US20200384027A1 - Methods of administering chimeric antigen receptor immunotherapy - Google Patents

Methods of administering chimeric antigen receptor immunotherapy Download PDF

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US20200384027A1
US20200384027A1 US16/865,369 US202016865369A US2020384027A1 US 20200384027 A1 US20200384027 A1 US 20200384027A1 US 202016865369 A US202016865369 A US 202016865369A US 2020384027 A1 US2020384027 A1 US 2020384027A1
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cells
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Rajul JAIN
Remus VEZAN
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Kite Pharma Inc
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Kite Pharma Inc
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Assigned to KITE PHARMA, INC. reassignment KITE PHARMA, INC. ASSIGNMENT OF ASSIGNORS INTEREST (SEE DOCUMENT FOR DETAILS). Assignors: JAIN, Rajul, VEZAN, Remus
Publication of US20200384027A1 publication Critical patent/US20200384027A1/en
Priority to US18/167,725 priority patent/US20230270785A1/en
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Definitions

  • the present disclosure relates generally to T cell therapies and more specifically to CD19-directed genetically modified autologous T cell immunotherapies comprising chimeric antigen receptors (CARs).
  • CARs chimeric antigen receptors
  • cancers are by their nature comprised of normal cells that have undergone a genetic or epigenetic conversion to become abnormal cancer cells. In doing so, cancer cells begin to express proteins and other antigens that are distinct from those expressed by normal cells. These aberrant tumor antigens may be used by the body's innate immune system to specifically target and kill cancer cells. However, cancer cells employ various mechanisms to prevent immune cells, such as T and B lymphocytes, from successfully targeting cancer cells.
  • Chimeric antigen receptors which comprise binding domains capable of interacting with a particular tumor antigen, allow T cells to target and kill cancer cells that express the particular tumor antigen.
  • the present disclosure is based, in part, on the surprising discovery that the administration methods disclosed herein identify and manage adverse side effects and safety of CAR T-cell immunotherapy.
  • the present disclosure relates to immunotherapy or T cell therapy and methods of enhancing treatment outcome and/or response.
  • the disclosure provides a method of treating relapsed or refractory diffuse large B-cell lymphoma (DLBCL) not otherwise specified, primary mediastinal large B-cell lymphoma, high grade B-cell lymphoma, or DLBCL arising from follicular lymphoma after two or more lines of systemic therapy in a patient comprising: administering to the patient in need thereof axicabtagene ciloleucel suspension by intravenous infusion at a dose between about 1 ⁇ 10 6 and about 2 ⁇ 10 6 CAR-positive viable T cells per kg body weight up to a maximum dose of about 1 ⁇ 10 8 CAR-positive viable T cells, wherein axicabtagene ciloleucel is a CD19-directed genetically modified autologous T cell immunotherapy, comprising the patient's own T cells harvested and genetically modified ex vivo by retroviral transduction to express a chimeric antigen receptor (CAR) comprising an anti-CD19 single chain variable fragment (scFv)
  • the disclosure provides a method of treating relapsed or refractory diffuse large B-cell lymphoma (DLBCL) and primary mediastinal large B-cell lymphoma (PMBCL), after two or more lines of systemic therapy in a patient comprising: administering to the patient in need thereof axicabtagene ciloleucel suspension by intravenous infusion at a dose between about 0.4 ⁇ 10 8 and about 2 ⁇ 10 8 CAR-positive viable T cells, wherein axicabtagene ciloleucel is a CD19-directed genetically modified autologous T cell immunotherapy, comprising the patient's own T cells harvested and genetically modified ex vivo by retroviral transduction to express a chimeric antigen receptor (CAR) comprising an anti-CD19 single chain variable fragment (scFv) linked to CD28 and CD3-zeta co-stimulatory domains.
  • CAR chimeric antigen receptor
  • the intravenous infusion time is between 15 and 120 minutes. In some embodiments, the intravenous infusion time is up to 30 minutes. In some embodiments, the infusion volume is between 50 and 100 mL. In some embodiments, the infusion volume is about 68 mL. In some embodiments, the immunotherapy is infused from an infusion bag. In some embodiments, the infusion bag is agitated during the infusion. In some embodiments, the immunotherapy is administered within 3 hours after thawing.
  • the suspension further comprises albumin. In some embodiments, albumin is present in an amount of about 2-3% (v/v). In some embodiments, albumin is present in an amount of about 2.5% (v/v). In some embodiments, albumin is human albumin. In some embodiments, the suspension further comprises DMSO. In some embodiments, DMSO is present in an amount of about 4-6% (v/v). In some embodiments, DMSO is present in an amount of about 5% (v/v).
  • the disclosure provides a method of treating relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy in a patient comprising: (a) administering to the patient in need thereof CD19-directed genetically modified autologous T cell immunotherapy; and (b) monitoring the patient following infusion for signs and symptoms of an adverse reaction.
  • the relapsed or refractory large B-cell lymphoma is diffuse large B-cell lymphoma (DLBCL) not otherwise specified, primary mediastinal large B-cell lymphoma, high grade B-cell lymphoma, or DLBCL arising from follicular lymphoma.
  • DLBCL diffuse large B-cell lymphoma
  • the adverse reaction is selected from the group consisting of cytokine release syndrome (CRS), a neurologic toxicity, a hypersensitivity reaction, a serious infection, a cytopenia and hypogammaglobulinemia.
  • the signs and symptoms of adverse reactions are selected from the group consisting of fever, hypotension, tachycardia, hypoxia, and chills, include cardiac arrhythmias (including atrial fibrillation and ventricular tachycardia), cardiac arrest, cardiac failure, renal insufficiency, capillary leak syndrome, hypotension, hypoxia, organ toxicity, hemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS), seizure, encephalopathy, headache, tremor, dizziness, aphasia, delirium, insomnia anxiety, anaphylaxis, febrile neutropenia, thrombocytopenia, neutropenia, and anemia.
  • CRS cytokine release syndrome
  • the method further comprises administering an IL-6 receptor inhibitor. In some embodiments, the method further comprises administering an effective amount of tocilizumab to treat a symptom of an adverse reaction. In some embodiments, tocilizumab is administered at a dose of about 8 mg/kg intravenously. In some embodiments, tocilizumab is administered intravenously over about 1 hour. In some embodiments, tocilizumab is administered about every 8 hours. In some embodiments, tocilizumab is administered for no more than about 24 hours.
  • the method further comprises administering a steroid (e.g. corticosteroid to treat a symptom of an adverse reaction) or improve safety.
  • a steroid e.g. corticosteroid to treat a symptom of an adverse reaction
  • the corticosteroid is at least one of methylprednisone or dexamethasone.
  • methylprednisone is administered at a dose of about 1 mg/kg intravenously. In some embodiments, methylprednisone is administered twice daily. In some embodiments, methylprednisone is administered at a dose of about 1,000 mg per day intravenously. In some embodiments, methylprednisone is administered intravenously for about 3 days. In some embodiments, dexamethasone is administered at a dose of about 10 mg. In some embodiments, dexamethasone is administered intravenously about every 6 hours.
  • the adverse reaction is cytokine release syndrome (CRS).
  • the monitoring for signs and symptoms of cytokine release syndrome (CRS) is at least daily for about 7 days following infusion. In some embodiments, the monitoring for signs and symptoms of cytokine release syndrome (CRS) is at least daily for about 8 days, about 9 days, or about 10 days following infusion. In some embodiments, the monitoring for signs and symptoms of cytokine release syndrome (CRS) is at least daily for about 10 days following infusion. In some embodiments, the monitoring for signs and symptoms of cytokine release syndrome (CRS) is for about 4 weeks following infusion.
  • the adverse reaction is neurologic toxicity. In some embodiments, the monitoring for signs and symptoms of neurologic toxicity up to about 8 weeks following infusion.
  • the method further comprises administering a non-sedating, anti-seizure medicine for seizure prophylaxis.
  • the non-sedating, anti-seizure medicine is levetiracetam.
  • the adverse reaction is a cytopenia.
  • the cytopenia is thrombocytopenia, neutropenia, and/or anemia.
  • the method further comprises administering at least one of erythropoietin, darbepoetin alfa, platelet transfusion, colony-stimulating factor (CSF), granulocyte colony-stimulating factor, filgrastim, pegfilgrastim, or granulocyte-macrophage colony-stimulating factor.
  • CSF colony-stimulating factor
  • the method further comprises measuring cytokine and chemokine levels.
  • the level of at least one of IL-6, IL-8, IL-10, IL-15, TNF- ⁇ , IFN- ⁇ , and sIL2R ⁇ is measured.
  • the disclosure provides a container comprising a suspension of CD19-directed genetically modified autologous T cells, about 5% dimethylsulfoxide (DMSO) and about 2.5% human albumin (v/v).
  • the container comprises a suspension of between about 0.4 ⁇ 10 8 -2 ⁇ 10 8 CD19-directed genetically modified autologous T cells (CAR-positive viable T cells).
  • the container is a sterile infusion bag.
  • the infusion bag volume is about 100 mL, 250 mL, 500 mL, 750 mL, 1000 mL, 1500 mL, 2000 mL or 3000 m L.
  • the disclosure provides a method of treating relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy in a human comprising administering to the human in need thereof CD19-directed genetically modified autologous T cell immunotherapy comprising: (a) administering to the patient a composition comprising CD19-directed chimeric antigen receptor (CAR) positive viable T cells; (b) monitoring the patient following administration for signs and symptoms of an adverse reaction; and (c) if cytokine release syndrome (CRS) greater than Grade 2 is observed in (b), administering tocilizumab at a dose of about 8 mg/kg IV over 1 hour, repeating tocilizumab every 8 hours as needed if not responsive to IV fluids or increasing supplemental oxygen; (d) if CRS symptoms observed in (b) do not improve after 24 hours of (c), administering methylprednisolone about 1 mg/kg IV twice daily or administering equivalent dexamethasone dose and continuing corticosteroids use until the event
  • the disclosure provide a method of treating relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy in a patient comprising administering to the patient in need thereof CD19-directed genetically modified autologous T cell immunotherapy comprising: (a) administering to the patient a composition comprising CD19-directed chimeric antigen receptor (CAR) positive viable T cells; (b) monitoring the patient following administration for signs and symptoms of an adverse reaction; and (c) if cytokine release syndrome (CRS) and/or neurologic toxicity is observed, managing cytokine release syndrome (CRS) and/or neurologic toxicity according to Table 1 and/or Table 2.
  • CAR CD19-directed chimeric antigen receptor
  • a method of treating relapsed or refractory diffuse large B-cell lymphoma (DLBCL) not otherwise specified, primary mediastinal large B-cell lymphoma, high grade B-cell lymphoma, or DLBCL arising from follicular lymphoma after two or more lines of systemic therapy in a patient comprising:
  • axicabtagene ciloleucel suspension by intravenous infusion at a dose between about 1 ⁇ 10 6 and about 2 ⁇ 10 6 CAR-positive viable T cells per kg body weight up to a maximum dose of about 1 ⁇ 10 8 CAR-positive viable T cells, wherein axicabtagene ciloleucel is a CD19-directed genetically modified autologous T cell immunotherapy, comprising the patient's own T cells harvested and genetically modified ex vivo by retroviral transduction to express a chimeric antigen receptor (CAR) comprising an anti-CD19 single chain variable fragment (scFv) linked to CD28 and CD3-zeta co-stimulatory domains.
  • CAR chimeric antigen receptor
  • the intravenous infusion time is between 15 and 120 minutes, or up to 30 minutes; the infusion volume is between 50 and 100 mL, or about 68 mL; and/or the immunotherapy is infused from an infusion bag, optionally, wherein the infusion bag is agitated during the infusion; optionally, wherein the immunotherapy is administered within 3 hours after thawing.
  • albumin optionally, wherein albumin is present in an amount of about 2-3% (v/v), or in an amount of about 2.5% (v/v); and optionally wherein albumin is human albumin; and/or further comprises DMSO.
  • a method of treating relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy in a patient comprising:
  • the GM-CSF inhibitor is selected from lenzilumab; namilumab (AMG203); GSK3196165/MOR103/otilimab (GSK/MorphoSys); KB002 and KB003 (KaloBios); MT203 (Micromet and Nycomed); MORAb-022/gimsilumab (Morphotek); or a biosimilar of any one of the same; E21R; and a small molecule; (ii) the CSF1 inhibitor is selected from RG7155, PD-0360324, MCS110/lacnotuzumab), or a biosimilar version of any one of the same; and a small molecule; and/or (iii) the GM-CSFR inhibitor and the CSF1R inhibitor is/are selected from Mucunimumab (formerly CAM-3001; Medlmmune, Inc.); cabiralizumab (Five Prime Therapeutics); LY3022855 (IMC)
  • the adverse reaction is (1) neurologic toxicity, optionally, wherein the symptom of neurologic toxicity is encephalopathy, headache, tremor, dizziness, aphasia, delirium, insomnia, and/or anxiety, and/or (2) cytopenia.
  • the method further comprises administering a non-sedating, anti-seizure medicine for seizure prophylaxis; administering at least one of erythropoietin, darbepoetin alfa, platelet transfusion, filgrastim, or pegfilgrastim; and/or administering tocilizumab.
  • a method of treating relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy in a human comprising administering to the human in need thereof CD19-directed genetically modified autologous T cell immunotherapy comprising:
  • composition comprising CD19-directed chimeric antigen receptor (CAR) positive viable T cells;
  • a method of treating relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy in a patient comprising administering to the patient in need thereof CD19-directed genetically modified autologous T cell immunotherapy comprising:
  • composition comprising CD19-directed chimeric antigen receptor (CAR) positive viable T cells;
  • a method of treating relapsed or refractory large ALL in a patient comprising administering to the patient in need thereof CD19-directed genetically modified autologous T cell immunotherapy comprising:
  • composition comprising CD19-directed chimeric antigen receptor (CAR) positive viable T cells;
  • a method of treating relapsed or refractory diffuse large B-cell lymphoma (DLBCL) not otherwise specified, primary mediastinal large B-cell lymphoma, high grade B-cell lymphoma, or DLBCL arising from follicular lymphoma in a patient in need thereof comprising:
  • axicabtagene ciloleucel suspension by intravenous infusion at a dose between about 1 ⁇ 10 6 and about 2 ⁇ 10 6 CAR-positive viable T cells per kg body weight up to a maximum dose of about 1 ⁇ 10 8 CAR-positive viable T cells in combination with rituximab,
  • axicabtagene ciloleucel is a CD19-directed genetically modified autologous T cell immunotherapy, comprising the patient's own T cells harvested and genetically modified ex vivo by retroviral transduction to express a chimeric antigen receptor (CAR) comprising an anti-CD19 single chain variable fragment (scFv) linked to CD28 and CD3-zeta co-stimulatory domains.
  • CAR chimeric antigen receptor
  • the disclosure is directed to a method of treating relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy in a human comprising administering to the human in need thereof CD19-directed genetically modified autologous T cell immunotherapy comprising: (a) administering to the patient a composition comprising CD19-directed chimeric antigen receptor (CAR) positive viable T cells; (b) monitoring the patient following administration for signs and symptoms of an adverse reaction; and (c) if cytokine release syndrome (CRS) greater than Grade 2 is observed in (b), administering tocilizumab at a dose of about 8 mg/kg IV over 1 hour, repeating tocilizumab every 8 hours as needed if not responsive to IV fluids or increasing supplemental oxygen; (d) if CRS symptoms observed in (b) do not improve after 24 hours of (c), administering methylprednisolone about 1 mg/kg IV twice daily or administering equivalent dexamethasone dose and continuing corticosteroids use until
  • the disclosure is directed to a method of treating relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy in a patient comprising administering to the patient in need thereof CD19-directed genetically modified autologous T cell immunotherapy comprising: (a) administering to the patient a composition comprising CD19-directed chimeric antigen receptor (CAR) positive viable T cells; (b) monitoring the patient following administration for signs and symptoms of an adverse reaction; and (c) if cytokine release syndrome (CRS) and/or neurologic toxicity is observed, managing cytokine release syndrome (CRS) and/or neurologic toxicity according to Table 1, Table 2, Table 3, and/or Table 4.
  • CRS cytokine release syndrome
  • CRS neurologic toxicity
  • the disclosure is directed to a method of treating relapsed or refractory large ALL in a patient comprising administering to the patient in need thereof CD19-directed genetically modified autologous T cell immunotherapy comprising: (a) administering to the patient a composition comprising CD19-directed chimeric antigen receptor (CAR) positive viable T cells; (b) monitoring the patient following administration for signs and symptoms of an adverse reaction; and (c) if cytokine release syndrome (CRS) and/or neurologic toxicity is observed, managing cytokine release syndrome (CRS) and/or neurologic toxicity according to Table 1, Table 2, Example 2, and/or Example 3.
  • CRS cytokine release syndrome
  • CRS neurologic toxicity
  • the terms “or more”, “at least”, “more than”, and the like, e.g., “at least one” are understood to include but not be limited to at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105
  • nucleotides includes 100, 99, 98, 97, 96, 95, 94, 93, 92, 91, 90, 89, 88, 87, 86, 85, 84, 83, 82, 81, 80, 79, 78, 77, 76, 75, 74, 73, 72, 71, 70, 69, 68, 67, 66, 65, 64, 63, 62, 61, 60, 59, 58, 57, 56, 55, 54, 53, 52, 51, 50, 49, 48, 47, 46, 45, 44, 43, 42, 41, 40, 39, 38, 37, 36, 35, 34, 33, 32, 31, 30, 29, 28, 27, 26, 25, 24, 23, 22, 21, 20, 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, 2, 1, and 0 nucleotides. Also included is any lesser number or fraction in
  • the terms “plurality”, “at least two”, “two or more”, “at least second”, and the like, are understood to include but not limited to at least 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106,
  • the term “about” refers to a value or composition that is within an acceptable error range for the particular value or composition as determined by one of ordinary skill in the art, which will depend in part on how the value or composition is measured or determined, i.e., the limitations of the measurement system. For example, “about” or “approximately” may mean within one or more than one standard deviation per the practice in the art. “About” or “approximately” may mean a range of up to 10% (i.e., ⁇ 10%).
  • “about” may be understood to be within 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1%, 0.5%, 0.1%, 0.05%, 0.01%, or 0.001% greater or less than the stated value.
  • about 5 mg may include any amount between 4.5 mg and 5.5 mg.
  • the terms may mean up to an order of magnitude or up to 5-fold of a value.
  • any concentration range, percentage range, ratio range or integer range is to be understood to be inclusive of the value of any integer within the recited range and, when appropriate, fractions thereof (such as one-tenth and one-hundredth of an integer), unless otherwise indicated.
  • administering refers to the physical introduction of an agent to a subject, using any of the various methods and delivery systems known to those skilled in the art.
  • exemplary routes of administration for the formulations disclosed herein include intravenous, intramuscular, subcutaneous (SQ), intraperitoneal, spinal or other parenteral routes of administration, for example by injection or infusion.
  • parenteral administration means modes of administration other than enteral and topical administration, usually by injection, and includes, without limitation, intravenous (IV), intramuscular, intraarterial, intrathecal, intralymphatic, intralesional, intracapsular, intraorbital, intracardiac, intradermal, intraperitoneal (IP), transtracheal, subcutaneous, subcuticular, intraarticular, subcapsular, subarachnoid, intraspinal, epidural and intrasternal injection and infusion, as well as in vivo electroporation.
  • the formulation is administered via a non-parenteral route, e.g., orally.
  • non-parenteral routes include a topical, epidermal or mucosal route of administration, for example, intranasally, vaginally, rectally, sublingually or topically.
  • Administering may also be performed, for example, once, a plurality of times, and/or over one or more extended periods. Where one or more therapeutic agents are administered, the administration can be done concomitantly or sequentially. Sequential administration comprises administration of one agent only after administration of the other agent or agents has been completed.
  • an antibody includes, without limitation, a glycoprotein immunoglobulin which binds specifically to an antigen.
  • an antibody may comprise at least two heavy (H) chains and two light (L) chains interconnected by disulfide bonds, or an antigen-binding molecule thereof.
  • Each H chain comprises a heavy chain variable region (abbreviated herein as VH) and a heavy chain constant region.
  • the heavy chain constant region comprises three constant domains, CH1, CH2 and CH3.
  • Each light chain comprises a light chain variable region (abbreviated herein as VL) and a light chain constant region.
  • the light chain constant region comprises one constant domain, CL.
  • the VH and VL regions may be further subdivided into regions of hypervariability, termed complementarity determining regions (CDRs), interspersed with regions that are more conserved, termed framework regions (FR).
  • CDRs complementarity determining regions
  • FR framework regions
  • Each VH and VL comprises three CDRs and four FRs, arranged from amino-terminus to carboxy-terminus in the following order: FR1, CDR1, FR2, CDR2, FR3, CDR3, and FR4.
  • the variable regions of the heavy and light chains contain a binding domain that interacts with an antigen.
  • the constant regions of the Abs may mediate the binding of the immunoglobulin to host tissues or factors, including various cells of the immune system (e.g., effector cells) and the first component (C1q) of the classical complement system.
  • Antibodies may include, for example, monoclonal antibodies, recombinantly produced antibodies, monospecific antibodies, multispecific antibodies (including bispecific antibodies), human antibodies, engineered antibodies, humanized antibodies, chimeric antibodies, immunoglobulins, synthetic antibodies, tetrameric antibodies comprising two heavy chain and two light chain molecules, an antibody light chain monomer, an antibody heavy chain monomer, an antibody light chain dimer, an antibody heavy chain dimer, an antibody light chain-antibody heavy chain pair, intrabodies, antibody fusions (sometimes referred to herein as “antibody conjugates”), heteroconjugate antibodies, single domain antibodies, monovalent antibodies, single chain antibodies or single-chain Fvs (scFv), camelized antibodies, affybodies, Fab fragments, F(ab′)2 fragments, disulfide-linked Fvs (sdFv), dual (ScFv) 2 -Fab, anti-idiotypic (anti-Id) antibodies (including, e.g., anti-anti-Id antibodies), mini
  • an “antigen binding molecule,” “antigen binding portion,” or “antibody fragment” refers to any molecule that comprises the antigen binding parts (e.g., CDRs) of the antibody from which the molecule is derived.
  • An antigen binding molecule may include the antigenic complementarity determining regions (CDRs).
  • Examples of antibody fragments include, but are not limited to, Fab, Fab′, F(ab′)2, and Fv fragments, dAb, linear antibodies, scFv antibodies, and multispecific antibodies formed from antigen binding molecules.
  • Peptibodies i.e., Fc fusion molecules comprising peptide binding domains are another example of suitable antigen binding molecules.
  • the antigen binding molecule binds to an antigen on a tumor cell. In some embodiments, the antigen binding molecule binds to an antigen on a cell involved in a hyperproliferative disease or to a viral or bacterial antigen. In some embodiments, the antigen binding molecule binds to CD19. In further embodiments, the antigen binding molecule is an antibody fragment that specifically binds to the antigen, including one or more of the complementarity determining regions (CDRs) thereof. In further embodiments, the antigen binding molecule is a single chain variable fragment (scFv). In some embodiments, the antigen binding molecule comprises or consists of avimers.
  • an “antigen” refers to any molecule that provokes an immune response or is capable of being bound by an antibody or an antigen binding molecule.
  • the immune response may involve either antibody production, or the activation of specific immunologically-competent cells, or both.
  • An antigen may be endogenously expressed, i.e. expressed by genomic DNA, or may be recombinantly expressed.
  • An antigen may be specific to a certain tissue, such as a cancer cell, or it may be broadly expressed.
  • fragments of larger molecules may act as antigens.
  • antigens are tumor antigens.
  • CD19-directed genetically modified autologous T cell immunotherapy refers to a suspension of chimeric antigen receptor (CAR)-positive T cells.
  • CAR chimeric antigen receptor
  • An example of such immunotherapy is axicabtagene ciloleucel (also known as Axi-celTM, YESCARTA®), developed by Kite Pharmaceuticals, Inc.
  • Other non-limiting examples include JCAR017, JCAR015, JCAR014, Kymriah (tisagenlecleucel), Uppsala U. anti-CD19 CAR (NCT02132624), and UCART19 (Celectis).
  • neutralizing refers to an antigen binding molecule, scFv, antibody, or a fragment thereof, that binds to a ligand and prevents or reduces the biological effect of that ligand.
  • the antigen binding molecule, scFv, antibody, or a fragment thereof directly blocking a binding site on the ligand or otherwise alters the ligand's ability to bind through indirect means (such as structural or energetic alterations in the ligand).
  • the antigen binding molecule, scFv, antibody, or a fragment thereof prevents the protein to which it is bound from performing a biological function.
  • autologous refers to any material derived from the same individual to which it is later to be re-introduced.
  • eACTTM engineered autologous cell therapy
  • allogeneic refers to any material derived from one individual which is then introduced to another individual of the same species, e.g., allogeneic T cell transplantation.
  • the vector is a retroviral vector, a DNA vector, a RNA vector, an adenoviral vector, a baculoviral vector, an Epstein Barr viral vector, a papovaviral vector, a vaccinia viral vector, a herpes simplex viral vector, an adenovirus associated vector, a lentiviral vector, or any combination thereof.
  • a “cancer” refers to a broad group of various diseases characterized by the uncontrolled growth of abnormal cells in the body. Unregulated cell division and growth results in the formation of malignant tumors that invade neighboring tissues and may also metastasize to distant parts of the body through the lymphatic system or bloodstream.
  • a “cancer” or “cancer tissue” may include a tumor. Examples of cancers that may be treated by the methods disclosed herein include, but are not limited to, cancers of the immune system including lymphoma, leukemia, myeloma, and other leukocyte malignancies.
  • the methods disclosed herein may be used to reduce the tumor size of a tumor derived from, for example, bone cancer, pancreatic cancer, skin cancer, cancer of the head or neck, cutaneous or intraocular malignant melanoma, uterine cancer, ovarian cancer, rectal cancer, cancer of the anal region, stomach cancer, testicular cancer, uterine cancer, carcinoma of the fallopian tubes, carcinoma of the endometrium, carcinoma of the cervix, carcinoma of the vagina, carcinoma of the vulva, multiple myeloma, Hodgkin's Disease, non-Hodgkin's lymphoma (NHL), primary mediastinal large B cell lymphoma (PMBC), diffuse large B cell lymphoma (DLBCL), follicular lymphoma (FL), transformed follicular lymphoma, splenic marginal zone lymphoma (SMZL), cancer of the esophagus, cancer of the small intestine, cancer of the endocrine system
  • NHL non
  • the cancer is multiple myeloma.
  • the particular cancer may be responsive to chemo- or radiation therapy or the cancer may be refractory.
  • a refractor cancer refers to a cancer that is not amendable to surgical intervention and the cancer is either initially unresponsive to chemo- or radiation therapy or the cancer becomes unresponsive over time.
  • an “anti-tumor effect” as used herein refers to a biological effect that may present as a decrease in tumor volume, a decrease in the number of tumor cells, a decrease in tumor cell proliferation, a decrease in the number of metastases, an increase in overall or progression-free survival, an increase in life expectancy, or amelioration of various physiological symptoms associated with the tumor.
  • An anti-tumor effect may also refer to the prevention of the occurrence of a tumor, e.g., a vaccine.
  • a “cytokine,” as used herein, refers to a non-antibody protein that is released by one cell in response to contact with a specific antigen, wherein the cytokine interacts with a second cell to mediate a response in the second cell.
  • Cytokine as used herein is meant to refer to proteins released by one cell population that act on another cell as intercellular mediators.
  • a cytokine may be endogenously expressed by a cell or administered to a subject. Cytokines may be released by immune cells, including macrophages, B cells, T cells, and mast cells to propagate an immune response. Cytokines may induce various responses in the recipient cell.
  • Cytokines may include homeostatic cytokines, chemokines, pro-inflammatory cytokines, effectors, and acute-phase proteins.
  • homeostatic cytokines including interleukin (IL) 7 and IL-15, promote immune cell survival and proliferation, and pro-inflammatory cytokines may promote an inflammatory response.
  • homeostatic cytokines include, but are not limited to, IL-2, IL-4, IL-5, IL-7, IL-10, IL-12p40, IL-12p70, IL-15, and interferon (IFN) gamma.
  • pro-inflammatory cytokines include, but are not limited to, IL-1a, IL-1b, IL-6, IL-13, IL-17a, tumor necrosis factor (TNF)-alpha, TNF-beta, fibroblast growth factor (FGF) 2, granulocyte macrophage colony-stimulating factor (GM-CSF), soluble intercellular adhesion molecule 1 (sICAM-1), soluble vascular adhesion molecule 1 (sVCAM-1), vascular endothelial growth factor (VEGF), VEGF-C, VEGF-D, and placental growth factor (PLGF).
  • TNF tumor necrosis factor
  • FGF fibroblast growth factor
  • GM-CSF granulocyte macrophage colony-stimulating factor
  • sICAM-1 soluble intercellular adhesion molecule 1
  • sVCAM-1 soluble vascular adhesion molecule 1
  • VEGF vascular endothelial growth factor
  • VEGF-C vascular endot
  • effectors include, but are not limited to, granzyme A, granzyme B, soluble Fas ligand (sFasL), and perforin.
  • acute phase-proteins include, but are not limited to, C-reactive protein (CRP) and serum amyloid A (SAA).
  • “Chemokines” are a type of cytokine that mediates cell chemotaxis, or directional movement. Examples of chemokines include, but are not limited to, IL-8, IL-16, eotaxin, eotaxin-3, macrophage-derived chemokine (MDC or CCL22), monocyte chemotactic protein 1 (MCP-1 or CCL2), MCP-4, macrophage inflammatory protein 1 ⁇ (MIP-1 ⁇ , MIP-1a), MIP-1 ⁇ (MIP-1b), gamma-induced protein 10 (IP-10), and thymus and activation regulated chemokine (TARC or CCL17).
  • a “therapeutically effective amount,” “effective dose,” “effective amount,” or “therapeutically effective dosage” of a therapeutic agent, e.g., engineered CART cells, is any amount that, when used alone or in combination with another therapeutic agent, protects a subject against the onset of a disease or promotes disease regression evidenced by a decrease in severity of disease symptoms, an increase in frequency and duration of disease symptom-free periods, or a prevention of impairment or disability due to the disease affliction.
  • the ability of a therapeutic agent to promote disease regression may be evaluated using a variety of methods known to the skilled practitioner, such as in human subjects during clinical trials, in animal model systems predictive of efficacy in humans, or by assaying the activity of the agent in in vitro assays.
  • an “effective amount” of an agent e.g., an inhibitor, or combination of inhibitors, of GM-CSF, CSF1, GM-CSFR, or CSF1R
  • an adverse reaction e.g., neurotoxicity
  • an agent e.g., an inhibitor, or combination of inhibitors, of GM-CSF, CSF1, GM-CSFR, or CSF1R
  • an adverse reaction e.g., neurotoxicity
  • an adverse reaction e.g., neurotoxicity
  • lymphocyte as used herein includes natural killer (NK) cells, T cells, or B cells.
  • NK cells are a type of cytotoxic (cell toxic) lymphocyte that represent a major component of the inherent immune system. NK cells reject tumors and cells infected by viruses. It works through the process of apoptosis or programmed cell death. They were termed “natural killers” because they do not require activation in order to kill cells.
  • T cells play a major role in cell-mediated-immunity (no antibody involvement). Its T cell receptors (TCR) differentiate themselves from other lymphocyte types. The thymus, a specialized organ of the immune system, is primarily responsible for the T cell's maturation.
  • T cells There are six types of T cells, namely: Helper T cells (e.g., CD4+ cells), Cytotoxic T cells (also known as TC, cytotoxic T lymphocyte, CTL, T-killer cell, cytolytic T cell, CD8+ T cells or killer T cell), Memory T cells ((i) stem memory TSCM cells, like naive cells, are CD45RO ⁇ , CCR7+, CD45RA+, CD62L+ (L-selectin), CD27+, CD28+ and IL-7R ⁇ +, but they also express large amounts of CD95, IL-2R ⁇ , CXCR3, and LFA-1, and show numerous functional attributes distinctive of memory cells); (ii) central memory TCM cells express L-selectin and the CCR7, they secrete IL-2, but not IFN ⁇ or IL-4, and (iii) effector memory TEM cells, however, do not express L-selectin or CCR7 but produce effector cytokines like IFN ⁇ and IL-4
  • B-cells play a principal role in humoral immunity (with antibody involvement). It makes antibodies and antigens and performs the role of antigen-presenting cells (APCs) and turns into memory B-cells after activation by antigen interaction. In mammals, immature B-cells are formed in the bone marrow, where its name is derived from.
  • the term “genetically engineered” or “engineered” refers to a method of modifying the genome of a cell, including, but not limited to, deleting a coding or non-coding region or a portion thereof or inserting a coding region or a portion thereof.
  • the cell that is modified is a lymphocyte, e.g., a T cell, which may either be obtained from a patient or a donor.
  • the cell may be modified to express an exogenous construct, such as, e.g., a chimeric antigen receptor (CAR) or a T cell receptor (TCR), which is incorporated into the cell's genome.
  • CAR chimeric antigen receptor
  • TCR T cell receptor
  • an “immune response” refers to the action of a cell of the immune system (for example, T lymphocytes, B lymphocytes, natural killer (NK) cells, macrophages, eosinophils, mast cells, dendritic cells and neutrophils) and soluble macromolecules produced by any of these cells or the liver (including Abs, cytokines, and complement) that results in selective targeting, binding to, damage to, destruction of, and/or elimination from a vertebrate's body of invading pathogens, cells or tissues infected with pathogens, cancerous or other abnormal cells, or, in cases of autoimmunity or pathological inflammation, normal human cells or tissues.
  • a cell of the immune system for example, T lymphocytes, B lymphocytes, natural killer (NK) cells, macrophages, eosinophils, mast cells, dendritic cells and neutrophils
  • soluble macromolecules produced by any of these cells or the liver including Abs, cytokines, and complement
  • immunotherapy refers to the treatment of a subject afflicted with, or at risk of contracting or suffering a recurrence of, a disease by a method comprising inducing, enhancing, suppressing or otherwise modifying an immune response.
  • immunotherapy include, but are not limited to, T cell therapies.
  • T cell therapy may include adoptive T cell therapy, tumor-infiltrating lymphocyte (TIL) immunotherapy, autologous cell therapy, engineered autologous cell therapy (eACTN, and allogeneic T cell transplantation.
  • TIL tumor-infiltrating lymphocyte
  • eACTN engineered autologous cell therapy
  • T cell therapies are described in U.S. Patent Publication Nos. 2014/0154228 and 2002/0006409, U.S. Pat. Nos. 7,741,465, 6,319,494, 5,728,388, and International Publication No. WO 2008/081035.
  • T cells of the immunotherapy may come from any source known in the art.
  • T cells may be differentiated in vitro from a hematopoietic stem cell population, or T cells may be obtained from a subject.
  • T cells may be obtained from, e.g., peripheral blood mononuclear cells (PBMCs), bone marrow, lymph node tissue, cord blood, thymus tissue, tissue from a site of infection, ascites, pleural effusion, spleen tissue, and tumors.
  • PBMCs peripheral blood mononuclear cells
  • the T cells may be derived from one or more T cell lines available in the art.
  • T cells may also be obtained from a unit of blood collected from a subject using any number of techniques known to the skilled artisan, such as FICOLLTM separation and/or apheresis. Additional methods of isolating T cells for a T cell therapy are disclosed in U.S. Patent Publication No. 2013/0287748, which is herein incorporated by references in its entirety.
  • eACTTM engineered Autologous Cell Therapy
  • adoptive cell transfer is a process by which a patient's own T cells are collected and subsequently genetically altered to recognize and target one or more antigens expressed on the cell surface of one or more specific tumor cells or malignancies.
  • T cells may be engineered to express, for example, chimeric antigen receptors (CAR).
  • CAR positive (+) T cells are engineered to express an extracellular single chain variable fragment (scFv) with specificity for a particular tumor antigen linked to an intracellular signaling part comprising at least one costimulatory domain and at least one activating domain.
  • scFv extracellular single chain variable fragment
  • the CAR scFv may be designed to target, for example, CD19, which is a transmembrane protein expressed by cells in the B cell lineage, including all normal B cells and B cell malignances, including but not limited to diffuse large B-cell lymphoma (DLBCL) not otherwise specified, primary mediastinal large B-cell lymphoma, high grade B-cell lymphoma, and DLBCL arising from follicular lymphoma, NHL, CLL, and non-T cell ALL.
  • DLBCL diffuse large B-cell lymphoma
  • Example CART cell therapies and constructs are described in U.S. Patent Publication Nos. 2013/0287748, 2014/0227237, 2014/0099309, and 2014/0050708, and these references are incorporated by reference in their entirety.
  • a “patient” as used herein includes any human who is afflicted with a cancer (e.g., a lymphoma or a leukemia).
  • a cancer e.g., a lymphoma or a leukemia.
  • subject and patient are used interchangeably herein.
  • an in vitro cell refers to any cell which is cultured ex vivo.
  • an in vitro cell may include a T cell.
  • peptide refers to a compound comprised of amino acid residues covalently linked by peptide bonds.
  • a protein or peptide contains at least two amino acids, and no limitation is placed on the maximum number of amino acids that may comprise a protein's or peptide's sequence.
  • Polypeptides include any peptide or protein comprising two or more amino acids joined to each other by peptide bonds.
  • the term refers to both short chains, which also commonly are referred to in the art as peptides, oligopeptides and oligomers, for example, and to longer chains, which generally are referred to in the art as proteins, of which there are many types.
  • Polypeptides include, for example, biologically active fragments, substantially homologous polypeptides, oligopeptides, homodimers, heterodimers, variants of polypeptides, modified polypeptides, derivatives, analogs, fusion proteins, among others.
  • the polypeptides include natural peptides, recombinant peptides, synthetic peptides, or a combination thereof.
  • stimulation refers to a primary response induced by binding of a stimulatory molecule with its cognate ligand, wherein the binding mediates a signal transduction event.
  • a “stimulatory molecule” is a molecule on a T cell, e.g., the T cell receptor (TCR)/CD3 complex, that specifically binds with a cognate stimulatory ligand present on an antigen present cell.
  • a “stimulatory ligand” is a ligand that when present on an antigen presenting cell (e.g., an APC, a dendritic cell, a B-cell, and the like) may specifically bind with 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.
  • Stimulatory ligands include, but are not limited to, an anti-CD3 antibody, an MHC Class I molecule loaded with a peptide, a superagonist anti-CD2 antibody, and a superagonist anti-CD28 antibody.
  • costimulatory signal refers to a signal, which in combination with a primary signal, such as TCR/CD3 ligation, leads to a T cell response, such as, but not limited to, proliferation and/or upregulation or down regulation of key molecules.
  • a “costimulatory ligand,” as used herein, includes a molecule on an antigen presenting cell that specifically binds a cognate co-stimulatory molecule on a T cell. Binding of the costimulatory ligand provides a signal that mediates a T cell response, including, but not limited to, proliferation, activation, differentiation, and the like. A costimulatory ligand induces a signal that is in addition to the primary signal provided by a stimulatory molecule, for instance, by binding of a T cell receptor (TCR)/CD3 complex with a major histocompatibility complex (MHC) molecule loaded with peptide.
  • TCR T cell receptor
  • MHC major histocompatibility complex
  • a co-stimulatory ligand may include, but is not limited to, 3/TR6, 4-1BB ligand, agonist or antibody that binds Toll ligand receptor, B7-1 (CD80), B7-2 (CD86), CD30 ligand, CD40, CD7, CD70, CD83, herpes virus entry mediator (HVEM), human leukocyte antigen G (HLA-G), ILT4, immunoglobulin-like transcript (ILT) 3, inducible costimulatory ligand (ICOS-L), intercellular adhesion molecule (ICAM), ligand that specifically binds with B7-H3, lymphotoxin beta receptor, MHC class I chain-related protein A (MICA), MHC class I chain-related protein B (MICB), OX40 ligand, PD-L2, or programmed death (PD) L1.
  • HVEM herpes virus entry mediator
  • HLA-G human leukocyte antigen G
  • ILT4 immunoglobulin-like transcript
  • ILT inducible
  • a co-stimulatory ligand includes, without limitation, an antibody that specifically binds with a co-stimulatory molecule present on a T cell, such as, but not limited to, 4-1BB, B7-H3, CD2, CD27, CD28, CD30, CD40, CD7, ICOS, ligand that specifically binds with CD83, lymphocyte function-associated antigen-1 (LFA-1), natural killer cell receptor C (NKG2C), OX40, PD-1, or tumor necrosis factor superfamily member 14 (TNFSF14 or LIGHT).
  • LFA-1 lymphocyte function-associated antigen-1
  • NSG2C natural killer cell receptor C
  • OX40 PD-1
  • TNFSF14 or LIGHT tumor necrosis factor superfamily member 14
  • a “costimulatory molecule” is a cognate binding partner on a T cell that specifically binds with a costimulatory ligand, thereby mediating a costimulatory response by the T cell, such as, but not limited to, proliferation.
  • Costimulatory molecules include, but are not limited to,
  • a “costimulatory molecule” is a cognate binding partner on a T cell that specifically binds with a costimulatory ligand, thereby mediating a costimulatory response by the T cell, such as, but not limited to, proliferation.
  • Costimulatory molecules include, but are not limited to, 4-1BB/CD137, B7-H3, BAFFR, BLAME (SLAMF8), BTLA, CD 33, CD 45, CD100 (SEMA4D), CD103, CD134, CD137, CD154, CD16, CD160 (BY55), CD18, CD19, CD19a, CD2, CD22, CD247, CD27, CD276 (B7-H3), CD28, CD29, CD3 (alpha; beta; delta; epsilon; gamma; zeta), CD30, CD37, CD4, CD4, CD40, CD49a, CD49D, CD49f, CD5, CD64, CD69, CD7, CD80, CD83 ligand, CD84, CD86, CD8alpha, CD8beta, CD9, CD96 (Tactile), CDI-Ia, CDI-Ib, CDI-Ic, CDI-Id, CDS, CEACAM1, CRT AM, DAP-10,
  • reducing and “decreasing” are used interchangeably herein and indicate any change that is less than the original. “Reducing” and “decreasing” are relative terms, requiring a comparison between pre- and post-measurements. “Reducing” and “decreasing” include complete depletions.
  • Treatment or “treating” of a subject refers to any type of intervention or process performed on, or the administration of an active agent to, the subject with the objective of reversing, alleviating, ameliorating, inhibiting, slowing down or preventing the onset, progression, development, severity or recurrence of a symptom, complication or condition, or biochemical indicia associated with a disease.
  • treatment or “treating” includes a partial remission. In another embodiment, “treatment” or “treating” includes a complete remission.
  • Chimeric antigen receptors CARs or CAR-Ts
  • TCRs T cell receptors
  • engineered receptors may be readily inserted into and expressed by immune cells, including T cells, in accordance with techniques known in the art.
  • a CAR a single receptor may be programmed to both recognize a specific antigen and, when bound to that antigen, activate the immune cell to attack and destroy the cell bearing or expressing that antigen.
  • an immune cell that expresses the CAR may target and kill the tumor cell.
  • An aspect of the present disclosure is a chimeric antigen receptor (CAR), or a T cell receptor, which comprises (i) an antigen binding molecule, (ii) a costimulatory domain, and (iii) an activating domain.
  • the costimulatory domain may comprise an extracellular domain, a transmembrane domain, and an intracellular domain.
  • the extracellular domain comprises a hinge, or a truncated hinge domain.
  • the antigen-binding molecule is a molecule that comprises the antigen binding parts (e.g., CDRs) of the antibody from which the molecule is derived.
  • An antigen binding molecule may include the antigenic complementarity determining regions (CDRs).
  • antigen-binding molecules include, but are not limited to, Fab, Fab′, F(ab′)2, and Fv fragments, dAb, linear antibodies, scFv antibodies, and multispecific antibodies formed from antigen binding molecules.
  • Peptibodies i.e., Fc fusion molecules comprising peptide binding domains
  • the CD19 CAR construct comprises an anti-CD 19 single-chain FV.
  • a “Single-chain Fv” or “scFv” antibody binding fragment comprises the variably heavy (V H ) and variable light (V L ) domains of an antibody, where these domains are present in a single polypeptide chain.
  • the Fv polypeptide further comprises a polypeptide linker between the V H and V L domains, which enables the scFv to form the desired structure for antigen binding.
  • All antibody-related terms used herein take the customary meaning in the art and are well understood by one of ordinary skill in the art.
  • the CAR comprises one or more costimulatory domains.
  • the costimulatory is a signaling region of CD28, OX-40, 4-1BB/CD137, CD2, CD7, CD27, CD30, CD40, programmed death-1 (PD-1), inducible T cell costimulator (ICOS), lymphocyte function-associated antigen-1 (LFA-1 (CDI Ia/CD18), CD3 gamma, CD3 delta, CD3 epsilon, CD247, CD276 (B7-H3), LIGHT (tumor necrosis factor superfamily member 14; TNFSF14), NKG2C, Ig alpha (CD79a), DAP-10, Fc gamma receptor, MHC class I molecule, TNF receptor proteins, Immunoglobulin-like proteins, cytokine receptors, integrins, signaling lymphocytic activation molecules (SLAM proteins), activating NK cell receptors, BTLA, a Toll ligand receptor,
  • PD-1 programmed
  • the intracellular domain comprises a signaling region of 4-1BB/CD137, activating NK cell receptors, B7-H3, BAFFR, BLAME (SLAMF8), BTLA, CD100 (SEMA4D), CD103, CD160 (BY55), CD18, CD19, CD19a, CD2, CD247, CD27, CD276 (B7-H3), CD29, CD3 delta, CD3 epsilon, CD3 gamma, CD30, CD4, CD40, CD49a, CD49D, CD49f, CD69, CD7, CD84, CD8alpha, CD8beta, CD96 (Tactile), CDI Ia, CDI Ib, CDI Ic, CDI Id, CDS, CEACAM1, CRT AM, cytokine receptors, DAP-10, DNAM1 (CD226), Fc gamma receptor, GADS, GITR, HVEM (LIGHTR), IA4, ICAM-1, ICAM-1, ICAM-1, I
  • the CAR comprises a hinge region between the transmembrane domain and the binding molecule.
  • the hinge region is of IgG1, IgG2, IgG3, IgG4, IgA, IgD, IgE, IgM, CD28, or CD8 alpha.
  • the transmembrane domain is a transmembrane domain of CD28, 4-1BB/CD137, an alpha chain of a T cell receptor, a beta chain of a T cell receptor, CD3 epsilon, CD4, CD5, CD8 alpha, CD9, CD16, CD19, CD22, CD33, CD37, CD45, CD64, CD80, CD86, CD134, CD137, CD154, or a zeta chain of a T cell receptor, or any combination thereof.
  • the activation domain may be derived from, e.g., any form of CD3-zeta. In some embodiments, the activation domain comes from DAP10, DAP12, or other TCR-type activating signaling molecule.
  • the present application is directed to CD19 CART cell therapy.
  • the CD19 CAR construct comprises an anti-CD19 scFv domain, an intracellular domain, a transmembrane domain, one or more costimulatory domains, and an activation domain.
  • the transmembrane domain is derived from transmembrane domain of CD28, 4-1BB/CD137, CD8 alpha, or any combination thereof.
  • the costimulatory domain is derived from CD8, CD28 OX40, 4-1BB/CD137, or a combination thereof.
  • the activation domain is derived from CD3zeta.
  • the CD19 CAR construct comprises a 4-1BB costimulatory domain.
  • the CD19 CAR construct comprises a CD28 costimulatory domain. In one embodiment, the CD19 CAR construct comprises an anti-CD19 scFv, hinge/transmembrane and costimulatory domains from CD28, and an activation domain from CD3zeta. In one embodiment, the CAR is that expressed in axicabtagene ciloleucel. In one embodiment, the CAR is that is expressed in KymriahTM. Additional CD19 directed CARs that may be used with the methods of the disclosure include, but are not limited to, JCAR017, JCAR015, JCAR014, Uppsala U.
  • NCT02132624 anti-CD19 CAR
  • UCART19 Celectis
  • the T cells of the immunotherapy may be engineered to express any of the CAR described above or others and are referred to as CAR-T cells.
  • CAR-T cells may be engineered to express other molecules and may be of any one of the following exemplary types or others available in the art: first, second, third, fourth, fifth (etc.) CAR-T cells; Armored CAR-T cells, Motile CAR-T cells, TRUCK T-cells, Switch receptor CAR-T cells; Gene edited CAR T-cells; dual receptor CAR T-cells; suicide CAR T-cells, drug-inducible CAR-T cells, synNotch inducible CAR T-cells; and inhibitory CAR T-cells.
  • the T cells are autologous T-cells.
  • the T cells are autologous stem cells (for autologous stem cell therapy or ASCT).
  • the T cells are non-autologous T-cells.
  • T cells of the disclosure may come from any source known in the art.
  • T cells may be differentiated in vitro from a hematopoietic stem cell population, or T cells may be obtained from a subject.
  • T cells may be obtained from, e.g., peripheral blood mononuclear cells (PBMCs), bone marrow, lymph node tissue, cord blood, thymus tissue, tissue from a site of infection, ascites, pleural effusion, spleen tissue, and tumors.
  • PBMCs peripheral blood mononuclear cells
  • the T cells may be derived from one or more T cell lines available in the art.
  • T cells may also be obtained from a unit of blood collected from a subject using any number of techniques known to the skilled artisan, such as FICOLLTM separation and/or apheresis. Additional methods of isolating T cells for a T cell therapy are disclosed in U.S. Patent Publication No. 2013/0287748, in International Application No. PCT/US2015/014520 (published as WO2015/120096) and in International Application No. PCT/US2016/057983 (published as WO2017/070395), all of which are herein incorporated by reference in their totality for the purposes of describing these methods and in their entirety.
  • the CD19 CAR-T cells may be prepared by any manufacturing method of preparing T cells for immunotherapy, including, without limitation, those described in International Application No. PCT/US2015/014520 (published as WO2015/120096) and in International Application No. PCT/US2016/057983 (published as WO2017/070395), both of which are herein incorporated by reference in their totality for the purposes of describing these methods; any and all methods used in the preparation of Axicabtagene ciloleucel or Yescarta®; any and all methods used in the preparation of Tisagenlecleucel/KymriahTM; any and all methods used in the preparation of “off-the-shelf” T cells for immunotherapy; and any other methods of preparing lymphocytes for administration to humans.
  • the manufacturing process is adapted to specifically remove circulating tumor cells from the cells obtained from the patient.
  • the cells of the present disclosure may be obtained through T cells obtained from a subject.
  • the T cells may be obtained from, e.g., peripheral blood mononuclear cells, bone marrow, lymph node tissue, cord blood, thymus tissue, tissue from a site of infection, ascites, pleural effusion, spleen tissue, and tumors.
  • the T cells may be derived from one or more T cell lines available in the art.
  • T cells may also be obtained from a unit of blood collected from a subject using any number of techniques known to the skilled artisan, such as FICOLLTM separation and/or apheresis.
  • the cells collected by apheresis are washed to remove the plasma fraction and placed in an appropriate buffer or media for subsequent processing.
  • the cells are washed with PBS.
  • a washing step may be used, such as by using a semiautomated flow through centrifuge, e.g., the CobeTM 2991 cell processor, the Baxter CytoMateTM, or the like.
  • the washed cells are resuspended in one or more biocompatible buffers, or other saline solution with or without buffer.
  • the undesired components of the apheresis sample are removed. Additional methods of isolating T cells for a T cell therapy are disclosed in U.S. Patent Pub. No. 2013/0287748, which is herein incorporated by references in its entirety.
  • T cells are isolated from PBMCs by lysing the red blood cells and depleting the monocytes, e.g., by using centrifugation through a PERCOLLTM gradient.
  • a specific subpopulation of T cells such as CD4+, CD8+, CD28+, CD45RA+, and CD45RO+ T cells is further isolated by positive or negative selection techniques known in the art. For example, enrichment of a T cell population by negative selection may be accomplished with a combination of antibodies directed to surface markers unique to the negatively selected cells.
  • cell sorting and/or selection via negative magnetic immunoadherence or flow cytometry that uses a cocktail of monoclonal antibodies directed to cell surface markers present on the cells negatively selected may be used.
  • a monoclonal antibody cocktail typically includes antibodies to CD8, CD11b, CD14, CD16, CD20, and HLA-DR.
  • flow cytometry and cell sorting are used to isolate cell populations of interest for use in the present disclosure.
  • PBMCs are used directly for genetic modification with the immune cells (such as CARs) using methods as described herein.
  • T lymphocytes are further isolated, and both cytotoxic and helper T lymphocytes are sorted into naive, memory, and effector T cell subpopulations either before or after genetic modification and/or expansion.
  • CD8+ cells are further sorted into naive, central memory, and effector cells by identifying cell surface antigens that are associated with each of these types of CD8+ cells.
  • the expression of phenotypic markers of central memory T cells includes CCR7, CD3, CD28, CD45RO, CD62L, and CD127 and are negative for granzyme B.
  • central memory T cells are CD8+, CD45RO+, and CD62L+ T cells.
  • effector T cells are negative for CCR7, CD28, CD62L, and CD127 and positive for granzyme B and perforin.
  • CD4+ T cells are further sorted into subpopulations. For example, CD4+ T helper cells may be sorted into naive, central memory, and effector cells by identifying cell populations that have cell surface antigens.
  • the immune cells e.g., T cells
  • the immune cells are genetically modified following isolation using known methods, or the immune cells are activated and expanded (or differentiated in the case of progenitors) in vitro prior to being genetically modified.
  • the immune cells e.g., T cells
  • Methods for activating and expanding T cells are known in the art and are described, e.g., in U.S. Pat. Nos.
  • Such methods include contacting PBMC or isolated T cells with a stimulatory agent and costimulatory agent, such as anti-CD3 and anti-CD28 antibodies, generally attached to a bead or other surface, in a culture medium with appropriate cytokines, such as IL-2.
  • a stimulatory agent and costimulatory agent such as anti-CD3 and anti-CD28 antibodies
  • cytokines such as IL-2.
  • Anti-CD3 and anti-CD28 antibodies attached to the same bead serve as a “surrogate” antigen presenting cell (APC).
  • APC antigen presenting cell
  • One example is The Dynabeads® system, a CD3/CD28 activator/stimulator system for physiological activation of human T cells.
  • the T cells are activated and stimulated to proliferate with feeder cells and appropriate antibodies and cytokines using methods such as those described in U.S. Pat. Nos. 6,040,177 and 5,827,642 and PCT Publication No. WO 2012/129514, the contents of which are hereby incorporated by reference in their entirety.
  • the T cells are obtained from a donor subject.
  • the donor subject is human patient afflicted with a cancer or a tumor.
  • the donor subject is a human patient not afflicted with a cancer or a tumor.
  • the composition comprises a pharmaceutically acceptable carrier, diluent, solubilizer, emulsifier, preservative and/or adjuvant.
  • the composition comprises an excipient.
  • the composition is selected for parenteral delivery, for inhalation, or for delivery through the digestive tract, such as orally.
  • the preparation of such pharmaceutically acceptable compositions is within the ability of one skilled in the art.
  • buffers are used to maintain the composition at physiological pH or at a slightly lower pH, typically within a pH range of from about 5 to about 8.
  • the composition when parenteral administration is contemplated, is in the form of a pyrogen-free, parenterally acceptable aqueous solution comprising a composition described herein, with or without additional therapeutic agents, in a pharmaceutically acceptable vehicle.
  • the vehicle for parenteral injection is sterile distilled water in which composition described herein, with or without at least one additional therapeutic agent, is formulated as a sterile, isotonic solution, properly preserved.
  • the preparation involves the formulation of the desired molecule with polymeric compounds (such as polylactic acid or polyglycolic acid), beads or liposomes, that provide for the controlled or sustained release of the product, which are then be delivered via a depot injection.
  • implantable drug delivery devices are used to introduce the desired molecule.
  • the methods of treating a cancer in a subject in need thereof comprise a T cell therapy.
  • the T cell therapy disclosed herein is engineered Autologous Cell Therapy (eACTTM).
  • the method may include collecting blood cells from the patient.
  • the isolated blood cells e.g., T cells
  • the CART cells or the TCR T cells are administered to the patient.
  • the CART cells or the TCR T cells treat a tumor or a cancer in the patient.
  • the CART cells or the TCR T cells reduce the size of a tumor or a cancer.
  • the donor T cells for use in the T cell therapy are obtained from the patient (e.g., for an autologous T cell therapy). In other embodiments, the donor T cells for use in the T cell therapy are obtained from a subject that is not the patient.
  • the T cells may be administered at a therapeutically effective amount.
  • a therapeutically effective amount of the T cells may be at least about 10 4 cells, at least about 10 5 cells, at least about 10 6 cells, at least about 10 7 cells, at least about 10 8 cells, at least about 10 9 , or at least about 10 10 .
  • the therapeutically effective amount of the T cells is about 10 4 cells, about 10 5 cells, about 10 6 cells, about 10 7 cells, or about 10 8 cells.
  • the therapeutically effective amount of the CART cells is about 2 ⁇ 10 6 cells/kg, about 3 ⁇ 10 6 cells/kg, about 4 ⁇ 10 6 cells/kg, about 5 ⁇ 10 6 cells/kg, about 6 ⁇ 10 6 cells/kg, about 7 ⁇ 10 6 cells/kg, about 8 ⁇ 10 6 cells/kg, about 9 ⁇ 10 6 cells/kg, about 1 ⁇ 10 7 cells/kg, about 2 ⁇ 10 7 cells/kg, about 3 ⁇ 10 7 cells/kg, about 4 ⁇ 10 7 cells/kg, about 5 ⁇ 10 7 cells/kg, about 6 ⁇ 10 7 cells/kg, about 7 ⁇ 10 7 cells/kg, about 8 ⁇ 10 7 cells/kg, or about 9 ⁇ 10 7 cells/kg.
  • the therapeutically effective amount of the CAR-positive viable T cells is between about 1 ⁇ 10 6 and about 2 ⁇ 10 6 CAR-positive viable T cells per kg body weight up to a maximum dose of about 1 ⁇ 10 8 CAR-positive viable T cells. In some embodiments, the therapeutically effective amount of the CAR-positive viable T cells is between about 0.4 ⁇ 10 8 and about 2 ⁇ 10 8 CAR-positive viable T cells.
  • the therapeutically effective amount of the CAR-positive viable T cells is about 0.4 ⁇ 10 8 , about 0.5 ⁇ 10 8 , about 0.6 ⁇ 10 8 , about 0.7 ⁇ 10 8 , about 0.8 ⁇ 10 8 , about 0.9 ⁇ 10 8 , about 1.0 ⁇ 10 8 , about 1.1 ⁇ 10 8 , about 1.2 ⁇ 10 8 , about 1.3 ⁇ 10 8 , about 1.4 ⁇ 10 8 , about 1.5 ⁇ 10 8 , about 1.6 ⁇ 10 8 , about 1.7 ⁇ 10 8 , about 1.8 ⁇ 10 8 , about 1.9 ⁇ 10 8 , or about 2.0 ⁇ 10 8 CAR-positive viable T cells.
  • the methods disclosed herein may be used to treat a cancer in a subject, reduce the size of a tumor, kill tumor cells, prevent tumor cell proliferation, prevent growth of a tumor, eliminate a tumor from a patient, prevent relapse of a tumor, prevent tumor metastasis, induce remission in a patient, or any combination thereof.
  • the methods induce a complete response. In other embodiments, the methods induce a partial response.
  • Cancers that may be treated include tumors that are not vascularized, not yet substantially vascularized, or vascularized.
  • the cancer may also include solid or non-solid tumors.
  • the cancer is a hematologic cancer.
  • the cancer is of the white blood cells.
  • the cancer is of the plasma cells.
  • the cancer is leukemia, lymphoma, or myeloma.
  • the cancer is acute lymphoblastic leukemia (ALL) (including non T cell ALL), acute lymphoid leukemia (ALL), and hemophagocytic lymphohistocytosis (HLH)), B cell prolymphocytic leukemia, B-cell acute lymphoid leukemia (“BALL”), blastic plasmacytoid dendritic cell neoplasm, Burkitt's lymphoma, chronic lymphocytic leukemia (CLL), chronic myelogenous leukemia (CML), chronic myeloid leukemia (CML), chronic or acute granulomatous disease, chronic or acute leukemia, diffuse large B cell lymphoma, diffuse large B cell lymphoma (DLBCL), follicular lymphoma, follicular lymphoma (FL), hairy cell leukemia, hemophagocytic syndrome (Macrophage Activating Syndrome (MAS), Hodgkin's Disease, large cell granuloma, leukocyte adhe
  • ALL
  • the cancer is a myeloma. In some embodiments, the cancer is multiple myeloma. In some embodiments, the cancer is a leukemia. In some embodiments, the cancer is acute myeloid leukemia. in some embodiments, a CD19-directed genetically modified autologous T cell immunotherapy indicated for the treatment of patients with relapsed or refractory large B-cell lymphoma as a first line of therapy, after one line of therapy, or after two or more lines of systemic therapy, including diffuse large B-cell lymphoma (DLBCL) not otherwise specified, primary mediastinal large B-cell lymphoma, high grade B-cell lymphoma, and DLBCL arising from follicular lymphoma. In some embodiments, the cancer is CLL. In some embodiments, the CD19-directed genetically modified autologous T cell immunotherapy is axicabtagene ciloleucel (Axi-celTM, YESCARTA®).
  • the lines of prior therapy may be any prior anti-cancer therapy, including, but not limited to Bruton Tyrosine Kinase inhibitor (BTKi), check-point inhibitors (e.g., anti-PD1 antibodies, pembrolizumab (Keytruda), Cemiplimab (Libtayo), nivolumab (Opdivo); anti-PD-L1 antibodies, Atezolizumab (Tecentriq), Avelumab (Bavencio), Durvalumab (Imfinzi); anti-CTLA-4 antibodies, Ipilimumab (Yervoy)), anti-CD19 antibodies (e.g. blinatumomab), anti-CD52 antibodies (e.g.
  • BTKi Bruton Tyrosine Kinase inhibitor
  • check-point inhibitors e.g., anti-PD1 antibodies, pembrolizumab (Keytruda), Cemiplimab (Libtayo), nivolum
  • the eligible patients may have refractory disease to the most recent therapy or relapse within 1 year after autologous hematopoietic stem cell transplantation (HSCT/ASCT).
  • HSCT/ASCT autologous hematopoietic stem cell transplantation
  • the methods further comprise administering a chemotherapeutic.
  • the chemotherapeutic selected is a lymphodepleting (preconditioning) chemotherapeutic.
  • Beneficial preconditioning treatment regimens, along with correlative beneficial biomarkers are described in U.S. Provisional Patent Applications 62/262,143 and 62/167,750 which are hereby incorporated by reference in their entirety herein.
  • methods of conditioning a patient in need of a T cell therapy comprising administering to the patient specified beneficial doses of cyclophosphamide (between 200 mg/m 2 /day and 2000 mg/m 2 /day) and specified doses of fludarabine (between 20 mg/m 2 /day and 900 mg/m 2 /day).
  • One such dose regimen involves treating a patient comprising administering daily to the patient about 500 mg/m 2 /day of cyclophosphamide and about 60 mg/m 2 /day of fludarabine for three days prior to administration of a therapeutically effective amount of engineered T cells to the patient.
  • the conditioning regimen comprises cyclophosphamide 500 mg/m 2 +fludarabine 30 mg/m 2 for 3 days. In some embodiments, they are administered at days ⁇ 4, ⁇ 3, and ⁇ 2. In some embodiments, they are administered at days ⁇ 5, ⁇ 4, and ⁇ 3. In one embodiment, the conditioning regimen comprises 900 mg/m 2 at day ⁇ 2 and fludarabine 25 mg/m 2 at days ⁇ 4, ⁇ 3, ⁇ 2 (day 0 being the day of administration of the cells. In some embodiments, the conditioning regimen comprises cyclophosphamide 500 mg/m 2 daily for two days and fludarabine 30 mg/m 2 for 4 days.
  • the antigen binding molecule, transduced (or otherwise engineered) cells (such as CARs), and the chemotherapeutic agent are administered each in an amount effective to treat the disease or condition in the subject, alone or in combination with other agents and treatments described herein.
  • compositions comprising CAR-expressing immune effector cells disclosed herein may be administered in conjunction with any number of chemotherapeutic agents.
  • chemotherapeutic agents include alkylating agents such as thiotepa and cyclophosphamide (CYTOXANTM); alkyl sulfonates such as busulfan, improsulfan and piposulfan; aziridines such as benzodopa, carboquone, meturedopa, and uredopa; ethylenimines and methylamelamines including altretamine, triethylenemelamine, trietylenephosphoramide, triethylenethiophosphaoramide and trimethylolomelamine resume; nitrogen mustards such as chlorambucil, chlornaphazine, cholophosphamide, estramustine, ifosfamide, mechlorethamine, mechlorethamine oxide hydrochloride, melphalan, novembichin,
  • paclitaxel (TAXOLTM, Bristol-Myers Squibb) and doxetaxel (TAXOTERE®, Rhone-Poulenc Rorer); chlorambucil; gemcitabine; 6-thioguanine; mercaptopurine; methotrexate; platinum analogs such as cisplatin and carboplatin; vinblastine; platinum; etoposide (VP-16); ifosfamide; mitomycin C; mitoxantrone; vincristine; vinorelbine; navelbine; novantrone; teniposide; daunomycin; aminopterin; xeloda; ibandronate; CPT-11; topoisomerase inhibitor RFS2000; difluoromethylomithine (DMFO); retinoic acid derivatives such as TargretinTM (bexarotene), PanretinTM, (alitretinoin); ONTAKTM (denileukin diftitox
  • compositions comprising CAR- and/or TCR-expressing immune effector cells disclosed herein may be administered in conjunction with an anti-hormonal agent that acts to regulate or inhibit hormone action on tumors such as anti-estrogens including for example tamoxifen, raloxifene, aromatase inhibiting 4(5)-imidazoles, 4-hydroxytamoxifen, trioxifene, keoxifene, LY117018, onapristone, and toremifene (Fareston); and anti-androgens such as flutamide, nilutamide, bicalutamide, leuprolide, and goserelin; and pharmaceutically acceptable salts, acids or derivatives of any of the above.
  • an anti-hormonal agent that acts to regulate or inhibit hormone action on tumors
  • anti-estrogens including for example tamoxifen, raloxifene, aromatase inhibiting 4(5)-imidazoles, 4-hydroxytamoxifen, trioxif
  • Combinations of chemotherapeutic agents are also administered where appropriate, including, but not limited to CHOP, i.e., Cyclophosphamide (Cytoxan®), Doxorubicin (hydroxydoxorubicin), Vincristine (Oncovin®), and Prednisone.
  • CHOP Cyclophosphamide
  • Doxorubicin hydroxydoxorubicin
  • Vincristine Oncovin®
  • Prednisone i.e., Cyclophosphamide (Cytoxan®)
  • Doxorubicin hydroxydoxorubicin
  • Vincristine Oncovin®
  • Prednisone Prednisone
  • the chemotherapeutic agent is administered at the same time or within one week after the administration of the engineered cell or nucleic acid. In other embodiments, the chemotherapeutic agent is administered from 1 to 4 weeks or from 1 week to 1 month, 1 week to 2 months, 1 week to 3 months, 1 week to 6 months, 1 week to 9 months, or 1 week to 12 months after the administration of the engineered cell or nucleic acid. In some embodiments, the chemotherapeutic agent is administered at least 1 month before administering the cell or nucleic acid. In some embodiments, the methods further comprise administering two or more chemotherapeutic agents.
  • additional therapeutic agents may be used in conjunction with the compositions or agents/treatments described herein.
  • additional therapeutic agents include PD-1 inhibitors such as nivolumab (OPDIVO®), pembrolizumab (KEYTRUDA®), pembrolizumab, pidilizumab (CureTech), and atezolizumab (Roche).
  • Additional therapeutic agents suitable for use in combination with the compositions or agents/treatments and methods disclosed herein include, but are not limited to, ibrutinib (IMBRUVICA®), ofatumumab (ARZERRA®), rituximab (RITUXAN®), bevacizumab (AVASTIN®), trastuzumab (HERCEPTIN®), trastuzumab emtansine (KADCYLA®), imatinib (GLEEVEC®), cetuximab (ERBITUX®), panitumumab (VECTIBIX®), catumaxomab, ibritumomab, ofatumumab, tositumomab, brentuximab, alemtuzumab, gemtuzumab, erlotinib, gefitinib, vandetanib, afatinib, lapatinib, neratinib, axitinib,
  • composition or agents/treatments comprising CAR immune cells are administered with an anti-inflammatory agent.
  • Anti-inflammatory agents or drugs may include, but are not limited to, steroids and glucocorticoids (including betamethasone, budesonide, dexamethasone, hydrocortisone acetate, hydrocortisone, hydrocortisone, methylprednisolone, prednisolone, prednisone, triamcinolone), nonsteroidal anti-inflammatory drugs (NSAIDS) including aspirin, ibuprofen, naproxen, methotrexate, sulfasalazine, leflunomide, anti-TNF medications, cyclophosphamide and mycophenolate.
  • steroids and glucocorticoids including betamethasone, budesonide, dexamethasone, hydrocortisone acetate, hydrocortisone, hydrocortisone, methylprednisolone, prednisolone, prednis
  • Exemplary NSAIDs include ibuprofen, naproxen, naproxen sodium, Cox-2 inhibitors, and sialylates.
  • Exemplary analgesics include acetaminophen, oxycodone, tramadol of propoxyphene hydrochloride.
  • Exemplary glucocorticoids include cortisone, dexamethasone, hydrocortisone, methylprednisolone, prednisolone, or prednisone.
  • Exemplary biological response modifiers include molecules directed against cell surface markers (e.g., CD4, CD5, etc.), cytokine inhibitors, such as the TNF antagonists, (e.g., etanercept (ENBREL®), adalimumab (HUMIRA®) and infliximab (REMICADE®), chemokine inhibitors and adhesion molecule inhibitors.
  • TNF antagonists e.g., etanercept (ENBREL®), adalimumab (HUMIRA®) and infliximab (REMICADE®
  • chemokine inhibitors esion molecule inhibitors.
  • adhesion molecule inhibitors include monoclonal antibodies as well as recombinant forms of molecules.
  • Exemplary DMARDs include azathioprine, cyclophosphamide, cyclosporine, methotrexate, penicillamine, leflunomide, sulfasalazine, hydroxychloroquine, Gold (oral (auranofin) and intramuscular), and minocycline.
  • compositions or agents/treatments described herein are administered in conjunction with a cytokine.
  • cytokines are lymphokines, monokines, and traditional polypeptide hormones. Included among the cytokines are growth hormones such as human growth hormone, N-methionyl human growth hormone, and bovine growth hormone; parathyroid hormone; thyroxine; insulin; proinsulin; relaxin; prorelaxin; glycoprotein hormones such as follicle stimulating hormone (FSH), thyroid stimulating hormone (TSH), and luteinizing hormone (LH); hepatic growth factor (HGF); fibroblast growth factor (FGF); prolactin; placental lactogen; mullerian-inhibiting substance; mouse gonadotropin-associated peptide; inhibin; activin; vascular endothelial growth factor; integrin; thrombopoietin (TPO); nerve growth factors (NGFs) such as NGF-beta; platelet-growth factor;
  • growth hormones such
  • CD19-directed genetically modified autologous T cell immunotherapy indicated for the treatment of adult patients with relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy, including diffuse large B-cell lymphoma (DLBCL) not otherwise specified, primary mediastinal large B-cell lymphoma, high grade B-cell lymphoma, and DLBCL arising from follicular lymphoma.
  • CD19-directed genetically modified autologous T cell immunotherapy is not indicated for the treatment of patients with primary central nervous system lymphoma.
  • the immunotherapy is indicated for the treatment of ALL or CLL.
  • the immunotherapy is indicated as a first line of therapy.
  • the immunotherapy is indicated for administration after one line of therapy. Other indications may be found throughout this disclosure.
  • an infusion bag of CD19-directed genetically modified autologous T cell immunotherapy comprises a suspension of chimeric antigen receptor (CAR)-positive T cells in approximately 68 mL.
  • the target dose may be between about 1 ⁇ 10 6 and about 2 ⁇ 10 6 CAR-positive viable T cells per kg body weight, with a maximum of 2 ⁇ 10 8 CAR-positive viable T cells.
  • the CD19-directed genetically modified autologous T cell immunotherapy is Axi-celTM (YESCARTA®, axicabtagene ciloleucel).
  • Amounts of CART cells, dosage regimens, methods of administration, subjects, cancers, that fall within the scope of these methods are described elsewhere in this disclosure, alone or in combination with another chemotherapeutic agent, with or without preconditioning, and to any of the patients described elsewhere in the disclosure.
  • CD19-directed genetically modified autologous T cell immunotherapy is for autologous use.
  • the patient's identity must match the patient identifiers on the CD19-directed genetically modified autologous T cell immunotherapy cassette and infusion bag. If the information on the patient-specific label does not match the intended patient, the CD19-directed genetically modified autologous T cell immunotherapy cannot be administered.
  • the availability of CD19-directed genetically modified autologous T cell immunotherapy must be confirmed prior to starting the lymphodepleting regimen.
  • the immunotherapy is done with allogeneic “off-the-shelf” lymphocytes.
  • the patient is pre-treated prior to CD19-directed genetically modified autologous T cell immunotherapy infusion with administration of lymphodepleting chemotherapy.
  • a lymphodepleting chemotherapy regimen of cyclophosphamide 500 mg/m 2 IV and fludarabine 30 mg/m 2 IV on the fifth, fourth, and third day before infusion of CD19-directed genetically modified autologous T cell immunotherapy is administered.
  • Other beneficial preconditioning treatment regimens, along with correlative beneficial biomarkers include those described in U.S. Provisional Patent Applications 62/262,143 and 62/167,750 which are hereby incorporated by reference in their entirety herein.
  • cyclophosphamide between 200 mg/m 2 /day and 2000 mg/m 2 /day
  • fludarabine between 20 mg/m 2 /day and 900 mg/m 2 /day.
  • One such dose regimen involves treating a patient comprising administering daily to the patient about 500 mg/m 2 /day of cyclophosphamide and about 60 mg/m 2 /day of fludarabine for three days prior to administration of a therapeutically effective amount of engineered T cells to the patient.
  • Other examples of such regimens may be found, for example, in U.S. Pat. No. 9,855,298.
  • the patient is premedicated prior to CD19-directed genetically modified autologous T cell immunotherapy infusion by oral administration of acetaminophen at a dose between about 500-1000 mg, about 600-1000 mg, about 700-1000 mg, about 800-1000 mg, about 900-1000 mg, about 500-900 mg, about 500-800 mg, about 500-700 mg, about 500-600 mg, about 600-900 mg, about 600-800 mg, about 600-700 mg, about 700-900 mg, about 700-800 mg, or about 800-900 mg.
  • the patient is premedicated prior to CD19-directed genetically modified autologous T cell immunotherapy infusion by oral administration of acetaminophen at a dose of about 500 mg, about 525 mg, about 550 mg, about 575 mg, about 600 mg, about 625 mg, about 650 mg, about 675 mg, about 700 mg, about 725 mg, about 750 mg, about 775 mg, about 800 mg, about 825 mg, about 850 mg, about 875 mg, about 900 mg, about 925 mg, about 950 mg, about 975 mg or about 1000 mg.
  • the patient is premedicated prior to CD19-directed genetically modified autologous T cell immunotherapy infusion by administration of acetaminophen 650 mg by mouth and diphenhydramine 12.5 mg intravenously or by mouth approximately 1 hour before CD19-directed genetically modified autologous T cell immunotherapy infusion.
  • the prophylactic use of systemic steroids is avoided as it may interfere with the activity of CD19-directed genetically modified autologous T cell immunotherapy.
  • the timing of CD19-directed genetically modified autologous T cell immunotherapy thaw and infusion is coordinated.
  • the infusion time is confirmed in advance, and the start time of CD19-directed genetically modified autologous T cell immunotherapy thaw is adjusted such that it will be available for infusion when the patient is ready.
  • the patient identity is confirmed prior to CD19-directed genetically modified autologous T cell immunotherapy thaw.
  • patient's identity Prior to CD19-directed genetically modified autologous T cell immunotherapy preparation, patient's identity is matched with the patient identifiers on the CD19-directed genetically modified autologous T cell immunotherapy cassette.
  • the CD19-directed genetically modified autologous T cell immunotherapy product bag is not removed from the cassette if the information on the patient-specific label does not match the intended patient.
  • CD19-directed genetically modified autologous T cell immunotherapy product bag is removed from the cassette and the patient information on the cassette label is confirmed to match the bag label.
  • the method comprises inspecting the product bag for any breaches of container integrity such as breaks or cracks before thawing.
  • the infusion bag is placed inside a second sterile bag per local guidelines.
  • the method comprises thawing the CD19-directed genetically modified autologous T cell immunotherapy at approximately 37° C. using either a water bath or dry thaw method until there is no visible ice in the infusion bag.
  • the method comprises mixing or agitating the contents of the bag to disperse clumps of cellular material.
  • the contents of the bag are gently mixed or agitated.
  • the method comprises inspecting the bag for the presence of visible cell clumps remaining and mixing or agitation is continued. Small clumps of cellular material should disperse with gentle manual mixing.
  • the method does not comprise a wash, spin down, and/or re-suspension of CD19-directed genetically modified autologous T cell immunotherapy in new media prior to infusion.
  • CD19-directed genetically modified autologous T cell immunotherapy may be stored at room temperature (20° C. to 25° C.) for up to 3 hours. In some embodiments, the immunotherapy is administered immediately.
  • the presently disclosed methods of administration of CD19-directed genetically modified autologous T cell immunotherapy comprise on or more of the following as steps or as considerations:
  • administration of CD19-directed genetically modified autologous T cell immunotherapy occurs at a certified healthcare facility.
  • the methods disclosed herein comprise monitoring patients at least daily for 7 days at the certified healthcare facility following infusion for signs and symptoms of CRS and neurologic toxicities.
  • the methods disclosed herein comprise monitoring patients at least daily for 10 days at the certified healthcare facility following infusion for signs and symptoms of CRS and neurologic toxicities.
  • patients are instructed to remain within proximity of the certified healthcare facility for at least 4 weeks following infusion.
  • the method comprises management of adverse reactions.
  • the adverse reaction is selected from the group consisting of cytokine release syndrome (CRS), a neurologic toxicity, a hypersensitivity reaction, a serious infection, a cytopenia and hypogammaglobulinemia.
  • CRS cytokine release syndrome
  • Neutralization or Reduction of the CSF/CSFR1 Axis is used, alone or in combination with other treatments, in the prophylaxis or treatment of adverse reactions.
  • prophylaxis and/or treatment with adverse reactions and their syndromes is done with an agent like tocilizumab (or another anti-IL6/IL6R agent/antagonist) and/or steroids (e.g., corticosteroids).
  • the agent is an antagonist or inhibitor of TL-6 or the IL-6 receptor (TL-6R).
  • the agent is an antibody that neutralizes TL-6 activity, such as an antibody or antigen-binding fragment that binds to TL-6 or IL-6R.
  • the agent is or comprises tocilizumab (atlizumab) or sarilumab, anti-IL-6R antibodies.
  • the agent is an anti-IL-6R antibody described in U.S. Pat. No. 8,562,991.
  • the agent that targets IL-6 is an anti-TL-6 antibody, such as siltuximab, elsilimomab, ALD518/BMS-945429, sirukumab (CNTO 136), CPSI-2634, ARGX 109, FE301, FM101, or olokizumab (CDP6038).
  • the agent may neutralize IL-6 activity by inhibiting the ligand-receptor interactions.
  • the IL-6/IL-6R antagonist or inhibitor is an IL-6 mutein, such as one described in U.S. Pat. No. 5,591,827.
  • the agent that is an antagonist or inhibitor of IL-6/IL-6R is a small molecule, a protein or peptide, or a nucleic acid.
  • cytokine or receptor is IL-10, TL-6, TL-6 receptor, IFN ⁇ , IFNGR, IL-2, IL-2R/CD25, MCP-1, CCR2, CCR4, MIP13, CCR5, TNFalpha, TNFR1, such as TL-6 receptor (IL-6R), IL-2 receptor (IL-2R/CD25), MCP-1 (CCL2) receptor (CCR2 or CCR4), a TGF-beta receptor (TGF-beta I, II, or III), IFN-gamma receptor (IFNGR), MIP1P receptor (e.g., CCR5), TNF alpha receptor (e.g., TNFR1), IL-1 receptor (IL1-Ra/IL-1RP), or IL-10 receptor (IL-10R), IL-1, and IL-1Ralpha/IL-1be
  • the agent comprises situximab, sarilumab, olokizumab (CDP6038), elsilimomab, ALD518/BMS-945429, sirukumab (CNTO 136), CPSI-2634, ARGX 109, FE301, or FM101.
  • the agent is an antagonist or inhibitor of a cytokine, such as transforming growth factor beta (TGF-beta), interleukin 6 (TL-6), interleukin 10 (IL-10), IL-2, MIP13 (CCL4), TNF alpha, IL-1, interferon gamma (IFN-gamma), or monocyte chemoattractant protein-I (MCP-1).
  • TGF-beta transforming growth factor beta
  • TL-6 interleukin 6
  • IL-10 interleukin 10
  • IL-2 interleukin-2
  • MIP13 CCL4
  • TNF alpha IL-1
  • IFN-gamma interferon gamma
  • MCP-1 monocyte chemoattractant protein-I
  • MCP-1 monocyte chemoattractant protein-I
  • MCP-1 monocyte chemoattractant protein-I
  • MCP-1 monocyte chemoattractant protein-I
  • MCP-1 monocyte chemoattractant protein
  • a cytokine receptor such as TL-6 receptor (IL-6R), IL-2 receptor (IL-2R/CD25), MCP-1 (CCL2) receptor (CCR2 or CCR4), a TGF-beta receptor (TGF-beta I, II, or III), IFN-gamma receptor (IFNGR), MIP1P receptor (e.g., CCR5), TNF alpha receptor (e.g., TNFR1), IL-1 receptor (IL1-Ra/IL-1RP), or IL-10 receptor (IL-10R).
  • IL-6R TL-6 receptor
  • IL-2R/CD25 IL-2 receptor
  • CCL2 or CCR4 MCP-1 receptor
  • TGF-beta I, II, or III TGF-beta receptor
  • IFN-gamma receptor IFN-gamma receptor
  • MIP1P receptor e.g., CCR5
  • TNF alpha receptor e.g., TNFR1
  • tocilizumab is administered in a dosage amount of from or from about 1 mg/kg to 10 mg/kg, 2 mg/kg to 8 mg/kg, 2 mg/kg to 6 mg/kg, 2 mg/kg to 4 mg/kg or 6 mg/kg to 8 mg/kg, each inclusive, or the tocilizumab is administered in a dosage amount of at least or at least about or about 2 mg/kg, 4 mg/kg, 6 mg/kg or 8 mg/kg. In some embodiments, tocilizumab is administered in a dosage amount from about 1 mg/kg to 12 mg/kg, such as at or about 10 mg/kg. In some embodiments, tocilizumab is administered by intravenous infusion.
  • the signs and symptoms of adverse reactions are selected from the group consisting of fever, hypotension, tachycardia, hypoxia, and chills, include cardiac arrhythmias (including atrial fibrillation and ventricular tachycardia), cardiac arrest, cardiac failure, renal insufficiency, capillary leak syndrome, hypotension, hypoxia, organ toxicity, hemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS), seizure, encephalopathy, headache, tremor, dizziness, aphasia, delirium, insomnia anxiety, anaphylaxis, febrile neutropenia, thrombocytopenia, neutropenia, and anemia.
  • cardiac arrhythmias including atrial fibrillation and ventricular tachycardia
  • cardiac arrest including atrial fibrillation and ventricular tachycardia
  • cardiac failure including atrial fibrillation and ventricular tachycardia
  • renal insufficiency including atrial fibrill
  • the method comprises identifying Cytokine Release Syndrome (CRS) based on clinical presentation.
  • CRS Cytokine Release Syndrome
  • the method comprises evaluating for and treating other causes of fever, hypoxia, and hypotension. If CRS is observed or suspected, it may be managed according to the recommendations in Table 1, which may also be used in combination with the other treatments of this disclosure, including Neutralization or Reduction of the CSF/CSFR1 Axis. Patients who experience ⁇ Grade 2 CRS (e.g., hypotension, not responsive to fluids, or hypoxia requiring supplemental oxygenation) should be monitored with continuous cardiac telemetry and pulse oximetry. In some embodiments, for patients experiencing severe CRS, consider performing an echocardiogram to assess cardiac function.
  • tocilizumab may be used instead of tocilizumab in the methods disclosed herein.
  • another anti-IL6R may be used instead of tocilizumab.
  • CRS Grading and Management Guidance CRS Grade (a) Tocilizumab Corticosteroids Grade 1 N/A N/A Symptoms require symptomatic treatment only (e.g., fever, nausea, fatigue, headache, myalgia, malaise).
  • Grade 2 Administer tocilizumab (c) 8 Manage per Grade 3 if no Symptoms require and mg/kg IV over 1 hour (not to improvement within 24 hours respond to moderate exceed 800 mg). after starting tocilizumab. intervention. Repeat tocilizumab every 8 Oxygen requirement less than hours as needed if not 40% FiO 2 or hypotension responsive to IV fluids or responsive to fluids or low- increasing supplemental dose of one vasopressor or oxygen.
  • Grade 2 organ toxicity (b).
  • the method comprises monitoring patients for signs and symptoms of neurologic toxicities (Table 2). In some embodiments, the method comprises ruling out other causes of neurologic symptoms. Patients who experience ⁇ Grade 2 neurologic toxicities should be monitored with continuous cardiac telemetry and pulse oximetry. Provide intensive care supportive therapy for severe or life-threatening neurologic toxicities.
  • anti-seizure medicines e.g., levetiracetam
  • seizure prophylaxis for any ⁇ Grade 2 neurologic toxicities.
  • the following treatments may be used in combination with the other treatments of this disclosure, including Neutralization or Reduction of the CSF/CSFR1 Axis.
  • Grade 3 Administer tocilizumab per Table 1 Administer dexamethasone 10 for management of Grade 2 CRS. mg IV every 6 hours. In addition, administer dexamethasone Continue dexamethasone use 10 mg IV with the first dose of until the event is Grade 1 tocilizumab and repeat dose every or less, then taper over 6 hours. Continue dexamethasone use 3 days. until the event is Grade 1 or less, then taper over 3 days.
  • anti-seizure medicines e.g., levetiracetam
  • Grade 4 Administer tocilizumab per Table 1 Administer methylprednisolone for management of Grade 2 CRS.
  • the disclosure provides a method of treating relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy in a human comprising administering to the human in need thereof CD19-directed genetically modified autologous T cell immunotherapy comprising:
  • the disclosure provides a method of treating relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy in a patient comprising administering to the patient in need thereof CD19-directed genetically modified autologous T cell immunotherapy comprising:
  • Administration of corticosteroids and/or tocilizumab at Grade 1 may be considered prophylactic.
  • Supportive care may be provided in all protocols at all CRS and NE severity grades.
  • tocilizumab and/or corticosteroids are administered as follows: Grade 1 CRS: no tocilizumab; no corticosteroids; Grade 2 CRS: tocilizumab (only in case of comorbidities or older age); and/or corticosteroids (only in case of comorbidities or older age); Grade 3 CRS: tocilizumab; and/or corticosteroids; Grade 4 CRS: tocilizumab; and/or corticosteroids.
  • tocilizumab and/or corticosteroids are administered as follows: Grade 1 CRS: tocilizumab (if no improvement after 3 days); and/or corticosteroids (if no improvement after 3 days); Grade 2 CRS: tocilizumab; and/or corticosteroids; Grade 3 CRS: tocilizumab; and/or corticosteroids; Grade 4 CRS: tocilizumab; and/or corticosteroids, high dose.
  • tocilizumab and/or corticosteroids are administered as follows: Grade 1 NE: no tocilizumab; no corticosteroids; Grade 2 NE: no tocilizumab; no corticosteroids; Grade 3 NE: tocilizumab; and/or corticosteroids (only if no improvement to tocilizumab, standard dose); Grade 4 NE: tocilizumab; and/or corticosteroids.
  • tocilizumab and/or corticosteroids are administered as follows: Grade 1 NE: no tocilizumab; and/or corticosteroids; Grade 2 NE: tocilizumab; and/or corticosteroids; Grade 3 NE: tocilizumab; and/or corticosteroids, high dose; Grade 4 NE: tocilizumab; and/or corticosteroids, high dose.
  • corticosteroid treatment is initiated at CRS grade ⁇ 2 and tocilizumab is initiated at CRS grade ⁇ 2. In one embodiment, corticosteroid treatment is initiated at CRS grade ⁇ 1 and tocilizumab is initiated at CRS grade ⁇ 1. In one embodiment, corticosteroid treatment is initiated at NE grade ⁇ 3 and tocilizumab is initiated at CRS grade ⁇ 3. In one embodiment, corticosteroid treatment is initiated at CRS grade ⁇ 1 and tocilizumab is initiated at CRS grade ⁇ 2. In some embodiments, prophylactic use of tocilizumab administered on Day 2 may decrease the rates of Grade ⁇ 3 CRS.
  • glucocorticoids include synthetic and non-synthetic glucocorticoids.
  • Exemplary glucocorticoids include, but are not limited to: alclomethasones, algestones, beclomethasones (e.g. beclomethasone dipropionate), betamethasones (e.g.
  • betamethasone 17 valerate betamethasone sodium acetate, betamethasone sodium phosphate, betamethasone valerate), budesonides, clobetasols (e.g. clobetasol propionate), clobetasones, clocortolones (e.g. clocortolone pivalate), cloprednols, corticosterones, cortisones and hydrocortisones (e.g. hydrocortisone acetate), cortivazols, deflazacorts, desonides, desoximethasones, dexamethasones (e.g.
  • dexamethasone 21-phosphate dexamethasone acetate, dexamethasone sodium phosphate
  • diflorasones e.g. diflorasone diacetate
  • diflucortolones difluprednates
  • enoxolones fluazacorts
  • flucloronides fludrocortisones
  • flumethasones e.g. flumethasone pivalate
  • flunisolides fluocinolones
  • fluocinolone acetonide fluocinonides, fluocortins, fluocortolones, fluorometholones (e.g. fluorometholone acetate), fluperolones (e.g., fluperolone acetate), fluprednidenes, flupredni solones, flurandrenolides, fluticasones (e.g. fluticasone propionate), formocortals, halcinonides, halobetasols, halometasones, halopredones, hydrocortamates, hydrocortisones (e.g.
  • prednisolone 25-diethylaminoacetate prednisolone sodium phosphate, prednisolone 21-hemisuccinate, prednisolone acetate; prednisolone farnesylate, prednisolone hemisuccinate, prednisolone-21 (beta-D-glucuronide), prednisolone metasulphobenzoate, prednisolone steaglate, prednisolone tebutate, prednisolone tetrahydrophthalate), prednisones, prednivals, prednylidenes, rimexolones, tixocortols, triamcinolones (e.g.
  • triamcinolone acetonide triamcinolone benetonide, triamcinolone hexacetonide, triamcinolone acetonide 21 palmitate, triamcinolone diacetate.
  • glucocorticoids and the salts thereof are discussed in detail, for example, in Remington's Pharmaceutical Sciences, A. Osol, ed., Mack Pub. Co., Easton, Pa. (16th ed. 1980) and Remington: The Science and Practice of Pharmacy, 22nd Edition, Lippincott Williams & Wilkins, Philadelphia, Pa. (2013) and any other editions, which are hereby incorporated by reference.
  • the glucocorticoid is selected from among cortisones, dexamethasones, hydrocortisones, methylprednisolones, prednisolones and prednisones.
  • the glucocorticoid is dexamethasone.
  • the steroid is a mineralcorticoid. Any other steroid may be used in the methods provided herein.
  • corticosteroids may be administered at any dose and frequency of administration, which may be adjusted to the severity/grade of the adverse event (e.g., CRS and NE).
  • Tables 1 and 2 provide examples of dosage regimens for management of CRS and NE, respectively.
  • corticosteroid administration comprises oral or IV dexamethasone 10 mg, 1-4 times per day.
  • Another embodiment, sometimes referred to as “high-dose” corticosteroids comprises administration of IV methylprednisone 1 g per day alone, or in combination with dexamethasone.
  • the one or more cortico steroids are administered at doses of 1-2 mg/kg per day.
  • the corticosteroid may be administered in any amount that is effective to ameliorate one or more symptoms associated with the adverse events, such as with the CRS or neurotoxicity.
  • the corticosteroid e.g., glucocorticoid
  • the corticosteroid such as a glucocorticoid is administered at an amount between at or about 0.4 and 20 mg, for example, at or about 0.4 mg, 0.5 mg, 0.6 mg, 0.7 mg, 0.75 mg, 0.8 mg, 0.9 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7 mg, 8 mg, 9 mg, 10 mg, 11 mg, 12 mg, 13 mg, 14 mg, 15 mg, 16 mg, 17 mg, 18 mg, 19 mg or 20 mg per dose, to an average adult human subject.
  • the corticosteroid may be administered, for example, at a dosage of at or about 0.001 mg/kg (of the subject), 0.002 mg/kg, 0.003 mg/kg, 0.004 mg/kg, 0.005 mg/kg, 0.006 mg/kg, 0.007 mg/kg, 0.008 mg/kg, 0.009 mg/kg, 0.01 mg/kg, 0.015 mg/kg, 0.02 mg/kg, 0.025 mg/kg, 0.03 mg/kg, 0.035 mg/kg, 0.04 mg/kg, 0.045 mg/kg, 0.05 mg/kg, 0.055 mg/kg, 0.06 mg/kg, 0.065 mg/kg, 0.07 mg/kg, 0.075 mg/kg, 0.08 mg/kg, 0.085 mg/kg, 0.09 mg/kg, 0.095 mg/kg, 0.1 mg/kg, 0.15 mg/kg, 0.2 mg/kg, 0.25 mg/kg, 0.30 mg/kg, 0.35 mg/kg, 0.40 mg/kg, 0.45 mg/kg,
  • the dose of corticosteroid administered is dependent upon the specific corticosteroid, as a difference in potency exists between different corticosteroids. It is typically understood that drugs vary in potency, and that doses can therefore vary, in order to obtain equivalent effects. Equivalence in terms of potency for various glucocorticoids and routes of administration is well known. Information relating to equivalent steroid dosing (in a non-chronotherapeutic manner) may be found in the British National Formulary (BNF) 37, March 1999.
  • any of these embodiments is practiced with autologous anti-CD19 CART cell therapy is done with axicabtagene ciloleucel prepared by the described in International Application No. PCT/US2016/057983, with or without AKT inhibitor.
  • this therapy is used to treat patients with ALL.
  • this therapy is used to treat any other cancer, as set forth elsewhere in the specification.
  • the patients are adult patients with relapsed/refractory Acute Lymphoblastic Leukemia (ALL).
  • ALL relapsed/refractory Acute Lymphoblastic Leukemia
  • the patients received conditioning therapy.
  • the conditioning therapy comprises cyclophosphamide 500 mg/m 2 and fludarabine 30 mg/m 2 both for 3 days, at days ⁇ 4, ⁇ 3, ⁇ 2 of the treatment (DO).
  • these patients are administered axicabtagene ciloleucel at 0.5 ⁇ 10 6 , 1 ⁇ 10 6 , or 2 ⁇ 10 6 CAR+ cells/kg.
  • the patient is administered steroids at Grade 2 for NE. In some embodiments the patient is administered steroids at Grade 3 for NE. In some of these embodiments, the patient is administered tocilizumab in the context of CRS, alone or in combination with steroids. In some other embodiments, the patient is administered anti-IL6 antibodies (e.g. Siltuximab) to manage CRS. In some other embodiments, the patient is administered anti-IL6 antibodies (e.g. Siltuximab) to manage Neurotoxicity (e.g., Neurotoxic Events). In some embodiments, the patient is refractory to anti-IL6 treatment. In some embodiments, the patient receives siltuximab as third-line treatment for CRS, after failure of both tocilizumab and corticosteroid therapy.
  • siltuximab as third-line treatment for CRS, after failure of both tocilizumab and corticosteroid therapy.
  • axicabtagene ciloleucel treatment is combined with an inhibitor or antagonist of a member of the colony-stimulating factor (CSF) protein family or of their receptors (e.g., CSF1R, CSF2R) for the management of adverse effects, safety, and/or neurotoxicity.
  • CSF colony-stimulating factor
  • These treatments may be used in any setting, including, but not limited to, prophylactically. They may also be used in combination with steroids.
  • the inhibitors or antagonists used in the combination treatment may be, without limitation, antibodies, neutralizers expressed in CAR-T cells, small molecules, and other agents.
  • treatment with other CD19-directed genetically modified autologous T cell immunotherapy e.g., axicabtagene ciloleucel; other examples of such immunotherapy are described elsewhere in the specification
  • CD19-directed genetically modified autologous T cell immunotherapy e.g., axicabtagene ciloleucel; other examples of such immunotherapy are described elsewhere in the specification
  • an inhibitor or antagonist of a member of the colony-stimulating factor (CSF) protein family or of their receptors e.g., CSF1R, CSF2R.
  • the CSF family member is GM-CSF (Granulocyte-macrophage colony-stimulating factor, also known as CSF2).
  • GM-CSF may be produced by a number of haemopoietic and nonhaemopoietic cell types upon stimulation, and it may activate/‘prime’ myeloid populations to produce inflammatory mediators, such as TNF and interleukin 1 ⁇ (IL1 ⁇ ).
  • the GM-CSF inhibitor is an antibody that binds to and neutralizes circulating GM-CSF.
  • the antibody is selected from Lenzilumab; namilumab (AMG203); GSK3196165/MOR103/Otilimab (GSK/MorphoSys), KB002 and KB003 (KaloBios), MT203 (Micromet and Nycomed), and MORAb-022/gimsilumab (Morphotek).
  • the antibody is a biosimilar of the same.
  • the antagonist is E21R, a modified form of GM-CSF that antagonizes the function of GM-CSF.
  • the inhibitor/antagonist is a small molecule.
  • the CSF family member is M-CSF (also known as macrophage colony-stimulating factor or CSF1).
  • agents that inhibit or antagonize CSF1 include small molecules, antibodies, chimeric antigen receptors, fusion proteins, and other agents.
  • the CSF1 inhibitor or antagonist is an anti-CSF1 antibody.
  • the anti-CSF1 antibody is selected from those made by Roche (e.g., RG7155), Pfizer (PD-0360324), Novartis (MCS110/lacnotuzumab), or a biosimilar version of any one of the same.
  • the inhibitor or antagonist inactivates the activity of either the GM-CSF-R-alpha (aka CSF2R) or CSF1R receptors.
  • the inhibitor is selected from Mucunimumab (formerly CAM-3001), a fully human GM-CSF Receptor a monoclonal antibody currently being developed by Medlmmune, Inc.; cabiralizumab (Five Prime Therapeutics); LY3022855 (IMC-CS4)(Eli Lilly), Emactuzumab, also known as RG7155 or R05509554; FPA008, a humanized mAb (Five Prime/BMS); AMG820 (Amgen); ARRY-382 (Array Biopharma); MCS110 (Novartis); PLX3397 (Plexxikon); ELB041/AFS98/TG3003 (ElsaLys Bio, Transgene), SNDX-6352 (Syndax).
  • the inhibitor or antagonist is expressed in CAR-T cells.
  • the inhibitor is a small molecule (e.g. heteroaryl amides, quinolinone series, pyrido-pyrimide series); BLZ945 (Novartis), PLX7486, ARRY-382, Pexidrtinib (also known as PLX3397) or 5-((5-chloro-1H-pyrrolo[2,3-b]pyridin-3-yl)methyl)-N-06-(trifluoromethyl)pyridin-3-yl)methyl)pyridin-2-amine; GW 2580 (CAS 870483-87-7), K ⁇ 20227 (CAS 623142-96-1), AC708 by Ambit Siosciences, or any CSF1R inhibitor listed in Cannearliest et al.
  • a small molecule e.g. heteroaryl amides, quinolinone series, pyrido-pyrimide series
  • BLZ945 Novartis
  • GM-CSF as a target in inflammatory/autoimmune disease: current evidence and future therapeutic potential” Hamilton, J. A. Expert Rev. Clin. Immunol., 2015; and “Targeting GM-CSF in inflammatory diseases” Wicks, I. P., Roberts, A. W. Nat. Rev. Rheumatol., 2016.
  • the inhibitor, or combination of inhibitors, of GM-CSF, CSF1, GM-CSFR, or CSF1R may be administered in different dosages.
  • One of ordinary skill in the art is routinely capable of determining their effective amount and timing of administration.
  • mavrilimumab and/or lenzilumab may be used in combination with treatment with CD19-directed genetically modified autologous T cell immunotherapy, which may be, in one example, axicabtagene ciloleucel.
  • CD19-directed genetically modified autologous T cell immunotherapy which may be, in one example, axicabtagene ciloleucel.
  • Other examples of such immunotherapies are described elsewhere in the specification.
  • mavrilimumab is administered SQ, IV, or OP/IP at DO of CAR-T cell treatment.
  • a single dose of either 100 mg or 150 mg is administered SQ or IP.
  • Mavrilimumab may be administered prior to, concomitantly with, or after administration of axicabtagene ciloleucel.
  • both drugs are administered on Day zero (DO) of treatment with CAR-T cells.
  • mavrilimumab is administered at a single dose of 30 mg. In one embodiment, mdressimumab is administered at a single dose of 50 mg.
  • mrajimumab is administered at a dose of 10 to 500 mg, 100 to 200 mg, 30 to 100 mg, or 30 to 150 mg. In one embodiment, mparkedimumab is administered once at 1 mg/kg of body weight, 2 mg/kg, 3 mg/kg, 4 mg/kg, 5 mg/kg, 6 mg/kg, 7 mg/kg, 8 mg/kg, 9 mg/kg, 10 mg/kg, 11 mg/kg, 12 mg/kg, 13 mg/kg, 14 mg/kg, 15 mg/kg, 16 mg/kg, 17 mg/kg, 18 mg/kg, 19 mg/kg, 20 mg/kg, 21 mg/kg, 22 mg/kg, 23 mg/kg, 24 mg/kg, 25 mg/kg, 26 mg/kg, 27 mg/kg, 28 mg/kg, 29 mg/kg, or 30 mg/kg, subcutaneously, OP/IP, or IV, preferably on Day 0.
  • mavrilimumab is administered once at 3 mg/kg of body weight, preferably on Day 0 mdressimumab may be administered as a single dose or in multiple doses (e.g., every week, every other week). In one embodiment, mdressimumab is administered as a single dose between 0.01-10.0 mg/kg, SQ, IV, or IP.
  • lenzilumab is administered at 10 mg/kg (600 mg max), 20 mg/kg (1200 mg max), or 30 mg/kg (1800 mg max) via IP infusion.
  • Lenzilumab may be administered prior to, concomitantly with, or after administration of axicabtagene ciloleucel.
  • both drugs are administered on DO.
  • lenzilumab is administered as a single dose between 0.01-50.0 mg/kg.
  • the single dose is 1, 3, 10, 50, or 100 mg/kg.
  • the single dose is 200 mg, 400 mg, or 600 mg.
  • lenzilumab is administered at a weekly dosing of 10, 50, or 100 mg/kg.
  • the inhibitor or antagonist of GM-CSF, M-CSF, GM-CSF-R-alpha (aka CSF2R) or CSF1R receptors maybe administered any day between Day ⁇ 5 and Day 5 relative to the start of treatment with CD19-directed genetically modified autologous T cell immunotherapy (D0).
  • the inhibitor is administered any day between Day ⁇ 2 and Day 10, in one or more daily doses.
  • the inhibitor is administered one or more weeks after the immunotherapy is started (D0).
  • GM-CSF receptor such as mucunimumab
  • BM-CSF such as lenzilumab
  • GM-CSF receptor such as mucunimumab
  • BM-CSF such as lenzilumab
  • axicabtagene ciloleucel treatment is combined with treatment with an anti-CD20 agent.
  • the agent is rituximab.
  • the agent is an antibody selected from Arzerra, Gazyva, ibritumomab tiuxetan, obinutuzumab, ofatumumab, ocrelizumab, veltuzumab, Rituxan Hycela, Rituxan, Bexxar, Zevalin, and biosimilars of the same. These antibodies have been described in J. M. L. Casan, J. Wong, M. J. Northcott, and S.
  • CD19-directed genetically modified autologous T cell immunotherapy is available as a cell suspension for infusion.
  • a single dose of CD19-directed genetically modified autologous T cell immunotherapy comprises a target dose between about 1 ⁇ 10 6 and about 2 ⁇ 10 6 CAR-positive viable T cells per kg of body weight (or maximum of 2 ⁇ 10 8 CAR-positive viable T cells for patients 100 kg and above) in approximately 68 mL suspension in an infusion bag.
  • the CD19-directed genetically modified autologous T cell immunotherapy is axicabtagene ciloleucel (YESCARTA®).
  • a single dose of CD19-directed genetically modified autologous T cell immunotherapy is present in a container.
  • Such container may be sterile.
  • the container is an infusion bag.
  • the infusion bag volume is about 100 mL, 150 mL, 200 mL, 250 mL, 300 mL, 500 mL, 750 mL, 1,000 mL, 1,500 mL, 2,000 mL or 3,000 mL.
  • CD19-directed genetically modified autologous T cell immunotherapy is available through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS).
  • REMS Risk Evaluation and Mitigation Strategy
  • CRS Cytokine Release Syndrome
  • the health care facility ensures that two doses of tocilizumab are available prior to infusion of CD19-directed genetically modified autologous T cell immunotherapy. In some embodiments, the health care facility ensures that four doses of tocilizumab are available prior to infusion of CD19-directed genetically modified autologous T cell immunotherapy. In some embodiments, the method comprises monitoring patients at least daily for 7 days at the certified healthcare facility following infusion for signs and symptoms of CRS. In some embodiments, the method comprises monitoring patients at least daily for 7-10 days at the certified healthcare facility following infusion for signs and symptoms of CRS. In some embodiments, the method comprises monitoring patients at least daily for 8 days at the certified healthcare facility following infusion for signs and symptoms of CRS.
  • the method comprises monitoring patients at least daily for 9 days at the certified healthcare facility following infusion for signs and symptoms of CRS. In some embodiments, the method comprises monitoring patients at least daily for 10 days at the certified healthcare facility following infusion for signs and symptoms of CRS. In some embodiments, the method comprises monitoring patients for signs or symptoms of CRS for 4 weeks after infusion. In some embodiments, the method comprises counseling patients to seek immediate medical attention should signs or symptoms of CRS occur at any time. In some embodiments, the method comprises instituting treatment with supportive care, tocilizumab or tocilizumab and corticosteroids as indicated at the first sign of CRS.
  • the method comprises monitoring patients at least daily for 7 days at the certified healthcare facility following infusion for signs and symptoms of neurologic toxicities. In some embodiments, the method comprises monitoring patients at least daily for 7-10 days at the certified healthcare facility following infusion for signs and symptoms of CRS. In some embodiments, the method comprises monitoring patients at least daily for 10 days at the certified healthcare facility following infusion for signs and symptoms of CRS. In some embodiments, the method comprises monitoring patients for signs or symptoms of neurologic toxicities for 4 weeks after infusion and treat promptly.
  • Allergic reactions may occur with the infusion of CD19-directed genetically modified autologous T cell immunotherapy.
  • serious hypersensitivity reactions including anaphylaxis may be due to dimethyl sulfoxide (DMSO) or residual gentamicin in CD19-directed genetically modified autologous T cell immunotherapy.
  • DMSO dimethyl sulfoxide
  • Hepatitis B virus (HBV) reactivation in some cases resulting in fulminant hepatitis, hepatic failure and death, may occur in patients treated with drugs directed against B cells.
  • the method comprises performing screening for HBV, HCV, and HIV in accordance with clinical guidelines before collection of cells for manufacturing.
  • patients may exhibit cytopenias for several weeks following lymphodepleting chemotherapy and CD19-directed genetically modified autologous T cell immunotherapy infusion.
  • the method comprises monitoring blood counts after CD19-directed genetically modified autologous T cell immunotherapy infusion.
  • B-cell aplasia and hypogammaglobulinemia may occur in patients receiving treatment with CD19-directed genetically modified autologous T cell immunotherapy.
  • the method comprises monitoring immunoglobulin levels after treatment with CD19-directed genetically modified autologous T cell immunotherapy and managing using infection precautions, antibiotic prophylaxis and immunoglobulin replacement.
  • vaccination with live virus vaccines is not recommended for at least 6 weeks prior to the start of lymphodepleting chemotherapy, during CD19-directed genetically modified autologous T cell immunotherapy treatment, and until immune recovery following treatment with CD19-directed genetically modified autologous T cell immunotherapy.
  • patients treated with CD19-directed genetically modified autologous T cell immunotherapy may develop secondary malignancies.
  • the method comprises monitoring life-long for secondary malignancies.
  • TLS Tumor Lysis Syndrome
  • the method comprises evaluating patients for elevated uric acid or high tumor burden and administering allopurinol, or an alternative prophylaxis, prior to axicabtagene ciloleucel infusion. Signs and symptoms of TLS should be monitored and events managed according to standard guidelines.
  • the method comprises advising patients to refrain from driving and engaging in hazardous occupations or activities, such as operating heavy or potentially dangerous machinery, during this initial period.
  • CD19-directed genetically modified autologous T cell immunotherapy is supplied in an infusion bag containing approximately 68 mL of frozen suspension of genetically modified autologous T cells in 5% DMSO and 2.5% albumin (human). In some embodiments, CD19-directed genetically modified autologous T cell immunotherapy is supplied in an infusion bag containing approximately 68 mL of frozen suspension of genetically modified autologous T cells in 5% DMSO and 2.5% albumin (human) (NDC 71287-119-01). In some embodiments, CD19-directed genetically modified autologous T cell immunotherapy comprises Cryostor CS10. In some embodiments, CD19-directed genetically modified autologous T cell immunotherapy comprises 300 mg sodium per infusion.
  • CD19-directed genetically modified autologous T cell immunotherapy is supplied in an infusion bag containing approximately 50-100 mL, 50-90 mL, 50-80 mL, 50-70 mL, 60-70 mL, 60-75 mL, or 65-75 mL, of suspension of genetically modified autologous T cells in 5% DMSO and 2.5% albumin (human).
  • CD19-directed genetically modified autologous T cell immunotherapy is supplied in an infusion bag containing less than 100 mL, less than 90 mL, less than 80 mL, less than 70 mL, less than 70 mL, less than 72 mL, or less than 75 mL, of suspension of genetically modified autologous T cells in 5% DMSO and 2.5% albumin (human).
  • CD19-directed genetically modified autologous T cell immunotherapy is supplied in an infusion bag containing greater than 50 mL, greater than 60 mL, greater than 65 mL, greater than 66 mL, greater than 67 mL, or greater than 68 mL, of suspension of genetically modified autologous T cells in 5% DMSO and 2.5% albumin (human). In some embodiments, the suspension is frozen.
  • the CD19-directed genetically modified autologous T cell immunotherapy infusion bag is supplied in ethylene-vinyl acetate cryostorage bag with sealed addition tube and two available spike ports, containing approximately 68 mL of cell dispersion.
  • the CD19-directed genetically modified autologous T cell immunotherapy infusion bag is individually packed in a metal cassette. In some embodiments, the CD19-directed genetically modified autologous T cell immunotherapy infusion bag is individually packed in a metal cassette (NDC 71287-119-02). In some embodiments, the CD19-directed genetically modified autologous T cell immunotherapy infusion bag is stored in the vapor phase of liquid nitrogen. In some embodiments, the CD19-directed genetically modified autologous T cell immunotherapy infusion bag is supplied in a liquid nitrogen dry shipper.
  • the method comprises matching the identity of the patient with the patient identifiers on the cassette and infusion bag upon receipt.
  • CD19-directed genetically modified autologous T cell immunotherapy is stored frozen in the vapor phase of liquid nitrogen (less than or equal to minus 150° C.). In some embodiments, the CD19-directed genetically modified autologous T cell immunotherapy is thaw before using.
  • CAR-T cell treatment may be associated with a variety of adverse events, for example, cerebral edema may be detected in the treatment with CD19 CAR-T as described herein.
  • the application provides a method of recovering from cerebral edema following CD19 CAR-T treatment comprising administering an immunosuppressant that depletes T lymphocytes, such as anti-thymocyte globulin (ATG).
  • ATG is administered at 2 mg/kg/d, IV.
  • ATG is administered together with methylprednisolone and/or tocilizumab to reduce systemic cytokine storm.
  • the ATG is rabbit ATG or equine ATG.
  • ATG may be administered in one or more doses.
  • ASCT means autologous stem cell transplant
  • DLBCL diffuse large B cell lymphoma
  • ECOG Eastern Cooperative Oncology Group performance status
  • IPI International Prognostic Index
  • PD progressive disease
  • PMBCL primary mediastinal B cell lymphoma
  • SPD sum of product diameters
  • TFL transformed follicular lymphoma means autologous stem cell transplant
  • DLBCL diffuse large B cell lymphoma
  • ECOG Eastern Cooperative Oncology Group performance status
  • IPI International Prognostic Index
  • PD progressive disease
  • PMBCL primary mediastinal B cell lymphoma
  • SPD sum of product diameters
  • TFL transformed follicular lymphoma means autologous stem cell transplant
  • DLBCL diffuse large B cell lymphoma
  • ECOG Eastern Cooperative Oncology Group performance status
  • IPI International Prognostic Index
  • PD progressive disease
  • PMBCL primary mediastinal B cell lymphoma
  • SPD sum of product diameters
  • Leukapheresis is a procedure for collecting peripheral blood mononuclear (PBMCs).
  • PBMCs peripheral blood mononuclear
  • subjects or patients with relapsed or refractory aggressive B-cell non-Hodgkin lymphoma undergo leukapheresis to obtain T cells for generating axicabtagene ciloleucel.
  • Eligible patients may have refractory disease to the most recent therapy or relapse within 1 year after autologous hematopoietic stem cell transplantation (HSCT).
  • HSCT autologous hematopoietic stem cell transplantation
  • lymphodepleting regimen which may comprise cyclophosphamide 500 mg/m 2 IV and fludarabine 30 mg/m 2 IV, both given on the fifth, fourth, and third day before receiving axicabtagene ciloleucel at a dose of 2 ⁇ 10 6 CAR-positive viable T cells/kg (maximum permitted dose: 2 ⁇ 10 8 cells) via IV infusion (Day 0).
  • subjects may receive mzarimumab or lenzilumab.
  • Mucunimumab may be administered at a dose of 100 mg or 150 mg.
  • Mucunimumab may be administered once, on Day 0, SQ, OP/IP, or IV at 3 mg/kg of body weight.
  • Lenzilumab may be administered at a dose of 10 mg/kg (600 mg max), 20 mg/kg (1200 mg max), or 30 mg/kg (1800 mg max). Mucunimumab and lenzilumab may be administered on day 0 prior to, concomitantly with, or after receiving axicabtagene ciloleucel.
  • Neurological assessment may be conducted on Day 0, on Day 1, and on every other day during the observation period, which would be 7 days.
  • the common neurologic toxicities may include encephalopathy, headache, tremor, dizziness, aphasia, delirium, insomnia, and anxiety.
  • the grading scale may be the NCI Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 or other guidelines.
  • CCAE Common Terminology Criteria for Adverse Events
  • To evaluate whether the subjects exhibit reduced or modulated neurologica events, several parameters including the levels of cytokines, GS-CSF, CD19 CAR-T cells, anti-tumor effects, and/or the cytokine/chemokine milieu may be determined at different time, e.g. 28 days, or monthly for at least one, two, three, four, five, six, seven, eight, nine, or ten years.
  • GM-CSF receptor such as with mucuninab
  • BM-CSF such as with lenzilumab
  • GM-CSF receptor such as with mucuninab
  • BM-CSF such as with lenzilumab
  • PK and PD analysis may be conducted on blood (levels of antiCD19 CAR T cells) or serum (cytokines) as potential predictive markers for the efficacy and safety of axicabtagene ciloleucel.
  • the cytokines and chemokines may include homeostatic, pro-inflammatory and immune modulating cytokines IL-2, IL-6, IL-10, IL-12p40/p70, IL-15, IL-17a, TNF- ⁇ , IFN- ⁇ and GM-CSF; acute phase reactants, such as CRP; chemokines IL-8, MCP-1 and MIP-1 ⁇ and IP-10; and HLH-related markers such as ferritin and IL-2R ⁇ .
  • Efficacy is established on the basis of complete remission (CR) rate and duration of response (DOR), as determined by an independent review committee.
  • Parameters such as objective response rate (ORR), complete remission rate, partial remission rate, and/or duration of response may be used to determine or measure efficacy.
  • ORR objective response rate
  • the ORR may be determined by 2007 revised International Working Group criteria, as assessed by the independent review committee or other similar guideline.
  • Duration of response parameters may include number of responders, DOR (months) (median, 95% CI, range), DOR if best response is CR and DOR if best response is PR (months; median, 95% CI, range); and median follow up for DOR (months).
  • DOR duration of response
  • NE not estimable
  • PR partial remission.
  • DOR is measured from the date of first objective response to the date of progression or death from relapse or toxicity.
  • R/R LBCL including DLBCL, PMBCL, TFL, and high-grade B cell lymphoma
  • a minimum prior therapy included anti-CD20 antibody or an anthracycline containing chemotherapy.
  • Patients were leukapheresed and received conditioning chemotherapy cyclophosphamide 500 mg/m 2 and fludarabine 30 mg/m 2 , both at days ⁇ 4, ⁇ 3, and ⁇ 2 followed by 2 ⁇ 10 6 anti-CD19 CART cells/kg at day 0.
  • bridging therapy between leukapheresis and conditioning chemotherapy
  • rituximab 375 mg/m 2 weekly for 3 weeks
  • dexamethasone 20 to 40 mg/day or equivalent for 1 to 4 days
  • methylprednisolone 1 g/m 2 for 1 to 3 days
  • bendamustine 90 mg/m 2 for 2 days
  • bendamustine 375 mg/m 2 for 1 day
  • This study applied the revised adverse event management (or revised AE management), where patients showing Grade 1 CRS (cytokine release syndrome) received either tocilizumab or corticosteroid; and patients showing Grade 1 NE (neurologic events) received corticosteroid; and patients showing Grade 2 NE (neurologic events) received either tocilizumab or corticosteroid.
  • Corticosteroids included oral or IV dexamethasone 10 mg, 1-4 times per day, or IV methylprednisone 1 g per day. Tocilizumab was not administered prophylactically. The primary endpoint was incidence and severity of CRS and NE.
  • Grade ⁇ 3 AEs were observed in 95% of patients. The most frequent Grade ⁇ 3 AEs were decreased neutrophil count (33%), anemia (29%), neutropenia (29%) and pyrexia (24%). Grade 1 or 2 NE were observed in 48% of patients; Grade ⁇ 3 NE were observed in 10% of patients. Grade ⁇ 3 NE symptoms were somnolence (10%), confusional state (10%), encephalopathy (5%), and aphasia (5%).
  • Revised adverse event management was implemented for patients in a 1 ⁇ 10 6 dose cohort: corticosteroids were at onset of Grade 2 NEs (instead of Grade 3) and tocilizumab was used only for active toxicity. The primary endpoint was the dose-limiting toxicity (DLT) rate. Patients with prior allogeneic SCT>100 days and/or prior blinatumomab were included. The median age was 46 y (range, 18-77); 30 patients (66%) had 3 prior therapies and the median pre-conditioning BM blasts was 70% (range, 0-97). Six, 23, and 16 patients received 2, 1, and 0.5 ⁇ 10 6 cells/kg, respectively. There were no DLTs in the DLT-evaluable pts.
  • R/R LBCL including DLBCL, PMBCL, TFL, and high-grade B cell lymphoma
  • R/R LBCL including DLBCL, PMBCL, TFL, and high-grade B cell lymphoma
  • Corhort 1 Patients receive rituximab (RITUXAN®) 375 mg/m 2 (intravenously) on Day ⁇ 5, and condition chemotherapy with fludarabine 30 mg/m 2 and cyclophosphamide 500 mg/m 2 on day ⁇ 5, ⁇ 4, and ⁇ 3.
  • Patients receive axicabtagene ciloleucel at a target dose of 2 ⁇ 10 6 anti-CD19 CART cells/kg on Day 0.
  • Patients also receive rituximab for 5 additional doses at 28-day intervals after CART cell infusion.
  • Cohort 2 Patients receive lenalidomide 10 mg (REVLIMID®) daily starting 7 days after leukapheresis and continuing through Day 3 after axicabtagene ciloleucel infusion.
  • Condition chemotherapy with fludarabine 30 mg/m 2 and cyclophosphamide 500 mg/m 2 are administered on day ⁇ 5, ⁇ 4, and ⁇ 3.
  • Patients receive axicabtagene ciloleucel at a target dose of 2 ⁇ 10 6 anti-CD19 CART cells/kg on Day 0.
  • the primary outcome measure is Complete Response (CR) Rate CR rate is defined as the incidence of a CR per the Lugano Classification.
  • Secondary Outcome Measures include and not limit to: Percentage of Participants Experiencing Adverse Events; Percentage of Participants Experiencing Clinically Significant Changes in Safety Laboratory Values; Objective Response Rate (ORR, as the incidence of either a CR or a partial response (PR) per the Lugano Classification; Duration of Response (DOR, for participants who experience an objective response and is the time from the first objective response to disease progression per the Lugano Classification; Progression-Free Survival (PFS, as the time from the infusion date to the date of disease progression per Lugano Classification; Overall Survival (OS, as the time from infusion to the date of death; Levels of Axicabtagene Ciloleucel in Blood.
  • Some of the patient selection parameters include: Histologically proven large B-cell lymphoma (including Diffuse large B-cell lymphoma (DLBCL) not otherwise specified, Primary mediastinal large B-cell lymphoma, DLBCL arising from follicular lymphoma, and High-grade B-cell lymphoma); Chemotherapy-refractory disease (including no response to first-line therapy (primary refractory disease), individuals who are intolerant to first-line therapy chemotherapy are excluded, Progressive Disease (PD) as best response to first-line therapy Stable Disease (SD) as best response after at least 4 cycles of first-line therapy (e.g., 4 cycles of RCHOP) with SD duration no longer than 6 months from last dose of therapy), No response to second or greater lines of therapy (including PD as best response to most recent therapy regimen, SD as best response after at least 2 cycles of last line of therapy with SD duration no longer than 6 months from last dose of therapy); Refractory after Autologous stem cell transplant (ASCT)(including disease progression or
  • Growth factor 7 days prior to screening is not allowed to meet ANC eligibility criteria; Platelet count ⁇ 100,000/ ⁇ L. Transfusion 7 days prior to screening is not allowed to meet platelet eligibility criteria; Absolute lymphocyte count ⁇ 100/ ⁇ L; Adequate renal, hepatic, pulmonary, and cardiac function defined as creatinine clearance (as estimated by Cockcroft Gault) ⁇ 60 serum alanine aminotransferase (ALT)/aspartate aminotransferase (AST) ⁇ 2.5 upper limit of normal (ULN), total bilirubin ⁇ 1.5 mg/dL, except in individuals with Gilbert's syndrome, cardiac ejection fraction ⁇ 50% and no evidence of pericardial Effusion, no clinically significant pleural effusion, baseline oxygen saturation >92% on room air; Individuals must be able to comply with the requirements of REVLIMID REMS®.
  • Some of the patient exclusion criteria include: Known CD19 negative or CD20 negative tumor; History of Richter's transformation of Chronic Lymphocytic Leukemia (CLL); Prior lenalidomide or other immunomodulatory imide drug (IMiD) treatment; Prior CAR therapy or other genetically modified T-cell therapy; Hypersensitivity to rituximab; History of severe, immediate hypersensitivity reaction attributed to aminoglycosides; Presence or suspicion of fungal, bacterial, viral, or other infection that is uncontrolled or requiring IV antimicrobials for management, simple urinary tract infection (UTI) and uncomplicated bacterial pharyngitis are permitted if responding to active treatment and after consultation with the sponsor's medical monitor; History of human immunodeficiency virus (HIV) infection or acute or chronic hepatitis B or hepatitis C infection.
  • CLL Chronic Lymphocytic Leukemia
  • IMD immunomodulatory imide drug
  • the anti-CD19 CAR T-cell products used in CD19 CAR-T were manufactured by obtaining leukocytes from the leukapheresis product and enriched by selection for CD4+/CD8+ T cells, activated by culturing with anti-CD3 and anti-CD28 antibodies, and transduced with a retroviral vector containing an anti-CD19 CAR gene.
  • MCL mantle cell lymphoma
  • ibrutinib-refractory stage IV relapsed/refractory pleomorphic mantle cell lymphoma
  • the subject was previously treated with rituximab plus bendamustine (partial remission) with maintenance rituximab (progression), followed by 2 cycles rituximab plus bendamustine (mixed response) with 3 doses maintenance rituximab, approximately 17 cycles of acalabrutinib (complete response followed by progression), and 1 cycle of ibrutinib (progression) which ended 3 weeks prior to leukapheresis. There was no history of prior neurologic disease.
  • the patient Prior to CD19 CAR-T infusion, the patient had an ECOG performance status score of 0, non-bulky disease, and a Ki-67 proliferation index of 80%-90%. Following leukapheresis, the patient received conditioning chemotherapy followed by CD19 CAR-T infusion. Prior to infusion, Prophylactic levetiracetam was initiated and there was no evidence of fever or infection.
  • Grade 1 CRS was observed and treated with tocilizumab (8 mg/kg intravenously (IV)). Vancomycin and aztreonam (each 1 gm IV twice daily) were administered Grade 2 encephalopathy was observed.
  • the subject had leucocytopenia with a white blood cell count of 3.7 K/uL (normal absolute neutrophil count).
  • siltuximab 11 mg/kg IV was used to treat Grade 2 CRS.
  • Methylprednisolone 500 mg IV twice daily was initiated. Some clinical improvement was observed, but subject's condition deteriorated, and a second dose of tocilizumab was administered. Grade 4 encephalopathy was observed.
  • CSF Cerebrospinal fluid
  • EEG showed bihemispheric cortical dysfunction and MRI showed cerebral edema and sulcal hyperintensity.
  • Neurosurgery placed an external ventricular drain to treat the cerebral edema.
  • Prophylactic acyclovir was initiated to mitigate risk of infection.
  • ATG (2 mg/kg/d IV) was administered along with increased methylprednisolone (1 g twice daily) and a third dose of tocilizumab to dampen systemic cytokine storm.
  • an MRI showed stable changes, and a second dose of ATG was given. Improvement in transaminitis was noted.
  • a third dose of ATG was given on Day 8 after which the transaminitis resolved.
  • Over the next 11 days he received tapering doses of methylprednisolone with clinical improvement.
  • the ventricular drain was removed on Day 14 and the encephalopathy was resolved.
  • An MRI on Day 20 showed persistent but significantly improved periventricular white matter T2 hyperintensity and resolution of abnormal signal in the dorsal brainstem/thalami.
  • the patient was discharged to a rehabilitation facility with tapering doses of oral steroids. Two months post-CD19 CAR-T, brain MRI findings were completely resolved. The patient remains on study, and after 24-months follow-up, is in complete remission with no persistent neurologic or cognitive deficits.
  • IL-2 a homeostatic cytokine produced by activated CART cells
  • serum was measured in serum at 16.7 pg/mL on Day 3 and may be associated with CART cell expansion.
  • the median at this same time point in the broader cohort was 4.7 pg/mL (IQR, 2.2-10.0), showing a 3.6-fold increase.
  • Post-ATG Day 7
  • IL-2 was suppressed (below limit of detection in the assay used), indicating a potential impact of ATG on anti-CD19 CAR T-cell activity.
  • Additional serum biomarker analysis post-CD19 CAR-T indicated increased CART cell and myeloid related activity that were controlled.
  • Monocyte chemoattractant protein (MCP-1; CCL2), a marker of myeloid-related activity associated with CD19-directed CAR T-cell toxicity, was 1500 pg/ml (above quantitation limit) at Day 3 (cohort median, 712.3 pg/ml [IQR, 517.6-1142.4]), indicating the possibility of excessive myeloid activity post-infusion as a contributing factor.
  • serum MCP-1 was reduced to 96.9 pg/mL (cohort median, 463.8 [IQR, 271.4-954.1]), further demonstrating the impact of ATG in suppressing myeloid-related inflammation.
  • CXCL10 IFN ⁇ -induced protein 10
  • MCP-1 MCP-1
  • IL-1 receptor antagonist IL-2 receptor alpha
  • Elevated levels of these cytokines in the CSF are consistent with CART cell and myeloid trafficking to the central nervous system (CNS) and may have contributed to the NE.
  • the subject experienced a full recovery with no neurological deficits and achieved a deep and durable response.
  • An improvement in cerebral edema was observed after the administration of ATG, which correlated with an improved transaminitis.
  • the results may lead to revisions in the adverse event management guidelines for NE and CRSS.
  • C1+2 In Cohorts 1+2 (C1+2) of a study of axicabtagene ciloleucel in patients with refractory LBCL, Grade ⁇ 3 cytokine release syndrome (CRS) and neurologic events (NEs) occurred in 11% and 32% of patients, respectively.
  • the objective response rate (ORR) was 83%
  • the complete response (CR) rate was 58%.
  • Eligible patients were leukapheresed, may have receive optional bridging chemotherapy (not allowed in C1+2), and received conditioning chemotherapy (fludarabine and cyclophosphamide) prior to axicabtagene ciloleucel infusion at a target dose of 2 ⁇ 10 6 anti-CD19 CART cells/kg.
  • Patients in C4 received early steroid intervention starting at Grade 1 NE and at Grade 1 CRS when no improvement was observed after 3 days of supportive care.
  • the primary endpoints were incidence and severity of CRS and NE. Additional endpoints were efficacy outcomes and biomarker analyses, including levels of CART cells and inflammatory markers in blood. ORR and CAR T cell levels in C1+2 and 4 were compared across quartiles of tumor burden, the values of which were determined by C1+2.
  • Tumor tissue samples from patients in Cohorts 1 and 2 of the same study described above were analyzed for protein expression of B cell lineage markers (CD19, CD20, PAX5, CD79a, and CD22) by multiplex immunohistochemistry (IHC), followed by multiplex immunofluorescence (IF) staining and confocal microscopy in representative cases.
  • Pretreatment tissue samples were available from 96 patients, and 21 were available post-relapse. Paired pretreatment and post-relapse samples were available for 16 patients.
  • CD19 and CD20 H-scores were derived based on proportion and intensity of antigen expression. Scores of 0-5 were considered negative, and scores of 6-300 were considered positive.
  • CD19 splice variants were assessed by RNA sequencing.
  • RNA sequencing showed alternative splicing of CD19 with loss of exon 2 and/or exons 5/6 in diffuse large B cell lymphoma tumors at baseline and/or relapse, similar to what has been described previously in B cell acute lymphoblastic leukemia.
  • several novel splice junctions have been identified.
  • the correlation between H-scores and CD19 splice forms and clinical outcomes, including response and progression-free survival were analyzed.
  • loss of CD19 expression was common by IHC as compared to pretreatment, which may be related to alternative splicing and selection of variants devoid of target epitope.
  • the data showed that expression of alternate B cell lineage antigens was preserved.
  • CD20 cell surface expression was increased in most tumors despite prior rituximab-based treatments.
  • the median age overall was 61 years, 101 (34%) patients were ⁇ 65 years, and 197 (67%) patients were male.
  • Baseline clinical characteristics included Eastern Cooperative Oncology Group (ECOG) performance score 0-1 (77%), transformed lymphoma (27%), double-hit lymphoma (36%), prior autologous transplant (34%), and chemotherapy-resistant disease (66%) prior to treatment.
  • the median time from diagnosis to infusion was 18 months (range 2-274 months).
  • Overall response rate (ORR) was 70% (complete response [CR] 52% and partial response [PR] 18%).
  • AEs Neurologic adverse events
  • AEs neurologic adverse events
  • axicabtagene ciloleucel infusion were reported in 181 (61%) patients.
  • One patient was reported to die from cerebral edema.
  • the median time to onset of any grade neurologic AEs was 6 days (range, 1-82 days), and 88% resolved by time of data submission with a median duration of 8 days (range, 1 to 105 days).
  • Corticosteroids were used in 56% of patients for treatment.
  • Refractory disease was defined as no response to last chemotherapy, or relapse months post-Autologous Stem Cell Therapy (ASCT). Patients were also required to have an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1 and to have received prior treatment with both an anti-CD20 monoclonal antibody and an anthracycline-containing regimen.
  • DLBCL diffuse large B-cell lymphoma
  • PMBCL primary mediastinal B-cell lymphoma
  • TTL transformed follicular lymphoma
  • Refractory disease was defined as no response to last chemotherapy, or relapse months post-Autologous Stem Cell Therapy (ASCT). Patients were also required to have an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1 and to have received prior treatment with both an anti-CD20 monoclonal antibody and an anthracycline-containing regimen.
  • EOG Eastern Cooperative Oncology Group
  • axicabtagene ciloleucel (2 ⁇ 10 6 CAR T cells/kg). Patients were followed for a minimum of 24 months from the axicabtagene ciloleucel infusion (median follow-up was 27.1 months).
  • AE adverse event
  • CRS cytokine release syndrome
  • SPD sum of product diameter
  • *Shown are most common grade ⁇ 3 AEs that occurred in 25% of either age group.
  • ⁇ Neutropenia included the terms neutropenia, febrile neutropenia, and neutrophil count decreases.
  • Thrombocytopenia included the terms thrombocytopenia and platelet count decreased.
  • ⁇ Symptoms shown are those that occurred in ⁇ 10% of patients in either age group. ⁇ Patients in response as of the data cutoff. Efficacy outcomes were analyzed. For this analysis, there were a total of 24 patients ⁇ 65 years old and 77 patients ⁇ 65 years old.
  • ORRs objective response rates
  • Adverse events are summarized in Table 4.
  • the most common grade ⁇ 3 AEs were cytopenias, which occurred at similar rates in treated patients ⁇ 65 and ⁇ 65 years of age.
  • the most common grade ⁇ 3 cytopenia present on or after post-treatment day 93 was neutropenia, which was reported in 15% and 10% of patients ⁇ 65 and ⁇ 65 years, respectively.
  • Rates of grade ⁇ 3 cytokine release syndrome (CRS) were 7% vs 12%, respectively.
  • Grade ⁇ 3 neurologic events were observed in 44% vs 28%, respectively.
  • axicabtagene ciloleucel induced a high rate of durable responses with a manageable safety profile, regardless of age. No age-related differences in efficacy, pharmacokinetic profile, or safety were observed, suggesting that age alone may not limit axicabtagene ciloleucel use. Overall, axicabtagene ciloleucel showed substantial clinical benefit for older patients with refractory large B-cell lymphoma, a population for whom treatment options are limited. (Nastoupil U, et al.
  • Axicabtagene Ciloleucel (Axi-cel) CD19 Chimeric Antigen Receptor (CAR) T-Cell Therapy for Relapsed/Refractory Large B-Cell Lymphoma: Real World Experience. Blood. 2018; 132(Suppl 1):abstract 91).

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