Introduction

Progressive malignancy is the leading cause of death after allogeneic hematopoietic stem cell transplantation (alloHSCT). After alloHSCT, B-cell malignancies are often treated with infusions of unmanipulated donor lymphocytes (DLIs) from the transplant donor. DLIs are frequently not effective at eradicating malignancy, and DLIs often cause graft-versus-host disease (GVHD), which is a potentially lethal allogeneic immune response against normal recipient tissues.

Methods

We conducted a clinical trial of allogeneic T cells that were genetically engineered to express a chimeric antigen receptor (CAR) targeting the B-cell antigen CD19. The CAR was encoded by a gamma-retroviral vector and included a CD28 costimulatory domain. Patients with B-cell malignancies after alloHSCT received a single infusion of CAR T cells. No chemotherapy or other therapies were administered. The T cells were obtained from each recipient's alloHSCT donor.

Findings

Eight of 20 treated patients obtained remissions, including 6 complete remissions (CR) and 2 partial remissions. The response rate was highest for acute lymphoblastic leukemia with 4/5 patients obtaining minimal-residual-disease-negative CRs, but responses also occurred in chronic lymphocytic leukemia (CLL) and lymphoma. The longest ongoing CR is 30+ months in a patient with CLL. No patient developed new-onset acute GVHD after CAR T-cells were infused. Toxicities included fever, tachycardia, and hypotension.

Median peak blood CAR T-cell levels were higher in patients who obtained remissions (39 CAR+ cells/mL) than in patients who did not obtain remissions (2 CAR+ cells/mL, P=0.001). Presence of endogenous normal or malignant blood B lymphocytes before CAR T-cell infusion was associated with higher post-infusion median blood CAR T-cell levels (P=0.04). Compared to patients who did not obtain a remission of their malignancies, patients obtaining remissions had a higher CD8:CD4 ratio of blood CAR+ T cells at the time of peak CAR T-cell levels (P=0.007). The mean percentage of CAR+CD8+ T cells expressing the programmed cell death-1 (PD-1) protein increased from 12% at the time of infusion to 82% at the time of peak blood CAR T-cell levels (P<0.0001). The mean percentage of CAR+CD4+ T cells expressing PD-1 increased from 32% at the time of infusion to 91% at the time of peak blood CAR T-cell levels (P<0.0001).

Interpretation

Infusion of allogeneic anti-CD19 CAR T cells is a promising approach for treating B-cell malignancies after alloHSCT. Our findings point toward a future in which antigen-specific T-cell therapies will be an important part of the field of allogeneic hematopoietic stem cell transplantation.

Table.
Patient
Number
MalignancyTransplant typeTotal T cells
infused/kg
Anti-CD19
CAR-expressing
T cells infused/kg
Malignancy
response
at last follow-up
(interval from infusion to last follow-up in months)
CLL URD 10/10 HLA match 1x106 0.4x106 SD (3) 
DLBCL Sibling 2x106 0.7x106 SD (1) 
CLL Sibling 4x106 2.4x106 PD 
DLBCL Sibling 4x106 2.2x106 SD (31+) 
CLL URD 10/10 HLA match 1.5x106 1.0x106 CR (30+) 
MCL Sibling 7x106 4.6x106 SD (3) 
CLL URD 10/10 HLA match 1x106 0.7x106 PD 
MCL Sibling 7x106 3.9x106 SD (24+) 
MCL URD 10/10 HLA match 4x106 2.2x106 PR (3) 
10 MCL Sibling 10x106 7.8x106 SD (2) 
11 CLL URD 9/10 HLA match 5x106 3.1x106 PR (12+) 
12 ALL Ph+ Sibling 7x106 5.2x106 MRD-negative CR (15+) 
13 MCL Sibling 10x106 7.1x106 SD (9) 
14 ALL Ph-neg Sibling 10x106 7.0x106 MRD-negative CR (5) 
15 ALL Ph-neg Sibling 10x106 6.9x106 MRD-negative CR (3) 
16 ALL Ph-neg Sibling 7x106 5.6x106 PD 
17 DLBCL Sibling 10x106 8.2x106 CR (6+) 
18 DLBCL Sibling 10x106 3.1x106 SD (2) 
19 FL transformed to DLBCL URD 10/10 HLA match 5x106 4.3x106 PD 
20 ALL Ph-neg URD 9/10 HLA match 5x106 4.2x106 MRD-negative CR (3+)^ 
Patient
Number
MalignancyTransplant typeTotal T cells
infused/kg
Anti-CD19
CAR-expressing
T cells infused/kg
Malignancy
response
at last follow-up
(interval from infusion to last follow-up in months)
CLL URD 10/10 HLA match 1x106 0.4x106 SD (3) 
DLBCL Sibling 2x106 0.7x106 SD (1) 
CLL Sibling 4x106 2.4x106 PD 
DLBCL Sibling 4x106 2.2x106 SD (31+) 
CLL URD 10/10 HLA match 1.5x106 1.0x106 CR (30+) 
MCL Sibling 7x106 4.6x106 SD (3) 
CLL URD 10/10 HLA match 1x106 0.7x106 PD 
MCL Sibling 7x106 3.9x106 SD (24+) 
MCL URD 10/10 HLA match 4x106 2.2x106 PR (3) 
10 MCL Sibling 10x106 7.8x106 SD (2) 
11 CLL URD 9/10 HLA match 5x106 3.1x106 PR (12+) 
12 ALL Ph+ Sibling 7x106 5.2x106 MRD-negative CR (15+) 
13 MCL Sibling 10x106 7.1x106 SD (9) 
14 ALL Ph-neg Sibling 10x106 7.0x106 MRD-negative CR (5) 
15 ALL Ph-neg Sibling 10x106 6.9x106 MRD-negative CR (3) 
16 ALL Ph-neg Sibling 7x106 5.6x106 PD 
17 DLBCL Sibling 10x106 8.2x106 CR (6+) 
18 DLBCL Sibling 10x106 3.1x106 SD (2) 
19 FL transformed to DLBCL URD 10/10 HLA match 5x106 4.3x106 PD 
20 ALL Ph-neg URD 9/10 HLA match 5x106 4.2x106 MRD-negative CR (3+)^ 

CLL, chronic lymphocytic leukemia; ALL Ph+, Philadelphia chromosome positive acute lymphoblastic leukemia; ALL Ph-neg, Philadelphia chromosome negative acute lymphoblastic leukemia; MCL, mantle cell lymphoma; DLBCL, diffuse large B-cell lymphoma; FL, follicular lymphoma; Sibling, human leukocyte antigen-matched sibling donor; URD, unrelated donor; HLA, human leukocyte antigen; PD, progressive disease; SD, stable disease; PR, partial remission; CR, complete remission; MRD-negative, minimal residual disease negative. ^Patient 20 underwent a second alloHSCT 3.5 months after anti-CD19 CAR T-cell infusion while in MRD-negative CR.

Disclosures

Goy:Celgene: Consultancy, Research Funding, Speakers Bureau; Allos, Biogen Idec, Celgene, Genentech, and Millennium. Gilead: Speakers Bureau. Rosenberg:Kite Pharma: Other: CRADA between Surgery Branch-NCI and Kite Pharma.

Author notes

*

Asterisk with author names denotes non-ASH members.

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