Sharon Yim

We conducted a phase 2 study in which patients undergoing allogeneic hematopoietic stem cell transplantation received tocilizumab in addition to standard immune suppression with tacrolimus and methotrexate for graft-versus-host disease prophylaxis. Thirty-five patients were enrolled between January 2015 and June 2016. The median age of the cohort was 66 (range: 22-76). All patients received busulfan-based conditioning, and were transplanted with human leukocyte antigen-matched related or matched unrelated bone marrow or peripheral stem cell grafts. The cumulative incidences of grades II-IV and III-IV acute graft-versus-host disease were 14% (95% CI 5-30) and 3% (95% CI 0-11) at day 100, and 17% (95% CI 7-31) and 6% (95% CI 1-16) at day 180, respectively. Notably, there were no cases of graft-versus-host disease of the lower gastrointestinal tract within the first 100 days. A comparison to 130 matched controls who only received tacrolimus and methotrexate demonstrated a lower cumulative incidence of grades II-IV acute graft-versus-host disease (17% versus 45%, P=0.003) and a significant increase in grades II-IV acute graft-versus-host disease-free survival at six months (69% versus 42%, P=0.001) with tocilizumab, tacrolimus and methotrexate, which was the primary endpoint of the study. Immune reconstitution was preserved in patients treated with tocilizumab, tacrolimus and methotrexate, as T-cell and B-cell subsets recovered to near normal levels by 6-12 months post-transplantation. We conclude that tocilizumab has promising activity in preventing acute graft-versus-host disease, particularly in the lower gastrointestinal tract, and warrants examination in a randomized setting.

Abstract Background: CAR-T cell therapy directed against the CD19 antigen is a breakthrough treatment for patients (pts) with relapsed/refractory (R/R) B-cell NHL. Despite impressive outcomes, not all pts respond and many that respond still relapse. Affordability and accessibility are further considerations that limit current commercial models of CAR-T products. Commercial CAR-T manufacturing is complex, time consuming, and expensive with a supply chain starting at the treating center with apheresis of mononuclear cells, cryopreservation, and shipping to and from a centralized third-party manufacturing site. We addressed these limitations in a Phase 1 clinical trial evaluating a first-in-human bispecific tandem CAR-T cell directed against both CD19 and CD20 (CAR-20.19-T) antigens for pts with R/R B-cell NHL. Through dual targeting we hope to improve response rates and durability of response while limiting antigen escape. We eliminated third party shipping logistics utilizing the CliniMACS Prodigy, a compact tabletop device that allows for automated manufacturing of CAR-T cells within a GMP compliant environment within the hospital. Most materials and reagents used to produce the CAR-T cell product were single-sourced from the device manufacturer. Methods: Phase 1 (NCT03019055), single center, dose escalation + expansion study to demonstrate feasibility and safety of locally manufactured second generation 41BB + CD3z CAR-20.19-T cells via the CliniMACS Prodigy. Feasibility was measured by ability to generate a target CAR-20.19-T cell dose for a minimum of 75% of subjects. Safety was assessed by the presence of dose limiting toxicities (DLTs) through 28 days post-infusion. Dose was escalated in a 3+3 fashion with a starting dose of 2.5 x 10^5 cells/kg, a target DLT rate <33%, and a goal treatment dose of 2.5 x 10^6 cells/kg. Adults with R/R Diffuse Large B-cell Lymphoma (DLBCL), Follicular Lymphoma (FL), Mantle Cell Lymphoma (MCL) or Chronic Lymphocytic Leukemia (CLL) were eligible. CAR-T production was set for a 14-day manufacturing process. Day 8 in-process testing was performed to ensure quality and suitability of CAR-T cells for a potential fresh infusion. On Day 10, pts eligible for a fresh CAR-T infusion initiated lymphodepletion (LDP) chemotherapy with fludarabine 30 mg/m2 x 3 days and cyclophosphamide 500 mg/m2 x 1 day, and cells were administered after harvest on Day 14. Pts ineligible for fresh infusion received cryopreserved product and LDP was delayed accordingly. Results: 6 pts have been enrolled and treated with CAR-20.19-T cells: 3 pts at 2.5 x 10^5 cells/kg and 3 pts at 7.5 x 10^5 cells/kg. Median age was 53 years (48-62). Underlying disease was MCL in 3 pts, DLBCL in 2 pts, and CLL in 1 patient. Baseline data and prior treatments are listed in Table 1. CAR-T production was successful in all runs and all pts received their target dose. Three pts received fresh CAR-T cells and 3 pts received CAR-T cells after cryopreservation. To date there are no DLTs to report. No cases of Grade 3/4 cytokine release syndrome (CRS) or neurotoxicity (NTX) were observed. One patient had Grade 2 CRS and Grade 2 NTX requiring intervention. The other had self-limited Grade 1 CRS and Grade 1 NTX. Median time to development of CRS was Day +11 post-infusion. All pts had neutrophil recovery (ANC>0.5 K/µL) by Day 28. Response at Day 28 (Table 2) is as follows: 2/6 pts achieved a complete response (CR), 2/6 achieved a partial response (PR), and 2/6 had progressive disease (PD). One subject with a PR subsequently progressed at Day 90. The 3 pts who did progress all underwent a repeat biopsy, and all retained either CD19 or CD20 positivity. Pts are currently being enrolled at the target dose (2.5 x 10^6 cells/kg) and updated results will be provided at ASH. Conclusions: Dual targeted anti-CD19 and anti-CD20 CAR-T cells were successfully produced for all pts demonstrating the feasibility of a point-of-care manufacturing process via the CliniMACS Prodigy device. With no DLTs or Grade 3-4 CRS or NTX to report, and 2/6 heavily pre-treated pts remaining in CR at 3 and 9 months respectively our approach represents a feasible and promising alternative to existing CAR-T models and costs. Down-regulation of both target antigens was not identified in any patient following CAR-T infusion, and in-process studies suggest that a shorter manufacturing timeline is appropriate for future trials (10 days). Disclosures Shah: Juno Pharmaceuticals: Honoraria; Lentigen Technology: Research Funding; Oncosec: Equity Ownership; Miltenyi: Other: Travel funding, Research Funding; Geron: Equity Ownership; Exelexis: Equity Ownership. Zhu:Lentigen Technology Inc., A Miltenyi Biotec Company: Research Funding. Schneider:Lentigen Technology Inc., A Miltenyi Biotec Company: Employment. Krueger:Lentigen Technology Inc., A Miltenyi Biotec Company: Employment. Worden:Lentigen Technology Inc., A Miltenyi Biotec Company: Employment. Hamadani:Sanofi Genzyme: Research Funding, Speakers Bureau; Merck: Research Funding; Janssen: Consultancy; MedImmune: Consultancy, Research Funding; Cellerant: Consultancy; Celgene Corporation: Consultancy; Takeda: Research Funding; Ostuka: Research Funding; ADC Therapeutics: Research Funding. Johnson:Miltenyi: Research Funding. Dropulic:Lentigen, A Miltenyi Biotec company: Employment. Orentas:Lentigen Technology Inc., A Miltenyi Biotec Company: Other: Prior Employment. Hari:Takeda: Consultancy, Honoraria, Research Funding; Janssen: Honoraria; Kite Pharma: Consultancy, Honoraria; Celgene: Consultancy, Honoraria, Research Funding; Spectrum: Consultancy, Research Funding; Bristol-Myers Squibb: Consultancy, Research Funding; Amgen Inc.: Research Funding; Sanofi: Honoraria, Research Funding.

Abstract Background With the rising number of chimeric antigen receptor (CAR) T cell treated patients, it is increasingly important to understand the treatment’s impact on patient-reported outcomes (PROs) and, ideally, identify biomarkers of central nervous system (CNS) adverse effects. Methods The purpose of this exploratory study was to assess short-term PROs and serum kynurenine metabolites for associated neurotoxicity among patients treated in an anti-CD20, anti-CD19 (LV20.19) CAR T cell phase I clinical trial (NCT03019055). Fifteen CAR T treated patients from the parent trial provided serum samples and self-report surveys 15 days before and 14, 28, and 90 days after treatment. Results Blood kynurenine concentrations increased over time in patients with evidence of neurotoxicity ( p = 0.004) and were increased in self-reported depression ( r = 0.52, p = 0.002). Depression improved after CAR T infusion ( p = 0.035). Elevated 3-hydroxyanthranilic acid (3HAA) concentrations prior to cell infusion were also predictive of neurotoxicity onset ( p = 0.031), suggesting it is a biomarker of neurotoxicity following CAR T cell therapy. Conclusions Elevated levels of kynurenine pathway metabolites among CAR T cell recipients are associated with depressed mood and neurotoxicity. Findings from this exploratory study are preliminary and warrant validation in a larger cohort.

Abstract Introduction: Bispecific lentiviral anti-CD20, anti-CD19 (LV20.19) CAR T-cells may improve outcomes in relapsed, refractory (R/R) B-cell malignancies by limiting relapse from single antigen downregulation (Shah et al. Nature Med. 2020). Preclinical models suggest that CAR T-cells cultured with IL7 & IL15 (IL7+15) can improve cell expansion, in vivo persistence, tumor cytotoxicity, and increase frequency of a T-stem cell memory phenotype (Xu et al. Blood 2014) In an ongoing phase 1/2 clinical trial we examined the impact of IL7+15 (in lieu of IL-2 in our prior study) and varying lengths of manufacturing (MF) on LV20.19 CAR T-cell safety and efficacy in R/R B-cell non-Hodgkin lymphoma (NHL). Methods: We conducted a Phase 1/2 single center, prospective trial (NCT04186520) evaluating LV20.19 CAR T-cells at a fixed dose of 2.5x10^6 cells/kg for patients (pts) with R/R B-cell NHL. LV20.19 CAR T-cells were locally manufactured in the CliniMACS Prodigy device with IL7+15 for cell expansion with goal of fresh infusion at varying lengths of MF (8 vs 12 days). There are four cohorts in this study. Cohort 1 was a 6-patient phase 1 safety run-in of IL7+15 expanded LV20.19 CAR T-cells manufactured for 8 and 12 days respectively (n=3 in each arm). Cohort 2 & 3 were phase 1b arms comparing flexible 8/12-day MF versus fixed 12-day MF for pts with diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), and marginal zone lymphoma (MZL). Cohort 4 is a phase 2 arm in mantle cell lymphoma (MCL) utilizing a flexible 8/12-day MF protocol. The primary outcome of the Phase 1 cohorts is safety. Dose limiting toxicity (DLT) was evaluated during the first 28 days post-CAR treatment. Results: In total, 22 pts received LV20.19 CAR T-cells at the specified dose of 2.5x10^6 cells/kg. Median age was 63 (44-78). There were 11 pts with DLBCL, 8 with MCL, and 3 with FL. Median lines of prior therapy was 4 (2-11) (Table 1). Outcomes (all pts) There were no DLTs in the Phase 1 safety run-in allowing accrual to open in the two Phase 1b and Phase 2 MCL arms. In total, there was one DLT in the Phase 1b 12-day arm with prolonged grade 3 ICANS and grade 4 acute kidney injury. There were two non-relapse mortality (NRM) events outside the DLT period from infectious complications (pneumonia and gram-negative rod sepsis). Cytokine release syndrome (CRS) occurred in 19 pts (86%), mostly Grade 1-2 (18/19) (Table 2). ICANS occurred in 6 pts (27%); 3 pts had grade 3 ICANS (14%). Median day to CRS was day 1 (range 0-8) which correlated with rapid in-vivo expansion (Figure 1). Among all pts, the overall response rate (ORR) was 91% (55% complete response [CR]) and 2 pts had progressive disease (PD) at Day 28, one of which was a prior anti-CD19 CAR failure. Seventeen pts had ClonoSEQ minimal residual disease (MRD) testing between Days 28-60, and 13 were MRD-negative. The median follow up of survivors is 6 months. The median PFS and OS have not been reached to date (Figure 2). Twenty of 22 pts received fresh CAR T-cells without cryopreservation. Outcomes by 8 vs 12-day MF (Phase 1 & 1B cohorts) Pts with DLBCL, FL, and MZL (n=14) were assigned consecutively to either 8-day or 12-day MF schema (n=7 in each arm). ORR in the 8-day MF arm was 100% (CR 71%) vs 71% (CR 29%) in the 12-day arm. Immunophenotyping of LV20.19 CAR T-cells demonstrated that nearly all 12-day MF cells had an effector-memory phenotype and contained few, if any, less differentiated T-cells while 8-day MF cells contained T-cells with a central-memory phenotype. Rates of CRS were higher in the 8-day MF arm (100% vs 57%, p=0.05) with no difference in ICANS. MCL outcomes In total, 8 pts with MCL received LV20.19 CAR cells (3 pts in Phase 1 & 5 in the Phase 2 cohort). Six of 8 patients had LV20.19 CAR T-cells manufactured in 8 days. Median lines of therapy were 5 (4-8) and 6 progressed on covalent BTK inhibitors. The ORR at day 28 was 100% (CR=63%), and 6 of 7 evaluated for MRD were negative at day 28. At last follow-up, no patient has relapsed with median follow-up time of 5 months (1.5 to 12 months). One of the two NRM events was in the MCL phase II cohort. There was no grade ≥3 CRS and only one grade 3 ICANS. Conclusions: Bispecific LV20.19 CAR T-cells expanded with IL7+15 are safe and efficacious for R/R B-cell NHL with a high ORR and low rates of grade ≥3 CRS or ICANS. Early results demonstrate immunophenotypic differences and improved responses among pts treated with a shorter 8-day MF process. MCL outcomes were impressive with a 100% ORR and no relapses to date. Figure 1 Figure 1. Disclosures Shah: Miltenyi Biotec: Consultancy, Honoraria, Research Funding; Lily: Consultancy, Honoraria, Research Funding; Legend: Consultancy; Incyte: Consultancy; Umoja: Consultancy; Kite: Consultancy; Epizyme: Consultancy. Schneider: Lentigen Technology: Current Employment. Hamadani: Sanofi, Genzyme, AstraZeneca, BeiGene: Speakers Bureau; Takeda, Spectrum Pharmaceuticals and Astellas Pharma: Research Funding; Janssen, Incyte, ADC Therapeutics, Omeros, Morphosys, Kite: Consultancy. Fenske: TG Therapeutics: Consultancy, Speakers Bureau; Servier Pharmaceuticals: Consultancy; Seattle Genetics: Speakers Bureau; Sanofi: Speakers Bureau; Pharmacyclics: Consultancy; MorphoSys: Consultancy; Kite (Gilead): Speakers Bureau; KaryoPharm: Consultancy; CSL Therapeutics: Consultancy; Bristol-Myers Squibb: Speakers Bureau; Biogen: Consultancy; Beigene: Consultancy; AstraZeneca: Speakers Bureau; ADC Therapeutics: Consultancy; Adaptive Biotechnologies: Consultancy; AbbVie: Consultancy. Johnson: Miltenyi Biotec: Research Funding. Hari: Adaptive Biotech: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other, Research Funding, Speakers Bureau; Karyopharm: Consultancy; Millenium: Membership on an entity's Board of Directors or advisory committees, Research Funding; GSK: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other, Research Funding, Speakers Bureau; Oncopeptides: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Sanofi: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other, Research Funding, Speakers Bureau; Celgene-BMS: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other, Research Funding, Speakers Bureau; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other, Research Funding, Speakers Bureau.