The EBMT/EHA CAR-T Cell Handbook

123

Nicolaus Kröger

John Gribben

Christian Chabannon

Ibrahim Yakoub-Agha

Hermann Einsele

Editors

The EBMT/EHA

CAR-T Cell

Handbook

The EBMT/EHA CAR-T Cell Handbook

Nicolaus Kröger • John Gribben

Christian Chabannon • Ibrahim Yakoub-Agha

Hermann Einsele

Editors

The EBMT/EHA CAR-T Cell

Handbook

Editors

Nicolaus Kröger

Department of Stem Cell Transplantation

University Medical Center

Hamburg-Eppendorf

Hamburg, Germany

Christian Chabannon

Institut Paoli-Calmettes Comprehensive

Cancer Center

Aix-Marseille Université School of

Medicine

Marseille, France

Hermann Einsele

Department of Internal Medicine II

University Hospital Würzburg

Würzburg, Bayern, Germany

John Gribben

Bart’s Cancer Institute

Queen Mary University of London

London, UK

Ibrahim Yakoub-Agha

Maladies du Sang

Unité de Thérapie Cellulaire

Centre hospitalier-Universitaire de Lille

Lille, France

ISBN 978-3-030-94352-3 ISBN 978-3-030-94353-0 (eBook)

https://doi.org/10.1007/978-3-030-94353-0

Open Access This book is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit

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Preface

Chimeric antigen receptor T cell therapy (CAR-T) is a new class of medicinal prod-

ucts that are genetically engineered from T cells. It is expected that other forms of

Immune Effector Cells-based therapies will soon reach the market, manufactured

from other subsets of immune cells, and engineered through other technologies than

currently used defective retroviral or lentiviral vectors. Cell-based immunotherapies

add to the broader eld of immunotherapies, now populated with monoclonal anti-

bodies including immune checkpoint inhibitors, immune-conjugates, and bi- and

tri-specic antibodies. Approximately 30years after the rst publications reporting

on the development of genetically engineered T cells, expression of a rst genera-

tion chimeric antigen receptor (CAR), and the demonstration of its capability to

recognize antigens in the absence of MHC presentation in the 1980s, the rst com-

mercially available CAR-T cell medicinal products were approved by the FDA and

later by the EMA for the treatment of relapsed/refractory diffuse large B cell lym-

phoma and relapsed/refractory acute lymphoblastic leukemia.

To foster CAR-T cell development and patients’ access to these novel cellular

therapies in Europe, the European Society of Blood and Marrow Transplantation

(EBMT) and the European Hematology Association (EHA) combined forces from

2018—the year of the rst approvals of CAR-T Cells in Europe—by working

closely together in the elds of education, scientic developments, and communica-

tion with health authority and all other stakeholders. It started with the organization

in 2019 of the rst and immediately successful edition of an annual and jointly

organized European CAR-T cell meeting that has become the premier event in the

eld on the European continent. Beyond this major educational initiative, the two

continental professional associations have established the “GoCART-Coalition”

that aims to provide a neutral ecosystem that allows the many interested parties to

communicate and commonly search to solve the many hurdles that the eld is fac-

ing to fully exploit the medical value of these innovative therapies.

In line with this collaboration, the EBMT/EHA Handbook “CAR-T cell ther-

apy”—of which you read the rst edition—was developed. The aim of this hand-

book is to provide the state-of-the-art information on ongoing scientic developments

and medical practices in the eld of CAR-T cell therapies, to enhance knowledge

and practice skills for all categories of healthcare professionals and scientists.

EBMT and EHA want to express their gratitude to the enormous effort of all

authors in planning and writing the different chapters and especially Isabel Sánchez-

Ortega and Francesco Cerisoli for their continuous and tireless support.

On behalf of EBMT and EHA, we hope this CAR-T cell handbook will be help-

ful in your daily practice.

Hamburg, Germany NicolausKröger

London, UK JohnGribben

Marseille, France ChristianChabannon

Lille, France IbrahimYakoub-Agha

Würzburg, Germany HermannEinsele

Preface

vii

Part I The Science Behind CAR-T Cells

1 Structure of and Signalling Through Chimeric Antigen Receptor . . . 3

Christian Chabannon and Chiara Bonini

2 Genetic Engineering of Autologous or Allogeneic Immune

Effector Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Karim Benabdellah, Simone Thomas, and Hinrich Abken

3 What Defines a Good Tumour Antigen? . . . . . . . . . . . . . . . . . . . . . . . . . 11

Emma C. Morris and J. H. F. (Fred) Falkenburg

4 Tumour Escape from CAR-T Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Leo Rasche, Luca Vago, and Tuna Mutis

5 CART Initiatives in Europe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Alvaro Urbano-Ispizua and Michael Hudecek

Part II Manufacturing CAR-T Cells: The Supply Chain

6 Providing the Starting Material to the Manufacturer

of an Approved and Commercially Available Autologous

CAR-T Cell Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Halvard Bonig, Christian Chabannon, and Miquel Lozano

7 Receiving, Handling, Storage, Thawing, Distribution,

and Administration of CAR-T Cells Shipped from the

Manufacturing Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Catherine Rioufol and Christian Wichmann

8 Point-of-Care Production of CAR-T Cells . . . . . . . . . . . . . . . . . . . . . . . 45

Julio Delgado, Claire Roddie, and Michael Schmitt

9 Off-the-Shelf Allogeneic CAR-T Cells or Other Immune

Effector Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Stephane Depil and Waseem Qasim

Contents

viii

Part III Clinical Indications for CAR-T Cells

10 Paediatric Acute Lymphoblastic Leukaemia (ALL) . . . . . . . . . . . . . . . 57

Peter Bader, Franco Locatelli, and Christina Peters

11 Adult Acute Lymphoblastic Leukaemia . . . . . . . . . . . . . . . . . . . . . . . . . 61

Elad Jacoby, Nicola Gökbuget, and Arnon Nagler

12 Diffuse Large B Cell Lymphoma and Primary Mediastinal

Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Bertram Glass and Marie José Kersten

13 Mantle Cell Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Noel Milpied and Martin Dreyling

14 Chronic Lymphocytic Leukaemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Olivier Tournilhac and Peter Dreger

15 Indolent Lymphomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Franck Morschhauser and Pier Luigi Zinzani

16 Multiple Myeloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Ibrahim Yakoub-Agha and Hermann Einsele

17 Developments in Other Haematological Malignancies:

Other Lymphoid Malignancies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Paolo Corradini and Lorenz Trümper

18 Myeloid Malignancies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Christophe Ferrand and Alessandro Rambaldi

19 Developments in Solid Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Paolo Pedrazzoli and John B. A. G. Haanen

Part IV Clinical Management of Patients Treated with CAR-T Cells

20 Bridging Chemotherapy: Adult Acute Lymphoblastic Leukaemia . . . 111

Nicolas Boissel and Fabio Ciceri

21 Bridging to CAR-T Cells in Children, Adolescents,

and Young Adults with ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

André Baruchel

22 Bridging Chemotherapy: Relapsed/Refractory

Aggressive B-Cell Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Catherine Thieblemont and Peter Borchmann

23 Bridging Chemotherapy: Follicular Lymphoma,

Mantle Cell Lymphoma, and CLL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

Nico Gagelmann, John Gribben, and Nicolaus Kröger

Contents

24 Bridging Chemotherapy: Multiple Myeloma . . . . . . . . . . . . . . . . . . . . . 127

Salomon Manier, Artur Jurczyszyn, and David H. Vesole

25 Lymphodepleting Conditioning Regimens . . . . . . . . . . . . . . . . . . . . . . . 131

Mohamad Mohty and Monique C. Minnema

26 Management of Cytokine Release Syndrome (CRS) and HLH . . . . . . 135

Francis Ayuk Ayuketang and Ulrich Jäger

27 Management of Immune Effector Cell- Associated

Neurotoxicity Syndrome (ICANS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Jeremy H. Rees

28 Management of Hypogammaglobulinaemia and B-Cell Aplasia . . . . . 147

Max Topp and Tobias Feuchtinger

29 Management of Myelotoxicity (Aplasia) and Infectious

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

Marion Subklewe and Reuben Benjamin

30 Management of Other Toxicities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

Hermann Einsele and Ibrahim Yakoub-Agha

31 ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

Udo Holtick and Elie Azoulay

32 Post-CAR-T Cell Therapy (Consolidation and Relapse):

Acute Lymphoblastic Leukaemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

Jordan Gauthier

33 Post-CAR-T Cell Therapy (Consolidation and Relapse):

Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Didier Blaise and Sabine Fürst

34 Post-CAR-T Cell Therapy (Consolidation and Relapse):

Multiple Myeloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

Paula Rodríguez-Otero and Jesús F. San Miguel

35 Immune Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

Susanna Carolina Berger, Boris Fehse, and Marie-Thérèse Rubio

36 Long-Term Follow-Up and Late Effects . . . . . . . . . . . . . . . . . . . . . . . . . 183

Patrick Hayden, Nico Gagelmann, and John Snowden

Part V Access to CAR-T Cells

37 The Regulatory Framework for CAR-T Cells in Europe:

Current Status and Foreseeable Changes AND Centre

Qualification by Competent Authorities and Manufacturers . . . . . . . . 191

Eoin McGrath and Petr Machalik

Contents

38 How Can Accreditation Bodies, Such as JACIE

or FACT, Support Centres in Getting Qualified? . . . . . . . . . . . . . . . . . 199

Riccardo Saccardi and Fermin Sanchez-Guijo

39 Educational Needs for Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

Nicolaus Kröger, John Gribben, and Isabel Sánchez-Ortega

40 Education Needs for Nurses in Adult and Paediatric Units . . . . . . . . . 207

Michelle Kenyon, John Murray, Rose Ellard, and Daphna Hutt

41 Role of Pharmacists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Margherita Galassi and Maria Estela Moreno-Martínez

42 Educational Needs for Cell Processing Facility Personnel . . . . . . . . . . 219

Boris Calmels

43 GoCART . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

Soe R. Terwel, Jürgen Kuball, Martin Dreyling,

and Francesco Cerisoli

44 Patient Referral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

John Snowden and Rafael F. Duarte

45 Treatment Coverage and Reimbursement . . . . . . . . . . . . . . . . . . . . . . . 229

Cornelie Haag

46 The Value of CAR-T-cell Immunotherapy in Cancer . . . . . . . . . . . . . . 231

Mohamed Abou-el-Enein and Jordan Gauthier

47 What do Patients Want? The Importance of Patient-reported

Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

Hélène Schoemans, Natacha Bolaños, and Lorna Warwick

Contents

Part I

The Science Behind CAR-T Cells

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_1

C. Chabannon (*)

Institut Paoli-Calmettes, Centre de Lutte Contre le Cancer, Centre d’Investigations Cliniques

en Biothérapie, Université d’Aix-Marseille, Inserm CBT-1409, Marseille, France

e-mail: CHAB[email protected].fr

C. Bonini

Experimental Hematology Unit, Division of Immunology, Transplantation and Infectious

Diseases, Vita-Salute San Raffaele University, IRCCS Ospedale San Raffaele Scientic

Institute, Milan, Italy

e-mail: bonini.chiara@hsr.it

Structure ofandSignalling Through

Chimeric Antigen Receptor

ChristianChabannon

andChiaraBonini

Chimeric antigen receptor (CAR) is a synthetic transmembrane protein expressed at

the surface of immune effector cells (IECs) that are reprogrammed either invitro or

invivo (June etal. 2018; June and Sadelain 2018). Techniques for genetic engineering

of autologous or allogeneic IECs are described in the next chapter. The synthetic CAR

incorporates several functional domains. The extracellular domain is composed of a

single chain variable fragment (ScFV) of immunoglobulin and recognizes the

“tumour” antigen. The clinical relevance of the selected tumour antigen—with a view

to minimize “on-target/off-tumour” side effects—is discussed in the third chapter of

this section. Bispecic and trispecic CARs are currently being evaluated in preclini-

cal and early clinical trials (Bielamowicz etal. 2018; Shah etal. 2020). The use of an

immunoglobulin domain as the ligand of the target antigen means that recognition is

not restricted to HLA antigens and that CAR-T cells are universally applicable as

opposed to T cell receptor (TCR) transgenic T cells that recognize antigenic peptides

presented in the context of a dened major histocompatibility complex (MHC), limit-

ing clinical applications to subsets of patients with dened HLA typing. The intracel-

lular domain is composed of the intracellular domain of the zeta chain of the CD3

component of the TCR, which will trigger signalling when the CAR engages the tar-

geted ligand. The transmembrane region links the two extracellular and intracellular

domains through the cell membrane and plays an important role in determining the

conformation and exibility of the CAR and its ability to efciently bind the targeted

antigen/epitope. Association of only these three functional domains characterized rst

generation CARs, as described in the original publications (Kuwana et al. 1987;

Eshhar etal. 1993). However, full activation of T cells requires the addition of one

(second generation CARs) or two (third generation CARs) domains from costimula-

tory molecules, such as CD28, 4-1BB/CD137, or OX40/CD134, that provide the T

cell costimulatory signal. Currently approved CAR-T cells are second generation

CAR-T cells; as an illustration, the CAR in tisagenlecleucel contains a 4-1BB domain,

while the CAR in axicabtagene ciloleucel contains a CD28 domain. The nature of the

costimulatory domain inuences the ability of CAR-T cells to expand or persist (limit

T cell exhaustion) invivo after infusion into the patient, although it is unclear how this

translates clinically and affects disease control, occurrence of adverse events, and

overall survival due to the lack of head-to-head comparison between approved prod-

ucts. Finally, fourth generation CAR-T cells have been developed for preclinical proj-

ects. These cells, named armoured CAR cells or T cells redirected for universal

cytokine-mediated killing (TRUCKS), encode not only a CAR (usually with one

costimulatory domain, such as in second generation CARs) but also a cytokine, inter-

leukin, pro-inammatory ligand, or chemokine that will counteract the immune sup-

pressive microenvironment that prevails in most solid tumours (Eshhar etal. 1993;

Chmielewski and Abken 2015).

When the CAR engages its ligand, signalling involves several components of the

naturally occurring TCR.These include molecules such as lymphocyte-specic pro-

tein tyrosine kinase (LCK). Some components of the signalling cascade are actionable

with existing drugs, which offers opportunities for pharmacologic modulation of

CAR activity invivo, such as described with tyrosine kinase inhibitors (Mestermann

etal. 2019; Weber etal. 2019); this represents an appealing alternative to the inclusion

of a suicide gene in the CAR construct (Casucci etal. 2013; Gargett and Brown 2014;

Sakemura etal. 2016). Synthetic biology applied to the CAR-T cell eld led to engi-

neering of combinatorial antigen recognition constructs. The “OR” gate strategy (i.e.,

CD19 and CD22) allows CAR-T cell activation upon recognition of at least 1 of the 2

targeted antigens, thus reducing the risk of cancer immune evasion. The “OR” and

“NOT” gate strategies are designed to improve the safety prole of CAR-T cells, since

tumour cells and healthy cells can be discriminated by CAR-T cells based on the

expression pattern of 2 antigens (Weber etal. 2020).

Key Points

• A chimeric antigen receptor is a synthetic transmembrane molecule

encoded by a DNA sequence that combines domains from immunoglobu-

lins, one chain of the T cell receptor, and typically domains from costimu-

latory molecules involved in T cell activation.

• Currently approved and commercially available CAR-T cells are second

generation CAR-T cells that contain a single costimulatory domain.

• The machinery for cell signalling contains actionable elements, thus offer-

ing opportunities for invivo modulation of CAR-T cell activities and miti-

gation of adverse events.

C. Chabannon and C. Bonini

References

Bielamowicz K, Fousek K, Byrd TT, Samaha H, Mukherjee M, Aware N, et al. Trivalent

CAR-T cells overcome interpatient antigenic variability in glioblastoma. Neuro-Oncology.

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targeted T cells mediate potent antitumor effects against acute myeloid leukemia and multiple

myeloma. Blood. 2013;122(20):3461–72.

Chmielewski M, Abken H. TRUCKs: the fourth generation of CARs. Expert Opin Biol Ther.

2015;15(8):1145–54.

Eshhar Z, Waks T, Gross G, Schindler DG.Specic activation and targeting of cytotoxic lym-

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gamma or zeta subunits of the immunoglobulin and T-cell receptors. Proc Natl Acad Sci U S

A. 1993;90(2):720–4.

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Kuwana Y, Asakura Y, Utsunomiya N, Nakanishi M, Arata Y, Itoh S, etal. Expression of chime-

ric receptor composed of immunoglobulin-derived V regions and T-cell receptor-derived C

regions. Biochem Biophys Res Commun. 1987;149(3):960–8.

Mestermann K, Giavridis T, Weber J, Rydzek J, Frenz S, Nerreter T, et al. The tyrosine kinase

inhibitor dasatinib acts as a pharmacologic on/off switch for CAR-T cells. Sci Transl Med.

2019;11(499):eaau5907.

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Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

1 Structure ofandSignalling Through Chimeric Antigen Receptor

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_2

K. Benabdellah

Centre for Genomics and Oncological Research (GENYO), Genomic Medicine Department,

Pzer-University of Granada-Andalusian Regional Government, Granada, Spain

e-mail: [email protected]

S. Thomas

Department of Genetic Immunotherapy, Regensburg Center for Interventional Immunology,

Regensburg, Germany

Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany

e-mail: [email protected]urg.de

H. Abken (

Department of Genetic Immunotherapy, Regensburg Center for Interventional Immunology,

Regensburg, Germany

e-mail: hinrich.abken@ukr.de

Genetic Engineering ofAutologous

orAllogeneic Immune Effector Cells

KarimBenabdellah, SimoneThomas, andHinrichAbken

Manufacturing immune effector cells (T or NK cells) with CAR-encoding DNA

sequences requires efcient and safe genetic engineering procedures. For this pur-

pose, an appropriate genetic vector is chosen according to numerous factors, includ-

ing the vector genome packaging capacity, cellular tropism, genomic integration,

immune toxicity, and other factors. In clinical trials, genomes integrating viral vec-

tors, in particular vectors based on members of the Retroviridae family, such as

retroviruses and lentiviruses, have been successfully used for more than 20years.

These vectors contain an RNA genome that when transcribed into double-stranded

DNA by reverse transcriptase integrates into the genome of the transduced cell.

Several precautions are taken to ensure the safe use of such integrating vectors.

First, the viral genome is split into three different expression constructs to reduce

the risk of recombination events re-establishing replication-competent viruses.

Second, long terminal repeats (LTRs) with their enhancer/promoter sequences are

deleted, resulting in self-inactivated (SIN) vectors to avoid transactivation of cellu-

lar genes in the vicinity of the viral integration site. Third, the viral envelope is

pseudotyped with heterologous glycoproteins, such as gibbon ape leukaemia virus

(GALV) or vesicular stomatitis virus (VSV)-G protein, to restrict the cell tropism

for transduction. The viral vectors have undergone generations of modications and

are classied according to their packaging plasmid. During manufacturing, the use

of transduction enhancers, including cationic polymers, lipids, and peptides, such as

Retronectin or Vectofusin-1, which is a histidine-rich cationic amphipathic short

peptide (Jamali etal. 2019), improves the transduction efciencies.

Retroviral vectors modied with the LTRs of the myeloproliferative sarcoma

virus and an improved 5′ untranslated region, named MP71 retroviral vectors, can

achieve high transduction efciencies in human T cells. While retroviral vectors

require actively dividing cells for integration, lentiviral vectors have the capacity to

transduce nondividing or slowly proliferating cells and are currently increasingly

used for genetic modication of T cells in clinical trials. Cycling T cells can ef-

ciently complete the reverse transcription process of the viral vector, facilitate

nuclear import, and enhance the expression of the transgene. Obtaining high virus

titres and ultimately sufcient transduction frequencies for production of CAR-T

cells on a clinical scale and preserving the T cell phenotype and functional proper-

ties after transduction remain a challenge. Despite vector integration into the host

genome, T cells have a negligible risk of transformation; thus far, no leukaemia has

been observed in T cell-based therapy.

Alternatively, articial virus-like particles (VLPs) pseudotyped with VSV-G can

be used for transfer into haematopoietic cells (Mangeot etal. 2019). DNA packed

into transposon vectors, such as sleeping beauty and piggyBac, are transferred to T

cells via electroporation (Kebriaei etal. 2016). Transposon-based genetic engineer-

ing does not require time-consuming and cost-intensive virus production and is

increasingly considered for clinical manufacture of CAR-T cells.

In contrast to integrating DNA transfer technologies, mRNA transfer via electro-

poration or cationic lipid-mediated transfection produces T cells with transient

CAR expression for a few days (Miliotou and Papadopoulou 2020). Such transient

CAR-T cell approaches have been investigated and found to produce antitumour

reactivity for a limited time to avoid any undesirable effects in patients; however,

very few clinical trials using RNA-modied CAR-T cells have been registered.

Genome editing is an upcoming tool to engineer CAR-T cells using specic

endonucleases, including meganucleases (MGNs), transcription activator-like

effector nucleases (TALENs), megaTAL nucleases, zinc-nger nucleases

(ZFNs) and, more recently, clustered regularly interspaced short palindromic

repeat (CRISPR)-Cas9-associated nucleases (Pavlovic etal. 2020). These tech-

nologies allow insertion of a specic DNA sequence at a predened emplace-

ment, such as endogenous genetic locus. While efciently applied in

haematopoietic or mesenchymal stem cell modication for years, genome edit-

ing in primary T cells has only recently been successfully applied towards ef-

cient CAR-T cell engineering. Examples for potential clinical application are

targeting the respective genes for programmed cell death-1 (PD1, CD279), T

cell receptor (TCR) α and β chains, CD52, human leukocyte antigens (HLAs),

and β2-microglobulin (β2M).

K. Benabdellah et al.

One major application of genome editing is creating “off-the-shelf” alloge-

neic CAR-T cells to avoid certain limitations associated with autologous T cells,

such as the personalized production process, the several weeks of time required

for manufacturing, and the risk of manufacturing failure. Such allogeneic CAR-T

cells were engineered by genetically eliminating the TCRα constant (TRAC)

locus and/or HLA from the T cell surface, reducing the risk of graft versus host

disease (GvHD) and allograft rejection. In particular, Torikai et al. combined

sleeping beauty transposon- based gene transfer with ZFN-mediated deletion of

TCR α and β chains (Torikai etal. 2012); subsequent approaches also eliminated

the endogenous TCR (Roth etal. 2018; Legut etal. 2018; Osborn etal. 2016).

TALEN-mediated TRAC/CD52 knockout of CD19-specic CAR-T cells

(UCART19) was administered to two patients with relapsed ALL in a proof-of-

concept study, and no GvHD was reported (Qasim etal. 2017). Several approaches

using ZFNs and CRISPR/Cas9, including base editing variants, were used to

eliminate HLA class I expression by targeting β2M (Webber et al. 2019) and

eliminating the HLA class II transactivator CIITA (Kagoya et al. 2020), all

reducing the risk of allogeneic CAR-T cell rejection. To reduce GvHD and frat-

ricide, the CD7 locus was disrupted along with TCRα editing (Gomes-Silva etal.

2017). Eliminating the gene for the TGF-β receptor or PD-1 enhanced CAR-T

cell antitumour potency by reducing repression by the tumour stroma (Tang

etal. 2020).

Genome editing has also been used to insert the CAR-encoding DNA sequence

into the TCR α locus (Eyquem etal. 2017), thereby utilizing the TCR expression

machinery for properly regulated CAR expression. Similarly, CAR-encoding DNA

was inserted into the TCR α locus, and IL-12-encoding DNA was inserted into the

IL2Rα or PDCD1 locus, resulting in CAR-redirected T cell activation along with

IL-12 secretion (Sachdeva etal. 2019). Such genome editing approaches can be

applied to target other signalling pathways to engineer CAR-T cells with therapeu-

tic outputs in a highly regulated manner. Currently, most of these editing technolo-

gies are being explored in mouse models or in a very limited number of patients,

making it difcult to draw a denitive conclusion concerning safety and efcacy in

the long term.

Key Points

• Lentiviral gene transfer is the most frequently applied procedure to engi-

neer CAR-T cells for clinical use.

• Nonviral transposon-mediated DNA transfer is an upcoming technology to

obtain CAR-T cells.

• Allogeneic “off-the-shelf” CAR-T cells are engineered by genetically

eliminating the TCRα constant (TRAC) locus and/or HLA from the T cell

surface, reducing the risk of graft versus host disease (GvHD) and allograft

rejection.

2 Genetic Engineering ofAutologous orAllogeneic Immune Eector Cells

References

Eyquem J, Mansilla-Soto J, Giavridis T, etal. Targeting a CAR-T o the TRAC locus with CRISPR/

Cas9 enhances tumour rejection. Nature. 2017;543:113–7.

Gomes-Silva D, Srinivasan M, Sharma S, etal. CD7-edited T cells expressing a CD7-specic CAR

for the therapy of T-cell malignancies. Blood. 2017;130:285–96.

Jamali A, Kapitza L, Schaser T, etal. Highly efcient and selective CAR-gene transfer using CD4-

and CD8-targeted lentiviral vectors. Mol Ther Methods Clin Dev. 2019;13:371–9.

Kagoya Y, Guo T, Yeung B, etal. Genetic ablation of HLA class I, class II, and the T-cell recep-

tor enables allogeneic T cells to be used for adoptive T-cell therapy. Cancer Immunol Res.

2020;8:926–36.

Kebriaei P, Singh H, Huls MH, etal. Phase I trials using sleeping beauty to generate CD19-specic

CAR-T cells. J Clin Invest. 2016;126:3363–76.

Legut M, Dolton G, Mian AA, etal. CRISPR-mediated TCR replacement generates superior anti-

cancer transgenic T cells. Blood. 2018;131:311–22.

Mangeot PE, Risson V, Fusil F, etal. Genome editing in primary cells and invivo using viral-

derived nanoblades loaded with Cas9-sgRNA ribonucleoproteins. Nat Commun. 2019;10:45.

Miliotou AN, Papadopoulou LC.In vitro-transcribed (IVT)-mRNA CAR-T therapy development.

Methods Mol Biol. 2020;2086:87–117.

Osborn MJ, Webber BR, Knipping F, etal. Evaluation of TCR gene editing achieved by TALENs,

CRISPR/Cas9, and megaTAL nucleases. Mol Ther. 2016;24:570–81.

Pavlovic K, Tristán-Manzano M, Maldonado-Pérez N, etal. Using gene editing approaches to ne-

tune the immune system. Front Immunol. 2020;11:570672.

Qasim W, Zhan H, Samarasinghe S, etal. Molecular remission of infant B-ALL after infusion of

universal TALEN gene-edited CAR-T cells. Sci Transl Med. 2017;9:eaaj2013.

Roth TL, Puig-Saus C, Yu R, etal. Reprogramming human T cell function and specicity with

non-viral genome targeting. Nature. 2018;559:405–9.

Sachdeva M, Busser BW, Temburni S, etal. Repurposing endogenous immune pathways to tailor

and control chimeric antigen receptor T cell functionality. Nat Commun. 2019;10:5100.

Tang N, Cheng C, Zhang X, etal. TGF-beta inhibition via CRISPR promotes the long-term ef-

cacy of CAR-T cells against solid tumors. JCI Insight. 2020;5:e133977.

Torikai H, Reik A, Liu PQ, etal. A foundation for universal T-cell based immunotherapy: T cells

engineered to express a CD19-specic chimeric-antigen-receptor and eliminate expression of

endogenous TCR.Blood. 2012;119:5697–705.

Webber BR, Lonetree CL, Kluesner MG, etal. Highly efcient multiplex human T cell engineer-

ing without double-strand breaks using Cas9 base editors. Nat Commun. 2019;10:5222.

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

K. Benabdellah et al.

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_3

E. C. Morris (*)

Institute of Immunity and Transplantation, University College London, London, UK

e-mail: [email protected]

J. H. F. (Fred) Falkenburg

Leiden University Medical Center, Leiden, The Netherlands

e-mail: j.h.falkenb[email protected]

What Defines aGood Tumour Antigen?

EmmaC.Morris andJ.H.F.(Fred)Falkenburg

Compared to standard anticancer therapies, such as chemotherapy, small molecule

inhibitors and radiation, T cell immunotherapies have the advantages of a high

degree of specicity and durability of response typically associated with cellular

therapies. The functional specicity of a T cell is determined by its antigen recogni-

tion receptor and the target antigen (Bjorkman etal. 1987; Garcia etal. 1996).

The majority of CAR-T cells currently applied in clinical practice do not recog-

nize tumour-specic target antigens but pan-B cell antigens (CD19, CD20, CD22)

or maturation antigens (e.g., BCMA), which are abundantly expressed cell surface

molecules on both malignant and normal cells (Sadelain et al. 2017; June and

Sadelain 2018). In reality, these are only ‘ideal’ or ‘good’ tumour antigens because

the depletion of normal B cells is generally well tolerated. In contrast to endogenous

T cell receptors (TCRs), which are HLA-restricted and recognize peptide-MHC

complexes on the target cell surface, CARs recognize extracellular, membrane-

bound targets. These are typically nonpolymorphic proteins or glycoproteins. This

is advantageous over TCR-mediated recognition because CAR-T cell therapies are

not limited by patient HLA type.

What denes a ‘good’ tumour antigen for recognition by a CAR-T cell?

1. Extracellular expression (i.e., expressed on the cell surface and readily accessible)

2. Uniform or consistent expression on all malignant cells

3. Not subject to downregulation or deletion (i.e., no escape variants). This only

occurs if the antigen is a molecule critical for maintenance of the malignant

population

4. Should be expressed on malignant stem cells, and

5. Should not be expressed on normal tissue cells, at least not in nonessential nor-

mal tissues (i.e., tumour specic).

Tumour-Specific Antigens (TSAs)

TSAs are highly specic and typically result from genetic mutations within malig-

nant cells that give rise to neoantigens not present in untransformed (nonmalignant)

cells (Schumacher and Schreiber 2015; Schumacher et al. 2019). By denition,

there is a low likelihood of ‘on-target off-tumour’ toxicity because the tumour anti-

gen is not expressed on normal cells. ‘On-target on-tumour’ toxicities and ‘off-

target off-tumour’ toxicities may occur as a result of CRS or receptor cross-reactivity.

Unfortunately, no nonpolymorphic tumour-specic extracellular target antigens are

known. The only highly specic extracellular tumour target antigens are neopep-

tides presented in the context of (polymorphic) HLA molecules.

Multiple Tumour Antigens Resulting

ina‘Tumour-Specific Phenotype’

Recent studies have demonstrated that simultaneous targeting of two or more target

antigens may improve tumour specicity and reduce the risk of antigen escape

(Shah etal. 2020; Dai etal. 2020). In such cases, one target antigen may be lineage-

specic but not tumour specic, but the combination may be tumour specic. For

CAR-T cells to be fully activated, the target cell must express both target antigens

(i.e., combined antigen expression). This approach is not expected to ameliorate the

risk of CRS, and it is difcult to estimate the risk of ‘on-target off-tumour’ toxicity,

which will depend on the ability of CAR-T cells to discriminate between cells with

combined or single antigen expression. In this case, there would be a potential risk

of ‘off-target off-tumour’ toxicity for single antigens (expression of a single antigen

in normal cells or aberrant antigen expression in normal cells).

Lineage-Specific andDifferentiation Antigens

These antigens are commonly targeted by CAR-T cells and include CD19, CD20,

CD22, and BCMA, which are B cell lineage antigens. Lineage-specic antigens can

be optimal targets in the case of tumours associated with cell lineages and/or tissues

that are nonredundant or temporarily replaceable, such as the B cell lineage, plasma

cells, and thyroid, prostate, and ovarian cells. In these circumstances, their function

can be rescued by a second therapeutic intervention. For example, profound B cell

lymphopenia following CD19 CAR-T cell therapy can result in hypogammaglobu-

linaemia and absent or impaired vaccine responses, requiring long-term immuno-

globulin replacement therapy. More recent developments aimed at generating

E. C. Morris and J. H. F. (Fred) Falkenburg

CAR-T cells for treatment of AML and other myeloid malignancies target lineage-

specic and differentiation antigens (i.e., CD33 and CD123) but risk profound cyto-

penia or bone marrow aplasia and depend on the ability to subsequently replace

haematopoietic stem cells and myeloid precursors (Gill etal. 2014). Recent pre-

clinical studies have attempted to ne-tune CAR-T cell responses through the incor-

poration of safety switch mechanisms (Loff etal. 2020). In the case of lineage-specic

antigens, ‘on-target off-tumour’ toxicity is common, resulting in depletion of spe-

cic cell lineages or other cells in the case of aberrant antigen expression. CRS may

be common, due in part to wide antigen expression in both normal and malig-

nant cells.

Lineage-Specific Polymorphic/Heterogeneic Antigens

These target antigens are similar to lineage-specic antigens (above) with the

advantage that only part of the system is eliminated (following CAR-T cell target-

ing) due to intrinsic heterogeneity or antigen expression. Examples include target-

ing immunoglobulin subclasses or kappa versus lambda light chains in association

with immunoglobulin receptors.

References

Bjorkman PJ, Saper MA, Samraoui B, et al. Structure of the human class I histocompatibility

antigen, HLA-A2. Nature. 1987;329(6139):506–12.

Dai H, Wu Z, Jia H, etal. Bispecic CAR-T cells targeting both CD19 and CD22 for therapy

of adults with relapsed or refractory B cell acute lymphoblastic leukemia. J Hematol Oncol.

2020;13(1):30.

Garcia KC, Degano M, Staneld RL, etal. An alphabeta T cell receptor structure at 2.5 A and its

orientation in the TCR-MHC complex. Science. 1996;274(5285):209–19.

Gill S, Tasian SK, Ruella M, etal. Preclinical targeting of human acute myeloid leukemia and

myeloablation using chimeric antigen receptor-modied T cells. Blood. 2014;123:2343–54.

June CH, Sadelain M.Chimeric antigen receptor therapy. N Engl J Med. 2018;379:64–73.

Loff S, Dietrich J, Meyer JE, etal. Rapidly switchable universal CAR-T cells for treatment of

CD123-positive leukemia. Mol Ther Oncolytics. 2020;17:408–20.

Sadelain M, Rivière I, Riddell S.Therapeutic T cell engineering. Nature. 2017;545:423–31.

Key Points

1. Most CAR-T cells and all currently approved products target lineage-

specic antigens.

2. This results in loss of nonmalignant cells that also express these antigens

(e.g., normal B cells).

3. With commercially available CAR-T products, these side effects are man-

ageable but may be more limiting with other novel targets under

development.

3 What Denes aGood Tumour Antigen?

Schumacher TN, Schreiber RD.Neoantigens in cancer immunotherapy. Science. 2015;348:69–74.

Schumacher TN, Scheper W, Kvistborg P.Annu Rev Immunol. 2019;37:172–200.

Shah NN, Johnson BD, Schneider D, et al. Bispecic anti-CD20, anti-CD19 CAR-T cells

for relapsed B cell malignancies: a phase 1 dose escalation and expansion trial. Nat Med.

2020;26(10):1569–75.

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

E. C. Morris and J. H. F. (Fred) Falkenburg

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_4

L. Rasche

Department of Internal Medicine 2, University Hospital of Würzburg, Würzburg, Germany

Mildred Scheel Early Career Center, University Hospital of Würzburg, Würzburg, Germany

e-mail: rasche_l@ukw.de

L. Vago

Vita-Salute San Raffaele University, Milan, Italy

Unit of Immunogenetics, Leukemia Genomics and Immunobiology, IRCCS San Raffaele

Scientic Institute, Milan, Italy

e-mail: vago.luca@hsr.it

T. Mutis (

Department of Hematology, Amsterdam University Medical Centers, Location VUmc,

Amsterdam, The Netherlands

e-mail: [email protected]

Tumour Escape fromCAR-T Cells

LeoRasche, LucaVago, andTunaMutis

Over the past decade, CAR-T cells have emerged as one of the most powerful cel-

lular immune therapy approaches in the battle against haematological malignancies.

Nonetheless, similar to other immunotherapeutic approaches, tumour cells develop

strategies to evade CAR-T cell therapy, often with the support of a highly immuno-

suppressive and protective tumour microenvironment. To date, antigen loss, immune

dysfunction, exhaustion and (microenvironment-mediated) upregulation of anti-

apoptotic pathways have been identied as major modes of tumour escape from

CAR-T cell therapy. This chapter will focus on our current understanding of these

modes of immune escape from CAR-T cells.

Leo Rasche, Luca Vago and Tuna Mutis contributed equally with all other contributors.

Immune Escape andCAR-T Cell Resistance Related

toAntigen Loss

Antigen loss represents the ultimate adaptation of a cancer cell to the selective pres-

sure of targeted immunotherapy. While antigen downregulation or dim expression is

a well-known event in lymphoma and myeloma treated with therapeutic IgG anti-

bodies (Plesner etal. 2020; Jilani etal. 2003), complete target loss is a phenomenon

typically occurring after T-cell-based therapy, such as CAR-T cell or T cell engag-

ing bispecic antibodies (TCE) therapy, and rarely after treatment with antibody-

drug conjugates (ADCs).

In B cell malignancies, CD19 loss has been noted in up to 40% of patients with

B cell acute lymphoblastic leukaemia treated with different CAR 19 products

(Orlando etal. 2018). Point mutations in CD19 have been described to lead to

nonfunctional anchoring of the CD19 protein to the cell membrane and conse-

quently to a loss of surface antigen (Orlando etal. 2018). Deleterious mutations

and alternatively spliced CD19 mRNA variants were identied in two other stud-

ies (Asnani etal. 2020; Sotillo etal. 2015). In B-ALL with rearrangement of the

mixed lineage leukaemia (MLL) gene, some patients relapsed with clonally

related acute myeloid leukaemia after treatment with CD19 CAR-T cells, adding

a switch to a CD19- negative myeloid phenotype as another mechanism of resis-

tance (Gardner etal. 2016). In DLBCL, the frequency of CD19 loss after CAR19

axicabtagene ciloleucel (axi-cel) treatment was 33% (Neelapu etal. 2017; Neelapu

etal. 2019), and alternatively spliced CD19 mRNA species could be identied. In

follicular lymphoma and DLBCL treated with CD20 X CD3 bispecic TCE,

CD20 loss relapses were seen, but the frequency is yet to be reported (Bannerji

etal. 2018). Furthermore, a single case of CD22 loss was described after ADC

inotuzumab-ozogamicin treatment in a paediatric patient with B-ALL (Paul etal.

2019). Taken together, antigen loss is a key mechanism of resistance to novel

immunotherapies targeting CD19, CD20, and CD22. In myeloma, downregula-

tion of BCMA was recorded in a signicant proportion of patients following

BCMA CAR-T therapy, but intensity increased back towards baseline in almost

all patients (Cohen etal. 2019). However, three case reports described irreversible

BCMA loss after anti-BCMA CAR-T cell treatment (Da Via etal. 2021; Samur

etal. 2020; Leblay etal. 2020). In two of these cases, homozygous BCMA gene

deletions were identied as the biological underpinning of antigen loss. In the

third case, the authors found a heterozygous BCMA deletion together with a

BCMA mutation, leading to antigen loss. In summary, biallelic events impacting

the BCMA locus represent one molecular mechanism of antigen loss after BCMA

CAR-T therapy. However, these events seem to be rare. In the KarMMa trial, only

4% of patients relapsed without an increase in soluble BCMA, which is thought

to be a biomarker of this type of resistance (Munshi etal. 2021). Heterozygous

BCMA deletions, present in approximately 7% of anti-BCMA naïve patients, rep-

resent a risk factor for BCMA loss-relapse after T-cell-based therapy (Da Via

etal. 2021). While a plethora of alternative antigens, such as FCRH5 or GPRC5D,

are currently being investigated in early clinical trials (Rasche et al. 2020),

L. Rasche et al.

antigen loss for these targets has not been reported thus far. However, MM is a

disease associated with high frequencies of copy number aberrations, including

deletions impacting genes encoding immunotherapy targets, and we expect bial-

lelic events leading to antigen loss to also be relevant for MM targets other than

BCMA. Multispecic CAR-T cells or combinations of monospecic targeted

immunotherapies may overcome antigen loss in future trials (Fernández de Larrea

etal. 2020).

Immune Dysfunction andExhaustion ofCAR-T Cells

In addition to antigen loss, a number of other mechanisms also limit or abrogate the

effective recognition of cancer cells by CAR-T cells, either directly conveyed by

tumour cells or through rewiring of the microenvironment. In preclinical models,

especially in solid tumours, it was shown that tumour-inltrating CAR-T cells

undergo rapid loss of functionality, limiting their therapeutic efcacy. This hypore-

sponsiveness appears to be reversible when the T cells are isolated away from the

tumour and is associated with upregulation of intrinsic T cell inhibitory enzymes

(diacylglycerol kinase and SHP-1) and with the expression of surface inhibitory

receptors (PD1, LAG3, TIM3, and 2B4) (Moon etal. 2014).

Additionally, in patients with diffuse large B cell lymphoma (DLBCL) treated

with axicabtagene ciloleucel (axi-cel), it has been shown that tumour-inltrating

CAR-T cells express the inhibitory receptor PD1 and that they represent only a

minor fraction of the immune cells detectable in the tumour (Chen etal. 2020).

Of note, immunogenic chemotherapy can enhance the recruitment of CAR-T

cells to the tumour bed by inducing the release of chemokines from monocytes,

and this can potently synergize with immune checkpoint blockade (Srivastava

et al. 2021). In another recent study in DLCBL, interferon (IFN) signalling

expression, along with high blood levels of monocytic myeloid-derived suppres-

sor cells (M-MDSCs), IL-6 and ferritin, was associated with a lack of a durable

response to axi-cel. The authors showed that high IFN signalling is associated

with the expression of multiple checkpoint ligands, including PD-L1, on lym-

phoma cells and that these levels were higher in patients who lacked a durable

response to CAR-T therapy (Jain etal. 2021). However, impairment of IFN sig-

nalling, such as through mutations or downmodulation of JAK2 and other path-

way components, can confer tumour cell resistance to killing by CAR-redirected

T cells (Arenas etal. 2021).

These ndings have direct implications for the design of next-generation CAR-T

cell protocols: a number of strategies are now being explored to combine immune

checkpoint blockade with CAR-T cell therapy, either by coinfusion of genetically

modied lymphocytes with monoclonal antibodies or by engineering the cell to

produce the relevant scFv (Carneiro and El-Deiry 2020), be resistant to inhibitory

signals (Cullen et al. 2010), or even transform signals under activating stimuli

(Sutton etal. 2000). Moreover, novel promising compounds have been shown to

counteract the activity of T cell inhibitory enzymes (Moon etal. 2014).

4 Tumour Escape fromCAR-T Cells

Microenvironment-Mediated Tumour Resistance toCAR-T Cells

Immune suppression or exhaustion is not the only mechanism by which tumour

cells can become less susceptible to CAR-T cell-mediated cytotoxicity. In many

haematological cancers, the bone marrow tumour microenvironment (BMME) is

known to upregulate antiapoptotic mechanisms in tumour cells through tight cross-

talk of mesenchymal stromal cells (MSCs) and tumour cells. Remarkably, tumour

cell lysis by T and NK cells is also largely mediated via activation of extrinsic and

intrinsic apoptosis pathways (Hanabuchi et al. 1994; Falschlehner et al. 2009;

Carneiro and El-Deiry 2020; Cullen etal. 2010; Sutton etal. 2000). Thus, the idea

that BMMSCs might also induce resistance to T and MK cell-mediated cytotoxic

activity through upregulation of antiapoptotic mechanisms has recently been tested,

and the results showed that MM cell-BMMSC interactions can indeed protect MM

cells from conventional cytotoxic T cells and from (daratumumab redirected) NK

cells (McMillin etal. 2012; de Haart etal. 2013; de Haart etal. 2016). These studies

were recently extended to CAR-T cells by testing a panel of nine different

MM-reactive CAR-T cells that were reactive to three different MM-associated anti-

gens (CD138, BCMA, and CD38) with different target afnities and with different

costimulatory domains (CD28, 4-1BB, or CD28 plus 4-1BB) (Holthof etal. 2021a).

In the absence of BMMSCs, BCMA

bb2121

CAR-T cells, high afnity CD38 CAR-T

cells, and intermediate afnity CD38 CAR-T cells containing CD28 costimulatory

domains showed high levels of anti-MM cell lysis, whereas other CAR-T cells

showed moderate cytotoxic activity against MM cells. BMMSCs did not modulate

the lytic activity of highly lytic CAR-T cells but readily protected MM cells against

all other CAR-T cells with intermediate killing capacity. Overall, a strong inverse

correlation was demonstrated between the lytic capacity of the CAR-T cells and the

extent of BMMSC-mediated protection. Furthermore, the BMMSC-mediated pro-

tection of MM cells from these CAR-T cells was readily abrogated by inhibition of

survivin, MCL-1, and Xiap using the small molecule FL118. Thus, the results con-

rmed that BMMSC-mediated immune resistance was mediated by negative regula-

tion of apoptotic pathways. In addition, the importance of the tumour stroma in the

efcacy of CAR-T cells has also been suggested in a solid tumour mouse model,

where destruction of the tumour stroma contributed to eradication of large tumours

by HER2-specic CAR-T cells (Textor etal. 2014). Based on these studies, over-

coming BMMSC-mediated immune resistance seems possible by increasing the

overall avidity and killing activity of CAR-T cells. This may be achieved by design-

ing CARs containing high afnity antigen recognition domains, tandem CARs, or

dual CAR strategies (van der Schans etal. 2020). Alternatively, using the CD28

costimulatory domain (Drent etal. 2019; Drent etal. 2017) or engineering CAR-T

cells with cytotoxic effector molecules can upregulate CAR-T cell activity. Indeed,

it has recently been demonstrated that BMSMSC-mediated immune resistance

towards the NK cell line KHYG-1 can be abrogated by engineering it with a CD38

CAR and/or with a DR5-specic, optimized TRAIL variant (Holthof etal. 2021b).

CAR-T cells may also be equipped with caspase-independent apoptotic molecules,

such as granzyme-A (Borner and Monney 1999).

L. Rasche et al.

In addition, a number of earlier and recent studies indicate the importance of

apoptotic pathways for the efcacy of other CAR-T cells. For instance, CD19

CAR-T cells were previously found to benet from combination with the BCL-2

inhibitor ABT-737 (Karlsson etal. 2013). Recently, similar results were observed

when third-generation CD19 CAR-T cells were combined with another BCL-2

inhibitor, ABT199 (Yang etal. 2019). Finally, two independent loss-of-function

screens in ALL cell lines identied impaired death receptor pathways as another

mechanism of resistance to CD19-targeted CAR therapy. Loss of FADD, BID, and

tumour necrosis factor-related apoptosis-inducing ligand 2 (TRAIL2) in leukaemia

cells was shown to render them more resistant to cytotoxicity and to drive T cell

exhaustion upon prolonged stimulation (Singh etal. 2020; Dufva etal. 2020). The

combination of CAR-T cells with the SMAC mimetic compound birinapant sig-

nicantly improved the lysis of malignant cells (Dufva etal. 2020). Thus, when

increasing the lytic capacity of CAR-T cells is not possible or desirable, especially

if the target antigen is not entirely tumour-specic, tumour cells can be made more

sensitive by combining CAR-T cells with small molecules targeting regulatory

proteins in the intrinsic and extrinsic apoptotic pathways, as shown in these studies.

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1. Loss of expression of the target antigen on tumour cells via the selective

immune pressure of CAR-T cells is a major mechanism of CAR-T cell

therapy failure.

2. T cell exhaustion of CAR-T cells can decrease their function.

3. Multiple other cells in the tumour microenvironment can contribute to

inhibition of CAR-T cell function.

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4 Tumour Escape fromCAR-T Cells

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

L. Rasche et al.

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_5

A. Urbano-Ispizua

Institute of Hematology and Oncology. Hospital Clinic of Barcelona. University of

Barcelona, Barcelona, Spain

e-mail: [email protected]

M. Hudecek (

Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany

e-mail: Hudecek_M@ukw.de

CART Initiatives inEurope

AlvaroUrbano-Ispizua andMichaelHudecek

The efcacy of chimeric antigen receptor T cells (CARTs) in B cell neoplasms,

ALL, large B cell lymphoma, and now multiple myeloma has been one of the great

achievements in the ght against cancer in recent decades (Porter et al. 2011).

However, there is still a need to increase the proportion of responses (especially in

NHL) (Locke etal. 2019) and to decrease the proportion of relapse (especially in

ALL) (Grupp etal. 2013). More importantly, currently, commercial CAR-T prod-

ucts are not available for T cell neoplasms, myeloid malignant haemopathies, or

solid tumours. As a reection of the necessary efforts to expand the efcacy of

CARTs, more than 500 clinical trials are currently underway worldwide, mostly led

by American or Chinese groups. Unfortunately, European institutions are under-

represented in these initiatives. It is our duty to push and harmonize European aca-

demic clinical trials. We identied 35 early clinical trials promoted by European

groups in Eudract and ClinTrialsGov (20 February 2021) (Table5.1). Among them,

20 are initiatives from academic institutions, and 15 are initiatives from European

companies allied with European academic institutions. In this summary, CART

clinical trials promoted by European academic centres or by small to medium

European companies are listed. The aim is to inform European groups treating hae-

mato-oncology diseases of the current situation in this eld, facilitating the inclu-

sion of patients in these clinical trials. We aim to support the groups promoting

these studies to increase collaboration.

Table 5.1 Ongoing CART clinical trials in Europe

A. Urbano-Ispizua and M. Hudecek

(continued)

5 CART Initiatives inEurope

Table 5.1 (continued)

A. Urbano-Ispizua and M. Hudecek

Twelve European institutions are responsible for the 20 academic clinical trials

(University College London, n= 4; Hospital Clinic of Barcelona, n = 3; Great

Ormond Street Hospital, n=2; Bambino Gesù, n=2; University of Uppsala, n=2;

King’s College, n=1; Matilde Tettamanti, n=1; Hospital Sant Pau, n=1; University

of Heidelberg, n=1; and University of Wurzburg, n=1). The most frequent target

is CD19 (n=12; for ALL, n=5; NHL, n=1; all B-lymphoid neoplasms, n=6).

Other targets are BCMA (n=1; MM), CD30 (n=1; HL and T-NHL), SLAMF7

(n=1; MM), GD2 (n=2, neuroblastoma), ErbBR (n=1, neck and head tumours),

Fap (n=1, mesothelioma), and IL-1 RAP (n=1, CML). Of the 20 clinical trials, 8

only included adults, 5 only included children, and 7 included all ages.

There were 16 additional clinical trials promoted by seven European pharma

companies (Autolous, n=6; Miltenyi, n=3; Servier, n=2; MolMed, n=1; Celyad,

n=1; Cellectis, n=1; TcBiopharm, n=1, BioNTech, n=1). Again, the most fre-

quent target is CD19 (n=4; for ALL, n=2; NHL, n=1; all B-lymphoid neoplasms,

n=1). Other targets are dual CD19/CD20 or CD19/CD22 (n=3; ALL, n=1; NHL,

n=2), CD20 (n=2; melanoma, lymphoma), BCMA (n=1; MM), CD123 (n=1;

AML), CD33 (n=1, AML), NKG2D (n=1, colon cancer), CD44v6 (n=1, MM),

TRCDB1 (n=1, T-NHL), and CLDN6 (n=1; colon cancer).

Hopefully, this list will grow as more clinical trials are set up. We intend to com-

pile an ad hoc workshop to provide more comprehensive data, such as the charac-

teristics of the genetic construct (type of costimulatory molecule, 2nd- or

third-generation CAR), the vector (viral or nonviral), and the method of expansion

(automated or manual) and the plans of these groups to go beyond a particular clini-

cal trial (hospital exemption, EMA). We believe this information will be useful to

increase efforts and fuel this eld in Europe.

Two initiatives have recently been launched to foster collaboration and increase

CART activity in Europe: GoCART and T2 EVOLVE Consortium.

GoCART is a strategic partnership between EBMT and EHA that includes a

multistakeholder coalition of patient representatives, health care professionals,

pharmaceutical companies, regulators, health technology assessment (HTA) bodies,

reimbursement agencies, and medical organizations. Some of its most important

aims include the following:

• Collaborate and share data and knowledge.

• Promote harmonization of data collection, education, standards of care, regula-

tory approval, centre qualication, and reimbursement processes.

• Set up a pre- and postmarketing registry that supports regulatory and shared

research purposes.

• Develop a cellular therapy education and information program for patients and

health care professionals.

T2EVOLVE is an alliance of academic and industry leaders in cancer immuno-

therapy under the European Union’s Innovative Medicines Initiative (Supported

from the European Union’s Horizon 2020 Research and Innovation Programme).

The key objective of T2EVOLVE is to accelerate development and increase the

5 CART Initiatives inEurope

awareness and access of cancer patients to immunotherapy with immune cells that

harbour a genetically engineered TCR or CAR.Simultaneously, T2EVOLVE aims

to provide guidance on sustainable integration of these treatments into the EU health

care system. The T2EVOLVE consortium aims to achieve its goal by working on

and improving the state of the art in the following key aspects:

• Selection of optimal lymphodepletion regimens.

• Optimization of preclinical models for the best safety and efcacy prediction.

• To involve and guide patients throughout their clinical journey.

• Denition of gold standard analytical methods pre- and post-engineered T cell

infusion.

• Production of GMP guidance and establishment of standard product proles.

• To produce excellent cancer therapies accessible to all European patients.

References

Grupp SA, Kalos M, Barrett D, etal. Chimeric antigen receptor–modied T cells for acute lym-

phoid leukemia. N Engl J Med. 2013;368:1509–18.

Locke FL, Ghobadi A, Jacobson CA, etal. Long-term safety and activity of axicabtagene ciloleu-

cel in refractory large B-cell lymphoma (ZUMA-1): a single-arm, multicentre, phase 1–2 trial.

Lancet Oncol. 2019;20:31–42. https://doi.org/10.1016/S1470- 2045(18)30864- 7.

Porter DL, Levine BL, Kalos M, etal. Chimeric antigen receptor–modied T cells in chronic lym-

phoid leukemia. N Engl J Med. 2011;365:725–33.

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

Key Points

1. Two initiatives have been launched to foster collaboration and increase

CART activity in Europe: GoCART and T2 EVOLVE Consortium.

2. A large number of CAR-T cell clinical trials are underway.

3. Most clinical trials are occurring in the USA and China, and although

Europe has lagged behind, there is evidence of increasing activity.

4. Initiatives to enhance clinical trial activity and cooperation across Europe

are needed, and various initiatives are planned to facilitate this.

A. Urbano-Ispizua and M. Hudecek

Part II

Manufacturing CAR-T Cells: The Supply Chain

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_6

H. Bonig

Translational Development of Cellular Therapeutics, Institute for Transfusion Medicine and

Immunohematology, Goethe University, Frankfurt, Germany

Medicine/Hematology, University of Washington, Seattle, WA, USA

Transfusion Medicine, University of Ljubljana, Ljubljana, Slovenia

e-mail: [email protected]

C. Chabannon (

Institut Paoli-Calmettes, Centre de Lutte Contre le Cancer, Centre d’Investigations Cliniques

en Biothérapie, Université d’Aix-Marseille, Inserm CBT-1409, Marseille, France

e-mail: CHAB[email protected].fr

M. Lozano

Department of Hemotherapy and Hemostasis, Institute of Hematology and Oncology, Clinic

University Hospital, University of Barcelona, IDIBAPS, Barcelona, Catalonia, Spain

e-mail: [email protected]

Providing theStarting Material

totheManufacturer ofanApproved

andCommercially Available Autologous

CAR-T Cell Treatment

HalvardBonig, ChristianChabannon

, andMiquelLozano

Introduction

CAR-T cell manufacturing starts from a collection of mononuclear cells (MNCs,

although specically only T lymphocytes will be used for the preparation) from the

patient using apheresis. Although several initiatives are working on the develop-

ment of allogeneic CAR-T cells, currently only CAR-T therapies of autologous

origin are approved in the European Union. The present chapter only discusses

already or soon-to-be marketed autologous CAR-T cells and excludes investiga-

tional CAR-T cells or rare CAR-T cells approved in the context of hospital exemp-

tion, such as the ARI-001 product (Ortiz-Maldonado et al. 2021); on this topic,

please refer to Chap. 3.

Institutions aspiring to be CAR-T centres must generate sufcient apheresis

capacity to ensure immediate access to apheresis slots; apheresis capacity must

grow in synchrony with the CAR-T program (Tables 6.1, 6.2, 6.3, 6.4, and 6.5).

Table 6.1 Before apheresis collection

Apheresis units might require a visit during the screening of patients for CAR-T therapies

In the visit the following aspects should be evaluated (Yakoub-Agha etal. 2020):

– Discontinue drugs that affect the number and functionality of circulating T lymphocytes

(e.g., steroids, immune-suppressors, and chemotherapy) as long as possible before

apheresis. Minimal stopping rules are dened in institutional guidelines and manufacturing

authorization holder (MAH) instructions. Steroids are usually stopped at least 3–7days

before apheresis.

– Evaluate for systemic infection, particularly in patients with an intravenous central line.

Bacteremia is a relative contraindication for MNC apheresis due to the risk of

contamination of the product. Note, however, that a contaminated blood product—

although denitely not ideal—is not always rejected by the manufacturer because the

manufacturing process may plan for the addition of antibiotics.

– Assess venous access, ideally including an ultrasound evaluation if upper arm peripheral

veins are not adequate by palpation (Gopalasingam etal. 2017) before deciding that a

central line catheter must be placed. Blood can be collected from most adult patients via

peripheral access sites. Central catheters are most often needed in low-weight children.

Indwelling catheters are suitable (Jarisch etal. 2020).

– Evaluate whether any form of sedation is necessary (mostly for the paediatric population)

through a joint evaluation between the paediatricians and apheresis medical director or

practitioner.

– Review complete blood count (CBC) and differential (absolute lymphocyte count) results

to calculate target process volume.

– Check the MCV to rule out the presence of beta thalassemia minor. Microcytosis leads to

abnormal sedimentation behaviour, necessitating modication of apheresis settings

(Constantinou etal. 2017).

– Note height and weight and calculate total blood volume. In particular, in low-weight

children, consider the need for priming of the apheresis tubing set with irradiated red blood

cell concentrate (which needs to be pre-ordered so as not to delay initiation of apheresis).

– If the patient is transfused with cellular components in the days prior to apheresis

collection, they must be gamma irradiated.

– Note concurrent medications, especially anti-hypertensives. Angiotensin-converting

enzyme inhibitors and beta-blockers increase the risk of hypotension reactions during

apheresis.

– Evaluate electrolyte levels: potassium, (ionized) calcium, and magnesium levels drop

during apheresis and thus can become critically low if already abnormal before apheresis

(Stenzinger and Bonig 2018).

– Negative infectious markers of HIV, HBV, and HCV (in some countries also HTLV-1 and

syphilis) must be available within 30days of collection, in compliance with applicable

laws and regulations for autologous cell products. MAH will require that results be

available upon shipment of the starting material to the manufacturing site.

H. Bonig et al.

Table 6.2 Designing apheresis collection

– Select the apheresis platform suitable for the collection. Depending on the platform

selected, the characteristics of the product collected might vary signicantly. For instance,

if an Amicus separator (Fresenius-Kabi, Bad Homburg, Germany) is used, the platelet

content is very low in comparison to Spectra Optia (Terumo BCT, Lakewood, CO, USA)

(Cid etal. 2019), see Table6.3.

– Check if the total blood volume of the patient requires priming of the apheresis separator.

– Check lymphocyte count to dene the blood volume to be processed, see Table6.4 for

apheresis targets of different manufacturers.

– Consider prophylactic administration of calcium and magnesium during the collection

depending on the volume to be processed (Sörensen etal. 2013).

– Evaluate the haemoglobin and platelet count, consider transfusion prior to or after

apheresis depending on circumstances. A haemoglobin level of 7g/dL, better yet 8g/dL,

prior to apheresis facilitates establishment of interphase during apheresis. Spectra Optia

will reduce platelet count by approximately 11% per total blood volume processed.

– Evaluate the potassium level and consider supplementation.

Table 6.3 Characteristics of the apheresis platforms typically used for collection

Amicus Spectra optia

Manufacturer Fresenius-Kabi (Bad

Homburg, Germany)

TerumoBCT, Lakewood, Co, USA

Software kit Continuous MNC

(CMNC)

MNC

Flow type Discontinuous Continuous Dual-stage separation

Flow rate 10–80 (85) mL/min

10–142mL/min 10–125mL/min

Operation Automatic Semi-automatic Semi-automatic

Mononuclear cell

collection

Elutriation Aspiration Aspiration followed

by elutriation

Platelets Returned to the donor Collected Partially returned to

donor

Depending on the leukocyte count

6 Providing the Starting Material to the Manufacturer of an Approved…

Table 6.4 Collection requirements of different manufacturers of CAR-T therapies

Product

Axicabtagene

ciloleucel

Brexucabtagene

autoleucel Tisagenlecleucel

Lisocabtagene

maraleucel

Idecabtagene

vicleucel

Ciltacabtagene

autoleucel

Registered name Yescarta

Tecartus

Kymriah

Breyanzi

Abecma

Manufacturer Gilead Gilead Novartis Juno-Celgene-

BMS

BlueBird

Bio-Celgene-

BMS

Legend

Therapeutics-

Janssen

Antigen

recognized

CD19 CD19 CD19 CD19 BCMA BCMA

Target cell dose

during apheresis

5–10×10

MNCs 1–4×10

CD3

cells

≥2×10

TNCs

≥3% CD3+ of TNCs

(rounding rules apply)

Target volume to

be processed

12–15L 6–10L

Manufacturer’s recommendation

MNCs mononuclear cells, TNCs total nucleated cells

H. Bonig et al.

References

Cid J, Carbasse G, Alba C, Perea D, Lozano M.Leukocytapheresis in nonmobilized donors for

cellular therapy protocols: evaluation of factors affecting collection efciency of cells. J Clin

Apher. 2019;34:672–9.

Constantinou VC, Bouinta A, Karponi G, etal. Poor stem cell harvest may not always be related to

poor mobilization: lessons gained from a mobilization study in patients with beta-thalassemia

major. Transfusion. 2017;57:1031–9.

Gopalasingam N, Thomsen AE, Folkersen L, Juhl-Olsen P, Sloth E. A successful model to

learn and implement ultrasound-guided venous catheterization in apheresis. J Clin Apher.

2017;32:437–43.

Jarisch A, Rettinger E, Sorensen J, et al. Unstimulated apheresis for chimeric antigen receptor

manufacturing in pediatric/adolescent acute lymphoblastic leukemia patients. J Clin Apher.

2020;35(5):398–405. https://doi.org/10.1002/jca.21812.

Ortiz-Maldonado V, Rives S, Castella M, etal. CART19-BE-01: a multicenter trial of ARI-0001 cell

therapy in patients with CD19(+) relapsed/refractory malignancies. Mol Ther. 2021;29:636–44.

Sörensen J, Jarisch A, Smorta C, etal. Pediatric apheresis with a novel apheresis device with elec-

tronic interface control. Transfusion. 2013;53:761–5.

Stenzinger M, Bonig H. Risks of leukapheresis and how to manage them—a non-systematic

review. Transfus Apher Sci. 2018;57:628–34.

Yakoub-Agha I, Chabannon C, Bader P, et al. Management of adults and children undergoing

CAR-T cell therapy: best practice recommendations of the EBMT and JACIE.Haematologica.

2020;105:297–316.

Key Points

• Prepare for apheresis by assessing the clinical and biological condition of

the patient.

• Discontinue treatments that can lower immune effector cell numbers and

functions.

• Tailor apheresis parameters to the patient condition.

• Tailor apheresis parameters to suit the manufacturer’s needs and

requirements.

• Tightly coordinate with the Cell Processing Facility to ensure smooth ship-

ment to the manufacturing site, in compliance with the manufacturer’s

needs and requirements.

Table 6.5 Interim storage, cryopreservation, and logistics

• Interim storage at 4–8°C

• Tisagenlecleucel: Adjust concentration to 10

/mL (0.5–2×10

); freeze as soon as feasible

but no later than 24h after collection, with DMSO as a cryoprotectant in a controlled-rate

freezer; store in LN2 (institutional SOP to be validated by the manufacturer prior to start of

operations).

• All other CAR-T cells: Ship as soon as possible at 4–8°C, following the manufacturers’

instructions and requirements.

• MAH to arrange pick-up, with temperature-controlled shipping containers of the appropriate

temperature.

• Scheduling, documentation of pick-up, hand-over, and tracking supported by MAH- supplied

specic web tools.

6 Providing the Starting Material to the Manufacturer of an Approved…

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

H. Bonig et al.

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_7

C. Rioufol (*)

Hospices Civils de Lyon, UCBL1, EA 3738 CICLY, Lyon, France

e-mail: [email protected]

C. Wichmann

Department of Transfusion Medicine, Cell Therapeutics and Hemostaseology, University

Hospital, LMU Munich, Munich, Germany

e-mail: Christian.W[email protected]

Receiving, Handling, Storage, Thawing,

Distribution, andAdministration

ofCAR-T Cells Shipped

fromtheManufacturing Facility

CatherineRioufol andChristianWichmann

Definition

In the manufacturing process for antigen receptor T cell (CAR-T cell) therapies, the

patient’s T cells acquire medicinal product status after enrichment, genetic modi-

cation, and expansion.

This pharmacologic effect results from insertion of a transgene coding for CAR,

recognizing the tumour antigen, lysing the tumour cells, and activating the immune

system see Chaps. 1, 2 and 3 in Section 1. Moreover, CAR-T cells massively expand

upon interaction with antigen- positive cells within the blood system, thereby

increasing the number of administered ATMP cells to high numbers (June et al.

2018). Due to this pharmacologic mechanism, CAR-T cells, despite their cellular

nature, are gene therapy medicinal products. Whether from patients or healthy

donors, CAR-T cells belong to the class of advanced therapy medicinal products

(ATMPs), as dened in Regulation EC N°1394/2007 of the European Parliament

and in Directive 2009/120/EC of the Council of November 13, 2007 on ATMPs,

amending Directive 2001/83/EC and Regulation N° 726/2004.

As a consequence of this medicinal status, CAR-T cells fall under the responsi-

bility of the hospital pharmacist. The manufacturer ships the released drugs to the

pharmacy of the treatment centre; the hospital pharmacist is responsible of each

step: reception, handling, storage, thawing, and dispensation (Pinturaud etal. 2018),

regardless of whether the CAR-T cells are on the market or being used experimen-

tally in a clinical trial. In hospitals with a Cell Processing Facility, the pharmacy

may elect to subcontract certain technical operations to the Cell Processing Facility,

as dened in an internal agreement. The overall handling and working process must

be compliant with legal requirements enforced by local and national health authori-

ties, and with the technical requirements of the drug-producing company (checked

through audits and training courses).

Workow Description of the process

Handling

– Handling of CAR-T cells according to ATMP requirements, ensuring

product safety and health care worker protection. Personal protective

equipment (PPE) to protect the handling team involved throughout the

various stages of the ‘CAR-T pathway’

– ‘CAR-T hospital pathway’ is supervised by the pharmacist; the steps are

dened by the pharmaceutical team in coordination with the medical and

nursing teams of the Haematology Department to meet objectives and ease

the patient’s care pathway

– Need of a reliable adapted quality assurance system with initial and

continuous training programs for all those involved, and periodic

assessment, in addition to the centre qualication by the pharmaceutical

laboratories

– At many centres, CAR-T cell products are managed by specialized

oncology pharmaceutical teams involved in cancer patient monitoring and

treatment, and in close contact with the oncology department

– Staff training and on-site inspection conducted by the manufacturer

– Process control through web-based communication tools, with access

provided by the manufacturer

Reception and

conformity

check

Critical steps:

– Treatment conrmation in the context of a multidisciplinary meeting that

examines that the indication is consistent with the marketing approval/

SmPC and that the patient condition is compatible with the expected safety

prole of the CAR-T cells

– The hospital pharmacist’s order is placed with the manufacturer

– Planication of the collection of the starting material through

leukapheresis at the cell collection facility (which may be operated by the

treating hospital or subcontracted to another hospital or a blood bank)

– Shipment of the starting material from the cell processing facility, which

works in close collaboration with the cell collection facility (the cell

processing facility may be operated by the treating hospital or

subcontracted to another hospital or a blood bank)

– Turnaround time of 4–6weeks between ordering and receiving to allow for

manufacturing and transportation (based on the experience of the rst

active European centres)

– Tracking of the consecutive steps of on-demand medicinal product

manufacturing on the manufacturer’s website, allowing the date and time

of reception to be known in advance to mobilize the necessary human

resources for reception without interruption of the cold chain

– Usual presentation of CAR-T cells: bag or syringe for infusion, delivered

in a dry-shipper (vapour phase nitrogen) at approximately −160°C

C. Rioufol and C. Wichmann

Workow Description of the process

– Reception of the dry-shipper in ventilated premises

– Conformity check at reception with reception documents (travel

documents, certicates of analysis and release, temperature logs, labels):

Cryo-shipper check: no visible damage and/or leaks

Opening of the metal cassette to fully inspect the frozen cell product

Checking the completeness and accuracy of information printed on the

CAR-T cell label: patient identity and drug identity. Proper labelling is key

to maintain the Chain of Identity/Chain of Custody throughout the

manufacturing process, up to administration of the medicinal product to

the intended recipient

– Back-up bag: whether a back-up bag is available at the manufacturer’s site

should be systematically stated in the reception documents. In case of

nonconformity detected at reception, this information is very useful for the

pharmacist and haematologists in determining the treatment strategy: a

back-up bag enables timely administration within 48h via replacement of

the defective CAR-T cells

– All retrieved information is entered on the manufacturer’s website

– Transfer of the CAR-T cells to a cryogenic recipient

– Management of out-of-range temperature or other abnormalities: storage

of CAR-T cells in quarantine and contact of the manufacturer for

instructions

– Final check of Out of Specications (OOS)

– Double control involving two members of the pharmacy team or one

member each from the pharmacy and cell processing facility for reception,

conformity checking, and transfer to the cryogenic recipient

Storage

– Storage in vapour phase nitrogen tanks. In hospitals with a cell processing

facility, storage is possible in a dedicated nitrogen tank. Respective

responsibilities are then dened in an agreement approved by the health

authority

– The cryogenic premises preferably contain several nitrogen tanks for

back-up in case of dysfunction. Having several distinct tanks also allows

CAR-T cells with market authorization to be distinguished from those

used in clinical trials or from other ATMPs. The tanks are fed by a central

lling tank, and lling should be automated and levels monitored in real

time, with a 24/7 alarm at the lower threshold. Temperature courses must

be regularly monitored, saved, and controlled

– Nitrogen storage time: approximately 6months

– Prevention of burns and hypoxia accidents in handling the CAR-T cells in

and out of the nitrogen in the cryogenic recipients: ventilated premises,

with secure access reserved to trained and retrained personnel, no access

alone to the cryogenic area, and an oculus in the door so that any incident

can be detected from the outside. Oxygen levels at the oor are recorded in

real time and displayed with visual and sound alarms at the hospital

security station. The nitrogen storage symbol is displayed. First-aid

procedures are set out, with pictograms inside and outside the premises

– Protection of the staff: use of PPE to prevent burning via nitrogen contact

(gloves with sleeves up to the elbow, protective glasses, a lab coat, and

boots). Follow institutional standard operating procedures for liquid

nitrogen handling

– Organization: stand-by duty rotation implemented for nights, weekends,

and holidays to enable intervention in case of any malfunction outside of

pharmacy opening times

Regular maintenance ensures good functioning of premises and tanks

7 Receiving, Handling, Storage, Thawing, Distribution, and Administration of CAR-T…

Workow Description of the process

Thawing

– After medicinal product recovery from the storage tank, a double check

(four-eyes principle) is again necessary to avoid any error in

administration: this includes a careful check of patient identity:

name, birth

date, apheresis-ID, and batch number

– Check of concordance between the product and the haematologist’s

prescription: patient identity, CAR-T denomination, administration date

– Check of the expiration date (even though CAR-T cells are stable over a

period of several months at temperatures below −160°C)

– Beginning of the thawing once the haematologist has given the green light

– Thawing operations:

Performed by the pharmaceutical team on the day of administration,

with as short a time as possible; this requires coordinated planning with

the Haematology Department

Conducted on the pharmacy premises (or in the cell processing facility

if subcontracted), after double-wrapping the bag of CAR-T cells in a

protective plastic bag in a clean room, in a dedicated 37±2°C water bath

until all ice crystals have melted in the bag. Depending on local

organization, a dry thaw method may also be used

Recommendation: double-wrap the bag in a watertight plastic bag for

thawing, to protect the bag of CAR-T cells and observe and control any

solution leakage due to accidental piercing of the original bag that may

have been overlooked at reception

After thawing, the CAR-T cells are stable at room temperature for

approximately 30 to 90min, depending on the manufacturer (please refer

to the SmPC and the manufacturer’s instructions)

– Usually, no processing step (wash, spin down, etc.) is required or allowed

– Commercial products should not be sampled

Preparation

– In case of CAR-T cells requiring processing before dispensation, injection

preparation in a pressurized preparation room with vertical laminar airow

with no air recycling is necessary to prevent the risk of microbiological

contamination of the product and to minimize risks to personnel and the

environment

Transport

to the

Haematology

departmen

– The interval between thawing and administration is 30 to 90min,

depending on the manufacturer, requiring precise timing, including

transport of the cells from the pharmacy to the department in a dedicated

and clearly identied container at room temperature

Warning: it is especially important to adhere to the manufacturer’s

recommended interval as it seems to be a question of the presence of

dimethyl sulfoxide (DMSO), a cryopreservation agent that impairs cell

quality and viability at room temperature, in the CAR-T cell medium (Li

etal. 2019)

– In most cases, due to the short lifespan of CAR-T cells after thawing and

the risk of patient death in case of failure to administer, transport by the

pharmacist or a member of the pharmacy staff is recommended

Dispensing in

the

Haematology

Departmen

– Dispensation under a ready-to-administer form from the pharmacy,

preferably to the nurse who will be in charge of injection in the

Haematology Department. Recording the dispensation time

– Check by the pharmacist that the nurse has all the specic administration

devices, notably including a non-leukodepleting in-line lter

– All material that has been in contact with the CAR-T cell product (solid and

liquid waste) should be handled and disposed of as potentially infectious

waste and genetically modied organisms (GMOs) in accordance with local

biosafety guidelines and local and national regulations

C. Rioufol and C. Wichmann

Administration

Five to seven days ahead of CAR-T cell injection, lymphodepleting chemotherapy

is started (Maus and June 2016). It is recommended to await reception and confor-

mity checking of the CAR-T ATMP to avoid unnecessarily reducing patient lym-

phocyte levels in cases where nonconformity prevents administration.

CAR-T cell administration is scheduled by the haematology department in coor-

dination with the pharmacy team and the Cell Processing Facility to allow for com-

pletion of the circuit under optimal conditions without delay of administration.

Patient information and consent for the entire CAR-T process, including CAR-T

cell infusion, is provided in advance by haematologists.

The cells are delivered intravenously at a 10–20mL/min infusion rate (gravity

ow) without prewarming through a peripheral or central catheter. A non-

leukodepleting in-line lter is used.

At some centres, the pharmacist is present at the bedside to respond to any

request by the nurse, such as for an extra device. Even if not physically present, the

pharmacist must remain quickly available upon request.

The hospital stay is approximately 2weeks but longer in cases of major adverse

events, such as cytokine release syndrome (CRS) or neurotoxicity, which may

require transfer to the intensive care unit. Another important responsibility that lays

with the hospital pharmacy is to ensure that two doses of tocilizumab (anti-IL-6R

antibody) are immediately available for each treated patient as per SmPC.

Patients Treated withCAR-T Cells: New Missions

fortheHospital Pharmacist

The steps along the CAR-T pathway highlight the role of the hospital pharmacist in

this therapeutic innovation.

In the future, the increasing number and variety of ATMPs may require signi-

cant changes in pharmacy organization, notably in terms of premises and equipment

(e.g., nitrogen tanks and vertical laminar airow hoods) for proper and safe han-

dling of the various types of ATMPs: somatic cell therapy medicinal products, gene

therapy medicinal products (including CAR-T cells), and other categories of

ATMPs, such as acellular gene therapy medicinal products, tissue engineering prod-

ucts, and combined medicinal products.

Key Points

• High medicinal standards of cell therapy products supervised by hospital

pharmacists.

• Cryopreservation: a strictly regulated working environment that ensures

safety of the products and requires implementation of stringent measures

to protect the physical safety of involved staff.

7 Receiving, Handling, Storage, Thawing, Distribution, and Administration of CAR-T…

References

Commission Directive 2009/120/EC of 14 September 2009 amending Directive 2001/83/CE of

the European Parliament and of the Council on the Community code relating to medicinal

products for human use as regards Advanced Therapy Medicinal Products (text with EEA

relevance).

June CH, O'Connor RS, Kawalekar OU, Ghassemi S, Milone MC.CAR-T cell immunotherapy

for human cancer. Science. 2018;359(6382):1361–5. https://doi.org/10.1126/science.aar6711.

Li R, Johnson R, Yu G, McKenna DH, Hubel A. Preservation of cell-based immunotherapies

for clinical trials. Cytotherapy. 2019;21(9):943–57. Epub 2019 Aug 12. PMID: 31416704;

PMCID: PMC6746578. https://doi.org/10.1016/j.jcyt.2019.07.004.

Maus MV, June CH.Making better chimeric antigen receptors for adoptive T-cell therapy. Clin

Cancer Res. 2016;22(8):1875–84. https://doi.org/10.1158/1078-0432.CCR-15-1433.

Pinturaud M, Vasseur M, Odou P.Role of the hospital pharmacist in the management of a cat-

egory of advanced therapy medicinal product: chimeric antigen receptor T-cells. Bull Cancer.

2018;105:S205–13.

Regulation (EC) N° 1394/2007 of the European Parliament and of the Council of 13 November

2007 on Advanced Therapy Medicinal Products and amending Directive 2001/83/EC and

Regulation (EC) n°726/2004 (text with EEA relevance), vol 324, 2007. http://data.europa.eu/

eli/reg/2007/1394/oj/fra

• High technical requirements, including 24/7 monitoring of the cell stor-

age site.

• Patient pathway: plan lymphodepletion chemotherapy after reception of

CAR-T cells.

• Statement in the reception document regarding whether a back-up bag is

available.

• Overall, the process is conducted within different facilities and requires

good communication skills and a multidisciplinary approach.

C. Rioufol and C. Wichmann

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

7 Receiving, Handling, Storage, Thawing, Distribution, and Administration of CAR-T…

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_8

J. Delgado

Department of Haematology, Hospital Clinic of Barcelona, Barcelona, Spain

e-mail: [email protected]

C. Roddie (

University College London Cancer Institute, London, UK

e-mail: [email protected]

M. Schmitt

Medizinische Klinik (Krehl-Klinik), Zentrum für Innere Medizin, Klinik für Hämatologie,

Onkologie und Rheumatologie, Innere Medizin V, Heidelberg, Germany

e-mail: [email protected]

Point-of-Care Production ofCAR-T Cells

JulioDelgado, ClaireRoddie, andMichaelSchmitt

CAR-T cells for clinical application are classied as advanced therapy medicinal

products (ATMPs), and their manufacture is subject to laws and regulations gov-

erned by the European Medicines Agency (EMA) and by federal and regional

authorities. CAR-T cells must be manufactured to achieve good manufacturing

practice (GMP) compliance and are dened as potent products manufactured safely

according to standardized methods under closely controlled, reproducible, and

auditable conditions. BioPharma supplies the vast majority of CAR-T products for

patients, but some academic centres have developed point-of-care cGMP CAR-T

manufacturing capability, striving to uphold the same stringency of product quality

while improving patient access to CAR-T cells and streamlining the costs of ther-

apy. Point-of-care CAR-T manufacturing can only be performed in facilities with

the appropriate regulatory approvals in place.

GMP Vector Production

Retroviral and lentiviral vectors are the most common gene delivery methods used

in CAR-T manufacture. Viral vectors are considered an intermediate reagent by

regulatory agencies, but in manufacturing, adherence to cGMP conditions is

recommended.

Vector manufacture is conducted in grade A laminar ow cabinets in grade B

clean rooms, commonly using HEK293T packaging cell lines derived from a master

cell bank (MCB), assuming the appropriate licencing agreements with Rockfeller

University are in place. Quality control of the MCB is outlined in Table8.1 (Perpiñá

etal. 2020).

Nonviral techniques for gene transduction or gene-editing are under investiga-

tion in preclinical and early clinical trials (Prommersberger etal. 2021).

The vector manufacturing process takes 10 to 14 days and is outlined here.

Packaging cells are expanded in asks and transferred into cell culture chambers

followed by plasmid transfection using polyethylenimine. Fixed quantities of plas-

mids encoding CAR, viral envelope, and gagpol are required. Following transfec-

tion, supernatants containing the secreted vector are harvested, claried using

0.45-mm membranes, concentrated prior to dialtration and cryopreservation in

aliquots, and stored at −80°C until use. Quality measures are outlined in Table8.2

(Castellà etal. 2019).

Table 8.1 Quality control for the HEK293T master cell bank

Parameter

Method

Acceptance criteria

Appearance Visual inspection Presence of adherent cells with

thin extensions

Sterility Microbial growth Sterile

Mycoplasma PCR Absent

Adventitious viruses PCR Absent

Karyotype G-band staining Informative

Cell viability (%) after

thawing

Neubauer cell counting with

trypan blue exclusion

>70%

Table 8.2 Quality control for GMP-grade virus production

Parameter

Method

Acceptance criteria

Appearance Visual inspection Yellowish liquid solution

Viral titre Limiting dilution >3.75×10

TU/mL

Sterility Microbial growth Sterile

Mycoplasma PCR Absent

Identity PCR Positive

Replication-competent lentivirus Real-time PCR Absent

J. Delgado et al.

Manufacturing CAR-T Cells

CAR-T cell manufacturing is conducted over approximately 8–12 days in an

approved cGMP clean room facility in a closed or functionally closed system to

reduce the risk of product contamination (Roddie etal. 2019; Schubert et al. 2019;

Castellá etal. 2020).

Starting material for CAR-T cells includes CD3+ T cells derived from nonmobi-

lized leukapheresis (see Chap. 6). Mandated leukapheresis requirements of aca-

demic manufacturers for total nucleated cells (TNCs) and CD3+ T cells must be

dened; as an illustration, the Uni. Heidelberg HD-CAR-1 protocol (EudraCT No.

2016-004808-60) requires 20×10

TNCs and 10×10

CD3+ T cells, similar to

Novartis requirements for the manufacture of tisagenlecleucel. Leukapheresis mate-

rial may be cryopreserved prior to manufacture, but in a bid to shorten the manufac-

turing process, there is a trend towards using fresh leukapheresis material. CAR-T

manufacture is a stepwise process outlined in Table8.3:

Upon completion of manufacturing, CAR-T products must comply with quality

control/end-product specications stipulated in the certicate of analysis. Parameters

may vary, but CAR-T products are usually characterized for release according to

Table 8.3 CAR-T manufacturing methodology

Potential methods

Timepoint

Step 1:

T cell enrichment post-

leukapheresis (optional)

Ficoll density gradient centrifugation;

elutriation; immunomagnetic bead separation

Day 1

Step 2:

T cell activation using

synthetic antigen presenting

technologies (CD3 +/−

CD28) (required)

Soluble monoclonal antibodies; Para-magnetic

anti-CD3/CD28 antibody coated beads;

polymeric biodegradable CD3/28 incorporating

nanomatrix (TransAct™)

Days 1, 2

Step 3:

T cell stimulation (required)

IL-2, IL-7, and IL-15in the culture medium (as

per protocol) (Hoffmann etal. 2018; Gong

et al. 2019)

From day 1

onwards

Step 4:

Gene delivery/transduction

with a retroviral or lentiviral

CAR vector (required)

In some processes, retronectin or Vectofusin

used to enhance transduction (optional)

Days 2, 3

Step 5:

T cell expansion (required)

T-asks, plates or culture bags; bioreactors,

e.g., G-Rex™ ask (Wilson Wolf

Manufacturing); Xuri WAVE™ Bioreactor

(GE Life Systems); CliniMACS Prodigy™

(Miltenyi BioTec)

Days 3, 4

and onwards

Step 6:

T cell harvest and

cryopreservation (required)

The cryopreservation methodology often

mirrors processes dened for haematopoietic

cells. Methods include passive freezing

(−80°C freezer) and controlled-rate freezing

Day 8

onwards

Step 7:

CAR-T cell quality assurance

control and release testing

In-process and end of process controls are

taken to ensure the product complies with

release criteria specications

Day 8

onwards

8 Point-of-Care Production ofCAR-T Cells

immunophenotypic, functional, and sterility assessments (Table 8.4). An out-of-

specication (OOS) product cannot be released in the usual way, and its clinical use

is at the discretion of the treating physician in concert with the regulatory authori-

ties, informed through an OOS report.

Table 8.4 Quality control of CAR-T cell biology and microbiology

Parameter

Method

Acceptance criteria

Appearance Visual inspection Cloudy liquid solution

CAR+ cells (%)

Flow cytometry >20%

CD3+ cells (%) Flow cytometry >70%

Cell viability (%) Neubauer cell counting with

trypan blue exclusion

>70%

Sterility Microbial growth E.Ph. 2.6.1 Sterile from bacteria/fungi

Mycoplasma PCR

Absent

Endotoxin Chromogenic assay <0.5EU/mL

Optional/R&D

CAR/CD45RA/CCR7

For detection of TE/

TEM/TEMRA/TCM/TN

subpopulations

Flow cytometry A high proportion of immature T

cells is desirable for a long-

lasting CAR-T cell effect in the

patient

Cytotoxic potency Cr-51 release assays in tumour

CAR-T cell co-culture,

assessed by ow cytometry

>40% killing at an effector/target

ratio of 10:1 (or higher ratio) in a

4-h assay

Adventitious viruses PCR Absent

Number of transgene

copies/cell

Real-time PCR (Kunz et al.

2019; Schubert et al. 2020)

<10 (range <7–15!) copies/cell

Automated cell counters, such as Luna™, are highly recommended

Highly specic detection reagents (e.g., the Miltenyi Detection Reagent™) are strongly advised

to distinguish CAR-T cells from the negative fraction

European standards stipulate PCR methodology, in contrast to US regulations, which require

serology

Differs between countries and products

Summary and Key Points

• Point-of-care/decentralized CAR-T cell manufacturing has the potential to

enhance patient access to CAR-T products.

• Limitations include the requirement for local cGMP facilities/trained staff

and lack of standardization across multiple sites.

• Potential solutions include implementation of standardized, semiauto-

mated manufacturing platforms, such as the Miltenyi CliniMACS

Prodigy™, and the use of standardized release assays reported in a com-

mon format across manufacturing sites to enable the manufacture of con-

sistent, high-quality products between patients.

J. Delgado et al.

References

Castellà M, etal. Development of a novel anti-CD19 chimeric antigen receptor: a paradigm for

an affordable CAR-T cell production at academic institutions. Mol Ther Methods Clin Dev.

2019;12:134–44.

Castellá M, etal. Point-of-care CAR-T cell production (ARI-0001) using a closed semi-automatic

bioreactor: experience from an academic phase I clinical trial. Front Immunol. 2020;11:482.

Gong W, Hoffmann JM, Stock S, Wang L, Liu Y, Schubert ML, Neuber B, Hückelhoven-Krauss

A, Gern U, Schmitt A, Müller-Tidow C, Shiku H, Schmitt M, Sellner L.Comparison of IL-2

vs IL-7/IL-15 for the generation of NY-ESO-1-specic T cells. Cancer Immunol Immunother.

2019;68(7):1195–209. Epub 2019 Jun 8. https://doi.org/10.1007/s00262- 019- 02354- 4.

Hoffmann J-M, Schubert M-L, Wang L, Hückelhoven A, Sellner L, Stock S, Schmitt A, Kleist

C, Gern A, Loskog A, Wuchter A, Hofmann S, Ho AD, Müller-Tidow C, Dreger P, Schmitt

M.Differences in expansion potential of naive chimeric antigen receptor T cells from healthy

donors and untreated chronic lymphocytic leukemia patients. Front Immunol. 2018;8:1956.

https://doi.org/10.3389/mmu.2017.01956.

Kunz A, Gern U, Schmitt A, Neuber N, Wang L, Hückelhoven-Krauss A, Michels B, Hofmann S,

Müller-Tidow C, Dreger P, Schmitt M, Schubert M-L.Optimized assessment of qPCR-based

vector copy numbers as a safety parameter for GMP-grade CAR-T cells and monitoring of

frequency in patients. Mol Ther Methods Clin Dev. 2019;17:448–54.

Perpiñá U, etal. Cell banking of HEK293T cell line for clinical-grade lentiviral particles manufac-

turing. Transl Med Comm. 2020;5:22.

Prommersberger S, Reiser M, Beckmann J, Danhof S, Amberger M, Quade-Lyssy P, et al.

CARAMBA: a rst-in-human clinical trial with SLAMF7 CAR-T cells prepared by virus-

free Sleeping Beauty gene transfer to treat multiple myeloma. Gene Ther. 2021;28(9):560–71.

https://doi.org/10.1038/s41434-021-00254-w. Epub 2021 Apr 13. PMID: 33846552.

Roddie C, et al. Manufacturing chimeric antigen receptor T cells: issues and challenges.

Cytotherapy. 2019;21(3):327–40. https://doi.org/10.1016/j.jcyt.2018.11.009.

Schubert M-L, Schmitt A, Sellner L, Neuber B, Kunz J, Wuchter P, Kunz A, Gern U, Michels

B, Hofmann S, Hückelhoven-Krauss A, Kulozik A, Ho AD, Müller-Tidow C, Dreger P,

Schmitt M.Treatment of patients with relapsed or refractory CD19+ lymphoid disease with

T lymphocytes transduced by RV-SFG. CD19.CD28.4-1BBzeta retroviral vector: a unicen-

tre phase I/II clinical trial protocol. BMJ Open. 2019;9:e026644. https://doi.org/10.1136/

bmjopen- 2018- 026644.

Schubert ML, Kunz A, Schmitt A, Neuber B, Wang L, Hückelhoven-Krauss A, Langner S, Michels

B, Wick A, Daniel V, Müller-Tidow C, Dreger P, Schmitt M.Assessment of CAR-T cell fre-

quencies in Axicabtagene Ciloleucel and Tisagenlecleucel patients using duplex quantitative

PCR.Cancers (Basel). 2020;12(10):2820.

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

8 Point-of-Care Production ofCAR-T Cells

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_9

S. Depil (*)

Cancer Research Center of Lyon, Léon Bérard Cancer Center, University Claude Bernard

Lyon 1, Lyon, France

e-mail: [email protected].fr

W. Qasim

UCL Great Ormond Street Institute of Child Health, London, UK

e-mail: w[email protected]

Off-the-Shelf Allogeneic CAR-T Cells

orOther Immune Effector Cells

StephaneDepil andWaseemQasim

“Off-the-shelf” allogeneic CAR TCRαβ T cells and other immune effector cells,

such as natural killer (NK) or gamma delta (gd) T cells, can be premanufactured

from healthy donors and may offer alternatives to autologous strategies. However,

major barriers, namely HLA disparity resulting in graft versus host disease (GvHD)

and host-mediated rejection, must be addressed.

Strategies toAvoid Graft Versus Host Disease (GvHD)

Genome Edited αβTCR-Deleted T Cells

Strategies to reduce TCRαβ activity have included the use of truncated dominant-

negative CD3ζ proteins (Gilham et al. 2018), protein expression blockers (PEBLs)

(Kamiya etal. 2018), small hairpin RNA (Bunse etal. 2014), and genome editing.

Platforms for the latter have included zinc-nger nucleases (ZFN) homing endo-

nucleases/meganucleases, transcription activator-like effector nucleases (TALEN),

megaTALs, clustered regularly interspaced short palindromic repeat (CRISP/cas9),

and base editors (BEs) (Depil etal. 2020). Clinical trials of universal TCR-depleted

CAR19 T cells produced using TALENs (Servier/Allogene) have been published

(Qasim etal. 2017; Benjamin etal. 2020), and the rst applications of meganuclease

(Precision Bio) and CRISPR engineering were recently reported (CRISPR

Therapeutics). The manufacturing steps share common aspects of healthy donor T

cell activation with anti-CD3/CD28 antibodies, editing by electroporation of nucle-

ases and viral vector delivery of the CAR transgene. Depletion of residual TCRαβ

T cells using a magnetic bead column ensures that the carriage of potentially allore-

active T cells is kept below the threshold that might lead to GvHD.

Virus-Specific T (VST) Cells

Third-party, donor-derived VST cells have been investigated in allogeneic SCT and

appear to induce reduced levels of GvHD, presumably due to their restricted, virus-

specic, repertoire, and memory T cell phenotype. Examples include allogeneic

EBV-specic T cells transduced to express CAR19 (Curran etal. 2011) and anti-

CD30 CAR (Savoldo 2007).

Alternative Immune Effector Cells

Immune effector cells not associated with induction of GvHD, including NK cells

modied via lentiviral transduction to express CAR 19, exhibited early phase ef-

cacy in CLL (Liu etal. 2020). Similarly, iNKT or γδT cells may have advantages

against solid tumours, but clinical experience is still limited (Gentles etal. 2015).

Engineering of CAR macrophages with antitumour properties has also been

described recently (Klichinsky etal. 2020).

Strategies toAvoid Host-Mediated Rejection ofAllogeneic

Immune Cells

Beyond partial HLA matching of third-party donor cell banks, there are two main

strategies to address the risk of host-mediated rejection.

Resistance toLymphodepletion andImmunosuppression

CAR-T cells have been genome edited to become resistant to an anti-CD52

monoclonal antibody through disruption of CD52 (Benjamin etal. 2020). This

approach has the advantage of suppressing all CD52+ immune cells that can

mediate rejection, such as T, B, and NK cells, although prolonged immunosup-

pression is associated with a higher risk of serious virus reactivation. Engineering

strategies have also been used to confer resistance to calcineurin inhibitors.

Manufacturing steps can be multiplexed alongside editing of the TCR locus dur-

ing electroporation or added to the vector design and incorporated into transduc-

tion steps.

S. Depil and W. Qasim

Removal ofHLA forEvading Host Immunity

Removal of HLA class I molecules on the cell surface to avoid CD8

T cell- mediated

rejection can be achieved by disrupting the common beta 2-microglobulin gene.

This approach is currently being investigated via multiplexed editing of CAR19 T

cells (CRISPR Tx). In theory, the complete absence of HLA class I molecules may

increase NK-mediated rejection through ‘missing self’ responses, and in modelling,

this can be prevented by the expression of nonpolymorphic HLA molecules, such as

HLA-E.Rejection through recognition of HLA class II on activated T cells may be

addressed by disruption of critical transcription factors, such as CIITA and RFXANK

(Depil etal. 2020).

Manufacturing Aspects of‘Off-the-Shelf’ CARs

The majority of ‘off-the-shelf’ T cell therapies have utilized healthy donor peripheral

blood mononuclear cells (MNCs) acquired via steady-state leukapheresis, although

alternative sources, including whole blood and umbilical cord blood, may be suitable.

In the future, immune effector cells may also be derived from induced pluripotent

stem cells (iPSCs). Theoretically, a master iPSC cell line has an unlimited capability

to self-renew and can be banked and used indenitely. In general, manipulations must

be performed in a clean room setting under GMP conditions with suitable licencing

and regulatory approvals. Most cell gene transfer and genome engineering strategies

require cells to be actively in mitosis to ensure open chromatin and accessible DNA,

and activation steps are crucial early in the manufacturing process. Closed system

culture and expansion is now routine, with automation reducing labour intensive

aspects. High-quality viral vector preparations and improved electroporation steps for

genome editing and supplies of stabilized mRNA have been critical. Cryopreservation

in convenient dose formulations and efcient cold chain shipping and storage is an

essential component of premanufactured ‘off- the- shelf’ therapies.

Key Points

• Off-the-shelf allogeneic CAR-T cells devoid of signicant GvHD potential

can be manufactured.

• αβTCR-deleted CAR-T cells and CAR NK cells have successfully entered

the early clinical trial phase.

• Several strategies have been developed to avoid host-mediated rejection of

allogeneic effector cells.

9 O-the-Shelf Allogeneic CAR-T Cells orOther Immune Eector Cells

References

Benjamin R, etal. Genome-edited, donor-derived allogeneic anti-CD19 chimeric antigen receptor

T cells in paediatric and adult B-cell acute lymphoblastic leukaemia: results of two phase 1

studies. Lancet. 2020;396(10266):1885–94.

Bunse M, etal. RNAi-mediated TCR knockdown prevents autoimmunity in mice caused by mixed

TCR dimers following TCR gene transfer. Mol Ther. 2014;22(11):1983–91.

Curran KJ, etal. Validation of donor derived virus specic T-lymphocytes genetically modied to

target the CD19 antigen for the treatment of relapsed leukemia. Mol Ther. 2011;19:S90.

Depil S, etal. ‘Off-the-shelf’ allogeneic CAR-T cells: development and challenges. Nat Rev Drug

Discov. 2020;19(3):185–99.

Gentles AJ, etal. The prognostic landscape of genes and inltrating immune cells across human

cancers. Nat Med. 2015;21(8):938–45.

Gilham DE, et al. TCR inhibitory molecule as a promising allogeneic NKG2D CAR-T cell

approach. J Clin Oncol. 2018;36(15_suppl):e15042–2.

Kamiya T, etal. A novel method to generate T-cell receptor-decient chimeric antigen receptor T

cells. Blood Adv. 2018;2(5):517–28.

Klichinsky M, etal. Human chimeric antigen receptor macrophages for cancer immunotherapy.

Nat Biotechnol. 2020;38(8):947–53.

Liu E, etal. Use of CAR-transduced natural killer cells in CD19-positive lymphoid tumors. N Engl

J Med. 2020;382(6):545–53.

Qasim W, etal. Molecular remission of infant B-ALL after infusion of universal TALEN gene-

edited CAR-T cells. Sci Transl Med. 2017;9(374):eaaj2013.

Savoldo B.Blood. 2007;110(7):2620–30. https://doi.org/10.1182/blood- 2006- 11- 059139.

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

S. Depil and W. Qasim

Part III

Clinical Indications for CAR-T Cells

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_10

P. Bader (*)

Division for Stem Cell Transplantation, Immunology and Intensive Care Medicine,

Department for Children and Adolescents, University Hospital Frankfurt, Goethe University,

Frankfurt, Germany

e-mail: peter[email protected]

F. Locatelli

Department of Pediatric Hematology/Oncology and Cell and Gene Therapy, IRCCS Bambino

Gesù Children’s Hospital, Rome, Italy

e-mail: [email protected]

C. Peters

Department of Pediatrics, St. Anna Children’s Hospital, Medical University of Vienna,

Vienna, Austria

e-mail: [email protected]

Paediatric Acute Lymphoblastic

Leukaemia (ALL)

PeterBader, FrancoLocatelli, andChristinaPeters

Acute lymphoblastic leukaemia (ALL) is the most frequent malignant disease in

childhood and adolescence, with an annual incidence of approximately 3–4 cases

per 100,000 children under 15years of age. Multimodal chemotherapy forms the

base of current ALL treatment. Based on excellent national and international col-

laboration in consecutive prospective, randomized clinical trials, the prognosis of

childhood ALL has signicantly improved over time. Currently, up to 90% of all

paediatric patients with ALL will survive.

However, 15–20% of ALL patients eventually develop disease relapse. Of these

patients, 60–80% will achieve a second complete remission (CR) with intensive

chemotherapy regimens. Despite this high probability of obtaining a second CR,

patients with early bone marrow relapse (namely those occurring within 30months

from diagnosis) have a poor prognosis even if allogeneic stem cell transplantation

(allo-SCT) is used as consolidation therapy (Locatelli et al. 2012). According to

data from the Berlin- Frankfurt- Münster Group (BFM), patients can be grouped (S1,

S2, S3, and S4) according to the site of relapse, immune phenotype, and the time

interval between diagnosis and relapse. In S3 and S4 patients, prognosis is worse

compared to S1/S2 children, with survival rates of only 25%–30% in the whole

cohort of patients (von Stackelberg etal. 2011) and most recently 65% and 69% in

patients who achieved remission and could receive a transplant from a matched

donor (Peters etal. 2021).

In high-risk patients in CR 1 or in relapsed patients with low-risk proles (CR2,

S2), conventional chemotherapy followed by allo-SCT can cure up to 80% of

patients (Peters etal. 2015, 2021). In contrast, in patients who relapse after allo-

SCT, long-term survival is unlikely, and only 15% of these patients will survive the

disease (Kuhlen etal. 2018). Thus far, long-term survival is only possible through a

second allo-SCT if patients can obtain an additional CR and are t enough to receive

a second transplant. Second allo-SCT carries a considerable rate of toxicity and

mortality, and treatment lasts approximately 6–8 months; nally, approximately

30% of these patients survive (Yaniv etal. 2018).

Thus, there is an unmet medical need among children and adolescents who have

the following conditions:

– Primary refractory ALL,

– Treatment refractory relapsed ALL,

– A second relapse of their ALL, or

– Patients who relapse after allogeneic SCT and

– Patients with very high-risk ALL who should undergo allo-SCT but are not eli-

gible for the procedure for medical reasons.

Consequently, with the introduction of CD-19-directed CAR-T cell therapies,

these patients are candidates for clinical studies and nally for licencing trials of

different CAR-T cell products (Maude etal. 2018). For this patient group up to the

age of 25years, one CAR-T cell product is currently approved by the FDA and

EMA.Children, adolescents, and young adults belonging to one of the abovemen-

tioned patient groups have an indication for treatment with CAR-T cell therapies.

Whether these are the right candidates who benet most from the novel treatment

options remains to be demonstrated. Prospective studies are planned, and a few have

already begun to investigate whether the best benet of CAR-T cell treatment can

be obtained if patients were treated early in the course of the disease.

Key Points

• Patients with ALL in the second relapse, with refractory disease or who

relapse after allo-SCT may be considered for CD19 CAR-T cell therapy.

• Effective lymphodepleting chemotherapy is needed to allow expansion of

CAR-T cells.

• The level of measurable residual disease (MRD) seems to be correlated

with response and durable remission.

P. Bader et al.

References

Kuhlen M, Willasch AM, Dalle JH, Wachowiak J, Yaniv I, Ifversen M, Sedlacek P, Guengoer T, Lang

P, Bader P, Suiarska S, Balduzzi A, Strahm B, von Luettichau I, Hoell JI, Borkhardt A, Klingebiel

T, Schrappe M, von Stackelberg A, Glogova E, Poetschger U, Meisel R, Peters C.Outcome of

relapse after allogeneic HSCT in children with ALL enrolled in the ALL-SCT 2003/2007 trial. Br

J Haematol. 2018;180(1):82–9. Epub 2017 Nov 28. https://doi.org/10.1111/bjh.14965.

Locatelli F, Schrappe M, Bernardo ME, Rutella S.How I treat relapsed childhood acute lympho-

blastic leukemia. Blood. 2012;120(14):2807–16. Epub 2012 Aug 15. https://doi.org/10.1182/

blood- 2012- 02- 265884.

Maude SL, Laetsch TW, Buechner J, Rives S, Boyer M, Bittencourt H, Bader P, Verneris MR,

Stefanski HE, Myers GD, Qayed M, De Moerloose B, Hiramatsu H, Schlis K, Davis KL,

Martin PL, Nemecek ER, Yanik GA, Peters C, Baruchel A, Boissel N, Mechinaud F, Balduzzi

A, Krueger J, June CH, Levine BL, Wood P, Taran T, Leung M, Mueller KT, Zhang Y, Sen

K, Lebwohl D, Pulsipher MA, Grupp SA. Tisagenlecleucel in children and young adults

with B-cell lymphoblastic leukemia. N Engl J Med. 2018;378(5):439–48. PMID: 29385370;

PMCID: PMC5996391. https://doi.org/10.1056/NEJMoa1709866.

Peters C, Schrappe M, von Stackelberg A, Schrauder A, Bader P, Ebell W, Lang P, Sykora KW,

Schrum J, Kremens B, Ehlert K, Albert MH, Meisel R, Matthes-Martin S, Gungor T, Holter

W, Strahm B, Gruhn B, Schulz A, Woessmann W, Poetschger U, Zimmermann M, Klingebiel

T. Stem-cell transplantation in children with acute lymphoblastic leukemia: a prospective

international multicenter trial comparing sibling donors with matched unrelated donors-the

ALL-SCT-BFM-2003 trial. J Clin Oncol. 2015;33(11):1265–74. Epub 2015 Mar 9. https://doi.

org/10.1200/JCO.2014.58.9747.

Peters C, Dalle JH, Locatelli F, Poetschger U, Sedlacek P, Buechner J, Shaw PJ, Staciuk R, Ifversen

M, Pichler H, Vettenranta K, Svec P, Aleinikova O, Stein J, Güngör T, Toporski J, Truong TH,

Diaz-de-Heredia C, Bierings M, Arifn H, Essa M, Burkhardt B, Schultz K, Meisel R, Lankester

A, Ansari M, Schrappe M, IBFM Study Group, von Stackelberg A, IntReALL Study Group,

Balduzzi A, I-BFM SCT Study Group, Corbacioglu S, EBMT Paediatric Diseases Working

Party, Bader P.Total body irradiation or chemotherapy conditioning in childhood ALL: a mul-

tinational, randomized, noninferiority phase III study. J Clin Oncol. 2021;39(4):295–307. Epub

2020 Dec 17. https://doi.org/10.1200/JCO.20.02529.

von Stackelberg A, Völzke E, Kühl JS, Seeger K, Schrauder A, Escherich G, Henze G, Tallen G,

ALL-REZ BFM Study Group. Outcome of children and adolescents with relapsed acute lym-

phoblastic leukaemia and non-response to salvage protocol therapy: a retrospective analysis of

the ALL-REZ BFM Study Group. Eur J Cancer. 2011;47(1):90–7. Epub 2010 Oct 20. https://

doi.org/10.1016/j.ejca.2010.09.020.

Yaniv I, Krauss AC, Beohou E, Dalissier A, Corbacioglu S, Zecca M, Afanasyev BV, Berger M,

Diaz MA, Kalwak K, Sedlacek P, Varotto S, Peters C, Bader P.Second hematopoietic stem cell

transplantation for post-transplantation relapsed acute leukemia in children: a retrospective

EBMT-PDWP study. Biol Blood Marrow Transplant. 2018;24(8):1629–42. Epub 2018 Mar 13.

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

10 Paediatric Acute Lymphoblastic Leukaemia (ALL)

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_11

E. Jacoby · A. Nagler (*)

Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel

e-mail: [email protected].il; [email protected].il

N. Gökbuget

Department of Haematology/Oncology, Goethe University,

Frankfurt am Main, Hessen, Germany

e-mail: [email protected]

Adult Acute Lymphoblastic Leukaemia

EladJacoby, NicolaGökbuget, andArnonNagler

ALL is a malignancy of lymphoid progenitor cells, with a bimodal incidence, peak-

ing in early childhood and in older age. In children, ALL tends to have an excellent

prognosis, with more than 85% of patients achieving long-term survival. The out-

come of younger adults has improved considerably as well. However, overall sur-

vival decreases with age (Dores etal. 2012), partially due to the different genetic

background of adult ALL, with a higher proportion of Philadelphia chromosome-

positive (Ph+) ALL and Ph-like and KMT2A rearrangements in comparison to

childhood ALL (Iacobucci and Mullighan 2017). The introduction of paediatric-

inspired regimens has improved outcomes in adults, but these regimens are less

tolerated in older patients (Curran and Stock 2015).

The standard upfront therapy for ALL includes corticosteroids, multiagent che-

motherapy, antimetabolite therapy, and intrathecal therapy. Following induction,

consolidation and maintenance therapy are initiated. In high-risk cases, allogeneic

haematopoietic stem-cell transplantation (allo-HSCT) is considered during the rst

remission. Adults with relapsed ALL have a poor chance of achieving remission

with chemotherapy (Frey and Luger 2015). Novel agents, such as inotuzumab ozo-

gamicin, an antibody–drug conjugate targeting CD22, and blinatumomab, a bispe-

cic engager targeting CD19 and CD3, improve remission rates, but overall survival

remains poor (Kantarjian etal. 2016, 2017). Relapse therapy is usually followed by

allo-HSCT if not performed earlier. ALL cases refractory to two or more lines of

therapy can be considered for CAR-T cell therapy.

CAR-T Cell Therapy forAdult ALL

Currently, in 2021, no regulatory agency has approved a CAR-T cell product for

adult ALL patients above 25years of age. Young adults aged 18–25 were included

in the pivotal ELIANA study and are eligible for tisagenlecleucel (Maude et al.

2018). Other single-institutional studies also included young adults in a paediatric-

focused study. Only a few groups have reported clinical trials in adults with ALL

(Table11.1). Most trials include small patient numbers, usually younger adults, and

may represent selected patient populations. Remission rates across trials are high,

with more than 70% of patients achieving complete remission, regardless of cytoge-

netic background, prior therapies and age. Occasionally, response rates are reported

as intent-to-treat, referring to all included patients in contrast to only those receiving

CAR-T cell therapy.

Toxicity has been a signicant issue in all trials, and fractionation of the dose by

administration of a partial dose on Day 0 and the remainder after several days was

shown to be safer (Frey etal. 2019; Park etal. 2018). Several groups also adminis-

tered lower doses to patients with a high disease burden to prevent toxicity (Roddie

etal. 2020). Alternative approaches to enhance safety include earlier administration

of tocilizumab and low-dose steroids (Gardner etal. 2019; Kadauke etal. 2021; Liu

etal. 2020). Using a novel low afnity CD19 CAR-T cell was also associated with

lower toxicity (Ghorashian etal. 2019; Roddie etal. 2020).

The prognostic factors that are associated with higher remission rates and better

outcome in adult ALL include lower disease burden, as assessed by the blast count

in bone marrow; lower LDH; and higher platelet count prior to lymphodepletion

(Hay etal. 2019; Park etal. 2018). Due to the time delay between the detection of

relapse and infusion of CAR-T cells, in many cases, it is necessary to deliver bridg-

ing therapy. The optimal regimens need to be dened.

Assessing the leukaemia burden before CAR-T-infusion and after potential

bridging therapies is recommended because the outcome of patients with a high

disease burden is inferior to that of those without persistent disease or minimal

residual disease (MRD) only. The results may be inferior in ALL patients previ-

ously treated with blinatumomab (Pillai etal. 2019), although this may represent

a selection of more resistant patients. TP53 mutations were associated with a

worse outcome. Additionally, conditioning with udarabine and cyclophospha-

mide was superior to cyclophosphamide alone in adults, similar to ndings in

children.

Many trials report MRD status determined by ow cytometry post CAR-T

cell therapy, showing that almost all remissions are (based on ow-cytometry)

MRD negative. Molecular detection of MRD via PCR or next-generation

sequencing (NGS) is more sensitive, and NGS-MRD negativity after CAR-T

cells has been shown to be associated with an improved long-term outcome

(Hay etal. 2019).

E. Jacoby et al.

Table 11.1 Clinical trials reporting the outcome of adult ALL treated with CAR-T cells

Group

n LD Construct Dose CR (%)

MRD neg

of CR

Consolidative

therapy

Comments

U.Penn

(Frey

etal.)

35 Cy (300×6,

n=25), Flu/Cy

(n=5), other

(n=3), none

(n=2)

FMC63-41BBz 5×10

single/

fractionated

24 (69) 100%

(ow)

9 HSCT, 15

none

2 y OS 47%;

fractionation of dose is

safer

FHCRC

(Hay etal.)

53 Cyclophosphamide

(n=11) vs. u/cy

(n=42)

FMC63-41BBz

at CD4:CD8

prespecied

ratios

2×10

/kg

(n=33),

2×10

/kg

(n=20)

45 (85) 100%

(ow),

71%

(20/28

NGS)

18 HSCT, 27

none

Low LDH and high

platelet levels pre-LD

improve outcome;

median OS 20months

in responders

MSKCC

(Park

etal.)

53 Cyclophosphamide

(3g/m

, n=43),

Flu/Cy (n=10)

MSKCC-28z 1–3×10

/kg 44 (83%) 72% (32

of 44)

17 HSCT, 26

none, 1 other

Median survival

12.9months

Beijing

(Dai etal.)

6 Flu/Cy CD19/22 (m971/

FMC63)-41BBz

1.7–3×10

/kg 6 (100) 100% 3 relapsed, short

follow-up time

UCL

AUTO1

(Roddie

etal.)

19 Flu/Cy CAT-41BBz 10–100×10

16 (84) 100% 2 HSCT, 14

none

Lu Daopei

(Zhang

etal.)

110 (39

adults)

Flu/Cy CD19-28z

(n=21),

CD19-41BBz

(n=89)

1–10×10

/kg 102 (92) 94% 75 HSCT, 27

none

Worse outcome with

TP53 mutations

11 Adult Acute Lymphoblastic Leukaemia

Consolidation After CAR-T Cell Therapy

Despite durable CAR-T cells being applied as denitive therapy for relapsed ALL

in children, adult data are controversial. Outcomes were not improved by allo-

HSCT in patients treated with CD28-based CAR-T cells, which have short-term

persistence (Park etal. 2018). In contrast, adults treated with CLT019 (Frey etal.

2019) had better outcomes if transplanted during CR after CAR-T cell therapy.

Several centres recommend allo-HSCT for adult ALL patients following CAR-T

cell therapy even in the presence of MRD-negative remission (Hay et al. 2019;

Zhang etal. 2020; Zhao etal. 2020). Patients with molecular MRD positivity fol-

lowing CAR-T cell therapy, patients with rapid loss of CAR-T cells, and patients

who have not received a previous HSCT are candidates for consolidative HSCT

(Jacoby 2019; Jiang etal. 2020).

Relapse After CAR-T Cell Therapy

Relapse after CAR-T cell therapy occurs in 30–50% of patients. In instances of

durable CAR-T cells, there is a higher probability that relapsed ALL will not express

CD19, occurring in up to 40% of cases. If CAR-T cells are lost early, CD19 expres-

sion may be preserved. A second dose of CAR-T cells led to rare responses in

patients with ALL who relapsed after CAR-T cell therapy or were refractory to this

treatment (Gauthier etal. 2020). Other therapies, such as novel antibody-based or

CAR-T cells targeting other antigens, are optional.

References

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adults. Blood. 2015;125:3702–10. https://doi.org/10.1182/blood- 2014- 11- 551481.

Dores GM, Devesa SS, Curtis RE, Linet MS, Morton LM.Acute leukemia incidence and patient

survival among children and adults in the United States, 2001–2007. Blood. 2012;119:34–43.

https://doi.org/10.1182/blood- 2011- 04- 347872.

Key Points

• No CAR-T cell product is approved for patients with ALL older than

25years.

• Clinical trial data for adult ALL are limited.

• CAR-T cells appear to me more effective and tolerated better if used in the

MRD setting of ALL.

• The use of consolidative HSCT after CAR-T cells in adults is still a matter

of debate.

E. Jacoby et al.

Frey NV, Luger SM. How I treat adults with relapsed or refractory Philadelphia chromosome-

negative acute lymphoblastic leukemia. Blood. 2015;126:589–96. https://doi.org/10.1182/

blood- 2014- 09- 551937.

Frey NV, Shaw PA, Hexner EO, Pequignot E, Gill S, Luger SM, et al. Optimizing chimeric

antigen receptor T-cell therapy for adults with acute lymphoblastic leukemia. J Clin Oncol.

2019;38:415–22.

Gardner RA, Ceppi F, Rivers J, Annesley C, Summers C, Taraseviciute A, etal. Preemptive miti-

gation of CD19 CAR-T cell cytokine release syndrome without attenuation of antileukemic

efcacy. Blood. 2019;134:2149–58. https://doi.org/10.1182/blood.2019001463.

Gauthier J, Bezerra ED, Hirayama AV, Fiorenza S, Sheih A, Chou CK, etal. Factors associated

with outcomes after a second CD19-targeted CAR-T cell infusion for refractory B cell malig-

nancies. Blood. 2020;137:323–35. https://doi.org/10.1182/blood.2020006770.

Ghorashian S, Kramer AM, Onuoha S, Wright G, Bartram J, Richardson R, et al. Enhanced

CAR-T cell expansion and prolonged persistence in pediatric patients with ALL treated

with a low- afnity CD19 CAR. Nat Med. 2019;25(9):1408–14. https://doi.org/10.1038/

s41591- 019- 0549- 5.

Hay KA, Gauthier J, Hirayama AV, Voutsinas JM, Wu Q, Li D, et al. Factors associated with

durable EFS in adult B-cell ALL patients achieving MRD-negative CR after CD19 CAR-T

cells. Blood. 2019;133:1652–63. https://doi.org/10.1182/blood- 2018- 11- 883710.

Iacobucci I, Mullighan CG. Genetic basis of acute lymphoblastic leukemia. J Clin Oncol.

2017;35:975–83. https://doi.org/10.1200/JCO.2016.70.7836.

Jacoby E.The role of allogeneic HSCT after CAR-T cells for acute lymphoblastic leukemia. Bone

Marrow Transplant. 2019;54:810–4. https://doi.org/10.1038/s41409- 019- 0604- 3.

Jiang H, Hu Y, Mei H.Consolidative allogeneic hematopoietic stem cell transplantation after chi-

meric antigen receptor T-cell therapy for relapsed/refractory B-cell acute lymphoblastic leuke-

mia: who? when? why? Biomark Res. 2020;8:66. https://doi.org/10.1186/s40364- 020- 00247- 8.

Kadauke S, Myers RM, Li Y, Aplenc R, Baniewicz D, Barrett DM, etal. Risk-adapted preemptive

tocilizumab to prevent severe cytokine release syndrome after CTL019 for pediatric B-cell

acute lymphoblastic leukemia: a prospective clinical trial. J Clin Oncol. 2021;39(8):920–30.

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Kantarjian HM, DeAngelo DJ, Stelljes M, Martinelli G, Liedtke M, Stock W, etal. Inotuzumab

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2016;375:740–53. https://doi.org/10.1056/NEJMoa1509277.

Kantarjian H, Stein A, Gökbuget N, Fielding AK, Schuh AC, Ribera J-M, etal. Blinatumomab ver-

sus chemotherapy for advanced acute lymphoblastic leukemia. N Engl J Med. 2017;376:836–47.

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Liu S, Deng B, Yin Z, Pan J, Lin Y, Ling Z, et al. Corticosteroids do not inuence the ef-

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CAR-therapy in acute lymphoblastic leukemia. N Engl J Med. 2018;378:449–59. https://doi.

org/10.1056/NEJMoa1709919.

Pillai V, Muralidharan K, Meng W, Bagashev A, Oldridge DA, Rosenthal J, etal. CAR-T cell ther-

apy is effective for CD19-dim B-lymphoblastic leukemia but is impacted by prior blinatumomab

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org/10.1182/blood- 2020- 137768.

11 Adult Acute Lymphoblastic Leukaemia

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cell therapy in 110 patients with B-cell acute lymphoblastic leukemia with high-risk features.

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Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

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The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

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the copyright holder.

E. Jacoby et al.

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_12

B. Glass

Clinic for Haematology, Oncology, Tumour Immunology, and Palliative Care, Helios

Klinikum Berlin-Buch, Berlin, Germany

e-mail: [email protected]

M. J. Kersten (

Department of Hematology, Amsterdam University Medical Centers, University of

Amsterdam, Amsterdam, The Netherlands

e-mail: [email protected]

Diffuse Large B Cell Lymphoma

andPrimary Mediastinal Lymphoma

BertramGlass andMarieJoséKersten

The outcome of patients with large B cell lymphoma (LBCL) who did not respond

to a classical immunochemotherapy regimen at any time or relapsed within 1 year

following chemoimmunotherapy is poor. The Scholar-One-Study showed long-term

event-free survival for less than 20% of these patients (Crump etal. 2017). The

introduction of chimeric antigen receptor T cell therapy (CAR-T) is a substantial

advancement for these patients, offering long-term remission and a curative pros-

pect for 30 to 40% of patients (summarized in Table12.1), (Abramson etal. 2020;

Neelapu etal. 2017; Schuster etal. 2019b). To date, in Europe, two products (axi-

cabtagene ciloleucel and tisagenlecleucel) have been licenced by the European

Medical Agency, and a third product (lisocabtagene maraleucel) will become avail-

able in 2022. All these products are licenced for patients who have failed at least two

prior lines of systemic therapy. This initially denes, however broad, a range of

possible situations in which the application of CART is indicated. The following

considerations may help to further dene the patient population that should be

offered CAR-T cells as the next line of treatment. Recently the results of three ran-

domized phase III clinical studies comparing CD19-CART with standard of Care in

transplant eligible patients were reported. The BELINDA-Trial using Tisa-cel did

not reach its primary endpoint EFS (Bishop et al. 2021). Two of the studies,

ZUMA-7 using the construct Axi-cel and TRANSFORM using Liso-cel were posi-

tive for their primary endpoint EFS as well as for the key secondary endpoints PFS

and ORR (Kamdar et al. 2021; Locke et al. 2021). In both studies a strong numerical

trend towards a positive result regarding OS was observed with Hazard ratios of

0.72 and 0.51, respectively. TRANSFORM had a short median observation time so

the results regarding OS were immature. In both studies showed signicant advan-

tages in quality of life for CART therapy over ASCT. Anti-CD19 CART therapy

with one of these compounds should be considered standard of care in transplant-

eligible patients as second line therapy in R/R LBCL.

Patient Population toConsider: Lymphoma-Specific Aspects

Treatment History

Depending on clinical risk factors, between 5 and 50% of LBCL patients may fail

standard rst-line immunochemotherapy (Coifer etal. 2010; Cunningham etal.

2013; Pfreundschuh etal. 2011; Schmitz etal. 2012). Overall, 30–40% of patients

will need salvage treatment. Patients eligible for high-dose chemotherapy currently

receive a platinum-containing salvage protocol, followed by high- dose chemother-

apy and autologous stem cell transplantation (autoSCT). In short, the remission rate

varies between 35 and 50%, and with another approximately 50% failure rate after

autoSCT, the overall long-term event-free survival rate is in the range of 25%. Thus,

approximately 75% of younger patients with relapsed/refractory aggressive B cell

lymphoma are theoretically eligible for CAR-T cell therapy. All young, t patients

without remission after salvage therapy in second- line situations should be consid-

ered for CAR-T cell therapy.

Elderly patients with relapsed or refractory LBCL have poor results with

second- line therapy. An analysis of the secondary overall survival of patients in a

large randomized rst-line study revealed that patients with primary refractory

disease never achieved long-term remission, and the median overall survival was

less than 6 months (Glass etal. 2017). In 20–30% of patients, induction of remis-

sion is possible with platinum- or bendamustine-containing regimens, such as

Table 12.1 Results of pivotal trials of anti-CD19 CAR-T cell therapy

References

Axi-cel

Zuma1

Tisa-cel

Juliet

Liso-cel

Transcend

n (pts infused vs. apheresed) 101/111 (91%) 115/167 (69%) 294/344 (85%)

Age 58 (23–76) 56 (22–76) 63 (18–86)

Prior lines of therapy (median) 3 (1–8) 2 (1–6) 3 (1–8)

Patients refractory (%) 78 (77%) 61 (55%) 181 (67%)

Bridging therapy (%) 0 92 59

ORR (%) 82 52 73

CR (%) 54 32 53

PFS (%) 41 31 44 (1 year)

TRM (%) 4 0 3

25 patients received a non-conforming product

B. Glass and M. J. Kersten

R- gemcitabine-oxaliplatin; however, due to the lack of effective consolidative

therapy, the long-term outcome was poor in all series (Dhanapal et al. 2017;

Franch-Sarto etal. 2019). In the three pivotal CD19 CAR-T trials, 23–42% of

patients were ≥65years old, and there are currently no indications that the ef-

cacy of CAR-T cells in terms of remission rate and progression-free survival is

inferior for elderly patients (Neelapu, Schuster, Abramson). In a real-world series,

the percentage of elderly patients was higher, and there was some evidence of

increased toxicity, especially neurotoxicity, but the efcacy appeared to be at last

equal (Pasquini CIBMTR, Nastoupil).

Therefore, the option of CAR-T cell therapy must be discussed for most trans-

plant ineligible but t patients with relapsed or refractory aggressive B cell lym-

phoma after 2 prior lines of systemic therapy.

Remission Status and Tumour Bulk Prior to CAR-T Cell Infusion

CAR-T cells have been evaluated in patients with refractory and early relapsed dis-

ease. In pivotal studies of the three licenced CAR-T products, the fraction of refrac-

tory patients varied between 52 and 79%. Being refractory to the last line of

chemotherapy was not a signicant prognostic factor in these studies. Therefore, in

contrast to autologous or allogeneic SCT, being in remission is not a prerequisite for

the application of CAR-T therapy. However, pivotal clinical studies and the rst

real-world evidence reports identify high tumour volume, reected by the sum of

product diameters (SPD) or simply an elevated LDH, prior to lymphodepleting

therapy as a signicant negative prognostic factor for the ongoing complete response

rate or PFS (Nastoupil etal. 2020), with a hazard ratio of 3.0. In addition, patients

with rapidly progressing disease often do not respond to attempts at bridging ther-

apy, and the need for systemic bridging therapy is a negative predictor for response

and survival.

When discussing the value of CAR-T cell therapy for an individual patient, this

parameter—disease control prior to CAR-T cell infusion—must be considered.

However, this parameter also has an impact on the results of any alternative treat-

ment, and at which point CAR-T cell therapy cannot achieve long-term remission

and should not be offered is still a matter of debate.

Histology

The majority of patients in ZUMA-1, JULIET, and TRANSCEND had DLBCL

(76%, 80% and 64%); transformed FL was present in 16–22% of cases, and only

a small number of patients with PMBCL (8% in ZUMA-1 and 6% in TRANSCEND)

were included. Data on DH/TH lymphoma were not available for all patients.

There were no signicant differences in response rates or PFS in specic

subgroups.

12 Diuse Large B Cell Lymphoma andPrimary Mediastinal Lymphoma

Patient Population toConsider: Patient-Specific Aspects

CAR-T cell therapy can lead to unusual and sometimes severe acute toxicities, with

cytokine release syndrome (CRS) and immune effector cell-associated neurotoxic-

ity (ICANS) being the most important. These toxicities typically occur between

Day 2 and Day 10 after infusion and may persist for several days to weeks.

Treatment-related mortality is a rare event, and in most cases, the toxicity is revers-

ible. Other important side effects include severe neutropenia, which may last for

several weeks or months, long-term B cell depletion, and hypogammaglobulinae-

mia, which is an on-target off-tumour toxicity. Compared to the morbidity and mor-

tality associated with other treatment modalities applied in this situation, such as

allogeneic SCT, the impact of CAR-T cell-associated toxicity on the overall out-

come is moderate. It has been claimed that the good results of CAR-T therapy in

terms of toxicity are due to the strict eligibility criteria of the pivotal studies, but

recent analyses of data from real-world application of CAR-T therapy showed that

efcacy and toxicity were similar, even if elderly and more comorbid patients were

treated (Nastoupil etal. 2020). The risk factors for TRM after CAR-T cell therapy

are not well dened, and conclusions from other treatment options might be difcult

to transfer to CAR-T cell therapy. The best approximation might be the use of the

high-dose chemotherapy comorbidity index and its results for patients undergoing

autologous SCT.In such an analysis, the HDT-correlated NRM ranged from 3.3 to

7.7% (Berro etal. 2017) after 1year, which is in line with what has been observed

after CAR-T cell therapy (therapy-related mortality <5%).

Alternative Treatments

In the past, allogeneic stem cell transplantation was the only option for consolida-

tion in chemorefractory patients after additional salvage therapy. Recently, anti-

body–drug conjugates and bispecic antibodies have shown interesting results in

the patient population discussed here. Polatuzumab vedotin, the rst drug in these

groups, has been licenced in Europe and the USA.Many other drugs may enter the

arena in the near future. Integration of CAR-T cell therapy with these new treatment

options will be a major task in the future.

• Allogeneic stem cell transplantation

In the past, alloSCT has mostly been used in patients who relapse after autolo-

gous stem cell transplantation, and data have been reported from international

registries (Fenske etal. 2016; van Kampen etal. 2011). One prospective clinical

trial in patients with high-risk aggressive lymphoma showed a PFS and OS of

39% and 40%, respectively, after 4years (Glass etal. 2014). Taking the potential

bias of indirect comparison of treatment results between studies and registry data

into account, it can be grossly stated that in many series of allogeneic stem cell

transplantation, the overall results in terms of progression-free survival may be

comparable to that of CAR-T therapy; however, the balance between the anti-

B. Glass and M. J. Kersten

lymphoma effect and toxicity is dramatically different from that of CAR-T ther-

apy. Treatment-related mortality and morbidity are dramatically higher after

allogeneic stem cell transplantation in any age group of patients. Thus, currently,

even in patients eligible for alloSCT, CAR-T cells should be offered rst.

Allogeneic SCT remains a treatment modality that should be considered in

patients failing CART therapy, provided they respond to salvage treatment.

• Antibody drug conjugates

Polatuzumab vedotin is the rst ADC that has been licenced for transplant-

ineligible patients with DLBCL after failure of at least one prior therapy. In the

pivotal randomized phase II study (Sehn etal. 2020a) and the recently reported

expansion cohort (Sehn etal. 2020b), the patient population treated was compa-

rable to the populations in most of the CAR-T cell studies. The best overall

response rate was 57.9%, with a CR rate of 52.6%. Some of the responses seem

to be ongoing after the end of treatment. With the limited number of patients and

the limited observation time, it can be estimated that approximately 15–20% of

patients might be in ongoing remission after 2years. Thus, the potential to serve

as a curative treatment is small if it exists at all, and a longer follow-up time and

validation in other prospective clinical trials are warranted. ADCs, such as

polatuzumab vedotin, might be good candidates for achieving control of the dis-

ease prior to CAR-T cell application in a so-called bridging approach.

Polatuzumab is licenced in combination with bendamustine, a drug with excep-

tionally high T cell toxicity. The application of bendamustine should be avoided

prior to apheresis of autologous T cells for CAR-T cell production.

• Bispecic antibodies

A number of bispecic, T cell-engaging antibodies using the CD20 antigen as

a lymphoma-specic target and CD3 as a T cell binding site have been reported

with very encouraging results (Table12.2) (Bannerji etal. 2020; Hutchings etal.

2020a,b; Schuster et al. 2019a). The response rates are high for some of the

agents, and the toxicity is quite limited. However, the observation time is still

short, and data on PFS are not yet available. There is an indication that the DOR

of patients achieving CR is particularly good thus far and in the same range as

that observed in trials of CAR-T cells. Bispecic antibodies may have the poten-

Table 12.2 Results of prospective randomized trials of second-line treatment for aggres-

sive B-NHL

Study

Salvage

regimen ORR (%) PFS/EFS OS FU

References

CORAL R-DHAP 62.8 51

42% 21%

EFS

51% 40%

years

Gisselbrecht

etal. (2010)

R-ICE 63.5 31% 47%

NCIC-CTG

LY.12

R-DHAP 44.1 26% EFS 39% 4

years

Crump etal.

(2014)

R-GDP 45.1 26% EFS 39%

ORCHARD R-DHAP 42 26% 38% 2

years

van Imhoff

etal. (2017)

O-DHAP 38 24% 41%

Results in patients receiving rituximab as rst-line therapy

The study included 8% of patients with T cell lymphoma; 67% of patients received prior rituximab

12 Diuse Large B Cell Lymphoma andPrimary Mediastinal Lymphoma

tial to induce long-lasting remissions without further consolidation, but this

treatment is often given until progression or toxicity occurs. Once available in

routine practice, their differential indication for treatment compared to CAR-T

cells will become an important clinical challenge and should preferably be inves-

tigated in head-to-head clinical trials.

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phosphamide, doxorubicin, vincristine, and prednisolone in patients with newly diagnosed dif-

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14-day versus 21-day cycles. Lancet. 2013;381:1817–26.

Key Points

• Patients with LBCL, including transformed FL and PMBCL, should be

considered for CD19 CAR-T cell therapy in cases of relapsed/refractory

disease after ≥2 lines of systemic therapy.

• There is no upper age limit, but patients should full eligibility criteria in

terms of tness, cardiac function, and other organ functions.

• Patients with high LDH and rapidly progressing disease are less likely to

benet.

B. Glass and M. J. Kersten

Dhanapal V, Gunasekara M, Lianwea C, Marcus R, De Lord C, Bowcock S, etal. Outcome for

patients with relapsed/refractory aggressive lymphoma treated with gemcitabine and oxaliplatin

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provides durable remission in a subset of DLBCL patients relapsing after autologous transplan-

tation. Br J Haematol. 2016;174:235–48.

Franch-Sarto M, Sorigue M, Lopez L, Moreno M, Ribera JM, Sancho JM. Overall survival in

patients with relapsed/refractory high grade B-cell lymphomas treated with gemcitabine, oxali-

platin with or without rituximab. Leuk Lymphoma. 2019;60:3324–6.

Gisselbrecht C, Glass B, Mounier N, Singh GD, Linch DC, Trneny M, etal. Salvage regimens

with autologous transplantation for relapsed large B-cell lymphoma in the rituximab era. J Clin

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relapsed aggressive B-cell lymphoma failing (R)-CHOP: an analysis of patients treated on the

RICOVER-60 trial. Ann Oncol. 2017;28:3058–64.

Hutchings M, Carlo-Stella C, Bachy E, Offner FC, Morschhauser F, Crump M, etal. Glotamab

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non-Hodgkin lymphoma. Blood. 2020a;136:46–8.

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Epcoritamab induces complete responses with an encouraging safety prole across relapsed/

refractory B-cell non-Hodgkin lymphoma subtypes, including patients with prior CAR-T ther-

apy: updated dose escalation data. Blood. 2020b;136:45–6.

van Imhoff GW, McMillan A, Matasar MJ, Radford J, Ardeshna KM, Kuliczkowski K, et al.

Ofatumumab versus rituximab salvage chemoimmunotherapy in relapsed or refractory diffuse

large B-cell lymphoma: the ORCHARRD Study. J Clin Oncol. 2017;35:544.

Kamdar M, Solomon SR, Arnason JE, Johnston PB, Glass B, Bachanova V, et al. Lisocabtagene

Maraleucel (liso-cel), a CD19-Directed Chimeric Antigen Receptor (CAR) T Cell Therapy,

Versus Standard of Care (SOC) with Salvage Chemotherapy (CT) Followed By Autologous

Stem Cell Transplantation (ASCT) As Second-Line (2L) Treatment in Patients (Pts) with

Relapsed or Refractory (R/R) Large B-Cell Lymphoma (LBCL): Results from the Randomized

Phase 3 Transform Study. Blood. 2021;138:91–91.

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Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

B. Glass and M. J. Kersten

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_13

N. Milpied

Department of Hematology and Stem Cell Transplantation, Centre Hospitalier Universitaire,

Bordeaux, France

e-mail: [email protected]

M. Dreyling (

Department of Medicine III, LMU Hospital, Munich, Germany

e-mail: [email protected]

Mantle Cell Lymphoma

NoelMilpied andMartinDreyling

Mantle cell lymphoma is a distinct lymphoma subtype with a widely varying clini-

cal course. Established high-risk biological factors include blastoid cytomorphol-

ogy, high cell proliferation (Ki-67>67%), and p53 mutations (Aukema etal. 2018).

While current rst-line approaches are still chemotherapy-based, BTK inhibitors

are the preferred targeted approach, especially in early relapse cases (POD24)

(Dreyling et al. 2017; Visco et al. 2021). However, cases of relapse/progression

under BTK inhibitors display extremely aggressive features with a dismal outcome

after conventional regimens (Martin etal. 2016).

Clinical Indications forCAR-T Cells

Following a conditional marketing authorization issued by the EMA in December

2020, Tecartus

(Gilead) is the rst autologous anti-CD-19 CAR-T cell therapy that

can be administered to patients with mantle cell lymphoma in Europe. Patients

deemed eligible for this treatment are those with histologically veried mantle cell

lymphoma resistant to or relapsing after two or more lines of treatment, including a

Bruton tyrosine kinase (BTK) inhibitor.

This registration is based on the results of recently reported a multicentre phase

2 trial (Wang etal. 2020a). Briey, 74 patients with a median age of 65 (38–79)

were enrolled, and 88% were refractory to or relapsed after BTK inhibitor treatment

at any time point. The CAR-T cell product could be manufactured for 71, and 68

received 2×10

CAR-T cells/kg on Day 0 after a conditioning regimen consisting

of udarabine (30mg/m

/day) and cyclophosphamide (500mg/m

/day) from Day 5

to Day 3. The overall response rate of all 74 patients (intent-to-treat population) was

85%, with a CR rate of 59%. More importantly, after 15months, 59% of the 60

evaluable patients were still in remission (Wang etal. 2020b) (Table13.1).

Interestingly, in contrast to conventional strategies, the percentages of patients

with an objective response were consistent among key subgroups, including patients

with high-risk features (Wang etal. 2020a).

Adverse events were mainly cytopenias (≥ grade 3: 94%) and infections (≥

grade 3: 32%). A total of 26% of the patients had grade 3 or higher cytopenias more

than 90days after the administration of KTE-X19, including neutropenia (in 16%

of patients), thrombocytopenia (16%), and anaemia (12%).

These encouraging results have also been conrmed for another CAR-T cell con-

struct (Lisocabtagene Maraleucel; Palomba etal. 2020).

Critical Evaluation

These excellent results were achieved in the context of a prospective study in highly

selected patients. Recently similar results have been reported in a “real life setting”

(Wang et al. 2021).

In the current algorithm of the approved indication, several other conditions must

be fullled before implementation of this treatment: careful work-up of the patient,

an experienced interdisciplinary team, and a specialized hospital with follow-up

resources. In future trials, the benet–risk ratio of this demanding treatment will be

rechallenged in earlier treatment lines.

Table 13.1 Updated response rates (Wang etal. 2020b)

ORR (%) CR (%)

PFS (%) OS (%)

12m 15m 12m 15m

Intent to Tx (74 patients) 85 59

Prim analysis (60 patients) 93 67 61 59 83 76

Key Points

• Patients with relapsed MCL progressing under the BTK inhibitor ibrutinib

should be considered for CD19 CAR-T cell therapy.

• Effective lymphodepleting chemotherapy is needed to allow expansion of

CAR-T cells.

N. Milpied and M. Dreyling

References

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of MCL independent of MIPI and Ki-67 in trials of the European MCL Network. Blood.

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phoma. Blood. 2016;127(12):1559–63.

Palomba ML, Gordon LI, Siddiqi T, etal. Safety and preliminary efcacy in patients with relapsed/

refractory mantle cell lymphoma receiving Lisocabtagene Maraleucel in TRANSCEND NHL

001. ASH; 2020, #118.

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patients with mantle cell lymphoma: results from the MANTLE-FIRST study. Leukemia.

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Wang M, Munoz J, Goy A, et al. One-year follow-up of ZUMA-2, the multicenter, registra-

tional study of KTE-X19 in patients with relapsed/refractory mantle cell lymphoma. ASH;

2020b, #1120.

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lymphoma: real world experience from the US lymphoma CAR T consortium. ASH 2021, #744.

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

13 Mantle Cell Lymphoma

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_14

O. Tournilhac (*)

Service d’Hematologie Clinique et de Therapie Cellulaire, CHU, Universite Clermont

Auvergne, Clermont Ferrand, France

e-mail: [email protected]

P. Dreger

Department of Medicine V, Hematology, Oncology and Rheumatology, University Hospital

Heidelberg, Heidelberg, Germany

e-mail: peter[email protected]

Chronic Lymphocytic Leukaemia

OlivierTournilhac andPeterDreger

Clinical Development ofCAR-T Cells forCLL

Although chronic lymphocytic leukaemia (CLL) was one of the rst two entities in

which CAR-T cells were evaluated, it has not yet arrived in the clinical routine.

Since the landmark study by Porter etal. (2011), only six CLL-specic clinical tri-

als have been published, altogether comprising no more than 155 patients (Porter

etal. 2015; Gill etal. 2018; Turtle etal. 2017; Gauthier etal. 2020; Siddiqi etal.

2020; Wierda et al. 2020; Frey et al. 2020). All six of these studies investigated

CD19-directed CAR-T constructs in heavily pretreated patients, mostly having

failed BTKi +/− venetoclax therapy. Despite overall response rates of 60–95%,

including MRD clearance in a large proportion of patients, the CR rates appear to

be relatively low, and only a few durable responses have been reported in patients

achieving a CR (Porter etal. 2015; Frey etal. 2020; Cappell etal. 2020). While

toxicity includes 5–20% grade 3 cytokine release syndrome and 5–25% grade 3

neurotoxicity and appears manageable, long-term efcacy remains an unresolved

issue. CLL-specic efcacy barriers for CD19 CAR-T cells could include a reduced

capacity for sustained T cell expansion in extensively pretreated elderly CLL

patients (Lemal and Tournilhac 2019), along with impaired T cell motility, impaired

T cell mitochondrial tness, and T cell exhaustion (Bair and Porter 2019). Concurrent

use of ibrutinib might reduce the CRS rate and severity (Gauthier etal. 2020; Gill

etal. 2018; Wierda etal. 2020) without impairing CAR-T cell expansion.

Current Indications forCAR-T Cells intheTreatment

Landscape ofCLL

In the absence of studies with informative sample sizes and follow-up and without

an approved CAR-T cell preparation available, there is currently no indication for

CAR-T cells in CLL outside of a clinical trial. However, if a suitable trial is avail-

able, CAR-T cells can be proposed as an alternative in patients with high-risk-2

CLL who have a high transplant risk according to the EBMT-ERIC recommenda-

tions (Dreger etal. 2018). In patients with a low transplant risk, allogeneic haema-

topoietic cell transplantation (alloHCT) still appears to be the more promising

approach in terms of long-term disease control (Tournilhac etal. 2020; Roeker etal.

2020; Mato etal. 2020). The advent of more effective CAR-T cell therapies for CLL

is eagerly awaited and may rapidly change this algorithm.

Prospective Studies ofAutologous Anti-CD19 CAR-T Cell

Therapy forCLL

Porter

etal.

(2015)

Frey

etal.

(2020)

Gill

etal.

(2018)

Turtle

etal.

(2017)

Gauthier

etal.

(2020)

Siddiqi

etal.

(2020)

Wierda

etal.

(2020)

Patients (n) 14 38 19 24 (5RT) 19 (4RT) 22 (1RT) 19

CAR-T

with

ibrutinib

CTL019

CART-

CTL119

Yes

JCAR014

Yes

JCAR017

Yes

Age (years) 66 (51–78) 61

(49–

76)

(42–76)

(40–73)

(40–71)

66 (50–80) 60

(50–77)

lines (n)

5 (1–11) 3.5

(2–7)

2 (1–16) 5 (3–9) 5 (1–10) 4 (2–11) 4 (2–11)

Ibrutinib

(R/R)

1 (1) 9 (?) 5 (0) 24 (19) 19 (19) 23 (17) 19 (19)

Venetoclax

(R/R)

0 1 0 6 (6) 11 (6) 13 (11) 11 (na)

CK (%) Na Na Na 67 74 48 42

TP53 alt.

(%)

43 39

58 Del=58 Del=74 Mut=61

Del=35

Mut=32

Del=42

ORR (%) 57 44

70 83

CR (%) 29 28

17 22

MRD(−)

BM (%)

29 na 78

• Currently, there is no standard indication for CAR-T cells in CLL.

• CAR-T cells may be an alternative to alloHCT in high-risk patients in

clinical trials.

O. Tournilhac and P. Dreger

Porter

etal.

(2015)

Frey

etal.

(2020)

Gill

etal.

(2018)

Turtle

etal.

(2017)

Gauthier

etal.

(2020)

Siddiqi

etal.

(2020)

Wierda

etal.

(2020)

CRS (all/

G3) (%)

64/43 63/24 95/16 83/8 74/0 74/9 74/5

NT (all/

G3) (%)

36/7 na/8 26/5 33/25 26/26 39/22 32/16

FU (m) 19 (6–53) 32

(2–75)

(8–28)

NA 12 (4–17) 24 10

PFS (m)

PFS >24m

(n)

28%

@18m

1m

8.5m

38%

@12m

50%

@18m

NRM (n)

cause

(infection)

(cardiac)

(CRS/

NT)

(cardiac)

RT Richter transformation, R/R relapsed/refractory, TP53 alt. TP53 mutation and/or 17p deletion,

CRS cytokine release syndrome, NT neurotoxicity, allG all grades, G≥3 grade≥3, na not avail-

able, CK complex karyotype (≥3 abnormalities), BM bone marrow, MRD(−) BM negative bone

marrow minimal residual disease, NRM non relapse mortality

Transcend CLL 004 study with lisocabtagene maraleucel

Assessment limited to evaluable patients

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with Ibrutinib for the treatment of chronic lymphocytic leukemia shows a high response rate.

Blood. 2018;132(Suppl 1):298.

Key Points

• Autologous CAR-T cells for CLL have been in development for almost

10years, with interesting results in poor-risk disease, including patients

double refractory to both BTKi and BCL2i.

• However, more data, including clinical trials with a longer follow-up time,

are required before adding CAR-T cells to clinical practice.

14 Chronic Lymphocytic Leukaemia

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Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

O. Tournilhac and P. Dreger

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_15

F. Morschhauser (*)

Department of Hematology, University of Lille, CHU Lille, ULR 7365– GRITA– Groupe de

Recherche sue les forms injectables et les Technologies Associees, Lille, France

e-mail: [email protected]

P. L. Zinzani

Institute of Hematology “L. e A.Seràgnoli” University of Bologna, Bologna, Italy

e-mail: [email protected]

Indolent Lymphomas

FranckMorschhauser andPierLuigiZinzani

Indolent non-Hodgkin lymphoma (iNHL), including follicular (FL) and marginal

zone (MZL) lymphoma, now enjoy durable disease control with rst-line immuno-

chemotherapy, with a median overall survival (OS) of over 15years in most series

(Kahl and Yang 2016). However, iNHL is still widely considered incurable in most

cases, and disease history remains characterized by a relapsing and remitting course,

with each remission period shorter than the previous one, and OS and progression-

free survival (PFS) decrease with each subsequent line of conventional therapy

(Batlevi etal. 2020). Patients with unmet needs include approximately 20% of FL

patients who experience disease progression within 24months (POD24) after initial

chemoimmunotherapy (with a 5-year OS of 48% (Casulo etal. 2015)—although it

remains unclear how much this worse outcome is driven by misdiagnosed trans-

formed follicular lymphoma (Freeman etal. 2019)); those who fail multiple regi-

mens (5-year PFS of 23%) (Rivas-Delgado et al. 2019), have double refractory

disease (Gopal etal. 2017) or experience relapse after autologous stem cell trans-

plantation (ASCT) (Sesques etal. 2020). Although promising results were obtained

with an immunomodulatory regimen combining anti-CD20 Moab and lenalidomide

(Leonard etal. 2019; Morschhauser etal. 2019), most current approved therapies do

not overcome incremental disease resistance, resulting in multiple lines of treatment

with cumulative toxicity over a patient’s lifetime. The autologous anti-CD19 chime-

ric antigen receptor T cell (CAR-T) therapies tisa-cel and axi-cel, which are now

approved for patients with relapsed/refractory (r/r) large B cell lymphoma (LBCL),

have also been tested in iNHL, with promising results.

The ZUMA-5 phase 2 trial evaluated the efcacy and safety of axi-cel in 146

patients with r/r iNHL (FL: 124; MZL: 22) after at least two lines of therapy

(Jacobson etal. 2020). Among the 104 patients available for the efcacy analysis

(84 with FL and 20 with MZL), the overall response rate (ORR) was 92%, with 76%

of patients obtaining complete remission (CR). In FL patients, the ORR was 94%,

with a CR rate of 80%. Response rates were consistent among patients with high-

risk features. With a median follow-up of 17.5months, 64% of FL patients remained

in response. The median duration of response (DoR), PFS, and OS were not reached

(Gopal etal. 2017). The safety prole was manageable and appeared favourable in

patients with FL compared with that previously reported in LBCL (Neelapu etal.

2017; Locke etal. 2019). Grade≥3 adverse events (AEs) occurred in 126 patients

(86%), most commonly neutropenia and infection. Fewer instances of any grade

(78%) and high-grade (6%) cytokine release syndrome (CRS) were observed in the

FL cohort. The onset of CRS was delayed compared with that seen in LBCL.The

event was not resolved in only one patient, who ultimately died due to multiorgan

failure (Jacobson etal. 2020). Fifty-six percent of patients experienced neurological

events (NEs) of any grade; 15% had grade≥3 events. Most NEs (67/70) resolved

by the data cut-off time (Jacobson etal. 2020).

The same reliable results were seen with tisa-cel. In the phase 2 ELARA study,

98 adult patients with r/r FL within 6months after second or later therapy or that

relapsed after ASCT were enrolled (Fowler et al. 2020). Ninety-seven patients

received tisa-cel, but 52 were evaluable for efcacy. Unlike the ZUMA-5 trial,

bridging therapy was allowed, and 43% of patients received it. Thirty-four of 52

patients (65.4%) achieved a CR, with an ORR of 82.7%. With a median follow-up

of 9.9months, 69% of patients were still in response. Median DoR, PFS, and OS

were not reached. Of the 97 patients evaluable for safety (median follow-up of

6.6months), 69% experienced grade≥3 AEs, most commonly neutropenia; 48% of

patients had CRS, but none of them experienced a grade≥3 AE.Any grade NEs

occurred in 10% of patients; 2% had a grade≥3 NE, and all recovered. No deaths

seen were treatment-related (Fowler etal. 2020).

These preliminary data from the ELARA and ZUMA-5 trials suggest that anti-

CD19 CAR-T cell treatment is effective in high-risk or extensively treated r/r iNHL,

resulting in a high CR and ORR. Although the benet/risk ratio seems highly

favourable in high-risk FL patients, such as young, double refractory, relapse post-

ASCT patients or those with POD24, longer follow-up times are needed to better

dene the potential for cure and the limited long-term toxicities, especially in view

of the emergence of highly efcient competitive therapies, such as bispecic anti-

bodies (Bannerji etal. 2020; Hutchings etal. 2020a,b; Assouline etal. 2020). Data

remain scarce in MZL.Clearly, phase III randomized trials are mandatory to con-

rm the role of CAR-T cells in R/R in NHL, especially in POD24 patients.

F. Morschhauser and P. L. Zinzani

References

Assouline SE, Kim WS, Sehn LH, etal. Mosunetuzumab shows promising efcacy in patients

with multiply relapsed follicular lymphoma: updated clinical experience from a phase I dose-

escalation trial. ASH Congress; 2020, abstract 702.

Bannerji R, Allan JN, Arnason JE, et al. Odronextamab (REGN1979), a human CD20 x CD3

bispecic antibody, induces durable, complete responses in patients with highly refrac-

tory B-cell non-Hodgkin lymphoma, including patients refractory to CAR-T therapy ASH

Congress; 2020, abstract 400.

Batlevi L, Sha F, Alperovich A, et al. Blood. Cancer J. 2020;10(7):74. https://doi.org/10.1038/

s41408- 020- 00340- z.

Casulo C, Byrtek M, Dawson KL, etal. Early relapse of follicular lymphoma after rituximab plus

cyclophosphamide, doxorubicin, vincristine, and prednisone denes patients at high risk for

death: an analysis from the National LymphoCare Study. J Clin Oncol. 2015;33(23):2516–22.

https://doi.org/10.1200/JCO.2014.59.7534. Epub 2015 Jun 29.

Fowler NH, Dickinson M, Dreyling M, et al. Efcacy and safety of tisagenlecleucel in adult

patients with relapsed/refractory follicular lymphoma: interim analysis of the phase 2 Elara

Trial ASH Congress; 2020, abstract 1149.

Freeman CL, Kridel R, Moccia AA, et al. Early progression after bendamustine-rituximab is

associated with high risk of transformation in advanced stage follicular lymphoma. Blood.

2019;134(9):761–4. https://doi.org/10.1182/blood.2019000258. Epub 2019 Jul 12.

Gopal AK, Kahl BS, Flowers CR, etal. Idelalisib is effective in patients with high-risk follicular

lymphoma and early relapse after initial chemoimmunotherapy. Blood. 2017;129(22):3037–9.

https://doi.org/10.1182/blood- 2016- 12- 757740. Epub 2017 Mar 21.

Hutchings M, Mous R, Roost Clausen M, et al. Subcutaneous Epcoritamab induces complete

responses with an encouraging safety prole across relapsed/refractory B-cell non-Hodgkin

lymphoma subtypes, including patients with prior CAR-T therapy: updated dose escalation

data. ASH Congress 2020a, abstract 402.

Hutchings M, Carlo-Stella C, Bachy E, etal. Glotamab step-up dosing induces high response

rates in patients with hard-to-treat refractory or relapsed non-Hodgkin lymphoma. ASH

Congress; 2020b, abstract 403.

Jacobson C, Chavez JC, Sehgal AR, et al. Primary analysis of Zuma-5: a phase 2 study of

Axicabtagene Ciloleucel (Axi-Cel) in patients with relapsed/refractory (R/R) indolent non-

Hodgkin lymphoma (iNHL). ASH Congress; 2020, abstract700.

Kahl BS, Yang DT. Follicular lymphoma: evolving therapeutic strategies. Blood.

2016;127(17):2055–63. https://doi.org/10.1182/blood- 2015- 11- 624288.

Key Points

• Anti-CD19 CAR-T cell treatment achieves high CR and ORRs in exten-

sively treated r/r FLs with an acceptable safety prole.

• The response appears durable, but the median follow-up time remains short.

• Data remain scarce in MZL.

• Phase 3 randomized trials are mandatory to conrm the role of CAR-T

cells in r/r iNHL, especially in POD24 patients.

15 Indolent Lymphomas

Leonard JP, Trneny M, Izutsu K, etal. AUGMENT: a phase III study of Lenalidomide plus ritux-

imab versus placebo plus rituximab in relapsed or refractory indolent lymphoma. J Clin Oncol.

2019;37(14):1188–99. https://doi.org/10.1200/JCO.19.00010. Epub 2019 Mar 21.

Locke FL, Ghobadi A, Jacobson CA, etal. Long-term safety and activity of axicabtagene cilo-

leucel in refractory large B-cell lymphoma (ZUMA-1): a single-arm, multicentre, phase 1-2

trial. Lancet Oncol. 2019;20(1):31–42. https://doi.org/10.1016/S1470- 2045(18)30864- 7. Epub

2018 Dec 2.

Morschhauser F, Le Gouill S, Feugier P, etal. Obinutuzumab combined with lenalidomide for

relapsed or refractory follicular B-cell lymphoma (GALEN): a multicentre, single-arm, phase 2

study. Lancet Haematol. 2019;6(8):e429–37. https://doi.org/10.1016/S2352- 3026(19)30089- 4.

Epub 2019 Jul 8.

Neelapu SS, Locke FL, Bartlett NL, etal. Axicabtagene Ciloleucel CAR-T cell therapy in refrac-

tory large B-cell lymphoma. N Engl J Med. 2017;377(26):2531–44. https://doi.org/10.1056/

NEJMoa1707447. Epub 2017 Dec 10.

Rivas-Delgado A, Laura Magnano L, Moreno-Velázquez M, etal. Response duration and survival

shorten after each relapse in patients with follicular lymphoma treated in the rituximab era. Br

J Haematol. 2019;184(5):753–9. https://doi.org/10.1111/bjh.15708. Epub 2018 Dec 4.

Sesques P, Bourcier J, Goler C, etal. Clinical characteristics and outcomes of relapsed follicular

lymphoma after autologous stem cell transplantation in the rituximab era. Hematol Oncol.

2020;38(2):137–45. https://doi.org/10.1002/hon.2713. Epub 2020 Jan 30.

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

F. Morschhauser and P. L. Zinzani

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_16

I. Yakoub-Agha

Maladies du Sang, Unité de Thérapie Cellulaire, Centre hospitalier-Universitaire de Lille,

Lille, France

e-mail: [email protected]

H. Einsele (

Department of Internal Medicine II, University Hospital Würzburg, Würzburg,

Bayern, Germany

e-mail: Einsele_H@ukw.de

Multiple Myeloma

IbrahimYakoub-Agha

andHermannEinsele

To date, over 100 clinical trials investigating the use of CAR-T cells in MM have

been registered at clinicaltrials.gov. Although several CD19-directed CAR-T cell

products have been approved (Ghobadi 2018; Yassine etal. 2020), CD19 surface

expression on plasma cells is limited or absent, leading to uncertain efcacy in clini-

cal trials that used anti-CD19 alone in patients with MM (Garfall etal. 2015, 2019).

Using superresolution microscopy, CD19 can be detected on a large proportion of

myeloma cells, which could explain the successful targeting and lysis of myeloma

cells by CD19-detecting CAR-T cells (Nerreter etal. 2019). Of note, some ongoing

studies in which CD19 is targeted in combination with other antigens, especially

BCMA, are being conducted (Beauvais etal. 2020).

BCMA-directed CAR-T cells have shown promising efcacy and safety proles

in various phase I/II clinical trials (Munshi etal. 2021; Brudno etal. 2018; Cohen

etal. 2019; Mailankody etal. 2020; Zhao etal. 2018). Indeed, the overall response

rate ranged from 75 to 100%, with median event-free survival ranging from 11 to

24months, in heavily pretreated MM patients, which is far better than all other cur-

rently available drugs and agents in this patient cohort.

At least two BCMA-directed CAR-T cell products will likely move into routine

clinical use in the near future. Outside clinical trials, the main indication for CAR-T

cell therapy in MM would be limited to patients with R/R MM after at least two

lines of prior therapy that included PIs (proteasome inhibitors), iMIDs

(immunomodulatory agents, e.g., lenalidomide, pomalidomide), and anti-C38

monoclonal antibodies.

Although CAR-T cell therapy appears promising, the duration of disease control

is limited, and almost all patients ultimately relapse. This might partially reect the

fact that CAR-T cells have thus far only been given to heavily pretreated patients

with advanced, resistant disease (Beauvais etal. 2020; Gauthier and Yakoub-Agha

2017). Thus, CAR-T cell exhaustion and the reduction and even irreversible loss of

expression of the target antigen BCMA on tumour cells (Da Vià etal. 2021; Samur

etal. 2021), which are often genetically highly unstable, are other factors limiting

CAR-T cell efcacy. Thus, novel targets or even dual targeting (including targeting

of GPRC5D (de Larrea et al. 2020), SLAMF7 (Gogishvili et al. 2017), CD229

(Radhakrishnan etal. 2020), and CD38 (Gauthier and Yakoub-Agha 2017; Verkleij

etal. 2020)) is currently being explored.

Additionally, to increase efcacy, CAR-T cell therapy is moved to earlier lines of

therapy to increase the tness and persistence of the generated MM-specic CAR-T

cells. However, CAR-T cell therapy in MM—less when compared to patients with

aggressive lymphomas—can be associated with substantial, potentially life-

threatening toxicity. Thus, administering CAR-T cells with a better effector func-

tion and proliferation potential may be a challenge as CAR-T therapy is used at

earlier stages of disease (Prommersberger etal. 2018).

References

Beauvais D, Danhof S, Hayden PJ, Einsele H, Yakoub-Agha I.Clinical data, limitations and per-

spectives on chimeric antigen receptor T-cell therapy in multiple myeloma. Curr Opin Oncol.

2020;32(5):418–26.

Brudno JN, Maric I, Hartman SD, Rose JJ, Wang M, Lam N, Stetler-Stevenson M, Salem D, Yuan

C, Pavletic S, etal. T cells genetically modied to express an anti-B-cell maturation antigen

chimeric antigen receptor cause remissions of poor-prognosis relapsed multiple myeloma. J

Clin Oncol. 2018;36(22):2267–80.

Cohen AD, Garfall AL, Stadtmauer EA, Melenhorst JJ, Lacey SF, Lancaster E, Vogl DT, Weiss

BM, Dengel K, Nelson A, etal. B cell maturation antigen-specic CAR-T cells are clinically

active in multiple myeloma. J Clin Invest. 2019;129(6):2210–21.

Key Points

• BCMA is the major target for CAR-T cell therapy in MM.

• Two BCMA-directed CAR-T cell products are moving into the clinical

routine in the near future (one has already been approved by the FDA

and EMA).

• Irreversible BCMA loss on MM cells has been described in a few patients

as a cause of failure of BCMA-directed CAR-T cells.

• CAR-T cell therapy is moving to earlier lines of therapy in MM patients.

I. Yakoub-Agha and H. Einsele

Da Vià MC, Dietrich O, Truger M, Arampatzi P, Duell J, Heidemeier A, Zhou X, Danhof S,

Kraus S, Chatterjee M, Meggendorfer M, Twardziok S, Goebeler ME, Topp MS, Hudecek M,

Prommersberger S, Hege K, Kaiser S, Fuhr V, Weinhold N, Rosenwald A, Erhard F, Haferlach

C, Einsele H, Kortüm KM, Saliba AE, Rasche L.Homozygous BCMA gene deletion in response

to anti-BCMA CAR-T cells in a patient with multiple myeloma. Nat Med. 2021;27(4):616–19.

Garfall AL, Maus MV, Hwang WT, Lacey SF, Mahnke YD, Melenhorst JJ, Zheng Z, Vogl DT,

Cohen AD, Weiss BM, et al. Chimeric antigen receptor T cells against CD19 for multiple

myeloma. N Engl J Med. 2015;373(11):1040–7.

Garfall AL, Stadtmauer EA, Hwang WT, Lacey SF, Melenhorst JJ, Krevvata M, Carroll MP,

Matsui WH, Wang Q, Dhodapkar MV et al. Anti-CD19 CAR-T cells with high-dose mel-

phalan and autologous stem cell transplantation for refractory multiple myeloma. JCI Insight.

2019;4(4):e127684.

Gauthier J, Yakoub-Agha I. Chimeric antigen-receptor T-cell therapy for hematological malig-

nancies and solid tumors: clinical data to date, current limitations and perspectives. Curr Res

Transl Med. 2017;65(3):93–102.

Ghobadi A.Chimeric antigen receptor T cell therapy for non-Hodgkin lymphoma. Curr Res Transl

Med. 2018;66(2):43–9.

Gogishvili T, Danhof S, Prommersberger S, Rydzek J, Schreder M, Brede C, Einsele H, Hudecek

M.SLAMF7-CAR-T cells eliminate myeloma and confer selective fratricide of SLAMF7(+)

normal lymphocytes. Blood. 2017;130(26):2838–47.

de Larrea CF, Staehr M, Lopez AV, Ng KY, Chen Y, Godfrey WD, Purdon TJ, Ponomarev V,

Wendel HG, Brentjens RJ, Smith EL.Dening an optimal dual-targeted CAR-T cell therapy

approach simultaneously targeting BCMA and GPRC5D to prevent BCMA escape-driven

relapse in multiple myeloma. Blood Cancer Discov. 2020;1(2):146–54.

Mailankody S, Jakubowiak AJ, Htut M, Costa LJ, Lee K, Ganguly S, Kaufman JL, Siegel DSD,

Bensinger W, Cota M, et al. Orvacabtagene autoleucel (orva-cel), a B-cell maturation anti-

gen (BCMA)-directed CAR-T cell therapy for patients (pts) with relapsed/refractory multiple

myeloma (RRMM): update of the phase 1/2 EVOLVE study (NCT03430011). J Clin Oncol.

2020;38(15_Suppl):8504.

Munshi NC, Anderson LD Jr, Shah N, Madduri D, Berdeja J, Lonial S, Raje N, Lin Y, Siegel D,

Oriol A, etal. Idecabtagene Vicleucel in relapsed and refractory multiple myeloma. N Engl J

Med. 2021;384(8):705–16.

Nerreter T, Letschert S, Götz R, Doose S, Danhof S, Einsele H, Sauer M, Hudecek M. Super-

resolution microscopy reveals ultra-low CD19 expression on myeloma cells that triggers elimi-

nation by CD19 CAR-T.Nat Commun. 2019;10(1):3137.

Prommersberger S, Jetani H, Danhof S, Monjezi R, Nerreter T, Beckmann J, Einsele H, Hudecek

M.Novel targets and technologies for CAR-T cells in multiple myeloma and acute myeloid

leukemia. Curr Res Transl Med. 2018;66(2):37–8.

Radhakrishnan SV, Luetkens T, Scherer SD, Davis P, Vander Mause ER, Olson ML, Yousef S,

Panse J, Abdiche Y, Li KD, Miles RR, Matsui W, Welm AL, Atanackovic D.CD229 CAR-T

cells eliminate multiple myeloma and tumor propagating cells without fratricide. Nat Commun.

2020;11(1):798.

Samur MK, Fulciniti M, Aktas Samur A, Bazarbachi AH, Tai YT, Prabhala R, Alonso A,

Sperling AS, Campbell T, Petrocca F, Hege K, Kaiser S, Loiseau HA, Anderson KC, Munshi

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Verkleij CPM, Jhatakia A, Broekmans MEC, Frerichs KA, Zweegman S, Mutis T, Bezman NA,

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16 Multiple Myeloma

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etal. A phase 1, open-label study of LCAR-B38M, a chimeric antigen receptor T cell therapy

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Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

I. Yakoub-Agha and H. Einsele

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_17

P. Corradini

Divisione di Ematologia, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano,

Università degli Studi di Milano, Milan, Italy

e-mail: [email protected]

L. Trümper (

Department of Hematology and Oncology, Georg-August University Göttingen,

Göttingen, Germany

e-mail: [email protected]

Developments inOther Haematological

Malignancies: Other Lymphoid

Malignancies

PaoloCorradini andLorenzTrümper

Peripheral T cell lymphomas comprise a heterogeneous group of rare diseases, rep-

resenting 10–15% of all non-Hodgkin lymphomas (NHLs). Upfront treatment for

peripheral T cell lymphoma (pTNHL) includes CHOP-like (cyclophosphamide,

adriamycin, vincristine, prednisone) multiagent chemotherapy with or without eto-

poside, followed by stem cell transplantation as consolidation in responsive t

patients. This approach induces durable long-term remission in approximately 40%

of cases; early refractoriness during induction occurs in approximately 25% of

patients, with the remaining patients typically relapsing within 24months. With the

exception of patients with anaplastic large cell lymphomas who are eligible to

receive brentuximab vedotin, there is no standard of care in the relapse setting. In

patients not eligible to receive high-dose chemotherapy followed by allogeneic stem

cell transplantation, the prognosis is dismal.

CAR-T cells have shown impressive results in relapsed/refractory B-cell lym-

phoma and are currently under investigation in T cell lymphomas.

Target Antigens

The choice of the appropriate antigen constitutes the main challenge in targeting T

cell malignancies using CAR-T cells. Many target antigens are expressed by both

physiological T cells and engineered CAR-T cells (Tables 17.1 and 17.2).

Therefore, this shared antigen expression can potentially result in the follow-

ing issues:

– A fratricide effect on CAR-T cells.

– Ablation of physiological donor T cells after CAR-T cell infusion, leading to

deep and/or long-lasting immune deciency and T cell aplasia.

CAR-T Development inT Cell Malignancies

Some experimentally engineered CAR-T cell products targeting CD5, CD7, CD30,

and TRBC1 (T cell receptor beta chain 1) have been tested (Table17.3).

Table 17.1 Pan-T cell antigens

CD5 Expression in T cells, thymocytes, B-1 cells, and T cell malignancies:

90% T-ALL/Ly

85% PTCL-nos

96% AITL

26–32% ALCL

36% NK-T

85% ATLL

91% CTCL

CD7 Expression in T cells, thymocytes, NK cells, and T cell malignancies:

95% T-ALL/Ly

50% PTCL-nos

57% AITL

32–54% ALCL

79% NK-T

25% ATLL

18% CTCL

Table 17.2 Antigens with restricted expression

CD30 Expression in activated T and B cells and in T cell malignancies:

17% T-ALL/Ly

16% PTCL-nos

32–50% AITL

93% ALCL

64% NK-T

39% ATLL

18% CTCL

TRBC1 Expression in T cells and in T cell malignancies:

7–11% T-ALL/Ly

27% PTCL-nos

34% AITL

25% ALCL

P. Corradini and L. Trümper

Table 17.3 CAR-T cells targeting T lymphocyte antigens

CAR-T cells

targeting

CD5

Mamonkin etal. (Blood 2015), preclinical experience:

– CD5 CAR-T cells eliminate malignant T-ALL/Ly lines invitro and inhibit

disease progression in xenograft mouse models

– Second-generation CD5 CAR with a CD28 costimulatory domain: With the

loss of CD5 expression on the surface of T cells, CD5 CAR-T cells become

resistant to fratricide

Hill etal. (Blood 2019), phase I dose escalation study, MAGENTA trial:

– 9 patients enrolled (4T-ALL, 5T-NHL)

– CD5 CAR-T cells are safe and can induce clinical responses (3 patients in

complete response) in heavily pretreated relapsed/refractory T-ALL and

T-NHL, without inducing T cell aplasia

CAR-T cells

targeting

CD7

Gomes-Silva etal. (Blood 2017), preclinical models of T cell malignancies:

– Fulminant fratricide precluding expansion of CAR-T cells

– Abrogation of CD7 expression from the cell surface shows potential activity

A phase I study (CRIMSON trial) has been designed at Baylor College of

Medicine but is not yet recruiting

CAR-T cells

targeting

TRBC1

Maciocia etal. (Nat Med 2017), preclinical studies:

– CAR-T cells targeting TRBC1 are able to specically eliminate malignant T

cell lines expressing TRBC1

– TRBC1 CAR-T cells cannot target normal TRBC2-positive T cells

A phase I/II study (AUTO4) coordinated by the University College of London

is a single-arm trial evaluating the safety and clinical activity of a CAR-T cell

targeting TRBC1in patients with relapsed/refractory TRBC1-positive T cell

lymphomas

CAR-T cells

targeting

CD30

Dotti etal. (Immunol Rev. 2014), preclinical studies:

– CAR-T cells targeting CD30 generate tumour-specic T cells in patients with

Hodgkin and anaplastic T cell lymphomas

– Tumour recognition by CD30 CAR-T cells is MHC-unrestricted

– CAR-T cells targeting CD30 potentially overcome tumour escape

Several small clinical trials are being reported; some studies are ongoing and

recruiting:

– Two CAR-T constructs are under investigation, one CAR-T cell with the

antigen-binding domain of the anti-CD30 and ant-CD28 costimulatory

domain and another CAR-T cell targeting CD30 and 4-1BB as a

costimulatory domain

– In the Ramos etal. phase I study, 9 patients with relapsed/refractory Hodgkin

and EBV-negative, CD30-positive ALCL have been treated; results are

promising, with 1 patient in complete remission and 3in stable disease,

without relevant toxicities

– Wang etal. enrolled 18 patients (17 Hodgkin, one ALCL); seven patients

achieved a partial response and six achieved stable disease, with limited

acute toxicities but an increased risk of infections

– Grover etal. enrolled 24 patients (Hodgkin, ALCL, EATL, and Sezary

syndrome) in a phase Ib/II study with anti-CD30 CAR-T cells, which

demonstrated early clinical effects and good tolerability and safety

– A phase I study is ongoing at the National Cancer Institute to assess safety

and feasibility in advanced CD30-positive ALCL and PTCL-NOS

17 Developments in Other Haematological Malignancies: Other Lymphoid…

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Key Points

• Target antigens are expressed by normal T cells, malignant T cells, and

engineered CAR-T cells.

• Therefore, the major concern for targeting T cell malignancies with CAR-T

cells is a fratricide effect.

• A second major issue is the ablation of normal T cells after CAR-T cell

infusion, potentially causing severe and/or long-lasting immune deciency

and T cell aplasia.

• Currently, the most promising constructs are CAR-T cells targeting CD30.

• Phase I and II studies are ongoing in T cell malignancies and Hodgkin

lymphoma, thus far demonstrating feasibility, tolerability, and potential for

clinical efcacy.

P. Corradini and L. Trümper

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

17 Developments in Other Haematological Malignancies: Other Lymphoid…

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_18

C. Ferrand

EFS– INSERM UMR1098 RIGHT– UBFC, Molecular Onco Hematology Lab, EFS

Bourgogne Franche-Comté, Besançon, France

e-mail: [email protected]

A. Rambaldi (

Department of Oncology-Hematology, University of Milan and Azienda Socio Sanitaria

Territoriale Papa Giovanni XXIII, Bergamo, Italy

e-mail: [email protected]

Myeloid Malignancies

ChristopheFerrand andAlessandroRambaldi

In addition to chemotherapy, which remains the basic treatment, the treatment panel

for acute myeloid leukaemia (AML) has expanded considerably in recent years.

Clinicians now have a large choice of therapies: targeted therapies (anti-IDH1/2,

anti-FLT3, and anti-BCL2 therapies, among others), drugs targeting epigenetic

mechanisms, kinase inhibitors (FLT3, MAPK, and JAK2, etc.), immunotherapies

(monoclonal antibodies linked or not to a toxin, dual/bispecic), and cellular immu-

notherapies. Moreover, despite its toxicities, allogeneic transplantation often

remains an effective nal therapeutic alternative. However, most patients are refrac-

tory or relapsed (R/R) after several lines of therapy. Thus, there is a clinical need in

AML R/R patients, and CAR-T cells may be an option and can nd a place in the

treatment to reduce tumour burden and clinical evolution of the disease (Fig.18.1,

modied from Roussel etal. (2020)).

Several currently ongoing research programs aim to generate CAR-T cells

against myeloid malignancies (Hofmann etal. 2019). However, the absence of a

truly AML-specic marker generates remarkable uncertainty regarding the optimal

antigens to target, and signicant concern remains about off-target effects on nor-

mal haematopoiesis. The difculty of obtaining successful manufacture of CAR-T

cells from heavily pretreated patients has paved the way to investigation of different

cell sources to build alternative platforms for cellular therapy.

Single or Dual Antigen Targeting?

CAR-T cells targeting CD33 and CD123 have already been investigated in early

phase clinical trials. Unfortunately, these antigens do not avoid “on-target off-

tumour” effects, such as myelotoxicity and endothelial toxicity. For this reason,

CAR-T cells directed against other surface proteins, such as CCL-1, CD44v6,

FLT3, c-KIT (CD117), CD38, B7-H3 (also known as CD276), NKG2D, and

IL-1RAP, are also under preclinical and clinical investigation (Table18.1).

CD123 CAR-T cells induce haematopoietic toxicity but on a smaller scale than

CD33 CAR-T cells, particularly following anti-CD123 single chain fragment vari-

able (scFv) modications (Mardiros et al. 2013; Gill et al. 2014; Thokala et al.

2016). Nevertheless, based on their expression on stem cells, CD123 CAR-T cells

could be used as a myeloablative regimen before ASCT, thus representing an inter-

esting strategy for treatment of R/R AML patients (Gill etal. 2014; Cummins and

Gill 2019; Testa etal. 2019). Notably, IL-15 may enhance the anti-AML activity of

CD123 CAR-T cells (Mu-Mosley etal. 2019). Targeting FLT3 or CD117 could be

an attractive option, again in association with ASCT (Jetani etal. 2018; Myburgh

etal. 2020). Targeting of the Lewis Y antigen and NKG2DL CAR-T cells has also

been proposed, but phase 1 trials have shown short response durations, despite

reduced toxicity (Ritchie etal. 2013; Driouk etal. 2019). CAR-T cells targeting

CD44v6 mediate potent antitumour effects against AML while sparing normal hae-

matopoietic stem cells (Casucci etal. 2013), and a clinical trial is currently ongoing.

A potent effect on LSCs was observed with CAR-T cells targeting IL1RAP (Warda

etal. 2019) with no apparent effect on healthy haematopoietic stem cells. Similar

more specic antileukaemic activity was observed by targeting FLT3 and KIT

mutations (Mitchell etal. 2018). Interestingly, targeting IL1RAP decreases IL-1,

IL-6, IL-10, IL-13, IL-17, IL-22, IFNγ, and TNFα levels (Højen etal. 2019). The

Chemotherapy

Targeted

inhibitors

CAR T-cells

Induction

Consolidation

Salvage

ASCT

Consolidation

Maintenance

+/- ASCT

HMA

Ta rgeted inhibitor

Immunotherapy

CAR T-cells

HMA

Ta rgeted inhibitor

Immunotherapy

DLI

HMA

Ta rgeted inhibitor

Immunotherapy

tgTCR T-cells

Salvage ASCT

Maintenance

Relapse

CAR T-cells targeting:

• CD33

• CD33/CD123

• CD123

• CD44v6

• CD123/CCL-1

• CD13/TIM-3

• LeY

• NKGD2L

• FLT3

• IL-1RAP

T-cells

CAR

CD33

CD13

TIM-3

CD123

CD44v6

CCL-1

LeY

NKG2DL

IL-1RAP

FLT3

KIT

IL-1R

IL-33R

IL-36R

AML blast

AML Cell surface makers

AML tumor burden

AML disease status evolution

Fig. 18.1 Putative place of CAR-T cells in the AML treatment strategy. HMA hypomethylated

agent, DLI donor lymphocyte infusion, tgTCR transgenic T cell receptor T cells, ASCT allogeneic

stem cell transplantation

C. Ferrand and A. Rambaldi

reduced production of IL-4, IL-6 and IL-10 and absence of IL-17 production (Warda

etal. 2019) may in turn limit CAR-T cell cytokine release syndrome (CRS) and the

immune effector cell-associated neurotoxicity syndrome (ICAN) associated with

excessive production of IL-1 (Garcia Borrega etal. 2019). Notably, the reduction in

IL-1β, IL-6, and TNFα levels leads to decreased release of IL-10 and TGFβ, which

impair CAR-T cell functions (Epperly etal. 2020).

CAR-T cells simultaneously targeting CD33 and CD123 are also in development

and exhibit pronounced antileukaemic activity (Petrov et al. 2018). Similarly,

CD123 and CCL-1 compound CAR-T cells may be useful for active targeting of

leukaemia stem cells (LSCs) (Morsink etal. 2018; Shang and Zhou 2019).

Table 18.1 CAR-T cell immunotherapies under investigation in AML (based on www.clinicaltri-

als.gov at 05/25/2020)

CAR-T cells

Preclinical results Status

Clinical trials

CD33 Myeloablative, ASCT

requirement

Phase 1 NCT03126864

Phase 1/2 NCT03971799, NCT01864902

CD123 Myeloablative, ASCT

requirement

Phase 1 NCT03796390, NCT03585517,

NCT03114670, NCT03766126,

NCT04014881, NCT03190278,

NCT02159495, NCT04230265,

NCT04318678, NCT03672851

Phase 1/2 NCT04272125, NCT04265963,

NCT04109482, NCT03556982

CCL-1 AML and HSC targeting Phase 1 NCT04219163

CD38 AML targeting Phase 1/2 NCT04351022

CD44v6 AML targeting Phase 1/2 NCT04097301

FLT3 Myeloablative, ASCT

requirement

Phase 1 NCT03904069

KIT (CD117) Myeloablative, ASCT

requirement

Preclinical NCT03473457

B7-H3 HSC toxicity reduction Preclinical None

CD13 TIM-3 HSC toxicity reduction Preclinical None

PD-1 Antitumour enhancement Preclinical None

Lewis Y Short duration of response,

few toxicities

Phase 1 NCT01716364, no further study

NKGD2L Short duration of response,

few toxicities

Phase 1 NCT02203825, no further study

IL1RAP LSC targeting Preclinical NCT04169022

CD33/CD123 AML and HSC targeting Phase 1 NCT04156256

CCL-1/CD123 AML targeting Phase 2/3 NCT03631576

CCL-1/CD33 AML targeting Phase 1 NCT03795779

CCL-1/CD33

and/or CD123

AML targeting Phase 1/2 NCT04010877

Muc1/CLL1/

CD33/CD38/

CD56/ CD123

AML targeting Phase 1/2 NCT03222674

Studies investigating T cell immunotherapies in AML. AML acute myeloid leukaemia, LSC leu-

kaemic stem cell, HSC haematopoietic stem cell, ASCT allogeneic stem cell transplantation

18 Myeloid Malignancies

100

Bispecic CD13-TIM-3 CAR-T cells (He etal. 2020) and B7-H3 CAR-T cells

(Lichtman etal. 2018) showed reduced HSC toxicity. Moreover, the B7-H3 pan-

cancer target was also studied in solid tumours (Waldman etal. 2020). Preliminary

reports show that PD-1 inhibitors also regulate the CAR-T cell response, although

few data are available. Furthermore, delivery of PD-1-blocking scFv CAR-T cells

in preclinical investigations demonstrated interesting antitumour efcacy enhance-

ment (Anonymous 2019). Several challenges remain to be overcome, as recently

reported, and further investigations may provide a better understanding (Mardiana

and Gill 2020).

Molecular Engineering oftheChimeric Receptor

andAlternative Cell Sources

Beyond the selected target, optimizing the molecular engineering of the chimeric

receptor remains crucial. CD33 4-1BBz CAR-T cells have shown antileukaemic

activity and resistance to exhaustion with increasing central memory comportment

(Li etal. 2018). An additional strategy that has been proposed to reduce haemato-

poietic toxicity is the use of a transiently expressed CART33 to induce self-limiting

activity against AML cells (Kenderian etal. 2015). Another proposed strategy is to

inactivate the CD33 gene in HSCs prior to transplantation to prevent CD33-induced

haematopoietic toxicity of CAR-T cells (Kim etal. 2018).

In addition, to avoid or reduce the uncontrolled toxicity of expanding CAR-T

cells, the use of the anti-CD52 antibody alemtuzumab or a suicide gene strategy

based on CD20 protein coexpression in CD123 CAR-T cells has been proposed for

subsequent anti-CD20 targeting with rituximab (Introna et al. 2000; Tasian

etal. 2017).

Several clinical trials are currently evaluating the use of allogeneic CAR-T cells

in haematologic malignancies, employing different effector cell types, such as NK

cells (Daher and Rezvani 2021) or TCR-edited cells (Provasi etal. 2012), to limit

GvHD and develop strategies to avoid the rejection of allogeneic cells. In this

regard, the limited GvHD associated with the use of cytokine-induced killer (CIK)

cells (Martino Introna etal. 2017) was conrmed in a phase I/IIa study in which

B-ALL patients who relapsed after allogeneic transplantation were treated using

CD19-specic CAR CIK cells (CARCIK-CD19) manufactured from a previous

transplant donor (Magnani etal. 2020). Notably, this study provides evidence of the

feasibility of employing a nonviral sleeping beauty transposon system to success-

fully produce CARCIK cell products starting from a small amount of donor-derived

PB, thus offering a valid alternative to viral vectors. The use of CAR-engineered

CIK cells was also demonstrated to be effective for AML by characterizing the tar-

geting of the two most validated AML molecules, CD33 and CD123, invitro and

invivo (Tettamanti etal. 2013; Pizzitola etal. 2014; Arcangeli etal. 2017; Rotiroti

etal. 2020).

C. Ferrand and A. Rambaldi

101

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Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

18 Myeloid Malignancies

105

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_19

P. Pedrazzoli

Oncology Unit, Fondazione IRCCS Policlinico San Matteo, Department of Internal Medicine

and Medical Therapy, University of Pavia, Pavia, Italy

e-mail: [email protected].it

J. B. A. G. Haanen (

Divisions of Medical Oncology and Molecular Oncology & Immunology, The Netherlands

Cancer Institute, Amsterdam, The Netherlands

e-mail: [email protected]

Developments inSolid Tumours

PaoloPedrazzoli andJohnB.A.G.Haanen

Chimeric antigen receptor (CAR) T cells have emerged as breakthrough therapies in

patients with refractory haematologic malignancies, and the highly encouraging

clinical results have fuelled expectations of implementing these strategies in other

cancer types. However, a similar success of CAR-T cell treatment has not yet been

observed in solid tumours. Various factors, including the immunosuppressive nature

of the tumour microenvironment, hinder of CAR-T cell trafcking and inltration

into scarcely accessible tumour sites, and difculties in identifying targetable anti-

gens with optimal expression and a good toxicity prole, and limiting CAR-T dose

escalation, must be overcome to achieve success in the treatment of solid cancers

(Comoli etal. 2019).

Several clinical trials have tested the efcacy of CAR-T cells in solid tumours.

To date, clinical results have not been encouraging, with a general lack of therapeu-

tic response and the presence of on-target off-tumour toxicity. However, some stud-

ies have achieved promising outcomes that justify further exploration of this

approach in solid tumours, as is happening in many areas of the world (Comoli

etal. 2019).

Early experiences with GD2-specic CAR-T cells showed objective responses in

paediatric patients with neuroblastoma (Pule etal. 2008). Since then, lymphocytes

have been engineered via insertion of third-generation CARs and, more recently, by

delivery of a GD2-CAR-IL-15 construct to NK cells (Heczey etal. 2020).

106

Similarly, the safety and antitumour activity of CAR-T cells targeting a variety

of antigens, such as IL-13Rα2, epidermal growth factor receptor-vIII, and human

epidermal growth factor receptor-2 (HER2), have been assessed in patients with

glioblastoma multiforme (GBM). Infusion of second-generation CD28ζ HER2-

specic CAR-modied virus-specic T cells was well tolerated, with no dose-

limiting toxic effects, and led to clinical benet; 1 patient showed a partial response

(PR) lasting more than 9months, and 7 patients had stable disease (SD) for several

months (Ahmed etal. 2017). Other clinical trials have demonstrated the feasibility,

safety, and clinical efcacy of second-generation EGFRvIII-specic and IL13BBζ–

specic CAR-T cells (Brown etal. 2016) in patients with refractory GBM.

In gastrointestinal neoplasms, a clinical trial utilizing CEA CAR-T therapy in ten

patients with metastatic colorectal cancer (CRC) resulted in SD in seven patients,

without severe adverse events related to CAR-T therapy (Zhang etal. 2017). A pre-

vious case report of HER2-specic cell therapy for CRC using third generation

CAR-T cells caused fatal acute respiratory distress syndrome due to recognition of

lung epithelial cells expressing low levels of HER2 (Morgan etal. 2010). A phase I

study of second-generation CAR-T cells targeting HER2 was conducted in 11

patients with advanced biliary tract cancer or pancreatic cancer. A 4.5-month partial

response was observed, and 5 subjects achieved stable disease. Toxicity was man-

ageable, with grade 3 fever and one patient showing elevation of liver enzymes as

CAR-T-related adverse events; one episode of reversible severe upper gastrointesti-

nal haemorrhage occurred in a patient with gastric involvement 11days after the

HER2 CAR-T- cell infusion, and 2 cases of grade 1–2 delayed fever accompanied

by increases in C-reactive protein and interleukin-6 were observed (Feng et al.

2018). Epidermal growth factor receptor (EGFR) and CD133-specic CAR-T

sequential immunotherapy were employed by the same group in a patient with

advanced unresectable/metastatic cholangiocarcinoma (CCA), resulting in a PR

lasting more than 12 months; however, slight liver toxicity secondary to EGFR

CAR-T therapy and epidermal and endothelial damage due to CD133-specic

CAR-T immunotherapy was observed.

Similar to these experiences, second-generation HER2-specic CAR-T cells,

used in a phase I clinical trial conducted on 19 patients with refractory HER2-

positive sarcoma, induced SD lasting from 12weeks to 14months in 4 of the evalu-

able patients (Ahmed etal. 2015).

Investigators at the University of Pennsylvania explored an approach based on

mRNA-transduced CAR-T cells that target mesothelin (meso CAR-T) in patients

with advanced malignant pleural mesothelioma (MPM) or advanced pancreatic can-

cer. In the rst two patients reported, meso CAR-T cells showed some antitumour

activity in vivo in the absence of distinct toxicities (Beatty et al. 2014). Second-

generation CAR-T cells specic for EGFR were employed in a phase I study to treat

11 patients with advanced non-small-cell lung cancer (NSCLC), resulting in 2 PR

cases and 5 SD cases, lasting from 2 to 8months, with limited adverse events, includ-

ing skin toxicity, nausea, vomiting, dyspnoea, and hypotension (Feng etal. 2016).

A few phase I studies and case series have reported CAR-T cell treatment for

other solid tumours, such as melanoma, breast cancer, renal cell carcinoma, prostate

cancer, and ovarian and seminal vesicle cancer (reviewed Fucà etal. 2020).

P. Pedrazzoli and J. B. A. G. Haanen

107

Various toxicities were observed after CAR-T cell infusion for treatment of solid

tumours. In the setting of haematologic malignancies, cytokine release syndrome

(CRS) is a frequent, potentially severe adverse event following CAR-T cell therapy.

However, CRS, as well as the neurological toxicity (ICAN) sometimes observed in

the haematologic setting, has not yet become a common event after CAR-T cell ther-

apy for solid tumours, perhaps because of the lower tumour load. Conversely, CAR-T

cells trials conducted in solid tumour cohorts showed critical, unexpected on-target,

off-tumour toxicities resulting from the recognition by CAR-T cells of tumour anti-

gens expressed on healthy tissues (Morgan etal. 2010; Lamers etal. 2013). Targeting

tumour-specic antigens appears to result in fewer off-tumour effects, but whether

these CAR-T cells have promising clinical efcacy remains to be seen, and many tri-

als are still ongoing. Strategies to increase tumour selectivity while sparing healthy

tissues are being evaluated to control on-target off-tumour toxicity.

Despite novel genetic engineering techniques and combinatorial approaches to

counteract biological barriers, tumour heterogeneity, and the immunosuppressive

properties of the tumour microenvironment, targeting solid tumours with CAR-T

cells in the clinical setting remains challenging. Therefore, T cell therapy, alone or

in combination with immune checkpoint inhibitors or other agents targeting either

the cancer cell or the tumour environment, will likely play a role in improving can-

cer treatment outcomes (Apetoh et al. 2015). Designing and selecting the most

appropriate clinical trials or settings to rapidly identify combinatorial approaches

that are efcacious in different patient populations and identifying patients who will

best benet from immune checkpoint inhibitors alone (Chalabi etal. 2020) or from

the addition of other targeted immunotherapies will be the most pressing need for

the future success of CAR immunotherapy in solid cancer.

References

Ahmed N, Brawley VS, Hegde M, et al. Human epidermal growth factor receptor 2 (HER2)-

specic chimeric antigen receptor-modied T cells for the immunotherapy of HER2-positive

sarcoma. J Clin Oncol. 2015;20(33):1688–96.

Ahmed N, Brawley V, Hegde M, etal. HER2-specic chimeric antigen receptor-modied virus-

specic T cells for progressive glioblastoma: a phase 1 dose-escalation trial. JAMA Oncol.

2017;3:1094–101.

Key Points

• CAR-T therapy is under development for many solid cancer types, but

important breakthroughs have not yet been achieved.

• Tumour heterogeneity, the immunosuppressive tumour microenvironment,

and other barriers are hurdles that must be overcome before CAR-T cells

can be effective against solid cancers.

• The eld may benet from network models for CAR-T cell production in

academic centres.

19 Developments inSolid Tumours

108

Apetoh L, Ladoire S, Coukos G, etal. Combining immunotherapy and anticancer agents: the right

path to achieve cancer cure? Ann Oncol. 2015;26:1813–23.

Beatty GL, Haas AR, Maus MV, et al. Mesothelin-specic chimeric antigen receptor mRNA-

engineered T cells induce anti-tumor activity in solid malignancies. Cancer Immunol Res.

2014;2:112–20.

Brown C, Alizadeh D, Starr R, etal. Regression of glioblastoma after chimeric antigen receptor

T-cell therapy. N Engl J Med. 2016;375:2561–9.

Chalabi M, Fanchi LF, Dijkstra KK, et al. Neoadjuvant immunotherapy leads to pathologi-

cal responses in MMR-procient and MMR-decient early-stage colon cancers. Nat Med.

2020;26:566–76.

Comoli P, Chabannon C, Koehl U, Lanza F, Urbano-Ispizua A, Hudecek M, Ruggeri A, Secondino

S, Bonini C, Pedrazzoli P.Development of adaptive immune effector therapies in solid tumors.

Ann Oncol. 2019;30:1740–50.

Feng K, Guo Y, Dai H, etal. Chimeric antigen receptor-modied T cells for the immunotherapy

of patients with EGFR expressing advanced relapsed/refractory non-small cell lung cancer. Sci

China Life Sci. 2016;59:468–79.

Feng K, Liu Y, Guo Y, Qiu J, Wu Z, Dai H, etal. Phase I study of chimeric antigen receptor modi-

ed T cells in treating HER2-positive advanced biliary tract cancers and pancreatic cancers.

Protein Cell. 2018;9:838–47.

Fucà G, Reppel L, Landoni E, Savoldo B, Dotti G.Enhancing chimeric antigen receptor T-cell

efcacy in solid tumors. Clin Cancer Res. 2020;26:2444–51.

Heczey A, Courtney AN, Montalbano A, Robinson S, Liu K, Li M, Ghatwai N, Dakhova O, Liu

B, Raveh-Sadka T, Chauvin-Fleurence CN, Xu X, Ngai H, Di Pierro EJ, Savoldo B, Dotti G,

Metelitsa LS. Anti-GD2 CAR-NKT cells in patients with relapsed or refractory neuroblas-

toma: an interim analysis. Nat Med. 2020;26:1686–90.

Lamers CH, Sleijfer S, van Steenbergen S, etal. Treatment of metastatic renal cell carcinoma with

CAIX CAR-engineered T cells: clinical evaluation and management of on-target toxicity. Mol

Ther. 2013;21:904–12.

Morgan RA, Yang JC, Kitano M, Dudley ME, Laurencot CM, Rosenberg SA.Case report of a seri-

ous adverse event following the administration of T cells transduced with a chimeric antigen

receptor recognizing ERBB2. Mol Ther. 2010;18:843–51.

Pule M, Savoldo B, Myers GD, etal. Virus-specic T cells engineered to coexpress tumor-specic

receptors: persistence and antitumor activity in individuals with neuroblastoma. Nat Med.

2008;14:1264–70.

Zhang C, Wang Z, Yang Z, etal. Phase I escalating-dose trial of CAR-T therapy targeting CEA(+)

metastatic colorectal cancers. Mol Ther. 2017;25:1248–58.

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

P. Pedrazzoli and J. B. A. G. Haanen

Part IV

Clinical Management of Patients

Treated with CAR-T Cells

111

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_20

N. Boissel

URP-3518, Institut de Recherche Saint-Louis, Université de Paris, Paris, France

Service d’Hématologie Adolescents et Jeunes Adultes, Assistance Publique des Hôpitaux de

Paris, Paris, France

e-mail: [email protected]

F. Ciceri (

Vita-Salute San Raffaele University, Milan, Italy

Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Hospital,

Milan, Italy

e-mail: ciceri.fabio@hsr.it

Bridging Chemotherapy: Adult Acute

Lymphoblastic Leukaemia

NicolasBoissel andFabioCiceri

Bridging therapy can be given after leukapheresis and before lymphodepletion dur-

ing CAR-T cell manufacturing. The primary goal of bridging therapies is to prevent

uncontrolled progression of the underlying disease during the manufacturing period

before CAR-T cell infusion. Several studies indicate that a high tumour burden is

associated with an increased risk of complications after CAR-T cell infusion (Cohen

et al. 2019). Therefore, controlling the disease and even possibly decreasing the

tumour burden is critical during the manufacturing period. The choice of bridging

therapies is essential for the success of the procedure.

Clinical trials of CD19 CAR-T therapy in B-ALL reproducibly report high rates

of patient dropout after enrolment due to disease progression or treatment-related

complications (Park etal. 2018; Maude etal. 2018). For example, among 75 patients

who received a CAR-T infusion in the ELIANA study, 65 (87%) were treated with

bridging chemotherapy between enrolment and infusion, and 10 out of 92 patients

enrolled in the trial could not be infused due to signicant adverse events or death

(Maude et al. 2018). The rate of adult patients infused in the Memorial Sloan

Kettering (MSKCC) experience was 65% (54/83, 65%) of enrolled patients, mostly

due to disease progression and death (Park etal. 2018). This reects the challenges

in clinical management during the 3–6-week period necessary for autologous

CAR-T cell preparation (the bridging period).

112

Given that CD19 CAR-T therapies are currently indicated for relapsed/refractory

B-ALL patients who have already been exposed to one or more lines of potentially

effective therapies, often including combinations of several agents, and that these

patients often require therapeutic intervention against rapidly progressive disease or

a high tumour burden, the choice of the better approach is not trivial.

Several bridging therapy options now exist, including high-intensity chemo-

therapy, targeted agents (e.g., TKIs), immunotherapies (e.g., CD-19 or CD22-

directed), and low-intensity approaches (e.g., vincristine, 6-MP, steroids,

thioguanine, etc.). Each approach has pros and cons. For example, high-intensity

chemotherapy might be too toxic to allow treatment with CAR-T cells to pro-

ceed, while low-intensity approaches might fail in terms of tumour burden

reduction.

In addition, treatment with CD19-directed therapies, such as the bispecic T cell

engager blinatumomab, might have an impact on the efcacy of subsequent CD19

CAR-T cell therapy (Pillai etal. 2019), and common mechanisms of tumour escape

to CD19-directed therapies have now been reported (Boissel 2021). Blinatumomab

use was an exclusion criterion from the ELIANA trial (Maude etal. 2018), while it

was allowed for patients participating in other similar trials. In the expanded access

program for tisagenlecleucel, the overall response rate in patients with prior blina-

tumomab treatment was 67% versus 90% in other patients (Baruchel etal. 2020).

However, no univocal data on this important salvage option are available in this

setting.

In a recent study, the Memorial Sloan Kettering group reviewed different

bridging strategies and outcomes for all patients enrolled in a single-centre,

phase 1 trial of CD19-specific CAR-T cells for R/R adult ALL (ClinicalTrials.

gov NCT01044069) (Perica etal. 2021). They observed that reductions in dis-

ease burden during the bridging period are associated with favourable out-

comes after CAR-T therapy and thus suggest that optimal strategies to reduce

disease burden during bridging are warranted. They proposed a bridging strat-

egy based on disease burden at the time of the CAR-T therapy decision. They

recommended low-intensity therapy for patients with a low tumour burden,

low-intensity chemotherapy, or targeted therapy (e.g., inotuzumab) for patients

with a high disease burden who are chemorefractory (e.g., partial or short

response to prior line of chemotherapy) and unlikely to benefit from high-

intensity bridging, and a careful evaluation of the risks and benefits of high- vs.

low-intensity therapy for patients with high disease burden with expected che-

mosensitivity (e.g., limited prior chemotherapy exposure, late relapse, or sen-

sitivity to the last line). In fact, not surprisingly, the study showed an increased

rate of infections during the bridging period in the high-intensity chemother-

apy group.

In conclusion, tumour burden, patient comorbidities, and disease characteristics

should tailor the choice of the optimal bridging therapy. The goal of this therapy is

not complete disease eradication per se but reduction of tumour burden, preserving

N. Boissel and F. Ciceri

113

the patient in good clinical condition for CAR-T cell infusion. The benets of

tumour burden reduction may be twofold, with (1) a reduction in the early risk of

adverse events, including cytokine release syndrome and (2) a better outcome after

CAR-T cell therapy. Although the role of B-cell-directed therapies should be further

and carefully investigated in this setting, mainly to exclude possible interference

with CAR-T cell expansion or activity, targeted and low-intensity approaches could

be instrumental for this objective. Conversely, high-intensity chemotherapy should

be limited to those cases in which the benet and the probability of achieving a

rapid tumour load reduction overcome the risk of infection or another toxic event in

the context of a CAR-T-oriented strategy.

References

Baruchel A, Krueger J, Balduzzi A, etal. Tisagenlecleucel for pediatric/young adults with relapsed/

refractory acute lymphoblastic leukemia: preliminary report on B2001X study focusing on

prior exposure to blinatumomab and inotuzumab. J Clin Oncol. 2020;38(15 Suppl):10518.

Boissel N.ALL in escape room. Blood. 2021;137(4):432–4.

Cohen AD, Garfall AL, Stadtmauer EA, etal. B cell maturation antigen-specic CAR-T cells are

clinically active in multiple myeloma. J Clin Invest. 2019;129(6):2210–21.

Maude SL, Laetsch TW, Buechner J, Rives S, Boyer M, Bittencourt H, etal. Tisagenlecleucel in

children and young adults with B-cell lymphoblastic leukemia. N Engl J Med. 2018;378:439–48.

Park JH, Rivière I, Gonen M, etal. Long-term follow-up of CD19 CAR-therapy in acute lympho-

blastic leukemia. N Engl J Med. 2018;378:449–59.

Perica K, Flynn J, Curran KJ, etal. Impact of bridging chemotherapy on clinical outcome of CD19

CAR-T therapy in adult acute lymphoblastic leukemia. Leukemia. 2021;35(11):3268–71.

Pillai V, Muralidharan K, Meng W, et al. CAR-T cell therapy is effective for CD19-dim

B-lymphoblastic leukemia but is impacted by prior blinatumomab therapy. Blood Adv.

2019;3:3539–49.

Further Reading

Neill L, Rees J, Roddie C.Neurotoxicity– CAR-T cell therapy: what the neurologist needs to

know. Pract Neurol. 2020;20:287–95. https://doi.org/10.1136/practneurol- 2020- 002550.

Rubin DB, Danish HH, Ali AB, etal. Neurological toxicities associated with chimeric antigen

receptor T-cell therapy. Brain. 2019;142:1334–48. https://doi.org/10.1093/brain/awz053.

Tallantyre EC, Evans NA, Parry-Jones J, etal. Neurological updates: neurological complications

of CAR-T therapy. J Neurol. 2021;268:1544–54. https://doi.org/10.1007/s00415- 020- 10237- 3.

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

ICANS

Grade Management

Grade 3 Investigations and supportive care as per grade 1

Administer dexamethasone 10–20mg IV every 6h or methylprednisolone

equivalent until improvement to grade 1 and then taper

Management of seizures with lorazepam 0.5mg IV or other benzodiazepines as

needed, followed by loading with levetiracetam or other anticonvulsants as required

If fundoscopy reveals stage 1 or 2 papilloedema with cerebrospinal uid (CSF)

opening pressure>20mmHg, seek urgent advice from neurologist

Consider repeat neuroimaging (CT or MRI) every 2–3days if the patient has

persistent grade≥3 ICANS

Grade 4 Investigations and supportive care as per grade 1

Transfer patient to intensive care unit (ICU); consider mechanical ventilation for

airway protection

Seizure management as per grade 3

For convulsive status epilepticus, seek urgent advice from neurologist

Administer methylprednisolone 1000mg/day for 3days, then taper at 250mg every

12hrs for 2days, then 125mg every 12hrs for 2days, then 60mg every 12hrs for

2days

For management of raised intracranial pressure, consider acetazolamide 1000mg

IV, followed by 250–1000mg IV every 12h; elevating the head of the bed;

hyperventilation; and hyperosmolar therapy with mannitol

Table 27.3 (continued)

27 Management ofImmune Eector Cell-Associated Neurotoxicity Syndrome (ICANS)

147

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_28

M. Topp

Medizinischen Klinik und Polklinik II, Universitätsklinikum Würzburg, Würzburg, Germany

e-mail: Topp_M@ukw.de

T. Feuchtinger (

Department Pediatric Hematology, Oncology Hemostaseology and Stem Cell Transplantation,

Dr von Hauner Children’s Hospital, University Hospital, LMU, Munich, Germany

e-mail: T[email protected]

Management

ofHypogammaglobulinaemia

andB-Cell Aplasia

MaxTopp andTobiasFeuchtinger

The development and regulatory approval of CAR-T cell therapies targeting

B-lineage surface antigens (Maude etal. 2018), such as CD19 or CD22, represents

a major milestone in cancer immunotherapy. This treatment results in the depletion

of malignant and normal B cells and is associated with hypogammaglobulinaemia.

These on-target, off-tumour toxicities may result in an increased risk of infection.

Careful long-term follow-up assessment of patients receiving CAR-T cell therapy is

important. Management of these on-target, off-tumour effects should be well coor-

dinated between treatment and referring centres if the patient returns to local pro-

viders following therapy. Aims of this toxicity management:

• Prophylaxis of acute and chronic infections.

• Treatment of infections.

• Prevention of organ damage due to silent and/or chronic infections (e.g.,

bronchiectasis).

• Best-possible quality of life.

Monitoring B-cell aplasia provides information on two aspects of treatment.

First, B-cell aplasia is a sign of functional CAR persistence and often shows longer

persistence than direct detection of the CAR-T cells themselves. Monitoring B-cell

aplasia can guide decisions on the interval of monitoring of the malignant disease

(e.g., imaging, MRD) and subsequent allogeneic HSCT in cases of CAR-T cell

failure. Therefore, B-cell aplasia should be monitored together with remission

148

status and CAR persistence. Second, B-cell aplasia is a helpful parameter to guide

tapering or continuation of IgG substitution. The evidence level for the recommen-

dation concerning monitoring B-cell aplasia is based on expert opinion and may

vary in different patient age groups.

Because anti-CD19 and anti-CD22 CAR-T cells attack B-lineage precursors,

long-term hypogammaglobulinaemia or agammaglobulinaemia are commonly seen

in patients after CAR-T cell treatment. In paediatric centres, it has been the standard

of care to perform immunoglobulin replacement following CAR-T cell therapy

(Maude etal. 2014). However, there is no consensus regarding systematic IgG sup-

plementation in adults with plasma-cell aplasia and hypogammaglobulinaemia after

CAR-T cell therapy. Since persistent B-cell aplasia is associated with sinopulmo-

nary infections, notably with encapsulated bacteria (Fishman etal. 2019), intrave-

nous immunoglobulin replacement is performed in all patients with

hypogammaglobulinaemia plus recurrent or chronic infections, especially pneumo-

nia. After allogeneic HSCT plus CAR-T cell therapy, patients face an increased risk

of infection-related morbidity and hence may require intensied (perhaps lifelong)

IgG substitution regimens.

The duration of IgG substitution may be lifelong or last at least until recovery of

functional B cells and plasma cells. However, data regarding the efcacy of prophy-

lactic IgG replacement in CAR-T cell therapy recipients are limited (Hill et al.

2019), and current expert recommendations (Mahadeo etal. 2019, Yakoub-Agha

etal. 2020) are extrapolated from the data for individuals with primary immune

deciencies (Perez etal. 2017, Picard etal. 2018). The long-term follow-up data

from patients with Bruton agammaglobulinaemia provide a rationale to closely

monitor immunoglobulin levels and acute, chronic and especially silent infections

to prevent organ damage and maintain long-term quality of life. Individualized regi-

mens aim to maintain serum immunoglobulin levels above 400μg/l in adults and

age-adapted normal ranges for children. Intravenous immunoglobulins (IVIGs) are

usually given every 3–6weeks or subcutaneously weekly (SCIGs). IVIG doses start

at 0.4g/kg body weight and SCIG doses at 0.1–0.15g/kg body weight. Doses and

intervals are adapted due to infections and serum IgG levels. After reaching a steady

state, serum IgG levels should be controlled at least every 3months.

Studies are needed to establish evidence-based approaches for management of

B-cell aplasia and hypogammaglobulinaemia. Prophylactic immunoglobulin

administration in this context and strategies may differ by patient and CAR-T cell

product characteristics.

Key Points

• Long-term (potentially lifelong) monitoring of B-cell aplasia and IgG lev-

els is necessary after CD19/CD22 targeting CAR-T cell therapies.

• Maintain serum immunoglobulin levels at physiologic levels through regu-

lar intravenous or subcutaneous substitution.

• The evidence level of this recommendation is at the expert opinion level.

M. Topp and T. Feuchtinger

149

References

Fishman JA, Hogan JI, Maus MV. Inammatory and Infectious Syndromes Associated With

Cancer Immunotherapies. Clin Infect Dis. 2019;69(6):909–20.

Hill JA, Giralt S, Torgerson TR, Lazarus HM. CAR-T - and a side order of IgG, to go? -

Immunoglobulin replacement in patients receiving CAR-T cell therapy. Blood Rev.

2019;38:100596. e-pub ahead of print 2019/08/17

Mahadeo KM, Khazal SJ, Abdel-Azim H, Fitzgerald JC, Taraseviciute A, Bollard CM, et al.

Management guidelines for paediatric patients receiving chimeric antigen receptor T cell ther-

apy. Nat Rev Clin Oncol. 2019;16(1):45–63. e-pub ahead of print 2018/08/08

Maude SL, Frey N, Shaw PA, Aplenc R, Barrett DM, Bunin NJ, etal. Chimeric antigen receptor T

cells for sustained remissions in leukemia. N Engl J Med. 2014;371(16):1507–17. e-pub ahead

of print 2014/10/16

Maude SL, Laetsch TW, Buechner J, Rives S, Boyer M, Bittencourt H, etal. Tisagenlecleucel in chil-

dren and young adults with B-cell lymphoblastic leukemia. N Engl J Med. 2018;378(5):439–48.

Perez EE, Orange JS, Bonilla F, Chinen J, Chinn IK, Dorsey M, etal. Update on the use of immu-

noglobulin in human disease: A review of evidence. J Allergy Clin Immunol. 2017;139(3S):S1–

S46. e-pub ahead of print 2017/01/04

Picard C, Bobby Gaspar H, Al-Herz W, Bousha A, Casanova JL, Chatila T, etal. International

Union of Immunological Societies: 2017 Primary immunodeciency diseases committee

report on inborn errors of immunity. J Clin Immunol. 2018;38(1):96–128. e-pub ahead of print

2017/12/12

Yakoub-Agha I, Chabannon C, Bader P, Basak GW, Bonig H, Ciceri F, etal. Management of adults

and children undergoing chimeric antigen receptor T-cell therapy: best practice recommenda-

tions of the European Society for Blood and Marrow Transplantation (EBMT) and the Joint

Accreditation Committee of ISCT and EBMT (JACIE). Haematologica. 2020;105(2):297–316.

e-pub ahead of print 2019/11/23

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

28 Management ofHypogammaglobulinaemia andB-Cell Aplasia

151

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_29

M. Subklewe (*)

Med. Klinik & Poliklinik III, LMU– Klinikum der Universität München, München, Germany

e-mail: [email protected]

R. Benjamin

King’s College Hospital, London, UK

e-mail: [email protected]

Management ofMyelotoxicity (Aplasia)

andInfectious Complications

MarionSubklewe andReubenBenjamin

Haematologic toxicity is the most common adverse event after CAR-T cell therapy,

with a cumulative 1-year incidence of 58% (CTCAE grade≥3) in the real-world

setting (Wudhikarn etal., Blood Advances 2020). It is characterized by a biphasic

temporal course and is often prolonged (Fried etal., Bone Marrow Transplant 2019,

Rejeski et al., Blood et al. 2021a, b, Fig. 29.1). In a report of Axi-Cel-treated

patients, only 30% demonstrated a neutrophil count >1×10

/L and 50% showed a

platelet count >50×10

/L at 30days following CAR-T cell treatment (Jain etal.,

Blood Advances 2020). In a long-term follow-up study of patients with ongoing CR

and an absence of MDS, 16% of patients experienced prolonged signicant cytope-

nias that lasted up to 22months after CAR-T cell treatment (Cordeiro etal., Biol

Blood Marrow Transplant 2020). These ndings highlight that cytopenia can pres-

ent long after lymphodepletion and the resolution of acute CRS.Risk factors include

severe CRS/ICANS, cytopenia prior to initiation of lymphodepleting chemother-

apy, and prior allogeneic stem cell transplantation (Jain et al., Blood Advances

2020, Fried et al., BMT, 2019). Importantly, cytopenia predisposes patients to

severe infectious complications, which are the most frequent cause of non-relapse

mortality (Nastoupil etal., JCO 2020).

The use of growth factors to manage early cytopenias after CAR-T cell therapy

remains controversial. Cytokine proles and mouse xenograft models have impli-

cated GM-CSF in the pathogenesis of CRS and neuroinammation (Sterner etal.,

Blood 2019). Accordingly, current recommendations discourage the use of GM-CSF

and to initiate G-CSF only after resolution of CRS and/or ICANS (Yakoub- Agha

et al., Haematologica 2020). However, in a report by Galli et al., prophylactic

152

G-CSF was used safely in 42 patients with grade 4 neutropenia on day 5 after

CAR-T cell infusion, with no increased risk of CRS or ICANS and no negative

impact on disease outcomes (Galli et al., Bone Marrow Transplantation 2020).

Further studies are needed to identify patients at high risk for prolonged neutropenia

and with an increased risk of infection that will benet from early G-CSF initiation.

The diagnostic workup for patients with prolonged cytopenia unresponsive to

G-CSF should include screening for haematinic deciency, viral infections (e.g.,

CMV, EBV, Hepatitis B/C, Parvovirus B19), concomitant myelosuppressive drugs

(e.g., co-trimoxazole), secondary haemophagocytic lymphohistiocytosis, and the

presence of disease in the bone marrow. In the event of severe bone marrow aplasia

unresponsive to G-CSF, autologous or allogeneic stem cell rescue may be consid-

ered where possible (Rejeski etal., BMC ID 2021a, b, Godel etal., Haemasphere

2021). Other options include anti-inammatory therapy (e.g., dexamethasone, anti-

IL- 6 blocking therapy) and thrombopoietin receptor agonists (e.g., eltrombopag)

(Fig.29.2).

Infections are another signicant complication of CAR-T therapy as a result of

prolonged neutropenia, long-term CD4 T cell lymphopenia, or B-cell aplasia (Hill

and Seo etal., Blood 2020a, b). Other risk factors associated with infections include

higher CRS grade and use of immunosuppressive agents, such as steroids, tocili-

zumab, and anakinra. The majority of infections occur early within the rst 28days,

with bacterial infections being the most common, followed by viral and fungal

infections. Late infections, especially with respiratory viruses, are also seen up to

90 days post CAR-T therapy (Cordeiro et al., BBMT 2020). Invasive fungal

6000

5000

4000

3000

2000

Abs. Neutrophil Count/µl

1000

-5 -4 -3 -2 -1

012345678910 11 12 13 14 W3 W4 W5 W6 W7 W8 M3 M4

MonthsWeeksDays

Baseline

Clinical Phenotypes of neutropenia after CAR T-cell transfusion

Quick Recovery Intermittent Recovery Aplastic

Fig. 29.1 Clinical Phenotypes of neutropenia (adapted from Rejeski etal., Blood 2021a, b)

M. Subklewe and R. Benjamin

153

infections, both yeasts and moulds, have been reported in 1–15% of CAR-T-treated

patients.

The use of antiviral, antifungal, and anti-pneumocystis (PCP) prophylaxis to

reduce the risk of infections post-CAR-T cell therapy is recommended; however,

there is no consensus on the optimal choice and duration of prophylaxis. Patients

typically receive acyclovir or valacyclovir, yeast or mould-active antifungal prophy-

laxis, and co-trimoxazole to prevent PCP.Patients considered “high risk” for mould

infections based on pre-infusion neutropenia, history of mould infection within

6 months, prior allo-SCT or underlying diagnosis of acute leukaemia as well as

those who have had post-infusion grade≥3 CRS/ICANS or prolonged treatment

with steroids or other immunosuppressants should be offered mould-active prophy-

laxis. In the absence of high-risk factors, yeast-active prophylaxis may be sufcient,

with pre-emptive monitoring for moulds recommended (Garner et al., J Fungi

2021). Antifungal prophylaxis is generally continued until recovery of the neutro-

phil count and cessation of immunosuppressants. PCP prophylaxis is typically

given for 6months or until the CD4 T cell count is >200 cells/μl. Monthly intrave-

nous immunoglobulins may be considered when there is persistent severe hypogam-

maglobulinaemia and a history of recurrent infections. Treatment of suspected/

conrmed infections post CAR-T therapy should follow Institutional guidelines and

is generally similar to the management of infections after stem cell transplantation.

The efcacy of vaccination following administration of CD19- or BCMA-targeted

CAR-T cells remains unknown, but patients do need to be considered for vaccina-

tion at 6months post-CAR-T therapy and guided by post-vaccine antibody titres

(Hill etal., Blood 2020a, b). Effective strategies to prevent and manage infectious

complications following CAR-T cell infusion are crucial in improving the outcomes

of this promising therapy.

ANC < 1000/µl

D7-10 post CAR-T

Filgrastim 0.5 Mio

IE/kgKG

until ANC > 1000/µl

“G-CSF

responsive”

“G-CSF

unresponsive”

• Vigilant outpatient monitoring of CBC

• consider bone marrow aspiration /

histology, if continuous G-CSF is

needed

• Posaconazol 300 mg p.o. or

Micafungin 50 mg i.v.

• Surveillance: Asp. AG, CMV/

EBV PCR weekly

• if ANC > 500/µl: watch and wait

• Pegylated G-CSF: e.g.

Lipegfilgrastim 6 mg s.c.

• Pulse-Dose Steriods:

Dexamethason 20mg x 4 days

• Anti-cytokine-Therapy: e.g.

Anakinra or Tocilizumab

• TPO-Agonist: e.g. Eltrombopag

50mg x 7-14 days

yes

Infectious Prophylaxis:

Bone Marrow

Studies:

r/o Bone Marrow

infiltration?

Check for

autologous

back-up?

AutoSCT

individual

decision

regeneration?

Ultima Ratio:

Allogeneic SCT

Refractory

Extend Staging and

diagnostic studies. Consider

integrating CAR T-cell

monitoring => Initiate anti-

lymphoma/leukemia

therapy accoding to

patient-specific features

Warning:

Initiate therapy:

ANC < 1000/µl

ANC < 500/µl

Work-up:

• CBC

• reticulocytes, RPI

• r/o substrate

deficiency

• r/o drug induced

cytopenia

• bone marrow

aspiration /

histology

Rejeski et al, 2021, Godel et al, 2021

Hill and Seo et al, Blood Advances 2020

Fig. 29.2 Treatment algorithm for CD19 CAR-T cell-associated myelotoxicity

29 Management ofMyelotoxicity (Aplasia) andInfectious Complications

154

References

Cordeiro A, etal. Late events after treatment with CD19-targeted chimeric antigen receptor modi-

ed T cells. Biol Blood Marrow Transplant. 2020;26(1):26–33.

Fried S, etal. Early and late hematologic toxicity following CD19 CAR-T cells. Bone Marrow

Transplant. 2019;54(10):1643–50.

Galli E, Allain V, Blasi R, Bernad S, Vercellino L, Morin F, Moatti H, Caillat-Zucman S, Chevret

S, Thieblemont C.G-CSF does not worsen toxicities and efcacy of CAR-T cells in refractory/

relapsed B-cell lymphoma. Bone Marrow Transplant. 2020;55:2347–9.

Goedel P, Sieg N, Heger JM, Kutsch N, Herling C, Bärmann B-N, Scheid C, Borchmann

HU.Hematologic rescue of CAR-T cell mediated prolonged pancytopenia using autologous

peripheral blood hematopoietic stem cells in a lymphoma patient. Hema. 2021;5(3):e545.

Hill JA, Seo SK.How I prevent infections in patients receiving CD19-targeted chimeric antigen

receptor T cells for B-cell malignancies. Blood. 2020b;136(8):925–35.

Hill JH, Seo S.How I prevent infections in patients receiving CD19-targeted chimeric antigen

receptor T cells for B-cell malignancies. Blood. 2020a;136(8):925–35.

Jain T, etal. Hematopoietic recovery in patients receiving chimeric antigen receptor T-cell therapy

for hematologic malignancies. Blood Adv. 2020;4(15):3776–87.

Nastoupil LJ, Jain MD, Feng L, etal. Standard-of-care Axicabtagene Ciloleucel for relapsed or

refractory large B-cell lymphoma: results from the US lymphoma CAR-T consortium. J Clin

Oncol. 2020;38(27):3119–28.

Rejeski, K etal, CAR-HEMATOTOX: A model for CAR-T cell related hematological toxicity in

relapsed/refractory large B-cell lymphoma. Blood 2021a Jun 24; online ahead of print.

Rejeski K, Kunz WG, Rudelius M, Bücklein V, Blumenerg V, Schmidt C, Karschnia P, Schöberl F,

Dimitriadis K, Von Baumgarten L, Stemmler J, Weigert O, Dreyling M, Von Bergwelt-Baildon

M, Subklewe M.Severe Candida glabrata pancolitis and fatal Aspergillus fumigatus pulmo-

nary infection in the setting of bone marrow aplasia after CD19-directed CAR-T cell therapy- a

case report. BMC Infect Dis. 2021b;21(1):121.

Sterner R, Sakemura R, Cox M, Yang N, Khadka R, Forsman C, Hansen M, Jin F, Ayssou K, Hefazi

M, Schick K, Walters D, Chappell D, Ahmed O, Sahmoud t, Durrant C, Nevala W., Patnaik M,

Pease L, Hedin K, Kay N, Johnson A, Kenderian S.CM-SF inhibition reduces CRS and neuro-

inammation but enhances CAR-T cell function in xenografts. Blood. 2019;133(7):697–709.

Will Garner W, Samanta P, Haidar G. Invasive fungal infections after anti-CD19 chimeric anti-

gen receptor-modied T-cell therapy: state of the evidence and future directions. J Fungi.

2021;7:156.

Key Points

• Haematological toxicity is the most common adverse event after CD19-

specic CAR-T cell therapy and can predispose patients to severe infec-

tious complications.

• Administering prophylactic G-CSF from day 5 in neutropenic patients

does not increase the incidence of severe CRS/ICANS and is safe in pre-

serving CAR-T antilymphoma activity. Evidence level III-B.

• Post-CART immunosuppression is multifactorial (e.g., neutropenia, lym-

phopenia, steroid use, B-cell aplasia, and hypogammaglobulinaemia), and

infections signicantly contribute to non-relapse mortality.

• Anti-infective prophylaxis should follow institutional guidelines based on

the patient-specic risk factors.

M. Subklewe and R. Benjamin

155

Wudhikarn K, etal. DLBCL patients treated with CD19 CAR-T cells experience a high burden of

organ toxicities but low nonrelapse mortality. Blood Adv. 2020;4(13):3024–33.

Yakoub-Agha I, Chabannon C, Bader P, Basak GW, Bonig H, Ciceri F, Corbacioglu S, Duarte RF,

Einsele H, Hudecek M, Kersten MJ, Köhl U, Kuball J, Mielke S, Mohty M, Murray J, Nagler

A, Robinson S, Saccardi R, Sanchez-Guijo F, Snowden JA, Srour M, Styczynski J, Urbano-

Ispizua A, Hayden PJ, Kröger N. Management of adults and children undergoing chimeric

antigen receptor T-cell therapy: best practice recommendations of the European Society for

Blood and Marrow Transplantation (EBMT) and the joint accreditation committee of ISCT and

EBMT (JACIE). Haematologica. 2020;105(2):297–316.

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

29 Management ofMyelotoxicity (Aplasia) andInfectious Complications

157

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_30

H. Einsele

Department of Internal Medicine II, University Hospital Würzburg, Würzburg,

Bayern, Germany

e-mail: Einsele_h@ukw.de

I. Yakoub-Agha (

Maladies du Sang, Unité de Thérapie Cellulaire, Centre hospitalier-Universitaire de Lille,

Lille, France

e-mail: [email protected]

Management ofOther Toxicities

HermannEinsele

andIbrahimYakoub-Agha

Secondary haemophagocytic lymphohistiocytosis (sHLH) or macrophage activa-

tion syndrome (MAS) is a life-threatening hyperinammatory syndrome that can

occur in patients with severe infections, e.g., COVID-19 infection, malignancy or

autoimmune diseases. It is also a rare complication of allogeneic haematopoietic

cell transplantation (allo-HCT), independent of the underlying trigger mechanism

or underlying disorders associated with high mortality. There have been increasing

reports of sHLH/MAS occurrence following CAR-T cell therapy, but its differentia-

tion from cytokine release syndrome (CRS) is often difcult (Sandler etal. 2020).

The diagnosis of sHLH/MAS post-HCT requires observation of the clinical

signs and symptoms of hyperinammation, which can overlap with the symptoms

of cytokine release syndrome or infectious complications, requiring a differential

diagnosis. Typically, these symptoms include fever, cytopenia of more than one

lineage, and multiorgan failure. Persistent fever without an identied infective cause

or worsening fever in patients who have been treated for infection should prompt

screening for sHLH/MAS (Karakike and Giamarellos-Bourboulis 2019). Serum

ferritin is a suitable and readily available biomarker of sHLH/MAS and can also be

used to monitor response to treatment.

CAR-T cell therapy, while emerging as an effective treatment for both haemato-

logical and nonhaematological malignancies, is associated with cytokine release

syndrome (CRS), an acute toxicity resulting in hyperinammation. Patients can

present with CRS across a spectrum of severities, from low-grade constitutional

symptoms to higher-grade systemic illness with multiorgan dysfunction, and in its

158

most severe form, CRS can progress to fulminant sHLH/MAS.Neelapu etal. pro-

posed diagnostic criteria for sHLH/MAS in patients with CRS post-CAR-T cell

therapy demonstrating a peak serum ferritin measurement of >10,000μg/L and two

of the following ndings: a grade>3 increase in serum transaminase or bilirubin;

grade > 3 oliguria or increase in serum creatinine; grade > 3 pulmonary oedema or

histological evidence of haemophagocytosis in the bone marrow or organs (Neelapu

etal. 2018) (Tables 30.1 and 30.2).

For effective treatment of sHLH/MAS, aggressive immunosuppression is

required to control the hyperinammatory state. Prompt recognition and treatment

are important and reduce mortality. Corticosteroids remain the cornerstone of induc-

tion treatment, although over half of patients are steroid resistant (Fukaya et al.

2008) (Table 30.3).

Anakinra, an IL-1 antagonist, is effective in refractory sHLH/MAS and relatively

safe in patients with sepsis (Shakoory et al. 2016) (Eloseily et al. 2019). Thus,

anakinra has been used for refractory sHLH/MAS and was found to be effective in

adult sHLH/MAS for patients with severe sHLH/MAS.Intravenous immunoglobu-

lin (IVIG) infusions may also be effective in steroid-resistant and infection (EBV)-

triggered sHLH/MAS (Chen etal. 1995).

A treatment protocol for sHLH/MAS accepting the heterogeneity of this syn-

drome has been recently published. The rst-line treatment is intravenous

Table 30.1 Use of published criteria to support the diagnosis of sHLH/MAS after CAR-T cell

therapy (adapted from Sandler etal. 2020)

Table 30.2 The Hscore adapted to CAR-T cell therapy

H. Einsele and I. Yakoub-Agha

159

methylprednisolone (IVMP) 1 g/day for 3–5 days plus IVIG 1 g/kg for 2 days,

which can be repeated on day 14. If there is evidence of established sHLH/MAS or

clinical deterioration, anakinra is added at 1–2mg/kg daily, increasing up to 8mg/

kg/day. CSA is considered for early or steroid-resistant disease. Etoposide should

be considered in refractory cases but can be problematic due to the already preexist-

ing cytopenias in patients with sHLH/MAS following CAR-T cell therapy.

Additionally, triggers, such as EBV, bacterial infection or underlying malignancy,

particularly lymphoma, should be screened for and treated if adequately dened

(Vatsayan etal. 2016).

Considerations forPatients Undergoing CAR-T Cell Therapy

• Steroids remain the cornerstone for sHLH/MAS treatment, but 50% of patients

are resistant.

• A recent recommendation for HLH/MAS after CAR-T therapy:

– Methylprednisolone 1g/day for 3–5days + IVIG 1g/kg for 2days, repeated

on day 14.

– In the case of deterioration, IV anakinra can be added up to 100mg x 4/day.

– Etoposide for refractory cases.

• Other treatments for sHLH/MAS after CAR-T cell therapy.

– Ruxolitinib: found to be effective in a case report and small phase 1 study

• Cytokine blockers might be used

• IVIG: might be effective, especially if the underlying cause is infection.

Table 30.3 Use of published protocols in the management of sHLH/MAS post-HSCT or CAR-T

cell therapy

Key Points

• Patients with persistent fever without an identied infection should be

screened for sHLH/MAS.

• Serum ferritin is a suitable and readily available biomarker of sHLH/MAS.

• Corticosteroids are the cornerstone of induction treatment.

• >50% of patients are steroid-refractory.

• IV anakinra is the second line treatment.

• Etoposide can be used in refractory sHLH/MAS.

30 Management ofOther Toxicities

160

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G, Snowden JA.Diagnosis and Management of Secondary HLH/MAS Following HSCT and

CAR-T Cell Therapy in Adults; A Review of the Literature and a Survey of Practice Within

EBMT Centres on Behalf of the Autoimmune Diseases Working Party (ADWP) and Transplant

Complications Working Party (TCWP). Front Immunol. 2020;31(11):524.

Shakoory B, Carcillo JA, Chatham WW, Amdur RL, Zhao H, Dinarello CA, etal. Interleukin-1

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2016;44:275–81.

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Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

H. Einsele and I. Yakoub-Agha

161

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_31

U. Holtick (*)

Department I of Internal Medicine, University Hospital Cologne, Cologne, Germany

e-mail: [email protected]

E. Azoulay

Critical Care Department, Saint-Louis Hospital, Paris University, Paris, France

e-mail: [email protected]

ICU

UdoHoltick andElieAzoulay

CAR-T cell treatment comes with signicant side effects that challenge the struc-

ture and capacity of haematology wards and will regularly necessitate intermittent

patient transfer to the ICU.Life-threatening adverse events include cytokine release

syndrome and immune effector cell-associated neurotoxicity syndrome, which can

occur within hours or days after administration. Sepsis might also require ICU

admission within the days that follow CAR-T infusion in these high-risk immuno-

compromised patients.

Critical care and ICU specialists play an important role in the management of

patients receiving CAR-T therapies. A substantial number of patients require an

ICU bed, and CRS is the leading reason for ICU admission (Fitzgerald etal. 2017;

Gutierrez etal. 2020). Prompt and appropriate ICU management relies on a ne-

tuned dialogue between haematologists and ICU specialists and on an appropriate

denition of the threshold moment to target ICU admission. Hence, less than half of

patients require high-dose vasopressors, mechanical ventilation, or renal replace-

ment therapy (Azoulay etal. 2020). However, critical care also benets those in

whom appropriate antibiotics, source control of sepsis, echo-guided uid expan-

sion, prevention of acute kidney injury, and an optimal oxygenation strategy are

provided.

In some patients with comorbidities, the role of ICU specialists starts at the time

of patient eligibility for CAR-T cell therapy. Evaluation of patient frailty and risk

for developing organ dysfunction and sepsis helps dene the optimal timing of ICU

admission. When patients are starting lymphodepletion, the ICU specialists at least

receive a transmission. Of course, when patients have persistent stage 1 or stage 2

162

CRS, again, the ICU specialist is alerted. Overall, these careful strategies have

allowed a reduction in the need for ICU admission, with the numbers balanced with

widespread use of cell therapy and immunotherapy worldwide, which has been

helpful in a setting of scarce ICU beds.

To optimally manage CAR-T recipients, haematologists, oncologists, and inten-

sivists need to acquire the necessary knowledge and skills. Transdisciplinary meet-

ings ease harmonization of patient management, keeping all participants aware of

the advances in each specialty. Until recently, the ICU has primarily been used as a

bridge to cure patients with cancer (Azoulay etal. 2017; Gray etal. 2021). However,

CAR-T cell therapy challenges these concepts, producing a time-limited trial that is

offered to every CAR-T cell recipient, despite the underlying refractory malignancy,

and signicant hopes are put towards complete remission or bridging to another

promising therapy. However, not all patients respond to treatment with CAR-T

cells, and many patients ultimately relapse. Thus, we will need to adapt the approach

to admission and discharge from the ICU in a context of uncertainty and with hope

for recovery.

The key points below emphasize the role of the ICU specialist throughout the

CAR-T cell recipient journey and proposes the importance of maintaining tight col-

laboration across the involved specialties.

Key Points

CAR-T cell therapy: Framework to emphasize multidisciplinary

collaboration.

Adapted from Azoulay E etal., Am J Respir Crit Care Med. 2019

• Consultation with an ICU specialist to assess eligibility for CAR-T cell

therapy and anticipate post-infusion risks; consultation at the time of lym-

phodepletion and once any sign of toxicity or sepsis occurs.

• Apply a common information network to share important information.

• Reach agreement on the goals of care.

• Time-limited trials should be considered for all CAR-T cell recipients.

• CRS and ICANS must be assessed clinically several times per day for at

least 7days.

• Elicit prompt ICU admission once CRS reaches grade II.

• Leverage the latest advances.

• Liaise with all stakeholders to facilitate research.

• Share experiences with other specialists.

U. Holtick and E. Azoulay

163

References

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Intensive Care Med. 2020;46(9):1723–6. https://doi.org/10.1007/s00134- 020- 06193- 1.

Azoulay E, Schellongowski P, Darmon M, etal. The intensive care medicine research agenda

on critically ill oncology and hematology patients. Intensive Care Med. 2017;19 https://doi.

org/10.1007/s00134- 017- 4884- z.

Azoulay E, Shimabukuro-Vornhagen A, Darmon M, von Bergwelt-Baildon M. Critical Care

Management of Chimeric Antigen Receptor T Cell-related Toxicity. Be aware and prepared.

Am J Respir Crit Care Med. 2019;200(1):20–3. https://doi.org/10.1164/rccm.201810- 1945ED.

Fitzgerald JC, Weiss SL, Maude SL, et al. Cytokine release syndrome after chimeric antigen

receptor T cell therapy for acute lymphoblastic leukemia. Crit Care Med. 2017;45(2):e124–31.

https://doi.org/10.1097/CCM.0000000000002053.

Gray TF, Temel JS, El-Jawahri A.Illness and prognostic understanding in patients with hemato-

logic malignancies. Blood Rev. 2021;45:100692. https://doi.org/10.1016/j.blre.2020.100692.

Gutierrez C, Brown ART, Herr MM, etal. The chimeric antigen receptor-intensive care unit (CAR-

ICU) initiative: surveying intensive care unit practices in the management of CAR-T cell asso-

ciated toxicities. J Crit Care. 2020;58:58–64. https://doi.org/10.1016/j.jcrc.2020.04.008.

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

31 ICU

165

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_32

J. Gauthier (*)

Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA

Division of Medical Oncology, University of Washington, Seattle, WA, USA

e-mail: [email protected]

Post-CAR-T Cell Therapy (Consolidation

andRelapse): Acute Lymphoblastic

Leukaemia

JordanGauthier

Role of consolidative allogeneic haematopoietic cell transplantation (allo-HCT)

for B-cell acute lymphoblastic leukaemia (B-ALL) patients in minimal residual

disease- negative (MRD) complete remission (CR) after CD19 CAR-T cell

therapy.

The role of consolidative allo-HCT in B-ALL patients achieving MRD-negative

CR after CD19 CAR-T cell therapy is still debated. At the last update of the ELIANA

clinical trial, which investigated tisagenlecleucel in children and young adults with

relapsed or refractory (R/R) B-ALL, the median duration of remission and overall

survival was not reached (median follow-up, 24months). The 24-month relapse-

free survival probability in responders was 62%, with plateauing of the probability

curves after 1year (Grupp etal. 2019). Consolidation with allo-HCT was reported

in only 9% of CR patients, suggesting that CD19 CAR-T cell therapy alone with

tisagenlecleucel may be curative in a signicant proportion of paediatric patients. In

contrast, to date, the data do not suggest that CD19 CAR-T cell therapy is a deni-

tive approach in most adults with R/R B-ALL. Across the main academic and

industry- sponsored clinical trials of CD19 CAR-T cell therapy for adult B-ALL, the

median durations of response ranged from 8 to 19months, with important variations

in the proportion of patients receiving consolidative allo-HCT in CR after treatment

(35–75%) (Shah etal. 2019; Frey etal. 2020; Hay etal. 2019; Park etal. 2018). In

our experience, we observed favourable outcomes in patients undergoing allo-HCT

while in MRD-negative CR after dened-composition CD19 CAR-T cell therapy,

with 2-year EFS and OS probabilities of 61% and 72%, respectively. After adjusting

for previously identied prognostic factors for event-free survival (EFS; pre-

lymphodepletion LDH concentration and platelet count, cyclophosphamide-

udarabine lymphodepletion), the hazard ratio for allo-HCT was 0.39 (95% CI

166

0.13–1.15, p=0.09), suggesting a benecial effect on EFS.Based on these ndings,

our approach in adult patients is to recommend consolidative allo-HCT in adult

patients with R/R B-ALL in MRD-negative CR after CD19 CAR-T cell therapy.

Additionally, patient age and preferences, comorbidities, a history of prior trans-

plant, and MRD must be taken into account. Investigators from the NCI/NIH (Lee

etal. 2016) and Seattle Children’s Hospital (Summers etal. 2018) reported a sur-

vival advantage in children and young adults consolidated with allo-HCT after

CD19 CAR-T cell therapy. However, notably, to date, the available data rely on

nonrandomized, retrospective analyses, and are potentially subject to important

biases (Suissa 2007; Lévesque etal. 2010).

Management ofRelapsed B-ALL After CD19 CAR-T Cell Therapy

CD19-Positive Disease After CD19 CAR-T Cell Therapy

If cryopreserved end-manufacturing CAR-T cells are available and the target anti-

gen is still expressed, an attractive approach is to use the “left-over” cells to manu-

facture a second CAR-T cell product. We have shown that second CD19 CAR-T

cell infusions are feasible and well tolerated, but in most cases directed at the murine

single chain variable fragment (scFv) CAR domain, antitumour efcacy is limited

by anti-CAR immune responses. We observed superior outcomes in patients who

received cyclophosphamide and udarabine lymphodepletion prior to the rst

CAR-T cell infusion and who received a higher CAR-T cell dose (10 times higher

than the rst CAR-T cell infusion). However, second CAR-T cell infusions achieved

a CR in only 3 of 14 ALL patients (21%) (Gauthier etal. 2020). Efforts are under-

way to mitigate or circumvent anti-CAR immune responses using a CAR compris-

ing humanized or fully human scFvs (Gauthier etal. 2018; Brudno etal. 2020).

Maude etal. evaluated the use of the humanized scFv-bearing CD19 CAR-T cell

product CTL119in 38 children and young adults (Grupp etal. 2015). MRD-negative

CR could be achieved in murine CAR-exposed patients (43%), although at a lower

rate than in the CAR-naïve population (100%). The 12-month relapse-free survival

probabilities in responding patients were 82% and 56% in the CAR-exposed and

CAR-naïve cohorts, respectively. In another report, Cao etal. observed CR in 2 of 5

patients previously exposed to murine CD19 CAR-T cells(Cao etal. 2019). Further

studies are needed to determine whether immunogenicity, poor CAR-T cell func-

tion or disease-related factors underlie the reduced efcacy of CD19 CAR-T cells

employing fully human or humanized scFv in the murine CAR-exposed setting.

CD19-Negative Disease After CD19 CAR-T Cell Therapy

Encouraging results have been reported using CD22-targeted CAR-T cells, includ-

ing in patients with CD19-negative B-ALL blasts after prior CD19 CAR-T cell

therapy. Shah etal. reported their experience in 58 children and young adults with

J. Gauthier

167

R/R B-ALL, including 62% of patients who were previously treated with a CD19

CAR-T cell product (Shah et al. 2020). CD22 CAR-T cells achieved an MRD-

negative CR in 61% of cases, with a median duration of response of 6months (13

of 35 MRD-negative CR patients [37%] went on to receive allo-HCT). The MRD-

negative CR rate in patients previously treated with CD19 CAR-T cells was 64%. In

another report from Pan etal., CD22 CAR-T cells were administered to 34 children

and adult patients. Prior failure of CD19 CAR-T cell therapy was documented in

91% of patients. CD22 CAR-T cells achieved MRD-negative CRs in 76% of

patients. Responses were durable, with a 1-year leukaemia-free survival probability

of 58% in CR patients (11 of 30 CR patients [37%] went on to receive allo-HCT)

(Pan etal. 2019).

References

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CD19 CAR-T cells with fully human binding domains in patients with B-cell lymphoma. Nat

Med. 2020;26(2):270–80.

Cao J, Cheng H, Qi K, Chen W, Shi M, Zheng J, etal. Humanized CD19-specic chimeric antigen

receptor T cells for acute lymphoblastic leukemia. Blood. 2019;134(Supplement_1):3872.

Frey NV, Shaw PA, Hexner EO, Pequignot E, Gill S, Luger SM, et al. Optimizing chimeric

antigen receptor T-cell therapy for adults with acute lymphoblastic leukemia. J Clin Oncol.

2020;38(5):415–22.

Gauthier J, Bezerra E, Hirayama AV, Pender BS, Vakil A, Steinmetz RN, etal. Repeat infusions

of CD19 CAR-T cells: factors associated with response, CAR-T cell invivo expansion, and

progression-free survival. ASTCT. 2020;26(3):S267–S8.

Gauthier J, Hirayama AV, Hay KA, Sheih A, Pender BS, Hawkins RM, etal. Immunotherapy with

T-cells engineered with a chimeric antigen receptor bearing a human CD19-binding single

chain variable fragment for relapsed or refractory acute lymphoblastic leukemia and B-cell

non-Hodgkin lymphoma. Blood. 2018;132(Supplement 1):1415.

Grupp SA, Maude SL, Rives S, Baruchel A, Boyer M, Bittencourt H, et al. Tisagenlecleucel

for the treatment of pediatric and young adult patients with relapsed/refractory acute lym-

phoblastic leukemia: updated analysis of the ELIANA clinical trial. Biol Blood Marrow Tr.

2019;25(3):S126–S7.

Key Points

• When feasible, allo-HCT should be offered to adult patients with R/R

B-ALL in MRD-negative CR after CD19 CAR-T cell therapy.

• CD22 CAR-T cells are associated with high response rates after CD19

CAR-T cell failure, and the most durable responses are observed after con-

solidative allo-HCT.

• CD19 CAR-T cells with fully human or humanized scFv are under inves-

tigation to mitigate anti-CAR immune responses, potentially impeding the

efcacy of repeat CAR-T cell infusions.

32 Post-CAR-T Cell Therapy (Consolidation and Relapse): Acute Lymphoblastic…

168

Grupp SA, Maude SL, Shaw PA, Aplenc R, Barrett DM. Durable remissions in children with

relapsed/refractory ALL treated with T cells engineered with a CD19-targeted chimeric antigen

receptor (CTL019). Blood. 2015;126(23):681.

Hay KA, Gauthier J, Hirayama AV, Voutsinas JM, Wu Q, Li D, et al. Factors associated with

durable EFS in adult B-cell ALL patients achieving MRD-negative CR after CD19 CAR-T cell

therapy. Blood. 2019;133(15):1652–63.

Lee DW, Stetler-Stevenson M, Yuan CM, Shah NN, Delbrook C, Yates B, etal. Long-term out-

comes following CD19 CAR-T cell therapy for B-ALL are superior in patients receiving a

Fludarabine/cyclophosphamide preparative regimen and post-CAR hematopoietic stem cell

transplantation. Blood. 2016;128(22):218.

Lévesque LE, Hanley JA, Kezouh A, Suissa S.Problem of immortal time bias in cohort studies:

example using statins for preventing progression of diabetes. BMJ. 2010;340(mar12 1):b5087.

Pan J, Niu Q, Deng B, Liu S, Wu T, Gao Z, et al. CD22 CAR-T cell therapy in refractory or

relapsed B acute lymphoblastic leukemia. Leukemia. 2019;33(12):2854–66.

Park JH, Riviere I, Gonen M, Wang X, Senechal B, Curran KJ, etal. Long-term follow-up of CD19

CAR-therapy in acute lymphoblastic leukemia. N Engl J Med. 2018;378(5):449–59.

Shah BD, Bishop M, Oluwole OO, Logan A, Baer MR, Donnellan W, etal. End of phase I results

of ZUMA-3, a phase 1/2 study of KTE-X19, anti-CD19 chimeric antigen receptor (CAR) T

cell therapy, in adult patients (pts) with relapsed/refractory (R/R) acute lymphoblastic leukemia

(ALL). ASCO. 2019;37(15_suppl):7006.

Shah NN, Highll SL, Shalabi H, Yates B, Jin J, Wolters PL, et al. CD4/CD8 T-cell selection

affects chimeric antigen receptor (CAR) T-cell potency and toxicity: updated results from a

phase I anti-CD22 CAR-T cell trial. J Clin Oncol. 2020;38(17):1938–50.

Suissa S. Immortal time bias in observational studies of drug effects. Pharmacoepidem Dr

S. 2007;16(3):241–9.

Summers C, Annesley C, Bleakley M, Dahlberg A, Jensen MC, Gardner R.Long term follow-up

after SCRI-CAR19v1 reveals late recurrences as well as a survival advantage to consolidation

with HCT after CAR-T cell induced remission. Blood. 2018;132(Supplement 1):967.

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

J. Gauthier

169

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_33

D. Blaise (*) · S. Fürst

Transplant and Cellular Immunotherapy Program, Department of Hematology, Institute

Paoli-Calmettes, Marseille, France

e-mail: [email protected].fr; [email protected]

Post-CAR-T Cell Therapy (Consolidation

andRelapse): Lymphoma

DidierBlaise andSabineFürst

Even after a decade of use, CAR-T cell therapy for non-Hodgkin lymphoma (NHL)

is still evolving, and disease control is now the main concern in the majority of

experienced centres. Indeed, despite highly appealing objective response (OR) rates

in refractory patients, the long-term overall survival (OS) of this population has

only slightly improved. Pivotal studies have suggested that 2-year OS rates do not

surpass 30%, even though results improve when complete response (CR) is achieved

within the rst 3months after treatment (Wang etal. 2020; Schuster etal. 2019;

Neelapu et al. 2017). Although achieving this exceptionally high level of OR is

praiseworthy, similar improvements have not been made regarding OS, and current

OS probabilities are not satisfactory. Of course, there are multiple reasons for this;

a substantial proportion of patients either do not achieve an initial response or expe-

rience progression very soon after treatment, with poor OS (Chow etal. 2019). Both

populations present with disease burden or aggressive cancer prior to CAR-T cell

therapy, possibly having been referred too late in the course of treatment or waited

too long before CAR-T cells were processed for them. Both of these issues have

potential solutions, such as more widely publicizing the efcacy of CAR-T cells,

which may increase referrals at an earlier stage, and developing methods, which are

already being heavily investigated, for shortening the manufacturing process (Raq

etal. 2020). In the latter case, the use of allogeneic lymphocytes could allow for

already prepared cells to be readily used when needed and would most likely be the

most efcient strategy as long as the risk of graft-versus host disease is offset

(Graham and Jozwik 2018). Thus, achieving CR is a crucial step in increasing OS,

as patients with partial response (PR) or stable disease (SD) present with lower OS,

while currently, recurrence appears to be rare when CR is maintained for more than

6months (Komanduri 2021). However, the disease will likely recur in more than

170

half of patients in the months following treatment, possibly due to issues such as the

poor persistence of CAR-T cells (which may not be as crucial as once thought for

acute lymphoblastic leukaemia (Komanduri 2021)) or the loss of target antigen

expression (which has been regularly documented (Raq etal. 2020)). Both of these

mechanisms could potentially be used to develop methods that reduce recurrence

after CAR-T cell therapy. In fact, the most popular approaches currently being

investigated are attempting to either use two CAR-T cell types that each target dif-

ferent antigens or to create CAR-T cell constructs that target either multiple anti-

gens or an antigen other than CD19 (Shah etal. 2020). The concomitant infusion of

CAR-T cells with targeted therapies is also being explored in other B-cell malignan-

cies and appears to both increase the CR rate and decrease recurrence (Gauthier

etal. 2020). When recurrence does occur, patient OS is rather dismal, and the best

remaining option would most likely be inclusion in a clinical trial. If this option is

not available, salvage therapy may be attempted, although cytotoxic treatments are

extremely limited given that most diseases have been refractory to numerous lines

of treatment prior to immunotherapy. A few case reports and studies with a small

patient population receiving anti-PD-1 antibodies, ibrutinib, or ImiDs have been

reported with largely anecdotal supporting evidence (Byrne etal. 2019). However,

even in the case of a new objective response (OR), the subsequent risk of recurrence

is substantial and may invite further consolidation with allogeneic haematopoietic

stem cell transplantation (Byrne etal. 2019), which has already been performed in

patients treated for acute lymphoblastic leukaemia (Hay etal. 2019). However, the

efcacy of this strategy remains to be validated in NHL patients in clinical trials.

Further supporting evidence, although limited, has recently been reported concern-

ing an additional treatment with CAR-T cells inducing an OR. Of the 21 NHL

patients included in the study, the OR rate after the second infusion was 52% (CR,

n = 4; PR, n = 7), with some durable responses inviting further investigations

(Gauthier etal. 2021). Overall, with such poor outcomes after recurrence, current

efforts are also focused on predicting the patients most likely to experience disease

progression and that are potential candidates for preemptive consolidation therapy,

although there is no doubt that patients who do not achieve a rapid CR should be the

rst candidates. Additionally, immune monitoring should encompass not only

CAR-T cell survival but also the detection of circulating tumour DNA (Komanduri

2021) because this could aid in detecting subclinical recurrence and in deciding

whether consolidation or maintenance therapy should be administered. However,

currently, all these approaches are highly speculative and require further clini-

cal study.

Key Points

• Relapse after CAR-T cell treatment for NHL is associated with a dismal

outcome.

• Presently, there is no consensus on salvage therapy.

• Investigating methods to prevent recurrence is mandatory.

• Inclusion in clinical trials is recommended.

D. Blaise and S. Fürst

171

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Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

33 Post-CAR-T Cell Therapy (Consolidation andRelapse): Lymphoma

173

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_34

P. Rodríguez-Otero · J. F. SanMiguel (*)

Department of Hematology, Clínica Universidad de Navarra, University of Navarra,

Pamplona, Spain

e-mail: paurodriguez@unav.es; sanmiguel@unav.es

Post-CAR-T Cell Therapy (Consolidation

andRelapse): Multiple Myeloma

PaulaRodríguez-Otero andJesúsF.SanMiguel

Adoptive cell therapy with BCMA-directed autologous CAR-T cells has shown

very encouraging results in end-stage relapse and refractory multiple myeloma

(MM), with overall response rates ranging between 73% and 96.9%, complete

response (CR) rates between 33% and 67.9%, and MRD negativity in 50–74% of

patients in the two largest phase 2 studies of ide-cel (idecabtagene autoleucel,

KarMMa) and cilta-cel (ciltacabtagene autoleucel, CARTITUDE 1) reported thus

far (Madduri etal. 2020; Munshi etal. 2021). Unfortunately, responses are usually

not maintained, and no plateau has yet been seen in the survival curves. The median

progression-free survival (PFS) in the KarMMa study of ide-cel was 8.8months

(95% CI, 5.6–11.6) among all 128 patients infused, increased to 12.1months (95%

CI, 8.8–12.3) among patients receiving the highest dose (450×10

CAR+T cells)

and increased to 20.2months (95% CI, 12.3–NE) among those achieving a CR.In

the CARTITUDE-1 study, with a median follow-up of 12.4months, the median PFS

has not yet been reached, and the 12-month PFS rate was 76.6% (95% CI; 66.0–84.3).

The absence of a clear plateau in PFS differs from what has been observed in

DLBCL or B-ALL with currently approved CD-19-directed CAR-T cells, where

(albeit with a shorter PFS and lower rates of CR) patients remaining free from

relapse beyond 6 months are likely to enjoy prolonged disease control or even

be cured.

Mechanisms of resistance and relapse following CAR-T cell therapy in MM are

poorly understood, and several factors may explain these differences in survival

(D’Agostino and Raje 2020; Rodríguez-Otero etal. 2020). MM is a very heteroge-

neous disease with important clonal heterogeneity and a highly deregulated marrow

microenvironment. In addition, CAR-T cell therapy has been evaluated in very

heavily pretreated populations, with a signicant proportion of patients being

174

triple-class refractory and exposed to all available therapies, reecting a difcult-to-

treat population with an expected PFS of less than 4months (Gandhi etal. 2019).

To maintain responses and prolong survival, different strategies are being inves-

tigated, such as dual targeting to prevent antigen loss (Jiang etal. 2020) and manu-

facturing changes to increase the proportion of long-lived T cells with a memory

phenotype in the infused product, which has been associated with improved out-

comes and longer CAR-T cell persistence (Alsina etal. 2020; Costello etal. 2019;

Fraietta etal. 2018). The most advanced strategy to consolidate responses is combi-

nation with immunostimulatory drugs, such as IMIDs or checkpoint inhibitors, to

improve functional CAR-T cell persistence and avoid exhaustion. Several clinical

trials using these strategies are ongoing.

Interestingly, considering relapse after CAR-T cell therapy, emerging data show

a discordance between PFS and overall survival (OS). In the updated results from

the CRB-401 phase 1 study, the median PFS and OS reported were 8.8 (95% CI

5.9–11.9) and 34.2 (95% CI, 19.2–NE) months, respectively, across all doses (Lin

etal. 2020). OS data in the KarMMa study are still immature, with 66% of patients

censored overall (Munshi etal. 2021). Thus far, this gap between PFS and OS is not

as clear in other studies, but the follow-up time is still very short for the majority of

the trials. In the Legend-2 study, one of the BCMA studies with a longer follow-up

time, the median PFS for all treated patients was 20months, and the median OS was

not reached, with an 18-month OS rate of 68% (Chen etal. 2019). This suggests that

MM patients relapsing after CAR-T cell therapy may subsequently respond to sal-

vage treatments, including drug combinations that have previously failed. One can

speculate about potential modications of the immune system or the bone marrow

microenvironment induced by CAR-T cells. Unfortunately, data addressing this

phenomenon are not yet available. Furthermore, CAR-T cell therapy has been

shown to signicantly improve health-related quality of life (Cohen etal. 2020;

Martin III etal. 2020; Shah etal. 2020), and this better physical condition together

with a prolonged treatment-free interval are two key factors that may predispose

patients to accept additional rescue therapies, which would also contribute to the

OS gain.

Unfortunately, data are not yet available to elucidate what optimal rescue thera-

pies should be proposed after CAR-T cell progression. Anecdotal cases of patients

progressing after BCMA-directed CAR-T cell infusion and then treated with other

BCMA agents, such as belantamab mafodotin or checkpoint inhibitors, have been

reported and showed that this approach has limited efcacy (Cohen etal. 2019).

Nevertheless, the optimal approach in patients failing BCMA-directed CAR-T cell

therapy will be to employ therapies with different mechanisms of action (Melufen,

CELMODs, Selinexor) or immunotherapies directed against different targets, such

as SLAMF7, GPRC5D or FcRH5, using either bispecic T-cell engagers

(Talquetamab or Cevostamab) or even CAR-T cells. Indeed, new treatment modali-

ties and data from early phase studies including patients relapsing after CAR-T cell

therapy will provide the answer to this challenging problem: “Relapse following

BCMA CAR-T cell therapy: hope for further life.”

P. Rodríguez-Otero and J. F. SanMiguel

175

References

Alsina M, Shah N, Raje NS, etal. Updated results from the phase I CRB-402 study of anti-BCMA

CAR-T cell therapy bb21217in patients with relapsed and refractory multiple myeloma: cor-

relation of expansion and duration of response with T cell phenotypes. Blood. 2020;136(Suppl

1):25–6. https://doi.org/10.1182/blood- 2020- 140410.

Chen L, Xu J, Fu W Sr, etal. Updated phase 1 results of a rst-in-human open-label study of Lcar-

B38M, a structurally differentiated chimeric antigen receptor T (CAR-T) cell therapy targeting

B-cell maturation antigen (BCMA). Blood. 2019;134(Suppl_1):1858. https://doi.org/10.1182/

blood- 2019- 130008.

Cohen AD, Garfall AL, Dogan A, etal. Serial treatment of relapsed/refractory multiple myeloma

with different BCMA-targeting therapies. Blood Adv. 2019;3(16):2487–90. https://doi.

org/10.1182/bloodadvances.2019000466.

Cohen AD, Hari P, Htut M, et al. Patient expectations and perceptions of treatment in

CARTITUDE-1: phase 1b/2 study of ciltacabtagene autoleucel in relapsed/refractory multiple

myeloma. Blood. 2020;136(Suppl 1):13–5. https://doi.org/10.1182/blood- 2020- 136383.

Costello CL, Gregory TK, Ali SA, etal. Phase 2 study of the response and safety of P-BCMA-101

CAR-T cells in patients with relapsed/refractory (r/r) multiple myeloma (MM) (PRIME).

Blood. 2019;134(Suppl_1):3184. https://doi.org/10.1182/blood- 2019- 129562.

D’Agostino M, Raje N.Anti-BCMA CAR-T cell therapy in multiple myeloma: can we do better?

Leukemia. 2020;34(1):21–34. https://doi.org/10.1038/s41375- 019- 0669- 4.

Fraietta JA, Lacey SF, Orlando EJ, etal. Determinants of response and resistance to CD19 chi-

meric antigen receptor (CAR) T cell therapy of chronic lymphocytic leukemia. Nat Med.

2018;24(5):563–71. https://doi.org/10.1038/s41591- 018- 0010- 1.

Gandhi UH, Cornell RF, Lakshman A, etal. Outcomes of patients with multiple myeloma refrac-

tory to CD38-targeted monoclonal antibody therapy. Leukemia. 2019;33(9):2266–75. https://

doi.org/10.1038/s41375- 019- 0435- 7.

Jiang H, Dong B, Gao L, etal. Clinical results of a multicenter study of the rst-in-human dual

BCMA and cd19 targeted novel platform fast CAR-T cell therapy for patients with relapsed/

refractory multiple myeloma. Blood. 2020;136(Suppl 1):25–6. https://doi.org/10.1182/

blood- 2020- 138614.

Key Points

• BCMA-directed CAR-T cell therapy shows very encouraging results in

triple- class refractory multiple myeloma populations, but there is not yet a

survival plateau.

• In the CRB-401 study, an important gap between PFS (median PFS of

8.8months) and OS (median OS of 34.2months) was observed, suggesting

that patients failing BCMA-directed CAR-T cell therapy may subsequently

respond to salvage treatments.

• Data are not yet available to elucidate what optimal rescue therapies should

be proposed after CAR-T cell progression.

• Salvage treatments after CAR-T cell treatment should include drugs with

new mechanisms of action (i.e., Melufen, Selinexor, CelMods) or target-

ing different antigens on the surface of plasma cells (i.e., GPRC5dD

(talquetamab) or FcRH5 (cevostamab).

34 Post-CAR-T Cell Therapy (Consolidation andRelapse): Multiple Myeloma

176

Lin Y, Raje NS, Berdeja JG, etal. Idecabtagene vicleucel (ide-cel, bb2121), a BCMA-directed

CAR-T cell therapy, in patients with relapsed and refractory multiple myeloma: updated

results from Phase 1 CRB-401 study. Blood. 2020;136(Suppl 1):26–7. https://doi.org/10.1182/

blood- 2020- 134324.

Madduri D, Berdeja JG, Usmani SZ, et al. CARTITUDE-1: phase 1b/2 study of ciltacabta-

gene autoleucel, a B-cell maturation antigen-directed chimeric antigen receptor T cell ther-

apy, in relapsed/refractory multiple myeloma. Blood. 2020;136(Suppl 1):22–5. https://doi.

org/10.1182/blood- 2020- 136307.

Martin T III, Lin Y, Agha M, etal. Health-related quality of life in the cartitude-1 study of cilt-

acabtagene autoleucel for relapsed/refractory multiple myeloma. Blood. 2020;136(Suppl

1):41–2. https://doi.org/10.1182/blood- 2020- 136368.

Munshi NC, Anderson LDJ, Shah N, etal. Idecabtagene vicleucel in relapsed and refractory mul-

tiple myeloma. N Engl J Med. 2021;384(8):705–16. https://doi.org/10.1056/NEJMoa2024850.

Rodríguez-Otero P, Prósper F, Alfonso A, etal. CAR-T cells in multiple myeloma are ready for

prime time. J Clin Med. 2020;9(11) https://doi.org/10.3390/jcm9113577.

Shah N, Delforge M, San-Miguel JF, et al. Secondary quality-of-life domains in patients with

relapsed and refractory multiple myeloma treated with the BCMA-directed CAR-T cell ther-

apy idecabtagene vicleucel (ide-cel; bb2121): results from the Karmma clinical trial. Blood.

2020;136(Suppl 1):28–9. https://doi.org/10.1182/blood- 2020- 136665.

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

P. Rodríguez-Otero and J. F. SanMiguel

177

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_35

S. C. Berger (*) · B. Fehse

Department of Stem Cell Transplantation (SCT) and Research Department Cell and Gene

Therapy, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany

e-mail: [email protected]; fehse@uke.de

M.-T. Rubio

Service d’Hematolgie, Hôpital Brabois, CHRU Nancy and Biopole de l’Université de

Lorraine, Vandoeuvre les Nancy, France

e-mail: m.rubio@chru-nancy.fr

Immune Monitoring

SusannaCarolinaBerger, BorisFehse,

andMarie-ThérèseRubio

CAR-T cell expansion and persistence are critical parameters for therapeutic ef-

cacy and toxicity (Locke etal. 2020). However, CAR-T cells are patient-specic

‘living drugs’ with an unpredictable ability to expand invivo. Thus, close postinfu-

sion monitoring should be a major prerequisite to better manage this therapy.

Critical parameters include CAR-T cell expansion kinetics and phenotype immune

reconstitution and serum biomarkers (Fig.35.1; Kalos etal. 2011; Hu and Huang

2020). Additionally, prospective collection and storage of patient specimens should

be planned for future hypothesis-driven studies at specialized research centres. To

date, despite the rapid expansion of CAR-T cell therapy, no standard recommenda-

tions exist for CAR monitoring, and harmonization of efforts across multiple cen-

tres is urgently needed.

Molecular Monitoring ofCAR-T Cells via Digital PCR (dPCR)

Most clinically used CAR-T cell products consist of autologous lymphocytes stably

transduced with retro- or lentiviral vectors encoding the respective CAR construct.

Integrated CAR vectors are commonly detected at the genomic level using real-time

quantitative PCR (qPCR) or dPCR.Surprisingly, outside of clinical trials, CAR-

specic diagnostic tools were initially missing, requiring the de novo design of lab-

made specic assays to enumerate CAR-T cells invivo (Badbaran etal. 2020; Fehse

178

etal. 2020; Kunz etal. 2020). Despite technological differences, both qPCR and

dPCR assays yield robust and accurate results, with limited requirements regarding

sample quality (Table35.1).

dPCR is extremely sensitive and does not rely on standard curves or multiple

repetitions. As a limitation, DNA-directed PCR monitoring provides no information

on the expression of the CAR construct. However, the expansion of CAR-T cells

strongly depends on the interaction of the CAR with its cognate antigen. In accor-

dance, our data have shown excellent correlation of dPCR with ow cytometry

(Badbaran etal. 2020) as well as clinical (Ayuk etal. 2021) results. Because ow

cytometry-based assays facilitate phenotypic characterization of CAR-T cells, the

two methods complement each other well.

Flow Cytometry Monitoring ofCAR-T Cells

Identication of CAR-T cells by ow cytometry (CMF) can be performed by using

monoclonal antibodies (mAbs) directly recognizing the CAR (idiotype, linker

region) or a specic tag included in the CAR construct. Alternatively, indirect detec-

tion can be achieved using antigen-Fc chimeric proteins containing the CAR target

antigen fused to a human IgG Fc fragment. A secondary staining step is required for

the detection of CAR-expressing cells with an anti-Fc or anti-biotin (if the antigen-

Fc is biotinylated) mAb labelled with a uorochrome (Hu and Huang 2020). In

practice, outside of clinical trials, patients receiving commercial CD19 CAR-T cells

are monitored with biotinylated CD19-Fc proteins in a two-step staining protocol.

The advantage of CMF is the possibility of combining CAR staining with other cell

surface markers to characterize CAR-T cells in terms of T cell subtype (CD4 and

CD8 expression), differentiation (naïve versus memory), and exhaustion (PD1,

TIM3, Lag3). In addition, the results can be provided in real time to physicians. The

limitation of the technique is the relatively low sensitivity. Below 0.5% of T cells,

the reliability of CMF is weak and justies pursuing monitoring via PCR. Two

important pieces of information can be obtained with sequential CMF analysis of

CAR-T

cells

Cy/Flu

Disease Assessment

y0 35 100 180 365**

‘Diagnostic’ Monitoring:

‘Research’ Monitoring:

CAR-T-cell expansion kinetics and phenotype

Immune reconstitution

Functional Analysis

Transgene-product specific immunity

Next-generation sequencing (e.g. TCR, RNASeq)

Multiplex immunfluorescent histopathology

*BM and/or Tumor

** Follow-up up to 15 year

Fig. 35.1 Schematic overview of monitoring after CAR-T cell therapy

S. C. Berger et al.

179

CAR-T cells in the peripheral blood after cell infusion: the expansion peak (Cmax,

maximum CAR-T cell rate in percentage or absolute value) and the area under the

curve of circulating CAR-T cells between D0 and D28 (AUC0-28). These two

parameters have been associated with the response and the risk of complications

after treatment in B-lymphoid malignancies (Park etal. 2018; Fraietta etal. 2018;

Locke etal. 2020; Ayuk etal. 2021). To determine these parameters, the recom-

mended frequency of CAR-T cell monitoring is two or three times a week for the

rst 2weeks after CAR-T cell administration, on days 21 and 28, once a month until

3months and then every 3months until 1year (Rubio etal. 2021).

Monitoring ofAdditional Immune Parameters (Non-CAR-T, B,

andNK Cells andCytokines)

Patients receiving anti-CD19 CAR-T cells might develop prolonged T CD4 lym-

phopenia as well as B-cell aplasia with severe hypogammaglobulinaemia, making

them particularly susceptible to bacterial and viral infections even after

Table 35.1 Comparison of molecular monitoring tools

qPCR

dPCR

Principle of analysis

Target-specic primer and

uorescent probes

Yes Yes

Analysis of the gene of

interest within the sample

At the population level After partitioning into tiny

droplets

Amplication Amplies and quanties

amplicon over PCR cycles

Amplies and quanties

amplicon separately within a

droplet

Quantication Continuous intermediate

uorescence measurements

Relies on end-point

uorescence

Data robustness and

reliability

High Very High

Requirement of a reference

sample/standard curve

Yes No

Single cell tools No Yes

Overall properties

Distribution of the

instruments

Commonly available Still less frequently available

Handling Easy to implement Requires more training &

technical skills

Cost (Campomenosi etal.

2016)

3.33 € per sample 3.66 € per sample

Multiplexing

Yes Yes

Certied instruments

commercially available?

Yes Yes (limited)

Compared to qPCR, very robust amplication kinetics and suppresses amplication noise

In the cited study, costs per sample were based on single measurements for dPCR vs. triplicate

analyses for qPCR.They did not include instrument amortization

Decreases sample/reagent use and pipetting noise, increases throughput

35 Immune Monitoring

180

haematopoietic recovery (Logue etal. 2021). Therefore, routine immune surveil-

lance of non-CAR-T CD4 and CD8 T cells, B cells, and NK cells and the levels of

serum immunoglobulins is recommended during the rst year of follow-up.

Many cytokines are produced in large quantities after CAR-T cell administration

as a result of activation of T lymphocytes (IL-6, IFN-γ, sIL2-Rα, sIL-6R, GM-CSF,

IL-2, and TNF-α), activation and attraction of mono-macrophages (IFNα, IL-1β,

IL-6, IL1Rα, IL10, IL-12, IL-13, IL-15, sIL6-R, TNF-α, CXCL10, CCL2, and IL-8)

and in response to tissue damage (IL-6, IL-8, G-CSF, and GM-CSF) (Brudno and

Kochenderfer 2019). Confounding factors, such as sepsis, degree of CAR-T cell

expansion and tumour burden, also impact cytokine levels. Some cytokine signa-

tures have been described to predict the occurrence of cytokine release syndrome

(CRS) (Teachey et al. 2016), immune effector cell-associated neurotoxicity syn-

drome (ICANS) (Santomasso etal. 2018) or the expansion capacity of CAR-T cells

invivo (Kochenderfer etal. 2017). One major limitation in clinical practice is the

absence of a validated fast cytokine quantication test predicting severe complica-

tions. Therefore, further studies are required in homogeneous groups of patients to

determine whether cytokines can predict the occurrence of complications or treat-

ment efcacy. Participation in prospective studies or collection of serum at each

time point of CAR-T cell analysis is recommended.

Key Points

Immune monitoring after CAR-T cell therapy should be carefully performed:

• Medical CAR-T cell products are complex ‘living drugs’ with unpredict-

able invivo performance. Thus, the establishment of accompanying diag-

nostic and research monitoring programmes is a priority for rational

development of this approach.

• Molecular monitoring, especially dPCR, is an excellent, robust, and sensi-

tive tool for real-time/on-site persistence tracking.

• Flow cytometry is an easy and rapid tool to monitor early CAR-T cell

expansion and characterize CAR-T cell phenotype, both of which have

been correlated with the response.

• Routine monitoring of T, B, and NK cell populations and immunoglobulin

levels is recommended to evaluate infection risk.

• Serum collection is recommended to further explore and identify cytokine

signatures that enable prediction of complications or response.

• Efforts to harmonize patient monitoring across multiple centres following

CAR-T cell infusion would be desirable (i.e., reference labs, shared data-

bases, and collaborations with dedicated centres for ‘next generation’

research). Successful implementation of these joint efforts will greatly

advance our understanding of the biology involved in transferring CAR-T

cells and, most importantly, serve our patients.

S. C. Berger et al.

181

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Park JH, Riviere I, Gonen M, etal. Long-term follow-up of CD19 CAR therapy in acute lympho-

blastic leukemia. N Engl J Med. 2018;378:449–59.

Rubio MT, Varlet P, Allain V, et al. Immunomonitoring of patients treated with CAR-T cells

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35 Immune Monitoring

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Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

S. C. Berger et al.

183

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_36

P. Hayden (*)

Department of Haematology, Trinity College Dublin, St. James’s Hospital, Dublin, Ireland

e-mail: [email protected]

N. Gagelmann

Department of Stem Cell Transplantation, University Medical Center Hamburg,

Hamburg, Germany

e-mail: [email protected]

J. Snowden

Department of Haematology, Shefeld Teaching Hospitals NHS Foundation Trust,

Shefeld, UK

Department of Oncology and Metabolism, The University of Shefeld, Shefeld, UK

e-mail: [email protected]

Long-Term Follow-Up andLate Effects

PatrickHayden, NicoGagelmann, andJohnSnowden

Little is known about the long-term effects of CAR-T cell therapy. Although

medium-term complications, such as cytopenia and hypogammaglobulinaemia,

may persist and require ongoing treatment, there do not appear to be other durable

toxicities specic to this new immunotherapeutic class (Fried etal. 2019; Cordeiro

etal. 2020; Cappell etal. 2020). However, to date, CAR-T therapy has been evalu-

ated in patients with multiple relapsed diseases following several lines of treatment,

including allogeneic stem cell transplantation, making it difcult to identify which

effects may be directly attributable to this novel treatment. Nonetheless, as the use

of CAR-T cell therapy increases, structured models for survivorship care will need

to be established. The factors that will affect care requirements include the primary

malignancy, prior treatment, the specic CAR-T therapy and patient age and frailty.

The main late effects identied to date are shown in Table 36.1.

Hypogammaglobulinaemia and prolonged cytopenias appear to be more common in

patients with ALL than in patients with B-NHL.In the ELIANA trial, which tested

tisagenlecleucel (Kymriah™) in ALL, the median time to B-cell recovery was not

reached at a median follow-up time of 13months (Maude etal. 2018). Prolonged

cytopenias in all three cell lines have also been commonly reported. In an Israeli

184

study of 29 patients with either ALL or B-NHL responding after treatment with

CTL109 with a CD28 costimulatory domain, factors associated with late cytopenias

were prior allo-HCT and higher-grade CRS (Fried etal. 2019).

Apart from one patient in the ZUMA-1 trial who developed MDS at 19months,

there were no secondary malignancies reported in the three clinical trials that led to

licensing of CD-19-directed therapy in B-ALL and B-NHL.In addition, some late

cancers are to be expected in such heavily pretreated patients. Although there is one

report of unintended insertion of the CAR gene into leukaemic B cells, thus far,

there have been no reports of insertional oncogenesis during CAR-T cell production.

The role of vaccinations following CAR-T cell therapy remains unclear. Until

evidence-based specic CAR-T vaccination programmes are produced, protocols

similar to HSCT should be considered (Majhail etal. 2012).

Follow-Up andProgrammes

As a specialized service, CAR-T therapy in Europe is generally provided based on

a hub-and-spoke model: patients are referred from local hospitals to regional cellu-

lar therapy centres. One option is to provide follow-up in JACIE-accredited allo-

HCT late effects clinics alongside transplant recipients. They operate on a checklist

model to ensure that survivors are systematically and longitudinally assessed for

late toxicities. Over time, dedicated CAR-T late effects clinics can be developed if

the growing pool of survivors reaches a critical mass. Service-level agreements

(SLAs) between CAR-T centres and referral centres should cover shared care and

outreach arrangements.

Table 36.1 Main late effects after CAR-T cell therapy

Effect

Occurrence

Management

Cytopenia (esp. neutropenia)

All grades

Two months after infusion:

~50%

~20%

Transfusion, growth factors,

infection prophylaxis

Hypogammaglobulinaemia ~50%, prolonged years after

infusion

Intravenous

immunoglobulins (IVIGs)

Infections Predominantly upper

respiratory tract, >50%

bacterial

IVIGs, antibiotics, viral

screening, vaccination

Secondary malignancies Solid tumour>haematological Surveillance, awareness

Neurological effects ~10%, neuropathy and

cerebrovascular events

Supportive care,

interdisciplinary approach to

diagnosis and therapy

Psychiatric issues ~10%, depression and anxiety

Immune-related issues <10%, alveolitis, pneumonitis,

dermatitis, arthralgia, and

myositis, etc.

Corticosteroids,

immunosuppression,

interdisciplinary approach to

diagnosis and therapy

P. Hayden et al.

185

Such clinics require multidisciplinary team (MDT) input, including physicians

involved in CAR-T administration, clinical nurse specialists, clinical psychologists,

data managers, and clinical trial staff. All CAR-T recipients will have been heavily

pretreated. Therefore, a cumulative burden of broader physical and psychological

late effects will need to be considered. Areas to cover in the clinic include CAR-T

persistence; secondary malignancies; autoimmune disease; endocrine, reproductive

and bone health; psychological health; and patient-reported outcomes, including

quality of life (Buitrago etal. 2019; Ruark etal. 2020). Importantly, the patient-

reported quality-of-life studies performed thus far indicate levels of physical and

mental health comparable to that in the normal population.

Initial follow-up will be determined by the status of the underlying disease.

Patients should be seen monthly for the rst year, when the focus will be on remis-

sion status alongside any short-term complications. Subsequent follow-up can focus

on longer-term effects, 6 months for the following 2 years, annually until the

15 year, and potentially indenitely. Patients who proceed to subsequent HSCT,

cytotoxic therapy and/or immune effector cell therapy should be followed as recom-

mended by Majhail etal. (2012).

Post-authorisation Safety Surveillance (PASS)

As both tisagenlecleucel (Kymriah™) and axicabtagene ciloleucel (Yescarta™) are

based on genetic modication of autologous T-cells using viral vectors, the EMA

and FDA made marketing approval conditional on a 15-year PASS.In 2019, the

cellular therapy module of the EBMT registry was found by the EMA to be t-for-

purpose for regulatory oversight of such pharmacoepidemiological studies. The

MED-A cell therapy form has been modied for use with CAR-T cells and other

academic- or industry-manufactured cell therapies. In November 2020, the German

health insurance regulator directed centres to report commercial CAR-T cell treat-

ments to the EBMT Registry and conrmed that reporting such data will be a condi-

tion for reimbursement of the costs of CAR-T cell therapy.

JACIE

FACT-JACIE standards were initially developed for the accreditation of HCT pro-

grammes (Snowden etal. 2017; Saccardi etal. 2019). The current seventh edition of

the standards also covers immune effector cells (IECs) to accommodate cellular

therapy, including CAR-T cells. In addition to clauses addressing the need for poli-

cies on the management of acute toxicities, standard B.7.12 species the need for

“policies and Standard Operating Procedures for monitoring by appropriate special-

ists of recipients for post-cellular therapy late effects”. Inspection of IEC standards

is incorporated within standard JACIE site visits.

For centres that undertake CAR-T cell therapy outside of an accredited allo-HCT

programme, there are a number of options. Given that most CAR-T cell therapies

36 Long-Term Follow-Up andLate Eects

186

are currently used to treat lymphoma, compliance with the IEC standards can be

achieved as part of the accreditation covering autologous HCT (auto-HCT). The

same considerations could apply to myeloma specialists working outside of allo-

HCT programmes. In the event of CAR-T cells or related therapies becoming appli-

cable more broadly to nonhaematological cancers, an alternative strategy already

adopted by FACT is to undertake independent IEC accreditation specically for

CAR-T cells and other IECs. JACIE also provides a robust method to ensure that

programmes meet the requirements for mandatory long-term data submission to the

EBMT Registry, as well as potential benchmarking of survival outcomes.

The eighth edition of the FACT-JACIE standards will be published in 2021 with

more detail on immune effector cells to help provide a framework for centres to

establish and assure the quality and safe practice of treatment administration and

short- and long-term follow-up of CAR-T therapy.

References

Buitrago J, Adkins S, Hawkins M, Iyamu K, Oort T.Adult survivorship: considerations following

CAR-T cell therapy. Clin J Oncol Nurs. 2019;23(2):42–8.

Cappell KM, Sherry RM, Yang JC, Goff SL, Vanasse DA, McIntyre L, etal. Long-term follow-

up of anti-cd19 chimeric antigen receptor T-cell therapy. J Clin Oncol. 2020;38(32):3805–15.

Cordeiro A, Bezerra ED, Hirayama AV, Hill JA, Wu QV, Voutsinas J, etal. Late events after treat-

ment with CD19-targeted chimeric antigen receptor modied T cells. Biol Blood Marrow

Transplant. 2020;26(1):26–33.

Fried S, Avigdor A, Bielorai B, Meir A, Besser MJ, Schachter J, etal. Early and late hematologic

toxicity following CD19 CAR-T cells. Bone Marrow Transplant. 2019;54(10):1643–50.

Key Points

• To date, few durable toxicities have been directly attributable to CAR-T

cell therapy.

• The principal late effects identied to date include hypogammaglobulinae-

mia, cytopenias, and infections.

• Structured models for survivorship care include JACIE-accredited allo-

HCT late effects clinics.

• Areas to monitor in the clinic include CAR-T persistence; secondary

malignancies; autoimmune disease; endocrine, reproductive and bone

health; psychological health; and patient-reported outcomes, including

quality of life.

• EMA has mandated 15-year postauthorization safety surveillance (PASS)

of all CAR-T cell therapies, and the cellular therapy module of the EBMT

registry has been approved for this purpose.

• The current seventh edition of the FACT-JACIE transplant standards also

covers immune effector cells (IECs) to accommodate cellular therapy,

including CAR-T cells.

P. Hayden et al.

187

Majhail NS, Rizzo JD, Lee SJ, Aljurf M, Atsuta Y, Bonm C, etal. Recommended screening

and preventive practices for long-term survivors after hematopoietic cell transplantation. Bone

Marrow Transplant. 2012;47(3):337–41.

Maude SL, Laetsch TW, Buechner J, Rives S, Boyer M, Bittencourt H, etal. Tisagenlecleucel in chil-

dren and young adults with B-cell lymphoblastic leukemia. N Engl J Med. 2018;378(5):439–48.

Ruark J, Mullane E, Cleary N, Cordeiro A, Bezerra ED, Wu V, etal. Patient-reported neuropsychi-

atric outcomes of long-term survivors after chimeric antigen receptor T cell therapy. Biol Blood

Marrow Transplant. 2020;26(1):34–43.

Saccardi R, McGrath E, Snowden AJ.JACIE accreditation of HSCT programs. In: The EBMT

handbook; 2019. p.35–40.

Snowden JA, McGrath E, Duarte RF, Saccardi R, Orchard K, Worel N, etal. JACIE accreditation

for blood and marrow transplantation: past, present and future directions of an international

model for healthcare quality improvement. Bone Marrow Transplant. 2017;52(10):1367–71.

Open Access

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36 Long-Term Follow-Up andLate Eects

Part V

Access to CAR-T Cells

191

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_37

E. McGrath

EBMT, Barcelona, Spain

e-mail: [email protected]

P. Machalik (

Be The Match BioTherapies, Minneapolis, MN, USA

e-mail: [email protected]

The Regulatory Framework forCAR-T

Cells inEurope: Current Status

andForeseeable Changes ANDCentre

Qualification by Competent Authorities

andManufacturers

EoinMcGrath andPetrMachalik

Current Framework

Under current European Union regulations, CAR-T cell therapies fall under the

advanced therapy medicinal products (ATMPs) framework. ATMPs represent a cat-

egory of medicinal products dened in EU Regulation 1394/2007 and subdivided

into four categories, of which autologous or allogeneic CAR-T cells, among other

therapies, are considered gene therapy medicinal products (GTMPs). ATMPs are

subject to a centralized evaluation framework whereby one authorization is valid for

all countries in the EU led by the European Medicines Agency’s Committee for

Advanced Therapies (CAT). The framework includes different regulatory pathways

for bringing ATMPs from clinical trials to market authorization, and the regulatory

pathway taken will depend on a product’s characteristics and the target patient pop-

ulation. In 2018, two chimeric antigen receptor (CAR) T cell therapies, Yescarta and

Kymriah, completed their authorization process via the priority medicines PRIME

scheme to Marketing Authorization (Detela and Lodge 2019).

The production, distribution, and administration of ATMPs require a completely

different organization plan than that used for HSCT, with manufacturing typically at

a central facility in compliance with good manufacturing practices (GMPs), a ver-

sion of which was released in 2017 by the European Commission to specically

192

deal with the manufacturing of ATMPs.

Since a majority of the ATMPs that prog-

ress to authorization or at least to clinical trials are manufactured from autologous

mononuclear cells, starting material is usually procured by hospital- or blood bank-

operated apheresis facilities, creating a peculiar situation in which a product starts

under one regulation—EU Tissues and Cells Directives

—before passing to

another—ATMP Regulation- and in which a hospital acts as a service provider to

industry, an interaction that requires further denition of the respective responsibili-

ties and liabilities (McGrath and Chabannon 2018). The Tissues and Cells Directives,

which cover all steps in the transplant process from donation, procurement, testing,

processing, preservation, storage, and distribution, are undergoing a review that is

expected to lead to a legislative proposal by the European Commission in late 2021,

and it is anticipated that the new framework will further consider how products

cross the interface between the two frameworks.

Given the high toxicity prole of CAR-T cell therapies, marketing authorization

may be subject to conditions that lead to a risk management plan (RMP). The RMP

for the currently authorized CAR-T therapies includes the need for manufacturers to

qualify the sites that will treat patients. Site qualication is addressed below.

Hospital Exemption

In recognizing that many potential ATMPs are used for limited numbers of patients

and with little commercial interest, Regulation 1394/2007 created the so-called hos-

pital exemption (HE) under Article 28, exempting from authorization requirements

those ATMPs manufactured in hospitals or universities where the medicine is pre-

scribed for individual patients under the care of a medical practitioner. This manu-

facturing should occur on a nonroutine basis according to specic quality standards

(GMPs) and only within the same member state.

In February 2021, the Spanish pharmaceutical regulator AEMPS authorized the

rst CAR-T cell therapy approved by a European national authority under the hos-

pital exemption clause for the ARI-0001 CAR-T developed by the Hospital Clinic

in Barcelona.

National authorities oversee the approval of HE products, which has resulted in

signicant variations between member states in how approval is applied, in turn

leading to criticism from both industry and academia that the approval process is

unclear and inconsistent.

Guidelines of 22.11.2017 Good Manufacturing Practice for Advanced Therapy Medicinal

Products. EudraLex The Rules Governing Medicinal Products in the European Union Volume 4

Good Manufacturing Practice.

Directive 2004/23 of the European Parliament and of the Council of 31 March 2004 on setting

standards of quality and safety for the donation, procurement, testing, processing, preservation,

storage, and distribution of human tissues and cells.

https://www.aemps.gob.es/informa/notasinformativas/medicamentosusohumano-3/2021-

medicamentosusohumano- 3/la-aemps-autoriza-el-car-t-ari-0001-del-hospital-clinic-para-

pacientes- con-leucemia-linfoblastica-aguda/?lang=en. Accessed 13/03/2021.

E. McGrath and P. Machalik

193

Role ofAcademia

Academia remains very active in the early phases of clinical trials designed to evalu-

ate innovative GTMPs as potential complements, substitutes, or bridges to historical

forms of haematopoietic cell transplants. One recent study calculated that even now,

when industry interest in these therapies has increased signicantly in the last

5–6years, over 50% of CAR-T cell trials in the USA are still sponsored by aca-

demia (Kassir et al. 2020). Many public institutions have invested signicant

resources to upgrade their processing facilities to GMP-compliant levels, thus

allowing for small-scale manufacturing of experimental medicinal products to sup-

port phase I and possibly phase II studies. Furthermore, academia must become a

proactive stakeholder in the regulatory area by engaging with the authorities, shar-

ing their know-how and voicing their opinion. Through continental registries, such

as EBMT, academic institutions will continue to play a key role due to their data and

procedural knowledge, which will be very useful not only for researchers but also

for industry, health care regulators and payers (Hildebrandt 2020).

Health Technology Assessment

For a marketing authorization holder, approval by EMA is just one step. To gain

market access in the EU, the manufacturer must now approach national health care

reimbursement authorities, collectively known as health technology assessment

(HTA) bodies, who will assess the cost of the added value of novel therapies com-

pared to the current standard of care. Unlike the centralized authorization process,

HTA assessments are performed at the national level and are subject to great vari-

ability between member states. Over the past decade, the EU has pursued a more

harmonized HTA process across Europe, although there remains signicant resis-

tance among member states, and a legislative proposal adopted by the Commission

in early 2018 is only very slowly progressing through the parliamentary process.

Future Focus

Access to ATMPs, including cellular therapies, is likely to be a particular challenge

for patients, health care professionals, and national health systems due to their

expected high costs and complexity. Foreseeable changes to the regulatory frame-

work could see closer alignment with MA and HTA to make them more concurrent

and less sequential processes. The EMA’s strategy for big data places an emphasis

on using real-world data (RWD) to support regulatory decisions, and signicant

efforts are being made to prepare the structures to support this move. Accelerated

processes, such as PRIME, will continue to evolve as regulators gain more knowl-

edge and the science and medicine develop. The interplay between European

medicinal product regulations and genetically modied organism (GMO) frame-

works will likely continue to be the focus of efforts to harmonize interpretations

37 The Regulatory Framework for CAR-T Cells in Europe: Current Status…

194

across the EU.Regulators will see more automation of manufacturing processes,

which should help reduce risk and variability, while decentralized or ‘bedside’ man-

ufacturing could become more common but still need regulatory approval and over-

sight. Allogeneic CAR-T products will also require substantial evidence to reassure

regulators regarding safety concerns about graft versus host disease, cell rejection,

and the risks associated with gene editing. Data protection measures under the

General Data Protection Regulation (GDPR) for health-related personal data could

see adaptations to better facilitate secondary use of data collected to support inves-

tigational and regulatory needs.

Centre Qualification by Competent Authorities

andManufacturers

Shared Goals

A high degree of competencies is required from centres involved in CAR-T cell

therapies by both the competent authorities and the manufacturers. With regard to

centre qualication, authorities and manufacturers share at least some own goals,

which is minimizing CAR-T cell therapy-associated risks for patients to deliver safe

and efcient therapy. Authorities at the international, national, or regional levels

assess the quality of care, level of practice and health outcomes, and qualify centres

that successfully demonstrate high standards of health care and patient safety. For a

manufacturer, accreditation by the competent authority veries that the required

standards are followed and the necessary qualications, processes and resources are

present. From the centre’s perspective, receiving necessary accreditations and

approvals from both the competent authority and the respective manufacturer is a

prerequisite to support concrete CAR-T cell therapy.

Centre Assessment

The presence of accreditation by a competent authority is among the rst items

checked by a manufacturer during the so-called feasibility assessment. The other

reviewed items include the scope of authorized activities; the centre’s ability to

perform particular procedures and tests, incorporate the manufacturer’s require-

ments, and guarantee specic environmental conditions; and the presence of

requested equipment and qualied personnel. For a manufacturer, the assessment is

a great chance to obtain a better understanding of a centre’s setup and daily routine

and its procedural and capacity constraints. The assessment might also reveal gaps,

such as the inadequateness or complete absence of required processes. Generally,

the feasibility assessment is a unique opportunity to evaluate prospective candidates

for collaboration, and it precedes all other steps in a centre’s qualication by a

manufacturer, which may vary in scope and detail depending on the particular

therapy.

E. McGrath and P. Machalik

195

Centre Auditing

The centre qualication audit is usually performed by a manufacturer prior to com-

mencement of any collaboration. The aim is to evaluate compliance with applicable

regulatory requirements and the centre’s own procedures or policies. Manufacturers

obtain an appropriate understanding of the performed services and the robustness of

engaged systems, including quality management, personnel training, and the capac-

ity of available resources. They usually request some of the centre’s internal docu-

ments and process details to be shared prior to the audit to allow for a thorough

review. During the audit, auditors examine more of the centre’s documentation,

interview personnel, inspect the facility’s key locations, and evaluate processes in

targeted functional areas.

In the course of an established collaboration, other types of audits can be orga-

nized. The so-called surveillance audit is a periodic audit to ensure that a centre is

continuing to comply with the required standards. The emphasis is on reviewing

signicant changes that have occurred in the relevant procedures, facility and its

quality system since the qualication audit. A follow-up on any previous audit nd-

ings, including the implementation of corrective and preventive actions, is also a

common part of surveillance audits, which are usually performed every 2–3years.

A for-cause audit can be called in response to serious circumstances, including

deciency in meeting regulatory requirements, occurrence of a major deviation,

repeated deviations, or the risk or occurrence of patient safety issues. This audit

generally focuses on identied nonconformities and areas of manufacturer concern.

Any type of audit will result in an audit report, which lists audit observations or

ndings that might be evaluated for signicance as minor, major, or critical. In

response to a nding, a centre’s own internal procedure usually mandates insurance

of a corrective action. This frequently means strengthening the existing processes or

creation of brand-new processes. Acceptable responses to audit ndings are required

to close an audit.

Centre Training

Audited centres are further qualied by the manufacturers for support of concrete

CAR-T cell therapy. Manufacturers usually do not aim to boost personnel’s general

knowledge or the skills and attitudes required for daily routine practice. Their focus

is on explaining the specicities of clinical trials or authorized therapies, with few

differences between the requirements of the two categories. Generally, the critical

parameters of procedures and products are explained, as well as timelines, environ-

mental conditions, types of equipment and material, completion and usage of

involved documents, and principles of communication among stakeholders. Due to

the complexity of CAR-T cell therapies, centre personnel qualied by manufactur-

ers perform a wide range of functions. Manufacturers usually train those involved in

patient or donor care; starting material procurement, processing, intermediate stor-

age, packaging, release, and testing; completion of documents; and ATMP receipt,

37 The Regulatory Framework for CAR-T Cells in Europe: Current Status…

196

storage, thawing and administration. In practice, these functions involve physicians,

nurses, pharmacists, apheresis and laboratory technicians, and administrative

workers.

Required procedure parameters include duration limits, processed volume tar-

gets, type of anticoagulant, environmental conditions (such as temperature and

humidity), and methods of disconnecting and sealing collection bags. Product

parameters that manufacturers like to specify include targets for collected volume,

yield and purity and the required number of units and samples. With regard to time-

lines, the importance of procedure scheduling and harmonization with other proce-

dural steps or treatment sessions is emphasized. Manufacturers are usually very

clear about the type of equipment and material required for procurement, intermedi-

ate storage, indoor transport, the processing and packaging of starting material or

storage, and thawing and administration of ATMPs. The purpose and usage of the

involved documents are explained, and instructions for completing, archiving, or

sharing with other stakeholders are provided. Colour-coded sample documents, pre-

populated forms, and checklists are among the most frequent support materials.

Centre qualication is not bound to its on-site execution. It can also be per-

formed remotely when travel or visitor restrictions or social distancing guidelines

make any externally driven on-site activities impossible. Internet-based applica-

tions, teleconferencing tools, and purposely developed virtual procedures have

recently been successfully used by manufacturers to perform feasibility assess-

ments, audits, and trainings.

Key Points

• CAR-T cell therapy falls under the ATMP framework, presenting chal-

lenges to all stakeholders, including health care providers and patients.

• Regulatory issues concern not only marketing authorization but also mech-

anisms for cost–benet assessment and, less directly, GMOs and data

protection.

• Academia will continue to play a signicant role in the development and

delivery of these new therapies and should expect to engage with other

stakeholders.

• The regulatory framework is not static and evolves with experience and

knowledge.

• Competent authorities and manufacturers have a common goal, which is

minimizing CAR-T cell therapy-associated risks for patients.

• Accreditation of a centre by a competent authority is understood as veri-

cation that the required standards are followed and the necessary qualica-

tions, processes and resources are present.

• Manufacturers qualify centres for support of a concrete CAR-T cell ther-

apy and focus on the specicities of a particular project.

• Centre qualication is not bound to on-site execution and can be performed

remotely using internet-based applications, teleconferencing tools, and

purposely developed virtual procedures.

E. McGrath and P. Machalik

197

Sources of Information

• World Health Organization—Patient Safety [Internet]. 13 September 2019.

Available from: https://www.who.int/news- room/fact- sheets/detail/patient-

safety (Accessed February 2021)

• Yakoub-Agha I, Chabannon C, Bader P, Basak GW, Bonig H, Ciceri F,

Corbacioglu S, Duarte RF, Einsele H, Hudecek M, Kernsten MJ, Köhl U, Kuball

J, Mielke S, Mohty M, Murray J, Nagler A, Robinson S, Saccardi R, Sanchez-

Guijo F, Snowden JA, Srour M, Styczynski J, Urbano-Ispizua A, Hayden PJ,

Kröger N. Management of adults and children undergoing chimeric antigen

receptor T-cell therapy: best practice recommendations of the European Society

for Blood and Marrow Transplantation (EBMT) and the Joint Accreditation

Committee of ISCT and EBMT (JACIE) [Internet]. February 2020. Available

from: https://haematologica.org/article/view/9515 (Accessed February 2021)

• Taylor L, Rodriguez ES, Reese A, Anderson K.Building a Program—Implications

for infrastructure, nursing education, and training for CAR-T cell therapy. Clin J

Oncol Nurs. 2019 Apr 1;23(2):20–26. https://doi.org/10.1188/19.CJON.

S1.20- 26. [Internet]. Available from: https://pubmed.ncbi.nlm.nih.gov/30880820/

(Accessed February 2021)

• Black A, Gabriel S, Cauleld D.Implementing chimeric antigen receptor T-cell

therapy in practice. The Pharmaceutical Journal [Internet]. 22 May 2020.

Available from: https://pharmaceutical- journal.com/article/ld/implementing-

chimeric- antigen- receptor- t- cell- therapy- in- practice (Accessed February 2021)

• Quality System Audit Program—Activate apheresis and cell collection sites

faster by licensing GTP audit results. Be The Match BioTherapies. [Internet].

Available from: https://bethematchbiotherapies.com/solutions/quality- -

system- audit- program/ (Accessed February 2021)

• Vincinis R. Major vs. Minor Audit Findings. The Auditor. [Internet].

Available from: https://www.theauditoronline.com/major- vs- minor- audit-

ndings/ (Accessed February 2021)

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ways to marketing authorisation. Mol Therap Method Clin Develop. 2019;13:205–32. https://

doi.org/10.1016/j.omtm.2019.01.010.

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drudis.2019.10.003.

Kassir Z, etal. Sponsorship and funding for gene therapy trials in the United States. JAMA Am

Med Assoc. 2020;323(9):890. https://doi.org/10.1001/jama.2019.22214.

McGrath E, Chabannon C.Regulatory aspects of ATMP versus minimally manipulated immune

cells. In: The EBMT handbook: hematopoietic stem cell transplantation and cellular therapies.

Springer; 2018. p.461–4. https://doi.org/10.1007/978- 3- 030- 02278- 5_62.

37 The Regulatory Framework for CAR-T Cells in Europe: Current Status…

198

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

E. McGrath and P. Machalik

199

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_38

R. Saccardi

Cell Therapy and Transfusion Medicine Unit, Careggi University Hospital, Florence, Italy

e-mail: [email protected].it

F. Sanchez-Guijo (

Cell Therapy Area and Hematology Department, University Hospital of Salamanca,

Salamanca, Spain

Department of Medicine, University of Salamanca, Salamanca, Spain

e-mail: [email protected]

How Can Accreditation Bodies, Such

asJACIE or FACT, Support Centres

inGetting Qualified?

RiccardoSaccardi andFerminSanchez-Guijo

The FACT-JACIE accreditation system is based on a standard-driven process cover-

ing all the steps of HSC transplant activity, from donor selection to clinical care.

Since the rst approval of the First Edition of the Standards in 1998, over 360 HSCT

programmes or facilities have been accredited at least once, most of them achieving

subsequent re-accreditations (Snowden et al. 2017). The positive impact of the

accreditation process in the EBMT Registry has been well established (Gratwohl

etal. 2014). Starting with version 6.1, the standards include new items specically

developed for other cellular therapy products, with special reference to immune

effector cells (IECs). This reects the rapid evolution of the eld of cellular therapy,

primarily (but not exclusively) through the use of genetically modied cells, such as

CAR-T cells. FACT-JACIE standards cover a wide range of important aspects that

can be of use for centres that aim to be accredited in their countries to provide IEC

therapy. Notably, FACT-JACIE accreditation itself is a key (or even a prerequisite)

condition in some countries for approval by health authorities to provide commer-

cial CAR-T cell therapy and is also valued by pharmaceutical companies (both

those developing clinical trials and those manufacturing commercial products),

which also inspect the cell therapy programmes and facilities established at each

centre (Hayden etal. 2021). Interest in applying for FACT-JACIE accreditation that

includes IEC therapeutic programmes is clearly increasing, from four applications

in 2017 to 36 applications approved in 2019. The standards do not cover the manu-

facturing of such cells but include the chain of responsibilities when the product is

200

provided by a third party (Maus and Nikiforow 2017). In any case, all the steps in

the process in which the centre is involved (e.g., patient or donor evaluations, cell

collection, cell reception, and storage) are covered by the standards, including the

appropriate agreements with the internal partners, including the pharmacy depart-

ment. In addition, from a clinical perspective, IECs may require special safety mon-

itoring systems due to the high frequency of acute adverse events related to the

massive immunological reaction against the tumour. Although examples and expla-

nations are found in the standard manual, here, the special importance of identifying

and managing cytokine release syndrome (CRS) should be emphasized, and the

standards focus not on specic therapeutic algorithms but on ensuring that medical

and nursing teams are sufciently trained in the early detection of this and other

potential complications (e.g., neurological complications). They also pay attention

to the full-time availability within the institution and its pharmacy of the necessary

medication to address complications and the capacitation and involvement of

Intensive Care and Neurology Department professionals to provide urgent care if

needed. Forthcoming cellular therapy products, currently under investigation, will

show a wider range of risk proles, therefore requiring product-specic risk assess-

ment and consequent adaptation of the clinical procedures for different classes of

products. The FACT-JACIE standards will continue to adapt to these future needs to

assist centres in their achievement of optimal clinical outcomes.

References

Gratwohl A, Brand R, McGrath E, etal. Use of the quality management system “JACIE” and out-

come after hematopoietic stem cell transplantation. Haematologica. 2014;99:908–15.

Hayden PJ, Roddie C, Bader P, Basak GW, Bonig H, Bonini C, et al. Management of adults and

children receiving CAR T-cell therapy: 2021 best practice recommendations of the European

Society for Blood and Marrow Transplantation (EBMT) and the Joint Accreditation Committee

of ISCT and EBMT (JACIE) and the European Haematology Association (EHA). Ann Oncol.

2021;S0923–7534(21):04876–6. https://doi.org/10.1016/j.annonc.2021.12.003. Online ahead

of print.

Maus MV, Nikiforow S.The why, what, and how of the new FACT standards for immune effector

cells. J Immunother Cancer. 2017;5:36.

Snowden JA, McGrath E, Duarte RF, etal. JACIE accreditation for blood and marrow transplan-

tation: past, present and future directions of an international model for healthcare quality

improvement. Bone Marrow Transplant. 2017;52:1367–71.

Key Points

• FACT-JACIE standards have helped accredited centres improve their

HSCT clinical outcomes for more than 20years.

• Standards have been adapted to cover immune effector cell (IEC) therapy

and are a key element in demonstrating optimal quality and performance

for seeking accreditation by both National Health Authorities and the phar-

maceutical companies involved.

• The IEC product chain of responsibilities, agreements with all involved

partners, and full coverage of related adverse events are among the key

elements of IEC- related standards.

R. Saccardi and F. Sanchez-Guijo

201

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

38 How Can Accreditation Bodies, Such as JACIE or FACT, Support Centres…

203

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_39

N. Kröger (*)

Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf,

Hamburg, Germany

e-mail: [email protected]

J. Gribben

Bart’s Cancer Institute, Queen Mary University of London, London, UK

e-mail: [email protected]

I. Sánchez-Ortega

EBMT, Executive Ofce, Barcelona, Spain

e-mail: [email protected]g

Educational Needs forPhysicians

NicolausKröger

, JohnGribben

, andIsabelSánchez-Ortega

CAR-T cells are novel therapies associated with promising and potentially curative

outcomes in patients with high-risk relapsed disease. In Europe, there are currently

three approved products (tisagenlecleucel, axicabtagene ciloleucel, and brexucabta-

gene autoleucel) for patients with acute lymphoblastic leukaemia, aggressive B-cell

lymphoma, and mantle cell lymphoma, although expanded haematologic and non-

haematologic indications are expected soon.

Cellular therapy, including CAR-T cells, is a rapidly evolving eld in haematol-

ogy, and treatment is becoming personalized and specic. To ensure optimal

decision- making by physicians, adequate education programmes must be available

and must be regularly updated. There is a need to identify knowledge gaps and bar-

riers to address these issues with continuous medical education. Adequate education

increases the competence and performance of physicians and improves the quality

of decision-making, ultimately resulting in the optimization of patient management.

The importance of education is also reected in the JACIE accreditation scheme, the

major objective of which is to promote quality medical and laboratory practice in

cellular therapy by offering accreditation based on internationally recognized stan-

dards. The relevant standards in this scheme require that clinical, collection, and

processing facility staff participate in continuous education activities (JACIE 2021).

However, there is also a need to educate the wider community (people who do not

204

work at JACIE accredited sites) to ensure sufcient knowledge to recognize the role

of CAR-T therapy, identify suitable patients and understand the process for timely

referral to treatment centres. There is an inevitable delay between referral, cell col-

lection, and delivery of the CAR-T products, and physicians must be aware of this

process and take steps to manage their patients, who are at high risk of rapid disease

progression and may require bridging therapy, ideally in close collaboration with

the CAR-T treatment centre. Therefore, referring physicians must be educated to

understand the patient selection process, T cell collection process, and the process-

ing and conditioning therapy to fully understand the path that their patients will

travel and the time frames involved in delivering these complex treatments.

CAR-T cell therapies are associated with remarkable therapeutic response rates

but also with unique and potentially lethal complications that require specic edu-

cational updates. Cytokine-release syndrome (CRS) and neurotoxicity are the most

frequent complications after CAR-T cell therapies. These complications can occur

concomitantly and may have a very rapid onset, with a spectrum of symptoms that

range from mild to life threatening. In addition, CRS onset is often indistinguish-

able from infection, which, in the setting of neutropenia, makes the management of

these complex patients even more challenging (Hayden etal. 2021). Haematologic

toxicity, most often seen as a complication of lymphodepleting induction therapy, is

frequent after CAR-T cell infusion, but the pattern, duration, and outcome are not

well described. Learning to monitor and adequately treat persistent cytopenias is

necessary for adequate management of these patients. Learning to dene the opti-

mal timing for ICU referral is also critical because any delay in ICU admission can

compromise patient outcomes. In addition, the unique toxicity prole of CAR-T

cell therapies makes incorporation of real-life data, including that from the patients’

perspective, essential, and initial data suggest that patient-reported toxicities and

mental health concerns are common throughout all stages of survivorship (Barata

etal. 2021; Hoogland etal. 2021). From the moment that a patient is identied as a

CAR-T candidate, education and supportive care of patients undergoing CAR-T

therapy is crucial to improve the knowledge and experience of the patients and their

families. To address these issues, a trained multidisciplinary team, including haema-

tologists, oncologists, intensivists, neurologists, pharmacists, psychologists, and

nurses, must work together from the time of potential patient identication to the

time of treatment and discharge, and their roles are crucial at different stages in the

CAR-T cell process.

Large registry studies with high-quality data may provide the basis of knowledge

for CAR-T cell therapies and open the door to the necessary specic subpopulation

investigations. To ensure continuous evaluation of the efcacy and safety of com-

mercially available CAR-T cells, the EMA endorsed the use of the EBMT registry

for collection of 15-year follow-up data of treated patients (EMA 2019). Likewise,

follow-up data of patients receiving academic and other pharmaceutical-sponsored

CAR-T cell therapies are also expected to be reported to the EBMT registry.

Therefore, the real-world data contained in the EBMT registry will likely be a major

source of knowledge to improve the use of CAR-T cell therapies and to understand

the short-term and long-term patient toxicities and outcomes. This will also allow us

N. Kröger et al.

205

to gain insights into potential biomarkers and the patient and disease characteristics

that might impact the efcacy of CAR-T-treatment, opening the path to more effec-

tive selection and stratication of patients.

Ongoing investigations of CAR-T cell therapies are seeking to elucidate the

mechanisms of resistance, immune escape, and relapse so that the current barriers

can be overcome and treatment efcacy can be improved. Research is also focused

on access to “off-the-shelf” allogeneic CAR-T products, simplifying the manufac-

turing process and mitigating side effects, among other aims. Thus, the complexity

and rapid changes in the eld of cellular therapies demands wide collaboration to

maintain up-to-date education on the entire pathway from collection to the manu-

facturer and back to the clinical unit. GoCART, a multistakeholder coalition

launched by EBMT and EHA, offers a platform to provide the required diversied

and topic-specic education on CAR-T cell therapies. Likewise, the annual EBMT/

EHA European CAR-T cell meeting provides specic continuous medical educa-

tion in this complex eld. In addition, educational online updates are provided on

the EBMT and EHA e-learning platforms (https://www.ebmt.org/education/e- -

learning, https://ehacampus.ehaweb.org) with specic webinars and e-learning

courses focused not only on CAR-T cells but also on other evolving immunotherapy

treatments that may impact the pathway towards CAR-T cell treatment. There is

still much to learn, and this rapidly evolving eld requires rapid and constant edu-

cational updates.

References

Barata A, Hoogland A, Hyland K, et al. Patient-reported toxicities in axicabtagene ciloleucel

recipients: 1-year follow-up. Transpl Cell Therap. 2021;27(3):S375. https://doi.org/10.1016/

S2666- 6367(21)00485- 1.

EMA qualication opinion on cellular therapy module of the EBMT Registry. 2019. Available

at: https://www.ema.europa.eu/en/cellular- therapy- module- european- society- blood- marrow-

transplantation- ebmt- registry.

Key Points

• Continuous medical education should ll unavoidable knowledge gaps in

a rapidly evolving eld.

• Big data registry studies, multistakeholder coalitions, and multidisci-

plinary educational meetings provide regular updates on the entire CAR-T

cell therapy process.

• Updates on specic topics and the latest scientic developments are also

required to provide individualized high-quality patient management.

• e-learning platforms and CAR-T cell meetings provide adequate and spe-

cic updates in this complex eld, but there is also a need to educate the

wider medical community, who refer patients to treatment centres.

• Continuous medical education is necessary, especially because this eld is

rapidly evolving.

39 Educational Needs forPhysicians

206

Hayden PJ, Roddie C, Bader P, Basak GW, Bonig H, Bonini C, etal. Management of adults and

children receiving CAR T-cell therapy: 2021 best practice recommendations of the European

Society for Blood and Marrow Transplantation (EBMT) and the Joint Accreditation Committee

of ISCT and EBMT (JACIE) and the European Haematology Association (EHA). Ann Oncol.

2021;S0923–7534(21):04876–6. https://doi.org/10.1016/j.annonc.2021.12.003. Online ahead

of print.

Hoogland A, Jayani R, Collier A, etal. Acute patient-reported outcomes in B-cell malignancies

treated with axicabtagene ciloleucel. Cancer Med. 2021;10(6):1936–43.

JACIE. 2021. Available at: https://www.ebmt.org/accreditation/jacie- standards.

Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

N. Kröger et al.

207

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_40

M. Kenyon (*)

Department of Haematological Medicine, King’s College Hospital, NHS Foundation Trust,

London, UK

e-mail: [email protected]

J. Murray

Haematology and Transplant Unit, The Christie NHS Foundation Trust, Manchester, UK

e-mail: [email protected]

R. Ellard

The Royal Marsden NHS Foundation Trust, London, UK

e-mail: [email protected]

D. Hutt

Department of Pediatric Hematology-Oncology and BMT, Edmond and Lily Safra Children’s

Hospital, Sheba Medical Center, Ramat Gan, Israel

e-mail: [email protected].il

Education Needs forNurses inAdult

andPaediatric Units

MichelleKenyon, JohnMurray, RoseEllard, andDaphnaHutt

Complex nursing care for patients on the CAR-T cell therapy pathway involves

many different nursing roles that have important functions at different stages in the

pathway. Within the multiprofessional team, nurse education is critical to safe and

competent care and to the patient’s treatment experience. As we consider the educa-

tion needs of the nursing workforce throughout the entire patient pathway, including

the supply chain, chain of custody, and clinical care delivery, we recognize the

important roles of expert nurses, practice educators, and the wider multiprofessional

team in sharing their knowledge and experience. Nurse education strategies should

include referring nursing teams to facilitate seamless patient care throughout refer-

ral, treatment, and follow-up to optimize communication and appropriately meet

patient and caregiver information needs.

Treatment plans can change rapidly; patients do not reach the point of treatment

or relapse during admission. The involvement of disciplines such as palliative care

and psychological therapy in the programme is key. The relationship between the

208

referring and treating centre is critical, and an active dialogue between teams from

the time of referral is imperative to optimize patient care.

Apheresis andCell Collection

Nurses with the knowledge, skills, and expertise to perform CAR-T-specic apher-

esis procedures do so in many JACIE accredited centres following training and

competency achievement. Apheresis booking is synchronized with the availability

of manufacturing space in the pharmaceutical company, but timing is critical to

maximize collection quality and minimize the risk of unsalvageable disease pro-

gression. Preprocedure work-up can include disease- and product-specic tests and

screening. Technically, apheresis is similar to donor lymphocyte or mononuclear

cell procedures but may be more challenging due to low lymphocyte counts follow-

ing earlier treatments. The patients may be symptomatic due to the disease burden

and previous therapies and can become unwell during harvest.

Cell Infusion

Thawing and cell infusion are performed in most centres by appropriately trained

nurses. Frozen cells are shipped from the manufacturer, and thawing occurs at the

bedside via a water bath or automated device. Specic training on defrosting and

infusing the product is mandatory. Soft waste will be disposed of into a double

clinical waste bag, tagged, numbered, and placed in a dedicated biohazard waste

container. Sharp waste, e.g., syringes and vials, must be placed in sealed and lidded

sharps container, which is tagged and labelled as biohazard waste. A disposal

record should be maintained. PPE should be worn at all times of disposal. If cloth-

ing becomes contaminated, it should be changed immediately and disposed of as

soft waste. If spillage occurs, the spill should be cleaned while wearing PPE and

using Clinell red wipes or other virucidal products. Routine checks are performed

at the bedside (patient ID, consent, prescription, vital signs, IV access).

Premedication is administered, ensuring that no steroids are given. The cells are

infused as per local policy and the product specication. The patient’s vital signs

are recorded during and following the infusion. All necessary documentation is

completed. The infusion is usually uneventful, but intensive care and neurology

services should be notied of the CAR-T infusion should their support be needed

during the postinfusion period.

Patient Monitoring

The two most common toxicities following CAR-T infusion are cytokine release

syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome

(ICANS).

M. Kenyon et al.

209

CRS is the most common acute toxicity. Frequently reported symptoms are

fever, hypoxia, and hypotension, which can mimic neutropenic sepsis. Thus, the

patient must be treated for suspected infection with intravenous antibiotics and a

full septic screen must be performed.

ICANS symptoms can be progressive and may include aphasia, an altered level

of consciousness, impairment of cognitive skills, motor weakness, seizures, and

cerebral oedema (Lee etal., 2019). Nurses should be aware of these symptoms, and

familiarity with the patient’s baseline condition aids in monitoring for subtle

changes.

Vital signs of inpatients should be recorded at least once every 4 h to monitor

for signs/symptoms of CRS.Patients may deteriorate quickly, and nurses should

promptly report concerns to the medical team to ensure early recognition and

treatment. The recommended monitoring and assessment tools for CRS and

ICANS are the American Society of Transplant and Cellular Therapy CRS con-

sensus grading (Table1in Chap. 26), immune effector cell-associated encepha-

lopathy (ICE) tool (Table 1 in Chap. 27), and the ASTCT ICANS consensus

grading (Table2in Chap. 27) (Lee etal., 2019). The CRS grade should be calcu-

lated if there is a deterioration in the patient’s vital signs and reported to the medi-

cal team. The ICE score should be calculated at least twice daily. This tool is of

particular benet, as subtle handwriting changes can be an early sign of ICANS.If

the ICE score is less than 10, the ASTCT ICANS grade (Table3 in Chap. 27)

should be calculated and the medical team notied of the change in the patient’s

condition. Patients require daily blood tests, including full blood count, biochem-

istry, CRP, and ferritin; some centres may have additional routine tests.

Toxicity Management

Treatment of symptoms is a key nursing role in the management of CAR-T toxici-

ties. Patients with suspected CRS may require supportive measures, such as

paracetamol, IV uids, or supplemental oxygen. The rst-line medicinal treatment

for CRS is tocilizumab, an anti-IL6 monoclonal antibody given intravenously. Up to

four doses can be given, at least 8 h apart. Second-line treatment for CRS is usually

corticosteroids, although these are always used with caution due to the potential

deleterious effect on CAR-T cell efcacy. However, ICANS is typically treated with

corticosteroids as a rst line because tocilizumab is a large molecule and does not

cross the blood–brain barrier.

Discharge

Upon discharge, patients and their caregivers should have written information about

potential side effects and who and how to contact an appropriate CAR-T member if

they develop problems or concerns. Patients must be aware of the symptoms of CRS

and serious neurological reactions and the need to report all symptoms to the CAR-T

40 Education Needs forNurses inAdult andPaediatric Units

210

team immediately. If discharged prior to day 28, patients are required to remain

within close proximity of the treatment centre until day 28. They are also advised

not to drive for 8 weeks post-infusion or resolution of neurologic symptoms due to

the risk of delayed neurotoxicity. Ideally, they should have a responsible adult as a

caregiver for the rst 3 months at home.

Long-Term Follow Up

In the CAR-T setting, the recommended minimum duration of follow-up is 15

years, with annual assessment, which fulls the regulatory requirements and allows

submission of longitudinal outcome data that can contribute to the growing evi-

dence base. The range of assessments and late effects screening can vary between

products and disease indications. Nurse awareness is necessary to support the

patient with appointments, coordination of tests, communication of results, and

escalation of patient concerns when raised. Early quality of life data show promis-

ing improvements (Tam et al. 2019) for some patients who achieve PR and

CR.Survivorship care, supporting the patient and caregiver through the transition

from treatment through recovery and beyond, is a key area for nurse development.

Paediatric Considerations

Currently, tisagenlecleucel (Kymriah™) is the only approved treatment for refrac-

tory/relapsed ALL in children and young adults up to 25 years of age. Apheresis in

small children is considered safe but challenging because it has potentially more

side effects than in adults due to the small body mass and unique physiology of

children. Venous access in small children can be difcult and limits inlet rates and

in some cases requires insertion of a leukapheresis catheter (Mahadeo etal. 2019).

Children weighing 20–25kg may require priming of the machine with packed red

cells prior to the apheresis procedure. Metabolic complications due to citrate toxic-

ity may present differently in children (Del Fante etal. 2018). Obtaining a sufcient

number of harvested cells could be a limiting factor in infants and small children

(Hayden etal. 2021). In the pre-apheresis consultation, the nurse should consider all

of the above issues and provide age-appropriate preparation for the procedure,

including descriptions of the sequence of events that will occur and accurate infor-

mation on what pain and sensations to expect.

Hypotension and hypoxia are the principal determinants of the consensus grad-

ing scale, and hypotension assessment should account for age and the patient’s indi-

vidual baseline. Although the 10-point ICE assessment is useful for screening adults

for encephalopathy, its use in children may be limited to those aged ≥12 years with

sufcient cognitive ability to perform it. In children aged <12 years, the Cornell

Assessment of Pediatric Delirium (CAPD) is recommended to aid in the overall

grading of ICANS (Lee etal. 2019) (Table40.1).

M. Kenyon et al.

211

After treatment, children with B-cell aplasia should receive immunoglobulin

replacement to maintain IgG levels according to institutional guidelines for IgG

substitution (i.e., ≥500 mg/dL) (Hayden etal. 2021).

For patients aged 1–2 years, the following serve as guidelines for the correspond-

ing questions:

1. Holds gaze, prefers primary parent, looks at speaker.

2. Reaches and manipulates objects, tries to change position, if mobile may try

to get up.

3. Prefers primary parent, upset when separated from preferred caregivers.

Comforted by familiar objects (i.e., blanket or stuffed animal).

4. Uses single words or signs.

5. No sustained calm state.

6. Not soothed by usual comforting actions, e.g., singing, holding, talking, and

reading.

7. Little if any play, efforts to sit up, pull up, and if mobile crawl or walk around.

8. Not following simple directions. If verbal, not engaging in simple dialogue with

words or jargon.

Table 40.1 Encephalopathy assessment for children age <12 years using the CAPD

Answer the following based on interactions with the child over the course of the shift

Never, 4 Rarely, 3 Sometimes, 2 Often, 1 Always, 0

1. Does the child make eye

contact with the caregiver?

2. Are the child’s actions

purposeful?

3. Is the child aware of his or

her surroundings?

4. Does the child communicate

needs and wants?

Never, 0 Rarely, 1 Sometimes, 2 Often, 3 Always, 4

5. Is the child restless?

6. Is the child inconsolable?

7. Is the child underactive; very

little movement while awake?

8. Does it take the child a long

time to respond to

interactions?

Adapted from Traube etal. 2021; reproduced with permission

40 Education Needs forNurses inAdult andPaediatric Units

212

References

Del Fante C, Seghatchian J, Perotti C.Reections on methodical approaches to hematopoietic stem

cell collection in children. Transfus Apher Sci. 2018;57(3):425–7. https://doi.org/10.1016/j.

transci.2018.05.005.

Hayden PJ, Roddie C, Bader P, Basak GW, Bonig H, Bonini C, etal. Management of adults and

children receiving CAR T-cell therapy: 2021 best practice recommendations of the European

Society for Blood and Marrow Transplantation (EBMT) and the Joint Accreditation Committee

of ISCT and EBMT (JACIE) and the European Haematology Association (EHA). Ann Oncol.

2021;S0923–7534(21):04876–6. https://doi.org/10.1016/j.annonc.2021.12.003. Online ahead

of print.

Lee DW, Santomasso BD, Locke FL, Ghobadi A, Turtle CJ, Brudno JN, etal. ASTCT consen-

sus grading for cytokine release syndrome and neurologic toxicity associated with immune

effector cells. Biol Blood Marrow Transplant. 2019;25(4):625–38. https://doi.org/10.1016/j.

bbmt.2018.12.758.

Mahadeo KM, Khazal SJ, Abdel-Azim H, Fitzgerald JC, Taraseviciute A, Bollard CM, et al.

Management guidelines for paediatric patients receiving chimeric antigen receptor T cell ther-

apy. Nat Rev Clin Oncol. 2019;16(1):45–63.

Schmidts A, Wehrli M, Maus MV.Toward better understanding and management of CAR-T cell-

associated toxicity. Annu Rev Med. 2021;72:365–82.

Tam C, Waller E, Jaeger U, Pacaud L, Ma Q, Maziarz R. Prolonged improvement in patient

reported quality of life (QoL) following tisagenlecleucel infusion in adult patients (pts) with

relapsed/refractory (r/r) diffuse large B-cell lymphoma (DLBCL): 19-month follow-up (FU) of

the Juliet study. BBMT. 2019;25(3):181–2.

Traube C, Gerber LM, Mauer EA, Small K, Broglie L, Chopra YR, et al. Delirium in children

undergoing hematopoietic cell transplantation: a multi-institutional point prevalence study.

Front Oncol. 2021;11:627726.

Key Points

• Nurse education strategies should recognize the importance of the range of

nursing roles at various stages in the CAR-T patient pathway and their dif-

fering education and training needs.

• Treatment plans may not always proceed as expected, and patients can

experience sudden and signicant changes.

• Apheresis is technically similar to donor lymphocyte or mononuclear cell

procedures but may be more challenging due to low lymphocyte counts,

poor physical condition or high symptom burden.

• Specic training on defrosting and infusing the product is mandatory.

• The two most common toxicities following CAR-T infusion are cytokine

release syndrome (CRS) and immune effector cell-associated neurotoxic-

ity syndrome (ICANS), for which patients are very closely monitored.

• Nurses must be trained in the use of the CRS and ICANS assessment tools,

local escalation protocols, and treatment strategies.

• Specic considerations exist for paediatric patients, and these nurses must

be trained accordingly.

M. Kenyon et al.

213

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International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

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40 Education Needs forNurses inAdult andPaediatric Units

215

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_41

M. Galassi

Centrale Produzione Farmaci, Hospital Pharmacy, National Cancer Institute of Milan,

Milan, Italy

e-mail: [email protected]

M. E. Moreno-Martínez (

Department of Pharmacy, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

e-mail: [email protected]

Role ofPharmacists

MargheritaGalassi andMariaEstelaMoreno-Martínez

The pharmacist has a key role in the management of CAR-T therapies. Selection,

ordering, reception, storage, preparation of the product for infusion, and dispensing

of CAR-T therapies are some of the pharmacy service responsibilities (Black 2018;

Moreno-Martínez etal. 2020; Booth etal. 2020). The pharmacist requires specic

training, ensuring coordination with all the professionals in the multidisciplinary

team who are involved in the management of these therapies, as summarized in

Table41.1.

The pharmacist must also know which types of CARs are available and can

arrive in the future. CAR-T cells are currently indicated for the treatment of B-cell

acute lymphoblastic leukaemia and diffuse large B-cell lymphoma, two haemato-

logical diseases that share expression of the CD-19 antigen, but the target antigens

are potentially many; therefore, the pharmacist must receive training that takes into

account new future possibilities. An example of other options is the advanced phase

experimentation of CAR-T cells and anti-B-cell maturation antigen (BCMA) for

multiple myeloma pathologies.

CAR-T cells are just the beginning, and CAR-Technology is being applied to

other immune cells:

• CAR natural killer (NK) cells: CAR-NK.

• CAR macrophages (M): CAR–M.

216

Finally, CAR-T cells may be effective against solid tumours, and the main prob-

lem related to the accessibility of the antigen can be solved in patients suffering

from glioblastoma and neuroblastoma with the injection of the cells on site.

The complexity of these therapies requires the intervention of the pharmacist

whose training must include implementation and management of advanced biotech-

nological procedures; therefore, specic skills not only in the preparation of classic

chemotherapies and monoclonal antibodies but also in how to handle, store, and

manage novel therapies and the specic medical devices that could be required

are needed.

One of the most important pharmacist interventions is patient follow-up, intended

to monitor toxicities, adverse events, and concomitant and contraindicated drugs.

Cytokine release syndrome is an extremely serious event that must be monitored by

a multidisciplinary team in which the pharmacist is the reference gure for the man-

agement of rescue drugs and pharmacovigilance studies.

Table 41.1 Pharmacist’s responsibilities

Pharmacist-specic training

Selection and indication for CAR-T cell therapy

• Review and approval for formulary addition

• Patient eligibility criteria

Ordering: know each procedure to order the drug

Reception

• Check integrity of the product, labelling, and temperature compliance

• Check certicate of analysis

Storage and handling

• Manage products stored at ultra-cold temperatures

• Action plan if temperature deviation

Dispensing

• Validate lymphodepleting chemotherapy and coordinate date of dispensing and time planned

for infusion

• Ensure chain of identity of cell product

• Check defrosting procedure. Record the date and time of all the procedures

Administration: conrm procedure and doses of tocilizumab stock ready to use

Follow-up

• Drugs permitted and contraindicated

• Monitoring and management of toxicities

• Ensure appropriate treatment is available

Patient and staff education

Key Points

• The pharmacist requires specic training in the management of CAR-T

therapies, ensuring coordination with all the professionals in the multidis-

ciplinary team.

• The pharmacist must know the types of CARs available and what will

arrive quite soon.

• New skills are needed to handle and store CARs and to follow-up with

patients.

M. Galassi and M. E. Moreno-Martínez

217

References

Black A.Pharmacy institutional readiness for marketed CAR-T therapy: checklists for pharmacy

services. Version 3.0. Specialist Pharmacy Service; 2018. Available at: https://www.sps.nhs.uk/

wp- content/uploads/2018/10/FINAL- Pharmacy- Institutional- Readiness- for- Marketed- CAR-

TDec- 2018.pdf

Booth JP, Kusoski CL, Kennerly-Shah JM.The pharmacist’s role in chimeric antigen receptor T

cell therapy. J Oncol Pharm Pract. 2020;26(7):1725–31.

Moreno-Martínez ME, Vinent-Genestar J, Muñoz-Sánchez C, Carreras-Soler MJ.Hospital phar-

macist’s roles and responsibilities with CAR-T medicines. Farm Hosp. 2020;44(1):26–31.

Open Access

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adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

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indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

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the copyright holder.

41 Role ofPharmacists

219

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_42

B. Calmels (*)

Cell Therapy Facility, Institut Paoli-Calmettes, Marseilles, France

e-mail: [email protected].fr

Educational Needs forCell Processing

Facility Personnel

BorisCalmels

Training on ATMP processes and procedures is systematically provided by the

sponsor after site certication/accreditation.

Chain of Identity (COI) and Chain of Custody (COC) are the most crucial items

to understand to ensure traceability and identication of a cellular product; for com-

mercial ATMPs, the COI and COC are usually managed through a dedicated secure

web-based platform.

In the autologous setting, cell processing staff is involved in most of the on-site

ATMP stages, from collection to administration: the information ow between all

protagonists must be well established to allow for timely delivery of information.

Pivotal training steps for cell processing staff:

– before apheresis: receipt of empty shipper (if apheresis is shipped after cryo-

preservation) and materials.

– after apheresis completion: control of product label, sampling, cryopreservation,

and/or packaging for transportation of fresh or frozen apheresis to the manufac-

turing site.

The responsibility for subsequent steps might be shared with or fullled by the

hospital pharmacy, depending on local regulations.

– after manufacturing completion and prior to initiating lymphodepletion: receipt

of shipper, conformity of transport temperature, frozen bag integrity, and transfer

of frozen product to on-site storage.

– the day of infusion: transport of bag(s) to the thawing site, clinical ward (if bed-

side), or cell therapy facility (recommended) if localized near the infusion site

(thawed ATMPs need to be infused asap).

220

Frozen bag handling and thawing require expertise and must be performed by

experienced, i.e., cell processing staff, whenever possible: this will also relieve

training of unexperienced staff, especially regarding the risks associated with liquid

nitrogen exposure, and anoxia or handling of accidental bag failures.

One of the many challenges of training is to become used to the quantity and

variety of forms associated with each step of the ATMP circuit; consequently, mock

(training) runs organized by sponsors are pivotal for staff training.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

Key Points

• Chain of Custody (COC) is crucial to ensure traceability through the mul-

tiple steps and stakeholders in the supply chain.

• Information that ows between all protagonists must be well dened.

• Frozen bag handling and thawing should be performed by skilled cell pro-

cessing staff.

B. Calmels

221

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_43

S. R. Terwel (*)

EBMT GoCART, Leiden, The Netherlands

e-mail: GoCAR[email protected]

J. Kuball

Department of Hematology, and Center for Translational Immunology, University Medical

Center Utrecht, Utrecht, The Netherlands

Legal Regulatory Affairs Committee (LRAC) of EBMT, Barcelona, Spain

e-mail: [email protected]

M. Dreyling

Department of Medicine III, Ludwig Maximilians University Munich, Munich, Germany

e-mail: [email protected]

F. Cerisoli

EHA, The Hague, The Netherlands

e-mail: f.cerisoli@ehaweb.org

GoC ART

SofieR.Terwel, JürgenKuball, MartinDreyling,

andFrancescoCerisoli

Cellular therapies manufactured from cells of haematopoietic origin, such as

CAR-T–cell therapies, provide a revolutionary treatment for patients suffering from

haematological diseases. Nonetheless, there are considerable challenges in the

implementation of these therapies in this rapidly evolving eld. These challenges

include but are not limited to the complexity of the supply chains for these living

drugs and the management of side effects, requiring centre qualication as well as

additional and ongoing education of health care professionals; the long-term fol-

low- up of patients treated with therapies with curative intent; the myriad regulatory

requirements at the European Union and local level; and reimbursement of the treat-

ments by budget-constrained authorities.

The challenges in the eld of cellular therapies require cross-stakeholder col-

laboration, including patient representatives, health care professionals, pharmaceu-

tical companies, health authorities, health technology assessment (HTA) bodies and

reimbursement agencies, and medical organizations at both the European and

national levels. For these reasons, EBMT and EHA have launched the GoCART

222

Coalition, a multistakeholder initiative aiming to promote patient access to novel

cellular therapies manufactured from cells and tissues of haematopoietic origin and

to contribute to health and well-being through innovation via multistakeholder col-

laboration on clinical data, standards of care, education, and policy.

The aims of the GoCART coalition:

• Improve health outcomes for patients.

• Engage stakeholders and establish a sustainable European coalition in the eld

of cellular therapy.

• Collaborate and share data and knowledge to prevent duplication of effort and

maximize resources.

• Promote harmonization of data collection, education, standards of care, regula-

tory approval, and reimbursement processes in Europe.

• Set up a pre- and post-marketing registry that supports regulatory decision-

making and shared research purposes.

• Develop a cellular therapy education and information programme for patients

and health care professionals.

• Harmonize standards of care and centre qualication.

• Advance policies that further the shared mission and vision.

The coalition is open to all stakeholders relevant to achieving its mission. Both

institutional and individual members are invited to participate in work packages that

implement the Coalition’s mission, vision, and goals. Work package chairs are

accountable to an executive committee with a balanced representation of stakehold-

ers, and the executive committee functions as the primary decision-making body

and determines the overall strategy of the coalition.

The following content work packages have been created:

1. Data harmonization

a. Context: In Europe, clinical data from patients treated with gene and cellular

therapies are reported to many registries, each built for a limited purpose,

with different governance rules and specic software tools managing the

data. This results in siloed data, inefciencies, and duplication of efforts.

b. Overall aim: Create a central EU data registry for harmonized collection of

clinical data on patients treated with cellular therapies to support collabora-

tive studies and regulatory decision-making.

2. Standards of care

a. Context: Gene and cellular therapies are inherently complex products, and

treatment administration is restricted to qualied centres. With rapid develop-

ments and pending product approvals, there is a need to develop treatment

guidelines and harmonize centre qualication procedures across pharmaceu-

tical companies, accreditation bodies, and national requirements.

b. Overall aims: (1) To develop harmonized guidelines on patient and product

management for health care professionals; (2) to reduce inspection burden

and redundancies by developing and implementing consensus-driven

S. R. Terwel et al.

223

requirements and qualication standards for clinical teams delivering gene

and cellular therapies from cells and tissues of haematopoietic origin.

3. HTA process

a. Context: Health technology assessment bodies and reimbursement agencies

need to make decisions based on the best available estimates of the properties

and impact of new therapies. This is particularly challenging for gene and

cellular therapies, considering that authorizations may be based on small

patient groups, limited availability of (long-term) follow-up and comparator

data, the high costs of the products, and the increasing number of therapies on

the horizon. Although national procedures on health technology assessments

and reimbursement vary considerably, there is a common need for reliable

safety and effectiveness data.

b. Overall aim: Leveraging the central registry for gene and cellular therapy as

a suitable data source for health technology assessment.

4. Education

a. Context: Gene and cellular therapies are complex products that require com-

prehensive and ongoing training of health care professionals as well as

patients and caregivers. A plethora of training courses are already offered by

MAHs as well as health organizations, which can lead to considerable

overlap.

b. Overall aim: Develop harmonized educational programmes for different

groups of health care professionals and patients.

5. Policy and advocacy

a. Context: Gene and cellular therapies are subject to EU and national regula-

tions affecting their preparation, administration and patient access. These

new therapies challenge these regulations, which were designed for more tra-

ditional pharmaceutical products, and health authorities are assessing how

they will adapt.

b. Overall aim: Represent and promote the interests of the GoCART coalition

and its stakeholders in EU policy-making by engaging with EU institutions

and other relevant stakeholders.

6. Scientic excellence

a. Context: Scientic research on gene and cellular therapies has increased

substantially in recent years. With real-world data becoming increasingly

available, many scientic questions can be explored from different per-

spectives. Only by working together can we leverage enough data to con-

duct meaningful research. GoCART wants to maximize the use of data

collected in the central registry as well as data available to other stakehold-

ers and to facilitate further collaboration between stakeholders. While

strongly protecting condentiality, the guiding principle should be ‘collect

once, use often’ to advance our knowledge in the eld of gene and cellular

therapies, support better decision- making, and drive efciencies for all

stakeholders.

b. Overall aim: Stimulate scientic discussion across stakeholders, facilitate the

setup of joint research projects, and avoid duplication of scientic efforts.

43 GoCART

224

Take a look at our webpage for the most recent information: https://thegocartco-

alition.com

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

Key Points

• The GoCART cell coalition is a multistakeholder initiative in the eld of

cellular therapies for haematological disease.

• Stakeholders include patient representatives, health care professionals,

pharmaceutical companies, health authorities, health technology assess-

ment (HTA) bodies and reimbursement agencies, and medical organiza-

tions at both the European and national levels.

• The mission is to promote patient access to novel cellular therapies manu-

factured from cells and tissues of haematopoietic origin and to contribute

to health and well-being through innovation via multistakeholder collabo-

ration on clinical data, standards of care, education, and policy.

• The GoCART Coalition aims to achieve its mission through activities

organized in work packages on (1) data harmonization, (2) standards of

care, (3) HTA, (4) education, (5) policy and advocacy, and (6) scientic

excellence.

S. R. Terwel et al.

225

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_44

J. Snowden (*)

Department of Haematology, Shefeld Teaching Hospitals NHS Foundation Trust and

University of Shefeld, Shefeld, UK

e-mail: [email protected]

R. F. Duarte

Department of Hematology, Hospital Universitario Puerta de Hierro Majadahonda and

Universidad Autónoma de Madrid, Madrid, Spain

e-mail: [email protected]

Patient Referral

JohnSnowden andRafaelF.Duarte

Early and efcient patient referral is a critical step in the ability of potential candi-

dates to access CAR-T therapy. Despite improvements in centre qualication and

availability, regulatory and reimbursement frameworks, and addressing the educa-

tional needs of the various members of the health care team, referring haematolo-

gists and oncologists identify major barriers to prescribing CAR-T therapy,

including cumbersome logistics, high cost and toxicity, and clinical challenges,

such as deterioration of the patient prior to CAR-T administration and the need for

bridging chemotherapy while awaiting manufacturing (Chavarría 2021).

Pathways for referral vary between countries and regions, but generally, patients

are referred to the regional CAR-T specialist multidisciplinary team (MDT) accord-

ing to agreed pathways, which in turn, may be linked with national committees

often necessary for additional clinical support and/or to conrm funding. These

specialist MDTs conrm patient eligibility in line with the manufacturer’s licence

and based on diagnosis, age, tness, disease, and treatment stage. Thereafter, the

CAR-T centres will arrange to assess the patient directly (with their carers) and

provide detailed information enabling the patient to understand the potential bene-

ts, risks, and complications of treatment and to provide informed consent.

Irrespective of the treatment site, clinicians must consider the eligibility of

potential patients for CAR-T cells at an early stage so that strategic decisions can be

made regarding the best therapeutic pathway. Eligibility should be directly con-

rmed with regard to age, tness, disease, and treatment stage. In addition, referring

226

clinicians should inform their patients of the potential of using CAR-T cells in their

treatment early in the pathway, especially if treatment may take place in another

centre some distance from their home or base centre (Gajra et al. 2020). In addition

to conrmation of eligibility and logistical arrangements with the treatment site,

prompt referral and good communication are also desirable to plan the salvage pro-

tocol for bridging CAR-T therapy, particularly because dened recovery periods

may be required before leukapheresis and the quality of circulating T-cells may

decrease with increasing chemotherapy exposure. Sometimes patients without a

high peripheral disease burden and sufcient circulating T-cells (e.g., total lympho-

cyte count of >0.5 × 10

/L or a peripheral blood CD3 count of >150 per μl) may be

able to undergo leukapheresis for CAR-T cells before starting salvage therapy for

relapse. For other patients, planning bridging therapy with the CAR-T therapy cen-

tre will be necessary. Therapies likely to signicantly impair lymphocyte number

and/or function should be avoided to allow successful leukapheresis for CAR-T cell

therapy. Therefore, careful scheduling and prioritization of patients is required,

including planning for leukapheresis, particularly given that CAR-T manufacture

can take over one month. Finally, capacity planning is required for subsequent

stages of care in the CAR-T centre, and later, shared care arrangements will enable

continuity of care after a patient returns home (Maus and Levine 1996).

References

Chavarría T. Real-world regulatory issues in the implementation of advanced therapies.

Multistakeholder forum at 47th EBMT annual meeting. 2021. Available at www.ebmt.org

Gajra A, Jeune-Smith Y, Kish J, Yeh T-C, Hime S, Feinberg B.Perceptions of community hema-

tologists/oncologists on barriers to chimeric antigen receptor T-cell therapy for the treatment of

diffuse large B-cell lymphoma. Immunotherapy. 2020;12(10):725–32. https://doi.org/10.2217/

imt- 2020- 0118.

Maus MV, Levine BL.Chimeric antigen receptor T-cell therapy for the community oncologist.

Oncologist. 1996;21:608–17. https://doi.org/10.1634/theoncologist.2015- 0421.

Key Points

• Prompt early patient referral from the base hospital to the treatment centre

facilitates various aspects of the planning for CAR-T therapy.

• The learning curve in the CAR-T therapy framework will also inform and

facilitate the management and referral of patients for other advanced ther-

apy medicinal products.

J. Snowden and R. F. Duarte

227

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

44 Patient Referral

229

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_45

C. Haag (*)

University Hospital Carl Gustav Carus Dresden, Dresden, Germany

e-mail: [email protected]

Treatment Coverage

andReimbursement

CornelieHaag

The conditions for reimbursement for CAR-T cell therapy are not uniform in

Europe. Most European countries use a DRG system for billing hospital services,

but the details vary. Nonetheless, the similarity is that expensive therapies, such as

CAR-T cell therapy, are initially not included in the DRG system. Most countries

possess instruments to ensure the nancing of such expensive therapies outside the

DRG system as separate payments. These reimbursement instruments of DRG sys-

tems are used in most countries both for short-term nancing for innovative and new

therapies and as long-term additional fees within the respective DRG system.

Individual countries maintain different regulations, and therefore, hospitals have the

responsibility to determine the specic requirements of their country before estab-

lishing CAR-T cell therapy.

One should consider that other signicant costs exist in addition to the price of

the actual CAR-T cell product, which has been agreed upon with the pharmaceuti-

cal industry. In addition to the usual hospitalization costs, the price of the inpatient

stay for the administration of CAR-T cells can include the costs for intensive care

and expensive medication, such as tocilizumab. These additional costs are generally

reimbursed through the established system in each country. However, at least 2

years are required to integrate the costs of a new therapy or method into the

existing DRG.

The special feature of CAR-T cell therapy is that the hospital needs to collect

lymphocytes from the patient in advance through apheresis. This initial product for

the production of CAR-T cells induces further costs that are usually not reimbursed.

The implementation of this new therapy in a hospital should not be underesti-

mated. In addition to the training of staff for this new type of therapy, high demands

are placed on quality management by both the pharmaceutical industry and the

government. These structural costs (mostly personnel costs) for the hospital must be

230

agreed upon separately with health insurance companies or the government, depend-

ing on the state-dependent reimbursement system.

A single hospital has a minor impact on the pricing of a CAR-T cell product; this

is usually done by negotiation between pharmaceutical companies and government

agencies.

In addition to the reimbursement of the CAR-T cell product at the price set by

these negotiations, the additional costs of this therapy are reimbursed differently,

particularly within Germany. Efforts are being made to centralize these negotia-

tions, but the success of such a centralized negotiation depends on the structures and

organization of the numerous health insurance companies in Germany.

In Germany, the individual hospital then becomes responsible for the specic

reimbursement of costs for each individual patient. In the case of extremely high

costs, advanced agreements are usually made between the health insurance and the

hospital.

Before initiating CAR-T cell therapy, every doctor or hospital should be aware of

the different regulations in each country to avoid not receiving reimbursement for

this expensive therapy.

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

Key Points

• Different rules in different countries.

• Additional costs aside from the cost of the CAR-T cell product.

C. Haag

231

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_46

M. Abou-el-Enein (*)

Division of Medical Oncology, Department of Medicine, and Department of Stem Cell

Biology and Regenerative Medicine, Keck School of Medicine, University of Southern

California, Los Angeles, CA, USA

Joint USC/CHLA Cell Therapy Program, University of Southern California, and Children

Hospital, Los Angeles, CA, USA

e-mail: [email protected]

J. Gauthier

Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA

Division of Medical Oncology, University of Washington, Seattle, WA, USA

e-mail: [email protected]

The Value ofCAR-T-cell Immunotherapy

in Cancer

MohamedAbou-el-Enein andJordanGauthier

The development of genetically modied chimeric antigen receptor (CAR) T-cells

to target cancer by conferring tumour antigen recognition has tremendously

improved the ght against the disease and broadened treatment options for haema-

tological malignancies (Elsallab etal. 2020b). However, in contrast to conventional

drugs that patients can easily access, the implementation of CAR-T-cell therapy in

routine clinical practice poses signicant challenges. Access to CAR-T-cell prod-

ucts is currently limited to specic certied centres meeting the requirements set up

by manufacturers and regulatory agencies. There are also issues regarding insurance

coverage, reimbursement, affordability, and pricing, which have critical impacts on

broadening patient access to these novel therapies (Abou-El-Enein etal. 2016a, b).

Current list pricing ranges between $373,000 and $475,000 per one-time infusion

for the ve CAR-T-cell therapies currently approved by the FDA (tisagenlecleucel,

Kymriah

; axicabtagene ciloleucel, Yescarta

; brexucabtagene autoleucel,

Tecartus

; lisocabtagene maraleucel, Breyanzi

; idecabtagene vicleucel, Abecma

In addition to the cost of the CAR- T- cell product, patient preparation (leukapheresis

and/or lymphodepletion), product infusion, pre- and post-infusion patient manage-

ment, and monitoring for side effects (Wagner etal. 2021) signicantly add to the

nal price tag. There are calls for restructuring the current payment and

232

reimbursement models to allow better access to CAR-T-cell therapies (Abou-El-

Enein et al. 2014). However, this would only be possible after examining the

strength of clinical evidence generated during product development (Abou-El-

Enein and Hey 2019; Elsallab etal. 2020a) and, most importantly, by determining

the value of CAR-T-cell therapy.

Efcacy does not automatically entail value. Quality-adjusted life years (QALYs)

per dollar spent reect a well-accepted measure of cost-effectiveness to assess

value. QALYs enable evaluation of the impact of a certain therapy on the entire

lifespan of a patient (quantity of life) and on health-related quality of life (HRQoL),

reecting a main parameter of treatment outcomes (Whitehead and Ali 2010). As

composite estimates of mortality and morbidity, QALYs are conventionally calcu-

lated by accumulating life years attained from a utility value specic to certain

health states. Preference elicitation studies in patients with a certain medical condi-

tion, such as in clinical trial scenarios, or in the general population serve as the basis

to derive this utility value (Prieto and Sacristán 2003; Whitehead and Ali 2010;

Sanders etal. 2016; Fiorenza etal. 2020).

Various models have been utilized to assess the cost-effectiveness of CAR-T-cell

therapy. With respect to Kymriah

and Yescarta

, Lin etal. used a decision analytic

Markov model and data from multicentre single-arm trials from a US health payer

perspective for patients with relapsed or refractory (r/r) adult large B-cell lym-

phoma. CAR-T-cell therapies were compared to salvage chemotherapy and stem

cell transplantation by incorporating certain assumptions regarding long-term effec-

tiveness in the model. Yescarta

was shown to prolong life expectancy by 8.2 years

at $129,000/QALY gained (95% uncertainty interval, $90,000 to $219,000) when

assuming a 40% 5-year progression-free survival (PFS). Kymriah

led to an increase

of 4.6 years at $168,000/QALY gained (95% uncertainty interval, $105,000 to

$414,000/QALY) when assuming a 35% 5-year PFS (Lin etal. 2019). The study

indicated that lowering the list price of Yescarta

and Kymriah

to $250,000 and

$200,000in the US, respectively, or implementing payment only for an initial com-

plete response (at current prices) would enable both CAR-T-cell therapies to cost

less than $150,000/QALY even at the more conservative assumption of a 25%

5-year PFS (Lin etal. 2019). Using data of paediatric patients with r/r B-cell ALL,

Sarkar et al. built a microsimulation model to measure the incremental cost-

effectiveness ratio (ICER) (Sanders etal. 2016) comparing CAR-T-cell therapy to

standard of care, considering ICERs below a threshold of $100,000 per QALY as

cost-effective (Sarkar etal. 2019). Assuming a 76% 1-year survival, they demon-

strated an increase in overall cost by $528,200 with improved effectiveness by 8.18

QALYs, leading to an ICER of $64,600/QALY. However, if the assumption was

modied to 57.8% 1-year survival, CAR-T-cell therapy in paediatric B-ALL patients

was no longer cost-effective. While probabilistic sensitivity analysis showed CAR-

T- cell therapy to be cost-effective in approximately 95% of iterations at a level of

willingness to pay $100,000/QALY (Sarkar etal. 2019), assumptions made regard-

ing long-term outcomes in both models need to be conrmed by real-world data

with longer follow-up duration to enable robust validation of study outcomes.

M. Abou-el-Enein and J. Gauthier

233

When discussing value-based considerations, social value gained by CAR-T-

cell therapy in the long term should also be taken into account. Offering a cure

to paediatric cancer patients would enable them to lead a more productive life

(Fiorenza etal. 2020). Moreover, successful milestones reached with respect to

patenting (Jürgens and Clarke 2019) and regulatory and clinical success

(Elsallab etal. 2020b) will increase public recognition, nancial support, and

advancements in the entire cellular therapy eld. A recent study applied an eco-

nomic framework to measure the social value of CAR-T-cell therapy as a sum of

consumer surplus and prot for the manufacturing company (Thornton Snider

etal. 2019). Consumer surplus reected the difference between the added value

of health gains achieved by the therapy and its incremental cost, accounting also

for indirect costs and patient benets. The gained social value was determined

to be as much as $6.5 billion and $34.8 billion for paediatric ALL and DLBCL,

respectively, with a net social value gain of $952,991 per child treated for

B-ALL, even after including costs for production and treatment. However, they

also showed a critical effect of treatment delays that negatively affect the social

value generated by CAR-T-cell therapy, with a 1, 2, or 6 month treatment delay

leading to a 9.8%, 36.2%, and 67.3% loss of social value, respectively, for pae-

diatric ALL patients and a 4.2%, 11.5%, and 46.0% loss of social value, respec-

tively, for patients with DLBCL (Thornton Snider et al. 2019). Thus, timely

patient access is a key factor in the level of value achieved. Other key parame-

ters to optimize the value of CAR-T-cell therapies rely on improving response

rates, minimizing the risk of relapse and lowering the costs of toxicity manage-

ment (Fiorenza etal. 2020).

Although CAR-T-cell therapy is undoubtedly transforming the therapeutic land-

scape for cancer patients, signicant economic challenges ought to be addressed to

allow broader and fairer access to these new therapies. Since most cost- effectiveness

models are highly assumption-sensitive, a longer follow-up duration is warranted to

better assess the value of CAR-T-cell therapies compared to alternative approaches.

Key Points

• CAR-T-cells have emerged as an important therapeutic approach for many

cancer patients; however, issues regarding insurance coverage, reimburse-

ment, affordability and pricing impact access to these novel therapies.

• Short-term clinical data have demonstrated the potential of CAR-T-cells to

become a cost-effective approach for cancer patients, but availability of

long- term clinical outcomes will be required to achieve this goal.

• The value of such a novel therapeutic modality should also be evaluated

within the social gains of cancer patients resuming normal and productive

lifestyles. However, these gains are dramatically inuenced by delays in

receiving the treatments.

The Value ofCAR-T-cell Immunotherapy in Cancer

234

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the EU market. Cell Stem Cell. 2016a;12:293–7. https://doi.org/10.1016/j.stem.2016.08.012.

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of advanced therapies: a comparative study with other biologicals. Mol Ther. 2020a;18:269–79.

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org/10.1200/JCO.18.02079.

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Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

M. Abou-el-Enein and J. Gauthier

235

N. Kröger et al. (eds.), The EBMT/EHA CAR-T Cell Handbook,

https://doi.org/10.1007/978-3-030-94353-0_47

H. Schoemans (*)

Department of Hematology, University Hospitals Leuven, Leuven, Belgium

Department of Public Health and Primary Care, ACCENT VV, Katholieke Universiteit

Leuven- University of Leuven, Leuven, Belgium

e-mail: [email protected]

N. Bolaños

Lymphoma Coalition, Madrid, Spain

e-mail: [email protected]

L. Warwick

Lymphoma Coalition, Management, Mississauga, ON, Canada

e-mail: [email protected]

What do Patients Want? TheImportance

ofPatient-reported Outcomes

HélèneSchoemans, NatachaBolaños, andLornaWarwick

Understanding of what it means for patients to receive CAR-T therapy remains

insufcient due to the small number of studies with a quality of life (QOL) focus,

selection bias of respondents, high risk of attrition due to disease relapse, and lim-

ited length of follow-up. CAR-T therapy is often presented as a last option for

patients with advanced disease. The primary aim of the treatment is patient survival

and hopefully disease elimination. However, understanding other aspects of health,

such as functional status, cognitive function, psychosocial concerns, and other

health-related (QOL) issues, is key to appreciating the full impact of such therapies

at both the individual and societal levels.

Such information can only be accessed by asking patients and caregivers directly,

without going through the lter of a third party, using either patient-reported out-

come measures and/or qualitative methods, such as interviews or focus groups. This

approach is supported by the cell therapy community, but evidence remains limited

(Chakraborty etal. 2019; Shalabi etal. 2021).

Side effects, such as CRS, neurotoxicity, and B-cell aplasia, are well documented.

Importantly, many patients report other concerns that impact their well- being and

require appropriate support from their health care team (Bamigbola et al. 2021).

236

Hoogland and colleagues recently showed that over half of adult CAR-T recipients

complained of moderate to severe fatigue (84%), decreased appetite (73%), dry mouth

(61%), and insomnia (55%) in the rst 100 days following therapy, with a symptom

peak seen after approximately two weeks (Hoogland etal. 2021). Compared to base-

line, physical functioning signicantly improved, with decreased pain, fatigue, and

depression, but anxiety increased (Hoogland etal. 2021). In a follow-up study up to

1-year post-CAR-T cell infusion, approximately one-third of patients presented last-

ing moderate to severe fatigue and insomnia, and 20% had decreased memory com-

pared to baseline (Barata etal. 2021). In contrast, in children and adolescents (3–21

years) who had undergone CAR-T therapy for acute leukaemia, a steady signicant

improvement in QOL compared to baseline was seen from 3 months post-treatment in

all domains examined (Laetsch etal. 2019).

Mental health is a long-term issue, considering that up to 20% of 1 to 5-year

adult survivors reported clinically meaningful depression or anxiety and over one-

third experienced cognitive difculties (Ruark etal. 2020). Marziaz and colleagues

also showed meaningful improvement in QOL up to month 18 in all domains,

except for mental health (Maziarz etal. 2020). Of note, there have been no signi-

cant associations identied between the severity of CRS or ICANS and long-term

quality of life to date.

Little is known about patient priorities and needs after CAR-T therapy, but the cur-

rent literature underscores the importance of appropriate information. By interviewing

patients, Matthews etal. found that most felt unprepared for the emotional aspects of

CAR-T therapy nor were they prepared for the intensity of the toxicities (Matthews

et al. 2019). The importance of addressing issues, such as clear information on the

treatment trajectory (Bamigbola etal. 2021), nancial toxicity, and the importance of

family members and other caregivers, has also been described (Foster etal. 2020).

Future studies are needed to broaden the understanding of CAR-T cell therapy

survivorship to identify the themes most important to patients, potentially including

themes identied in other cell therapy recipients, such as impact on informal care-

givers, return to school/work, nancial issues, and access to care (Burns etal. 2018).

Outcome evaluation in large groups of patients with extended longitudinal follow-

up is particularly important to identify predictors of QOL, specically of mental

health and cognitive function, so patients undergoing CAR-T therapy can be better

informed and supported.

Key Points

• Symptom burden generally decreases over time, starting from 3 months

post CAR-T therapy.

• Mental health and cognitive function remain a concern in long-term

survivors.

• Currently, there is no indication of an association between CRS or ICANs

and long-term QOL.

• Patient priorities, expectations, and needs regarding CAR-T cell therapy

urgently need to be assessed.

H. Schoemans et al.

237

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Open Access

This chapter is licensed under the terms of the Creative Commons Attribution 4.0

International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing,

adaptation, distribution and reproduction in any medium or format, as long as you give appropriate

credit to the original author(s) and the source, provide a link to the Creative Commons license and

indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative

Commons license, unless indicated otherwise in a credit line to the material. If material is not

included in the chapter's Creative Commons license and your intended use is not permitted by

statutory regulation or exceeds the permitted use, you will need to obtain permission directly from

the copyright holder.

47 What do Patients Want? TheImportance ofPatient-reported Outcomes