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This spelling was chosen for Maus as it was deemed the easiest spelling for English speakers to pronounce correctly. The German version of his name was "Wilhelm" or "Wolf" for short , and he became William when he moved to the U.
Her name became Anna when she and Vladek arrived in the U. Abell, Catharine Documentary Graphic Novels and Social Realism.
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Retrieved April 17, Blau, Rosie November 29, Financial Times. Retrieved April 18, We also discuss the outlook for CAR T-cell therapies, including managing toxicities and expanding the availability of personalized cell therapy as a promising approach to all hematologic malignancies.
Many questions remain in the field of CAR T cells directed to hematologic malignancies, but the encouraging response rates pave a wide road for future investigation.
Immune-based therapies for cancer have the tantalizing possibility of effecting long-term durable remissions and perhaps even offering the possibility of a cure.
This is the basis for the US Food and Drug administration FDA approval of interleukin-2 IL-2 in melanoma; more recent immune therapies that are FDA-approved treatments for cancer involve checkpoint blockade, which is a form of releasing the brakes on tumor-specific T cells and allowing them to persist and expand in vivo, leading to control or regression of cancer.
Adoptive T-cell therapy also offers this possibility but has thus far been limited in application to those patients with melanoma who have adequate culture and expansion of isolated tumor-infiltrating lymphocytes.
Therapeutic approaches to overcome immune tolerance to tumors. Cytokines and vaccines can be used to augment natural T-cell responses to tumor. Antibodies targeting negative regulatory molecules such as programmed death 1 PD-1 and cytotoxic T-cell lymphocyte-associated antigen 4 CTLA-4 can be infused to release the brakes on natural T cells responsive to tumor.
Chemotherapy can reduce immune suppressive cells such as Tregs and myeloid-derived suppressor cells MDSC in addition to its direct effect on the tumor cells.
The infusion of gene-modified T cells directed to specific target antigens offers the same possibilities of long-term disease control and has the added benefit of the rapid onset of action that is usually seen with cytotoxic chemotherapy or with targeted therapies.
In particular, T cells modified to express antibody-based chimeric antigen receptors circumvent both immune tolerance of the T-cell repertoire and MHC restriction.
Furthermore, advances in the culture process and molecular and virology techniques used to introduce novel genes into T cells have made the manufacturing of gene-modified peripheral blood—derived T cells relatively straightforward.
In the last 5 years, chimeric antigen receptor CAR -redirected T cells have emerged from the bench and made splashy headlines in the clinical setting at a number of academic institutions.
It is not surprising that CAR T cells directed to hematologic malignancies have been the first ones tested, given the extent of the known surface antigens expressed on hematologic cells, the relative ease of sampling tumor, and the natural preference of T-cell homing to hematologic organs such as the blood, bone marrow, and lymph nodes.
Here, we will introduce the various CAR designs that have been tested clinically, the results from a series of clinical trials testing CAR T cells, and an overview and comparison of the manufacturing processes used.
We will also discuss the emerging toxicity profiles and management strategies and future outlook of CAR T-cell therapies.
We limit our discussion to CAR T cells in hematologic malignancies and will not cover CARs that have been tested in solid tumors or engineered T-cell receptors TCRs that have been tested in any setting.
CARs are synthetic, engineered receptors that can target surface molecules in their native conformation. CARs typically engage the target via a single-chain variable fragment scFv derived from an antibody, although natural ligands have also been used.
Preclinical data suggest that the spatial location of epitope binding has a bigger effect on CAR activity than variation in affinity. The hinge and transmembrane domains are probably the least commented on aspect of CAR design, though they may make important contributions to the interaction with antigen, assembly of the immunologic synapse, and association of the CAR with other proteins necessary to transduce a robust activation signal.
Chimeric antigen receptors. CARs target surface antigens in an MHC-independent fashion and consist of an ectodomain, hinge domain, transmembrane domain, and endodomain.
The initial trials tested first-generation CARs that have a single cytoplasmic domain. Current trials are testing second- and third-generation CARs that have combinations of signaling domains.
Investigators in the field are using a variety of methods to introduce their CAR constructs into T cells. Non—viral-based DNA transfection was initially used because of cost and the low risk of insertional mutagenesis.
This method requires long-term culture and antibiotic selection due to the relative inefficiency of gene transfer. The long-term culture may be detrimental to the activity and persistence of the infused cells, and the antibiotic-resistance gene products may render them immunogenic.
Transposon-based systems can integrate transgenes more efficiently than plasmids that do not contain an integrating element.
Use of specific promoters in combination with lentiviral transduction has enabled sustained surface expression of CARs on transduced T cells; this likely extends the survival of functional CAR T cells in vivo.
The methods and duration of T-cell culture used in the manufacturing of CAR T cells may also be an important variable in the composition of the final CAR T-cell product.
Generally, the options have involved combinations of TCR stimulation through antibodies and supportive cytokines or artificial antigen-presenting cells that are either cell based or bead based.
There are 14 publications reporting clinical trials of CAR T cells in hematologic malignancies. The CAR design, manufacturing process, and results are summarized in Table 1.
Each group has designed slightly different protocols, and they vary with regard to design of the CAR, expression of the CAR on the T cells, T-cell culture conditions, lymphodepleting strategy, cytokine support for the infused T cells, disease targeted, and timing of CAR T-cell infusion with regard to standard therapy such as bone marrow transplantation.
Not surprisingly, the most effective CAR T-cell products are also associated with on-target toxicity. The results of these clinical trials point to several key factors that may have an impact on the efficacy of CAR-modified T cells in hematologic malignancies.
At the level of product characterization, the relative importance of the CD4:CD8 ratio or the proportion of regulatory T cells Tregs in the final product is not clear, and it is not known if the T-cell product can be improved upon by selection or graft engineering.
Characterization of the tumor microenvironment, and in particular the inhibitory factors that may affect or abrogate CAR T-cell lytic functions, will be even more complex to sort out.
Several investigators have also aimed to address the question of whether or which lymphodepletion strategy to use and whether supporting the infused T cells with systemically administered cytokines will improve their expansion or persistence; although both strategies appear to be improve T-cell engraftment, they may confound interpretation of efficacy and toxicity, and neither appears to be universally required for CAR T-cell—mediated responses.
At least a few key characteristics of efficacious CAR T-cell products have emerged. One is that expression of the CAR at the cell surface seems to be required for efficacy; another is that in vivo detection of the CAR T-cell product in the blood is a sign of adequate engraftment and that engraftment is required for responses.
Detection of the CAR transgene by polymerase chain reaction does not inform about the surface expression of the CAR, which is the only form that matters for efficacy.
Thus, the availability of reagents to specifically detect CARs at the cell surface by flow cytometry is crucial to understand the activity and engraftment of CAR T cells.
In addition, it is not yet clear if there is a relationship between the dose of CAR T cells administered and the level of engraftment that is achieved, ie, the in vivo dose.
Some degree of persistent engraftment is also required, although the length of this persistence has not been established.
We hypothesize that for CAR T cells to be able to replace allogeneic transplantation as definitive therapy, persistence for at least several months will probably be required based on the kinetics of tumor clearance that we have observed.
The question of whether CAR T cells are on par with the efficacy of transplant would best be answered in randomized trials.
However, short of this, we also anticipate many recipients of CAR T cells will not eligible for transplant or have comorbidities or only suboptimal donors available such that the transplant is impractical.
Long-term follow up of these patients will provide critical information about the durability of CAR T-cell—induced remissions.
Alternatively, the answer may come from patients who have relapsed after an allogeneic transplant, for whom a second transplant may not be possible or efficacious; these patients may benefit from CAR T-cell products that potentially offer durable remissions.
The use of CAR-modified donor T cells to treat relapsed ALL is being tested by our group and will hopefully be studied in a multisite trial.
In addition, multisite trials are underway in collaboration with Novartis, and a dual-center grant-funded trial between MSKCC and the University of Pennsylvania involves a competitive repopulation study design where T cells transduced with Penn vector and MSKCC vector are infused simultaneously into each patient.
Given the finding that, in most cases, cytokine release syndrome CRS seems to correlate with antitumor activity, one question that has emerged is the degree to which the innate immune system contributes to antitumor efficacy.
It is possible that the IL-6 is produced by the dying B cells, dying tumor cells, or activated macrophages that are recruited to digest lysed tumor cells.
Does interruption of the cytokine cascade lead to interruption of the antitumor effect? This remains an unanswered question and has direct clinical impact for patients and physicians deciding on when to abort the CRS.
Furthermore, although, in our experience, most responding patients have some degree of CRS, it is not yet clear whether the severity of CRS or macrophage activation syndrome MAS is related to antitumor efficacy.
The severity of CRS does appear to be related to the tumor burden. If engagement of the innate immune system contributes to the mechanism of action, this could bode well for the use of CAR T cells in solid tumors, where T cells may not preferentially home to and persist at the sites of tumors as efficiently as they do in hematologic malignancies.
Several patients in CDCAR trials across institutions have experienced obtundation, seizures, aphasia, and mental status changes, which have all been reversible.
Some of these may be related to CRS, but whether this results from systemic cytokines crossing the blood-brain barrier and engaging cytokine receptors in the brain or from direct cytokine production in the central nervous system CNS is not clear.
Blinatumomab, a type of bispecific T-cell—engaging antibody BiTE that is a fusion protein between an anti-CD19 scFv and an anti-CD3 scFv, also has neurologic toxicity and seizures as its dose-limiting toxicity, even though it does not appear to control CNS disease.
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