Targeting BCMA to Treat Multiple Myeloma: Updates From the 2021 ASH Annual Meeting

BCMA-targeted therapies in multiple myeloma: advances, challenges and future prospects

Multiple myeloma (MM) is hematological cancer characterized by the aberrant proliferation of plasma cells. The treatment of MM has historically presented challenges, with a limited number of patients achieving sustained remission. Recent advancements in the therapeutic landscape have been marked by the development of B-cell maturation antigen (BCMA)-targeted therapies. BCMA, a plasma cell surface protein, is instrumental in the proliferation and survival of myeloma cells. This review aims to critically assess recent developments in BCMA-targeted therapies. The focus is on evaluating their efficacy and accessibility, as well as discussing potential future directions in this field. Emphasis is placed on chimeric antigen receptor (CAR) T-cell therapy and bispecific antibodies as emerging therapeutic strategies. An extensive review of current clinical trials and studies was conducted, centering on BCMA-targeted therapies. This encompassed an analysis of CAR T-cell therapies, which involve the genetic modification of patient T-cells to target BCMA, and bispecific antibodies that bind to both BCMA on myeloma cells and CD3 on T-cells. Clinical trials have demonstrated the efficacy of BCMA-targeted therapies in MM, with some patients achieving complete remission. However, these therapies are associated with adverse effects such as cytokine release syndrome and neurotoxicity. Research efforts are ongoing to reduce these side effects and enhance overall therapeutic effectiveness. BCMA-targeted therapies signify a notable advancement in MM treatment, offering prospects for prolonged remission and potentially curative outcomes. Despite existing challenges, these therapies represent a significant shift in MM management. The review highlights the necessity of ongoing research to optimize these therapies, improve patient outcomes, and increase treatment accessibility.

Theranostics in Hematological Malignancies: Cutting-Edge Advances in Diagnosis and Targeted Therapy

Hematologic malignancies, including leukemia, lymphoma, and multiple myeloma, continue to challenge clinicians with complex treatment regimens that often involve significant side effects and limited success, especially in advanced stages. Recent advancements in nuclear medicine have introduced theranostic strategies that merge diagnostic imaging with targeted therapeutic approaches, offering the potential for more precise and personalized treatment. A key area of progress lies in the development of alpha-emitting radiopharmaceuticals, such as 225Ac, 211At, or 212Pb, which can deliver potent radiation directly to tumor cells, sparing healthy tissue and minimizing collateral damage. In parallel with these therapeutic advancements, molecular imaging using radiolabeled agents enables better disease monitoring, assessment of treatment efficacy, and personalized management of patients with hematologic malignancies. The integration of diagnostic imaging with radiotherapy allows for a more tailored approach, where treatment can be adjusted based on real-time information about tumor progression and response. This review examines the recent strides made in both the development of radiopharmaceuticals and their applications in molecular imaging, with a focus on the potential to improve precision, reduce toxicity, and optimize patient outcomes. The synergy between targeted therapy and molecular imaging represents a transformative shift in the management of hematologic malignancies. As these technologies evolve, they are poised to redefine treatment paradigms, offering new hope for patients and potentially improving survival rates with more effective and less toxic treatment options.

Remineralization Rate of Lytic Lesions of the Spine in Multiple Myeloma Patients Undergoing Radiation Therapy

Study DesignRetrospective cohort study.ObjectiveIn general, Multiple Myeloma (MM) patients are treated with systemic therapy including chemotherapy. Radiation therapy can have an important supportive role in the palliative management of MM-related osteolytic lesions. Our study aims to investigate the degree of radiation-induced remineralization in MM patients to gain a better understanding of its potential impact on bone mineral density and, consequently, fracture prevention. Our primary outcome measure was percent change in bone mineral density measured in Hounsfield Units (Δ% HU) between pre- and post-radiation measurements, compared to non-targeted vertebrae.MethodsWe included 119 patients with MM who underwent radiotherapy of the spine between January 2010 and June 2021 and who had a CT scan of the spine at baseline and between 3-24 months after radiation. A linear mixed effect model tested any differences in remineralization rate per month (βdifference) between targeted and non-targeted vertebrae.ResultsAnalyses of CT scans yielded 565 unique vertebrae (366 targeted and 199 non-targeted vertebrae). In both targeted and non-targeted vertebrae, there was an increase in bone density per month (βoverall = .04; P = .002) with the largest effect being between 9-18 months post-radiation. Radiation did not cause a greater increase in bone density per month compared to non-targeted vertebrae (βdifference = .67; P = .118).ConclusionOur results demonstrate that following radiation, bone density increased over time for both targeted and non-targeted vertebrae. However, no conclusive evidence was found that targeted vertebrae have a higher remineralization rate than non-targeted vertebrae in patients with MM.

Population Pharmacokinetics of Orvacabtagene Autoleucel, an Autologous BCMA-Directed Chimeric Antigen Receptor T-cell Product, in Patients with Relapsed/Refractory Multiple Myeloma

PURPOSE

Orvacabtagene autoleucel (orva-cel; JCARH125), a chimeric antigen receptor T-cell therapy targeting B-cell maturation antigen, was evaluated in patients with relapsed/refractory multiple myeloma in the EVOLVE phase I/II study (NCT03430011). We applied a modified piecewise model to characterize orva-cel transgene kinetics and assessed the impact of various covariates on its pharmacokinetics (PK).

EXPERIMENTAL DESIGN

The population PK analysis included 159 patients from the EVOLVE study. Traditional piecewise models, employing a first-order expansion rate with or without lag time followed by a biexponential contraction phase, were compared with a modified model incorporating a cell number-dependent expansion phase aligned with cellular physiology. Covariates assessed encompassed baseline demographics, dose levels (50-600 × 106 CD3+ chimeric antigen receptor+ T cells), prior/concomitant medications, baseline disease burden, and antitherapeutic antibody status.

RESULTS

Traditional piecewise models failed to accurately describe maximum orva-cel transgene level (Cmax) and underestimated the time to Cmax (Tmax). Our modified model incorporating a cell number-dependent expansion rate outperformed traditional models by (i) more accurately capturing the cellular expansion phase and (ii) yielding a Tmax that closely matches observed values. Additionally, dose level, percentage of plasma cells in bone marrow, and treatment-induced antitherapeutic antibody were identified as statistically significant covariates and associated with orva-cel expansion and/or persistence.

CONCLUSIONS

Orva-cel PK was adequately described by the modified piecewise model incorporating a cell number-dependent expansion phase, which aligns closely with T-cell biology.

Tandem CAR-T cell therapy: recent advances and current challenges

CAR-T cell therapy has revolutionized cancer treatment. However, despite the achievements of this approach, there are still clinical challenges to address, such as antigen loss and the design of an optimal CAR structure. Multi-targeted CAR-T therapies, including tandem CAR-T cells, have emerged as a strategy to overcome some of these limitations and improve outcomes. Tandem CAR-T cells are currently being evaluated in preclinical and clinical studies for the treatment of hematological malignancies and solid tumors, showing promising results. These CARs have demonstrated efficacy, safety, and a relatively low relapse rate in these studies. Research suggests that TanCAR-T cells can enhance the outcomes and benefits of CAR-T cell therapy. However, challenges such as identifying the ideal CAR construct, selecting appropriate targets, and improving transduction efficiency remain unresolved, and further research is essential to address these limitations. This review highlights the potential of tandem CAR-T cells as a cancer treatment, summarizing preclinical and clinical studies with this innovative therapy and emphasizing the importance of continued research to overcome its limitations and improve its effectiveness.

Development and manufacture of novel locally produced anti-BCMA CAR T cells for the treatment of relapsed/refractory multiple myeloma: results from a phase I clinical trial

Anti-B-cell maturation antigen (BCMA) chimeric antigen receptor T-cell (CAR T) therapy shows remarkable efficacy in patients with relapsed and/or refractory (R/R) multiple myeloma (MM). HBI0101, a novel second generation optimized anti- BCMA CAR T-cell therapy, was developed in an academic setting. We conducted a phase I dose-escalation study of HBI0101 (cohort 1: 150x106 CAR T cells, n=6; cohort 2: 450x106 CAR T cells, n=7; cohort 3: 800x106 CAR T cells, n=7) in 20 heavily pre-treated R/R MM patients. Grade 1-2 cytokine release syndrome (CRS) was reported in 18 patients (90%). Neither grade 3-4 CRS nor neurotoxicity of any grade were observed. No dose-limiting toxicities were observed in any cohort. The overall response rate (ORR), (stringent) complete response (CR/sCR), and very good partial response rates were 75%, 50%, and 25%, respectively. Response rates were dose-dependent with 85% ORR, 71% CR, and 57% minimal residual disease negativity in the high-dose cohort 3. Across all cohorts, the median overall survival (OS) was 308 days (range 25-466+), with an estimated OS of 55% as of June 27th (data cut-off). The median progression-free survival was 160 days, with 6 subjects remaining progression free at the time of data cut-off. Our findings demonstrate the manageable safety profile and efficacy of HBI0101. These encouraging data support the decentralization of CAR T production in an academic setting, ensuring sufficient CAR T supply to satisfy the increasing local demand. Clinicaltrials.gov NCT04720313.

Effectiveness and safety of anti-BCMA chimeric antigen receptor T-cell treatment in relapsed/refractory multiple myeloma: a comprehensive review and meta-analysis of prospective clinical trials

Background: Chimeric antigen receptor T cells treatment targeting B cell maturation antigen (BCMA) is an emerging treatment option for relapsed/refractory multiple myeloma (RRMM) and has demonstrated outstanding outcomes in clinical studies. Objective: The aim of this comprehensive review and meta-analysis was to summarize the effectiveness and safety of anti-BCMA CAR-T treatment for patients with relapsed/refractory multiple myeloma (RRMM). Our research identifies variables influencing outcome measures to provide additional evidence for CAR-T product updates, clinical trial design, and clinical treatment guidance. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard was followed for conducting this comprehensive review and meta-analysis, which was submitted to PROSPERO (CRD42023390037). From the inception of the study until 10 September 2022, PubMed, Web of Science, EMBASE, the Cochrane Library, CNKI, and WanFang databases were searched for eligible studies. Stata software (version 16.0) was used to assess effectiveness and safety outcomes. Results: Out of 875 papers, we found 21 relevant trials with 761 patients diagnosed as RRMM and were given anti-BCMA CAR-T treatment. The overall response rate (ORR) for the entire sample was 87% (95% CI: 80-93%) complete response rate (CRR) was 44% (95% CI: 34-54%). The minimal residual disease (MRD) negativity rate within responders was 78% (95% CI: 65-89%). The combined incidence of cytokine release syndrome was 82% (95% CI: 72-91%) and neurotoxicity was 10% (95% CI: 5%-17%). The median progression-free survival (PFS) was 8.77 months (95% CI: 7.48-10.06), the median overall survival (OS) was 18.87 months (95% CI: 17.20-20.54) and the median duration of response (DOR) was 10.32 months (95% CI: 9.34-11.31). Conclusion: According to this meta-analysis, RRMM patients who received anti-BCMA CAR-T treatment have demonstrated both effectiveness and safety. Subgroup analysis confirmed the anticipated inter-study heterogeneity and pinpointed potential factors contributing to safety and efficacy, which may help with the development of CAR-T cell studies and lead to optimized BCMA CAR-T-cell products. Systematic Review Registration: Clinicaltrials.gov, PROSPERO, CRD42023390037.

Molecular and therapeutic effect of CRISPR in treating cancer

Cancer has become one of the common causes of mortality around the globe due to mutations in the genome which allows rapid growth of cells uncontrollably without repairing DNA errors. Cancers could arise due alterations in DNA repair mechanisms (errors in mismatch repair genes), activation of oncogenes and inactivation of tumor suppressor genes. Each cancer type is different and each individual has a unique genetic change which leads them to cancer. Studying genetic and epigenetic alterations in the genome leads to understanding the underlying features. CAR T therapy over other immunotherapies such as monoclonal antibodies, immune checkpoint inhibitors, cancer vaccines and adoptive cell therapies has been widely used to treat cancer in recent days and gene editing has now become one of the promising treatments for many genetic diseases. This tool allows scientists to change the genome by adding, removing or altering genetic material of an organism. Due to advance in genetics and novel molecular techniques such as CRISPR, TALEN these genes can be edited in such a way that their original function could be replaced which in turn improved the treatment possibilities and can be used against malignancies and even cure cancer in future along with CAR T cell therapy due to the specific recognition and attacking of tumor.