Post-infusion Time Points Research Articles

Prospective Assessment of Quality of Life and Patient-Reported Toxicities Over the First Year After Chimeric Antigen Receptor T-Cell Therapy

Chimeric antigen receptor (CAR) T-cell therapy has transformed survival outcomes in patients with relapsed and refractory large B-cell lymphoma (LBCL), but it is associated with a variety of side effects. This study examined changes in patient-reported quality of life (QoL) and toxicities, as well as risk factors for worse QoL and toxicities, in the first year after treatment. Patients with LBCL completed questionnaires assessing QoL and toxicity severity before infusion, and 90, 180, and 360 days after infusion. Mixed models were used to examine changes in QoL and toxicities over time, and clinical moderators of change in QoL and toxicities. Patients reported improvements in physical functioning and fatigue in the year after treatment (P values <.01), but there were no changes in pain, anxiety, or depression over time. Patients with active disease at day 90 reported more physical dysfunction at all postinfusion timepoints (Ps ≤ .01) compared to patients who responded to treatment. Similarly, patients with active disease at day 90 reported worsening depression over time, such that at day 360, depressive symptoms were worse for patients with active disease than patients without active disease (P = .02). Patients treated with 4+ lines of prior therapy reported worsening pain and anxiety over time, such that at day 360, both pain and anxiety were significantly worse for patients previously treated with 4 of more lines of therapy than patients treated with fewer lines of therapy (Ps ≤ .01). Regarding toxicities, patients reported decreasing overall toxicity burden up to day 180, with subsequent worsening at day 360 (P = .02). Most patients reported at least one or two grade 2 toxicities at each timepoint. Patients demonstrated unchanging or improved QoL after treatment with CAR T-cell therapy, but active disease and greater prior lines of therapy were associated with worse QoL outcomes over time. Toxicity severity also improved during the first 6 months post-treatment, but worsened thereafter, particularly among patients with active disease after treatment.

Vincristine (VCR) pharmacokinetics (PK) in infants dosed using a body surface area (BSA) banded dosing table and in older children dosed based on BSA: A pediatric early phase clinical trial network study (PEPN22P1).

10015 Background: The Children’s Oncology Group developed and implemented a unified method of dosing anticancer drugs in infants and small children with a BSA &lt; 0.6 m2. The dosing tables use BSA-based dose banding and account for deliverable doses/volumes of the drugs. We studied the PK of VCR (1.5 mg/m2 dose level) in infants and children to determine whether this new infant dosing method achieves uniform drug exposures across the pediatric age span. Methods: We designed a sampling strategy to limit the blood volume required by focusing on the elimination (β) phase of the VCR concentration-time curve, which accounts for &gt; 80% of the total area-under the curve (AUC). Duplicate samples to detect contamination were drawn at 3 post-infusion time points (2, 6-8 and 18-24 hr) through a central venous catheter (CVC) after a 90 min flush. VCR concentrations were measured at the Children’s Hospital of Philadelphia using a validated high-pressure liquid chromatography/tandem mass spectrometry method with a lower limit of quantitation (LLQ) of 0.25 ng/mL. A one-compartment model was fit to the concentration-time data using population PK methods (Phoenix NLME). The AUCβ was derived from the dose and clearance for each patient. Patients were accrued in 4 age groups (≤6 mo, goal n = 20); &gt; 6 mo to ≤12 mo, goal n = 10; &gt; 12 mo to ≤36 mo, goal n = 10; and &gt; 36 mo to ≤12 yr, goal n = 10) to focus on infants and ensure representation across the pediatric age range. Results: 52 eligible patients have been enrolled and 39 are evaluable for PK analysis, including 9 ≤6 mo, 8 &gt; 6 mo and ≤12 mo, 12 &gt; 12 mo and ≤36 mo, and 10 &gt; 36 mo and ≤12 y,. The median (range) age is 13.5 mo (1.15-112 mo). VCR was quantifiable in all samples, and there was no evidence of contamination in the duplicate samples drawn through the CVC. The mean ± SD AUCβ in the 39 evaluable patients was 54.7 ± 19.8 ng⋅h/mL. As shown in the Table, the AUCβ is similar in patients with a BSA &lt; 0.6 m2 dosed according to the BSA-banded infant dosing table and patients with a BSA ≥0.6 m2 dosed by multiplying their BSA times 1.5 mg/m2 (p = 0.53, Mann Whitney test). Conclusions: The VCR BSA-banded infant dosing table appears to provide uniform VCR exposure for infants and young children compared to conventional BSA-based dosing in older children. The study design and sampling strategy facilitated rapid accrual of a young population and generated more VCR PK data in infants within a year than has been published since the drug was approved in 1963. This study demonstrates the feasibility of systematically studying other anticancer drugs in infants and other special populations to ensure they are receiving safe and effective doses. VCR AUCβ by dosing method. Clinical trial information: NCT05359237 . [Table: see text]

Early prediction of severe ICANS after standard-of-care CD19 CAR T-cell therapy using gradient-boosted classification trees.

7034 Background: Severe immune effector cell-associated neurotoxicity syndrome (ICANS) has arisen as a major complication leading to morbidity, mortality, and increased resource utilization. There is an urgent need to accurately predict the development of severe ICANS after CAR T-cell therapy. Here, we demonstrate the high performance of the XGBoost (“eXtreme Gradient Boosting”) machine learning algorithm in predicting the development of severe ICANS using commonly available laboratory and vital sign data from patients with B-cell lymphomas undergoing standard-of-care CD19 CAR T-cell therapy. Methods: We included patients who received axicabtagene ciloleucel (axi-cel) or brexucabtagene autoleucel (brexu-cel) per standard of care. ICANS was graded by CTCAE 4.03 criteria (pre-12/2018) or ASTCT Consensus Grading System (post-1/2019). Predictions were generated using XGBoost, a widely used supervised machine learning algorithm that trains ensembles of decision trees to learn iteratively from prior trees and allows for very flexible modeling (e.g. non-linear effects, complex high-order interaction effects). K-fold cross-validation was used to assess calibration and overfitting. Variables assessed included age, ferritin, CRP, LDH, IL-6, fibrinogen, platelet count, and temperature at pre-infusion, day 0, and day +3 post-infusion timepoints. Results: A total of 175 patients were included with 39 receiving brexu-cel (22%) and 136 receiving axi-cel (78%). Grade ≥3 ICANS occurred in 40 patients (23.3%). XGBoost modeling of factors demonstrated that serum ferritin level on day +3 was the most important variable predictive of grade ≥3 ICANS (accuracy gain: 0.28). Other influential factors included day 0 and +3 platelet count, patient age, day +3 IL-6 level, day 0 fibrinogen level, and day 0 and +3 CRP level, in descending order of importance. The XGBoost model maintained high discrimination (ability to distinguish high-risk from low-risk patients; mean AUROC 0.74, sensitivity 0.95, specificity 0.90). Longitudinal LOESS smoothing confirmed associations between severe ICANS and elevation in serum ferritin at day 0 (OR 3.01, 95% CI 1.41 – 6.73, p = 0.005) and day +3 (OR 5.50, 95% CI 2.31-14.5, p &lt;0.001). Conclusions: A supervised machine learning model using XGBoost incorporating age, temperature and commonly accessible laboratory data including ferritin, CRP, LDH, IL-6, fibrinogen, and platelet count predicted severe ICANS prior to the development of symptoms with high discrimination (AUROC 0.74) in patients undergoing standard of care CAR T-cell therapy. This allows for the early identification of patients at highest risk for developing severe ICANS who may benefit from prophylactic interventions. Once externally validated, we plan to develop a user-friendly web application to generate individualized predictions from our model.

Experiences of Awe Mediate Ketamine’s Antidepressant Effects: Findings From a Randomized Controlled Trial in Treatment-Resistant Depression

BackgroundKetamine, an NMDA receptor antagonist, provides rapid antidepressant effects. Although much research has focused on neural and molecular mechanisms of action, it is critical to also consider psychological mechanisms that may contribute to its therapeutic efficacy. The construct of an awe-inducing experience, which is a well-validated psychological phenomenon tied to emotional well-being, had not been applied previously in ketamine research. MethodsOne hundred sixteen participants with depression, 77 of whom received a ketamine infusion (0.5 mg/kg over 40 minutes) and 39 patients who received saline placebo, completed a validated measure of awe (the Awe Experience Scale [AWE-S]) at 40 minutes postinfusion. AWE-S scores were examined as potential mediators of depression outcomes (% improvement in Montgomery–Åsberg Depression Rating Scale score) at 5 postinfusion time points (24 hours and 5, 12, 21, and 30 days). Dissociative effects, measured by Clinician-Administered Dissociative States Scale scores, were tested in parallel mediation models for comparison. ResultsWe found that the psychological experience of awe was strongly reported by participants during ketamine infusion, but not saline infusion, and there were significant associations between total AWE-S scores and Montgomery–Åsberg Depression Rating Scale score improvement (% change) in the ketamine arm at all 5 time points. Furthermore, at all 5 time points, total AWE-S scores statistically mediated the relationship between ketamine and Montgomery–Åsberg Depression Rating Scale scores. By contrast, Clinician-Administered Dissociative States Scale scores did not mediate outcomes at any time point. ConclusionsKetamine infusion strongly induced heightened feelings of awe, and these experiences consistently mediated depression outcomes over a 1- to 30-day period, unlike general dissociative side effects. The specific awe-inspiring properties of ketamine may contribute to its antidepressant effects.

Clearance of Trehalose Lyophilized Platelets in Mice

Abstract The utilization of stored platelet transfusion has emerged as an effective approach in the management of thrombocytopenia. However, the limited availability of fresh platelets in veterinary medicine due to the challenging storage requirements poses a significant constraint. Lyophilized platelets offer extended shelf-life and convenient storage options, enhancing their accessibility for thrombocytopenic patients. However, only a limited number of studies have examined the clearance and survival rate of transfused lyophilized platelets, particularly regarding the lyophilization technique utilizing trehalose as a platelet stabilization agent. The objective of this study was to assess the recovery and survival rate of trehalose lyophilized platelets within the circulatory system. To investigate these parameters, CMFDA-labeled lyophilized platelets were administered to mice, and their recovery and survival rates were analyzed. Flow cytometric analysis revealed the rapid clearance of lyophilized platelets from the systemic circulation. The immediate post-infusion percent recovery of labeled platelet particles was 42.7 ± 8.15 %. The average survival rates at post-infusion time points at 15, 30, 45, and 60 minutes were 28.2 ± 4.31, 14.5 ± 3.56, 5.1 ± 2.02, and 0.82 ± 0.57, respectively. The calculated mean half-life was 8.39 ± 0.44 minutes. The most pronounced decrease in labeled lyophilized platelet count occurred during the 30-minute timeframe immediately following infusion. Subsequently, over 99% of lyophilized platelets were eliminated after 60 minutes post-infusion. These findings indicate that higher dosages and more frequent administration of trehalose lyophilized platelets might be necessary to achieve a therapeutic effect comparable to that of fresh platelets.

Undetectable MRD Status in Patients with R/R CLL/SLL with Stable Disease after Lisocabtagene Maraleucel Treatment: Exploratory Analysis of the TRANSCEND CLL 004 Study

Background:For patients (pts) with R/R CLL/SLL after failure of Bruton tyrosine kinase inhibitor (BTKi) and B-cell lymphoma 2 inhibitor (BCL2i)-based treatment, there is no established standard of care and therefore there is a high unmet therapeutic need. The phase 1/2 TRANSCEND CLL 004 study (NCT03331198) investigated the efficacy and safety of lisocabtagene maraleucel(liso-cel) monotherapy, an autologous CD19-directed CAR T cell therapy, in pts with heavily pretreated R/R CLL/SLL and ≥ 2 previous lines of therapy, including a BTKi. The primary analysis demonstrated durable CR/CR with incomplete marrow recovery (CRi) per 2018 International Workshop on CLL (iwCLL 2018) criteria, high undetectable MRD (uMRD; 10 −4 sensitivity) rates, and a manageable safety profile in pts who received liso-cel (Siddiqi T, et al. Lancet 2023). All evaluable responders (CR/CRi/PR) achieved blood uMRD status. Among evaluable pts with stable disease (SD), uMRD status was associated with longer median PFS (6.4 months) versus MRD-positive (MRD+) status (PFS, 2.8 months). This exploratory analysis aimed to better understand potential variables associated with achieving uMRD in pts who had SD with liso-cel. Methods: Among 96 pts in the full efficacy set who were treated with liso-cel at dose level 1 (50 × 10⁶ CAR + T cells) or 2 (100 × 10⁶ CAR + T cells), 80 pts were evaluable for peripheral blood MRD. Peripheral blood MRD status was assessed by next-generation sequencing (NGS; clonoSEQ) assay; uMRD was defined as &amp;lt; 10 −4 (&amp;lt; 1 CLL cell per 10,000) at 1 or more postinfusion time points. Additional exploratory analysis leveraged sample-level MRD results defined by total clonal cells/total nucleated cells assessed by NGS. Cellular kinetics were analyzed in peripheral blood samples by qPCR to detect the liso-cel transgene. Correlative analysis studies of baseline markers of tumor burden (sum of the product of diameters; CD19 + cells/μL; percent CLL cells in bone marrow biopsies or aspirates) with liso-cel expansion were evaluated by MRD status. Statistical analyses were performed using the Wilcoxon signed-rank test. Results:Of the 80 pts who were evaluable for peripheral blood MRD, 34 had a best overall response of SD, 19 of whom achieved uMRD and 15 who were MRD+. Greater liso-cel expansion parameters (median maximum expansion and area under the curve from 0-28 days postinfusion) were observed in all pts, including those with SD, who achieved uMRD versus MRD+ status ( P &amp;lt; 0.0001), suggesting that higher liso-cel expansion after infusion was associated with achievement of uMRD independent of iwCLL 2018 response. Regardless of baseline tumor burden, pts with higher liso-cel expansion achieved uMRD after liso-cel treatment. A positive association between tumor burden and liso-cel expansion in pts with SD and uMRD was also observed. In contrast, pts with SD who were MRD+ had lower liso-cel expansion and trends of higher baseline disease burden. Liso-cel expansion in pts with SD and uMRD clustered with the responders, who all achieved uMRD status (in those evaluable for MRD). Notably, 4 pts with SD and uMRD had a durable disease control of &amp;gt; 22 months. We wanted to further understand the relationship between uMRD and durable disease control. Given that the median PFS of pts with SD and uMRD was 6 months, we evaluated the association between tumor burden and liso-cel expansion in pts who had a PFS of ≤ 6 months or &amp;gt; 6 months. Although no clear association was observed with liso-cel expansion and tumor burden within these 2 groups, 4 out of 5 pts with SD and uMRD with longer disease control (PFS &amp;gt; 6 months) had a &amp;gt; 98% decrease in sample-level MRD from Month 1 to Month 3. In contrast, in pts with SD and uMRD with PFS ≤ 6 months, 5 out of 7 pts had a &amp;gt; 70% increase in sample-level MRD from Month 1 to Month 3. Conclusions:In this exploratory analysis of pts with R/R CLL who had SD by iwCLL 2018 criteria after liso-cel treatment, greater liso-cel expansion, regardless of baseline tumor burden, correlated with blood uMRD status. Additionally, those with a PFS &amp;gt; 6 months achieved deeper clearance of blood sample-level MRD within 3 months of treatment versus those with a PFS ≤ 6 months, suggesting that MRD kinetics may identify pts with SD who can achieve durable disease control despite not achieving a response per iwCLL 2018 criteria. Further investigation is needed to better understand which subsets of pts with CLL who had SD may derive clinical benefit from liso-cel.

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).

Association of Neurofilament Light Chain With the Antidepressant Effects of Low-Dose Ketamine Infusion Among Patients With Treatment-Resistant Depression.

The role of neurofilament light chain (NFL) in treatment-resistant depression (TRD) is unclear. Whether baseline NFL concentrations are associated with the antidepressant effects of low-dose ketamine infusion has not been determined. The NFL concentrations of 71 patients with TRD and 17 healthy controls were assessed. Patients with TRD were randomly administered a single infusion of 0.5mg/kg ketamine, 0.2mg/kg ketamine, or normal saline. Depressive symptoms were assessed prior to infusion and sequentially at postinfusion timepoints (after 240min and 2-7 and 14 days after infusion) using the Hamilton Depression Rating Scale (HDRS). After adjustment for age, sex, and body mass index, patients with TRD were more likely to have higher concentrations of NFL than healthy controls (p < 0.001). A generalized estimating equation model with adjustments for infusion group, age, sex, body mass index, and baseline HDRS scores showed that baseline NFL concentrations were positively associated with subsequent HDRS scores following low-dose ketamine infusion (p = 0.038). Higher concentrations of NFL were observed among patients with TRD compared with healthy controls. Baseline NFL concentrations may predict the antidepressant effects of low-dose ketamine infusion.

Effects of low-dose ketamine infusion on vascular endothelial growth factor and matrix metalloproteinase-9 among patients with treatment-resistant depression and suicidal ideation

BackgroundEvidence indicates that vascular endothelial growth factor (VEGF) and matrix metalloproteinase-9 (MMP-9) influence the pathophysiology of depression. However, whether low-dose ketamine regulates VEGF and MMP-9 levels and whether changes in VEGF and MMP-9 levels are associated with the antidepressant and antisuicidal effects of ketamine remained unclear. MethodsForty-eight patients with treatment-resistant depression and strong suicidal ideation (TRD-SI) were randomly assigned to a single infusion of 0.5-mg/kg ketamine or 0.045-mg/kg midazolam. The Montgomery–Åsberg Depression Rating Scale (MADRS) and Columbia-Suicide Severity Rating Scale–Ideation Severity Subscale (CSSRS-ISS) were used at baseline and subsequently at several postinfusion timepoints. VEGF and MMP-9 serum levels were analyzed at baseline and on day 3 postinfusion. ResultsAfter adjustment for baseline levels, no significant differences in VEGF (p = .912) and MMP-9 (p = .758) levels were identified on day 3 postinfusion between the study groups. Baseline VEGF levels but not MMP-9 levels were negatively associated with MADRS and CSSRS-ISS scores following infusion. DiscussionA single infusion of low-dose ketamine did not alter the VEGF and MMP-9 levels of the patients with TRD-SI. Higher baseline VEGF levels were associated with greater antidepressant and antisuicidal effects of single low-dose ketamine infusion.

LTBK-03. Targeted mass spectrometry of serial CSF and serum specimens from children with diffuse intrinsic pontine glioma treated with intracranial B7-H3 CAR T cells

Considering the high expression of B7-H3 (CD276) on diffuse intrinsic pontine glioma (DIPG) and preliminary evidence that repeated locoregional delivery of CAR T cells to patients with CNS tumors was feasible and tolerable, we open the phase 1 trial BrainChild-03 (NCT04185038). Children with DIPG in Dose Regimen 1 received 40 intraventricular B7H3CAR doses, with the two patients enrolling post-progression surviving >400 days from initial CAR T infusion. To evaluate for immune and tumor responses that may correlate with clinical and radiographic evaluations, we performed targeted proteomic analysis on serial CSF and serum biospecimens.MRM-MS is a targeted mass spectrometry that provides sensitive measurement of proteins in cancer tissues and fluids. In 2 patients with longitudinal biospecimens, we identified 50 CSF and 59 serum proteins above level of detection. In general, there were fewer serum fluctuations compared to the CSF, supporting that intracranial delivery provides local immune activation. Sharp fluctuations of several immunoregulatory peptides were measured in the CSF at pre and post infusion timepoints, including BCL10, CXCL13, TIM-3, ICOSLG, and PD-L2. Notably, several analytes tracked consistently in the CSF of both patients, including markers of macrophage maturation and immune cell recruitment, including CD14, CD163, CD44, CSF-1, CXCL13 and VCAM-1. B7-H3 was detected in the CSF and serum of both patients. S005, who progressed on protocol therapy, had a sharp increase in B7-H3 in the CSF during Course 2, while S008, who had clinical improvement on protocol therapy, had consistently lower B7-H3 present. Notably, serum B7-H3 steadily declined in both patients over time, with the exception of a transient increase in S005 between Courses 4 and 5. Future work for all enrolled patients with DIPG will explore the correlation of these targeted proteomic measurements with clinical end points for potential use as markers of efficacy of therapy or adverse events.

Abstract CT056: Durable complete responses to adoptive cell transfer using tumor infiltrating lymphocytes (TIL) in non-small cell lung cancer (NSCLC): A phase I trial

Abstract Study Objectives: A hallmark of tumor infiltrating lymphocytes (TIL) in melanoma is the potential for a complete response (CR) which can last for decades. This long-lived effect is attributed to persistence of memory T cells. However, clinical efficacy in metastatic non-small cell lung cancer (mNSCLC) has not previously been reported. We launched a phase I trial with the objective to evaluate the safety and efficacy in mNSCLC after evidence of progression on nivolumab. Methodology: Full eligibility criteria is described in trial registry (NCT03215810). Patients were required to have mNSCLC with at least 1 RECIST measurable lesion and also 1 lesion safely accessible for excisional biopsy, usually a supraclavicular lymph node or pleural nodule. This histologically confirmed metastasis was resected and TIL cultured. Autologously reactive cultures were pooled and cryopreserved. TIL was successfully expanded in 95% of patients, to a median dose of 103 billion CD3+ cells. Patients received nivolumab for 4 cycles with two serial CT scans. Patients with tumor enlargement or new lesions proceeded to lymphodepletion cyclophosphamide/fludarabine (Cy/Flu), TIL, and attenuated IL-2. After first CT scan, patients resumed nivolumab for up to 11 doses to augment TIL persistence. Results: Of 32 patients screened, 20 were eligible and enrolled. Median age 54 yrs (range 38 - 75), median PD-L1 proportion score 6%, median estimated TMB 5 mut/MB, 20% EGFR-mutant. The majority had bulky disease with mean sum of target lesion diameters of 7.0 cm. Of 20 enrolled, 13 had evidence of progression on nivolumab and received subsequent Cy/Flu/TIL/IL-2. Two more are progressing on nivolumab and set to receive TIL within next 2 months. Common non-hematologic adverse events (AEs) of the Cy/Flu/TIL/IL2 regimen included hypoalbuminemia (92%), hypophosphatemia (85%), nausea (77%), hyponatremia (69%), diarrhea (62%), the majority of these AEs resolving by Day +10 post-TIL. Initial tumor regression occurred in most patients at their first post-TIL CT scan, with the median best overall change in sum of target lesion diameters of -38% (range +20 to -100). Median time-on-trial post-TIL is 1.4 years. Two patients have achieved durable CRs which are still ongoing almost 1 year post-TIL. One is a never-smoker with EGFREx19 mutation and PD-L1 1%. Three additional patients were able to maintain a clinical remission by local ablative therapy of an isolated new lesion performed 6 to 17 months post-TIL. Persistence of the infused TCR-Vβ clonotypes at post-infusion timepoints was associated with clinical benefit. Neoantigen-specific T cells were detected in the TIL and post-TIL peripheral blood. Conclusions: TIL has manageable toxicity and capacity to achieve durable remission in mNSCLC after nivolumab treatment. TIL may be a promising option for fit mNSCLC patients. Citation Format: Ben Creelan, Chao Wang, Jamie Teer, Eric Toloza, John Mullinax, Jiqiang Yao, John Koomen, Sungjune Kim, Alberto Chiappori, James Saller, Leighann Montoya, Ana Marie Landin, Tawee Tanvetyanon, Bin Fang, Zachary Thompson, Xiaoping Yu, Andreas Saltos, Dung-Tsa Chen, Jose Conejo-Garcia, Eric Haura, Scott Antonia. Durable complete responses to adoptive cell transfer using tumor infiltrating lymphocytes (TIL) in non-small cell lung cancer (NSCLC): A phase I trial [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr CT056.

Phase I study of the combination of alisertib (MLN8237) and gemcitabine in advanced solid tumors.

3589 Background: Aurora Kinase A (AKA) is a key mitotic regulator overexpressed in multiple solid tumors. This open-label dose escalation and expansion phase I study evaluated the safety and tolerability of alisertib (MLN8237), an oral AKA inhibitor, in combination with gemcitabine. Methods: In dose escalation, patients (pts) &gt; 18y with refractory solid tumors received 28-day cycles of gemcitabine on days 1, 8, 15 and alisertib twice daily on days 1-3, 8-10, and 15-17. Gemcitabine was given at 1000mg/m2. Four dose levels (DL) of alisertib (20-50mg) were given per 3+3 design to investigate dose limiting toxicities (DLT) in cycle 1, to determine maximum tolerated dose (MTD) and recommended phase II dose (RP2D). In dose expansion, advanced pancreatic adenocarcinoma pts received the MTD dose twice daily on a modified dosing schedule to allow for pharmacokinetic (PK) evaluation. Anti-tumor activity was assessed by response rate (RECIST 1.1) and progression-free survival (PFS). PK evaluation of plasma gemcitabine and alisertib was performed on all pts enrolled in the dose expansion. PK sampling was performed before treatment, immediately after gemcitabine infusion, and at other pre-specified post-infusion timepoints. Results: Twenty-six pts were treated in total: 21 pts in dose escalation and 5 pts in dose expansion. Overall, median age was 57y [42-82]; 50% male; 62% PS 1 (16 pts); 2 [0-7] median prior therapies. In the dose escalation phase, 9 tumor types were included and NSCLC was most common (7 pts). Maximum administered dose (DL4) achieved 900 mg alisertib per cycle and was tolerated (1 DLT in 6 pts). The dose expansion phase enrolled 5 pts with advanced pancreatic adenocarcinoma; median age 63y [48-82]; 60% male; 60% PS 1 (3 pts); 2 [1-2] median prior therapies. Grade ≥3 TRAEs were observed in 73% of all pts and were predominantly hematologic, including neutropenia (54%), leukopenia (50%), and lymphopenia (31%). Similar TRAEs were seen at DL4; all 14 pts experienced neutropenia with 64% experiencing grade ≥3 neutropenia. Fourteen of 23 evaluable pts (61%) had stable disease and 2 pts (9%) had partial response (PR) as best overall response. Median PFS was 2.9 months (95% CI 2.0-4.2). Analysis of PK data is ongoing and will be reported. Conclusions: Alisertib can be safely administered with gemcitabine. RP2D for alisertib is 50 mg PO BID in combination with full dose gemcitabine. Best response was at least stable disease in a majority of pts with PR observed in 9% of this heavily pretreated group of patients. Most grade ≥3 TRAEs were hematologic. Results of PK studies will also be reported. Clinical trial information: NCT01924260 .

Effect of 7.5% hypertonic saline solution on whole blood coagulation in healthy dogs using thromboelastography.

ObjectiveTo evaluate the effects of 7.5% hypertonic saline solution (HSS) on whole blood coagulation in healthy dogs and to compare electrolyte and osmolality measurements between in vivo and in vitro dilution with HSS.DesignExperimental study.SettingUniversity teaching hospital.AnimalsTwelve adult purpose‐bred Beagles.InterventionsAll 12 dogs received 5 mL/kg 7.5% HSS at 1 mL/kg/min. After a 14‐day washout period, 5 of these dogs were randomly selected and received the same volume of 0.9% NaCl. Blood samples were collected before infusion, immediately after infusion, and at 30, 60, and 90 minutes after infusion for the measurement of coagulation using thromboelastography. For comparison of electrolyte concentrations and osmolality between in vitro dilution and in vivo dilution of HSS, 6‐mL blood samples were diluted with 7.5% HSS (1:18 ratio) at baseline.Measurements and Main ResultsNone of the thromboelastography variables differed significantly between the 7.5% HSS group and the 0.9% NaCl group. The sodium and chloride levels, and the osmolality, were significantly increased at all postinfusion time points compared to baseline, while those levels were significantly higher with in vitro dilution than all postinfusion time points. However, almost all the values gradually decreased and became similar to baseline values in case of in vivo dilution.ConclusionsThe clinically relevant dose of 7.5% HSS (5 mL/kg) did not affect whole blood coagulation significantly in healthy Beagles. Further studies are necessary to assess the effect of HSS on blood coagulation in canine patients with shock.

Ketamine for suicidal ideation in adults with psychiatric disorders: A systematic review and meta-analysis of treatment trials.

Ketamine may reduce suicidal ideation in treatment-resistant depression. But it is not known how quickly this occurs and how long it persists. We undertook a systematic review and meta-analysis to determine the short- and long-term effectiveness of ketamine for suicidality. CENTRAL, EMBASE, Medline, and PsycINFO were searched until 12 December 2018. Randomised controlled trials of ketamine or esketamine reporting data on suicidal ideation, self-harm, attempted or completed suicide in adults diagnosed with any psychiatric disorder were included. Two reviewers independently extracted data, and certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation tool. Standardised mean difference was used for continuous outcomes. Twenty-five reports from 15 independent trials, with a total of 572 participants diagnosed with predominately affective disorders, were included. The evidence was rated moderate to low. In most trials, ketamine was administered at 0.5 mg/kg via a single intravenous infusion over a 30- to 45-minute period. Only a single trial of intranasal esketamine was identified. At 4 hours post-infusion, treatment with ketamine was associated with a significant reduction in suicidal ideation scores (standardised mean difference = -0.51, 95% confidence interval = [-1.00, -0.03]), which persisted until 72 hours post-infusion (time points between 12 and 24 hours: standardised mean difference = -0.63, 95% confidence interval = [-0.99, -0.26]; between 24 and 72 hours: standardised mean difference = -0.57, 95% confidence interval = [-0.99, -0.14]), but not thereafter. However, there was marked heterogeneity of results. In a single trial of esketamine, marginal effects on suicidal ideation were observed. In terms of actual suicidal behaviour, there were virtually no data on effects of ketamine or esketamine. A single infusion of ketamine may have a short-term (up to 72 hours) beneficial impact on suicidal thoughts. While confirmation of these results in further trials is needed, they suggest possible use of ketamine to treat acute suicidality. Means of sustaining any anti-suicidal effect need to be found.

Durable and Robust Fetal Globin Induction without Anemia in Rhesus Monkeys Following Autologous Hematopoietic Stem Cell Transplant with BCL11A Erythroid Enhancer Editing

Elevated fetal hemoglobin (HbF, α2γ2) levels are clinically beneficial for patients with β-hemoglobinopathies. Editing of the erythroid-specific BCL11A enhancer induces HbF, inhibiting sickling and restoring globin chain balance in erythroid cells derived from hematopoietic stem and progenitor cells (HSPCs) from SCD and β-thalassemia patients respectively, without detectable genotoxicity or adverse effects on hematopoietic stem cell (HSC) function (Wu Y, Nat Med, 2019). Here, we sought to evaluate engraftment and HbF induction potential of erythroid-specific BCL11A enhancer edited CD34+ HSPCs in a non-human primate transplantation model in which hemoglobin switching is conserved. We targeted the erythroid-specific +58 DNAse I hypersensitive site of BCL11A, which has identical human and rhesus sequences at the spacer and protospacer adjacent motif (PAM) of the potent #1617 sgRNA. Ribonucleoprotein complex (RNP) composed of 3x-NLS SpCas9 protein and either BCL11A enhancer targeting (#1617) or AAVS1 targeting sgRNA was electroporated into rhesus CD34+ HSPCs (n=3). Following erythroid differentiation, substantial γ-globin expression (54-77%, p&lt;0.01) was observed in BCL11A edited cells (81-85% indels) as compared to 19-25% and 15-24% for non-electroporated and AAVS1 edited cells, respectively, with no significant difference in red blood cell (RBC) enucleation efficiency (44-47%) among groups. We tested BCL11A enhancer editing with autologous HSC transplant in two cohorts, with two macaques per cohort. For cohort 1, we performed competitive engraftment of BCL11A enhancer and AAVS1 edited HSPCs to test long-term reconstitution. For cohort 2, we evaluated BCL11A enhancer editing alone to evaluate HbF induction and hematopoietic reconstitution. For each cohort, purified CD34+ HSPCs were electroporated with RNP one day after G-CSF and plerixafor mobilization and cultured for two days prior to cryopreservation. HSPCs were thawed and infused following 2×5 Gy total body irradiation. For cohort 1 (n=2, ZL25 and ZL22, 1.34-1.39×106 CD34+ HSPCs/kg), we observed reduced indel frequencies (8-41%) at early post-infusion time points compared to cell products (18-49%), suggesting indels in unfractionated HSPCs may overestimate those in engrafting cells and/or hematopoietic ablation was incomplete. From weeks 6 to 83, stable indel frequencies were detected in both BCL11A (~3-18%) and AAVS1 (~10-45%), suggesting no selective advantage for BCL11A enhancer edited, AAVS1 edited, or non-edited HSCs. For cohort 2 (BCL11A enhancer editing alone (n=2, ZM17 and ZM26, 1.78-6.06×106 CD34+ cells/kg), cell products showed improved editing with ~95% indels and ~65-78% γ-globin protein after in vitro erythroid culture. Animals engrafted with typical kinetics and displayed stable indel ratios up to 28 weeks post-transplantation. A significant correlation was detected between γ-globin level and indel frequency comparing all 4 transplanted animals and unedited controls (R2=0.76, p&lt;0.01). In both edited and unedited animals γ-globin levels peaked in the first two months after transplantation and subsequently declined and plateaued. In ZM17 (~70% BCL11A enhancer indels at ~24 weeks), ~12% γ-globin was observed in peripheral blood (PB) at last measurement (compared to 0.5% γ-globin in RBC prior to transplant). In the same animal, editing ranged from 78-81% across all PB and bone marrow (BM) lineages (excluding CD3+ T-cells with 63% indels), including B-lymphoid, myeloid, erythroid, and HSPCs (in particular including 78% indels in CD71+ CD45- erythroblasts). Hemoglobin, hematocrit, and reticulocyte counts and peripheral smear appearance were all normal, suggesting no erythroid toxicity. Colony-forming ability of BM-derived mononuclear cells was similar in edited and control animals. In summary, we evaluated the clinical potential of autologous BCL11A erythroid enhancer editing in rhesus macaques. BCL11A enhancer edited HSCs can persist for at least 83 weeks post-transplant and provide therapeutic levels of HbF in peripheral RBCs without anemia or other apparent hematologic toxicity. Furthermore, these results emphasize input CD34+ HSPC dose and conditioning intensity as critical variables that influence gene editing following autologous HSCT. Overall, these findings support BCL11A erythroid enhancer genome editing as a promising strategy for therapeutic HbF induction. Disclosures Weiss: GlaxoSmithKline: Consultancy; Cellarity INC: Consultancy; Esperian: Consultancy; Beam Therapeutics: Consultancy; Rubius INC: Consultancy.

Use of highly characterized EBV-Specific T Cells outside of the immediate Post-Transplant setting

Background & Aim Given the efficacy of donor-derived EBV-specific T cells (EBVSTs) in the post- HSCT environment, and considering many lymphoma patients are immunocompromised, we hypothesized that third-party EBVSTs can effectively treat EBV+ lymphoma by directly killing lymphoma cells, and by reactivating endogenous immunity. To test this hypothesis, we designed a Phase 1 dose escalation trial (in accordance with regulatory agencies) of third party EBVSTs in patients with relapsed/refractory EBV+ lymphoma. Methods, Results & Conclusion We generated a bank of EBVSTs from eligible donors with diverse HLA haplotypes and highest antigen specificity to the EBV Type 2 latency antigens (LMP1/2, EBNA1, BARF1) using IFNγ ELIspot assay. We constructed a database containing the HLA restriction of antigen specificity for each line to ensure we only choose lines with antigen-specific activity restricted by alleles shared between donor and recipient. We identified a suitable partially matched line for 94% of referred patients within 2 days. We have treated 19 patients, 14 of which are evaluable. At the initial response evaluation timepoint, 8 of these 14 patients had a clinical response (complete, partial, or mixed responses), which was sustained for at least 6 months in 5 patients. Additionally, 4/14 patients experienced prolonged stable disease, despite previous refractory status. Infusions were safe, with no occurrences of graft-versus host disease or cytokine release syndrome. We observed enhanced and sustained viral and non-viral tumor antigen recognition in most responding patients, and early loss of antigen recognition in the 2 patients with progressive disease. Using technology from Adaptive Biotechnologies, we tracked the frequency of patient and line-specific clones at post-infusion timepoints in a subset of patients. While this analysis is still ongoing, early anaylsis indicates that some patients with favorable clinical responses had EBVST clones from the infused line that were identified at both early and late time points. Expansion corresponded with increased responses to EBV or tumor-associated antigens on ELIspot assays, suggesting EBVSTs may act as a “vaccine” for functional clones. We are exploring strategies to enhance persistence and antitumor activity, including lymphodepleting chemotherapy and engineering our T cells resistant to alloreactive rejection. Given the promising responses, we have recently extended our therapy to other EBV+ malignancies.

3525 Improvement in Suicidal Ideation after Repeated Ketamine Infusions: Relationship to Reductions in Symptoms of Posttraumatic Stress Disorder, Depression, and Pain

OBJECTIVES/SPECIFIC AIMS: Given the heightened risk for suicide seen in individuals with PTSD+MDD, this report explored the effect of repeated ketamine infusions on SI in a cohort of veterans. METHODS/STUDY POPULATION: Veterans with PTSD+MDD (n = 15) received six intravenous infusions of 0.5 mg/kg ketamine on a Monday-Wednesday-Friday schedule over a 12-day period. All subjects endorsed SI at baseline. Outcome measures included the Montgomery-Asberg Depression Rating Scale (MADRS) total score, MADRS suicidal ideation item, and PTSD symptom Checklist for DSM-5 (PCL-5) subscales (intrusion, avoidance, negative alterations in cognition and mood, and marked alterations in arousal and reactivity), and visual analog scale of pain. Measures were collected immediately before and 24-hours after each infusion. RESULTS/ANTICIPATED RESULTS: Significant improvement in SI was observed 24-hours after the first infusion (Z = 3.21; p = .001) and remained significantly improved at all other post-infusion time points. Improvement in SI at the conclusion of the infusion series was significantly correlated with PTSD subscales of avoidance (r(12) = .610, p = .021), negative alterations in cognition and mood (r(12) = .786, p = .001), alterations in arousal and reactivity (r(12) = .729, p = .003), and pain (r(12) = .591, p = .013), even when controlling for improvement in symptoms of depression. DISCUSSION/SIGNIFICANCE OF IMPACT: The present analysis provides evidence of improvement in SI in a cohort of veterans with PTSD+MDD. Improvements in suicidality were correlated with PTSD symptom subscales and pain independent of improvement in depression. This report extends the interpersonal theory of suicide as it applies to posttraumatic pathology by demonstrating a significant association between improvements in all subclusters of PTSD, improvement in pain and improvement in suicidal ideation.

Hypophosphatemia after High Dosage Iron Substitution with Ferric Carboxymaltose (FCM) and Iron Isomaltoside (IM) — the Randomised Controlled Home Afers 1 Trial

In iron deficiency anaemia patients, intravenous administration of either ferric carboxymaltose (FCM) or iron isomaltoside (IM) both allow high dosage iron substitution within a single outpatient visit. In contrast, other iron compounds require repetitive, low dosage infusions. Recently, FCM was reported to frequently induce acute, reversible hypophosphatemia. It remains enigmatic whether these hypophosphataemic effects of FCM are substance-specific, or whether they generally occur after high dosage iron substitution. A direct comparison of phosphorus regulation after high dosage iron substitution with either FCM or IM is clinically important, as hypophosphatemia after FCM has anecdotally been associated with osteomalacia and bone fractures.In the HOMe AFers 1 (HOMburg evaluations on application of Ferrum study 1) trial, we recruited normophosphatemic women with gynaecological bleeding and subsequent iron deficiency anaemia, in whom we assessed the longitudinal biochemical response over 28 days to a single intravenous injection of equivalent doses of randomly-assigned FCM and IM (1000 mg). The primary study hypothesis was that the incidence of hypophosphatemia - defined as plasma phosphorus < 2.0 mg/dl at least out of three post-infusion study time points (day 1, day 8, and week 5) - differs between FCM and IM. HOMe AFers 1 initially planned to recruit 60 women. An interim analysis was pre-specified and scheduled in July 2018, with the option to stop further patient recruitment if the incidence of hypophosphatemia differs significantly at this interim analysis.At the time point of the interim analysis, 26 patients have been recruited. One patient withdrew her acceptance to participate after day 1, leaving 25 patients for our per protocol interim analysis. Baseline plasma phosphorus did not differ significantly between FMC (3.3 ± 0.4 mg/dl) and IM (3.6 ± 0.6 mg/dl; p = 0.135). Analysis on the primary endpoint demonstrated that significantly more women developed hypophosphatemia < 2.0 mg/dl after FMC infusion (9 out of 12 patients) than after IM infusion (1 out of 13 patient) (p=0.001). Further, the minimum plasma phosphorus during any of the three post-infusion study time points was lower after FMC (1.8 ± 0.3 mg/dl) than after IM (2.7 ± 0.6 mg/dl; p < 0.001). As expected, ferritin and haemoglobin increased in both study groups after iron infusion. No severe adverse events occurred in either group.In conclusion, while both FCM and IM provide efficient iron substitution in iron deficiency anaemia, FCM induced a substantially higher incidence of hypophosphatemia. DisclosuresEmrich:Pharmacosmos: Consultancy, Honoraria, Research Funding. Stilgenbauer:Mundipharma: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; AbbVie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pharmcyclics: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Sanofi: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Genentech: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Genzyme: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Boehringer-Ingelheim: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Hoffmann La-Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; GSK: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Brandenburg:Pharmacosmos: Consultancy, Honoraria, Research Funding; Vifor: Consultancy, Honoraria. Heine:Pharmacosmos: Consultancy, Honoraria, Research Funding.

Long-Term Remission of CLL Sustained By Pauciclonal Anti-CD19 Chimeric Antigen Receptor T (CTL019) Cell Clones

Long-Term Remission of CLL Sustained By Pauciclonal Anti-CD19 Chimeric Antigen Receptor T (CTL019) Cell Clones

The use of ketamine as an antidepressant: a systematic review and meta-analysis.

The current meta-analysis examines the effects of ketamine infusion on depressive symptoms over time in major depressive disorder (MDD) and bipolar disorder (BD). Following a systematic review of the literature, data were extracted from 21 studies (n = 437 receiving ketamine) and analysed at four post-infusion time points (4 h, 24 h, 7 days and 12-14 days). The moderating effects of several factors were assessed including: repeat/single infusion, diagnosis, open-label/participant-blind infusion, pre-post/placebo-controlled design and the sex of patients. Effect sizes were significantly larger for repeat than single infusion at 4 h, 24 h and 7 days. For single infusion studies, effect sizes were large and significant at 4 h, 24 h and 7 days. The percentage of males was a predictor of antidepressant response at 7 days. Effect sizes for open-label and participant-blind infusions were not significantly different at any time point. Single ketamine infusions elicit a significant antidepressant effect from 4 h to 7 days; the small number of studies at 12-14 days post infusion failed to reach significance. Results suggest a discrepancy in peak response time depending upon primary diagnosis - 24 h for MDD and 7 days for BD. The majority of published studies have used pre-post comparison; further placebo-controlled studies would help to clarify the effect of ketamine over time.