Outcome of donor-derived TAA-T cell therapy in patients with high-risk or relapsed acute leukemia post allogeneic BMT

Hannah Kinoshita, Kenneth R Cooke, Melanie Grant, Maja Stanojevic, C Russell Cruz, Michael Keller, Maria Fernanda Fortiz, Fahmida Hoq, Haili Lang, A John Barrett, Hua Liang, Jay Tanna, Nan Zhang, Abeer Shibli, Anushree Datar, Kenneth Fulton, Divyesh Kukadiya, Anqing Zhang, Kirsten M Williams, Hema Dave, Jeffrey S Dome, David Jacobsohn, Patrick J Hanley, Richard J Jones, Catherine M Bollard, Hannah Kinoshita, Kenneth R Cooke, Melanie Grant, Maja Stanojevic, C Russell Cruz, Michael Keller, Maria Fernanda Fortiz, Fahmida Hoq, Haili Lang, A John Barrett, Hua Liang, Jay Tanna, Nan Zhang, Abeer Shibli, Anushree Datar, Kenneth Fulton, Divyesh Kukadiya, Anqing Zhang, Kirsten M Williams, Hema Dave, Jeffrey S Dome, David Jacobsohn, Patrick J Hanley, Richard J Jones, Catherine M Bollard

Abstract

Patients with hematologic malignancies relapsing after allogeneic blood or marrow transplantation (BMT) have limited response to conventional salvage therapies, with an expected 1-year overall survival (OS) of <20%. We evaluated the safety and clinical outcomes following administration of a novel T-cell therapeutic targeting 3 tumor-associated antigens (TAA-T) in patients with acute leukemia who relapsed or were at high risk of relapse after allogeneic BMT. Lymphocytes obtained from the BMT donor were manufactured to target TAAs WT1, PRAME, and survivin, which are over-expressed and immunogenic in most hematologic malignancies. Patients received TAA-T infusions at doses of 0.5 to 4 × 107/m2. Twenty-three BMT recipients with relapsed/refractory (n = 11) and/or high-risk (n = 12) acute myeloid leukemia (n = 20) and acute lymphoblastic leukemia (n = 3) were infused posttransplant. No patient developed cytokine-release syndrome or neurotoxicity, and only 1 patient developed grade 3 graft-versus-host disease. Of the patients who relapsed post-BMT and received bridging therapy, the majority (n = 9/11) achieved complete hematologic remission before receiving TAA-T. Relapsed patients exhibited a 1-year OS of 36% and 1-year leukemia-free survival of 27.3% post-TAA-T. The poorest prognosis patients (relapsed <6 months after transplant) exhibited a 1-year OS of 42.8% postrelapse (n = 7). Median survival was not reached for high-risk patients who received preemptive TAA-T posttransplant (n = 12). Although as a phase 1 study, concomitant antileukemic therapy was allowed, TAA-T were safe and well tolerated, and sustained remissions in high-risk and relapsed patients were observed. Moreover, adoptively transferred TAA-T detected by T-cell receptor V-β sequencing persisted up to at least 1 year postinfusion. This trial was registered at clinicaltrials.gov as #NCT02203903.

© 2022 by The American Society of Hematology. Licensed under Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0), permitting only noncommercial, nonderivative use with attribution. All other rights reserved.

Figures

Graphical abstract
Graphical abstract
Figure 1.
Figure 1.
Characterization of the TAA-T product by phenotype and TCR clonotype diversity. (A) Variable composition of the TAA-T products by phenotype (CD8+, CD4+, NK [natural killer], TCRγδ [γ δ T cells], NKT [natural killer T cells]) presented as percent of total cells in product as determined by 12-color flow cytometry (n = 23). (B-C) Memory phenotype described as central memory (TCM; CD3+CD4/8+CD45RO+CCR7+CD62L+), effector memory (TEM; CD3+CD4/8+CD45RO+CCR7−CD62L−), and effector T cells (TEFF; CD3+CD4/8+CD45RO−CCR7−CD62L) for evaluable samples (n = 11). (D) Diversity of TCR sequences of TAA-T products shown for representative patients in the relapsed group (P9, P3) and patients treated preemptively with TAA-T products (P12, P13).
Figure 2.
Figure 2.
Antigen specificity as measured by anti-IFNγ ELISpot, TNFα and IFNγ intracellular cytokine staining, and cytolytic function of the TAA-T products. (A) Target antigen specificity of the TAA-T product (n = 25) as determined by IFNγ production, measured by ELISpot. Target antigens were WT1, PRAME, survivin, and TAA (WT1, PRAME, and survivin pepmixes combined). The bottom dotted line denotes the median for negative control (actin = 12 SFU), the top dotted line denotes the median for positive control (SEB = 732 SFU). Mean antigen responses were statistically significantly different from actin for WT1 (P = .0469), PRAME (P = .0001), and TAA (P < .0001) but not for survivin (P = .7028). (B) TNFα and IFNγ intracellular cytokine staining (ICS) demonstrates antigen specificity for WT1 and PRAME shown for products (P6, P9). Antigen specificity measured by TNFα and IFNγ ICS of CD8+ T cells (C) and CD4+ T cells (D) of the TAA-T-cell product in evaluable samples (n = 7). SEB is used as the positive control and actin as negative control. (E) In vitro cytolytic activity of the HLA A*02+ TAA-T product against an HLA A*02+ AML cell line (THP-1) as compared with a donor lymphocyte infusion (donor PBMCs) product. (F) Superior cytolytic activity against THP-1 Violet+ CD33+ cells of the TAA-T product as compared with donor lymphocyte infusion (PBMC) is reproducible in the majority of A*02+ donor TAA-T products evaluated (as shown for P2, P6, P12). SEB, staphylococcal enterotoxin B.
Figure 2.
Figure 2.
Antigen specificity as measured by anti-IFNγ ELISpot, TNFα and IFNγ intracellular cytokine staining, and cytolytic function of the TAA-T products. (A) Target antigen specificity of the TAA-T product (n = 25) as determined by IFNγ production, measured by ELISpot. Target antigens were WT1, PRAME, survivin, and TAA (WT1, PRAME, and survivin pepmixes combined). The bottom dotted line denotes the median for negative control (actin = 12 SFU), the top dotted line denotes the median for positive control (SEB = 732 SFU). Mean antigen responses were statistically significantly different from actin for WT1 (P = .0469), PRAME (P = .0001), and TAA (P < .0001) but not for survivin (P = .7028). (B) TNFα and IFNγ intracellular cytokine staining (ICS) demonstrates antigen specificity for WT1 and PRAME shown for products (P6, P9). Antigen specificity measured by TNFα and IFNγ ICS of CD8+ T cells (C) and CD4+ T cells (D) of the TAA-T-cell product in evaluable samples (n = 7). SEB is used as the positive control and actin as negative control. (E) In vitro cytolytic activity of the HLA A*02+ TAA-T product against an HLA A*02+ AML cell line (THP-1) as compared with a donor lymphocyte infusion (donor PBMCs) product. (F) Superior cytolytic activity against THP-1 Violet+ CD33+ cells of the TAA-T product as compared with donor lymphocyte infusion (PBMC) is reproducible in the majority of A*02+ donor TAA-T products evaluated (as shown for P2, P6, P12). SEB, staphylococcal enterotoxin B.
Figure 3.
Figure 3.
Clinical outcomes for patients treated with TAA-T for relapsed disease after BMT (n = 11). (A) Swimmer plot showing clinical outcomes following salvage therapy and TAA-T infusion in patients with relapsed/refractory disease after BMT, categorized by dose level (1-4). Hematologic remission was achieved in 9/11 patients prior to TAA-T infusion with postinfusion clinical outcomes defined as CCR, PR, stable disease (SD), PD, and relapse. Patients in hematologic remission with MRD are noted as CCR*. Patients who did not achieve hematologic remission are noted as + (P3, P11). The dotted line denotes 1 year postinfusion. (B) Kaplan-Meier curve estimating LFS postinfusion of relapsed patients. One-year LFS 27.3%; median LFS was 64 days. Patients characterized as responders (CCR within 3 months of first TAA-T infusion; n = 4) had prolonged median LFS (839 days) compared with nonresponders (PD/R within 3 months of first TAA-T infusion; n = 7); median LFS was 42 days (P = .003). (C) Kaplan-Meier curve estimating OS postinfusion of relapsed patients. One-year OS was 36.36% with median survival of 255 days post–TAA-T infusion. Responders had prolonged median OS (1150 days) compared with nonresponders (150 days) (P = .003). (D) One-year postrelapse OS was 42% in early relapsers (patients with relapse within 6 months of transplant; n = 7) who received TAA-T infusion. (E) Qualitative grading of immunofluorescence expression of TAA targets (WT1, PRAME, and survivin) on blast population and clinical outcomes following TAA-T of evaluable patients with relapsed AML posttransplant. The paraffin-embedded tissues were deparaffinized and incubated post–antigen retrieval with anti-survivin, anti–Wilms tumor protein (abcam), and anti-PRAME (Sigma) followed by Alexa Fluor568 (Texas red channel) donkey anti-rabbit IgG secondary antibody for survivin and PRAME (abcam) and AlexaFluor488 (FITC) donkey anti-mouse IgG secondary antibody for WT1 (abcam). The sections were mounted with DAPI staining solution (abcam), and the images were captured at 20× magnification on an Olympus BX53-DP73 microscope using cellSens software. Clinical outcomes characterized as responder and nonresponder (as above). (F) Disease course and TCR unique clonotype frequencies over time for P5 with MDS/AML, relapsed 117 days posttransplant and subsequently achieved CR with salvage therapy (azacitidine) prior to TAA-T infusion. Hematologic relapse with peripheral blasts cleared with a second TAA-T infusion, azacitidine, and lenalidomide, though remained MRD+. (G) Disease course and unique TCR clonotype frequency over time for P8, a pediatric patient with Ph+ B-cell ALL with persistent BCR/ABL positivity posttransplant despite treatment with dasatinib. Briefly achieved BCR/ABL negativity following first TAA-T infusion followed by rise in BCR/ABL quantification ratio following the second TAA-T infusion. DAPI, 4′,6-diamidino-2-phenylindole; IgG, immunoglobulin G.
Figure 3.
Figure 3.
Clinical outcomes for patients treated with TAA-T for relapsed disease after BMT (n = 11). (A) Swimmer plot showing clinical outcomes following salvage therapy and TAA-T infusion in patients with relapsed/refractory disease after BMT, categorized by dose level (1-4). Hematologic remission was achieved in 9/11 patients prior to TAA-T infusion with postinfusion clinical outcomes defined as CCR, PR, stable disease (SD), PD, and relapse. Patients in hematologic remission with MRD are noted as CCR*. Patients who did not achieve hematologic remission are noted as + (P3, P11). The dotted line denotes 1 year postinfusion. (B) Kaplan-Meier curve estimating LFS postinfusion of relapsed patients. One-year LFS 27.3%; median LFS was 64 days. Patients characterized as responders (CCR within 3 months of first TAA-T infusion; n = 4) had prolonged median LFS (839 days) compared with nonresponders (PD/R within 3 months of first TAA-T infusion; n = 7); median LFS was 42 days (P = .003). (C) Kaplan-Meier curve estimating OS postinfusion of relapsed patients. One-year OS was 36.36% with median survival of 255 days post–TAA-T infusion. Responders had prolonged median OS (1150 days) compared with nonresponders (150 days) (P = .003). (D) One-year postrelapse OS was 42% in early relapsers (patients with relapse within 6 months of transplant; n = 7) who received TAA-T infusion. (E) Qualitative grading of immunofluorescence expression of TAA targets (WT1, PRAME, and survivin) on blast population and clinical outcomes following TAA-T of evaluable patients with relapsed AML posttransplant. The paraffin-embedded tissues were deparaffinized and incubated post–antigen retrieval with anti-survivin, anti–Wilms tumor protein (abcam), and anti-PRAME (Sigma) followed by Alexa Fluor568 (Texas red channel) donkey anti-rabbit IgG secondary antibody for survivin and PRAME (abcam) and AlexaFluor488 (FITC) donkey anti-mouse IgG secondary antibody for WT1 (abcam). The sections were mounted with DAPI staining solution (abcam), and the images were captured at 20× magnification on an Olympus BX53-DP73 microscope using cellSens software. Clinical outcomes characterized as responder and nonresponder (as above). (F) Disease course and TCR unique clonotype frequencies over time for P5 with MDS/AML, relapsed 117 days posttransplant and subsequently achieved CR with salvage therapy (azacitidine) prior to TAA-T infusion. Hematologic relapse with peripheral blasts cleared with a second TAA-T infusion, azacitidine, and lenalidomide, though remained MRD+. (G) Disease course and unique TCR clonotype frequency over time for P8, a pediatric patient with Ph+ B-cell ALL with persistent BCR/ABL positivity posttransplant despite treatment with dasatinib. Briefly achieved BCR/ABL negativity following first TAA-T infusion followed by rise in BCR/ABL quantification ratio following the second TAA-T infusion. DAPI, 4′,6-diamidino-2-phenylindole; IgG, immunoglobulin G.
Figure 4.
Figure 4.
Clinical outcomes for patients with high-risk disease treated preemptively with TAA-T after BMT (n = 12). (A) Swimmer plot showing clinical outcomes of patients treated preemptively with TAA-T infusion for high-risk disease after BMT, categorized by dose level (1-4). All patients were in CCR at the time of TAA-T infusion. The dotted line denotes 1 year postinfusion. (B) Kaplan-Meier curve estimating LFS postinfusion of preemptively treated patients. Median LFS has not been reached for all patients. Patients who relapsed in the first 6 months post–TAA-T infusion (n = 2) had median LFS of 99 days; median LFS for patients in persistent remission (no relapse or PD within 6 months of TAA-T infusion [n = 9]) has not been reached. (C) Kaplan-Meier curve estimating OS postinfusion of preemptively treated patients. Median OS has not been reached for all patients.

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