treat the cancer.
  • CAR chimeric antigen receptor
  • generating a real time soluble factor profile allows for intervention of the elevated soluble factors with the appropriate inhibitor in order to bring the levels down to normal levels.
  • the CAR of the invention comprises an extracellular domain having an antigen recognition domain that targets a desired antigen, a transmembrane domain, and a cytoplasmic domain.
  • the invention is not limited to a specific CAR. Rather, any CAR that targets a desired antigen can be used in the present invention.
  • Compositions and methods of making CARs have been described in PCT/US11/64191, which is incorporated by reference in its entirety herein.
  • the methods result in a measurable reduction in tumor size or evidence of disease or disease progression, complete response, partial response, stable disease, increase or elongation of progression free survival, increase or elongation of overall survival, or reduction in toxicity.
  • an element means one element or more than one element.
  • Activation refers to the state of a T cell that has been sufficiently stimulated to induce detectable cellular proliferation. Activation can also be associated with induced cytokine production, and detectable effector functions.
  • the term “activated T cells” refers to, among other things, T cells that are undergoing cell division.
  • Activators or “agonists” of a soluble factor are used herein to refer to molecules of agents capable of activating or increasing the levels of the soluble factor. Activators are compounds that increase, promote, induce activation, activate, or upregulate the activity or expression of soluble factor, e.g., agonists. Assays for detecting activators include, e.g., expressing the soluble factor in vitro, in cells, or cell membranes, applying putative agonist compounds, and then determining the functional effects on activity of the soluble factor, as described elsewhere herein.
  • antibody refers to an immunoglobulin molecule which specifically binds with an antigen.
  • Antibodies can be intact immunoglobulins derived from natural sources or from recombinant sources and can be immunoreactive portions of intact immunoglobulins. Antibodies are often tetramers of immunoglobulin molecules.
  • the antibodies in the present invention may exist in a variety of forms including, for example, polyclonal antibodies, monoclonal antibodies, Fv, Fab and F(ab) 2 , as well as single chain antibodies and humanized antibodies (Harlow et al., 1999, In: Using Antibodies: A Laboratory Manual, Cold Spring Harbor Laboratory Press, NY; Harlow et al., 1989, In: Antibodies: A Laboratory Manual, Cold Spring Harbor, N.Y.; Houston et al., 1988, Proc. Natl. Acad. Sci. USA 85:5879-5883; Bird et al., 1988, Science 242:423-426).
  • antibody fragment refers to a portion of an intact antibody and refers to the antigenic determining variable regions of an intact antibody.
  • antibody fragments include, but are not limited to, Fab, Fab′, F(ab′)2, and Fv fragments, linear antibodies, scFv antibodies, and multispecific antibodies formed from antibody fragments.
  • antigen or “Ag” as used herein is defined as a molecule that provokes an immune response. This immune response may involve either antibody production, or the activation of specific immunologically-competent cells, or both.
  • any macromolecule including virtually all proteins or peptides, can serve as an antigen.
  • antigens can be derived from recombinant or genomic DNA. A skilled artisan will understand that any DNA, which comprises a nucleotide sequences or a partial nucleotide sequence encoding a protein that elicits an immune response therefore encodes an “antigen” as that term is used herein.
  • an antigen need not be encoded solely by a full length nucleotide sequence of a gene. It is readily apparent that the present invention includes, but is not limited to, the use of partial nucleotide sequences of more than one gene and that these nucleotide sequences are arranged in various combinations to elicit the desired immune response. Moreover, a skilled artisan will understand that an antigen need not be encoded by a “gene” at all. It is readily apparent that an antigen can be generated synthesized or can be derived from a biological sample. Such a biological sample can include, but is not limited to a tissue sample, a tumor sample, a cell or a biological fluid.
  • auto-antigen means, in accordance with the present invention, any self-antigen which is recognized by the immune system as if it were foreign.
  • Auto-antigens comprise, but are not limited to, cellular proteins, phosphoproteins, cellular surface proteins, cellular lipids, nucleic acids, glycoproteins, including cell surface receptors.
  • autoimmune disease as used herein is defined as a disorder that results from an autoimmune response.
  • An autoimmune disease is the result of an inappropriate and excessive response to a self-antigen.
  • autoimmune diseases include but are not limited to, Addision's disease, alopecia greata, ankylosing spondylitis, autoimmune hepatitis, autoimmune parotitis, Crohn's disease, diabetes (Type I), dystrophic epidermolysis bullosa, epididymitis, glomerulonephritis, Graves' disease, Guillain-Barr syndrome, Hashimoto's disease, hemolytic anemia, systemic lupus erythematosus, multiple sclerosis, myasthenia gravis, pemphigus vulgaris, psoriasis, rheumatic fever, rheumatoid arthritis, sarcoidosis, scleroderma, Sjogren's syndrome, spondyloarthropathies, thyroid
  • autologous is meant to refer to any material derived from the same individual to which it is later to be re-introduced into the individual.
  • Allogeneic refers to a graft derived from a different animal of the same species.
  • Xenogeneic refers to a graft derived from an animal of a different species.
  • cancer as used herein is defined as disease characterized by the rapid and uncontrolled growth of aberrant cells. Cancer cells can spread locally or through the bloodstream and lymphatic system to other parts of the body. Examples of various cancers include but are not limited to, breast cancer, prostate cancer, ovarian cancer, cervical cancer, skin cancer, pancreatic cancer, colorectal cancer, renal cancer, liver cancer, brain cancer, lymphoma, leukemia, lung cancer and the like.
  • “combination therapy” is meant that a first agent is administered in conjunction with another agent.
  • “In conjunction with” refers to administration of one treatment modality in addition to another treatment modality.
  • “in conjunction with” refers to administration of one treatment modality before, during, or after delivery of the other treatment modality to the individual. Such combinations are considered to be part of a single treatment regimen or regime.
  • the term “concurrent administration” means that the administration of the first therapy and that of a second therapy in a combination therapy overlap with each other.
  • Co-stimulatory ligand includes a molecule on an antigen presenting cell (e.g., an aAPC, dendritic cell, B cell, and the like) that specifically binds a cognate co-stimulatory molecule on a T cell, thereby providing a signal which, in addition to the primary signal provided by, for instance, binding of a TCR/CD3 complex with an MHC molecule loaded with peptide, mediates a T cell response, including, but not limited to, proliferation, activation, differentiation, and the like.
  • an antigen presenting cell e.g., an aAPC, dendritic cell, B cell, and the like
  • a co-stimulatory ligand can include, but is not limited to, CD7, B7-1 (CD80), B7-2 (CD86), PD-L1, PD-L2, 4-1BBL, OX40L, inducible costimulatory ligand (ICOS-L), intercellular adhesion molecule (ICAM), CD30L, CD40, CD70, CD83, HLA-G, MICA, MICB, HVEM, lymphotoxin beta receptor, 3/TR6, ILT3, ILT4, HVEM, an agonist or antibody that binds Toll ligand receptor and a ligand that specifically binds with B7-H3.
  • a co-stimulatory ligand also encompasses, inter alia, an antibody that specifically binds with a co-stimulatory molecule present on a T cell, such as, but not limited to, CD27, CD28, 4-1BB, OX40, CD30, CD40, PD-1, ICOS, lymphocyte function-associated antigen-1 (LFA-1), CD2, CD7, LIGHT, NKG2C, B7-H3, and a ligand that specifically binds with CD83.
  • an antibody that specifically binds with a co-stimulatory molecule present on a T cell such as, but not limited to, CD27, CD28, 4-1BB, OX40, CD30, CD40, PD-1, ICOS, lymphocyte function-associated antigen-1 (LFA-1), CD2, CD7, LIGHT, NKG2C, B7-H3, and a ligand that specifically binds with CD83.
  • a “co-stimulatory molecule” refers to the cognate binding partner on a T cell that specifically binds with a co-stimulatory ligand, thereby mediating a co-stimulatory response by the T cell, such as, but not limited to, proliferation.
  • Co-stimulatory molecules include, but are not limited to an MHC class I molecule, BTLA and a Toll ligand receptor.
  • a “co-stimulatory signal,” as used herein, refers to a signal, which in combination with a primary signal, such as TCR/CD3 ligation, leads to T cell proliferation and/or upregulation or downregulation of key molecules.
  • a “disease” is a state of health of an animal wherein the animal cannot maintain homeostasis, and wherein if the disease is not ameliorated then the animal's health continues to deteriorate.
  • a “disorder” in an animal is a state of health in which the animal is able to maintain homeostasis, but in which the animal's state of health is less favorable than it would be in the absence of the disorder. Left untreated, a disorder does not necessarily cause a further decrease in the animal's state of health.
  • an “effective amount” as used herein means an amount which provides a therapeutic or prophylactic benefit.
  • endogenous refers to any material from or produced inside an organism, cell, tissue or system.
  • exogenous refers to any material introduced to an organism, cell, tissue or system that was produced outside the organism, cell, tissue or system.
  • expression is defined as the transcription and/or translation of a particular nucleotide sequence driven by its promoter.
  • “Expression vector” refers to a vector comprising a recombinant polynucleotide comprising expression control sequences operatively linked to a nucleotide sequence to be expressed.
  • An expression vector comprises sufficient cis-acting elements for expression; other elements for expression can be supplied by the host cell or in an in vitro expression system.
  • Expression vectors include all those known in the art, such as cosmids, plasmids (e.g., naked or contained in liposomes) and viruses (e.g., lentiviruses, retroviruses, adenoviruses, and adeno-associated viruses) that incorporate the recombinant polynucleotide.
  • “Homologous” refers to the sequence similarity or sequence identity between two polypeptides or between two nucleic acid molecules. When a position in both of the two compared sequences is occupied by the same base or amino acid monomer subunit, e.g., if a position in each of two DNA molecules is occupied by adenine, then the molecules are homologous at that position.
  • the percent of homology between two sequences is a function of the number of matching or homologous positions shared by the two sequences divided by the number of positions compared ⁇ 100. For example, if 6 of 10 of the positions in two sequences are matched or homologous then the two sequences are 60% homologous.
  • the DNA sequences ATTGCC and TATGGC share 50% homology. Generally, a comparison is made when two sequences are aligned to give maximum homology.
  • immunoglobulin or “Ig,” as used herein, is defined as a class of proteins, which function as antibodies. Antibodies expressed by B cells are sometimes referred to as the BCR (B cell receptor) or antigen receptor. The five members included in this class of proteins are IgA, IgG, IgM, IgD, and IgE.
  • IgA is the primary antibody that is present in body secretions, such as saliva, tears, breast milk, gastrointestinal secretions and mucus secretions of the respiratory and genitourinary tracts.
  • IgG is the most common circulating antibody.
  • IgM is the main immunoglobulin produced in the primary immune response in most subjects.
  • IgD is the immunoglobulin that has no known antibody function, but may serve as an antigen receptor.
  • IgE is the immunoglobulin that mediates immediate hypersensitivity by causing release of mediators from mast cells and basophils upon exposure to allergen.
  • immune response includes T cell mediated and/or B cell mediated immune responses.
  • exemplary immune responses include T cell responses, e.g., cytokine production and cellular cytotoxicity.
  • immune response includes immune responses that are indirectly effected by T cell activation, e.g., antibody production (humoral responses) and activation of cytokine responsive cells, e.g., macrophages
  • Immune cells involved in the immune response include lymphocytes, such as B cells and T cells (CD4+, CD8+, Th1 and Th2 cells); antigen presenting cells (e.g., professional antigen presenting cells such as dendritic cells, macrophages, B lymphocytes, Langerhans cells, and non-professional antigen presenting cells such as keratinocytes, endothelial cells, astrocytes, fibroblasts, oligodendrocytes); natural killer cells; myeloid cells, such as macrophages, eosinophils
  • lymphocytes such as B cells
  • Inhibitors or “antagonists” of a soluble factor are used herein to refer to molecules of agents capable of inhibiting, inactivating or reducing the levels of the soluble factor.
  • Inhibitors are compounds that, e.g., bind to, partially or totally block activity, decrease, prevent, delay activation, inactivate, desensitize, or down regulate the activity or expression of soluble factor, e.g., antagonists.
  • Inhibitors include polypeptide inhibitors, such as antibodies, soluble receptors and the like, as well as nucleic acid inhibitors such as siRNA or antisense RNA, genetically modified versions of the soluble factor, e.g., versions with altered activity, as well as naturally occurring and synthetic soluble factor antagonists, small chemical molecules and the like.
  • Assays for detecting inhibitors include, e.g., expressing the soluble factor in vitro, in cells, or cell membranes, applying putative antagonist compounds, and then determining the functional effects on activity of the soluble factor, as described elsewhere here
  • an “instructional material” includes a publication, a recording, a diagram, or any other medium of expression which can be used to communicate the usefulness of the compositions and methods of the invention.
  • the instructional material of the kit of the invention may, for example, be affixed to a container which contains the nucleic acid, peptide, and/or composition of the invention or be shipped together with a container which contains the nucleic acid, peptide, and/or composition.
  • the instructional material may be shipped separately from the container with the intention that the instructional material and the compound be used cooperatively by the recipient.
  • isolated means altered or removed from the natural state.
  • a nucleic acid or a peptide naturally present in a living animal is not “isolated,” but the same nucleic acid or peptide partially or completely separated from the coexisting materials of its natural state is “isolated.”
  • An isolated nucleic acid or protein can exist in substantially purified form, or can exist in a non-native environment such as, for example, a host cell.
  • a “lentivirus” as used herein refers to a genus of the Retroviridae family. Lentiviruses are unique among the retroviruses in being able to infect non-dividing cells; they can deliver a significant amount of genetic information into the DNA of the host cell, so they are one of the most efficient methods of a gene delivery vector. HIV, SIV, and FIV are all examples of lentiviruses. Vectors derived from lentiviruses offer the means to achieve significant levels of gene transfer in vivo.
  • level of a soluble factor in a biological sample typically refers to the amount of protein, protein fragment or peptide levels of the soluble factor that is present in a biological sample.
  • a “level of a soluble factor” need not be quantified, but can simply be detected, e.g., a subjective, visual detection by a human, with or without comparison to a level from a control sample or a level expected of a control sample.
  • moduleating mediating a detectable increase or decrease in the level of a response in a subject compared with the level of a response in the subject in the absence of a treatment or compound, and/or compared with the level of a response in an otherwise identical but untreated subject.
  • the term encompasses perturbing and/or affecting a native signal or response thereby mediating a beneficial therapeutic response in a subject, preferably, a human.
  • parenteral administration of an immunogenic composition includes, e.g., subcutaneous (s.c.), intravenous (i.v.), intramuscular (i.m.), or intrasternal injection, or infusion techniques.
  • patient refers to any animal, or cells thereof whether in vitro or in situ, amenable to the methods described herein.
  • the patient, subject or individual is a human.
  • first therapy and second therapy in a combination therapy are administered with a time separation of no more than about 15 minutes, such as no more than about any of 10, 5, or 1 minutes.
  • first and second therapies may be contained in the same composition (e.g., a composition comprising both a first and second therapy) or in separate compositions (e.g., a first therapy in one composition and a second therapy is contained in another composition).
  • first therapy and second therapy in a combination therapy are administered with a time separation of no more than about 15 minutes, such as no more than about any of 10, 5, or 1 minutes.
  • first and second therapies may be contained in the same composition (e.g., a composition comprising both a first and second therapy) or in separate compositions (e.g., a first therapy in one composition and a second therapy is contained in another composition).
  • an antibody which recognizes a specific antigen, but does not substantially recognize or bind other molecules in a sample.
  • an antibody that specifically binds to an antigen from one species may also bind to that antigen from one or more species. But, such cross-species reactivity does not itself alter the classification of an antibody as specific.
  • an antibody that specifically binds to an antigen may also bind to different allelic forms of the antigen. However, such cross reactivity does not itself alter the classification of an antibody as specific.
  • the terms “specific binding” or “specifically binding,” can be used in reference to the interaction of an antibody, a protein, or a peptide with a second chemical species, to mean that the interaction is dependent upon the presence of a particular structure (e.g., an antigenic determinant or epitope) on the chemical species; for example, an antibody recognizes and binds to a specific protein structure rather than to proteins generally. If an antibody is specific for epitope “A,” the presence of a molecule containing epitope A (or free, unlabeled A), in a reaction containing labeled “A” and the antibody, will reduce the amount of labeled A bound to the antibody.
  • a particular structure e.g., an antigenic determinant or epitope
  • stimulation is meant a primary response induced by binding of a stimulatory molecule (e.g., a TCR/CD3 complex) with its cognate ligand thereby mediating a signal transduction event, such as, but not limited to, signal transduction via the TCR/CD3 complex.
  • a stimulatory molecule e.g., a TCR/CD3 complex
  • Stimulation can mediate altered expression of certain molecules, such as downregulation of TGF- ⁇ , and/or reorganization of cytoskeletal structures, and the like.
  • a “stimulatory molecule,” as the term is used herein, means a molecule on a T cell that specifically binds with a cognate stimulatory ligand present on an antigen presenting cell.
  • a “stimulatory ligand,” as used herein, means a ligand that when present on an antigen presenting cell (e.g., an aAPC, a dendritic cell, a B-cell, and the like) can specifically bind with a cognate binding partner (referred to herein as a “stimulatory molecule”) on a T cell, thereby mediating a primary response by the T cell, including, but not limited to, activation, initiation of an immune response, proliferation, and the like.
  • an antigen presenting cell e.g., an aAPC, a dendritic cell, a B-cell, and the like
  • a cognate binding partner referred to herein as a “stimulatory molecule”
  • Stimulatory ligands are well-known in the art and encompass, inter alia, an MHC Class I molecule loaded with a peptide, an anti-CD3 antibody, a superagonist anti-CD28 antibody, and a superagonist anti-CD2 antibody.
  • subject is intended to include living organisms in which an immune response can be elicited (e.g., mammals). Examples of subjects include humans, dogs, cats, mice, rats, and transgenic species thereof.
  • substantially purified cell is a cell that is essentially free of other cell types.
  • a substantially purified cell also refers to a cell which has been separated from other cell types with which it is normally associated in its naturally occurring state.
  • a population of substantially purified cells refers to a homogenous population of cells. In other instances, this term refers simply to cell that have been separated from the cells with which they are naturally associated in their natural state.
  • the cells are cultured in vitro. In other embodiments, the cells are not cultured in vitro.
  • terapéutica as used herein means a treatment and/or prophylaxis.
  • a therapeutic effect is obtained by suppression, remission, or eradication of a disease state.
  • therapeutically effective amount refers to the amount of the subject compound that will elicit the biological or medical response of a tissue, system, or subject that is being sought by the researcher, veterinarian, medical doctor or other clinician.
  • therapeutically effective amount includes that amount of a compound that, when administered, is sufficient to prevent development of, or alleviate to some extent, one or more of the signs or symptoms of the disorder or disease being treated.
  • the therapeutically effective amount will vary depending on the compound, the disease and its severity and the age, weight, etc., of the subject to be treated.
  • a “transplant,” as used herein, refers to cells, tissue, or an organ that is introduced into an individual.
  • the source of the transplanted material can be cultured cells, cells from another individual, or cells from the same individual (e.g., after the cells are cultured in vitro).
  • Exemplary organ transplants are kidney, liver, heart, lung, and pancreas.
  • transfected or “transformed” or “transduced” as used herein refers to a process by which exogenous nucleic acid is transferred or introduced into the host cell.
  • a “transfected” or “transformed” or “transduced” cell is one which has been transfected, transformed or transduced with exogenous nucleic acid.
  • the cell includes the primary subject cell and its progeny.
  • ranges throughout this disclosure, various aspects of the invention can be presented in a range format. It should be understood that the description in range format is merely for convenience and brevity and should not be construed as an inflexible limitation on the scope of the invention. Accordingly, the description of a range should be considered to have specifically disclosed all the possible subranges as well as individual numerical values within that range. For example, description of a range such as from 1 to 6 should be considered to have specifically disclosed subranges such as from 1 to 3, from 1 to 4, from 1 to 5, from 2 to 4, from 2 to 6, from 3 to 6 etc., as well as individual numbers within that range, for example, 1, 2, 2.7, 3, 4, 5, 5.3, and 6. This applies regardless of the breadth of the range.
  • the treatment method comprises a first-line of therapy comprising administering the CAR of the invention into the patient to induce an anti-tumor immune response and monitoring the levels of soluble factors in the patient post T cell infusion to determine the type of second-line of therapy appropriate to treat the patient as a consequence of the first-line of therapy.
  • the second-line of therapy comprises evaluating the profile of soluble factors in a patient following receipt of an infusion of the appropriate CAR T (referred elsewhere herein as “post T cell infusion”) where when the soluble factor profile indicates an increase in a particular soluble factor post T cell infusion compared to pre T cell infusion, a skilled artisan can elect to administer to the patient in need of an effective amount of a soluble factor inhibitory compound in order to manage the elevated levels of the soluble factor post T cell infusion.
  • the second-line of therapy in one embodiment includes administering a type of soluble factor inhibitory therapy to manage the elevated levels of certain soluble factor s resulting from the first-line of therapy of using CART cells.
  • the second-line of therapy relating to administering a soluble factor inhibitory compound to the patient can be combined with other conventionally therapies used to treat, prevent or manage diseases or disorders associated with, or characterized by, undesired angiogenesis.
  • conventional therapies include, but are not limited to, surgery, chemotherapy, radiation therapy, hormonal therapy, biological therapy and immunotherapy.
  • the CAR of the invention can be engineered to comprise an extracellular domain having an antigen binding domain that targets tumor antigen fused to an intracellular signaling domain of the T cell antigen receptor complex zeta chain (e.g., CD3 zeta).
  • An exemplary tumor antigen B cell antigen is CD19 because this antigen is expressed on malignant B cells.
  • the invention is not limited to targeting CD19. Rather, the invention includes any tumor antigen binding moiety.
  • the antigen binding moiety is preferably fused with an intracellular domain from one or more of a costimulatory molecule and a zeta chain.
  • the antigen binding moiety is fused with one or more intracellular domains selected from the group of a CD137 (4-1BB) signaling domain, a CD28 signaling domain, a CD3zeta signal domain, and any combination thereof.
  • the CAR of the invention comprises a CD137 (4-1BB) signaling domain.
  • CD137 (4-1BB) signaling domain is partly based on the discovery that CAR-mediated T-cell responses can be further enhanced with the addition of costimulatory domains.
  • inclusion of the CD137 (4-1BB) signaling domain significantly increased CAR mediated activity and in vivo persistence of CAR T cells compared to an otherwise identical CAR T cell not engineered to express CD137 (4-1BB).
  • the invention is not limited to a specific CAR. Rather, any CAR that targets a tumor antigen can be used in the present invention. Compositions and methods of making and using CARs have been described in PCT/US11/64191, which is incorporated by reference in its entirety herein.
  • the treatment regimen of the invention result in a measurable reduction in tumor size or evidence of disease or disease progression, complete response, partial response, stable disease, increase or elongation of progression free survival, increase or elongation of overall survival, or reduction in toxicity.
  • the invention encompasses a first-line and a second-line therapy, wherein the first-line therapy comprises administering a CAR T cell of the invention to the patient in need thereof.
  • the treatment regimen of the invention allows for the management of the cancer and treatment thereof by evaluating the soluble factor profile in patients post T cell infusion.
  • An appropriate second-line therapy comprises administering an appropriate soluble factor inhibitor to the patient in order to reduce the elevated levels of the soluble factor resulting from the first-line therapy.
  • the appropriate second-line therapy comprises administering an appropriate soluble factor activator to the patient in order to increase the suppressed levels of the soluble factor resulting from the first-line therapy.
  • an appropriate second-line therapy comprises administering an appropriate cytokine inhibitor to the patient in order to reduce the elevated levels of the cytokine resulting from the first-line therapy.
  • the appropriate second-line therapy comprises administering an appropriate cytokine activator to the patient in order to increase the suppressed levels of the cytokine resulting from the first-line therapy.
  • differential levels are over expression (high expression) or under expression (low expression) as compared to the expression level of a normal or control cell, a given patient population, or with an internal control. In some embodiments, levels are compared between the patient and a normal individual, between the patient post T cell infusion and pre T cell infusion, or between the patient post T cell infusion at a first time point and a second time point.
  • the invention includes evaluating differential levels of one or more cytokines to generate a cytokine profile in a patient post T cell infusion in order to determine the type of cytokine therapy to be applied to the patient for the purpose of regulating the cytokine level back to normal levels.
  • the invention may therefore be applied to identify cytokine levels elevated as a result of the presence of the CART cells of the invention in the patient, which allows the specialized treatment of the patient with cytokine inhibitors to decrease the elevated levels of the cytokine.
  • invention may be applied to identify cytokine levels decreased as a result of the presence of the CART cells of the invention in the patient, which allows the specialized treatment of the patient with cytokine activators to increase the diminished levels of the cytokine.
  • cytokines levels that are elevated as a result of receiving a CART cell infusion include but are not limited to IL-1 ⁇ , IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, IL-13, IL-15, IL-17, IL-1Ra, IL-2R, IFN- ⁇ , IFN- ⁇ , MIP-1 ⁇ , MIP-1 ⁇ , MCP-1, TNF ⁇ , GM-CSF, G-CSF, CXCL9, CXCL10, CXCR factors, VEGF, RANTES, EOTAXIN, EGF, HGF, FGF- ⁇ , CD40, CD40L, ferritin, and the like.
  • the invention should not be limited to these listed cytokines. Rather, the invention includes any cytokine identified to be elevated in a patient as a result of receiving a CAR T cell infusion.
  • cytokines levels that are decreased as a result of receiving a CART cell infusion include but are not limited to IL-1 ⁇ , IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, IL-13, IL-15, IL-17, IL-1Ra, IL-2R, IFN- ⁇ , IFN- ⁇ , MIP-1 ⁇ , MIP-1 ⁇ , MCP-1, TNF ⁇ , GM-CSF, G-CSF, CXCL9, CXCL10, CXCR factors, VEGF, RANTES, EOTAXIN, EGF, HGF, FGF- ⁇ , CD40, CD40L, ferritin, and the like.
  • the invention should not be limited to these listed cytokines. Rather, the invention includes any cytokine identified to be decreased in a patient as a result of receiving a CAR T cell infusion.
  • the invention includes methods of detecting levels of a cytokine in a patient that has received infusion of a CART cell of the invention.
  • the presence or level of a cytokine can be used to select a candidate treatment.
  • the presence or levels of the cytokine can be used to determine the success during the course of or after treatment of the first-line, second-line, or both the first and second-line of therapy.
  • Biological samples in which the cytokine can be detected include, for example, serum.
  • biological samples include a tissue biopsy which may or may not have a liquid component.
  • Immunoassays can be used to qualitatively or quantitatively analyze the cytokine levels in a biological sample.
  • a general overview of the applicable technology can be found in a number of readily available manuals, e.g., Harlow & Lane, Cold Spring Harbor Laboratory Press, Using Antibodies: A Laboratory Manual (1999).
  • cytokine expression and levels can be made based on the level of gene expression of the particular cytokines.
  • RNA hybridization techniques for determining the presence and/or level of mRNA expression are well known to those of skill in the art and can be used to assess the presence or level of gene expression of the cytokine of interest.
  • the methods of the present invention utilize selective binding partners of the cytokine to identify the presence or determine the levels of the cytokine in a biological sample.
  • the selective binding partner to be used with the methods and kits of the present invention can be, for instance, an antibody.
  • monoclonal antibodies to the particular cytokine can be used.
  • polyclonal antibodies to the particular cytokine can be employed to practice the methods and in the kits of the present invention.
  • cytokine Commercial antibodies to the cytokine are available and can be used with the methods and kits of the present invention. It is well known to those of skill in the art that the type, source and other aspects of an antibody to be used is a consideration to be made in light of the assay in which the antibody is used. In some instances, antibodies that will recognize its antigen target on a Western blot might not applicable to an ELISA or ELISpot assay and vice versa.
  • the antibodies to be used for the assays of the present invention can be produced using techniques for producing monoclonal or polyclonal antibodies that are well known in the art (see, e.g., Coligan, Current Protocols in Immunology (1991); Harlow & Lane, supra; Goding, Monoclonal Antibodies: Principles and Practice (2d ed. 1986); and Kohler & Milstein, Nature 256:495-497 (1975).
  • Such techniques include antibody preparation by selection of antibodies from libraries of recombinant antibodies in phage or similar vectors, as well as preparation of polyclonal and monoclonal antibodies by immunizing rabbits or mice (see, e.g., Huse et al., Science 246:1275-1281 (1989); Ward et al., Nature 341:544-546 (1989)).
  • Such antibodies can be used for therapeutic and diagnostic applications, e.g., in the treatment and/or detection of any of the specific cytokine-associated diseases or conditions described herein.
  • Detection methods employing immunoassays are particularly suitable for practice at the point of patient care. Such methods allow for immediate diagnosis and/or prognostic evaluation of the patient.
  • Point of care diagnostic systems are described, e.g., in U.S. Pat. No. 6,267,722 which is incorporated herein by reference.
  • Other immunoassay formats are also available such that an evaluation of the biological sample can be performed without having to send the sample to a laboratory for evaluation.
  • these assays are formatted as solid assays where a reagent, e.g., an antibody is used to detect the cytokine.
  • Exemplary test devices suitable for use with immunoassays such as assays of the present invention are described, for example, in U.S. Pat. Nos. 7,189,522; 6,818,455 and 6,656,745.
  • the present invention provides methods for detection of polynucleotide sequences which code for the cytokine in a biological sample.
  • a biological sample refers to a cell or population of cells or a quantity of tissue or fluid from a patient. Most often, the sample has been removed from a patient, but the term “biological sample” can also refer to cells or tissue analyzed in vivo, i.e., without removal from the patient. Typically, a “biological sample” will contain cells from the patient, but the term can also refer to noncellular biological material.
  • amplification-based assays are used to measure the level of a desired cytokine.
  • nucleic acid sequences of the desired cytokine act as a template in an amplification reaction (e.g., Polymerase Chain Reaction, or PCR).
  • an amplification reaction e.g., Polymerase Chain Reaction, or PCR.
  • the amount of amplification product will be proportional to the amount of template in the original sample. Comparison to appropriate controls provides a measure of the copy number of the cytokine associated gene.
  • Methods of quantitative amplification are well known to those of skill in the art. Detailed protocols for quantitative PCR are provided, e.g., in Innis et al. (1990) PCR Protocols, A Guide to Methods and Applications, Academic Press, Inc.
  • RT-PCR methods are well known to those of skill (see, e.g., Ausubel et al., supra).
  • quantitative RT-PCR e.g., a TaqManTM assay, is used, thereby allowing the comparison of the level of mRNA in a sample with a control sample or value.
  • the known nucleic acid sequences for a desired cytokine are sufficient to enable one of skill to routinely select primers to amplify any portion of the gene.
  • Suitable primers for amplification of specific sequences can be designed using principles well known in the art (see, e.g., Dieffenfach & Dveksler, PCR Primer: A Laboratory Manual (1995)).
  • hybridization based assays can be used to detect the amount of a desired cytokine in the cells of a biological sample.
  • assays include dot blot analysis of RNA as well as other assays, e.g., fluorescent in situ hybridization, which is performed on samples that comprise cells.
  • Other hybridization assays are readily available in the art.
  • the level and/or presence of a cytokine polynucleotide or polypeptide will be detected in a biological sample, thereby detecting the differential expression of the cytokine to generate a cytokine profile from a biological sample derived from a patient infused with a CAR T cell of the invention compared to the control biological sample.
  • the amount of a cytokine polynucleotide or polypeptide detected in the biological sample indicates the presence of a cytokine to generate a cytokine profile for the purpose of classifying the patient for the appropriate cytokine treatment.
  • a skilled artisan can elect to administer to the patient in need of such management an effective amount of a cytokine inhibitory compound.
  • cytokine profile indicates a decrease in a particular cytokine post T cell infusion compared to control (e.g., pre T cell infusion)
  • control e.g., pre T cell infusion
  • a skilled artisan can elect to administer to the patient in need of such management an effective amount of a cytokine activator compound.
  • the difference in cytokine levels between the post T cell infusion sample and the control sample and be at least about 0.5, 1.0, 1.5, 2, 5, 10, 100, 200, 500, 1000 fold.
  • the present methods can also be used to assess the efficacy of a course of treatment.
  • the efficacy of an anti-IL-6 treatment can be assessed by monitoring, over time, IL-6.
  • a reduction in IL-6 polynucleotide or polypeptide levels in a biological sample taken from a patient following a treatment, compared to a level in a sample taken from the mammal before, or earlier in, the treatment indicates efficacious treatment.
  • a treatment regimen can be based on neutralizing the elevated cytokine.
  • antagonists of a cytokine can be selected for treatment.
  • Antibodies are an example of a suitable antagonist and include mouse antibodies, chimeric antibodies, humanized antibodies, and human antibodies or fragments thereof.
  • Chimeric antibodies are antibodies whose light and heavy chain genes have been constructed, typically by genetic engineering, from immunoglobulin gene segments belonging to different species (see, e.g., Boyce et al., Annals of Oncology 14:520-535 (2003)).
  • the variable (V) segments of the genes from a mouse monoclonal antibody may be joined to human constant (C) segments.
  • a typical chimeric antibody is thus a hybrid protein consisting of the V or antigen-binding domain from a mouse antibody and the C or effector regions from a human antibody.
  • Humanized antibodies have variable region framework residues substantially from a human antibody (termed an acceptor antibody) and complementarity determining regions substantially from a mouse-antibody, (referred to as the donor immunoglobulin). See Queen et al., Proc. NatL. Acad. Sci. USA 86:10029-10033 (1989) and WO 90/07861, U.S. Pat. No. 5,693,762, U.S. Pat. No. 5,693,761, U.S. Pat. No. 5,585,089, U.S. Pat. No. 5,530,101 and Winter, U.S. Pat. No. 5,225,539.
  • the constant region(s), if present, are also substantially or entirely from a human immunoglobulin.
  • Antibodies can be obtained by conventional hybridoma approaches, phage display (see, e.g., Dower et al., WO 91/17271 and McCafferty et al., WO 92/01047), use of transgenic mice with human immune systems (Lonberg et al., WO93/12227 (1993)), among other sources.
  • Nucleic acids encoding immunoglobulin chains can be obtained from hybridomas or cell lines producing antibodies, or based on immunoglobulin nucleic acid or amino acid sequences in the published literature.
  • an IL-6 antagonist is an anti-IL-6 antibody that specifically binds to IL-6.
  • a specific antibody has the ability to inhibit or antagonize the action of IL-6 systemically.
  • the antibody binds IL-6 and prevents it from interacting with or activating its receptors (e.g. IL-6Ra or IL-6R ⁇ ).
  • the activity of IL-6 can be antagonized by using an antagonist to the interleukin-6 receptors (IL-6R).
  • U.S. Application number 2006251653 describes methods for treating interleukin-6 related disease and discloses a number of interleukin-6 antagonists including, for example, humanized anti-IL-6R antibodies and chimeric anti-IL-6R antibodies.
  • an IL-6 or IL-6R derivative can be used to block and antagonize the interaction between IL-6/IL-6R.
  • the invention is not limited to the cytokines and their corresponding activators and inhibitors described herein. Rather, the invention includes the used of any cytokine activator and/or inhibitor that is used in the art to modulate the cytokine. This is because the invention is based on managing cancer treatment in a patient receiving infusion of CAR T cells of the invention wherein the infused CAR T cells result in increase and decrease levels of various cytokines.
  • One skilled in the art based on the disclosure presented herein that differential expression levels of a cytokine in a post T cell infusion sample compared to a control sample can be targeted for treatment for have the cytokine level be increased or decreased to normal levels.
  • the present invention encompasses a cell (e.g., T cell) transduced with a lentiviral vector (LV).
  • a cell e.g., T cell
  • LV lentiviral vector
  • the LV encodes a CAR that combines an antigen recognition domain of a specific antibody with an intracellular domain of CD3-zeta, CD28, 4-1BB, or any combinations thereof. Therefore, in some instances, the transduced T cell can elicit a CAR-mediated T-cell response.
  • the invention provides the use of a CAR to redirect the specificity of a primary T cell to a tumor antigen.
  • the present invention also provides a method for stimulating a T cell-mediated immune response to a target cell population or tissue in a mammal comprising the step of administering to the mammal a T cell that expresses a CAR, wherein the CAR comprises a binding moiety that specifically interacts with a predetermined target, a zeta chain portion comprising for example the intracellular domain of human CD3zeta, and a costimulatory signaling region.
  • the present invention includes a type of cellular therapy where T cells are genetically modified to express a CAR and the CAR T cell is infused to a recipient in need thereof.
  • the infused cell is able to kill tumor cells in the recipient.
  • CAR T cells are able to replicate in vivo resulting in long-term persistence that can lead to sustained tumor control.
  • the CAR T cells of the invention can undergo robust in vivo T cell expansion and can persist for an extended amount of time.
  • the CAR T cells of the invention evolve into specific memory T cells that can be reactivated to inhibit any additional tumor formation or growth.
  • it was unexpected that the CART 19 cells of the invention can undergo robust in vivo T cell expansion and persist at high levels for an extended amount of time in blood and bone marrow and form specific memory T cells.
  • CAR T cells may differentiate in vivo into a central memory-like state upon encounter and subsequent elimination of target cells expressing the surrogate antigen.
  • the anti-tumor immunity response elicited by the CAR-modified T cells may be an active or a passive immune response.
  • the CAR mediated immune response may be part of an adoptive immunotherapy approach in which CAR-modified T cells induce an immune response specific to the antigen binding moiety in the CAR.
  • a CART19 cells elicits an immune response specific against cells expressing CD19.
  • the invention should be construed to include any number of variations for each of the components of the construct as described elsewhere herein. That is, the invention includes the use of any antigen binding moiety in the CAR to generate a CAR-mediated T-cell response specific to the antigen binding moiety.
  • the antigen binding moiety in the CAR of the invention can target a tumor antigen for the purposes of treat cancer.
  • Cancers that may be treated include tumors that are not vascularized, or not yet substantially vascularized, as well as vascularized tumors.
  • the cancers may comprise non-solid tumors (such as hematological tumors, for example, leukemias and lymphomas) or may comprise solid tumors.
  • Types of cancers to be treated with the CARs of the invention include, but are not limited to, carcinoma, blastoma, and sarcoma, and certain leukemia or lymphoid malignancies, benign and malignant tumors, and malignancies e.g., sarcomas, carcinomas, and melanomas.
  • sarcomas e.g., sarcomas, carcinomas, and melanomas.
  • Adult tumors/cancers and pediatric tumors/cancers are also included.
  • Hematologic cancers are cancers of the blood or bone marrow.
  • hematological (or hematogenous) cancers include leukemias, including acute leukemias (such as acute lymphocytic leukemia, acute myelocytic leukemia, acute myelogenous leukemia and myeloblastic, promyelocytic, myelomonocytic, monocytic and erythroleukemia), chronic leukemias (such as chronic myelocytic (granulocytic) leukemia, chronic myelogenous leukemia, and chronic lymphocytic leukemia), polycythemia vera, lymphoma, Hodgkin's disease, non-Hodgkin's lymphoma (indolent and high grade forms), multiple myeloma, Waldenstrom's macroglobulinemia, heavy chain disease, myelodysplastic syndrome, hairy cell leukemia and myelodysplasia.
  • Solid tumors are abnormal masses of tissue that usually do not contain cysts or liquid areas. Solid tumors can be benign or malignant. Different types of solid tumors are named for the type of cells that form them (such as sarcomas, carcinomas, and lymphomas). Examples of solid tumors, such as sarcomas and carcinomas, include fibrosarcoma, myxosarcoma, liposarcoma, chondrosarcoma, osteosarcoma, and other sarcomas, synovioma, mesothelioma, Ewing's tumor, leiomyosarcoma, rhabdomyosarcoma, colon carcinoma, lymphoid malignancy, pancreatic cancer, breast cancer, lung cancers, ovarian cancer, prostate cancer, hepatocellular carcinoma, squamous cell carcinoma, basal cell carcinoma, adenocarcinoma, sweat gland carcinoma, medullary thyroid carcinoma, papillary thyroid carcinoma, pheochromocytomas se
  • the antigen bind moiety portion of the CAR of the invention is designed to treat a particular cancer.
  • the CAR designed to target CD19 can be used to treat cancers and disorders including but are not limited to pre-B ALL (pediatric indication), adult ALL, mantle cell lymphoma, diffuse large B-cell lymphoma, salvage post allogenic bone marrow transplantation, and the like.
  • the CAR can be designed to target CD22 to treat diffuse large B-cell lymphoma.
  • cancers and disorders include but are not limited to pre-B ALL (pediatric indication), adult ALL, mantle cell lymphoma, diffuse large B-cell lymphoma, salvage post allogenic bone marrow transplantation, and the like can be treated using a combination of CARs that target CD19, CD20, CD22, and ROR1.
  • pre-B ALL pediatric indication
  • adult ALL mantle cell lymphoma
  • diffuse large B-cell lymphoma diffuse large B-cell lymphoma
  • salvage post allogenic bone marrow transplantation and the like can be treated using a combination of CARs that target CD19, CD20, CD22, and ROR1.
  • the CAR can be designed to target mesothelin to treat mesothelioma, pancreatic cancer, ovarian cancer, and the like.
  • the CAR can be designed to target CD33/IL3Ra to treat acute myelogenous leukemia and the like.
  • the CAR can be designed to target c-Met to treat triple negative breast cancer, non-small cell lung cancer, and the like.
  • the CAR can be designed to target PSMA to treat prostate cancer and the like.
  • the CAR can be designed to target Glycolipid F77 to treat prostate cancer and the like.
  • the CAR can be designed to target EGFRvIII to treat gliobastoma and the like.
  • the CAR can be designed to target GD-2 to treat neuroblastoma, melanoma, and the like.
  • the CAR can be designed to target NY-ESO-1 TCR to treat myeloma, sarcoma, melanoma, and the like.
  • the CAR can be designed to target MAGE A3 TCR to treat myeloma, sarcoma, melanoma, and the like.
  • the invention should not be construed to be limited to solely to the antigen targets and diseases disclosed herein. Rather, the invention should be construed to include any antigenic target that is associated with a disease where a CAR can be used to treat the disease.
  • the CAR-modified T cells of the invention may also serve as a type of vaccine for ex vivo immunization and/or in vivo therapy in a mammal
  • the mammal is a human.
  • cells are isolated from a mammal (preferably a human) and genetically modified (i.e., transduced or transfected in vitro) with a vector expressing a CAR disclosed herein.
  • the CAR-modified cell can be administered to a mammalian recipient to provide a therapeutic benefit.
  • the mammalian recipient may be a human and the CAR-modified cell can be autologous with respect to the recipient.
  • the cells can be allogeneic, syngeneic or xenogeneic with respect to the recipient.
  • ex vivo culture and expansion of T cells comprises: (1) collecting CD34+ hematopoietic stem and progenitor cells from a mammal from peripheral blood harvest or bone marrow explants; and (2) expanding such cells ex vivo.
  • other factors such as flt3-L, IL-1, IL-3 and c-kit ligand, can be used for culturing and expansion of the cells.
  • the present invention also provides compositions and methods for in vivo immunization to elicit an immune response directed against an antigen in a patient.
  • the cells activated and expanded as described herein may be utilized in the treatment and prevention of diseases that arise in individuals who are immunocompromised.
  • the CAR-modified T cells of the invention are used in the treatment of CCL.
  • the cells of the invention are used in the treatment of patients at risk for developing CCL.
  • the present invention provides methods for the treatment or prevention of CCL comprising administering to a subject in need thereof, a therapeutically effective amount of the CAR-modified T cells of the invention.
  • compositions of the present invention may comprise a target cell population as described herein, in combination with one or more pharmaceutically or physiologically acceptable carriers, diluents or excipients.
  • compositions may comprise buffers such as neutral buffered saline, phosphate buffered saline and the like; carbohydrates such as glucose, mannose, sucrose or dextrans, mannitol; proteins; polypeptides or amino acids such as glycine; antioxidants; chelating agents such as EDTA or glutathione; adjuvants (e.g., aluminum hydroxide); and preservatives.
  • buffers such as neutral buffered saline, phosphate buffered saline and the like
  • carbohydrates such as glucose, mannose, sucrose or dextrans, mannitol
  • proteins polypeptides or amino acids
  • antioxidants such as glycine
  • chelating agents such as EDTA or glutathione
  • adjuvants e.g., aluminum hydroxide
  • preservatives e.g., aluminum hydroxide
  • compositions of the present invention may be administered in a manner appropriate to the disease to be treated (or prevented).
  • the quantity and frequency of administration will be determined by such factors as the condition of the patient, and the type and severity of the patient's disease, although appropriate dosages may be determined by clinical trials.
  • an immunologically effective amount When “an immunologically effective amount”, “an anti-tumor effective amount”, “an tumor-inhibiting effective amount”, or “therapeutic amount” is indicated, the precise amount of the compositions of the present invention to be administered can be determined by a physician with consideration of individual differences in age, weight, tumor size, extent of infection or metastasis, and condition of the patient (subject). It can generally be stated that a pharmaceutical composition comprising the T cells described herein may be administered at a dosage of 10 4 to 10 9 cells/kg body weight, preferably 10 5 to 10 6 cells/kg body weight, including all integer values within those ranges. T cell compositions may also be administered multiple times at these dosages.
  • the cells can be administered by using infusion techniques that are commonly known in immunotherapy (see, e.g., Rosenberg et al., New Eng. J. of Med. 319:1676, 1988).
  • the optimal dosage and treatment regime for a particular patient can readily be determined by one skilled in the art of medicine by monitoring the patient for signs of disease and adjusting the treatment accordingly.
  • T cells can be activated from blood draws of from 10 cc to 400 cc.
  • T cells are activated from blood draws of 20 cc, 30 cc, 40 cc, 50 cc, 60 cc, 70 cc, 80 cc, 90 cc, or 100 cc.
  • using this multiple blood draw/multiple reinfusion protocol may serve to select out certain populations of T cells.
  • compositions described herein may be administered to a patient subcutaneously, intradermally, intratumorally, intranodally, intramedullary, intramuscularly, by intravenous (i.v.) injection, or intraperitoneally.
  • the T cell compositions of the present invention are administered to a patient by intradermal or subcutaneous injection.
  • the T cell compositions of the present invention are preferably administered by i.v. injection.
  • the compositions of T cells may be injected directly into a tumor, lymph node, or site of infection.
  • cells activated and expanded using the methods described herein, or other methods known in the art where T cells are expanded to therapeutic levels are administered to a patient in conjunction with (e.g., before, simultaneously or following) any number of relevant treatment modalities, including but not limited to treatment with agents such as antiviral therapy, cidofovir and interleukin-2, Cytarabine (also known as ARA-C) or natalizumab treatment for MS patients or efalizumab treatment for psoriasis patients or other treatments for PML patients.
  • agents such as antiviral therapy, cidofovir and interleukin-2, Cytarabine (also known as ARA-C) or natalizumab treatment for MS patients or efalizumab treatment for psoriasis patients or other treatments for PML patients.
  • the T cells of the invention may be used in combination with chemotherapy, radiation, immunosuppressive agents, such as cyclosporin, azathioprine, methotrexate, mycophenolate, and FK506, antibodies, or other immunoablative agents such as CAM PATH, anti-CD3 antibodies or other antibody therapies, cytoxin, fludaribine, cyclosporin, FK506, rapamycin, mycophenolic acid, steroids, FR901228, cytokines, and irradiation.
  • immunosuppressive agents such as cyclosporin, azathioprine, methotrexate, mycophenolate, and FK506, antibodies
  • immunoablative agents such as CAM PATH, anti-CD3 antibodies or other antibody therapies
  • cytoxin fludaribine
  • cyclosporin FK506, rapamycin
  • mycophenolic acid steroids
  • steroids FR901228
  • cytokines irradiation
  • the cell compositions of the present invention are administered to a patient in conjunction with (e.g., before, simultaneously or following) bone marrow transplantation, T cell ablative therapy using either chemotherapy agents such as, fludarabine, external-beam radiation therapy (XRT), cyclophosphamide, or antibodies such as OKT3 or CAMPATH.
  • the cell compositions of the present invention are administered following B-cell ablative therapy such as agents that react with CD20, e.g., Rituxan.
  • subjects may undergo standard treatment with high dose chemotherapy followed by peripheral blood stem cell transplantation.
  • subjects receive an infusion of the expanded immune cells of the present invention.
  • expanded cells are administered before or following surgery.
  • the dosage of the above treatments to be administered to a patient will vary with the precise nature of the condition being treated and the recipient of the treatment.
  • the scaling of dosages for human administration can be performed according to art-accepted practices.
  • the dose for CAMPATH for example, will generally be in the range 1 to about 100 mg for an adult patient, usually administered daily for a period between 1 and 30 days.
  • the preferred daily dose is 1 to 10 mg per day although in some instances larger doses of up to 40 mg per day may be used (described in U.S. Pat. No. 6,120,766).
  • CRS Cytokine Release Syndrome
  • the invention is based partly on the discovery that in vivo proliferation of CART19 cells and the potent anti-tumor activity associated therewith is also associated with CRS, leading to hemophagocytic lymphohistiocytosis (HLH), also termed Macrophage Activation Syndrome (MAS).
  • HHLH hemophagocytic lymphohistiocytosis
  • MAS Macrophage Activation Syndrome
  • the invention provides a first-line of therapy comprising administering the CAR of the invention into the patient and a second-line of therapy comprising administering a type of therapy to manage the elevated levels of certain soluble factors resulting from the first-line of therapy of using CAR T cells.
  • the second-line of therapy comprises compositions and methods for the treatment of CRS.
  • Symptoms of CRS include high fevers, nausea, transient hypotension, hypoxia, and the like.
  • the present invention is based on the observation that CART19 cells induced elevated levels of soluble factors in the patient including but is not limited to IFN- ⁇ , TNF ⁇ , IL-2 and IL-6. Therefore, the second-line of therapy comprises compounds and methods for neutralizing the effects against the elevated cytokines resulting from the administration of the CART19 cells.
  • the neutralizing agents are capable of counteracting undesired concerted burst of cytokine expression/activity and, thus, are useful for the prevention, amelioration and treatment of CRS associated with CART19 therapy.
  • the treatment of CRS is performed around day 10-12 post-infusion of CART19 cells.
  • the second-line of therapy comprises administering a steroid to the patient. In another embodiment, the second-line of therapy comprises administering one of more of a steroid, an inhibitor of TNF ⁇ , and an inhibitor of IL-6.
  • a TNF ⁇ inhibitor is entanercept.
  • An example of an IL-6 inhibitor is Tocilizumab (toc).
  • results presented herein demonstrate that patients following infusion of CART cells exhibit differential expression levels of various cytokines.
  • the elevated levels of some cytokines are a result of the toxicity of the infused CAR T cells ( FIG. 1 ).
  • tocilizumab anti-IL6
  • anti-IL6 can ameliorate the toxicity of CARs and seemingly preserve antitumor effects in 2 of 2 patients ( FIG. 2 ).
  • anakinra and other reagents that block IL-1 may also be useful in this regard.
  • the data presented herein also demonstrates that IL-1 is elevated in patients, and this may lead to the later rise in IL-6.
  • Anakinra is an IL-1Ra recombinant protein which binds to the IL1 receptors and blocks both IL-1 alpha and beta signaling. Anakinra has a short 1 ⁇ 2 life. There is an advantage to use Anakinra to start treating patients since both IL-1 alpha and beta would be blocked, and also relieve the cytokine storm and keep the anti-tumor effect.
  • CD19-Redirected Chimeric Antigen Receptor T (CART19) Cells Induce a Cytokine Release Syndrome (CRS) and Induction of Treatable Macrophage Activation Syndrome (MAS) that can be Managed by the IL-6 Antagonist Tocilizumab (Toc)
  • HHLH hemophagocytic lymphohistiocytosis
  • Autologous T cells were lentivirally transduced with a CAR composed of anti-CD19 scFv/4-1BB/CD3-zeta, activated/expanded ex-vivo with anti-CD3/anti-CD28 beads, and then infused into ALL or CLL patients with persistent disease after 2-8 prior treatments.
  • CART19 anti ALL activity was also modeled in a xenograft mouse model with high level of human ALL/human T cell engraftment and simultaneous detection of CAR T cells and ALL using 2-color bioluminescent imaging.
  • results presented herein provides updated results of 10 patients who received CART19 cells, including 9 patients with CLL and 1 pediatric patient with relapsed refractory ALL. 6/9 evaluable patient s had a complete recovery (CR) or partial recovery (PR), including 4 sustained CRs. While there was no acute infusional toxicity, all responding patients also developed CRS. All had high fevers, as well as grade 3 or 4 hypotension/hypoxia. CRS preceded peak blood expression of CART19 cells, and then increased in intensity until the CART19 cell peak (D10-31 after infusion). The ALL patient experienced the most significant toxicity, with grade 4 hypotension and respiratory failure. Steroid therapy on D6 resulted in no improvement.
  • TNF ⁇ and IL-6 antagonists were administered. This resulted in resolution of fever and hypotension within 12 hr and a rapid wean from ventilator support to room air.
  • cytokine blockade To model the timing of cytokine blockade, xenografts using bioluminescent primary pediatric ALL were established and then treated with extra cells from the clinical manufacture. The CART19 cells proliferated and resulted in prolonged survival. Cytokine blockade prior to T cell infusion with toc and/or etanercept abrogated disease control with less in vivo proliferation of infused CART19 cells, confirming the result seen in the one patient given early toc (D3).
  • CART19 T cells can produce massive in-vivo expansion, long-term persistence, and anti-tumor efficacy, but can also induce significant CRS with features suggestive of MAS/HLH that responds rapidly to cytokine blockade.
  • blockade of TNF ⁇ and/or IL-6 may interfere with proliferation and effector function, but if given at a point where cell proliferation is underway, toc may ameliorate the symptoms that have been observed that correlate with robust clinical responses.
  • CAR T cells have clinical activity in acute lymphocytic leukemia (ALL). Briefly, two pediatric patients with relapsed and refractory pre-B cell ALL were treated with 10 6 to 10 7 /kg T cell transduced with anti-CD19 antibody and a T-cell signaling molecule (CTL019 CAR T cells; also referred to as CART19). The CTL019 T cells expanded more than 1000-fold in both patients, and trafficked to bone marrow. In addition, the CAR T cells were able to cross the blood brain barrier and persisted at high levels for at least 6 months, as measured in the cerebral spinal fluid. Eight severe adverse events were noted.
  • ALL acute lymphocytic leukemia
  • CRS cytokine release syndrome
  • B cell aplasia Both patients developed a cytokine release syndrome (CRS) and B cell aplasia.
  • CRS cytokine release syndrome
  • the CRS was severe and cytokine blockade with etanercept and tocilizumab was effective in reversing the syndrome, and yet did not prevent CAR T cell expansion and anti-leukemic efficacy.
  • Complete remission was observed in both patients, and is ongoing in one patient at 9 months after treatment. The other patient relapsed with blast cells that no longer express CD19 approximately 2 months after treatment.
  • CAR modified T cells are capable of killing even aggressive treatment refractory acute leukemia cells in vivo.
  • the emergence of tumor cells that no longer express the target indicates a need to target other molecules in addition to CD19 in some patients with ALL.
  • CTL019 CART19
  • CTL019 is a CAR that includes a CD137 (4-1BB) signaling domain and is expressed using lentiviral vector technology (Milone et al., 1009, Mol Ther 17:1453-64).
  • lentiviral vector technology Milone et al., 1009, Mol Ther 17:1453-64
  • CTL019 (CART19) production has been previously reported (Porter et al., 2011, N Engl J Med 365:725-33; Kalos et al., 2011, Science Translational Medicine 3:95ra73). CTL019 was detected and quantified in patient specimens as previously reported (Porter et al., 2011, N Engl J Med 365:725-33; Kalos et al., 2011, Science Translational Medicine 3:95ra73).
  • Samples peripheral blood, bone marrow were collected in lavender top (K2EDTA,) or red top (no additive) vacutainer tubes (Becton Dickinson). Lavender top tubes were delivered to the laboratory within 2 hours of draw, or shipped overnight at room temperature in insulated containers essentially as described (Olson et al., 2011, J Transl Med 9:26) prior to processing. Samples were processed within 30 minutes of receipt according to established laboratory SOP. Peripheral blood and marrow mononuclear cells were purified, processed, and stored in liquid nitrogen as described (Kalos et al., 2011, Science Translational Medicine 3:95ra73).
  • Red top tubes were processed within 2 hours of draw including coagulation time; serum isolated by centrifugation, aliquoted in single use 100 ⁇ L aliquots and stored at ⁇ 80° C. CSF was delivered to the laboratory within 30 minutes of aspiration and cells in CSF were collected by centrifugation of CSF fluid and processed for DNA and flow cytometry.
  • an 8-point standard curve was generated consisting of 5 to 10 6 copies CTL019 lentivirus plasmid spiked into 100 ng non-transduced control genomic DNA. Each data-point (sample, standard curve) was evaluated in triplicate with a positive Ct value in 3/3 replicates with % CV less than 0.95% for all quantifiable values.
  • a parallel amplification reaction to control for the quality of interrogated DNA was performed using 20 ng input genomic DNA from peripheral blood and marrow (2-4.3 ng for CSF samples), and a primer/probe combination specific for non-transcribed genomic sequence upstream of the CDKN1A gene as described (Kalos et al., 2011, Science Translational Medicine 3:95ra73).
  • MDA-CAR Jena and Cooper, 2013, L. Anti-idiotype antibody for CD19. PlosONE 2013; in press
  • a murine antibody to CD19 CAR conjugated to Alexa647 Antibodies for multi-parametric immunophenotyping: T cell detection panels: anti-CD3-FITC, anti-CD8-PE, anti-CD14-PE-Cy7, anti-CD16-PE-Cy7, anti-CD19-PE-Cy7 anti-CD16-PE-Cy7.
  • B cell detection panels anti-CD20-FITC, anti-CD45-PE, anti-CD45-APC, anti-CD19-PE-Cy7, anti-CD19-PE, anti-CD34-PCP-e710 and anti CD34-APC were procured from e-Biosciences.
  • T cells were stained in 100 ⁇ L PBS for 30 minutes on ice using antibody and reagent concentrations recommended by the manufacturer, washed, and resuspended in 0.5% paraformaldehyde and acquired using an Accuri C6 cytometer equipped with a Blue (488) and Red (633 nm) laser.
  • Accuri files were exported in FCS file format and analyzed using FlowJo software (Version 9.5.3, Treestar). Compensation values were established using single antibody stains and BD compensation beads (Becton Dickinson) and were calculated by the software.
  • the gating strategy for T cells was as follows: Live cells (FSC/SSC)>dump channel (CD14+CD16+CD19 ⁇ PECy7) vs CD3+>CD3+.
  • the general gating strategy for B cells was as follows: Live cells (FSC/SSC)>SSC low events>CD19+. More gating details for the CHOP-100 and CHOP-101 samples are described in the individual Figures.
  • CHOP-100 was a 7 yo girl in her second recurrence of ALL. She was diagnosed 2 years prior and achieved a minimal residual disease (MRD) negative remission, relapsing 17 months after diagnosis. She re-entered remission after reinduction chemotherapy but recurred 4 months later, after which she did not respond to furtheclofaribine/etoposide/cyclophosphamide. Her karyotype at baseline was 48,XX,del(9)(p21.3),+11,del(14)(q2?q24),+16/46,XX[4].
  • MRD minimal residual disease
  • PBMC Peripheral blood mononuclear cells
  • the second ALL patient was a 10 yo girl (CHOP-101) who had experienced her second relapse after a 4/6 matched unrelated umbilical cord transplant 28 months after diagnosis and 10 months before CTL019 infusion. She had experienced graft vs. host disease (GVHD) after her transplant, which resolved with treatment; she was off immunosuppression at the time of her relapse. She did not subsequently re-enter remission in spite of multiple cytotoxic and biologic therapies.
  • GVHD graft vs. host disease
  • Her baseline karyotype was 46 XX, del(1)(p13), t(2;9)(q?21;q?21), t(3;17)(p24;q23), del(6)(q16q21), del(9)(q13q22), der(16)t(1;?;16)(p13;?p13.3)[9],//46, Xy[1].
  • PBMC collection she was treated with two cycles of blinatumomab (Bargou et al., 2008, Science 321:974-7) with no response.
  • Her peripheral blood cells were 68% donor origin at the time of PBMC collection.
  • CTL019 T cells were manufactured and infused as a total dose of 10 7 cells/kg (1.4 ⁇ 10 6 CTL019 cells/kg) in a single dose, after etoposide/cyclophosphamide chemotherapy given for lymphodepletion the week before.
  • Her bone marrow on the day before CTL019 infusion was replaced by a population of CD19+/CD34+ALL cells, with variable expression of CD19 by standard clinical flow cytometry ( FIG. 7 ).
  • CHOP-101 experienced fever of unknown origin, suspected to be due to cytokine release ( FIG. 4B ), myalgias and two days of confusion (grade 3), which spontaneously resolved. She had no evidence of GVHD after the infusion of the CTL019 cells. Though these cells had been collected from the patient, they were largely of donor (cord blood) origin.
  • glucocorticoids were administered on D+5 with a brief response in the fever curve but without remission of hypotension.
  • a single course of anti-cytokine therapy consisting of etanercept and tocilizumab was given on D+8 and was followed by rapid clinical effects: within hours she defervesced, was weaned off vasoactive medications and ventilatory support as her clinical and radiologic ARDS resolved.
  • the fraction of CTL019 T cells in circulation progressively increased in vivo to 72% (CHOP-100) and 34% (CHOP-101) of T cells ( FIG. 5A ).
  • the initial transduction efficiency was 11.6% and 14.4% in the T cells infused in CHOP-100 and -101, respectively.
  • the total ALC increased substantially in both patients ( FIG. 4C )
  • the frequency of CTL019 cells progressively increased in vivo from the baseline frequency ( FIG. 8 )
  • there was a robust and selective expansion of CTL019 cells in both patients there was a robust and selective expansion of CTL019 cells in both patients.
  • the selective increase in T cells expressing CTL019 in both patients is consistent with an anti-leukemic mechanism involving CD19-driven expansion, and with the subsequent elimination of cells that express CD19 in both patients ( FIG. 6 and FIG. 9 ).
  • CTL019 cells expanded more than 1000-fold in the peripheral blood and bone marrow ( FIG. 5 ).
  • the frequency of CTL019 cells increased to more than 10% of circulating T cells by D+20 in both subjects ( FIG. 8 ), with the absolute magnitude of CTL019 expansion similar to that observed in patients with CLL (Kalos et al., 2011, Science Translational Medicine 3:95ra73).
  • cells in the CSF also showed a high degree of CTL019 gene marking and also persisted at high frequency out to 6 months ( FIG. 5B ).
  • the trafficking of CTL019 cells to the CSF was surprising given that neither patient had detectable CNS leukemia by cytospin at the time of infusion or at the 1 month post-treatment evaluation.
  • FIGS. 5A and 5B Since >70% of lymphocytes in circulation on D+10 were CTL019 cells ( FIGS. 5A and 5B ), most of the large granular lymphocytes shown in the left panel of FIG. 5D are likely CTL019 cells. Similarly, since many lymphocytes in the CSF obtained from CHOP-101 on D+23 were CTL019 cells ( FIGS. 5B and 5C ), the cytospin of CSF lymphocytes in FIG. 5D most likely represents the morphology of CTL019 cells in vivo that have trafficked to the CNS.
  • CHOP-101 experienced a clinical relapse apparent in the peripheral blood at 2 months after CTL019 infusion, as evidenced by the reappearance of blast cells in the circulation. These cells were CD45dim positive, CD34 positive and did not express CD19 ( FIG. 6 ). The absence of the original dominant CD34dim+CD34+CD19dim+ cells is consistent with a potent anti-leukemic selective pressure of the CTL019 CART cells directed to CD19 ( FIG. 9B ). Deep IGH sequencing revealed the presence of the malignant clone in peripheral blood and marrow as early as D+23 (Table 1), despite a clinical assessment of MRD negativity by flow cytometry at this timepoint ( FIG. 7 ). In addition, deep sequencing of material obtained at clinical relapse revealed that the CD45dimCD34+CD19-cells are clonally related to the initial dominant CD45dim+CD34+CD19dim+ cells, since they share the same IGH sequence.
  • results presented herein demonstrate the induction of remission of relapsed and refractory leukemia in the first two patients treated on this protocol. Remission has been sustained in one subject and was accompanied by relapse due to the emergence of CD19 negative blasts in the other subject. Genetically modified CTL019 cells trafficked to the CNS at high levels in both patients. Cytokine elevations were observed that were on target, reversible, and temporally accompanied by elimination of blast cells that expressed CD19 in both subjects.
  • CD19-negative blast cells in one subject is consistent with previous reports that document the existence of CD19-negative precursor cells in some cases of ALL (Hotfilder et al., 2005, Cancer Research 65:1442-9; le Viseur et al., 2008, Cancer Cell 14:47-58). It is possible that the coinfusion of CAR T cells redirected to novel specificities in addition to CD19 might decrease the likelihood of this event. Thus far, relapse with CD19-negative escape cells in adults with CLL after treatment with CTL019 cells have not been observed (Kalos et al., 2011, Science Translational Medicine 3:95ra73), suggesting that this issue may be specific for a subset of acute leukemias.
  • Macrophage activation syndrome is characterized by hyperinflammation with prolonged fever, hepatosplenomegaly, and cytopenias. Laboratory findings characteristic of this syndrome are elevated ferritin, triglycerides, transaminases, bilirubin (mostly conjugated) and soluble interleukin-2 receptor ⁇ -chain, and decreased fibrinogen (Janka et al., 2012, Annu Rev Med 63:233-46).
  • CTL019 The vigorous in vivo expansion of CTL019, persistent B-cell aplasia and prominent anti-leukemia activity imply substantial and sustained effector functions of the CTL019 cells in pediatric patients with advanced ALL.
  • the high efficiency of trafficking of CAR T cells to the CNS is encouraging as a mechanism for surveillance to prevent relapse in a sanctuary site such as the CNS (Pullen et al., 1993, J Clin Oncol 11(5):839-49), and supports the testing of CAR T-cell-directed therapies for CNS lymphomas and primary CNS malignancies.
  • immune-based therapies such as CTL019 may have a favorable profile of long-term adverse effects compared to the high doses of chemotherapy and radiation that are employed as the current standard of care for most cases of pediatric leukemia (Garcia-Manero and Thomas, 2001, Hematol Oncol Clin North Am 15(1):163-205).
  • Tocilizumab (anti-IL6) has promise for glucocorticoid resistant GVHD, and the results presented herein are consistent with these data. Further, it is interesting to note that in CHOP 100, the CRS manifesting as high fever, hypotension and multi-organ failure was resistant to the high doses of glucocorticoids administered over the previous 2 days before cytokine directed therapy. Finally, in CHOP-100 the biphasic changes in IL-1 ⁇ , IL-1RA and IL-2 shown in FIG. 4B may have been related to cytokine-directed therapy with etanercept and tocilizumab.
  • the induction of remission in a patient refractory to blinatumomab therapy further highlights the potency of CTL019 cells.
  • the high efficiency of trafficking of CAR T cells to the CNS is encouraging as a mechanism for surveillance to prevent relapse in a sanctuary site such as the CNS, and supports the testing of CAR T-cell-directed therapies for CNS lymphomas and primary CNS malignancies. Neither patient has experienced cognitive effects that might be ascribed to the trafficking of T cells to the CNS.
  • Various markers were measured in patients receiving CAR T cells.
  • Ferritin, Myoglobin, and plasminogen activator inhibitor-1 (PAI-1) were measure; see FIGS. 10 , 11 and 12 , respectively. Elevated levels of these markers correlated with outcome.
  • Patients designated as -01, -03, -09, -100 and -101 were classified as complete responders.
  • Patients designated as -02, -05, -10 (second infusion and response around D70) and -12 were classified as partial responders.
  • Patient designated as -06, -07 and -14 were classified as non-responders.

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