CC BY-NC-ND 4.0 · Indian Journal of Medical and Paediatric Oncology 2021; 42(01): 089-092
DOI: 10.1055/s-0041-1729437
Trainees’ Corner

Chimeric Antigen Receptor T-Cell Therapy

Azgar Abdul Rasheed
1  Department of Medical Oncology, Dr. BRA IRCH, AIIMS, New Delhi, India
,
Venkata Pradeep Babu Koyyala
2  Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
› Author Affiliations

The beginnings of “Immunotherapy” can arguably be traced back to the ancient Egyptians. They, like James Paget, Wilhelm Busch, and Friedrich Fehleisen in the mid-1800s, observed that some cancer patients experienced tumor regression after suffering from infections. By the late 1800s, the “Father of Immunotherapy” William Coley had started administering injections composed of dead Streptococcus pyogenes and Serratia marcescens as a crude form of immunotherapy. His work was carried forward by his daughter, Helen Coley Nauts, and eventually, Lloyd Old. Old worked on the antitumor effects of the Bacillus Calmette-Guérin vaccine and earned the title “Father of Modern Cancer Immunology.” Today, the domain of immunotherapy has delivered several new armaments in the war against cancer. These include targeted therapies using monoclonal antibodies, cytokine therapy (interferon-α [IFN-α] and interleukin-2 [IL-2]), immune checkpoint inhibitors (anti-CTLA-4, anti-PD1, and anti-PD-L1), oncolytic viruses (T-Vec/talimogene laherparepvec), cancer vaccines, immune costimulatory molecules, and adoptive cell therapy (ACT). Founded at the cross-roads of genetic engineering and molecular biology, ACT can be of various types: tumor-infiltrating lymphocyte (TIL) therapy, T-cell receptor (TCR)-engineered T-cell therapy, natural killer cell therapy, or chimeric antigen receptor (CAR) T-cell therapy. Among these, CAR T-cells have received the most attention and shown the most promise.

In TIL therapy, TILs are extracted from a patient’s tumor biopsy specimen and then cocultured with autologous dendritic cells exposed to neoantigens present in the patient’s tumor. TILs recognizing the patient-specific neoantigens are then selected, expanded in vitro using IL-2, and then infused back into the patient. TIL therapy has shown some promise in melanomas, colorectal cancer, and breast cancer. TCR T-cell therapy is less invasive than TIL therapy as the required lymphocytes are sourced from the patient’s peripheral blood and are more proliferative than TILs. After extraction, purification, and activation, the T-cells are genetically modified by retroviral/lentiviral transduction or nonviral methods (such as electroporation or transposon delivery systems) to express cell-surface receptors targeting specific antigens. These are still natural receptors and can detect antigens from anywhere in the cell, as long as they are presented to them by the major histocompatibility complex (MHC) molecules. Trials have shown some benefit in sarcomas and melanomas. However, they can only target peptide antigens and, to be effective, require adequate MHC expression by the patient’s tumor cells. TCRs may also cross-react with endogenous antigens and, hence, carry a risk of induced severe autoimmunity. The more advanced CAR T-cells have the advantage that they are not MHC restricted and can recognize both protein and nonprotein antigens independently of the MHC, without antigen processing/presentation by the target cells. Thus, they can be engineered against a wider array of targets. The “chimeric” in CARs refers to the fact that these combine both antigen-binding and T-cell activation functions into a single synthetic receptor. The antigen binding in CAR T-cells is achieved through the use of specific recombinant antibodies in the extracellular domain, earning them the nickname “T-bodies.” Just like TILs, TCR and CAR T-cells are also clonally expanded in vitro and, then, after subjecting the patient to a lymphodepleting chemotherapy, infused back into the patient, often with in vivo IL-2 support. The steps involved in CAR T-cell therapy are shown in [Fig. 1].

Zoom Image
Fig. 1 Chimeric antigen receptor T-cell production. CAR, chimeric antigen receptor.

“Immunotherapy” was the ASCO “Advance of the Year” in 2016 and 2017, and in 2018, the honor went to CAR T-cell research. Yet, the work had started much earlier, with Zelig Eshhar proposing the concept in the early 1980s and, subsequently, engineering the first CAR T-cell. First-generation CAR T-cells coupled an extracellular single-chain variable fragment (scFv) with an intracellular CD3-ξ, (zeta) signaling domain. A scFv should not be thought of as an antibody fragment; it is a fusion protein made by joining variable regions of light (VL) and heavy (VH) immunoglobulin chains with a peptide linker. Michel Sadelain was the first to conduct clinical trials in this area and used second-generation CAR T-cells with additional co-signaling molecules such as 4–1BB or CD28. He called these cells “living drugs,” capable of greater in vivo clonal expansion and longer persistence in circulation. In 2017, two CAR T-cell therapies received the Food and Drug Administration (FDA) approval—tisagenlecleucel and axicabtagene ciloleucel, both of which target CD19 ([Table 1]). The evolution of CAR T-cell therapy is depicted in [Fig. 2].

Table 1

Food and Drug Administration-approved chimeric antigen receptor T-cell therapies

Name

Tisagenlecleucel (Kymriah, Novartis)

Axicabtagene ciloleucel (Yescarta, Kite Pharma, Inc.)

Abbreviations: CRS, cytokine release syndrome; CAR, chimeric antigen receptor; OS, overall survival; CI, confidence interval; MRD, measurable residual disease; EFS, event-free survival; ORR, objective response rate; CR, complete response; PMBCL, primary mediastinal large B-cell lymphoma, FL, follicular lymphoma; DLBCL-NOS, diffuse large B-cell lymphoma-not otherwise specified; ALL, acute lymphoblastic leukemia; RFS, relapse-free survival; PR, partial response.

CAR

Anti-CD19 with 4–1BB costimulatory domain

Anti-CD19 with CD28 costimulatory domain

Indications

Patients aged ≤25 years with B-cell

R/R large B-cell lymphoma post

Adults with relapsed/refractory large

Precursor ALL refractory to standard treatment or in second or later relapse

≥2 lines of systemic therapy

B-cell lymphoma after two or more lines of systemic therapy, including DLBCL-NOS, PMBCL, high-grade B-cell lymphoma, and DLBCL arising from FL

Approval based on

Phase II JULIANA trial in 75 children and young adults with CD19+ relapsed or refractory B-cell ALL

Single-arm Phase II JULIET trial

Phase II of the ZUMA-1 trial, involving 101 patients with DLBCL, PMBCL, or transformed FL with refractory disease

Outcome

The overall remission rate at 3 months was 81%, and all those who responded had no detectable MRD as determined by flow cytometry

At 12 months, the EFS was 50% (95% CI: 35, 64) and OS was 76% (95% CI: 63, 86)

The median duration of remission was not reached

Tisa-cel was found to persist in the blood even at 20 months after administration

Overall response rate of 52% (95% CI: 41–62); 40% had CR and 12% had PR

At 12 months after the initial response, estimated RFS was 65%.

At 12 months, RFS was 79% among patients who had achieved a CR

ORR of 82% and CR rate of 54% OS at 18 months was 52%

Toxicities

73% of patients had Grade ¾ adverse events. 77% of patients experienced CRS and 20% had neurological toxicities

The most common Grade ¾ adverse events were CRS (22%), neurologic toxicities (12%), cytopenias (32%), infections (20%), and febrile neutropenia (14%)

Grade ¾ adverse events were recorded in 95%, including Grade ¾ CRS in 13% and Grade ¾ neurological events in 28%

Zoom Image
Fig. 2 Evolution of chimeric antigen receptor T-cell therapy. CAR, chimeric antigen receptor.


Publication History

Publication Date:
28 May 2021 (online)

© 2021. Indian Society of Medical and Paediatric Oncology. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

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