Axi-cel Infusion Research Articles

Tocilizumab Prophylaxis Following Axicabtagene Ciloleucel in Relapsed or Refractory Large B-Cell Lymphoma

Axicabtagene ciloleucel (axi-cel) is an autologous anti-CD19 chimeric antigen receptor (CAR) T-cell therapy approved in patients with relapsed/refractory (R/R) large B-cell lymphoma (LBCL). Most patients treated with axi-cel experience cytokine release syndrome (CRS) and/or adverse neurologic events (NEs). To explore potential approaches for reducing CAR T-cell-related toxicities with axi-cel, several safety expansion cohorts were added to the pivotal ZUMA-1 trial. ZUMA-1 Cohort 3 was an exploratory safety cohort that investigated the use of the IL-6 receptor-blocking antibody tocilizumab and anticonvulsant levetiracetam as prophylaxis against CRS and NEs in patients treated with axi-cel. Patients with R/R LBCL were enrolled in Cohort 3 and received conditioning chemotherapy on d -5 through -3 followed by a single infusion of axi-cel (2 × 106 cells/kg) on d 0. Prophylactic tocilizumab (8 mg/kg) was administered 48 h after axi-cel infusion. Primary endpoints were incidence and severity of CRS and NEs. Key secondary endpoints included the incidence of adverse events, objective response rate (ORR), duration of response, progression-free survival, overall survival (OS), and biomarker analyses (eg, circulating CAR T cells, cytokines, chemokines). Forty-two patients were enrolled in Cohort 3, 38 of whom received axi-cel. In the 24-month analysis, any-grade CRS and NEs occurred in 92% and 87% of patients, and Grade ≥3 CRS and NEs occurred in 3% and 42% of patients, respectively. One Grade 5 NE (cerebral edema) occurred. With 24-mo minimum follow-up, the ORR was 63%, and 39.5% of patients had ongoing response. With 48-month follow-up, median OS was 34.8 mo (95% CI, 5.4-not estimable). CAR T-cell expansion in ZUMA-1 Cohort 3 was comparable with pivotal Cohorts 1 and 2. Consistent with tocilizumab-mediated inhibition of IL-6R, serum IL-6 levels were increased relative to Cohorts 1 and 2. Grade ≥3 NEs were associated with elevated IL-6 levels, proinflammatory cytokines, and myeloid cells in the cerebrospinal fluid. Based on these findings, prophylactic tocilizumab is not recommended to prevent CAR T-cell-related adverse events, and beneficial effects of prophylactic levetiracetam remain uncertain in patients with R/R LBCL.

Decoding the mechanisms of chimeric antigen receptor (CAR) T cell-mediated killing of tumors: insights from granzyme and Fas inhibition

Chimeric antigen receptor (CAR) T cell show promise in cancer treatments, but their mechanism of action is not well understood. Decoding the mechanisms used by individual T cells can help improve the efficacy of T cells while also identifying mechanisms of T cell failure leading to tumor escape. Here, we used a suite of assays including dynamic single-cell imaging of cell-cell interactions, dynamic imaging of fluorescent reporters to directly track cytotoxin activity in tumor cells, and scRNA-seq on patient infusion products to investigate the cytotoxic mechanisms used by individual CAR T cells in killing tumor cells. We show that surprisingly, overexpression of the Granzyme B (GZMB) inhibitor, protease inhibitor-9 (PI9), does not alter the cytotoxicity mediated by CD19-specific CAR T cells against either the leukemic cell line, NALM6; or the ovarian cancer cell line, SkOV3-CD19. We designed and validated reporters to directly assay T cell delivered GZMB activity in tumor cells and confirmed that while PI9 overexpression inhibits GZMB activity at the molecular level, this is not sufficient to impact the kinetics or magnitude of killing mediated by the CAR T cells. Altering cytotoxicity mediated by CAR T cells required combined inhibition of multiple pathways that are tumor cell specific: (a) B-cell lines like NALM6, Raji and Daudi were sensitive to combined GZMB and granzyme A (GZMA) inhibition; whereas (b) solid tumor targets like SkOV3-CD19 and A375-CD19 (melanoma) were sensitive to combined GZMB and Fas ligand inhibition. We realized the translational relevance of these findings by examining the scRNA-seq profiles of Tisa-cel and Axi-cel infusion products and show a significant correlation between GZMB and GZMA expression at the single-cell level in a T cell subset-dependent manner. Our findings highlight the importance of the redundancy in killing mechanisms of CAR T cells and how this redundancy is important for efficacious T cells.

Effect of delayed cell infusion in patients with large B-cell lymphoma treated with chimeric antigen receptor T-cell therapy.

Complications occurring after lymphodepleting chemotherapy (LDC) may delay chimeric antigen receptor (CAR) T-cell infusion. The effect of these delays on clinical outcomes is unclear. We performed a retrospective analysis of 240 patients with relapsed/refractory large B-cell lymphoma treated with standard-of-care axicabtagene ciloleucel (axi-cel) and identified 40 patients (16.7%) who had delay in axi-cel infusion. Of these, 85% had delay due to infection. At time of LDC initiation, patients with delayed infusion had lower absolute neutrophil count (P=0.006), lower platelets (P=0.004), lower hemoglobin (P<0.001) and higher C-reactive protein (P=0.001) than those with on-time infusion. Patients with delayed infusion had lower day 30 overall response rates (59.0% vs. 79.4%; P=0.008) and shorter median progression-free survival (PFS) (3.5 vs. 8.2 months; P=0.002) and overall survival (7.8 vs. 26.4 months; P=0.046) than those with on-time infusion. The association with PFS was maintained on multivariate analysis. There was also an association between extent of delay and survival, with shorter median PFS in patients who had delays of 2-5 days (1.8 vs. 8.2 months; P=0.001) and >5 days (4.6 vs. 8.2 months; P=0.036), but not 1 day (5.7 vs. 8.2 months; P=0.238). Following propensity score matching, patients with delayed infusion continued to have shorter median PFS (3.5 vs. 6.0 months; P=0.015). Levels of pro-inflammatory cytokines on day of infusion were significantly higher in patients with delayed infusion. Together, these findings suggest that delays in CAR T-cell administration after initiation of LDC are associated with inferior outcomes. Further studies are needed to guide strategies to improve efficacy in such patients.

Acalabrutinib in Combination with Anti-CD19 Chimeric Antigen Receptor T-Cell Therapy in Relapsed/Refractory B-Cell Lymphoma: A Phase I/II Study of Safety, Efficacy and Immune Correlative Analysis

Introduction Limitations of effective CD19-targeted chimeric antigen receptor T-cell therapy (CAR-T) in relapsed/refractory (R/R) B-cell lymphoma include inability to control disease prior to CAR-T, lack of sustained remissions following CAR-T and the potential for life-threatening adverse effects such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). BTK inhibitors, ibrutinib and acalabrutinib are immunomodulatory and may enhance CAR-T expansion, engraftment and tumor clearance while decreasing the frequency and severity of CRS in chronic lymphocytic leukemia (Qin, et al. J Immunother 2020). Based on this, we hypothesized that acalabrutinib, when combined with CD19-targeted CAR-T, could enhance its efficacy and safety and may also serve as an effective bridging strategy. We report the initial safety, efficacy and correlative analysis of acalabrutinib in combination with axicabtagene ciloleucel (axi-cel) in R/R B-cell lymphoma. Methods We conducted a phase I/II, open-label trial (NCT04257578) involving adult patients meeting FDA-approved criteria for axi-cel; this included patients with R/R CD19+ large B-cell (LBCL) and follicular lymphoma (FL) with measurable disease. Acalabrutinib was continuously administered at 100 mg twice daily over the 3 study phases: 1) Bridging: Starting between 3 weeks and 24 hours prior to leukapheresis until lymphodepletion (LD), 2) Cell therapy: From LD to 30 days after axi-cel infusion, 3) Maintenance: From 30 days to 1 year after axi-cel infusion or until unacceptable toxicity or disease progression (Figure 1). Axi-cel was administered per institutional practice. The primary endpoint was safety based on rates of grade ≥3 CRS or ICANS within 30 days of axi-cel infusion. We also assessed bridging success rate (defined as receipt of axi-cel without any additional required treatment), overall response rate (ORR) and complete response (CR) rate following axi-cel infusion, progression-free survival, overall survival and immune response biomarkers. Results As of July 28, 2023, 17 patients have enrolled, 14 have received axi-cel infusion and are evaluable for response to CAR-T and 3 are earlier in treatment. Fourteen patients had LBCL (12 DLBCL [4 with double/triple hit, 3 with double/triple expressor, 1 with only MYC translocation] and 2 PMBCL) and 3 had FL (Table 1). Median age was 58 (range 34-74) years, largest lesion diameter was a median of 3.75 (1.7-7.1) cm and the median number of prior regimens was 3 (range 1-5). Of LBCL patients, 6 (43%) had primary refractory disease and 5 (38%) had relapsed within 12 months of initial therapy; 4 (31%) patients had previous autologous stem cell transplant. Fourteen of 15 patients (93%) who underwent axi-cel infusion were successfully bridged from prior to leukapheresis to LD with single agent acalabrutinib and no additional therapy; 1 received added radiation. After cell infusion, 13 (93%) and 8 (57%) patients had any grade CRS and ICANS, respectively. Three (20%) patients had grade 3 ICANS which resolved with dexamethasone and anakinra or tocilizumab. No patients received prophylactic dexamethasone. No patients experienced grade ≥3 CRS or any grade hemorrhage or tachyarrhythmia. No patients discontinued acalabrutinib at any time due to toxicity, meeting an interim safety endpoint. The ORR and CR rate at day 30 post axi-cel infusion was 93% and 71%, respectively. Through post axi-cel maintenance, there were no drug holds. One of the 3 patients with partial remission (PR) at day 30 converted to CR at day 180 post infusion while 2 suffered disease progression at day 90 post axi-cel infusion. No treatment related deaths were observed by time of data cutoff. At a median follow-up of 13.8 (range 1.7-29.1) months, 10 (73%) patients are alive and 9 are progression-free. Post axi-cel cytokines peaked at a median of day 6 [median IL-6 196 pg/ml (range 20-11803), ferritin 425 ng/ml (156-2051), CRP 52.9 mg/L (7.7-239.7), Table 1]. Impact of acalabrutinib on myeloid derived suppressor cells and the immunosecretome profile are underway and will be reported at time of presentation. Conclusions Acalabrutinib successfully bridged most patients in this trial when given concurrently with axi-cel and safely maintained high CR rates. CRP and ferritin levels were typically only modestly elevated after cell infusion. Severe CRS was not observed and high-grade ICANS was uncommon.

Bendamustine Is Less Toxic Than Fludarabine-Cyclophosphamide-Based Lymphodepletion before CD28-Costimulated CART19 through Reduced Inflammatory Cytokines

Introduction: Lymphodepletion (LD) is an integral component of anti-CD19 chimeric antigen receptor T cell (CART19) immunotherapy, creating the proper environment and cytokine milieu for CART engraftment and function. We previously demonstrated that bendamustine (Benda) LD is as effective as standard fludarabine and cyclophosphamide (Flu/Cy) LD prior to 4-1BB-costimulated tisagenlecleucel but is characterized by significantly reduced cytokine-release syndrome (CRS), neurotoxicity (ICANS), and hematological toxicities. However, whether Benda LD is also effective and safe in CD28 costimulated CART19, and the mechanism for the reduced toxicities associated with Benda LD remain unknown. Methods: We retrospectively evaluated the outcomes of 59 consecutive non-Hodgkin lymphoma patients (pts), including large B cell lymphomas (LBCL, n=48) and follicular lymphoma (FL, n=11), treated with commercial CD28 costimulated axicabtagene ciloleucel (axi-cel) at the University of Pennsylvania between January 2018 and March 2023. Data cut-off was June 30 th, 2023. LD regimens were Flu 30 mg/m 2/day and Cy 500 mg/m 2/day x 3 days or Benda 90 mg/m 2/day x 2 days. LD choice was at the treating physician's discretion, partially determined by Flu shortage. Pts were evaluated for 3-month response (Lugano criteria), survival, and toxicities (ASTCT, CTCAE) in the 30 days after axi-cel infusion. For hematological toxicities, we analyzed lymphocyte, neutrophil, platelet, and hemoglobin levels from the first day of LD to 30 days after axi-cel infusion. For long-term hematological toxicities, we retrieved blood values at 6 months in pts with ongoing remission. Moreover, we analyzed serum samples collected pre- and post-LD (CART19 infusion day) for changes in circulating cytokines (Luminex) and metabolites (Liquid Chromatography/Mass Spectrometry) in a second cohort of 32 pts undergoing CART19. Results: Of 59 pts, 37 received Flu/Cy while 22 Benda LD. The two groups were balanced for most clinical features. Responses with Flu/Cy and Benda LD were similar, with complete remission rates of 51.4% and 50.0%, respectively. Progression-free and overall survivals were similar in the two LD groups. However, any-grade CRS occurred in 91.9% of pts who received Flu/Cy versus 72.7% of pts who received Benda LD; any-grade ICANS after Flu/Cy occurred in 43.2% and after Benda LD in 18.2% of pts ( Fig.1A). These results were confirmed in both LBCL and FL cohorts. Both LD regimens induced profound lymphopenia by the time of axi-cel infusion. However, Flu/Cy LD induced a deeper reduction in median lymphocyte counts (Flu/Cy: 0.00x10 9/L; Benda, 0.20x10 9/L). Additionally, Flu/Cy was associated with a higher incidence of neutropenia of grade ≥3 (100.0% vs 54.5%). Consequently, Flu/Cy pts were more likely to develop infections (78.4% vs. 27.3%), and neutropenic fever (78.4% vs. 13.6%) than Benda receiving pts. By evaluating long-term hematological toxicities, 75.0% of Flu/Cy pts did not have lymphocyte recovery to normal values at 6 months compared to 37.5% with Benda LD. Mechanistically, both Flu/Cy (n=7) and Benda (n=25) LD regimens induced an increase in the levels of cytokines facilitating CART proliferation (IL2, IL7, IL15). Overall, Flu/Cy LD pts had a higher increase in inflammatory cytokine levels compared to Benda LD pts, including a higher increase in the levels of cytokines previously associated with CRS and ICANS (IL15, IL8, and MCP1, Fig.1B). Moreover, after LD, several indispensable anabolic metabolites, including carnitine esters, were decreased in pts receiving Flu/Cy. We also found that NADH and nicotinamide riboside, critical elements for cellular redox balance, were reduced in pts exposed to Flu/Cy LD. We speculate that the higher cytotoxicity/cytopenias, induced by Flu/Cy LD, causes a faster utilization of the above-mentioned metabolites in order to reconstitute the hematopoietic cell compartment to physiological levels, resulting in a higher patient susceptibility to additional metabolic stress. Conclusions: In this retrospective comparison,Benda LD is a safer alternative to Flu/Cy for CART19 immunotherapy with similar efficacy and significantly reduced toxicities. Our data can serve as guidance to clinicians for the selection of the best regimen for lymphodepletion. Our conclusions are supported by our mechanistic studies showing reduced inflammatory cytokines after Benda LD.

Clinical Outcomes with Prophylactic Corticosteroid Use for Axicabtagene Ciloleucel (axi-cel) in Patients with Relapsed/Refractory Large B-Cell Lymphoma (R/R LBCL): A Multicenter Analysis

Introduction: In Cohorts 1+2 of the ZUMA-1 Phase 1/2 study of axi-cel in R/R LBCL, 11% and 31% of patients (pts) experienced Grade ≥3 cytokine release syndrome (CRS) or neurologic evenets), respectively. To minimize the toxicities seen with axi-cel, a safety management cohort, Cohort 6 (N=40), was added to evaluate whether prophylactic (ppx) corticosteroids (CS) could decrease grade ≥ 3 CRS or ICANS. The 2-year update of ZUMA-1 Cohort 6 showed no grade ≥3 CRS and 15% grade ≥3 ICANS without any difference in objective response rate (ORR) or complete response rate (CR) when compared to cohorts 1+2 (Oluwole Blood 2022). The FDA had previously approved an update to the prescribing information for axi-cel to include use of ppx CS across all approved indications in January 2022. However, ppx CS is not a mandatory standard treatment and we sought to establish the clinical outcomes in the real-world practice. Methods: To assess the clinical outcomes of pts receiving ppx CS, we conducted a multicenter retrospective analysis of pts with R/R LBCL who were treated with axi-cel since the FDA approval of ppx CS in January 2022. Baseline characteristics, toxicities, and efficacy were compared between the no ppx and ppx CS groups. CRS and ICANS were graded based on ASTCT 2019 guidelines. Event-free survival (EFS) was defined as time from axi-cel infusion to progression, re-treatment, or death. Overall survival (OS) was defined as time from axi-cel infusion to death due to any cause. Results: A total of 66 pts at 5 centers received axi-cel between Jan 31, 2022, and June 20, 2023. Thirty-five (52%) pts received ppx CS, with a median age of 63 years (26-85 years). By histology, 75% (n=50) of the pts had DLBCL, 13.6% (n=9) had high grade B-cell lymphoma (HGBL), 9.1% (n=6) had transformed follicular lymphoma (TFL) and 1.5% (n=1) primary mediastinal LBCL (PMBCL). 59% of the pts (n=37) had IPI &amp;gt;2 and 66% (n=43) had stage III/IV disease. The baseline characteristics at the time of apheresis are shown in Table 1 and were comparable between the 2 groups, except for more HGBL, fewer prior lines of therapy and longer median time from apheresis to axi-cel infusion in the ppx CS group. Among the entire cohort, only 37% (n=25) met ZUMA-1 eligibility criteria at the time of lymphodepletion, and 67% (n=44) needed bridging therapy. Any grade CRS occurred in 88% (n=58) of the pts, with grade ≥2 CRS in 38% (n=25). Any grade ICANS occurred in 55% (n=37) of the pts, with grade ≥2 ICANS in 41% (n=27). Any grade ICANS was significantly lower in the ppx CS group than the no ppx group (45.7% vs 65.5%). The rates of any grade CRS, grade ≥2 CRS, grade ≥2 ICANS, the median time to CRS onset, ICANS onset, CRS duration, and ICANS duration were comparable between the 2 groups. Tocilizumab and steroids use was similar between two groups with a trend towards less ICU admission in patients in the ppx CS group. Overall, 14 (21%) pts developed infectious complications within 30 days of axi-cel infusion. The day 30 ORR was 84% and was comparable between the 2 groups (77% in the ppx group vs 93% in the no ppx group). The CR was 45.7% in ppx CS group compared to 65.5% in no ppx group. At a median follow up of 219 days (27-1178), 37 (56.1%) pts had progressed and 25 (37.9%) pts had died. The number of days to progress was significantly lower in the ppx CS arm. The median EFS and OS were not significant between the 2 groups. Conclusions: This multicenter retrospective study showed that the efficacy of treatment with axi-cel in R/R LBCL did not decrease with the use of ppx CS. No significant differences in efficacy or CAR-T-associated toxicities were noted in the 2 groups, potentially due to selective use with patients at presumed higher risk of severe CRS and ICANS. A larger dataset and longer follow-up is needed for risk-stratified analysis and the study is ongoing.

Long-Term Efficacy and Immune Reconstitution with Bendamustine As a Lymphodepleting Agent for Axicabtagene Ciloleucel (Axi-Cel) in Patients with Refractory or Relapsed Large B-Cell Lymphoma (LBCL)

Introduction: Lymphodepletion (LD) is crucial for the expansion and persistence of CAR T cells. Fludarabine in combination with cyclophosphamide (FC) is the LD standard regimen. A national fludarabine shortage in 2022 necessitated the exploration of alternative LD regimens. Bendamustine (benda) is a purine analog and an alkylating chemotherapy that has been used as an LD agent for tisagenlecleucel (Ghilardi et al.,2022). However, there is no data for benda LD in other commonly used CART products for relapsed or refractory non-hodgkin lymphoma (rel/ref NHL). Early safety, efficacy, and expansion kinetics data were presented previously (Bharadwaj, ASH 2022). We are now reporting long-term efficacy and immune reconstitution data. Methods: 84 consecutive patients with relapsed/refractory LBCL treated with axi-cel were included in this single-institution study. 27 patients who received Bendamustine lymphodepletion (90mg/m2 on days -4 and -3) were compared to a preceding 57-patient FC cohort. Response, survival, and cytopenia data were collected closest to the 12-month time point for all patients who had not progressed. Response was assessed using the Lugano 2014 criteria, while toxicities were evaluated using the CTCAE version 5.0 and the ASTCT grading. To reduce the influence of confounding variables in this study, a covariate balance propensity score weighting approach (IPTW) was implemented. Covariates included age, sex, presence of bridging therapy, IPI score at apheresis, number of prior therapy lines, absolute lymphocyte count at leukapheresis, prior auto SCT, and pre-lymphodepletion LDH, ALC, ANC, and platelet count. Continuous outcomes were compared using the Mann-Whitney U test, categorical outcomes using chi-square tests, and time-to-event outcomes using a log-rank test weighted in the IPTW sample. Statistical significance was considered when p &amp;lt; 0.05. All analyses were conducted in R 4.3.0. Results: There was no significant difference in the best complete response (CR) rate and best overall response rate (ORR) between the two groups, with a CR rate of 71.9% for FC and 74% for bendamustine (p = 0.182), and an ORR of 89.4% for FC and 85.1% for bendamustine (p = 0.502). For the FC group, 9-month progression-free survival (PFS) and overall survival (OS) were 63.16% (95% CI: 49.29% to 74.19%) and 78.95% (95% CI: 65.92% to 87.45%), respectively with a median follow-up of 15.5 months (IQR: 13.6, 16.8). 9-month PFS and OS point-estimates for the bendamustine group were 70.37% (95% CI: 49.4% to 83.94%) and 77.41% (95% CI: 56.41% to 89.18%), respectively, with a median follow-up of 9.5 months (IQR: 8.6, 9.8). No significant difference was found between groups in either 9 months PFS ( P=0.055) or 9 months OS ( P=0.6290). Median PFS and OS have not been achieved for either group [Figure 1]. Bendamustine was effective in achieving severe lymphodepletion, with a median absolute lymphocyte count (ALC) nadir of 0.11 K/ul (IQR: 0.04, 0.17) occurring within one day after axi-cel infusion. In comparison, the FC group had a lower median ALC nadir of 0.03 K/ul (IQR: 0.01, 0.06) occurring on the day of axi-cel infusion ( P=0.01). Both cohorts showed a similar pattern of lymphocyte recovery over 1, 3, and 6 months. Median ALC counts at 9-12 months post-infusion indicated better lymphocyte recovery in the bendamustine group with a median ALC of 1.55 K/ul (IQR: 1.04, 1.94) compared to 0.96 K/ul (IQR: 0.58, 1.23) in the FC group ( P=0.043) [Figure 2]. There was no significant difference in the recovery of absolute neutrophil count, hemoglobin, and platelets. Updated efficacy analysis and immune reconstitution data including T-cell, B-cell, and NK cell recovery will be reported at the time meeting, as all patients will have completed at least one year of follow-up by September 2023. Discussion: Bendamustine lymphodepletion prior to axi-cel therapy showed comparable efficacy and safety outcomes to the standard FC regimen in relapsed/refractory LBCL patients. Bendamustine demonstrated effective lymphodepletion and better lymphocyte recovery at 9-12 months post-infusion compared to FC cohort. These findings suggest that bendamustine may be an acceptable alternative lymphodepleting regimen. Prospective studies, ideally randomized control trial, are warranted.

Efficacy and Safety of Axicabtagene Ciloleucel (Axi-cel) for the Treatment of Relapse/Refractory Non-Hodgkin Lymphoma: Real-World Data in Chinese Population

Background: Autologous CD-19 directed chimeric antigen receptor (CAR) T-cell therapy has become the standard of care of patients with relapsed/refractory (R/R) large B-cell lymphoma (LBCL) who have received two or more prior lines of therapy. In June 2021, Axi-cel was approved by the China National Medical Products Administration (NMPA) for the treatment of these patients as the first commercial CAR-T product in China. To better understand the efficacy and safety of commercial Axi-cel in Chinese R/R NHL patients in a real-world setting, we conducted this multi-center, non-interventional study (ChiCTR2100047990). The accrual goal is 200 patients, and the primary endpoint is mOS. Here we made the pre-specific interim analysis and the reported the clinical outcomes. Methods: We included R/R NHL patients treated with commercial Axi-cel at 17 authorized treatment centers from November 2021 to February 2023. All the patients signed written informed consent. We reported best objective response rate (bORR), best complete response (bCR) rate and adverse events of special interest (AESI), including cytokine release syndrome (CRS) and neurological events (NE). Results: To the cut-off date of June 8, 2023, a total of 101 R/R NHL patients had undergone efficacy evaluation at month 3. The median age of patients was 56.5 (22, 80) years, with 23 patients (22.8%) aged 65 years or older. Fifty-nine patients were male. The baseline characteristics of these patients included 81 (80.2%) with diffuse large B-cell lymphoma, 4 (4.0%) with primary mediastinal B-cell lymphoma, and 7 (6.9%) with high-grade B-cell lymphoma. More than 50% of patients had an International Prognostic Index (IPI) score ≥3. The median number of prior treatment was 2. Thirty-eight patients (37.6%) had received 3 or more previous therapies and 10 patients (9.9%) had undergone autologous stem cell transplantation (ASCT). The primary refractory subgroup reached 46 (45.5%), and 41(40.6%) patients were refractory to second-line or subsequent therapy. Notably, compared to the baseline characteristics of Axi-cel real-world studies for R/R LBCL in other countries, a greater proportion of Chinese patients had an ECOG PS score ≥2 (32.7%), HBsAg (+) with normal HBV-DNA (23.1%), HBsAg (-) accompany with HBcAb (+) (37.1%). Bridging therapy was given in 73 patients (72.3%), while combination anti-lymphoma therapy was used after Axi-cel infusion and before disease progression in 52 patients (51.5%). The median follow-up was 12.7 months. The bORR and bCR rate was 83.2% (95%CI, 74.4 - 89.9) and 63.4% (95%CI, 53.2 - 72.7), respectively (Fig 1). The bORR was consistent across covariates including disease type, cell of origin and refractory subgroup, ECOG PS score ≥2, HBsAg (+) and normal HBV-DNA, and HBsAg (-) accompany with HBcAb (+), etc.. The median duration of response (DOR) was 13.7 months (95% CI, 11.1 - NA). mDOR was not reached in bCR patients (95% CI, 11.2 - NA), while patients with best response as PR have a median DOR as 4.7 months (95% CI, 1.8- 6.7). Median progression-free survival (PFS) was 14.6 months (95% CI, 7.6 - NA). Patients with ECOG PS score ≥2 had a shorter median PFS [7.6 months (95%CI 3.0 - NA)] compared to patients with PS 0-1 [14.6 months (95%CI 12.1 - NA)]. Median PFS also differed among patients based on their response at month 3. Patients with CR/PR/non-response at month3 had a median PFS of NR (95% CI, 12.1 - NA), NR (95%CI, 6.1 - NA) and 3.0 months (95%CI, 2.4 - 3.3), respectively (Fig 2). The median OS was not reached, and the estimated OS at 12 months was 80.4% (95%CI, 70.5 - 87.2). No new safety signals were observed in the Chinese population. The most common adverse events of grade ≥3 were decreased white blood cell count (82.2% of patients), neutropenia (81.3%) and lymphocytopenia (68.2%). CRS of any grade occurred in 90 patients (84.1%), with 15 patients (14.0%) experiencing grade ≥3. NE of any grade occurred in 27 patients (25.2%), with only 1 patient (0.9%) experiencing grade 4. No grade 5 CRS or NE appeared. Conclusions: This pre-specific interim analysis demonstrated the consistent efficacy of Axi-cel in Chinese R/R NHL patients, while NE of any grade and ≥grade 3 were lower. Similar to the result of the ZUMA-1 study, response at month 3 may predict PFS in Chinese R/R NHL patients treated with Axi-cel in real-world practice.

Real World Data of Axicabtagene Ciloleucel As Second Line Therapy for Patients with Large B Cell Lymphoma: First Results of a Lysa Study from the French Descar-T Registry

Background and Significance: Axicabtagene ciloleucel (axi-cel) has demonstrated superior efficacy as second-line therapy (2L) over standard of care chemo-immunotherapy in transplant-eligible patients with relapsed/refractory (R/R) large B-cell lymphoma (LBCL). In ZUMA-7 trial, 180 patients were randomized to receive axi-cel in 2L, achieving an estimated 4-year overall survival of 54% after a median follow-up of 47 months. In the ALYCANTE phase II study, 62 transplant-ineligible patients with R/R LBCL were treated with axi-cel as 2L, resulting in a 3-month complete metabolic response rate of 71% with a median progression free survival of 11.8 months. Here, we report the first real-world data of axi-cel as 2L for patients with early R/R LBCL treated in French centers. Study Design and Methods: DESCAR-T is a French nationwide registry collecting real-life data of all patients treated with approved CAR T-cell therapies (NCT04328298). All patients were informed before inclusion in the registry. The goal of the present analysis was to describe patients' characteristics, treatment course, and outcomes of all patients consecutively included in DESCART registry since July 2022, and infused with axi-cel according to the early access program supported by French authorities for patients with LBCL in early relapse (&amp;lt; 1 year) or refractory after a first line treatment. Results: Between July 2022 and March 2023, axi-cel was ordered and leukapheresis was performed for 85 patients. The first axi-cel infusion was performed in September 2022 and enrollment increased rapidly with 51 new patients waiting for a leukapheresis at the time of data cut-off in March 2023. No manufacturing failures occurred, at the data cut-off, 78 patients were infused with axi-cel in 22 centers, and 7 patients died before axi-cel infusion (5 because of progression, 2 from other cause). Among the 78 patients infused, 48 (61.5%) were male, median age was 60 years (range: 23-79), 35% were over 65 years old and 5% over 70 years old. Most patients had primary refractory disease (n = 58, 74.3%), a good performance status (n = 62, 79.5% ECOG 0-1), stage III-IV disease (n = 59, 75.6%) and elevated LDH (n = 48, 61.5%). The median time between leukapheresis and axi-cel infusion was 36 days, and 65 patients (83%) received bridging therapy, primarily immuno-chemotherapy (n = 57, 73%). At the time of lymphodepletion, patients had progressive (n = 35, 54%) or stable disease (n = 6, 9%), with only 23 patients (29%) responding to bridging therapy. The median follow-up since CAR-T-cells infusion was 1.1 month (range: 0-6). Safety information was reported for 65 patients: CRS occurred in 95% of patients, however only 3 patients (&amp;lt;5%) had a grade 3 or higher CRS. Neurotoxicity occurred in 43% of the cases, with 6 patients (9%) presenting grade 3 or higher toxicity. Furthermore, 13 patients (21%) were transferred to intensive care unit. Four patients (5%) died, 3 from lymphoma progression (missing data for the remaining patient). Among the 52 patients with at least 1 month of follow-up: the overall response and complete response rates at 1 month were 76.9% and 57.7% respectively (Figure 1). Conclusion: These preliminary results demonstrated that axi-cel in 2L for R/R LBCL is feasible and safe in real-life for transplant and non-transplant eligible patients. Although follow-up of our population remains short, early assessments of response are in line with those described in ZUMA-7 study. Inclusion in DESCART registry is on-going and updated results with at least 3 months of follow-up since infusion will be presented at the meeting.

Curative Potential of Axicabtagene Ciloleucel (Axi-Cel): An Exploratory Long-Term Survival Assessment in Patients with Refractory Large B-Cell Lymphoma from ZUMA-1

Background: Axi-cel is an autologous anti-CD19 chimeric antigen receptor (CAR) T-cell therapy approved for patients with relapsed or refractory (R/R) large B-cell lymphoma (LBCL). Long-term results from ZUMA-1, a multicenter, single-arm, Phase 1/2 study of axi-cel in patients with refractory LBCL, demonstrated sustained overall survival (OS), with a median of 25.8 months and a 5-year estimate of 43% (Neelapu SS, et al. Blood. 2023). Initial assessments of disease-specific survival (DSS) in ZUMA-1 suggested axi-cel may be curative for a subset of patients. However, endpoints defining curative potential in patients with LBCL are not yet clearly established. Here, we report exploratory analyses from the Phase 2 portion of ZUMA-1 using proposed endpoints to measure cure along with survival analyses with up to 6 years of follow-up. Methods: Eligible adults in the pivotal Phase 2 Cohorts (1 and 2) of ZUMA-1 had refractory LBCL (diffuse LBCL, primary mediastinal B-cell lymphoma, or transformed follicular lymphoma). Patients were leukapheresed at enrollment, then received lymphodepletion and axi-cel infusion (2×10 6 CAR T cells/kg; Neelapu et al. N Engl J Med. 2017). Exploratory analyses to assess curative potential included lymphoma-related event-free survival (LREFS), duration of complete response (DOCR), and DSS. LREFS was defined as the time from axi-cel infusion until disease progression, initiation of new lymphoma therapy, autologous stem cell transplantation, or death due to progression, whichever was earliest. DSS was defined as time from axi-cel infusion to death due to progression or axi-cel-related adverse events (AEs). Outcomes were analyzed via Kaplan-Meier (KM) estimates and competing risk analyses. Landmark analyses were used to explore prognostic potential of disease status at Week 4 and Months 3, 6, 12 and 24. Results: At a median follow-up of 63.1 months in the 5-year analysis (data cutoff on August 11, 2021), median LREFS was 5.8 months (95% CI, 3.4-13.9) and the 60-month LREFS rate by KM estimate was 33.5%. Among patients who achieved a complete response (CR) as best response (n=59), median DOCR was not reached (95% CI, 12.9 months-not estimable). Median LREFS among those with a CR was not reached (95% CI, 18.4 months-not estimable) and the 60-month LREFS rate was 56.8%. Among those with a CR at Months 12 and 24, 60-month estimated rates of LREFS and ongoing CR were &amp;gt;80% (Table 1). All 3 lymphoma-related events that occurred after Month 24 in those with a CR were disease progression. Among those with a partial response at Week 4 (n=33) and Month 3 (n=10), estimates of 60-month LREFS were 27.3% and 45.0%, respectively. The data cutoff date for the 6-year survival analysis was August 11, 2022. Median OS was 25.8 months (95% CI, 12.8-63.7). In a competing risk assessment of OS, the cumulative incidence of death at 72 months was 61.6%. Between Months 24 and 72, there appeared to be an increase of 6% in the cumulative incidences of death due to progression (40.6% and 46.6%, respectively) and other reasons (5.0% and 11%, respectively), while deaths due to axi-cel-related AEs remained 4.0% at each timepoint. Among patients with a best response of a CR, the cumulative incidence rates of death at Month 24 and Month 72 were 20.3% and 27.2% for progression, 3.4% (both timepoints) for axi-cel-related AEs, and 0% and 10.4% for other reasons, respectively. Those who had a CR at Months 12 and 24 had a 72-month cumulative incidence of death of 18.4% and 14.2%, respectively (Table 2). Additionally, those who had a CR at 12 and 24 months had 72-month KM-estimated DSS of 94.4% and 100%, respectively. Among those with a partial response at Week 4 and Month 3, 72-month cumulative incidences of death were 72.7% and 50.0%, respectively. Conclusion: In this post hoc analysis of ZUMA-1 with up to 6 years of follow-up, axi-cel had long-term LREFS in a substantial proportion of patients, with a 5-year rate of 34% (57% among patients who achieved a CR). Additionally, a CR at 12 and 24 months may be predictive of extended OS. Among patients who achieved a CR, deaths due to axi-cel-related AEs mainly occurred before Month 24. These results demonstrate the curative potential of axi-cel in a subset of patients with R/R LBCL.

Real-World Evidence in the United States (US) of the Impact of Bridging Therapy Prior to Axicabtagene Ciloleucel (Axi-Cel) for the Treatment of Relapsed or Refractory Large B-Cell Lymphoma (R/R LBCL)

Introduction: Axi-cel utilization expanded after demonstration of superior event-free survival in patients (pts) with early relapsed or primary refractory LBCL (Locke, et al. NEJM. 2022) and was reinforced by improved overall survival (OS) among these pts (Westin, et al. NEJM. 2023). Despite increased demand, limited data exist on the impact of bridging therapies (BT) on pt outcomes. Thus, BT use between leukapheresis and lymphodepletion (LD) is largely at the discretion of treating physicians. Here, we assessed the impact of BT on effectiveness and safety outcomes after axi-cel. Methods: Pts receiving axi-cel for 3L+ LBCL in the US between 2017-2020 were prospectively collected through the CIBMTR registry in a post-authorization safety study; data up to May 2023 were included. Effectiveness outcomes were overall response rate (ORR), complete response (CR) rate, duration of response (DOR), progression-free survival (PFS), and OS. Safety outcomes were cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) per ASTCT grading, non-relapse mortality (NRM), and other key adverse events. Propensity score-based inverse probability of treatment weighting (IPTW) was used in logistic and Cox regressions to account for potential confounding in BT use. For pts who had BT, effects of BT types and responses on outcomes were evaluated using conventional logistic and Cox regressions. Results: Of 1497 pts registered, 1307 had BT data available and were included (median follow-up, 36 mo). Overall, 430 pts (33%) received BT (median time from leukapheresis to LD, 23 days [IQR, 21-28]). Systemic therapy was used in 403 pts (31%), including 305 (23%) with chemotherapy (CT)-based BT (19% treated with CT + anti-CD20 monoclonal antibody [mAb; mainly rituximab] and 4% with CT only), and 98 (7%) with non-CT systemic therapy (Table). Radiotherapy (± systemic therapy) was used in 44 pts (3%). Pts with ≥3 lines of prior therapy (odds ratio [OR], 10.67 [95% CI, 7.17−15.87]) or mild hepatic impairment prior to infusion (OR, 1.64 [1.06−2.55]) were more likely to receive BT, while those with histologic transformation (OR, 0.69 [0.51−0.92]) or longer time from diagnosis to leukapheresis were less likely to receive BT. ORRs to axi-cel were 70% and 79% (CR rates 51% and 64%) for pts with or without BT, respectively. Unadjusted DOR, PFS, and OS at 3 years were 40%, 28%, and 37%, respectively, in pts with BT vs 49%, 39%, and 49%, respectively, in those without BT. After multivariate adjustment, no statistical significance was found between BT and any effectiveness outcome. Adjusted hazard ratios (HRs) for BT were 1.13 (95% CI, 0.94-1.36) for PFS and 1.11 (95% CI, 0.92-1.34) for OS, respectively (Figure). Most safety endpoints were consistent regardless of BT. Grade ≥3 CRS and ICANS occurred in 12% and 30% of pts, respectively, who received BT vs 10% and 24% of pts who did not. Use of BT was associated with more frequent prolonged neutropenia (OR, 2.24 [1.44-3.50]) and thrombocytopenia (OR, 2.33 [1.67-3.24]), but not associated with a higher rate of infections or NRM (Table). Among pts receiving BT, 74 (17%) had a CR or partial response to BT. Of them, median PFS and median OS post infusion were 12.7 mo (3.8-not estimable [NE]) and 48.7 mo (18.6-NE), respectively. Response to BT was associated with increased CR rate (OR, 2.00 [1.07-3.75]), PFS (HR, 0.69 [0.49-0.99]), and OS (HR, 0.59 [0.40-0.88]) and decreased any-grade ICANS (OR, 0.51 [0.29-0.92]). When different BT strategies were considered, effectiveness and most safety outcomes for CT + anti-CD20 mAb vs non-CT treatment were comparable without significant difference. CT + anti-CD20 mAb was associated with improved ORR (OR, 1.90 [1.00-3.60]), PFS (HR, 0.69 [0.49-0.98]), and OS (HR, 0.66 [0.46-0.95]) but increased any-grade CRS (OR, 2.16 [1.02-4.57]) vs CT only. CT use was associated with an increased risk of prolonged thrombocytopenia (41% vs 24% for pts receiving non-CT treatment; OR, 2.37 [1.39-4.02]). No significant association was found between use of radiotherapy as BT and any outcome. Conclusion: These US real-world findings suggest that the addition of BT prior to axi-cel is associated with more frequent prolonged cytopenias but does not impact effectiveness or other critical safety outcomes. Response to BT may prognosticate more favorable outcomes after axi-cel infusion. Further study is warranted to identify the optimal bridging regimen.

Axicabtagene Ciloleucel (Axi-Cel) in Patients with Relapsed/Refractory Indolent Non-Hodgkin Lymphoma: 4-Year Follow-up from the Phase 2 ZUMA-5 Trial

Introduction: ZUMA-5 is a multicenter Phase 2 study of axi-cel autologous anti-CD19 chimeric antigen receptor (CAR) T-cell therapy in patients with relapsed/refractory (R/R) indolent non-Hodgkin lymphoma (iNHL; follicular lymphoma [FL] and marginal zone lymphoma [MZL]). After a median of ≥3 years of follow-up, medians of progression-free survival (PFS) in patients with FL and MZL were 40.2 months and not reached, respectively, and no new safety signals were observed (Neelapu et al. ASH 2022. Abstract 4660). Here, we report updated outcomes from ZUMA-5 after a median follow-up of ≥4 years. Methods: Eligible patients had R/R FL or MZL after ≥2 lines of therapy including an anti-CD20 monoclonal antibody plus an alkylating agent. Patients underwent leukapheresis at enrollment, then received lymphodepletion and axi-cel infusion (2×10 6 CAR T cells/kg). The primary endpoint was overall response rate (ORR; complete response [CR] + partial response [PR]). Time-to-event endpoints were assessed by investigators in all enrolled patients. Exploratory analyses included lymphoma-specific survival, using competing risk assessment, in which deaths unrelated to progression, axi-cel, or lymphodepletion were competing risks. Results: In 159 enrolled patients (FL: 127, MZL: 31) at data cutoff (March 31, 2023), median follow-up was 52.5 months (range, 20.3-69.4; FL: 53.7, MZL: 43.8). The ORR in enrolled patients remained consistent with prior analyses (90% ORR, 75% CR rate). Median duration of response (DOR) was 55.5 months (95% CI, 38.6-not estimable; FL: 55.5, MZL: not reached). Medians for DOR were 60.4 months in those with a best response of CR and 4.9 months in those with a PR. At data cutoff, responses were ongoing in 48% of patients, consistent by disease type. Median PFS was 57.3 months (95% CI, 34.9-not estimable; FL: 57.3, MZL: 46.9); estimated 48-month PFS rate was 52% (FL: 53%, MZL: 47%; Figure 1). After data cutoff of the prior analysis, 1 patient with FL had disease progression. PFS rates at 48 months in patients with FL were consistent regardless of high-risk characteristics, including progression &amp;lt;2 years from initiating first anti-CD20-containing chemoimmunotherapy (POD24). Median time to next therapy was 62.2 months (95% CI, 37.8-not estimable; FL: 62.2, MZL: 46.9). Median overall survival (OS) was not reached (95% CI, 62.2-not estimable); 48-month OS rate was 72% (FL: 72%, MZL: 68%). Among enrolled patients with FL, the 48-month cumulative incidence of lymphoma-specific progression or death was 34%, while the cumulative incidence of competing risks was 13% (Figure 2). Additionally, the cumulative incidence of lymphoma-specific death at 48 months was 14%; the cumulative incidence of other or unknown death was 14%. After the 3-year analysis, among 152 treated patients (124 FL; 28 MZL), 6 experienced serious adverse events, 1 of which was related to axi-cel (FL, Grade 3 myelodysplastic syndrome). No new neurologic events, hypogammaglobulinemia cases, Grade ≥3 cytopenias, or Grade ≥3 infections occurred. Seven additional patients died due to progression (n=2; both patients received subsequent therapy after progression), new malignancy (n=1; not axi-cel related), and other causes (n=4; 2 cardiac arrest, 1 infection, and 1 unknown). Among treated patients with FL, those with ongoing response at 48 months continued to have higher median postinfusion CAR T-cell expansion by peak (52.2 cells/µL) and area under the curve (583.6 cells/µL×days) than those who relapsed (29.6 cells/µL and 337.6 cells/µL×days) or had no response (25.4 cells/µL and 269.9 cells/µL×days). Additionally, those with ongoing response had a higher proportion of naive (CCR7+CD45RA+) T cells in axi-cel product (25%) than relapsed (13%) or nonresponding patients (9%). Similar trends were observed in MZL. Conclusions: With a median ≥4 years of follow-up in ZUMA-5, axi-cel demonstrated continued durable response and long-term survival in patients with R/R FL and R/R MZL. Late progression or lymphoma-specific death was uncommon in FL, suggesting curative potential for those patients. The long-term safety profile of axi-cel was manageable.

Five Year Outcomes of Patients with Large B-Cell Lymphoma Treated with Standard-of-Care Axicabtagene Ciloleucel: Results from the US Lymphoma CAR-T Cell Consortium

Introduction Axicabtagene ciloleucel (axi-cel) is an autologous anti-CD19 Chimeric Antigen Receptor (CAR) T-cell therapy that induces durable responses in patients with relapsed or refractory large B-cell lymphoma. At a median of 63.1 months follow-up on the ZUMA-1 trial, median overall survival (OS) was 25.8 months with 5-year OS and PFS (progression-free survival) estimates of 42.6% (95% CI, 32.8-51.9) and 31.8% (95% CI, 22.9-41.1), respectively (Neelapu, Blood 2023). We previously reported outcomes of axi-cel patients treated with standard of care therapy, including 42% who did not meet eligibility criteria for ZUMA-1 based on co-morbidities (Nastoupil, JCO 2020). Here we report results from this cohort at a median follow up of 58 months, as well as late outcomes of interest. Results The US Lymphoma CAR-T Consortium is comprised of 17 US academic centers who contributed data independent of the manufacturer. Two hundred and ninety-eight patients underwent leukapheresis with intent to manufacture standard of care axi-cel (n=298) as of September 30, 2018. In infused patients (n=275), OS and PFS were calculated from date of infusion. After a median follow-up of 58 months, median OS was 34.9 months (95% CI 23.4 - 44.8) with the OS at 3, 4, and 5 years of 49.1% (95% CI 42.9 - 54.9%), 43% (95% CI 36.8 - 48.9%), and 40.3% (95% CI 34.2 - 46.4%), respectively. The median PFS was 8.7 months (95% CI 5.87 - 16.6) and the 3-,4-, and 5- year PFS were 36.1% (95% CI 30.4 - 41.8%), 30.7 (95% CI 25.2 - 36.4%), and 28.5% (95% CI 23 - 34.2%), respectively. Results of multi-variable modeling were similar to our prior analysis: male sex (HR 1.56, 95% CI 1.08 - 2.27, p =0.02); LDH above the upper limit of normal (HR 1.6, 95% CI 1.12 - 2.30, p = 0.01); ECOG status of 2-4 (HR 2.02, 95% CI 1.33 - 3.07, p = &amp;lt;0.001); and elevated bilirubin &amp;gt; 1.5 (HR 5.68, 95% CI 2.21 - 14.6, p = &amp;lt;0.001) were associated with decreased OS. Factors associated with decreased PFS included male sex (HR 1.68, 95% CI 1.20 - 2.37, p = 0.003), LDH above the upper limit of normal (HR 1.82, 95% CI 1.31 - 2.53, p = &amp;lt;0.001), ECOG status of 2-4 (HR 1.93, 95% CI 1.30 - 2.86, p = 0.001), elevated bilirubin (HR 3.68, 95% CI 1.45 - 9.37, p = 0.006) and receipt of 3 or more prior lines of therapy (HR 1.49, 95% CI 1.03 - 2.13, p = 0.032). We also assessed events of interest including late PFS events and causes of non-relapse mortality (NRM). One hundred and ninety-one PFS events occurred after axi-cel infusion during the follow-up period, 151 due to lymphoma progression and 40 NRM. In the first 12 months post infusion, 131 progression events occurred,13 between 1 and 2 years post infusion, and 7 relapses after 2 years with the latest occurring 46.4 months after infusion. Thirteen NRM events occurred in the 1st year post infusion, 6 between 1- and 2-years post infusion and 21 occurring later than 2 years after infusion. Of the 40 NRM events, 21 were secondary to infection including fungal infections (n = 3, 2 candidemia, 1 candidemia and pneumocystis jiroveci pneumonia), JC encephalitis (n=1) and COVID-19 (n = 2). Nine deaths were attributed to secondary malignancy. Other causes of NRM included cerebral edema (n=1), HLH (n=1), intracranial hemorrhage (n=1), suicide (n=1), and unknown (n=6). The 5-year cumulative risk of relapse was 55.2% and the 5-year risk of non-relapse mortality was 16.2%. Excluding non-melanoma skin cancers, twenty-three of 275 (8%) patients were diagnosed with subsequent malignancy after axi-cel treatment: 14/275 (5%) patients were diagnosed with myeloid malignancies (MDS (n=11), AML (n=2), CMML (n=1)); other malignancies included anal squamous cell carcinoma (ca) (n=1); histiocytic sarcoma (n=1); prostate ca (n=1); endometrial ca (n=1); lung ca (n=1); merkel cell ca (n = 1), mesothelioma (n=1), B-ALL (n = 1), and AITL (n=1). Conclusion This multi-center retrospective study showed similar 5-year results to the ZUMA-1 trial with a 5-year PFS and OS of 28.5% and 40.3%, despite including patients who did not meet ZUMA-1 eligibility criteria based on comorbidities. Non-relapse mortality was primarily due to infection and secondary malignancy. This report supports the curative potential of axi-cel but highlights the competing risk of NRM in this high-risk patient population.

3-Year Analysis of ZUMA-12: A Phase 2 Study of Axicabtagene Ciloleucel (Axi-Cel) As First-Line Therapy in Patients with High-Risk Large B-Cell Lymphoma (LBCL)

Background: Axi-cel is an autologous anti-CD19 chimeric antigen receptor (CAR) T-cell therapy approved for the treatment of relapsed/refractory (R/R) LBCL. ZUMA-12 (NCT03761056) is a Phase 2, multicenter, single-arm study of axi-cel as part of first-line treatment in patients with high-risk LBCL. In the primary efficacy analysis (n=37; median follow-up of 15.9 months), axi-cel demonstrated a high rate of investigator-assessed complete response (CR; 78%; 95% CI, 62-90) and an 89% objective response rate (ORR; 95% CI, 75-97). Axi-cel also had a manageable safety profile, with no new safety signals observed in the first-line setting (Neelapu et al. Nat Med. 2022). Here, we report updated efficacy and safety outcomes from ZUMA-12 in all patients treated with axi-cel after a median follow-up of ≥40 months. Methods: Eligible adults had high-risk LBCL, with MYC and BCL2 and/or BCL6 rearrangements (double- or triple-hit histology) per investigator or an International Prognostic Index (IPI) score ≥3, plus a positive interim PET per Lugano classification (Deauville score 4/5) after 2 cycles of an anti-CD20 monoclonal antibody and anthracycline-containing regimen. Patients underwent leukapheresis, followed by lymphodepleting chemotherapy (cyclophosphamide and fludarabine) on Days -5, -4, and -3, and a single axi-cel infusion of 2×10 6 CAR T cells/kg on Day 0. Per investigator discretion, non-chemotherapy bridging could be administered. The primary endpoint was investigator-assessed CR rate per Lugano classification (Cheson et al. J Clin Oncol. 2014). Secondary endpoints included ORR, duration of response (DOR), event-free survival (EFS), progression-free survival (PFS), overall survival (OS), safety, and levels of CAR T cells in blood and cytokines in serum. Results: As of May 3, 2023, 42 patients were enrolled and 40 were treated with axi-cel, with a median follow-up of 40.9 months (range, 29.5-50.2). In total, 37 patients were evaluable for response (centrally confirmed double- or triple-hit histology or IPI score ≥3). The CR rate was 86% (95% CI, 71-95), and 92% (95% CI, 78-98) of patients had an objective response. Patients with centrally confirmed double- or triple-hit histology (n=10) had a CR rate of 90%. Responses were ongoing in 73% of response-evaluable patients at data cutoff. Medians for DOR, EFS, PFS, and OS were not reached. The 36-month estimates for DOR, EFS (Figure 1), PFS, and OS (Figure 2) were 82%, 73%, 75%, and 81%, respectively. All treated patients (n=40) experienced adverse events (AEs) of any grade and 88% of patients had grade ≥3 AEs. Similar to the primary analysis, the most common any-grade AEs were pyrexia (100%), headache (70%), and neutrophil count decreased (55%). No new cases of cytokine release syndrome (CRS) or neurologic events of any grade occurred since the prior data cut and all cases of CRS and neurologic events reported were resolved by data cutoff. Prolonged cytopenias of any grade (present Day ≥30 post-infusion) occurred in 9 patients (n=7 neutrophil count decreased) and were resolved by data cutoff. There were 8 deaths due to progressive disease (n=5) and other causes not related to axi-cel (1 COVID-19, 1 esophageal adenocarcinoma, 1 septic shock on Days 350, 535, and 287 post axi-cel infusion, respectively). Two of the 8 deaths (1 progressive disease and 1 esophageal adenocarcinoma) occurred after the primary analysis. Among treated patients, post-infusion CAR T-cell expansion by peak and area under the curve was 36.9 cells/µL and 368.0 cells/µL×days, respectively, in those with ongoing responses at data cutoff (n=17), 45.1 cells/µL and 413.4 cells/µL×days in those who relapsed (n=6), and 34.7 cells/µL and 566.8 cells/µL×days in non-responders (n=3). Conclusion: In this updated analysis of ZUMA-12 with a median follow-up of ≥40 months, axi-cel demonstrated a high rate of durable responses and no new safety signals. Axi-cel may benefit patients exposed to fewer prior therapies and those with high-risk LBCL, a population with high unmet need and poor outcomes after standard first-line chemoimmunotherapy.

Impact of “Cell-of-Origin” on Outcome after Axicabtagene-Ciloleucel CAR-T Cell Therapy in Relapsed/Refractory Aggressive Non-Hodgkin B-Cell Lymphomas

Introduction: Despite significant advances in characterizing aggressive B-cell non-Hodgkin lymphomas (aNHL) based on molecular and genetic signatures, the Hans algorithm, determined by immunohistochemistry, remains the most commonly used approach to differentiate aNHLs based on the cell-of-origin (COO) into germinal center B-cell (GCB) and non-GCB types. Although the Hans algorithm has demonstrated reliability as a predictor of better outcomes in newly diagnosed GCB cases, conflicting evidence has emerged, particularly in the relapsed/refractory (R/R) setting, and there are no definitive data about the impact of COO in patients (pts) receiving CAR-T cells. Thus, we conducted a retrospective analysis to evaluate the impact of COO extended to R/R aNHLs who underwent treatment with axicabtagene-ciloleucel (axi-cel). Methods: We retrospectively collected data from pts with R/R aNHLs treated with axi-cel at Fred Hutchinson Cancer Center between February 2018 and August 2022. The Hans algorithm, using CD10, BCL6 and MUM1 markers, was employed to stratify the pts into two cohorts: GCB and non-GCB. Paired biopsies of diagnosis and relapse before CAR-T eligibility were reviewed at our institution. Response to CAR-T was assessed at one month per Lugano PET/CT criteria. Univariate cox proportional hazard regression was used to estimate associations between baseline factors and outcomes. Statistically significant factors ( p&amp;lt;.05) in univariate analysis were further evaluated by multivariate analysis. Continuous variables were compared by Mann-Whitney U test and categorical variables by Fischer's exact test. Progression-free survival (PFS) was calculated from the date of CAR-T cell infusion to the date of death from any cause, disease progression or relapse. Overall survival (OS) was calculated from the date of CAR-T cell infusion to the date of death from any cause. Results: Sixty-four pts were included in this analysis, with an equal distribution of pts in the two cohorts: 32 with GCB subtype and 32 with non-GCB subtype. Baseline pts' characteristics and histology subtypes are listed in Table 1. Transformed follicular lymphoma and primary mediastinal B-cell lymphoma were not included in this analysis. The presence of bulky disease (defined as &amp;gt;5cm diameter) was higher in the GCB subtype (56% vs 22%, p&amp;lt;.001). Although primary refractory cases were more frequent in the GCB cohort (87.5 vs 66%), statistical significance was not reached (NR)( p=.07). The same proportion of pts received bridging therapy in the two groups (53% vs 53%, p=.99). Pts evaluable for response assessment were 62. Median time to best response was 29 days (range, 21-186) for GCB pts and 31 days (range, 22-182) for non-GCB pts ( p=.91). The overall response rate was 70% for GCBs (34.5% complete response [CR], 34.5% partial response [PR]) and 75% for non-GCBs (44% CR, 31% PR). After a median follow-up of 24.5 months (range, 9-121), comparable outcomes were observed for both the COO groups: despite the estimated median OS of 14 months (95% CI, 4.73-NR) for GCB vs 40 months (95% CI, 12.55-67.46) for non-GCB, we did not find any significant differences ( p=.73) (Figure 1A). Estimated median PFS was 10 months (95% confidence interval [CI], 3.5-16) for GCB and 11 months (95% CI, 0-24) for non-GCB ( p=.57) (Figure 1B). The 2-year OS and PFS were: GCB, 45% (95% CI, 30-69) and 44% (95% CI, 29-67) respectively; non-GCB, 55% (95% CI, 38-79) and 29% (95% CI, 16-55), respectively. Treatment-related toxicities did not differ between GCB and non-GCB, with cytokine-release syndrome rates of 97% vs 94% ( p=.99) and neurotoxicity rates of 53% vs 62.5% ( p=.61), respectively. The incidence of infectious complications was 25% vs 19% ( p=.76). On univariate analysis, the impact of COO on OS (HR=0.82, 95% CI 0.39-1.73, p=.60) and PFS (HR=1.18, 95% CI 0.61-2.28, p=.62) was undetermined. After adjusting for bulky disease, elevated LDH, absolute lymphocyte count≤1000/uL, performance status≥2, &amp;gt;2 lines of therapy and response status before axi-cel infusion, the impact of COO on OS (adjusted HR [aHR]=1.73, 95% CI 0.71-4.22, p=.23) and PFS (aHR=2.01, 95% CI 0.93-4.35, p=.08), remained undetermined. Conclusion: We could not confirm an association between COO, as determined by Hans algorithm, and outcomes in R/R aNHLs who received axi-cel at our center. Prospective analyses on larger datasets and other types of CAR-T products are needed.

Factors Associated with Prolonged CRS and Neurotoxicity after Treatment with Axicabtagene Ciloleucel

BACKGROUND While chimeric antigen receptor T-cell (CAR-T) therapy has transformed the treatment of high-risk B-cell malignancies, it causes significant toxicities, specifically, cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). Most of the research to date has focused on the identification of factors associated with the peak severity of CRS and ICANS, which does not capture the duration of these toxicities. Yet protracted toxicities are observed in a subset of patients, and risk factors predictive of CRS/ICANS duration have not been reported. To address this limitation, we have previously reported the use of a novel clinical endpoint: time to CRS and ICANS (CRS/ICANS) resolution, which captures the longitudinal impact of these toxicities while allowing for censoring in the event of early deaths (Gazeau et al, TCT, 2023). Here, we applied this framework to provide the first characterization of factors associated with time to CRS/ICANS resolution in patients receiving the FDA-approved CD19 CAR T-cell product axicabtagene ciloleucel (axi-cel). METHODS Eighty-four patients (pts) treated at the Fred Hutch Bezos Family Immunotherapy Clinic with axi-cel per the FDA label outside of a clinical trial between 1/2018 and 4/2022 were included. CRS and ICANS were graded (G) using ASTCT criteria. Cause-specific Cox regression models were used to estimate associations between 60+ pre/post-infusion patient, disease-related, laboratory variables (e.g., platelet count, creatinine, PT, PTT, CRP, IL-6, fibrinogen, ferritin), and time to CRS/ICANS resolution. Endothelial Activation and Stress Index (EASIX) score was calculated at pre-/post-infusion timepoints. Time to CRS/ICANS resolution was defined as the time from axi-cel infusion left-truncated at the time of CRS/ICANS onset until CRS/ICANS symptom resolution (first day of grade 0 for at least three consecutive days), whichever toxicity happened last, censoring for death from any cause. RESULTS Baseline characteristics and toxicity outcomes are shown in Table1. The median age at infusion was 62 (range, 25-79). Histology was large B cell lymphoma in 79 pts (94%), and follicular lymphoma in 5 pts (6%). We observed any-grade CRS in 72 pts (86%) and G≥3 CRS in 7 pts (8%). Fifty-two pts (62%) developed any-grade ICANS, and 16 pts (19%) G≥3 ICANS (G1: 15 [18%], G2: 21 [25%], G3: 15 [18%], G4: 1 [1.2%]). The median time to CRS/ICANS resolution was 10 days (95%CI: 9,11). Two pts (2%) died prior to CRS/ICANS resolution. Using univariate cause-specific Cox regression, the following pre-infusion factors were associated with longer time to CRS/ICANS resolution: lower platelet count at day 0 (HR=0.41, 95%CI: 0.17-0.98, p=0.044), higher PTT at day 0 (HR=0.05, 95%CI: 0.00-0.86, p=0.039), higher preLD creatinine (HR=0.06, 95%CI: 0.01-0.50, p=0.009) and higher EASIX score preLD (HR=0.57, 95%CI:0.35-0.94, p=0.028) and at day 0 (HR=0.52, 95%CI: 0.29-0.96, p=0.035). Cumulative incidence curves of time to CRS/ICANS resolution for select predictors are shown in Figure 1B. At the time of CRS onset, a higher ferritin level (HR=0.51, 95%CI: 0.27-0.94, p=0.031) and peak CRS severity (HR = 0.73, 95%CI: 0.55-0.97, p=0.029) were associated with longer time to CRS/ICANS resolution. Higher ferritin levels over time (time dependent HR [tdHR]=0.38, 95%CI: 0.19-0.72, p=0.004), higher PTT (tdHR=0.028, 95%CI: 0.01-0.76, p=0.028), and peak ICANS severity (HR=0.58, 95%CI: 0.046, 0.72, p&amp;lt;0.001) were associated with longer time to CRS/ICANS resolution. In a multivariable Cox model after LASSO variable selection including day 0 PTT, ferritin, EASIX score, and peak CRS severity, lower day 0 platelet count remained independently associated with longer time to CRS/ICANS resolution (HR=6.96 per log10 increase, 95%CI:1.09-44.5, p=0.04; model discrimination: C-index=0.65). CONCLUSION This is to our knowledge the first study aimed at the identification of factors associated specifically with the duration of CRS and ICANS after CD19 CAR T-cell therapy. We successfully identified pre- and post-infusion factors associated with prolonged CRS/ICANS duration after CD19 CAR T-cell therapy with axi-cel. Our findings suggest that point-of-care assessments can identify patients at risk of prolonged toxicities and could guide the use of prophylactic corticosteroids or early interventions (e.g., anakinra).

Three-year follow-up analysis of axicabtagene ciloleucel in relapsed/refractory indolent non-Hodgkin lymphoma (ZUMA-5)

AbstractAxicabtagene ciloleucel (axi-cel) is an autologous anti-CD19 chimeric antigen receptor (CAR) T-cell therapy approved for relapsed/refractory (R/R) follicular lymphoma (FL). Approval was supported by the phase 2, multicenter, single-arm ZUMA-5 study of axi-cel for patients with R/R indolent non-Hodgkin lymphoma (iNHL; N = 104), including FL and marginal zone lymphoma (MZL). In the primary analysis (median follow-up, 17.5 months), the overall response rate (ORR) was 92% (complete response rate, 74%). Here, we report long-term outcomes from ZUMA-5. Eligible patients with R/R iNHL after ≥2 lines of therapy underwent leukapheresis, followed by lymphodepleting chemotherapy and axi-cel infusion (2 × 106 CAR T cells per kg). The primary end point was ORR, assessed in this analysis by investigators in all enrolled patients (intent-to-treat). After median follow-up of 41.7 months in FL (n = 127) and 31.8 months in MZL (n = 31), ORR was comparable with that of the primary analysis (FL, 94%; MZL, 77%). Median progression-free survival was 40.2 months in FL and not reached in MZL. Medians of overall survival were not reached in either disease type. Grade ≥3 adverse events of interest that occurred after the prior analyses were largely in recently treated patients. Clinical and pharmacokinetic outcomes correlated negatively with recent exposure to bendamustine and high metabolic tumor volume. After 3 years of follow-up in ZUMA-5, axi-cel demonstrated continued durable responses, with very few relapses beyond 2 years, and manageable safety in patients with R/R iNHL. The ZUMA-5 study was registered at www.clinicaltrials.gov as #NCT03105336.

Axicabtagene ciloleucel as second-line therapy in large B cell lymphoma ineligible for autologous stem cell transplantation: a phase 2 trial

Axicabtagene ciloleucel (axi-cel) demonstrated superior efficacy compared to standard of care as second-line therapy in patients with high-risk relapsed/refractory (R/R) large B cell lymphoma (LBCL) considered eligible for autologous stem cell transplantation (ASCT); however, in clinical practice, roughly half of patients with R/R LBCL are deemed unsuitable candidates for ASCT. The efficacy of axi-cel remains to be ascertained in transplant-ineligible patients. ALYCANTE, an open-label, phase 2 study, evaluated axi-cel as a second-line therapy in 62 patients with R/R LBCL who were considered ineligible for ASCT. The primary end point was investigator-assessed complete metabolic response at 3 months from the axi-cel infusion. Key secondary end points included progression-free survival, overall survival and safety. The study met its primary end point with a complete metabolic response of 71.0% (95% confidence interval, 58.1–81.8%) at 3 months. With a median follow-up of 12.0 months (range, 2.1–17.9), median progression-free survival was 11.8 months (95% confidence interval, 8.4–not reached) and overall survival was not reached. There was no unexpected toxicity. Grade 3–4 cytokine release syndrome and neurologic events occurred in 8.1% and 14.5% of patients, respectively. These results support axi-cel as second-line therapy in patients with R/R LBCL ineligible for ASCT. ClinicalTrials.gov Identifier: NCT04531046.

Bendamustine lymphodepletion is a well-tolerated alternative to fludarabine and cyclophosphamide lymphodepletion for axicabtagene ciloleucel therapy for aggressive B-cell lymphoma.

Fludarabine/cyclophosphamide (Flu/Cy) is established for lymphodepletion (LD) prior to standard-of-care CAR T-cell therapy for lymphoma. There is ongoing need to test alternative LD regimens to preserve efficacy, improve safety, and address challenges including the recent national fludarabine shortage. We retrospectively evaluated outcomes among patients with relapsed/refractory aggressive B-cell lymphoma who received bendamustine (n = 27) or Flu/Cy (n = 42) LD before axicabtagene ciloleucel (axi-cel) at our institution. The median change in absolute lymphocyte count from pre-LD to time of axi-cel infusion was -0.6×109 /L in bendamustine cohort and -0.7×109 /L in Flu/Cy cohort. The best overall response/complete response rates were 77.8% (95% CI: 57.7%-91.4%)/48.1% (95% CI: 28.7%-68.1%) among bendamustine cohort and 81.0% (95% CI: 65.9%-91.4%)/50.0% (95% CI: 34.2%-65.8%) among Flu/Cy cohort. Six-month progression-free survival were 43.8% (95% CI: 24.7%-61.3%) and 55.6% (95% CI: 39.0%-69.3%) in bendamustine and Flu/Cy cohorts, while 6-month overall survival were 81.5% (95% CI: 61.1%-91.8%) and 90.4% (95% CI: 76.4%-96.3%), respectively. Relative to Flu/Cy-treated patients, bendamustine-treated patients did not show an increase in hazards associated with experiencing progression/relapse/death (aHR:1.4 [95% CI: 0.7-2.8]; p = .32) or death (aHR:1.6 [95% CI: 0.5-5.6]; p = .46), after adjusting for baseline number of prior therapies and refractory disease. Any grade/grade ≥3 CRS were observed in 89%/3.7% and 86%/4.8% among bendamustine and Flu/Cy cohorts, while any grade ICANS/grade ≥3 ICANS were observed in 30%/19% and 55%/31% respectively. While more Flu/Cy-treated patients experienced grade ≥3 neutropenia compared with bendamustine-treated patients (100% vs. 68%), grade ≥3 infectious complications were comparable (24% vs. 19% respectively). More patients received bendamustine LD and axi-cel as outpatient than Flu/Cy cohort, without increased toxicities and with shorter median inpatient stays. In conclusion, we observed comparable efficacy and lower any grade ICANS among patients receiving bendamustine relative to Flu/Cy LD, followed by axi-cel.

The Dutch CAR-T Tumorboard Experience: Population-Based Real-World Data on Patients with Relapsed or Refractory Large B-Cell Lymphoma Referred for CD19-Directed CAR T-Cell Therapy in The Netherlands.

The real-world results of chimeric antigen receptor T-cell (CAR-T) therapy for patients with relapsed/refractory (R/R) large B-cell lymphoma (LBCL) substantially differ across countries. In the Netherlands, the CAR-T tumorboard facilitates a unique nationwide infrastructure for referral, eligibility assessment and data collection. The aim of this study was to evaluate real-world outcomes of axicabtagene ciloleucel (axi-cel) in the Dutch population, including the thus-far underreported effects on health-related quality of life (HR-QoL). All patients with R/R LBCL after ≥2 lines of systemic therapy referred for axi-cel treatment between May 2020-May 2022 were included (N = 250). Of the 160 apheresed patients, 145 patients received an axi-cel infusion. The main reason for ineligibility was rapidly progressive disease. The outcomes are better or at least comparable to other studies (best overall response rate: 84% (complete response: 66%); 12-month progression-free-survival rate and overall survival rate: 48% and 62%, respectively). The 12-month NRM was 5%, mainly caused by infections. Clinically meaningful improvement in several HR-QoL domains was observed from Month 9 onwards. Expert-directed patient selection can support effective and sustainable application of CAR-T treatment. Matched comparisons between cohorts will help to understand the differences in outcomes across countries and select best practices. Despite the favorable results, for a considerable proportion of patients with R/R LBCL there still is an unmet medical need.