Haematology laboratory parameters to assess efficacy of CD19-, CD22-, CD33-, and CD123-directed chimeric antigen receptor T-cell therapy in haematological malignancies

INTRODUCTION

Chimeric antigen receptor (CAR) T cell products are available to treat relapsed/refractory B-lymphoblastic leukaemia/lymphoma (B-ALL), diffuse large B-cell lymphoma, mantle-cell lymphoma, and myeloma. CAR products vary by their target epitope and constituent molecules. Hence, there are no common laboratory assays to assess CAR T cell expansion in the clinical setting. We investigated the utility of common haematology laboratory parameters to measure CAR T cell expansion and response.

METHODS

Archived CellaVision images, absolute lymphocyte counts, and Sysmex CPD parameters spanning 1 month after CD19-CAR, UCAR19, CD22-CAR, CD33-CAR, and UCAR123 therapy were compared against donor lymphocyte infused control patients. Additionally, CellaVision images gathered during acute EBV infection were analysed.

RESULTS

CellaVision images revealed a distinct sequence of three lymphocyte morphologies, common among CD19-CAR, CD22-CAR and UCAR19. This lymphocyte sequence was notably absent in CAR T cell non-responders and stem-cell transplantation controls, but shared some features seen during acute EBV infection. CD19-CAR engraftment kinetics monitored by quantitative PCR show an expansion and persistence phase and mirror CD19-CAR ALC kinetics. We show other novel CAR T cell therapies (UCAR19, CD22-CAR, CD33-CAR and UCAR123) display similar ALC expansion in responders and diminished ALC expansion in non-responders. Furthermore, the CPD parameter LY_WY fluorescence increased within the first week after CD19-CAR infusion, preceding the peak absolute lymphocyte count (ALC) by 3.7 days.

CONCLUSION

Autologous and allogeneic CAR T cell therapy produce unique changes in common haematology laboratory parameters and could be a useful surrogate to follow CAR T-cell expansion after infusion.

Clinical impact of genomic characterization of 15 patients with acute megakaryoblastic leukemia-related malignancies

Acute megakaryoblastic leukemia (AMKL) is a rare subtype of acute myeloid leukemia but is approximately 500 times more likely to develop in children with Down syndrome (DS) through transformation of transient abnormal myelopoiesis (TAM). This study investigates the clinical significance of genomic heterogeneity of AMKL in children with and without DS and in children with TAM. Genomic evaluation of nine patients with DS-related TAM or AMKL, and six patients with non-DS AMKL, included conventional cytogenetics and a comprehensive next-generation sequencing panel for single-nucleotide variants/indels and copy-number variants in 118 genes and fusions involving 110 genes. Recurrent gene fusions were found in all patients with non-DS, including two individuals with complex genomes and either a NUP98–KDM5A or a KMT2A–MLLT6 fusion, and the remaining harbored a CBFA2T3–GLIS2 fusion, which arose from both typical and atypical cytogenetic mechanisms. These fusions guided treatment protocols and resulted in a change in diagnosis in two patients. The nine patients with DS had constitutional trisomy 21 and somatic GATA1 mutations, and those with DS-AMKL had two to four additional clinically significant somatic mutations. Comprehensive genomic characterization provides critical information for diagnosis, risk stratification, and treatment decisions for patients with AMKL. Continued genetic and clinical characterization of these rare cancers will aid in improving patient management.

Pleural mass forming extramedullary hematopoiesis masquerading as a malignant neoplasm

Extramedullary hematopoiesis (EMH) represents the presence of immature hematopoietic elements and their differentiation into mature blood components outside of the medullary bone and may be seen in a variety of circumstances in the postnatal period, but is most strongly associated with disorders of the hematopoietic system. Postnatally, EMH is typically identified at sites of fetal hematopoiesis, the spleen, and liver, but occasional reports have identified it in nearly every tissue of the body. We report a case of EMH presenting as pleural mass, initially suspected to represent a neoplastic process in a patient with multiple comorbidities, including history of carcinoma, but without co-existing hematologic disorder. On-site evaluation of the fine-needle aspiration specimen was initially suspicious for a malignant neoplasm, but further evaluation revealed the lesion to be a mass forming focus of non-hepatosplenic EMH. In the era of increasing utilization of imaging, mass forming EMH is increasingly detected. When unsuspected, EMH may present a diagnostic challenge for the pathologist and may be confused for a neoplastic process.

In vivo disruption of T cell development by expression of a dominant-negative polypeptide designed to abolish the SLP-76/Gads interaction

Multi-molecular complexes nucleated by adaptor proteins play a central role in signal transduction. In T cells, one central axis consists of the assembly of several signaling proteins linked together by the adaptors linker of activated T cells (LAT), Src homology 2 domain-containing leukocyte-specific phosphoprotein of 76 kDa (SLP-76), and Grb2-related adaptor downstream of Shc (Gads). Each of these adaptors has been shown to be important for normal T cell development, and their proper sub-cellular localization is critical for optimal function in cell lines. We previously demonstrated in Jurkat T cells and a rat basophilic leukemic cell line that expression of a 50-amino acid polypeptide identical to the site on SLP-76 that binds to Gads blocks proper localization of SLP-76 and SLP-76-dependent signaling events. Here we extend these studies to investigate the ability of this polypeptide to inhibit TCR-induced integrin activity in Jurkat cells and to inhibit in vivo thymocyte development and primary T cell function. These data provide evidence for the in vivo function of a dominant-negative peptide based upon the biology of SLP-76 action and suggest the possibility of therapeutic potential of targeting the SLP-76/Gads interaction.

Combinatorial pattern recognition receptor signaling alters the balance of life and death in macrophages

Macrophage pattern recognition receptors (PRRs) play key roles in innate immunity, but they also may contribute to disease processes under certain pathological conditions. We recently showed that engagement of the type A scavenger receptor (SRA), a PRR, triggers JNK-dependent apoptosis in endoplasmic reticulum (ER)-stressed macrophages. In advanced atherosclerotic lesions, the SRA, activated JNK, and ER stress are observed in macrophages, and macrophage death in advanced atheromata leads to plaque necrosis. Herein, we show that SRA ligands trigger apoptosis in ER-stressed macrophages by cooperating with another PRR, Toll-like receptor 4 (TLR4), to redirect TLR4 signaling from prosurvival to proapoptotic. Common SRA ligands activate both TLR4 signaling and engage the SRA. The TLR4 effect results in activation of the proapoptotic MyD88-JNK branch of TLR4, whereas the SRA effect silences the prosurvival IRF-3-IFN-beta branch of TLR4. The normal cell-survival effect of LPS-induced TLR4 activation is converted into an apoptosis response by immunoneutralization of IFN-beta, and the apoptosis effect of SRA ligands is converted into a cell-survival response by reconstitution with IFN-beta. Thus, combinatorial signaling between two distinct PRRs results in a functional outcome-macrophage apoptosis that does not occur with either PRR alone. PRR-induced macrophage death may play important roles in advanced atherosclerosis and in other innate immunity-related processes in which the balance between macrophage survival and death is critical.

CD11b/CD18 mediates production of reactive oxygen species by mouse and human macrophages adherent to matrixes containing oxidized LDL

Production of reactive oxygen species (ROS) and other proinflammatory substances by macrophages adherent to matrix proteins that contain or have been modified by oxidized LDL (oxLDL) may play an important role in atherogenesis. In vitro, human macrophages adhere to matrixes containing oxLDL via scavenger receptors and are signaled to produce ROS partly by interactions of the class B scavenger receptor (SR-B) CD36 with ligands on the matrix. In this report, we show that macrophages from mice genetically deficient in SR-A or CD36 adhered equally as well and produced equal amounts of ROS on interaction with matrix-associated oxLDL. In contrast, macrophages from mice genetically deficient in the CD18 chain of beta(2)-integrins produced insignificant amounts of ROS on interaction with oxLDL-containing matrixes, even though they adhered to these matrixes as efficiently as did macrophages from wild-type mice. Antibodies against CD18, CD11b, or EDTA, the last of which chelates divalent cations required for integrin function, had no effect on adhesion of normal mouse or human macrophages to matrixes containing oxLDL but almost completely inhibited ROS production by macrophages adherent to this matrix. Thus, CD11b/CD18 plays an important role in regulating production of ROS by mouse and human macrophages adherent to matrixes containing oxLDL. It may play a hitherto-unsuspected role in regulating macrophage signaling pathways involved in inflammation and atherogenesis.