Chimeric Antigen Receptor Construct Research Articles

Novel chimeric antigen receptor targets and constructs for acute lymphoblastic leukemia: Moving beyond CD19.

Acute lymphoblastic leukemia (ALL) is the second most common acute leukemia in adults with a poor prognosis with relapsed or refractory (R/R) B-cell lineage ALL (B-ALL). Anti-CD19 chimeric antigen receptor (CAR) T-cell therapy has shown excellent response rates in RR B-ALL, but most patients relapse due to poor persistence of CAR T-cell therapy or other tumor-associated escape mechanisms. In addition, anti-CD19 CAR T-cell therapy causes several serious side effects such as cytokine release syndrome and neurotoxicity. In this review, we will discuss novel CAR targets, CAR constructs, and various strategies to boost CARs for the treatment of RR B-ALL. In addition, we discuss a few novel strategies developed to reduce the side effects of CAR.

CAR-modified Cellular Therapies in Chronic Lymphocytic Leukemia: Is the Uphill Road Getting Less Steep?

The clinical development of chimeric antigen receptor (CAR) T-cell therapy has been more challenging for chronic lymphocytic leukemia (CLL) compared to other settings. One of the main reasons is the CLL-associated state of immune dysfunction that specifically involves patient-derived T cells. Here, we provide an overview of the clinical results obtained with CAR T-cell therapy in CLL, describing the identified immunologic reasons for the inferior efficacy. Novel CAR T-cell formulations, such as lisocabtagene maraleucel, administered alone or in combination with the Bruton tyrosine kinase inhibitor ibrutinib, are currently under investigation. These approaches are based on the rationale that improving the quality of the T-cell source and of the CAR T-cell product may deliver a more functional therapeutic weapon. Further strategies to boost the efficacy of CAR T cells should rely not only on the production of CAR T cells with an improved cellular composition but also on additional changes. Such alterations could include (1) the coadministration of immunomodulatory agents capable of counteracting CLL-related immunological alterations, (2) the design of improved CAR constructs (such as third- and fourth-generation CARs), (3) the incorporation into the manufacturing process of immunomodulatory compounds overcoming the T-cell defects, and (4) the use of allogeneic CAR T cells or alternative CAR-modified cellular vectors. These strategies may allow to develop more effective CAR-modified cellular therapies capable of counteracting the more aggressive and still incurable forms of CLL.

Abstract A044: Screening and characterization of CD38 chimeric antigen receptors for the development of natural killer cell-based therapies

Abstract Background: CD38 is a transmembrane protein that is often overexpressed in multiple myeloma (MM) and other hematologic cancers. The success of anti-CD38 monoclonal antibodies, like daratumumab and isatuximab, in the treatment of MM supports the potential of CD38-targeting therapy candidates in development, including chimeric antigen receptor (CAR) engineered natural killer (NK) cells. Because CD38 is expressed on normal hematopoietic cells and other tissues, it is important to assess the affinity and epitope-specificity of the CD38-targeting moiety to limit potential on-target/off-tumor toxicities. To determine how different biophysical characteristics impact CAR activity, we identified a diverse panel of CD38-specific antibodies, which were shown to display a wide range of affinities and epitopes towards CD38 and converted these clones into CARs to evaluate their expression and target-specific and non-specific activation in a high-throughput (HTP) CD38-knockout (CD38 KO) Jurkat screen. Methods: Antibodies against CD38 were identified through hybridoma screening. Humanized mice were immunized with the extracellular domain of CD38, and lymphocytes from lymph nodes were fused with SP2/0 cells to generate hybridoma cells. Supernatants from single cell sorted hybridoma clones were screened against CD38+ and CD38 KO Jurkat cells and were assessed for affinity and epitope via surface plasmon resonance detection with the Carterra LSA. 96 unique clones were converted into CARs and transduced into CD38 KO Jurkat cells. CAR-expressing Jurkat cells were assayed for CAR expression and activation (via CD69 expression) when cultured overnight in the presence or absence of MM.1R target cells. Seven CARs were selected for additional characterization in primary NK cells. NK cells from healthy donors were expanded on our proprietary NKSTIM cell line, knocked out for CD38 using a CRISPR-Cas system, and transduced with CD38 CAR constructs. CD38 CAR NK-mediated cytotoxicity against MM.1S target cells was assessed by IncuCyte® S3 live cell analysis system. Results: Hybridoma screening identified many unique CD38-specific antibodies, displaying a wide range of affinities and epitopes towards CD38. Despite these biophysical differences, many of these antibodies, when converted to CARs, confer target-specific activity. Multiple epitopes on CD38 may be targeted and even low affinity antibodies were sufficient for target-specific CAR activation. Furthermore, the seven selected CAR candidates that were expressed in CD38 KO donor NK cells displayed potent in vitro target cell killing against MM.1S target cells. Conclusions: In summary, we have identified and characterized a range of CD38-specific antibodies. When converted into CARs, these targeting moieties mediate target-specific activation, despite differences in CD38 epitope and in affinity, demonstrating the utility of HTP CAR screening. Moreover, expression of the top seven CAR candidates in CD38 KO NK cells resulted in potent target cell killing, supporting further pre-clinical evaluation in relevant models. Citation Format: Emily N Kang, Jacinda T Chen, Bing Li, Kate Jamboretz, Nitin Patel, Daniel Bedinger, Kyle T Pratt, Jessica Hsieh, Luxuan TE Buren, Chao Guo, Ivan Chan, James B Trager, Sasha Lazetic. Screening and characterization of CD38 chimeric antigen receptors for the development of natural killer cell-based therapies [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Tumor Immunology and Immunotherapy; 2023 Oct 1-4; Toronto, Ontario, Canada. Philadelphia (PA): AACR; Cancer Immunol Res 2023;11(12 Suppl):Abstract nr A044.

Improving Anti-Tumor Efficacy of CAR T-Cell Therapy for Acute Myeloid Leukemia (AML): Results from a Multi-Drug Interaction Screening Approach

Background: Acute myeloid leukemia (AML) is a hematopoietic malignancy characterized by uncontrolled proliferation and impaired differentiation of myeloid progenitor cells. With a 5-year overall survival of approx. 30%, the prognosis of patients with acute myeloid leukemia remains poor, in particular for those with relapse or refractory disease. The adoptive transfer of T-cells genetically modified to express a chimeric antigen receptor (CAR) have shown impressive remission rates in patients with B-cell lymphoid malignancies. In contrast, CAR T-cell therapy for AML has induced durable remission only in a minority of patients so far, highlighting the need for strategies to improve anti-tumor efficacy and persistence of AML-specific CAR T-cell products. Adapting an established high throughput screening platform, we aimed to identify compounds with the potential to enhance CAR T-cell mediated cytotoxicity through interaction with tumor and/or CAR T-cells. Methods: We established a high throughput platform to determine the cytotoxicity of four different AML-specific CAR T-cell products targeting CD33 (CD33.CD28.41BB.zeta), CD70 (CD27.zeta), CLL1 (CLL1.CD28.zeta) and EMR2 (also known as ADGRE2; EMR2.41BB.zeta) in the presence of 32 compounds at five different concentrations in a 10,000-fold concentration range. CAR T-cells were generated by transduction of activated T-cells derived from peripheral blood mononuclear cells (PBMCs) of three healthy donors with a gamma retroviral vector containing the different CAR constructs. On day 11 after activation, CAR T-cells and non-CAR-transduced control T-cells were incubated with luciferase-expressing target cells at an effector-target ratio of 1:4 in 384-well plates. Viability of target cells cultured with CAR T-cells, control T-cells or in the absence of T-cells was calculated after 24 and 48 hours using a luciferase signal intensity assay. Combinatorial toxicities were calculated with the Bliss Independence model for synergistic effect and the highest single agent model for additive combination effect. Results: In quality analysis, the intensity of luminescence signals in control wells (tumor only, non-CAR-transduced control T-cells) of different plates was similar and principal component analysis (PCA) of samples derived from different days (batches) did not show significant differences ruling out relevant edge or batch effects that could negatively impact the screening results. Of all tested compounds birinapant, a peptidomimetic of second mitochondrial-derived activator of caspases (SMAC) and inhibitor of apoptosis protein (IAP) family proteins and the hypomethylating agent (HMA) decitabine showed the strongest improvement of CAR T cell cytotoxicity in an additive but also in a synergistic manner. These effects were evident in CAR T-cell products derived from all different T cell donors without significant differences. Depending on the structural composition of the CAR construct, the strongest drug-induced improvement of CAR T-cell cytotoxicity was seen either after 24 or 48 hours. The third generation CAR T- cell construct (CD33.CD28.41BB.zeta) showed enhanced cytotoxicity already after 24 hours, whereas significant anti-leukemic efficacy of CD27.zeta, CLL1.CD28.zeta and EMR2.41BB.zeta CAR T-cells became evident at the later 48 hours timepoint. Importantly, co-treatment with birinapant and decitabine particularly enhanced the cytotoxicity of EMR2-specific CAR T-cells which exhibited the lowest baseline anti-tumor efficacy compared to all other CAR constructs highlighting the potential of distinct chemical compounds to improve the functionality of AML-specific CAR T-cells. Conclusion: Our data suggest that high throughput drug interaction screens are a reliable approach to investigate the impact of chemical compounds on the functionality of AML-specific CAR T-cell products. HMA and SMAC mimetics are promising candidates that may potentially enhance the cytotoxicity of CAR T-cells. Ongoing studies are evaluating the effect of HMAs and SMAC mimetics on CAR T-cell proliferation and anti-tumor efficacy against AML cell lines and primary AML patient samples upon serial antigen stimulation. Furthermore, in-depth proteogenomic characterization to identify molecular signatures of enhanced functionality are currently being performed.

Development of a Regulated, Optimized Mesothelin Chimeric Antigen Receptor (CAR) for the Treatment of Mesothelin Positive Cancers

Introduction: Mesothelin (MSLN) is an attractive target for chimeric antigen receptor T cell (CAR-T) immunotherapy as it is highly expressed on mesothelioma, ovarian, lung cancer, and some forms of leukemia, including approximately 30% of acute myeloid leukemia (AML); however, MSLN directed CAR-T cells are prone to exhaustion, and soluble proteins, such as shed MSLN and MUC16 can inhibit anti-tumor efficacy. To address these deficiencies, we developed a novel, fully-human MSLN-specific CAR using our OutSpacer™ technology to optimize the immune synapse geometry. Further, this MSLN CAR is expressed using a novel regulatory response element to dynamically express the CAR molecule to enhance CAR-T potency and durability. Methods: A set of fully-human single domain binders (VHH) were produced and screened against a spacer library to identify high-performing CARs. The spacer library is composed of human extracellular polypeptides selected for optimal biophysical properties (e.g., flexibility), enabling systematic sampling to identify CAR constructs with optimal immune synapse geometry. More than 300 MSLN-directed CAR candidates were evaluated in vitro using 2D or 3D (spheroid) culture assays to measure tumor killing and cytokine production against several MSLN + cell lines that express different levels of the target protein. These functional assays were also performed in the presence of recombinant MSLN (10ug/mL) or MUC16 (1ug/mL) to assess potential inhibition by shed target or ligand. Top performing MSLN CARs were subsequently tested in NSG mice (2e6, 4e6 and 8e6 cells/animal; 2 donors) subcutaneously engrafted with MSLN + H1650 tumor cells to identify the best CAR candidate. To further improve the durability of T cell response, the MSLN CAR was expressed under the control of an engineered promoter (OP1) to dynamically regulate expression, and compared to CARs expressed constitutively using the MND promoter. CAR-T cells were repetitively stimulated (4x) by plate-bound antigen in combination with CD58 and ICAM1, and subsequently tested in a tumor spheroid assay for killing, cytokine production, CAR expression and T cell activation/ exhaustion markers (i.e., PD-1, TIGIT, CD39 and TIM3). Results: Anti-MSLN VHH domains targeting region 1 or 3 (RI and RIII) of the MLSN extracellular domain were paired with a defined spacer library to define the optimal immune synapse. Contrary to the conclusions of prior studies, RI (membrane-distal) binders outperformed RIII (membrane-proximal) binders when paired with their optimal spacer. Based on tumor killing and cytokine production, RI targeted CARs preferred a spacer length of approximately 75 Å, consistent with our previously-reported optimal CAR synapse of ~200 Å. All spacer optimized MSLN-specific CARs resisted inhibition by soluble MSLN and MUC16. In vivo studies with two donors in NSG mice engrafted with MSLN + tumors showed that one CAR (B8S8) eliminated tumors at a dose of 2e6 and 4e6 CAR-T cells per animal, where other CAR constructs, including a clinically-used MSLN-specific CAR, failed to control tumors even at 8e6 cells per animal. Secondly, we assessed whether a novel “stim-on” promoter (OP1) could enhance CAR-T activity by preserving T cell function. Here, B8S8 CAR was expressed via OP1 or the constitutive MND promoter (n=3 donors). Following chronic antigen exposure by plate-bound antigen, OP1 regulated MSLN CAR T cells retained the capacity to eliminate MSLN + H226 tumor spheroids compared to MND-driven CAR T constructs. OP1-regulated CAR T cells also continued to produce high levels of cytokines (IFN-γ and IL-2) whereas MND CAR-T cells lost cytokine production ability. Further, phenotypic analyses showed that MND CAR-T cells expressed elevated levels of PD-1 and TIGIT compared to OP1 CAR-T cells. Conclusions: Contrary to the conclusions of prior studies with MSLN-targeted CARs, membrane distal epitopes were superior to membrane proximal epitopes when binders were paired with the correct spacer, and shed MSLN and MUC16 were not inhibitory for the best-performing CARs, regardless of target epitope. Furthermore, regulated expression enhanced the potency and durability of response compared to constitutive expression. This approach may improve CAR activity in patients with MSLN + solid tumors or leukemia.

Development of Novel Lipid Nanoparticles and Virus-like Particles for In Vivo Engineering of Immune Cells for Targeted Cancer Therapy

Recent progress in genetic and cellular engineering has revolutionized medicine and cancer care, offering new avenues for effective treatments and potential cures. However, the success of these therapies depends on safe and efficient delivery of therapeutic molecules to target cells. Despite challenges, viral delivery methods remain the gold standard because the lack of alternative non-viral approaches matching their efficiency and safety. Here, we developed and tested two different targeted engineered non-viral therapeutic vehicles with the goal to perform in vivo immune cell engineering to specifically engineer T cells, natural killer (NK) cells or macrophages to express chimeric antigen receptors (CARs) to mediate improved anti-tumor activity. These studies developed cell-targeted mRNA-lipid nanoparticles (LNPs) and cell-targeted mRNA-viral-like particles (VLPs). The LNPs are targeted using cell-type specific antibodies conjugated to the LNP, whereas the VLPs are targeted to specific immune cells by engineered expression of designed ankyrin repeat proteins (DARPins). Using the ab-LNPs approach, human T cell line (Jurkat) were transduced at 80% with an anti-CD3 vector, the NK cell line (NK92) at 75% with an anti-NKp46 vector, and macrophages at 85% with an anti-CD14 vector. In contrast, there was little non-specific expression in each cell type using naked (non-targeted) LNPs, ensuring specificity. We were also able to specifically engineer and target the VLPs using several times lower concentrations (MOI=1-5) than what is typically used for intact viral transduction. Here, Jurkat cells were transfected at 15% with the anti-CD3 vector, NK92 cells at 20% with the anti-NKp46 vector and macrophages at 60% with the anti-CD14 vector. Testing ab-LNPs in human PBMCs, 1mg of anti-CD3-LNPs transduced the 90% of T cells, the anti-NKp46-LNPs transduced the 20% of NK cells, and the anti-CD14-LNPs transduced the 65% of monocytes, with all of them showing little or non-expression in all other cell lines. Using targeted-VLPs to engineer PBMCs, anti-CD3 vector transduced T cells at 20%, anti-NKp46 transduced NK cells at 20%, and anti-CD14 transduced monocytes at 50%, with low levels of non-specific expression in other cell types. Testing the capacity of our new guided engineered therapeutic vehicles to increase the potential of specific immune cells to kill tumor cells, we co-cultured the different immune cells (T cells, NK cell and macrophages) transduced with our therapeutic vectors (either targeted-VLPs or ab-LNPs) to express an anti-mesothelin (meso) CAR construct. These engineered cells were tested against meso-expressing A1847 ovarian cancer cells. All the immune cells increase their capacity to kill ovarian cancer cells by 2 to 7 times in a standard cytotoxicity assay (Figure 1A and 1B). To assess the in vivo transduction capability of our novel therapeutic delivery vehicles, we are using both immunocompetent B6 mice (for LNPs) and humanized immunodeficient NSG mice (for human VLPs). Our initial studies using targeted-VLPs for in vivo cell engineering demonstrated impressive efficiencies ranging from 15% (for NK cells) to 65% (for T cells). We are currently doing similar in vivo studies to test the efficiency of ab-LNPs. Next, we will translate these promising results to an in vivo ovarian cancer mice model to engineer endogenous immune cells to directly express CARs, as new strategy to overcome the current problems of cell and gene therapies, starting by develop an effective and safety therapy for treatment of diverse refractory malignancies.

Targeting B-Cell Malignancies with Anti-ROR1 CAR T-Cell Therapy

Anti-CD19 chimeric antigen receptor (CAR) T cell therapy has been shown to induce high complete response rates in the majority of B-cell lymphoma patients. However, over 50% of patients relapse within one year. A major cause of failure appears to be due to loss of CD19 expression on the tumor cell surface. This indicates that novel therapeutic strategies are still needed in clinic. Receptor tyrosine kinase like orphan receptor 1(ROR1) is an oncofetal receptor for Wnt5α that is expressed in multiple embryotic tissues but absent in virtually all adult tissues. However, ROR1 is expressed at high levels in chronic lymphocytic leukemia (CLL), mantle cell lymphoma (MCL), diffuse Large B-Cell Lymphoma (DLBCL), and several solid tumors. The high expression level of ROR1 in tumor cells is associated with adverse clinical prognosis. In addition, a small percentage of cancer cells with characteristics of undifferentiated leukemia cells or cancer stem cells were found to overexpress ROR1. Using hybridoma technology, we generated an anti-ROR1 monoclonal antibody that specifically recognized ROR1 protein. The antibody bound to ROR1-expressing MCL cell lines but not to normal donor T cells, B cells, or monocytes, indicating the specificity of the antibody. Lentiviral transduction of a CAR molecule derived from the anti-ROR1 antibody into primary human T cells redirected their specificity against B-cell lymphoma cell lines. We found the anti-ROR1 CAR T cells specifically lysed B- cell lymphoma tumor cells at high efficiency but not normal B cells. At an effector: target ratio of 1:1, the anti-ROR1 CAR T cells lysed over 95% of B-cell lymphoma tumor cells during 3-days of coculture. To determine the optimal CAR construct, we evaluated various hinge transmembrane, and costimulatory domains in the CAR molecule. We found that incorporation of the CD28 hinge and transmembrane domain in the CAR construct dramatically enhanced the in vitro lysis efficiency of anti-ROR1 CAR-T cells. In conclusion, we developed a novel and potent anti-ROR1 CAR T-cell therapy product that may be used for treatment of various B-cell malignancies and ROR1-expressing solid tumors.

Targeting Normal Myelopoiesis Negatively Affects CAR T Cell Activity

Chimeric antigen receptor (CAR) T cells have not been successful for the treatment of acute myeloid leukemia (AML) to date, and the reason for this is not clear. While CAR T cells have been traditionally studied as independent agents targeting tumor, in reality they work in the context of the endogenous host immune system, which may influence outcomes of therapy. We hypothesized that targeting normal myelopoiesis is detrimental to CAR T cell activity, and this creates a unique obstacle to effective CAR T cell therapy for AML. We generated prototypical CAR T cells targeting B cell (CD19) and myeloid (CD33) antigens, using a standard 2 nd generation CAR design with 4-1BB and CD3ζ costimulatory domains. In parallel we created tumor cell lines expressing both targets by adding CD33 expression to a CD19+ B cell line (Ramos +33), and by adding CD19 expression to a CD33+ myeloid cell line (THP1 +19). For ease of tracking tumor cells were labeled with GFP, and CAR T cells were labeled with RFP. CD19-targeting CAR T cells (CART19) and CD33-targeting CAR T cells (CART33) exhibited similar anti-tumor activity in standard in vitro cytotoxicity assays and in vivo NSG mouse models. We then proceeded to add PBMCs to CAR T cell and tumor co-culture and measured tumor cell clearance and CAR T cell expansion using flow cytometry and the Incucyte Live-Cell analysis system. Addition of PBMCs enhanced the tumor clearance and CAR T cell expansion of both CART19 and CART33 in short-term co-culture assays (7-10 days). Fractionation of PBMCs revealed that CD33+ classical monocytes were able to replicate the effect of PBMCs, while the presence of CD19+ B cells did not have any effect. Monocytes are viable in vitro for less than 7 days. To assess the long-term effects of monocytes on CAR T cells, we performed serial replating assays, in which fresh tumor cells and monocytes were added to CAR T cells every 7 days. Ongoing monocyte support further improved CART19 expansion and tumor clearance. However, the continuous presence of monocytes was detrimental to CART33 activity upon serial replating, as evidenced by suboptimal T cell expansion and loss of tumor control. To study the effects of normal myelopoiesis on CAR T cell activity in vivo, NSGS mice (NOD/SCID/IL2Rg null mice with human SCF, IL-3 and GM-CSF expression) were injected with human cord blood CD34+ cells to engraft human hematopoiesis. Mice were then injected with THP1 +19 tumor cells, followed by administration of untransduced (UTD) control T cells, CART19 or CART33. To prevent the confounding effect of allogeneic killing, CAR T cells were generated from the same cord blood product as the CD34+ cells. Consistent with our in vitro data, CART19 and CART33 showed better anti-tumor activity in the presence of human hematopoiesis. Notably, while the anti-tumor activity of CART19 and CART33 was equivalent in non-humanized mice, CART19 had better long-term activity in humanized mice, as mice treated with CART33 had late tumor relapses. To directly compare the effects of myeloid cells as bystanders versus targets, we lentivirally transduced cord blood CD34+ cells with human CD19 so that they would be targets for CART19. We then differentiated these cells into myeloid progenitors (MP) by culturing in IMDM with 20% FBS and the following cytokines: SCF (100ng/ml), FLT3L (50ng/ml), IL-3 (10ng/ml), and GM-CSF (10ng/ml). After 10 days of culture >95% of MP expressed CD33, and were selected for >95% CD19 expression (Fig A). Addition of non-transduced MP to CAR T cell and Ramos +33 co-culture enhanced CART19-mediated tumor clearance without affecting CART19 expansion. However, the presence of MP CD19+ had a detrimental effect on both tumor control and expansion of CART19, confirming that CAR T cells are less effective when targeting myeloid cells. In contrast, both MP and MP CD19+ had similar effects on CART33 that mirrored the negative effects of MP CD19+ on CART19 (Fig B). To summarize, we show that normal myeloid cells have beneficial effects on CAR T cell function, and targeting these same myeloid cells is detrimental to CAR T cell activity. These findings provide insight into the reason for suboptimal CAR T cell activity in AML, and show that independent of target antigen and CAR construct, the nature of the cells being targeted can change the effectiveness of this therapy.

CD28 CAR T Cells for the Treatment of T Cell Malignancies

CONCLUSION While synthetic immunotherapy has been introduced into the standard of care treatment of patients with B-lineage malignancies, patients with T-lineage malignancies have not gained benefit from this novel approach, yet. The main reason is the challenging choice of target antigen in T-lineage malignancies such as pediatric T cell acute lymphoblastic leukemia (T-ALL). As activating mutations of CD28 have already been described in T cell malignancies, we set out to quantify surface expression of CD28 and other costimulatory molecules on primary pediatric T-ALL samples and explore the utility of this functionally relevant molecule as a novel target antigen. Bone marrow (BM) samples of pediatric T-ALL patients (n=54) at time of diagnosis and healthy control individuals (n=14) were collected. We quantified surface expression of CD28 and 25 additional co-stimulatory or co-inhibitory molecules by flow cytometry after gating on T cell precursors (living singlets, CD45 dim/SSC-A low and CD7 +). Subsequently, we generated a set of 20 CD28 directed second-generation chimeric antigen receptors (CARs) based on five different monoclonal antibodies with variation in hinge domain and light chain / heavy chain chronology. We analyzed specific CAR activity against CD28 expressing T-ALL cell lines after retroviral transduction into primary human T cells. Additional CD28 knockout (KO) by CRISPR/Cas9 could prevent T cell fratricide. CAR constructs were subjected to in vivo testing in a T-ALL NSG mouse model with transplantation of 7.5e4 CCRF-CEM cells transduced with firefly luciferase on day 0 and transfer of 2.5e6 CD28 KO T cells on day 3 harboring either of both CD28 CAR molecules. We used CD7 CAR T cells as positive control, CD19 CAR T cells and CD28 KO T cells without CAR as negative controls. We observed significant upregulation of CD28 on T-ALL leukemia when compared to healthy BM donors (Figure 1A, mean 68.8% vs. 3.7%, p=0.0002). We confirmed upregulation of CD28 in published T-ALL RNA-expression data sets. Interestingly, other co-stimulatory molecules such as CD127 were upregulated, too (mean 50.0% vs. 14.6%, p=0.0001), while co-inhibitory molecules such as CD160, TIGIT and TIM-3 were strongly downregulated (>10fold and p<0.0001 each). We hypothesized that this could imply a functional relevance of CD28 in T-ALL. Therefore, we performed co-culture assays of monocyte derived dendritic cells (CDs) expressing CD28 ligands CD80 and CD86 with different T-lineage leukemia cell lines. The presence of DCs significantly increased proliferation of CD28 + T-ALL cell lines under stress conditions. In order to test the feasibility of CD28 CAR T cells, we generated CD28 KO primary T cells without CAR. When tested in co-culture assays with leukemia cells and T cell engagers, CD28 KO T cells showed unchanged cytotoxic capacity and target-dependent activation illustrating that CD28 KO T cells retain short-term effector functions. Based on cytotoxic capacity and CAR T cell expansion, we identified two lead CD28 CAR candidates out of a pool of 20 CD28 CARs. After CD28 KO, CD28 CAR-T cells showed in vitro expansion comparable to CD19 CAR T cells. Next, we asked how CD28 CAR T cells compare to CD7 CAR T cells, which are currently evaluated clinical trials for T-ALL therapy. Therefore, we generated CD7 KO T cells that were subsequently transduced with a functional CD7 CAR. In vitro, both CD28 CAR T cells and CD7 CAR T cells showed killing of CD28 +CD7 + CCRF-CEM cells of >90% at an effector:target (E:T) ratio of 0.2:1, with CD7 being outperformed by one of the CD28 CARs while outperforming the other CD28 CAR at an E:T ratio of 0.04:1 (Figure 1B). Finally, we went on to validate the functionality of CD28 CAR T cells in vivo. We observed significantly prolonged survival of mice treated with CD28 CAR T cells and CD7 CAR T cells when compared to CD19 CAR T cells or control T cells. No difference in survival between CD7 and CD28 CAR T cell treated mice could be observed in two independent experiments. We identify CD28 as novel target antigen for pediatric T-ALL and provide evidence that CD28 is an immunotarget with functional relevance for T-ALL. We demonstrate the feasibility of CD28 CAR T cell generation and that these novel CAR T cells perform equally well as CD7 CAR T cells both in vitro and in vivo. Novel and functionally relevant CAR targets will facilitate clinical development of immunotherapy for T-lineage malignancies.

Disinhibition of T Cell Activation Via CD5 Knockout Is a Universal Strategy to Enhance Adoptive T Cell Immunotherapies

Introduction: Adoptive cell therapies (ACT) are currently revolutionizing cancer treatment. In particular, chimeric antigen receptor (CAR) T cells have demonstrated unprecedented responses against aggressive B cell malignancies with six FDA-approved products either targeting CD19 or BCMA. Other strategies for solid cancers such as T cell receptor (TCR)-redirected or tumor infiltrating T cells will soon become commercially available for melanoma and other cancers. However, despite this exciting new wave of ACT, the majority of patients will ultimately fail treatment, even in the most potent products such as CART19. One key mechanism of failure is the inability of adoptively transferred T cells to fully activate and function in the tumor bed. Thus, there is a dire need to develop effective strategies to enhance T cell activation to improve long-term responses in patients. Most of the current strategies are focused on reducing T cells' exhaustion, but another avenue is to study early T cell activation as a key step for long-term efficacy. We sought to define a broadly applicable strategy to disinhibit T cell activation by focusing on CD5, a transmembrane protein shown to negatively regulate T cell activation and proliferation through mediators such as SHP-1, CBL, and CBL-B ( Fig. 1A). We previously presented the preliminary preclinical results of CD5 knocked out (KO) anti-CD19 CAR T cells (CART19) ( Blood (2020) 136 (Supplement 1): 51-52.) and demonstrated how CD5 KO dramatically increased T cell proliferation and enhanced tumor control. Here, we translate this effect to enhance ACT in multiple models including CAR T and TCR-redirected cells. We also compared early disinhibition of T cell activation (CD5 KO) compares with the highly studied PD1 KO to assess the translational potential of this strategy. Methods and Results: We initially tested CD5 KO CAR T cells in a model of pancreatic ductal cancer adenocarcinoma (PDAC; AsPC1 cell line). We deleted CD5 in anti-mesothelin CART cells (CARTmeso) using a clinically relevant CAR construct (M5 clone) (NCT03054298). CD5 KO CARTmeso cells demonstrated enhanced tumor control (by both tumor volume and bioluminescence) and prolonged overall survival ( Fig. 1B). As observed in the CART19 model, CD5 KO T cells showed increased expansion and persistence. Furthermore, CD5 KO CARTmeso cells established prolonged immune memory, as long-term surviving mice cleared rechallenged tumors (day 74). To study the effects of CD5 KO in TCR-redirected cells, we generated TCR α constant (TRAC) KO T cells further transduced with TCR-GP100 lentivirus and compared these to cells with a double KO of both TRAC and CD5 using the GP100+ melanoma cell line DM6. TRAC CD5 KO TCR-GP100 cells showed significantly reduced GP100+ DM6 tumor growth in vitro when compared to TRAC KO TCR-GP100 cells using a live imaging system, suggesting that CD5 KO could enhance the efficacy of adoptive T cell therapies as a whole. Immune checkpoint inhibitors targeting the PD1:PDL1 axis are routinely used in the clinic. More recently, deletion of PD1 in adoptively transferred T cells has shown feasibility in the clinic and there are currently over 30 clinical trials testing PD1 KO or inhibition in CART therapy for cancer. We, therefore, aimed to compare this established strategy to reduce T cell exhaustion with the disinhibition of early CART activation with CD5 deletion. To this goal, we used a clinically relevant sgRNA to knock out PD1 from CART19 cells and compared this to Mock and CD5 KO CART19 cells against CD19+ Nalm6 B-ALL cells in vivo. In a challenge dose model, PD1 KO CART19 were unable to enhance CART efficacy, while CD5 KO CART19 cells maintained strong tumor control that correlated with increased overall survival. We further compared CD5 versus PD1 KO CARTmeso in an in vivo solid tumor model of mesothelin+ PDAC. CD5 KO CARTmeso cells demonstrated enhanced tumor control and stronger response rates as determined by tumor volume and bioluminescence imaging. This increased tumor control allowed for enhanced survival that is likely explained by the significantly increased T cell count in CD5 KO CARTmeso-treated mice. Conclusion: In conclusion, this study demonstrates that CD5 is a negative regulator and possible novel immune checkpoint for adoptive T cell immunotherapies. We show that CD5 deletion leads to the enhancement of ACT anti-tumor function in several clinically relevant models of liquid and solid tumors.

Gp350-Targeted CAR-T Therapy in EBV-Positive NK/T-Cell Lymphoma: Pre-Clinical Development of gp350CAR-T

Introduction: Epstein-Barr virus (EBV) positive NK/T cell lymphoma is a subtype of non-Hodgkin's lymphoma strongly associated with EBV infection. EBV infection has been reported in 85-100% of cases. It has been suggested to be central in pathogenesis. The incidence of EBV+ NK/T cell lymphoma is increasing worldwide, particularly in Asia and Latin America, and it has a poor prognosis with few effective treatment options. Therefore, novel approaches for treating EBV-associated NK/T cell lymphoma are urgently needed. Developing chimeric antigen receptor (CAR)-T cells therapy targeting EBV specific protein in the context of this EBV-positive aggressive lymphoma will provide a novel therapeutic strategy for patients with limited treatment options. Targeting EBV lytic protein for control EBV in vivo replication and tumorigenesis have been explored lately. The gp350 protein is a major glycoprotein on the surface of EBV during its lytic phase, after fusion between virus and host cell membrane, gp350 is left on the host cell surface. The distinct surface distribution pattern of gp350 in both freshly infected host cells and the lytic phase host cells renders it an attractive target for immunotherapy. Method and Result: We developed EBV specific CAR-T cells targeting gp350. We utilized single-chain variable fragments (scFvs) derived from four novel, gp350-binding, neutralizing monoclonal antibodies (mAbs) (12C10, 7D11, 6A12, 7A8) to generate the CAR constructs. We demonstrated that these scFvs, when fused to a second-generation CAR backbone consisting of 4-1BB and CD3ζ signal domains, are efficiently expressed on the surface of transduced T cells. These gp350 CAR-T cells exhibit specific activation and cytotoxic effects in vitro. Of note, the clone 6A12 scFv of CAR displayed the most potent cytotoxicity effects in gp350 positive cancer coculture toxicity assays. To optimize the CAR structure further, we designed various linker and transmembrane domains based on the clone 6A12 scFv, including CD8 linker, IgG4 hinge, IgG1 Fc linker, and CD28 linker and transmembrane domains. Our cytotoxicity assay screening indicated that the CD8 linker and transmembrane domain resulted in the most advanced cytotoxicity and target specificity (Figure A, B). To assess gp350 CAR-T efficacy in vivo, we established a T-cell leukaemia animal model in NOD immune-deficient mice through intravenous injection of Jurkat-gp350-luc cells. On post xenograft day 7, the Jurkat-gp350-luc xenografted mice were separated into three groups and each group with 5 mice (except PBS group with 2 mice). CAR-T and T cell were infused by tail vein injection with mock T 2x10^6/mouse, 6A12CAR-T 2x10^6/mouse and PBS control. The tumor growth in mice was monitored by in vivo luminescence with IVIS imaging system. Upon engraftment, Jurkat-gp350-luc cells established disseminated leukaemia expanding preferentially in the spine, femur, head, and pelvis, with few cells in peripheral blood. Mice receiving control mock T cells or without T cell PBS control developed rapid disease progression and were euthanized by day 35 after Jurkat-gp350-luc engraftment. In contrast, mice receiving gp350 CART cells were significantly protected from rapid progression (Figure C, D). Conclusion: In pre-clinical development, we designed, constructed, and screened gp350 CAR-T cells to demonstrate its efficacy in vitro and in vivo against and kill gp350 positive leukaemia cells and prevent formation and development leukaemia in xenograft mice model.

Chimeric Antigen Receptor T Cell Therapies Clinical Trials in Pediatric Oncology: A Retrospective Analysis from Clinicaltrials.Gov

Background: Chimeric Antigen Receptor (CAR) T-cell clinical trials are growing exponentially. Database analysis can help identify scientific trends and generate projections regarding potential approvals before the results of the studies are completed or published. This is particularly interesting in pediatric oncology, where available analyses from repository databases are scarce or not available. Because of that reason, we sought to analyze the clinical trial public records from entries related to CAR T-cell clinical studies in pediatric patients (18 years or younger) uploaded to the clinicaltrials.gov database. Methods: We query the available data from clinicaltrials.gov using the following keywords: “CAR T cell in pediatrics”, “CAR T cell and cancer”, “chimeric antigen receptor”, “CAR T AND tumor antigen”, 'CAR T cell antigens“, ”Tumor antigens targeted by CAR T cells“, ”engineered T cells“, ”modified T cell“, ”CAR T cells in Cancer“, ”CAR T cell therapy“, ”CAR T cell therapy AND Cancer“ (data cut off July-2023). The data were tabulated, and the trials that did not meet the search criteria were excluded manually. Data cleansing was performed using published scientific data, web search-based information, and patent databases. Results: We found 4297 results in the Clinicaltrials.gov platform; we excluded 3978 clinical trials that did not involve the pediatric population (<18 years) or CAR T-cell intervention. The final analysis included 319 clinical trials posted on the clinicaltrials.gov website by the cut-off date. 207 (64.9%) were conducted in China, 74 (23.2%) in the US, and 21 (6.5%) in Europe. Most CAR T-cell trials focused on hematological cancer (89%), followed by non-CNS solid tumors 8%, and CNS tumors 3%. The most frequent targets were CD19 (46%), CD7 (7%), followed by GD2, CD22, CD123, CD19 + CD22 and CD30. Most clinical trials did not report the construct generation used in their CAR T cell product (58%). Among the trials with that information, second-generation constructs (2G) were used in 32% of the studies, followed by 3G and 4G constructs (5% of studies each). Most clinical trials were in early stages of development, Phase 1 or 2 (75%). We observed a continuous increase in the number of clinical trials registered yearly, except for a small reduction in 2022 and 2021, probably related to COVID restrictions and challenges. Overall, the general trend predicts at least a 50% yearly increase in registered studies ( Figure 1). Similarly, to what is observed in adult clinical trials, the most common signaling domains are 2G CAR constructs expressing either CD28 or 4-1BB as costimulatory domains. Among those, 4-1BB being is the most popular choice. Conclusion: Our findings indicate a growing interest in the clinical development of CAR T-cell therapies applied to pediatric oncology. Most of these studies are in early phase I and II and focus primarily on hematological cancers using second-generation constructs targeting CD19. The is a steady increase in the number of studies registered each year that predicts future FDA approvals using CAR T-cell products.

EXTH-02. A TERT-SPECIFIC TCR-LIKE ANTIBODY CAR T CELL APPROACH FACILITATES KILLING OF GLIOBLASTOMA

Abstract Glioblastoma (GBM) is a difficult form of brain cancer to treat as GBM cells utilize various strategies to evade host immune responses. Prior studies have shown autologous cytotoxic T cells (CTL) modified to express chimeric antigen receptors (CAR) facilitating host CTL responses against cancers. This study investigates the ability of T-cell receptor (TCR)-like antibody clones against TERT to facilitate specific CAR T cell mediated killing of GBM. Lentiviral vectors were created for five TCR-like antibody CAR constructs recognizing an HLA-A*02:01-restricted TERT-derived antigen. Nur77-GFP Jurkat reporter cell lines and 3 healthy donor-derived CTLs transduced with these vectors were used in flow-based and in vitro killing assays to assess specificity and functionality. K562 cells that did, and did not, express HLA-A*02:01 were targets in the flow-based assay. Flow cytometry captured activation of transduced Jurkat cells via GFP and CD69 upregulation. Three luciferase-transduced GBM cell lines were targets in the cytotoxic killing assay and visualized via bioluminescence imaging (BLI). Increased GFP and CD69 expression was seen on Jurkat cells transduced with clones 3A12 and 3H2 only when co-cultured with TERT antigen and A*02 positive K562 suggesting specific recognition of the TERT:HLA complex. Furthermore, healthy donor-derived CTL transduced with 3A12 and 3H2 CAR constructs demonstrated in vitro killing of tumor cells by BLI. Interestingly, the 3H2 construct only showed cytotoxicity in the presence of exogenous TERT antigen. However, when the heavy and light chains of the 3H2 clone were flipped in the lentiviral construct (3H2F), specificity to the TERT:HLA complex was preserved but the CAR T cells now demonstrated cytotoxicity of GBM without needing exogeneous peptide. TCR-like antibody clones 3A12 and 3H2F specifically recognize an HLA-A*02:01-restricted TERT-derived antigen, facilitating effective in vitro cytotoxicity of GBM cells. Ongoing experiments will evaluate the in vivo activity of these TERT-specific CAR constructs and assess potential off-target toxicity.

Generation and Screening of Various CD70 CAR NK Cells Identify the Most Effective Construct Against Hematologic Malignancies

The ability to re-direct the intrinsic power of the immune system against cancer has resulted in unprecedented outcomes in certain patients with otherwise incurable diseases. Natural killer (NK) cells, similar to T cells, are powerful immune effectors that possess intrinsic anti-tumor properties and are capable of generating a strong cytotoxic response upon engaging tumor cells. However, unlike T cells, NK cells do not identify specific antigens and do so in a way that is HLA-independent, posing minimal risk of GvHD. Thus, NK cells have are being explored as a possible allogeneic source for over-the-counter cellular immunotherapy. CD70, the ligand for the CD27 receptor, is an attractive “pan-cancer antigen”, since in addition to being expressed in hematologic malignancies such as acute myeloid leukemia (AML) and lymphoma, it is also expressed on many solid tumors, including bladder, lung, triple negative breast cancer, renal cell carcinoma, pancreatic cancer, and melanoma. Moreover, CD70 is only transiently found on activated T and B lymphocytes and on dendritic cells. To target CD70-expressing cancers, we designed and tested a number of different chimeric antigen receptors (CAR). Briefly, we used the natural interaction between CD70 and CD27 to make a CAR construct that incorporated the extracellular domain of human CD27, which is the natural receptor for CD70. We generated various second-generation CAR constructs that differed in their transmembrane domains (CD27 vs. CD28) and costimulatory domains. We included co-stimulatory domains that are NK-centric (DAP10 and DAP12), T-cell-centric (CD28), or bi-centric (4-1BB). The CD3ζ chain was used as a signaling endodomain, and all the CAR constructs also included IL-15 to enhance in vivo proliferation and persistence. Cord blood (CB)-derived NK cells were efficiently retrovirally transduced with the different CAR constructs and subjected to an in vitro functional screen against various cancer cells to evaluate the best constructs for in vivo validation (Figure 1). The top constructs from our in vitro screen were further evaluated in multiple in vivo models, including a Raji lymphoma model and a THP-1 AML model. The best CAR construct in terms of superior tumor control and prolongation of survival was selected for GMP manufacturing. Based on these preclinical findings, a Phase I/II clinical study is now being conducted at our center to assess the safety and effectiveness of CD70 CAR NK cells against CD70-expressing hematologic malignancies (NCT05092451). Figure 1: Flow chart showing the screening process to identify the most effective CAR construct.

Generation of Bi-Specific Chimeric Antigen Receptor (CAR) T Cell Therapy for the Treatment of AIDS-Related B Cell Malignancies from Healthy Donors and HIV Patients

Introduction: Individuals with human immunodeficiency virus (HIV) face a substantially greater likelihood of developing cancers compared to the general population. The prevalence of cancer diagnosis among HIV-positive individuals ranges from 25% to 40%. Non-Hodgkin lymphoma (NHL) stands out as the most prevalent cancer type associated with people living with HIV/AIDS (PLWHA). NHL primarily manifests in two forms in PLWHA: Burkitt lymphoma, which poses an 18-fold higher risk, and diffuse large B cell lymphoma (DLBCL), accounting for 75% of cases. The advent of chimeric antigen receptor (CAR) T cell therapies, notably CD19-targeting CAR T cells, has emerged as a groundbreaking treatment for B cell NHL. Unfortunately, PLWHA has been excluded from participating in all of these clinical trials for years due to safety concerns and the challenges associated with manufacturing CAR T cell products from HIV-positive donors. Recent researches explored the feasibility of developing CD19-targeting CAR T cell products utilizing cells from HIV-positive donors with lymphoma. Although these studies have provided promising evidence that alleviates concerns regarding the safety profile and limited effectiveness of CAR T cell therapy in this particular population, they do not address the underlying HIV condition. We previously generated CAR T cells targeting either lymphoma (CD19-CAR) or HIVgp120 (N6-CAR) that show efficacy against their respective diseases in clinical and preclinical testing, respectively. We hypothesized that a dual construct capable of targeting both antigens could simultaneously target lymphoma cells and HIV-infected cells in a same individual. We report our experience developing a bi-specific N6-huCD19 CAR T cell platform that can target both antigens in a single therapeutic product. Methods: We engineered 3 bi-specific CAR candidate designs including 2 tandem and 1 loop constructs. These constructs were developed by integrating a humanized (hu) CD19 single-chain variable fragment (scFv) and an N6 scFv from an anti-HIV broadly neutralizing antibody (bNAb) into a backbone of a 2 nd-generation CAR construct. The bi-specific tandem CAR constructs consisted of N6 and huCD19 scFvs fused with a G4S linker in either huCD19-N6 or N6-huCD19 orientation. The loop-CAR was generated by fusing huCD19(VL):N6(VH):N6(VL):huCD19(VH) with a whitlow linker. All constructs included the CD4 transmembrane domain, a double-mutated IgG4 Fc spacer, 4-1BB co-stimulatory and CD3-zetta signaling domains, and EGFRt separated by a T2A ribosomal skip sequence (Fig.1). We tested the 3 bi-specific constructs in healthy donor-derived T cells using cytotoxicity co-culture assay against either Raji (CD19+) or 8E5 (gp120+) target cells. We generated N6-huCD19 CAR T cells from HIV-positive patients and confirmed the functionality of these CAR T cells against tumor cells. Results: The functional assessment of all 3 bi-specific CAR constructs revealed their efficacy against CD19 and HIVgp120 antigens. However, the N6-huCD19 tandem CAR T cells demonstrated comparable and better efficacy against both antigens. Notably, the N6-huCD19 tandem CAR T cells exhibited the capability to sequentially target either a single antigen or alternate between the 2 antigens (Fig.2). We successfully generated N6-huCD19 tandem CAR T cells using HIV-positive donors, signifying the practicality of this approach within the context of PLWHA. Remarkably these HIV donor-derived N6-huCD19 CAR T cells effectively killed tumor cells expressing CD19 or HIVgp120 antigens, thus confirming their dual functionality against these 2 antigens. Conclusion: Here we demonstrate the development of the novel N6-huCD19 bi-specific CAR T cells with functionality against both CD19 and HIVgp120 antigens. We also showed the feasibility of generating these CAR T cells from HIV-donors. This strategy could potentially provide life-saving approach tailored for treatment of HIV-patients who develop CD19+ lymphomas.

Phase 1/2 Study of Donor-Derived Anti-CD33 Chimeric Antigen Receptor Expressing T Cells (VCAR33) in Patients with Relapsed or Refractory Acute Myeloid Leukemia after Allogeneic Hematopoietic Cell Transplantation

Background and Significance: Although allogeneic hematopoietic cell transplantation (alloHCT) is a potentially curative therapy for patients with high-risk acute myeloid leukemia (AML), relapse occurs in 30% to 40% of alloHCT recipients and is associated with a 2-year post-relapse survival rate of less than 20%. Chimeric antigen receptor (CAR) T cells targeting tumor-associated antigens have demonstrated efficacy in relapsed/refractory (R/R) acute lymphoblastic leukemia and other hematologic malignancies, but there is limited clinical experience with CAR T cell therapies for AML. Current challenges for autologous AML CAR T cell therapy include the inability to harvest adequate numbers of functional, undifferentiated T cells as CAR T cell starting material. In addition, the potential presence of AML blasts in an autologous cell collection can interfere with T cell proliferation and function during the manufacturing process. To circumvent these impediments in patients with R/R AML after alloHCT, VCAR33 represents a CD33-directed CAR T cell product generated from lymphocytes from each patient's prior allogeneic stem cell donor. CAR T cell manufacture from HLA-matched donors will likely not only eliminate delays and failures in production due to lymphopenia but also improve T cell function by using healthy starting material. CD33 is a preferential target for AML CAR T cell therapy as it is expressed on the majority (>80%) of AML blasts and because prior clinical experience with gemtuzumab ozogamicin (GO; tradename: Mylotarg TM) has demonstrated the safety and efficacy of targeting CD33. Study Design and Methods: Study NCTxxxxxxxx* is a multi-center phase 1/2 study evaluating the safety and preliminary efficacy of VCAR33, donor-derived allogeneic CAR T cells targeting CD33 (Figure 1). The CAR construct used for the manufacture of VCAR33 contains a lintuzumab-derived binding domain and a CD28 co-stimulatory domain. Key inclusion criteria include adult patients with relapsed or measurable residual disease positive (MRD+) AML after undergoing alloHCT with an 8/8 HLA-matched related or unrelated donor. Patients who have undergone alloHCT with trem-cel, a CD33-deleted allogeneic stem cell product intended to facilitate the post-HCT treatment with CD33-directed therapies by reducing on-target off-tumor hematotoxicity, may also participate. Patients will be assigned to one of two study arms based on their AML disease burden: Arm A for morphologic disease with ≥ 5% blasts in the bone marrow, or Arm B for MRD+ defined as < 5% blasts in the bone marrow with ≥ 0.1% CD33+ leukemia cells by flow cytometry. The patient's prior stem cell donor undergoes apheresis for collection of mononuclear cells, which are used as starting material for VCAR33 manufacturing. Patients will receive lymphodepletion on days -5 to -2 with fludarabine (total 120 mg/m 2) and cyclophosphamide (total 1000 mg/m 2) followed by infusion of VCAR33 on Day 0. Each study arm will enroll and escalate independently according to a standard 3+3 trial design, starting at 1 x 10 6 CAR T cells/kg for Dose Level 1. The dose limiting toxicity monitoring period is 28 days, at which time patients will undergo evaluation of disease response. Secondary endpoints include incidence of cytokine release syndrome, graft-vs-host disease, and clinical response. Exploratory endpoints aim to correlate VCAR33 properties with clinical response by characterizing T cell phenotypes within the VCAR33 product and by examining VCAR33 expansion and persistence after infusion. Follow up on trial will continue for up to 2 years after infusion followed by long term monitoring for up to 15 years. Patients may undergo second alloHCT for consolidation of remission or for rescue of prolonged cytopenia due to on-target off-tumor effects of VCAR33. *NCT number pending. Clinical trial information submitted to CT.gov on July 19, 2023.

Novel Peptide-Based Plectin-1 CAR T-Cells Target Specifically Pancreatic Cancer Cells

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is one of the most devastating cancers, and therapies to treat this malignancy have not evolved rapidly to fulfill the need of affected patients. PDAC, like many solid malignancies, is considered a “cold immunological tumor” where the lack of targetable tumor-associated antigens has hampered the development of successful immunotherapies. Despite newer treatment approaches, PDAC patients with advanced disease have a dismal prognosis. Therefore, there is an urgent need to develop new therapies. Plectin-1 is a high molecular weight protein (∼500 kDa) that participates in cytoskeleton network organization linking intermediate filaments to microtubules and microfilaments. Plectin-1 is aberrantly expressed in the PDAC cellular membrane, contributes to PDAC pathogenesis, and confers a poor prognosis. Plectin-1-targeting peptides (PTP) in mice and humans have been successfully explored for their use in PDAC imaging and targeted payload delivery (small molecules, radioisotopes, and chemotherapy). We sought to take advantage of the specific binding of PTP and develop a peptide-based plectin-1 chimeric antigen receptor (CAR), and test T-cell transduced with this construct in vitro against PDAC cell lines. Methods: Using in silico tools, we optimized different pepto-CAR constructs and selected one that showed the highest levels of cytotoxicity against plectin-1-expressing PDAC cell lines. A myc tag was incorporated in the hinge region for flow cytometry or western blot detection. The intracellular signaling domain of these CAR sequences included 4-1BB and the zeta chain of the CD3 molecule ( Figure 1A). Plasmids containing the CAR sequence were packaged on lentivirus particles using HEK293T cells. Purified plectin-1 CAR lentiviruses were used to transduce T-cells derived from human peripheral blood T-cells obtained and purified from healthy donor whole blood. The expanded CAR T-cells were used for cytotoxic experiments against different cell lines. Results: Expression of plectin-1 CAR was confirmed by flow cytometry using an anti-myc tag antibody ( Figure 1B). Plectin-1 expression was analyzed in different pancreatic cancer cell lines, and the BxPC-3 cells showed the highest expression level ( Figure 1B). Using a luciferase-based assay, we plated 50,000 BxPC-3 cells per well in duplicates with different effector-to-target (E:T) ratios. After 24 hours, luciferin was added, and the plate was read using a luminometer. As a negative control for effector cells, we use T-cells without a CAR ( Figure 1B), and for the target cells, we use the plectin-1 negative lung cancer cell line A549 ( Figure 1B). Plectin-1 CAR T-cells effectively killed BxPC-3 cells at different E:T ratios in a specific manner compared with controls using unmodified T-cells. Furthermore, no cytotoxicity was observed against plectin-1 negative A549 cells ( Figure 1A). Conclusion: Our results show that a novel peptide-based CAR construct design against plectin-1 can induce specific cytotoxicity on plectin-1 expressing PDAC cell line BxPC-3. Furthermore, these data demonstrate the feasibility of using a CAR with a peptide-based antigen binding domain instead of the traditional antibody-derived scFv. This novel peptide-based CAR design offers alternatives for cellular therapy bioengineering. Moreover, our results can significantly impact immune-oncology therapeutic applications, particularly in challenging diseases like pancreatic cancer. Figure 1 . A) In the above section, the Plectin-1 CAR construct is depicted. Cytotoxicity of unmodified T-cells and Plectin-1 CAR T-cells against BxPC-3 and A549 is shown below. B) Expression of Plectin-1 CAR in unmodified T-cells and Plectin-1 CAR T-cells is shown on the left. The expression of plectin-1 antigen on the surface of BxPC-3 cells and A549 cells is shown on the right. PTP: plectin-1 targeting peptide.

Dual Split-Signaling TIM3+CLEC12a Targeting CAR T-Cells with Optimized Signaling As a Safe Potential Therapy for Acute Myeloid Leukemia

Background: The success of chimeric antigen receptor (CAR) T-cell therapies targeting B cell maturation antigen (BCMA) in multiple myeloma and CD19 in B-cell malignancies has demonstrated the immense potential of this immunotherapeutic strategy. However, the translation of CAR T-cell therapy to acute myeloid leukemia (AML) patients has encountered challenges due to the absence of surface antigens specifically or preferentially expressed on AML cells. To overcome this hurdle, we explored the feasibility and safety of simultaneously targeting the AML-associated antigens CLEC12a and TIM3 using an AND-gate strategy in which the essential stimulatory and co-stimulatory T-cell activation signals are segregated into separate CARs. To improve the safety of our strategy we also attenuated signaling through the stimulatory anti-CLEC12a CAR via affinity-optimization or through targeted mutations in its immunoreceptor tyrosine-based activation motif (ITAM) regions. Methods: To identify the most optimal dual-split CAR T-cell configuration, we designed several chimeric antigen receptor constructs in which we targeted CLEC12a with stimulatory CARs (sCARs) with high (C hi) or low (C low) affinities. In addition, the high affinity C hi stimulatory CAR was mutated in the second and third ITAM regions (denoted as C hixx) to attenuate the CD3ζ stimulatory signal. TIM3 was targeted by a costimulatory CAR (cCAR) containing both CD28 and 41BB signaling domains. The dual-split CARs were generated using two separate retroviral constructs. After the assessment of the CAR expression and specific surface markers associated with memory phenotype and exhaustion, dual-split CAR T-cells were functionally tested using an isogenic cell line model for specific lysis against dual CLEC12a/TIM3 positive or single CLEC12a or TIM3 positive isogenic target cells as well as for dual antigen-specific cytokine secretion. The dual-split CAR T-cells were also tested for their efficiency to specifically eliminate leukemic stem/progenitor cells by the colony formatting unit (CFU) assay. Moreover, anti-AML activity and persistence of the dual-split CAR T-cells was assessed using an AML PDX mouse model in which human primary AML cells expressing TIM3 and CLEC12a were injected. Results: Using the isogenic cell line model, we revealed that the dual-split CAR T-cells with the combination of the high affinity CLEC12a sCAR and TIM3 cCAR (C hi+T) show antigen-specific cytokine secretion and cytotoxicity, and that this specificity was enhanced when the CLEC12a sCAR was attenuated through ITAM mutations (C hixx+T). In CFU assays, all tested CLEC12a/TIM3 dual-split CAR T-cell combinations exhibited potent inhibition (up to 95%) of leukemia blast viability and leukemia stem/progenitor self-renewal. In vivo, although AML did not engraft in all mice, the best-performing dual-split C hixx+T1 CAR T-cells displayed potent anti-leukemic activity, as they prevented engraftment in two additional mice compared to control groups (n=6 each group). Furthermore, in contrast to control groups dual-split CAR T-cells exhibited prolonged persistence in the blood up to 20 weeks after injection. Conclusion: We successfully generated highly specific dual-targeting CAR T-cells by splitting the T-cell activation signals into two simultaneously expressed CARs, and using a novel approach of attenuating the sCAR through mutations in ITAM regions. Overall, we show that dual-split CAR T cells targeting CLEC12a and TIM3, particularly the combination C hixx+T CAR T-cells, have specific and promising anti-AML activity. Our findings underscore the potential of innovative dual-split CAR T-cell therapies as a novel and effective immunotherapeutic approach for combating AML.

Heme Attenuates T Cell Exhaustion and Drives Effector Function: Implications for Immune and Adoptive T Cell Therapy

Introduction: Though frontline agents have been effective in multiple myeloma (MM) therapy, a significant proportion of MM patients relapse and succumb to refractory disease. B-cell maturation antigen (BCMA)-directed chimeric antigen receptor (CAR) T therapy represents an exciting novel therapeutic strategy for MM but still suffers from limited in vivo T cell expansion and CAR T cytotoxicity. Altering the CAR T manufacturing process to produce CAR T cells with less exhausted phenotypes and robust killing is an active area of research. Mitochondrial function and energetics play a central role in regulating T cell fate and function, and heme (iron-protoporphyrin IX) is critical for maintaining electron transport chain activity and oxidative phosphorylation. Heme can be sourced from the extracellular milieu, diet, or intrinsic heme biosynthesis and has a multitude of cellular functions throughserving as a cofactor for enzymatic and metabolic reactions. Additionally, heme is catabolized by heme oxygenase 1, producing the antioxidants biliverdin and bilirubin critical to preserving cellular redox homeostasis. In the present study, we investigate the effects of heme on CAR T cell efficacy. Our results suggest that heme supplementation during ex vivo CAR T manufacturing or supplementation during CAR T-tumor cell engagement can lead to decreased T cell exhaustion and increased tumor killing. Methods: Human healthy donor and MM patient T cells were activated and expanded with α-CD3/CD28 and IL-2 for 7 days +/- hemin, after which immunostaining and metabolic assays were conducted. For CAR T manufacture, T cells were transduced with CAR construct starting on day 3 and were co-cultured with antigen-expressing tumor cells in vitro on day 7-8. Cytotoxicity and cytokine production were assayed after 24 hours of co-culture. Results: In a dose-dependent manner, heme supplementation significantly decreases proportions of LAG3 + and TIM3 + and decreases proportions of CD62L + and TCF1 + cells in both CD4 + and CD8 + subsets isolated from healthy donor and MM patient peripheral blood. Supportive of these observations, inhibition of de novo heme biosynthesis leads to the opposite effect with an increase in proportions of PD1 +, LAG3 +, TIM3 +, and CD62-L + cells. CAR T cells manufactured with heme (heme-CAR T cells) have significantly reduced terminally exhausted phenotypes (PD1 +/LAG3 +/TIM3 +) and increased enrichment of effector memory cells (CD62L -CD45RA -) in both CD4 + and CD8 + subsets. Inquiry of cellular energetics of heme supplemented CAR T cells reveals reduced reactive oxygen species (ROS) and increased mitochondrial membrane potential, consistent with previous reports showing increased membrane potential in effector T cells for greater production of cytokines such as IL-17A, IL-17F, and IFNγ. In co-culture with tumor cells in vitro, heme-CAR T cells have higher tumor-specific lysis and production of TNFα and IL-2. CAR T-tumor cell engagement in the presence of heme resulted in significantly decreased proportions of exhausted CAR T cells and increased production of TNFα. Heme also increases BCMA surface expression in several MM cell lines, highlighting a viable strategy for enhancing BCMA CAR T engagement with MM. Lastly, MM patient bone marrow-localized T cells demonstrate significantly decreased terminally exhausted phenotypes and increased differentiation into effector subsets when expanded with heme. Conclusion: We show that heme increases effector T and CAR T cell function and decreases T cell exhaustion. Increased cytotoxicity of heme-supplemented CAR T cells was associated with reduced ROS and increased membrane potential. Ongoing in vivo studies aim to characterize the efficacy of heme-supplemented CAR T cells in MM xenograft models. Our studies have broader implications for investigating heme supplementation in ex vivo CAR T manufacturing for a wide range of hematological cancers and underscore the need for further investigation of heme uptake and metabolism for strategic enhancement of T-cell based immunotherapies.

A Novel CD64 CAR-T Therapy for the Treatment of Monocytic Acute Myeloid Leukemia

Introduction: Acute Myeloid Leukemia (AML) is a difficult to treat, life threatening malignancy with overall survival remaining extremely poor, approximately 15% at 5 years. Recent advances in therapeutic approaches for AML have significantly improved outcomes, most notably venetoclax and azacitidine which induces a remission in approximately 70% of patients. Despite this, the majority of patients ultimately relapse and succumb to their disease. We and others have previously shown that more monocytic (M5 by FAB classification) AML cells demonstrate increased resistance to venetoclax therapy and that relapse after venetoclax and azacitidine treatment shows a monocytic phenotype in approximately 30% of patients (Pei, et. al. Cancer Discovery, 2020). These patients experience decreased overall survival compared to patients with non-M5 AML. Furthermore, we have demonstrated that AML with a dominant monocytic phenotype can arise from a unique subclass of leukemia stem cells (LSCs) that we have termed monocytic-LSCs (m-LSCs) due to their immunophenotype, including expression of CD64. m-LSCs are highly resistant to venetoclax-based therapies (Pei, et. al., Cancer Discovery, 2023). As venetoclax is increasingly utilized in AML treatment regimens, it is essential to identify methods of targeting this m-LSC subtype to prevent and treat relapsed and refractory disease. Methods: To more effectively target monocytic AML, we have developed a novel chimeric antigen receptor (CAR) T cell therapy targeting CD64, an antigen commonly expressed in monocytic cells and strongly expressed in the m-LSC population. We generated two second-generation CAR constructs targeting CD64, one with CD28 and the other with 41BB costimulatory domains. We expressed these CARs in healthy donor human T cells via lentiviral transduction and tested their function in vitro and in vivo. Results: We demonstrate that CD64 CAR-T cells effectively treat monocytic AML using pre-clinical models. CD64 CAR-T cells eliminate CD64+ leukemia cell lines in vitro in a dose dependent manner with an effector to target (E:T) ratio of 1:4 and higher eliminating 100% of Molm14 leukemia cells at 18 hours compared to 0-10% in mock T-cell controls. We also show that CD64 CAR-T cells eliminate established Molm14 leukemia in vivo, with 100% of CAR-T treated mice surviving over 50 days with no evidence of leukemia versus less than 30 days survival with high tumor burden in mock treated mice (p<0.01, Figure 1). We find that CD64 CAR-T cells with CD28 verses 41BB costimulatory domains are similarly efficacious against monocytic AML, though we find more prolonged persistence of CD64-41BBz CAR-T cells in mice with long term leukemia free survival. Furthermore, we demonstrate that CD64 CAR-T cells kill CD64+ primary patient derived AML cells in ex vivo co-culture, resulting in a 60-80% reduction in viable AML cells at 18 hours across 1:1 to 1:16 E:T ratios compared to mock T cell controls. We further show that CD64 CAR-T cells target m-LSCs and reduce the engraftment potential of primary AML cells in mice with a nearly 9-fold reduction in leukemia burden in CAR-T treated versus control mice. Finally, preliminary experiments with AML patient derived xenograft models further support the in vivo efficacy of CD64 CAR-T cell treatment. Conclusions: Our data provide promising preclinical evidence for the efficacy of a novel CD64 CAR-T therapy in the treatment of monocytic AML. We propose that using this regimen to augment AML therapy is a potentially powerful means to eradicate m-LSCs, which are inherently resistant to venetoclax, and thereby increase remission duration. This concept serves as the basis for an upcoming clinical trial of CD64-directed CAR-T cells for CD64 expressing AML. Figure 1: CD64 CAR-T cells eliminate AML in in vivo murine leukemia models. A) NSG mice leukemia models of GFP expressing Molm14, a CD64+ human leukemia cell line, experience leukemia clearance within 3 days after treatment with CD64-28z CAR-T cells, as shown by decreased bioluminescent signal in images of CAR-T treated mice. Mock transduced human T-cells from the same human donor serve as a control. B) Survival curves demonstrate 100% survival of CAR-T treated mice over the experiment (p<0.01).