We have shown that infusion of autologous T cells genetically modified to express a chimeric antigen receptor (CAR) consisting of an external anti-CD19 domain, with the CD3z and 4-1BB signaling ...domains (CTL019 cells), can mediate potent anti-tumor effects in patients (pts) with advanced, R/R CLL and other CD19+ malignancies. In our initial pilot study, doses of 0.14-5.9 x 108 CTL019 cells were given to 14 pts with R/R CLL and the overall response rate (PR plus CR) was 57%. The majority of responses were sustained, and associated with marked expansion and long-term persistence of transduced cells. Given that CARTs can be self-replicating, it is unknown if there is an optimal biologic dose or merely a necessary threshold dose that must be achieved. To better define an optimal dose, we are performing a randomized phase II study of 2 doses of CTL019 cells in pts with R/R CLL.
Eligible pts have relapsed or persistent CLL after at least 2 previous treatments and progressed within 2 years of their last therapy. Pts are randomized to receive either 5x108 or 5x107 CTL019 cells. All pts receive lymphodepleting chemotherapy ending 3-5 days before T cell infusion. In stage 1, 12 evaluable pts per arm will be treated and in stage 2, an additional 8 pts will be treated at the selected dose. Data is examined through 7/1/14.
RESULTS
To date, 30 pts have been randomized; T cells did not adequately expand in 1, 1 pt was not eligible after screening and 26 pts were treated. 13 pts have been randomized to the higher dose (5 x 108 CTL019 cells) and 13 pts have been randomized to the lower dose (5 x 107 CTL019 cells). Pts were 67% men with a median age of 62 yrs (range 54-76). 10 pts had a known mutation of p53 or 17p del, and 2 pts had failed prior ibrutinib. Pts had received a median of 3 prior therapies (range 2-10) and all had active disease at the time of CTL019 infusion. 3 pts who did not receive the targeted dose are evaluable for toxicity but not response, leaving 23 are evaluable for response.
Median follow-up for all 26 pts was 7.3 mo (range 1-16 mo). Of 23 evaluable pts, 5 (22%) achieved a CR and 4 (17%) achieved PR, for an overall response rate of 35% (95% exact CI 20-61%). 3 responding pts progressed; 1 pt in CR and 1 in PR progressed at 1 and 6 mo after infusion with aggressive CD19-negative transformed lymphoma, and one pt who achieved PR progressed 9 mo after infusion with CD19+ CLL having lost persisting CTL019 cells.
14 of 26 pts experienced a delayed CRS. We devised a novel CRS grading scale that will be presented. Detailed cytokine profiles show marked elevations in IL6 and other cytokines during CRS CRS required intervention in 3 pts with tocilizumab (with or without steroids and additional anti-cytokine therapy) for hemodynamic or respiratory instability and was effective in reversing symptoms of CRS in all pts. 2 of these 3 responded to CTL019. There was no treatment-related mortality.
response or dose:toxicity relationship. 6 of 11 evaluable pts on the high dose responded, and 3 of 12 recipients at the lower dose responded (p=0.21). 6 of 11 evaluable on the high dose and 7/12 recipients of the low dose experienced CRS (p=1.0). The 13 evaluable pts who experienced CRS included 6 of 9 responding pts and 7 of 14 non- responders (p=0.67), and one pt not evaluable for response. All statistical tests were based on Fisher’s exact test.
CTL019 expansion in-vivo was noted in all responding pts. By flow cytometry, at peak expansion CTL019 cells represented 0.1-84.6% of CD3+ cells in the 9 responding pts (median 14.7%) and 0-10.6% (median 0.35%) in the 14 non-responders.
Neither response nor expansion correlated with typical patient or disease characteristics including age, number of prior therapies or mutated P53. Data regarding T cell phenotype before and after CAR modification will be presented.
In this ongoing dose optimization study of CTL019 cells, 9 of the first 23 evaluable pts have responded. As yet, there is no suggestion of a dose:response or dose:toxicity relationship at the doses being studied. CTL019 cells from R/R CLL pts can undergo robust in-vivo expansion and are associated with a CRS, manageable with anti-cytokine directed therapy. A novel grading scale was developed to better capture the clinical severity of CRS and help guide timing of intervention. This ongoing trial confirms that CTL019 cells can induce potent and durable responses for pts with advanced, R/R CLL with manageable toxicity.
Porter:Novartis: Patents & Royalties, Research Funding; Genentech (spouse employment): Employment. Off Label Use: Use of genetically modified T cells (CTL019) to treat CLL and use of tocilizumab to treat cytokine release syndrome.. Frey:Novartis: Research Funding. Hwang:NVS: Research Funding. Lacey:Novartis: Research Funding. Chew:Novartis: Patents & Royalties, Research Funding. Grupp:Novartis: Research Funding. Kalos:Novartis: Patents & Royalties, Research Funding. Litchman:Novartis: Employment. Mahnke:Novartis: Research Funding. Shen:Novartis: Employment. Wood:Novartis Pharma: Employment. Zheng:Novartis: Patents & Royalties, Research Funding. Levine:Novartis: Patents & Royalties, Research Funding. June:Novartis: Research Funding, Royalty income Patents & Royalties.
BACKGROUND: Autologous T cells genetically modified to express a chimeric antigen receptor consisting of an external anti-CD19 single chain antibody domain with CD3ζ and 4-1BB signaling domains ...(CTL019 cells) can mediate potent anti-tumor effects in patients (pts) with relapsed or refractory chronic lymphocytic and acute lymphoblastic leukemias. We are conducting a phase IIa clinical trial to evaluate the safety and efficacy of CTL019 cells in pts with relapsed or refractory CD19+ non-Hodgkin lymphomas (NHL).
METHODS: 30 evaluable pts are planned for analysis, including at least 8 with follicular lymphoma (FL), 8 with diffuse large B cell lymphoma (DLBCL), and 8 with mantle cell lymphoma. Eligible pts have CD19+ NHL with no available curative treatment options, a limited prognosis of several months to <2 years anticipated survival, and responsive or stable disease with most recent therapy. Pts with FL have progression of lymphoma within 2 years after second or higher line of therapy (not including single agent monoclonal antibody therapy); DLBCL pts have residual disease after primary therapy and are not eligible for autologous stem cell transplant (ASCT) or have relapsed or residual disease after ASCT. After steady state apheresis to collect peripheral blood leukocytes, pts receive lymphodepleting chemotherapy based on disease burden, histology, and past therapies. One to 4 days after chemotherapy, pts receive a single dose of CTL019 cells by intravenous infusion; total CTL019 target dose is 5 x 108 cells. Peripheral blood and marrow samples are collected for immunophenotypic, cytokine, and molecular studies at pre-specified times after T cell infusion. Initial tumor response assessment is performed 3 months after T cell infusion using International Working Group response criteria. Enrollment started in February 2014; data reported here are through July 30, 2014.
RESULTS: To date, 23 pts (DLBCL 16; FL 7) have enrolled. The median age is 56 years (range: 25-77), male: female ratio is 14:9, median number of prior therapies is 4 (range: 1-8), and number of pts with prior ASCT is 9 (39%). Ann Arbor stages at enrollment are: stage IV 11 pts (48%); stage III 5 pts (22%); stage II 5 pts (22%); stage IE 2 pts (8%); 5 pts (22%) had bone marrow involvement. LDH was increased in 17 pts (74%). Three pts (DLBCL 2 pts; FL 1 pt) were removed from the trial before therapy due to progressive disease. As of July 30, 2014, 14 pts have received CTL019 T cell infusions. Pre-infusion chemotherapy regimens were EPOCH (1 pt); cyclophosphamide (7 pt); bendamustine (5 pts); cyclophosphamide-fludarabine (1 pt). Median CTL019 T cell dose is 5.8 x 106 cells / kg (range: 3.7 – 8.9 x 106). In vivo expansion of CTL019 cells was brisk; the median peak CTL019% of CD3+ cells in peripheral blood was 6.1% (range: 0.7-43.1%) for all patients, 17.3% (range: 3.9-43.1) for responders, and 4.95% (range: 0.7-7.3) for non-responders. Peak CTL019 cell expansion generally occurred around 7 days after T cell infusion. All patients developed fever following T cell infusion, attributed to cytokine release syndrome (CRS). Severity of CRS according to our novel grading scale (reported separately) was: 12 pts grade 2; 1 pt grade 3; 1 pt grade 4. One pt received steroids and tocilizumab for grade 4 CRS. CRS occurred within the first week of T cell infusion in all pts. Neurologic toxicity was observed in 2 pts (1 pt with grade 3 encephalopathy that resolved with corticosteroids; 1 pt with grade 3 dysarthria and grade 3 ataxia). There was no treatment-related mortality. Eight pts are evaluable for response (DLBCL 6; FL 2). Overall response rate at 3 months is 50% with 3 complete responses (DLBCL 2 pts; FL 1 pt) and 1 partial response (FL); 4 pts with DLBCL had progressive disease before or at initial response assessment.
CONCLUSIONS: In this ongoing trial of CTL019 cells in relapsed or refractory NHL, 4 of the first 8 evaluable pts responded to therapy. These early results demonstrate that CTL019 cells can be prepared from previously treated pts with active NHL, can undergo robust in-vivo expansion, and can induce complete responses in pts with advanced, relapsed or refractory DLBCL and FL. Longer follow up will define toxicities, durability of response, and clinical benefit, as well as guide further development of this promising new therapeutic approach.
Schuster:Novartis: Research Funding. Porter:Novartis: Patents & Royalties, Research Funding; Genentech (spouse employment): Employment. Mahnke:Novartis: Research Funding. Lacey:Novartis: Research Funding. Chew:Novartis: Patents & Royalties, Research Funding. Shah:Novartis: Employment. Hasskarl:Novartis: Employment. Litchman:Novartis: Employment. Frey:Novartis: Research Funding. Zheng:Novartis: Patents & Royalties, Research Funding. Levine:Novartis: Patents & Royalties, Research Funding. June:Novartis: Patents & Royalties, Research Funding.
BACKGROUND
CARs combine a single chain variable fragment (scFv) of an antibody with intracellular signaling domains. We have previously reported on CTL019 cells expressing an anti-CD19 CAR. Infusion ...of these cells results in 100 to 100,000x in vivo proliferation, durable anti-tumor activity, and prolonged persistence in pts with B cell tumors, including sustained CRs in adults and children with ALL (Grupp et al., NEJM 2013, Maude et al., NEJM 2014). We now report on outcomes and longer follow up of the first 30 pts with relapsed, refractory ALL treated on our pilot trial in pediatric ALL.
METHODS
T cells were lentivirally transduced with a CAR composed of anti-CD19 scFv/4-1BB/CD3ζ, activated/expanded ex-vivo with anti-CD3/anti-CD28 beads, and then infused into children with relapsed or refractory CD19+ ALL. 26/30 pts received lymphodepleting chemotherapy the week prior to CTL019 infusion. The targeted T cell dose range was 107 to 108 cells/kg with a transduction efficiency of 11-45%. T cells for manufacturing were collected from the pt regardless of prior SCT status, not allo donors.
RESULTS
30 children median age 10y (5-22y) with CD19+ ALL were treated. 25/30 pts had detectable disease on the day before CTL019 cell infusion, while 5 were MRD(-). A median of 3.6x106 CTL019 cells/kg (1.1-18x106/kg) were infused over 1-3 days. There were no infusional toxicities >grade 2, although 9 pts developed fevers within 24 hrs of infusion and did not receive a planned 2nd infusion of CTL019 cells. 27 pts (90%) achieved a CR, including a patient with T cell ALL aberrantly expressing CD19+. 3 did not respond. MRD measured by clinical flow cytometry was negative in 23 responding pts and positive at 0.1% (negative at 3 mo), 0.09%, 0.22%, and 1.1% in 4 pts. With median follow up 8 mo (1-26 mo), 16 pts have ongoing CR, with only 3 patients in the cohort receiving subsequent treatment such as donor lymphocyte infusion or SCT, 6-month EFS measured from infusion is 63% (95% CI, 47-84%), and OS is 78% (95% CI, 63-95%). CTL019 cells were detected in the CSF of 17/19 pts and 2 pts with CNS2a disease experienced a CR in CSF. 10 pts with a CR at 1 mo have subsequently relapsed, half with CD19(-) blasts. 2/5 pts who relapsed with CD19(-) disease had previously been refractory to CD19-directed blinatumomab and subsequently went into CR with CTL019.
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All responding pts developed grade 1-4 cytokine release syndrome (CRS) at peak T cell expansion. Detailed cytokine analysis showed marked increases of IL6 and IFNγ (both up to 1000x), and IL2R. Treatment for CRS was required for hemodynamic or respiratory instability in 37% of patients and was rapidly reversed in all cases with the IL6-receptor antagonist tocilizumab, together with corticosteroids in 5 pts. Although T cells collected from the 21 pts who had relapsed after allo SCT were median 100% donor origin, no GVHD has been seen. Grade 4 CRS was strongly associated with high disease burden prior to infusion and with elevations in IL-6, ferritin (suggesting macrophage activation syndrome) and C reactive protein after infusion.
Persistence of CTL019 cells detected by flow cytometry and/or QPCR, and accompanied by B cell aplasia, continued for 1-26 months after infusion in pts with ongoing responses. QPCR showed very high levels of CTL019 proliferation, with all patients achieving peak levels >5000 copies/ug gDNA and 26 patients with peak levels >15,000 copies/ug gDNA. B cell aplasia has been treated with IVIg without significant infectious complications. Probability of 6-mo CTL019 persistence by flow was68% (95% CI, 50-92%) andrelapse-free B cell aplasia was 73% (95% CI, 57-94%).
CTL019 cells can undergo robust in-vivo expansion and can persist for 2 years or longer in pts with relapsed ALL, allowing for the possibility of long-term disease response without subsequent therapy such as SCT. This approach also has promise as a salvage therapy for patients who relapse after allo-SCT with a low risk of GVHD. CTL019 therapy is associated with a significant CRS that responds rapidly to IL-6-targeted anti-cytokine treatment. CTL019 cells can induce potent and durable responses for patients with relapsed/refractory ALL; however, recurrence with cells that have lost CD19 is an important mechanism of CLT019 resistance. CTL019 therapy has received Breakthrough Therapy designation from the FDA in both pediatric and adult ALL, and phase II multicenter trials have been initiated.
Grupp:Novartis: Consultancy, Research Funding. Barrett:Novartis: Research Funding. Chew:Novartis: Research Funding. Lacey:Novartis: Research Funding. Levine:Novartis: Patents & Royalties, Research Funding. Melenhorst:Novartis: Research Funding. Rheingold:Novartis: Consultancy. Shen:Novartis: Employment. Wood:Novartis Pharma: Employment. Porter:Novartis: managed according to U Penn Policy Patents & Royalties, Research Funding. June:Novartis: Research Funding, Royalty income Patents & Royalties.
The p160 family of steroid receptor coactivators (SRCs) are pleiotropic transcription factor coactivators and “master regulators” of gene expression that promote cancer cell proliferation, survival, ...metabolism, migration, invasion, and metastasis. Cancers with high p160 SRC expression exhibit poor clinical outcomes and resistance to therapy, highlighting the SRCs as critical oncogenic drivers and, thus, therapeutic targets. microRNAs are important epigenetic regulators of protein expression. To examine the regulation of p160 SRCs by microRNAs, we used and combined 4 prediction algorithms to identify microRNAs that could target SRC1, SRC2, and SRC3 expression. For validation of these predictions, we assessed p160 SRC protein expression and cell viability after transfection of corresponding microRNA mimetics in breast cancer, uveal melanoma, and prostate cancer (PC) cell lines. Transfection of selected microRNA mimetics into breast cancer, uveal melanoma, and PC cells depleted SRC protein expression levels and exerted potent antiproliferative activity in these cell types. In particular, microRNA-137 (miR-137) depleted expression of SRC1, SRC2, and very potently, SRC3. The latter effect can be attributed to the presence of 3 miR-137 recognition sequences within the SRC3 3′-untranslated region. Using reverse phase protein array analysis, we identified a network of proteins, in addition to SRC3, that were modulated by miR-137 in PC cells. We also found that miR-137 and its host gene are epigenetically silenced in human cancer specimens and cell lines. These results support the development and testing of microRNA-based therapies (in particular based on restoring miR-137 levels) for targeting the oncogenic family of p160 SRCs in cancer.
ObjectivesTen per cent of patients diagnosed with pancreatic cancer undergo pancreaticoduodenectomy. There is limited previous research focusing on psychological well-being; unmet support needs ...impact negatively on quality of life. This paper reports the psychological impact of a pancreatic cancer diagnosis and subsequent pancreaticoduodenectomy, exploring how patients’ lives alter following surgery and how they seek support.DesignInductive qualitative study involving in-depth semistructured interviews with 20 participants who had undergone pancreaticoduodenectomy for pancreatic or distal biliary duct cancer. Interviews were audiorecorded, transcribed and anonymised, and thematic analysis used principles of constant comparison.SettingSingle National Health Service Trust in Northwest England.ParticipantsPatients were eligible for inclusion if they had had pancreaticoduodenectomy for head of pancreas cancer, periampullary cancer or distal cholangiocarcinoma between 6 months and 6 years previously, and had completed adjuvant chemotherapy.ResultsAnalysis identified the following main themes: diagnosis and decision making around surgery; recovery from surgery and chemotherapy; burden of monitoring and ongoing symptoms; adjusting to ‘a new normal’; understanding around prognosis; support-seeking. Participants seized the chance to have surgery, often without seeming to absorb the risks or their prognosis. They perceived that they were unable to control their life trajectory and, although they valued close monitoring, experienced anxiety around their appointments. Participants expressed uncertainty about whether they would be able to return to their former activities. There were tensions in their comments about support-seeking, but most felt that emotional support should be offered proactively.ConclusionsPatients should be made aware of potential psychological sequelae, and that treatment completion may trigger the need for more support. Clinical nurse specialists (CNSs) were identified as key members of the team in proactively offering support; further training for CNSs should be encouraged. Understanding patients’ experience of living with cancer and the impact of treatment is crucial in enabling the development of improved support interventions.
ObjectivesThis paper reports the sources of stress and distress experienced by general practitioners (GP) as part of a wider study exploring the barriers and facilitators to help-seeking for mental ...illness and burnout among this medical population.DesignQualitative study using in-depth interviews with 47 GP participants. The interviews were audio-recorded, transcribed, anonymised and imported into NVivo V.11 to facilitate data management. Data were analysed using a thematic analysis employing the constant comparative method.SettingEngland.ParticipantsA purposive sample of GP participants who self-identified as: (1) currently living with mental distress, (2) returning to work following treatment, (3) off sick or retired early as a result of mental distress or (4) without experience of mental distress. Interviews were conducted face-to-face or over the telephone.ResultsThe key sources of stress/distress related to: (1) emotion work—the work invested and required in managing and responding to the psychosocial component of GPs’ work, and dealing with abusive or confrontational patients; (2) practice culture—practice dynamics and collegial conflict, bullying, isolation and lack of support; (3) work role and demands—fear of making mistakes, complaints and inquests, revalidation, appraisal, inspections and financial worries.ConclusionIn addition to addressing escalating workloads through the provision of increased resources, addressing unhealthy practice cultures is paramount. Collegial support, a willingness to talk about vulnerability and illness, and having open channels of communication enable GPs to feel less isolated and better able to cope with the emotional and clinical demands of their work. Doctors, including GPs, are not invulnerable to the clinical and emotional demands of their work nor the effects of divisive work cultures—culture change and access to informal and formal support is therefore crucial in enabling GPs to do their job effectively and to stay well.
Inhibitors of B-Raf and MEK kinases hold promise for the management of cutaneous melanomas harboring BRAF mutations. BRAF mutations are rare in uveal melanomas (UMs), but somatic mutations in the G ...protein α subunits Gαq and Gα11 (encoded by GNAQ and GNA11, respectively) occur in a mutually exclusive pattern in ∼80% of UMs. The impact of B-Raf and MEK inhibitors on Gα-mutant UMs remains unknown.
The impact of the B-Raf inhibitor PLX4720, the MEK inhibitor AZD6244, and the Akt inhibitor MK2206 on UM cell lines was assessed with the use of cell viability, proliferation, and apoptosis assays and immunoblot analysis.
BRAF-mutant UM cells were sensitive to both PLX4720 and AZD6244, undergoing cell cycle arrest but not apoptosis. UM cells with a Gα-protein mutation (GNAQ or GNA11) were mildly sensitive to AZD6244 but completely resistant to PLX4720. In fact, PLX4720 paradoxically increased ERK phosphorylation in Gα-mutant UM cells. The combination of AZD6244 with PLX4720 had synergistic anticancer activity in BRAF-mutant cells but not in Gα-mutant cells. The Akt inhibitor MK2206 sensitized BRAF-mutant cells to both PLX4720 and AZD6244 and sensitized Gα-mutant cells to AZD6244 but did not overcome the resistance of the Gα-mutant cells to PLX4720.
The response of UM cells to inhibition of B-Raf, MEK, and Akt depends on their genotype. Future use of such targeted therapies in clinical trials of UM patients will require careful design and patient selection based on genotype to provide personalized and effective therapy.
Glioblastoma multiforme (GBM) is the most prevalent and aggressive form of glioma, with poor prognosis and high mortality rates. As GBM is a highly vascularized cancer, antiangiogenic therapies to ...halt or minimize the rate of tumor growth are critical to improving treatment. In this review, antiangiogenic therapies, including small-molecule drugs, nucleic acids and proteins and peptides, are discussed. The authors further explore biomaterials that have been utilized to increase the bioavailability and bioactivity of antiangiogenic factors for better antitumor responses in GBM. Finally, the authors summarize the current status of biomaterial-based targeting moieties that target endothelial cells in GBM to more efficiently deliver therapeutics to these cells and avoid off-target cell or organ side effects.
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