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Molina JC, Steinberg SM, Yates B, Lee DW, Little L, Mackall CL, Shalabi H, Shah NN. Factors Impacting Overall and Event-Free Survival following Post-Chimeric Antigen Receptor T Cell Consolidative Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2021; 28:31.e1-31.e9. [PMID: 34687939 DOI: 10.1016/j.jtct.2021.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/20/2021] [Accepted: 10/12/2021] [Indexed: 11/16/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) may be used to consolidate chimeric antigen receptor (CAR) T cell therapy-induced remissions for patients with relapsed/refractory B cell acute lymphoblastic leukemia (B-ALL), but little is known about the factors impacting overall survival (OS) and event-free survival (EFS) for post-CAR hematopoietic stem cell transplantation (HSCT). The present study's primary objective was to identify factors associated with OS and EFS for consolidative HSCT following CAR-induced complete remission (CR) in transplantation-naïve patients. Secondary objectives included evaluation of OS/EFS, relapse-free survival and cumulative incidence of relapse for all patients who proceeded to HSCT, stratified by first and second HSCT, as well as the tolerability of HSCT following CAR-induced remission. This was a retrospective review of children and young adults enrolled on 1 of 3 CAR T cell trials at the National Cancer Institute targeting CD19, CD22, and CD19/22 (ClinicalTrials.gov identifiers NCT01593696, NCT02315612, and NCT03448393) who proceeded directly to HSCT following CAR T cell therapy. Between July 2012 and February 2021, 46 children and young adults with pre-B ALL went directly to HSCT following CAR therapy. Of these patients, 34 (74%) proceeded to a first HSCT, with a median follow-up of 50.8 months. Transplantation-naïve patients were heavily pretreated prior to CAR T cell therapy (median, 3.5 lines of therapy; range, 1 to 12) with significant prior immunotherapy exposure (blinatumomab, inotuzumab, and/or CAR T cell therapy in patients receiving CD22 or CD19/22 constructs (88%; 15 of /17)). Twelve patients (35%) had primary refractory disease, and the median time from CAR T cell infusion to HSCT Day 0 was 54.5 days (range, 42 to 127 days). The median OS following first HSCT was 72.2 months (95% confidence interval [CI], 16.9 months to not estimable [NE]), with a median EFS of 36.9 months (95% CI, 5.2 months to NE). At 12 and 24 months, the OS was 76.0% (95% CI, 57.6% to 87.2%) and 60.7% (95% CI, 40.8% to 75.8%), respectively, and EFS was 64.6% (95% CI, 46.1% to 78.1%) and 50.9% (95% CI, 32.6% to 66.6%), respectively. The individual factors associated with both decreased OS and EFS in univariate analyses for post-CAR consolidative HSCT in transplantation-naïve patients included ≥5 prior lines of therapy (not reached [NR] versus 12.4 months, P = .014; NR versus 4.8 months, P = .063), prior blinatumomab therapy (NR versus 16.9 months, P = .0038; NR versus 4.4 months, P = .0025), prior inotuzumab therapy (NR versus 11.5 months, P = .044; 36.9 months versus 2.7 months, P = .0054) and ≥5% blasts (M2/M3 marrow) pre-CAR T cell therapy (NR versus 17 months, P = .019; NR versus 12.2 months, P = .035). Primary refractory disease was associated with improved OS/EFS post-HSCT (NR versus 21.9 months, P = .075; NR versus 12.2 months, P = .024). Extensive prior therapy, particularly immunotherapy, and high disease burden each individually adversely impacted OS/EFS following post-CAR T cell consolidative HSCT in transplantation-naïve patients, owing primarily to relapse. Despite this, HSCT remains an important treatment modality in long-term cure. Earlier implementation of HSCT before multiply relapsed disease and incorporation of post-HSCT risk mitigation strategies in patients identified to be at high-risk of post-HSCT relapse may improve outcomes.
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Affiliation(s)
- John C Molina
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland; Department of Pediatric Oncology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Seth M Steinberg
- Biostatistics and Data Management Section, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Bonnie Yates
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Daniel W Lee
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Lauren Little
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Crystal L Mackall
- Department of Pediatrics, Stanford University, Stanford, California; Department of Medicine, Stanford University, Stanford, California; Center for Cancer Cell Therapy, Stanford Cancer Institute, Stanford University, Stanford, California
| | - Haneen Shalabi
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
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Myers RM, Li Y, Barz Leahy A, Barrett DM, Teachey DT, Callahan C, Fasano CC, Rheingold SR, DiNofia A, Wray L, Aplenc R, Baniewicz D, Liu H, Shaw PA, Pequignot E, Getz KD, Brogdon JL, Fesnak AD, Siegel DL, Davis MM, Bartoszek C, Lacey SF, Hexner EO, Chew A, Wertheim GB, Levine BL, June CH, Grupp SA, Maude SL. Humanized CD19-Targeted Chimeric Antigen Receptor (CAR) T Cells in CAR-Naive and CAR-Exposed Children and Young Adults With Relapsed or Refractory Acute Lymphoblastic Leukemia. J Clin Oncol 2021; 39:3044-3055. [PMID: 34156874 PMCID: PMC9851702 DOI: 10.1200/jco.20.03458] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE CD19-targeted chimeric antigen receptor (CAR)-modified T cells demonstrate unprecedented responses in B-cell acute lymphoblastic leukemia (B-ALL); however, relapse remains a substantial challenge. Short CAR T-cell persistence contributes to this risk; therefore, strategies to improve persistence are needed. METHODS We conducted a pilot clinical trial of a humanized CD19 CAR T-cell product (huCART19) in children and young adults with relapsed or refractory B-ALL (n = 72) or B-lymphoblastic lymphoma (n = 2), treated in two cohorts: with (retreatment, n = 33) or without (CAR-naive, n = 41) prior CAR exposure. Patients were monitored for toxicity, response, and persistence of huCART19. RESULTS Seventy-four patients 1-29 years of age received huCART19. Cytokine release syndrome developed in 62 (84%) patients and was grade 4 in five (6.8%). Neurologic toxicities were reported in 29 (39%), three (4%) grade 3 or 4, and fully resolved in all cases. The overall response rate at 1 month after infusion was 98% (100% in B-ALL) in the CAR-naive cohort and 64% in the retreatment cohort. At 6 months, the probability of losing huCART19 persistence was 27% (95% CI, 14 to 41) for CAR-naive and 48% (95% CI, 30 to 64) for retreatment patients, whereas the incidence of B-cell recovery was 15% (95% CI, 6 to 28) and 58% (95% CI, 33 to 77), respectively. Relapse-free survival at 12 and 24 months, respectively, was 84% (95% CI, 72 to 97) and 74% (95% CI, 60 to 90) in CAR-naive and 74% (95% CI, 56 to 97) and 58% (95% CI, 37 to 90) in retreatment cohorts. CONCLUSION HuCART19 achieved durable remissions with long-term persistence in children and young adults with relapsed or refractory B-ALL, including after failure of prior CAR T-cell therapy.
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Affiliation(s)
- Regina M. Myers
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Yimei Li
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA,Department of Biostatistics, Epidemiology, and Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Allison Barz Leahy
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David M. Barrett
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David T. Teachey
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Colleen Callahan
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Susan R. Rheingold
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Amanda DiNofia
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lisa Wray
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Richard Aplenc
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Diane Baniewicz
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hongyan Liu
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Pamela A. Shaw
- Department of Biostatistics, Epidemiology, and Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Edward Pequignot
- Center for Cellular Immunotherapies, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kelly D. Getz
- Department of Biostatistics, Epidemiology, and Informatics, Children's Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Andrew D. Fesnak
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Donald L. Siegel
- Center for Cellular Immunotherapies, Children's Hospital of Philadelphia, Philadelphia, PA,Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Megan M. Davis
- Center for Cellular Immunotherapies, Children's Hospital of Philadelphia, Philadelphia, PA,Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Chelsie Bartoszek
- Center for Cellular Immunotherapies, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Simon F. Lacey
- Center for Cellular Immunotherapies, Children's Hospital of Philadelphia, Philadelphia, PA,Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth O. Hexner
- Center for Cellular Immunotherapies, Children's Hospital of Philadelphia, Philadelphia, PA,Division of Hematology-Oncology and Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Anne Chew
- Center for Cellular Immunotherapies, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Gerald B. Wertheim
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bruce L. Levine
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Carl H. June
- Center for Cellular Immunotherapies, Children's Hospital of Philadelphia, Philadelphia, PA,Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Parker Institute for Cancer Immunotherapy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stephan A. Grupp
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Shannon L. Maude
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA,Center for Cellular Immunotherapies, Children's Hospital of Philadelphia, Philadelphia, PA,Shannon L. Maude, MD, PhD, Children's Hospital of Philadelphia, 3012 Colket Translational Research Bldg, 3501 Civic Center Blvd, Philadelphia, PA 19104; e-mail:
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