Efficacy and safety of CD19 CAR T constructed with a new anti-CD19 chimeric antigen receptor in relapsed or refractory acute lymphoblastic leukemia

Runxia Gu, Fang Liu, Dehui Zou, Yingxi Xu, Yang Lu, Bingcheng Liu, Wei Liu, Xiaojuan Chen, Kaiqi Liu, Ye Guo, Xiaoyuan Gong, Rui Lv, Xia Chen, Chunlin Zhou, Mengjun Zhong, Huijun Wang, Hui Wei, Yingchang Mi, Lugui Qiu, Lulu Lv, Min Wang, Ying Wang, Xiaofan Zhu, Jianxiang Wang, Runxia Gu, Fang Liu, Dehui Zou, Yingxi Xu, Yang Lu, Bingcheng Liu, Wei Liu, Xiaojuan Chen, Kaiqi Liu, Ye Guo, Xiaoyuan Gong, Rui Lv, Xia Chen, Chunlin Zhou, Mengjun Zhong, Huijun Wang, Hui Wei, Yingchang Mi, Lugui Qiu, Lulu Lv, Min Wang, Ying Wang, Xiaofan Zhu, Jianxiang Wang

Abstract

Background: Recent evidence suggests that resistance to CD19 chimeric antigen receptor (CAR)-modified T cell therapy may be due to the presence of CD19 isoforms that lose binding to the single-chain variable fragment (scFv) in current use. As such, further investigation of CARs recognize different epitopes of CD19 antigen may be necessary.

Methods: We generated a new CD19 CAR T (HI19α-4-1BB-ζ CAR T, or CNCT19) that includes an scFv that interacts with an epitope of the human CD19 antigen that can be distinguished from that recognized by the current FMC63 clone. A pilot study was undertaken to assess the safety and feasibility of CNCT19-based therapy in both pediatric and adult patients with relapsed/refractory acute lymphoblastic leukemia (R/R B-ALL).

Results: Data from our study suggested that 90% of the 20 patients treated with infusions of CNCT19 cells reached complete remission or complete remission with incomplete count recovery (CR/CRi) within 28 days. The CR/CRi rate was 82% when we took into account the fully enrolled 22 patients in an intention-to-treat analysis. Of note, extramedullary leukemia disease of two relapsed patients disappeared completely after CNCT19 cell infusion. After a median follow-up of 10.09 months (range, 0.49-24.02 months), the median overall survival and relapse-free survival for the 20 patients treated with CNCT19 cells was 12.91 months (95% confidence interval [CI], 7.74-18.08 months) and 6.93 months (95% CI, 3.13-10.73 months), respectively. Differences with respect to immune profiles associated with a long-term response following CAR T cell therapy were also addressed. Our results revealed that a relatively low percentage of CD8+ naïve T cells was an independent factor associated with a shorter period of relapse-free survival (p = 0.012, 95% CI, 0.017-0.601).

Conclusions: The results presented in this study indicate that CNCT19 cells have potent anti-leukemic activities in patients with R/R B-ALL. Furthermore, our findings suggest that the percentage of CD8+ naïve T cells may be a useful biomarker to predict the long-term prognosis for patients undergoing CAR T cell therapy.

Trial registration: ClinicalTrials.gov : NCT02975687; registered 29 November, 2016. https://ichgcp.net/clinical-trials-registry/NCT02975687.

Keywords: Acute lymphoblastic leukemia; Chimeric antigen receptor-modified T cell; HI19α; Single-chain variable fragment.

Conflict of interest statement

Jianxiang Wang received grant from Celgene. The other authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
FMC63 and HI19α had different binding epitopes on CD19. a Homology models of hCD19 ECD (left), FMC63 scFv (middle), and HI19α scFv (right). b Docking mode of FMC63 and hCD19 ECD. Green, hCD19 ECD epitopes; purple, FMC63 epitopes. c Docking mode of HI19α and hCD19 ECD. Green, hCD19 ECD epitopes; purple, HI19α epitopes. d Sequence of hCD19 ECD. Gray background, predicted binding amino acid residues on hCD19 ECD with scFvs. Upper panel, interaction with HI19α; lower panel, interaction with FMC63. Red color, shared antigen epitopes; yellow color, key epitopes; green color, both shared antigen epitopes and key epitopes. e Partial interaction modes showed the non-bond interaction between scFvs and hCD19 ECD. Upper panel, HI19α scFv and hCD19 ECD; lower panel, FMC63 scFv and hCD19 ECD. Green, hCD19 ECD epitopes; purple, scFvs epitopes. f Flow cytometry analysis of the proportion of CD19+ Nalm-6 cells stained with indicated concentrations of the antibody. Left panel, HI19α antibody; right panel, FMC63 antibody. g Representative flow cytometry analysis showing the proportion of CD19+ cells on Nalm-6 cells stained with 0.017 pM HI19α and 0.042 pM FMC63
Fig. 2
Fig. 2
Responses of all 20 R/R B-ALL patients to CNCT19 CAR T cell therapy. In this single-center, open-label, prospective clinical trial, a total of 20 patients diagnosed with resistant or refractory CD19+ B cell acute lymphoblastic leukemia received an infusion of CNCT19 CAR T cells. Responses over time of each patient are presented as a swimmer plot
Fig. 3
Fig. 3
Long-term survival. a–b Overall survival (a) and relapse-free survival (b) of the 20 R/R B-ALL patients treated with the CNCT19 CAR T cell infusion. Overall survival (c) and relapse-free survival (d) of patients who underwent hematopoietic stem cell transplantation. Overall survival (e) or relapse-free survival (f) of both pediatric and adult patients
Fig. 4
Fig. 4
The expansion kinetics of CAR T cells and different T cell subsets after CD19 CAR T cell infusion. a The expansion and persistence of CNCT19 CAR T cells after infusion. b The expansion and percentage of CD4+ or CD8+ T cells in peripheral blood after CAR infusion. c–d The phenotype of CD8+ T cells (c) or CD4+ T cells (d) in peripheral blood after CNCT19 CAR T cell infusion (TN, naïve T cells; TCM, central memory T cells; TEM, effective memory T cells; and TE, effector T cells)
Fig. 5
Fig. 5
The correlation between TN cell percentage and long-term survival. a, b Comparison of CD8+ TN cells (a) or CD4+ TN cell (b) percentage in peripheral blood at different time points after CAR T cell infusion between long-term response and relapsed patients (TN, naïve T cells). CD8+ or CD4+ TN cells percentage were ranked and divided into four quartiles, from lowest (Q1) to highest (Q4). c, d Relapse-free survival (c) or overall survival (d) difference between patients with low CD8+ TN cells percentage (Q1) and those with high CD8+ TN cells percentage (Q2–4). e, f Relapse-free survival (e) or overall survival (f) difference between patients with low CD4+ TN cells percentage (Q1) and high CD4+ TN cells percentage (Q2–4)

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