U.S. patent application number 16/164147 was filed with the patent office on 2019-05-23 for methods of administering chimeric antigen receptor immunotherapy.
The applicant listed for this patent is KITE PHARMA, INC.. Invention is credited to Jeffrey S. Wiezorek.
Application Number | 20190151361 16/164147 |
Document ID | / |
Family ID | 64477267 |
Filed Date | 2019-05-23 |
United States Patent
Application |
20190151361 |
Kind Code |
A1 |
Wiezorek; Jeffrey S. |
May 23, 2019 |
METHODS OF ADMINISTERING CHIMERIC ANTIGEN RECEPTOR
IMMUNOTHERAPY
Abstract
The disclosure provides cells comprising CD19-directed chimeric
antigen receptor (CAR) genetically modified autologous T cell
immunotherapy for the treatment of, e.g., relapsed or refractory
large B-cell lymphoma after two or more lines of systemic therapy,
including diffuse large B-cell lymphoma (DLBCL) not otherwise
specified, primary mediastinal large B-cell lymphoma, high grade
B-cell lymphoma, and DLBCL arising from follicular lymphoma. Some
aspects of the disclosure relate to methods of treatment and
monitoring following infusion of T cell therapy provided
herein.
Inventors: |
Wiezorek; Jeffrey S.; (Santa
Monica, CA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
KITE PHARMA, INC. |
Santa Monica |
CA |
US |
|
|
Family ID: |
64477267 |
Appl. No.: |
16/164147 |
Filed: |
October 18, 2018 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
|
62574159 |
Oct 18, 2017 |
|
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|
Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61K 38/1816 20130101;
A61K 38/193 20130101; A61K 31/573 20130101; A61K 39/001112
20180801; A61K 9/0019 20130101; A61K 38/35 20130101; C07K 14/7051
20130101; A61K 38/34 20130101; A61K 2039/804 20180801; A61K
2039/5158 20130101; A61K 2039/5156 20130101; A61K 38/31 20130101;
A61K 35/17 20130101; A61P 35/00 20180101; A61K 38/38 20130101; C07K
16/248 20130101 |
International
Class: |
A61K 35/17 20060101
A61K035/17; A61P 35/00 20060101 A61P035/00; C07K 14/725 20060101
C07K014/725; A61K 9/00 20060101 A61K009/00; C07K 16/24 20060101
C07K016/24 |
Claims
1. A method of treating relapsed or refractory diffuse large B-cell
lymphoma (DLBCL) not otherwise specified, primary mediastinal large
B-cell lymphoma, high grade B-cell lymphoma, or DLBCL arising from
follicular lymphoma after two or more lines of systemic therapy in
a patient comprising: administering to the patient in need thereof
axicabtagene ciloleucel suspension by intravenous infusion at a
dose between about 1.times.10.sup.6 and about 2.times.10.sup.6
CAR-positive viable T cells per kg body weight up to a maximum dose
of about 1.times.10.sup.8 CAR-positive viable T cells, wherein
axicabtagene ciloleucel is a CD19-directed genetically modified
autologous T cell immunotherapy, comprising the patient's own T
cells harvested and genetically modified ex vivo by retroviral
transduction to express a chimeric antigen receptor (CAR)
comprising an anti-CD19 single chain variable fragment (scFv)
linked to CD28 and CD3-zeta co-stimulatory domains.
2. The method of claim 1, wherein the intravenous infusion time is
between 15 and 120 minutes.
3. (canceled)
4. The method of claim 1, wherein the infusion volume is between 50
and 100 mL.
5. (canceled)
6. The method of claim 1, wherein the immunotherapy is infused from
an infusion bag.
7. The method of claim 6, wherein the infusion bag is agitated
during the infusion.
8. (canceled)
9. The method of claim 1, wherein the suspension further comprises
albumin.
10. The method of claim 9, wherein albumin is present in an amount
of about 2-3% (v/v).
11-12. (canceled)
13. The method of claim 1, wherein the suspension further comprises
DMSO.
14. A method of treating relapsed or refractory large B-cell
lymphoma after two or more lines of systemic therapy in a patient
comprising: (a) administering to the patient in need thereof
CD19-directed genetically modified autologous T cell immunotherapy;
and (b) monitoring the patient following infusion for signs and
symptoms of an adverse reaction.
15. The method of claim 14, wherein the relapsed or refractory
large B-cell lymphoma is diffuse large B-cell lymphoma (DLBCL) not
otherwise specified, primary mediastinal large B-cell lymphoma,
high grade B-cell lymphoma, or DLBCL arising from follicular
lymphoma.
16. The method of claim 14, wherein the adverse reaction is
selected from the group consisting of cytokine release syndrome
(CRS), a neurologic toxicity, a hypersensitivity reaction, a
serious infection, a cytopenia and hypogammaglobulinemia.
17. (canceled)
18. The method of claim 14, wherein the method further comprises
administering an effective amount of tocilizumab to treat a symptom
of an adverse reaction.
19. The method of claim 18, further comprising administering a
corticosteroid to treat a symptom of an adverse reaction.
20. (canceled)
21. The method of claim 14, comprising monitoring for signs and
symptoms of cytokine release syndrome (CRS) at least daily for
about 7 days following infusion.
22. (canceled)
23. The method of claim 14, wherein the method further comprises
administering a non-sedating, anti-seizure medicine for seizure
prophylaxis.
24. (canceled)
25. The method of claim 14, wherein the method further comprises
administering at least one of erythropoietin, darbepoetin alfa,
platelet transfusion, colony-stimulating factor (CSF), granulocyte
colony-stimulating factor, filgrastim, pegfilgrastim, or
granulocyte-macrophage colony-stimulating factor.
26. The method of claim 14, further comprising measuring cytokine
and chemokine levels.
27. The method of claim 26, wherein the level of at least one of
IL-6, IL-8, IL-10, IL-15, TNF-.alpha., IFN-.gamma., and
sIL2R.alpha. is measured.
28. A container comprising a suspension of CD19-directed
genetically modified autologous T cells, about 5% dimethylsulfoxide
(DMSO) and about 2.5% human albumin (v/v).
29. The method of claim 14, further comprising assessing if
cytokine release syndrome (CRS) greater than Grade 2 is observed
and administering tocilizumab at a dose of about 8 mg/kg IV over 1
hour, repeating tocilizumab every 8 hours as needed if not
responsive to IV fluids or increasing supplemental oxygen;
assessing if CRS symptoms observed do not improve after 24 hours of
administering tocilizumab, administering methylprednisolone about 1
mg/kg IV twice daily or administering equivalent dexamethasone dose
and continuing corticosteroids use until the event is Grade 1 or
less, then tapering over 3 days; assessing if CRS Grade 3 is
observed and, administering tocilizumab at a dose of 8 mg/kg IV
over 1 hour, repeating tocilizumab every 8 hours as needed if not
responsive to IV fluids or increasing supplemental oxygen and
administering methylprednisolone 1 mg/kg IV twice daily or
administering equivalent dexamethasone dose and continuing
corticosteroids use until the event is Grade 1 or less, then
tapering over 3 days; and assessing if CRS Grade 4 is observed and,
administering tocilizumab at a dose of about 8 mg/kg IV over 1
hour, repeating tocilizumab every 8 hours as needed if not
responsive to IV fluids or increasing supplemental oxygen and
administering about 1,000 mg IV methylprednisolone per day for 3
days.
30. (canceled)
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] This application claims priority to U.S. Provisional
Application No. 62/574,159, filed Oct. 18, 2017, which is
incorporated by reference herein in its entirety.
TECHNICAL FIELD
[0002] The present disclosure relates generally to T cell therapies
and more specifically to CD19-directed genetically modified
autologous T cell immunotherapies comprising chimeric antigen
receptors (CARs).
BACKGROUND
[0003] Human cancers are by their nature comprised of normal cells
that have undergone a genetic or epigenetic conversion to become
abnormal cancer cells. In doing so, cancer cells begin to express
proteins and other antigens that are distinct from those expressed
by normal cells. These aberrant tumor antigens may be used by the
body's innate immune system to specifically target and kill cancer
cells. However, cancer cells employ various mechanisms to prevent
immune cells, such as T and B lymphocytes, from successfully
targeting cancer cells.
[0004] Chimeric antigen receptors (CARs), which comprise binding
domains capable of interacting with a particular tumor antigen,
allow T cells to target and kill cancer cells that express the
particular tumor antigen.
SUMMARY
[0005] As described in detail below, the present disclosure is
based, in part, on the surprising discovery that the administration
methods disclosed herein identify and manage adverse side effects
of CAR T-cell immunotherapy.
[0006] Any aspect or embodiment described herein may be combined
with any other aspect or embodiment as disclosed herein. While the
present invention has been described in conjunction with the
detailed description thereof, the foregoing description is intended
to illustrate and not limit the scope of the present invention,
which is defined by the scope of the appended claims. Other
aspects, advantages, and modifications are within the scope of the
following claims.
[0007] In one aspect, the invention provides a method of treating
relapsed or refractory diffuse large B-cell lymphoma (DLBCL) not
otherwise specified, primary mediastinal large B-cell lymphoma,
high grade B-cell lymphoma, or DLBCL arising from follicular
lymphoma after two or more lines of systemic therapy in a patient
comprising: administering to the patient in need thereof
axicabtagene ciloleucel suspension by intravenous infusion at a
dose between about 1.times.10.sup.6 and about 2.times.10.sup.6
CAR-positive viable T cells per kg body weight up to a maximum dose
of about 1.times.10.sup.8 CAR-positive viable T cells, wherein
axicabtagene ciloleucel is a CD19-directed genetically modified
autologous T cell immunotherapy, comprising the patient's own T
cells harvested and genetically modified ex vivo by retroviral
transduction to express a chimeric antigen receptor (CAR)
comprising an anti-CD19 single chain variable fragment (scFv)
linked to CD28 and CD3-zeta co-stimulatory domains.
[0008] In another aspect, the invention provides a method of
treating relapsed or refractory diffuse large B-cell lymphoma
(DLBCL) and primary mediastinal large B-cell lymphoma (PMBCL),
after two or more lines of systemic therapy in a patient
comprising: administering to the patient in need thereof
axicabtagene ciloleucel suspension by intravenous infusion at a
dose between about 0.4.times.10.sup.8 and about 2.times.10.sup.8
CAR-positive viable T cells, wherein axicabtagene ciloleucel is a
CD19-directed genetically modified autologous T cell immunotherapy,
comprising the patient's own T cells harvested and genetically
modified ex vivo by retroviral transduction to express a chimeric
antigen receptor (CAR) comprising an anti-CD19 single chain
variable fragment (scFv) linked to CD28 and CD3-zeta co-stimulatory
domains.
[0009] In some embodiments, the intravenous infusion time is
between 15 and 120 minutes. In some embodiments, the intravenous
infusion time is up to 30 minutes.
[0010] In some embodiments, the infusion volume is between 50 and
100 mL. In some embodiments, the infusion volume is about 68
mL.
[0011] In some embodiments, the immunotherapy is infused from an
infusion bag. In some embodiments, the infusion bag is agitated
during the infusion.
[0012] In some embodiments, the immunotherapy is administered
within 3 hours after thawing.
[0013] In some embodiments, the suspension further comprises
albumin. In some embodiments, albumin is present in an amount of
about 2-3% (v/v). In some embodiments, albumin is present in an
amount of about 2.5% (v/v). In some embodiments, albumin is human
albumin.
[0014] In some embodiments, the suspension further comprises DMSO.
In some embodiments, DMSO is present in an amount of about 4-6%
(v/v). In some embodiments, DMSO is present in an amount of about
5% (v/v).
[0015] In one aspect, the invention provides a method of treating
relapsed or refractory large B-cell lymphoma after two or more
lines of systemic therapy in a patient comprising: (a)
administering to the patient in need thereof CD19-directed
genetically modified autologous T cell immunotherapy; and (b)
monitoring the patient following infusion for signs and symptoms of
an adverse reaction.
[0016] In some embodiments, the relapsed or refractory large B-cell
lymphoma is diffuse large B-cell lymphoma (DLBCL) not otherwise
specified, primary mediastinal large B-cell lymphoma, high grade
B-cell lymphoma, or DLBCL arising from follicular lymphoma.
[0017] In some embodiments, the adverse reaction is selected from
the group consisting of cytokine release syndrome (CRS), a
neurologic toxicity, a hypersensitivity reaction, a serious
infection, a cytopenia and hypogammaglobulinemia.
[0018] In some embodiments, the signs and symptoms of adverse
reactions are selected from the group consisting of fever,
hypotension, tachycardia, hypoxia, and chills, include cardiac
arrhythmias (including atrial fibrillation and ventricular
tachycardia), cardiac arrest, cardiac failure, renal insufficiency,
capillary leak syndrome, hypotension, hypoxia, organ toxicity,
hemophagocytic lymphohistiocytosis/macrophage activation syndrome
(HLH/MAS), seizure, encephalopathy, headache, tremor, dizziness,
aphasia, delirium, insomnia anxiety, anaphylaxis, febrile
neutropenia, thrombocytopenia, neutropenia, and anemia.
[0019] In some embodiments, the method further comprises
administering an IL-6 receptor inhibitor.
[0020] In some embodiments, the method further comprises
administering an effective amount of tocilizumab to treat a symptom
of an adverse reaction.
[0021] In some embodiments, tocilizumab is administered at a dose
of about 8 mg/kg intravenously. In some embodiments, tocilizumab is
administered intravenously over about 1 hour. In some embodiments,
tocilizumab is administered about every 8 hours. In some
embodiments, tocilizumab is administered for no more than about 24
hours.
[0022] In some embodiments, the method further comprises
administering a corticosteroid to treat a symptom of an adverse
reaction.
[0023] In some embodiments, the corticosteroid is at least one of
methylprednisone or dexamethasone.
[0024] In some embodiments, methylprednisone is administered at a
dose of about 1 mg/kg intravenously. In some embodiments,
methylprednisone is administered twice daily. In some embodiments,
methylprednisone is administered at a dose of about 1,000 mg per
day intravenously. In some embodiments, methylprednisone is
administered intravenously for about 3 days.
[0025] In some embodiments, dexamethasone is administered at a dose
of about 10 mg. In some embodiments, dexamethasone is administered
intravenously about every 6 hours.
[0026] In some embodiments, the adverse reaction is cytokine
release syndrome (CRS). In some embodiments, the monitoring for
signs and symptoms of cytokine release syndrome (CRS) is at least
daily for about 7 days following infusion. In some embodiments, the
monitoring for signs and symptoms of cytokine release syndrome
(CRS) is at least daily for about 8 days, about 9 days, or about 10
days following infusion. In some embodiments, the monitoring for
signs and symptoms of cytokine release syndrome (CRS) is at least
daily for about 10 days following infusion. In some embodiments,
the monitoring for signs and symptoms of cytokine release syndrome
(CRS) is for about 4 weeks following infusion.
[0027] In some embodiments, the adverse reaction is neurologic
toxicity.
[0028] In some embodiments, the monitoring for signs and symptoms
of neurologic toxicity up to about 8 weeks following infusion.
[0029] In some embodiments, the method further comprises
administering a non-sedating, anti-seizure medicine for seizure
prophylaxis.
[0030] In some embodiments, the non-sedating, anti-seizure medicine
is levetiracetam.
[0031] In some embodiments, the adverse reaction is a cytopenia. In
some embodiments, the cytopenia is thrombocytopenia, neutropenia,
and/or anemia.
[0032] In some embodiments, the method further comprises
administering at least one of erythropoietin, darbepoetin alfa,
platelet transfusion, colony-stimulating factor (CSF), granulocyte
colony-stimulating factor, filgrastim, pegfilgrastim, or
granulocyte-macrophage colony-stimulating factor.
[0033] In some embodiments, the method further comprises measuring
cytokine and chemokine levels. In some embodiments, the level of at
least one of IL-6, IL-8, IL-10, IL-15, TNF-.alpha., IFN-.gamma.,
and sIL2R.alpha. is measured.
[0034] In one aspect, the invention provides a container comprising
a suspension of CD19-directed genetically modified autologous T
cells, about 5% dimethylsulfoxide (DMSO) and about 2.5% human
albumin (v/v). In another aspect, the container comprises a
suspension of between about 0.4.times.10.sup.8-2.times.10.sup.8
CD19-directed genetically modified autologous T cells (CAR-positive
viable T cells).
[0035] In some embodiments, the container is a sterile infusion
bag. In some embodiments, the infusion bag volume is about 100 mL,
250 mL, 500 mL, 750 mL, 1000 mL, 1500 mL, 2000 mL or 3000 mL.
[0036] In one aspect, the invention provides a method of treating
relapsed or refractory large B-cell lymphoma after two or more
lines of systemic therapy in a human comprising administering to
the human in need thereof CD19-directed genetically modified
autologous T cell immunotherapy comprising: (a) administering to
the patient a composition comprising CD19-directed chimeric antigen
receptor (CAR) positive viable T cells; (b) monitoring the patient
following administration for signs and symptoms of an adverse
reaction; and (c) if cytokine release syndrome (CRS) greater than
Grade 2 is observed in (b), administering tocilizumab at a dose of
about 8 mg/kg IV over 1 hour, repeating tocilizumab every 8 hours
as needed if not responsive to IV fluids or increasing supplemental
oxygen; (d) if CRS symptoms observed in (b) do not improve after 24
hours of (c), administering methylprednisolone about 1 mg/kg IV
twice daily or administering equivalent dexamethasone dose and
continuing corticosteroids use until the event is Grade 1 or less,
then tapering over 3 days; (e) if CRS Grade 3 is observed in (b),
administering tocilizumab at a dose of 8 mg/kg IV over 1 hour,
repeating tocilizumab every 8 hours as needed if not responsive to
IV fluids or increasing supplemental oxygen and administering
methylprednisolone 1 mg/kg IV twice daily or administering
equivalent dexamethasone dose and continuing corticosteroids use
until the event is Grade 1 or less, then tapering over 3 days; and
(f) if CRS Grade 4 is observed in (b), administering tocilizumab at
a dose of about 8 mg/kg IV over 1 hour, repeating tocilizumab every
8 hours as needed if not responsive to IV fluids or increasing
supplemental oxygen and administering about 1,000 mg IV
methylprednisolone per day for 3 days.
[0037] In one aspect, the invention provide a method of treating
relapsed or refractory large B-cell lymphoma after two or more
lines of systemic therapy in a patient comprising administering to
the patient in need thereof CD19-directed genetically modified
autologous T cell immunotherapy comprising: (a) administering to
the patient a composition comprising CD19-directed chimeric antigen
receptor (CAR) positive viable T cells; (b) monitoring the patient
following administration for signs and symptoms of an adverse
reaction; and (c) if cytokine release syndrome (CRS) and/or
neurologic toxicity is observed, managing cytokine release syndrome
(CRS) and/or neurologic toxicity according to Table 1 and/or Table
2.
[0038] Other features and advantages of the disclosure will be
apparent from the following Detailed Description, including the
Examples, and the claims.
DETAILED DESCRIPTION
[0039] The present disclosure relates to engineered cells (e.g., T
cells) comprising a CD19 CAR genetically modified autologous T cell
immunotherapy indicated for the treatment of adult patients with
relapsed or refractory large B-cell lymphoma after two or more
lines of systemic therapy, including diffuse large B-cell lymphoma
(DLBCL) not otherwise specified, primary mediastinal large B-cell
lymphoma, high grade B-cell lymphoma, and DLBCL arising from
follicular lymphoma. In some embodiments, the present disclosure
provides methods of treatment using the engineered T cells for the
treatment of a patient suffering from a cancer.
[0040] To prepare CD19-directed genetically modified autologous T
cell immunotherapy, a patient's own T cells may be harvested and
genetically modified ex vivo by retroviral transduction to express
a chimeric antigen receptor (CAR) comprising a murine anti-CD19
single chain variable fragment (scFv) linked to CD28 and CD3-zeta
co-stimulatory domains. In some embodiments, the CAR comprises a
murine anti-CD19 single chain variable fragment (scFv) linked to
4-1BB and CD3-zeta co-stimulatory domain. The anti-CD19 CAR T cells
may be expanded and infused back into the patient, where they may
recognize and eliminate CD19-expressing target cells. YESCARTA.RTM.
(Axi-cel.TM.; axicabtagene ciloleucel) is an example of such
CD19-directed genetically modified autologous T cell immunotherapy.
See Kochenderfer, et al., (J Immunother 2009; 32:689 702).
Additional CD19 directed CAR therapies include JCAR017, JCAR015,
JCAR014, Kymriah (tisagenlecleucel). See Sadelain et al. Nature
Rev. Cancer Vol. 3 (2003), Ruella et al., Curr Hematol Malig Rep.,
Springer, N.Y. (2016) and Sadelain et al. Cancer Discovery (April
2013).
[0041] CD19-directed genetically modified autologous T cell
immunotherapy may be prepared from the patient's peripheral blood
mononuclear cells, which are typically obtained via a standard
leukapheresis procedure. The mononuclear cells may be enriched for
T cells and activated with anti-CD3 antibody in the presence of
IL-2, then transduced with the replication incompetent retroviral
vector containing the anti-CD19 CAR transgene. The transduced T
cells may be expanded in cell culture, washed, formulated into a
suspension, and/or cryopreserved. Typically, the product comprising
genetically modified autologous T cells must pass a sterility test
before release for shipping as a frozen suspension in a
patient-specific infusion container such as an infusion bag.
Typically, the product is thawed prior to infusion.
[0042] In addition to T cells, CD19-directed genetically modified
autologous T cell immunotherapy may contain NK and NK-T cells. In
some embodiments, the CD19-directed genetically modified autologous
T cell immunotherapy formulation contains about 5%
dimethylsulfoxide (DMSO) and about 2.5% albumin (human) (v/v).
[0043] CD19-directed genetically modified autologous T cells bind
to CD19-expressing cancer cells and normal B cells. Studies have
demonstrated that, following anti-CD19 CART cell engagement with
CD19-expressing target cells, the CD28 and CD3-zeta co-stimulatory
domains activate downstream signaling cascades that lead to T-cell
activation, proliferation, acquisition of effector functions and
secretion of inflammatory cytokines and chemokines. This sequence
of events leads to killing of CD19-expressing cells.
[0044] In one aspect, the invention provides a method of treating
relapsed or refractory diffuse large B-cell lymphoma (DLBCL) not
otherwise specified, primary mediastinal large B-cell lymphoma,
high grade B-cell lymphoma, or DLBCL arising from follicular
lymphoma after two or more lines of systemic therapy in a patient
comprising: administering to the patient in need thereof a
CD19-directed genetically modified autologous T cell suspension by
intravenous infusion at a dose between about 1.times.10.sup.6 and
about 2.times.10.sup.6 CAR-positive viable T cells per kg body
weight up to a maximum dose of about 1.times.10.sup.8 CAR-positive
viable T cells.
Definitions
[0045] In order for the present invention to be more readily
understood, certain terms are first defined below. Additional
definitions for the following terms and other terms are set forth
throughout the Specification.
[0046] As used in this Specification and the appended claims, the
singular forms "a," "an" and "the" include plural referents unless
the context clearly dictates otherwise.
[0047] Unless specifically stated or obvious from context, as used
herein, the term "or" is understood to be inclusive and covers both
"or" and "and".
[0048] The term "and/or" where used herein is to be taken as
specific disclosure of each of the two specified features or
components with or without the other. Thus, the term "and/or" as
used in a phrase such as "A and/or B" herein is intended to include
A and B; A or B; A (alone); and B (alone). Likewise, the term
"and/or" as used in a phrase such as "A, B, and/or C" is intended
to encompass each of the following aspects: A, B, and C; A, B, or
C; A or C; A or B; B or C; A and C; A and B; B and C; A (alone); B
(alone); and C (alone).
[0049] The terms "e.g.," and "i.e." as used herein, are used merely
by way of example, without limitation intended, and should not be
construed as referring only those items explicitly enumerated in
the specification.
[0050] The terms "or more", "at least", "more than", and the like,
e.g., "at least one" are understood to include but not be limited
to at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16,
17, 18, 19 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33,
34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50,
51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67,
68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84,
85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100,
101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113,
114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126,
127, 128, 129, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139,
140, 141, 142, 143, 144, 145, 146, 147, 148, 149 or 150, 200, 300,
400, 500, 600, 700, 800, 900, 1000, 2000, 3000, 4000, 5000 or more
than the stated value. Also included is any greater number or
fraction in between.
[0051] Conversely, the term "no more than" includes each value less
than the stated value. For example, "no more than 100 nucleotides"
includes 100, 99, 98, 97, 96, 95, 94, 93, 92, 91, 90, 89, 88, 87,
86, 85, 84, 83, 82, 81, 80, 79, 78, 77, 76, 75, 74, 73, 72, 71, 70,
69, 68, 67, 66, 65, 64, 63, 62, 61, 60, 59, 58, 57, 56, 55, 54, 53,
52, 51, 50, 49, 48, 47, 46, 45, 44, 43, 42, 41, 40, 39, 38, 37, 36,
35, 34, 33, 32, 31, 30, 29, 28, 27, 26, 25, 24, 23, 22, 21, 20, 19,
18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, 2, 1, and
0 nucleotides. Also included is any lesser number or fraction in
between.
[0052] The terms "plurality", "at least two", "two or more", "at
least second", and the like, are understood to include but not
limited to at least 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15,
16, 17, 18, 19 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32,
33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49,
50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66,
67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83,
84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99,
100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112,
113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125,
126, 127, 128, 129, 130, 131, 132, 133, 134, 135, 136, 137, 138,
139, 140, 141, 142, 143, 144, 145, 146, 147, 148, 149 or 150, 200,
300, 400, 500, 600, 700, 800, 900, 1000, 2000, 3000, 4000, 5000 or
more. Also included is any greater number or fraction in
between.
[0053] Throughout the specification the word "comprising," or
variations such as "comprises" or "comprising," will be understood
to imply the inclusion of a stated element, integer or step, or
group of elements, integers or steps, but not the exclusion of any
other element, integer or step, or group of elements, integers or
steps. It is understood that wherever aspects are described herein
with the language "comprising," otherwise analogous aspects
described in terms of "consisting of" and/or "consisting
essentially of" are also provided.
[0054] Unless specifically stated or evident from context, as used
herein, the term "about" refers to a value or composition that is
within an acceptable error range for the particular value or
composition as determined by one of ordinary skill in the art,
which will depend in part on how the value or composition is
measured or determined, i.e., the limitations of the measurement
system. For example, "about" or "approximately" may mean within one
or more than one standard deviation per the practice in the art.
"About" or "approximately" may mean a range of up to 10% (i.e.,
.+-.10%). Thus, "about" may be understood to be within 10%, 9%, 8%,
7%, 6%, 5%, 4%, 3%, 2%, 1%, 0.5%, 0.1%, 0.05%, 0.01%, or 0.001%
greater or less than the stated value. For example, about 5 mg may
include any amount between 4.5 mg and 5.5 mg. Furthermore,
particularly with respect to biological systems or processes, the
terms may mean up to an order of magnitude or up to 5-fold of a
value. When particular values or compositions are provided in the
instant disclosure, unless otherwise stated, the meaning of "about"
or "approximately" should be assumed to be within an acceptable
error range for that particular value or composition.
[0055] As described herein, any concentration range, percentage
range, ratio range or integer range is to be understood to be
inclusive of the value of any integer within the recited range and,
when appropriate, fractions thereof (such as one-tenth and
one-hundredth of an integer), unless otherwise indicated.
[0056] Units, prefixes, and symbols used herein are provided using
their Systeme International de Unites (SI) accepted form. Numeric
ranges are inclusive of the numbers defining the range.
[0057] Unless defined otherwise, all technical and scientific terms
used herein have the same meaning as commonly understood by one of
ordinary skill in the art to which this disclosure is related. For
example, Juo, "The Concise Dictionary of Biomedicine and Molecular
Biology", 2nd ed., (2001), CRC Press; "The Dictionary of Cell &
Molecular Biology", 5th ed., (2013), Academic Press; and "The
Oxford Dictionary Of Biochemistry And Molecular Biology", Cammack
et al. eds., 2nd ed, (2006), Oxford University Press, provide those
of skill in the art with a general dictionary for many of the terms
used in this disclosure.
[0058] "Administering" refers to the physical introduction of an
agent to a subject, using any of the various methods and delivery
systems known to those skilled in the art. Exemplary routes of
administration for the formulations disclosed herein include
intravenous, intramuscular, subcutaneous, intraperitoneal, spinal
or other parenteral routes of administration, for example by
injection or infusion. The phrase "parenteral administration" as
used herein means modes of administration other than enteral and
topical administration, usually by injection, and includes, without
limitation, intravenous, intramuscular, intraarterial, intrathecal,
intralymphatic, intralesional, intracapsular, intraorbital,
intracardiac, intradermal, intraperitoneal, transtracheal,
subcutaneous, subcuticular, intraarticular, subcapsular,
subarachnoid, intraspinal, epidural and intrasternal injection and
infusion, as well as in vivo electroporation. In some embodiments,
the formulation is administered via a non-parenteral route, e.g.,
orally. Other non-parenteral routes include a topical, epidermal or
mucosal route of administration, for example, intranasally,
vaginally, rectally, sublingually or topically. Administering may
also be performed, for example, once, a plurality of times, and/or
over one or more extended periods.
[0059] The term "antibody" (Ab) includes, without limitation, a
glycoprotein immunoglobulin which binds specifically to an antigen.
In general, and antibody may comprise at least two heavy (H) chains
and two light (L) chains interconnected by disulfide bonds, or an
antigen-binding molecule thereof. Each H chain comprises a heavy
chain variable region (abbreviated herein as VH) and a heavy chain
constant region. The heavy chain constant region comprises three
constant domains, CH1, CH2 and CH3. Each light chain comprises a
light chain variable region (abbreviated herein as VL) and a light
chain constant region. The light chain constant region is comprises
one constant domain, CL. The VH and VL regions may be further
subdivided into regions of hypervariability, termed complementarity
determining regions (CDRs), interspersed with regions that are more
conserved, termed framework regions (FR). Each VH and VL comprises
three CDRs and four FRs, arranged from amino-terminus to
carboxy-terminus in the following order: FR1, CDR1, FR2, CDR2, FR3,
CDR3, and FR4. The variable regions of the heavy and light chains
contain a binding domain that interacts with an antigen. The
constant regions of the Abs may mediate the binding of the
immunoglobulin to host tissues or factors, including various cells
of the immune system (e.g., effector cells) and the first component
(C1q) of the classical complement system.
[0060] Antibodies may include, for example, monoclonal antibodies,
recombinantly produced antibodies, monospecific antibodies,
multispecific antibodies (including bispecific antibodies), human
antibodies, engineered antibodies, humanized antibodies, chimeric
antibodies, immunoglobulins, synthetic antibodies, tetrameric
antibodies comprising two heavy chain and two light chain
molecules, an antibody light chain monomer, an antibody heavy chain
monomer, an antibody light chain dimer, an antibody heavy chain
dimer, an antibody light chain-antibody heavy chain pair,
intrabodies, antibody fusions (sometimes referred to herein as
"antibody conjugates"), heteroconjugate antibodies, single domain
antibodies, monovalent antibodies, single chain antibodies or
single-chain Fvs (scFv), camelized antibodies, affybodies, Fab
fragments, F(ab')2 fragments, disulfide-linked Fvs (sdFv),
anti-idiotypic (anti-Id) antibodies (including, e.g., anti-anti-Id
antibodies), minibodies, domain antibodies, synthetic antibodies
(sometimes referred to herein as "antibody mimetics"), and
antigen-binding fragments of any of the above. In some embodiments,
antibodies described herein refer to polyclonal antibody
populations.
[0061] An "antigen binding molecule," "antigen binding portion," or
"antibody fragment" refers to any molecule that comprises the
antigen binding parts (e.g., CDRs) of the antibody from which the
molecule is derived. An antigen binding molecule may include the
antigenic complementarity determining regions (CDRs). Examples of
antibody fragments include, but are not limited to, Fab, Fab',
F(ab')2, and Fv fragments, dAb, linear antibodies, scFv antibodies,
and multispecific antibodies formed from antigen binding molecules.
Peptibodies (i.e., Fc fusion molecules comprising peptide binding
domains) are another example of suitable antigen binding molecules.
In some embodiments, the antigen binding molecule binds to an
antigen on a tumor cell. In some embodiments, the antigen binding
molecule binds to an antigen on a cell involved in a
hyperproliferative disease or to a viral or bacterial antigen. In
some embodiments, the antigen binding molecule binds to CD19. In
further embodiments, the antigen binding molecule is an antibody
fragment that specifically binds to the antigen, including one or
more of the complementarity determining regions (CDRs) thereof. In
further embodiments, the antigen binding molecule is a single chain
variable fragment (scFv). In some embodiments, the antigen binding
molecule comprises or consists of avimers.
[0062] An "antigen" refers to any molecule that provokes an immune
response or is capable of being bound by an antibody or an antigen
binding molecule. The immune response may involve either antibody
production, or the activation of specific immunologically-competent
cells, or both. A person of skill in the art would readily
understand that any macromolecule, including virtually all proteins
or peptides, may serve as an antigen. An antigen may be
endogenously expressed, i.e. expressed by genomic DNA, or may be
recombinantly expressed. An antigen may be specific to a certain
tissue, such as a cancer cell, or it may be broadly expressed. In
addition, fragments of larger molecules may act as antigens. In
some embodiments, antigens are tumor antigens.
[0063] "CD19-directed genetically modified autologous T cell
immunotherapy" refers to a suspension of chimeric antigen receptor
(CAR)-positive T cells. An example of such immunotherapy is
axicabtagene ciloleucel (also known as Axi-cel.TM., YESCARTA.RTM.),
developed by Kite Pharmaceuticals, Inc.
[0064] The term "neutralizing" refers to an antigen binding
molecule, scFv, antibody, or a fragment thereof, that binds to a
ligand and prevents or reduces the biological effect of that
ligand. In some embodiments, the antigen binding molecule, scFv,
antibody, or a fragment thereof, directly blocking a binding site
on the ligand or otherwise alters the ligand's ability to bind
through indirect means (such as structural or energetic alterations
in the ligand). In some embodiments, the antigen binding molecule,
scFv, antibody, or a fragment thereof prevents the protein to which
it is bound from performing a biological function.
[0065] The term "autologous" refers to any material derived from
the same individual to which it is later to be re-introduced. For
example, the engineered autologous cell therapy (eACT.TM.) method
described herein involves collection of lymphocytes from a patient,
which are then engineered to express, e.g., a CAR construct, and
then administered back to the same patient.
[0066] The term "allogeneic" refers to any material derived from
one individual which is then introduced to another individual of
the same species, e.g., allogeneic T cell transplantation.
[0067] The terms "transduction" and "transduced" refer to the
process whereby foreign DNA is introduced into a cell via viral
vector (see Jones et al., "Genetics: principles and analysis,"
Boston: Jones & Bartlett Publ. (1998)). In some embodiments,
the vector is a retroviral vector, a DNA vector, a RNA vector, an
adenoviral vector, a baculoviral vector, an Epstein Barr viral
vector, a papovaviral vector, a vaccinia viral vector, a herpes
simplex viral vector, an adenovirus associated vector, a lentiviral
vector, or any combination thereof.
[0068] A "cancer" refers to a broad group of various diseases
characterized by the uncontrolled growth of abnormal cells in the
body. Unregulated cell division and growth results in the formation
of malignant tumors that invade neighboring tissues and may also
metastasize to distant parts of the body through the lymphatic
system or bloodstream. A "cancer" or "cancer tissue" may include a
tumor. Examples of cancers that may be treated by the methods
disclosed herein include, but are not limited to, cancers of the
immune system including lymphoma, leukemia, myeloma, and other
leukocyte malignancies. In some embodiments, the methods disclosed
herein may be used to reduce the tumor size of a tumor derived
from, for example, bone cancer, pancreatic cancer, skin cancer,
cancer of the head or neck, cutaneous or intraocular malignant
melanoma, uterine cancer, ovarian cancer, rectal cancer, cancer of
the anal region, stomach cancer, testicular cancer, uterine cancer,
carcinoma of the fallopian tubes, carcinoma of the endometrium,
carcinoma of the cervix, carcinoma of the vagina, carcinoma of the
vulva, multiple myeloma, Hodgkin's Disease, non-Hodgkin's lymphoma
(NHL), primary mediastinal large B cell lymphoma (PMBC), diffuse
large B cell lymphoma (DLBCL), follicular lymphoma (FL),
transformed follicular lymphoma, splenic marginal zone lymphoma
(SMZL), cancer of the esophagus, cancer of the small intestine,
cancer of the endocrine system, cancer of the thyroid gland, cancer
of the parathyroid gland, cancer of the adrenal gland, sarcoma of
soft tissue, cancer of the urethra, cancer of the penis, chronic or
acute leukemia, acute myeloid leukemia, chronic myeloid leukemia,
acute lymphoblastic leukemia (ALL) (including non T cell ALL),
chronic lymphocytic leukemia (CLL), solid tumors of childhood,
lymphocytic lymphoma, cancer of the bladder, cancer of the kidney
or ureter, carcinoma of the renal pelvis, neoplasm of the central
nervous system (CNS), primary CNS lymphoma, tumor angiogenesis,
spinal axis tumor, brain stem glioma, pituitary adenoma, Kaposi's
sarcoma, epidermoid cancer, squamous cell cancer, T cell lymphoma,
environmentally induced cancers including those induced by
asbestos, other B cell malignancies, and combinations of said
cancers. In some embodiments, the cancer is multiple myeloma. The
particular cancer may be responsive to chemo- or radiation therapy
or the cancer may be refractory. A refractor cancer refers to a
cancer that is not amendable to surgical intervention and the
cancer is either initially unresponsive to chemo- or radiation
therapy or the cancer becomes unresponsive over time.
[0069] An "anti-tumor effect" as used herein, refers to a
biological effect that may present as a decrease in tumor volume, a
decrease in the number of tumor cells, a decrease in tumor cell
proliferation, a decrease in the number of metastases, an increase
in overall or progression-free survival, an increase in life
expectancy, or amelioration of various physiological symptoms
associated with the tumor. An anti-tumor effect may also refer to
the prevention of the occurrence of a tumor, e.g., a vaccine.
[0070] A "cytokine," as used herein, refers to a non-antibody
protein that is released by one cell in response to contact with a
specific antigen, wherein the cytokine interacts with a second cell
to mediate a response in the second cell. "Cytokine" as used herein
is meant to refer to proteins released by one cell population that
act on another cell as intercellular mediators. A cytokine may be
endogenously expressed by a cell or administered to a subject.
Cytokines may be released by immune cells, including macrophages, B
cells, T cells, and mast cells to propagate an immune response.
Cytokines may induce various responses in the recipient cell.
Cytokines may include homeostatic cytokines, chemokines,
pro-inflammatory cytokines, effectors, and acute-phase proteins.
For example, homeostatic cytokines, including interleukin (IL) 7
and IL-15, promote immune cell survival and proliferation, and
pro-inflammatory cytokines may promote an inflammatory response.
Examples of homeostatic cytokines include, but are not limited to,
IL-2, IL-4, IL-5, IL-7, IL-10, IL-12p40, IL-12p70, IL-15, and
interferon (IFN) gamma. Examples of pro-inflammatory cytokines
include, but are not limited to, IL-1a, IL-1b, IL-6, IL-13, IL-17a,
tumor necrosis factor (TNF)-alpha, TNF-beta, fibroblast growth
factor (FGF) 2, granulocyte macrophage colony-stimulating factor
(GM-CSF), soluble intercellular adhesion molecule 1 (sICAM-1),
soluble vascular adhesion molecule 1 (sVCAM-1), vascular
endothelial growth factor (VEGF), VEGF-C, VEGF-D, and placental
growth factor (PLGF). Examples of effectors include, but are not
limited to, granzyme A, granzyme B, soluble Fas ligand (sFasL), and
perforin. Examples of acute phase-proteins include, but are not
limited to, C-reactive protein (CRP) and serum amyloid A (SAA).
[0071] "Chemokines" are a type of cytokine that mediates cell
chemotaxis, or directional movement. Examples of chemokines
include, but are not limited to, IL-8, IL-16, eotaxin, eotaxin-3,
macrophage-derived chemokine (MDC or CCL22), monocyte chemotactic
protein 1 (MCP-1 or CCL2), MCP-4, macrophage inflammatory protein
1.alpha. (MIP-1.alpha., MIP-1a), MIP-1.beta. (MIP-1b),
gamma-induced protein 10 (IP-10), and thymus and activation
regulated chemokine (TARC or CCL17).
[0072] A "therapeutically effective amount," "effective dose,"
"effective amount," or "therapeutically effective dosage" of a
therapeutic agent, e.g., engineered CAR T cells, is any amount
that, when used alone or in combination with another therapeutic
agent, protects a subject against the onset of a disease or
promotes disease regression evidenced by a decrease in severity of
disease symptoms, an increase in frequency and duration of disease
symptom-free periods, or a prevention of impairment or disability
due to the disease affliction. The ability of a therapeutic agent
to promote disease regression may be evaluated using a variety of
methods known to the skilled practitioner, such as in human
subjects during clinical trials, in animal model systems predictive
of efficacy in humans, or by assaying the activity of the agent in
in vitro assays.
[0073] The term "lymphocyte" as used herein includes natural killer
(NK) cells, T cells, or B cells. NK cells are a type of cytotoxic
(cell toxic) lymphocyte that represent a major component of the
inherent immune system. NK cells reject tumors and cells infected
by viruses. It works through the process of apoptosis or programmed
cell death. They were termed "natural killers" because they do not
require activation in order to kill cells. T cells play a major
role in cell-mediated-immunity (no antibody involvement). Its T
cell receptors (TCR) differentiate themselves from other lymphocyte
types. The thymus, a specialized organ of the immune system, is
primarily responsible for the T cell's maturation. There are six
types of T cells, namely: Helper T cells (e.g., CD4+ cells),
Cytotoxic T cells (also known as TC, cytotoxic T lymphocyte, CTL,
T-killer cell, cytolytic T cell, CD8+ T cells or killer T cell),
Memory T cells ((i) stem memory TSCM cells, like naive cells, are
CD45RO-, CCR7+, CD45RA+, CD62L+(L-selectin), CD27+, CD28+ and
IL-7R.alpha.+, but they also express large amounts of CD95,
IL-2R.beta., CXCR3, and LFA-1, and show numerous functional
attributes distinctive of memory cells); (ii) central memory TCM
cells express L-selectin and the CCR7, they secrete IL-2, but not
IFN.gamma. or IL-4, and (iii) effector memory TEM cells, however,
do not express L-selectin or CCR7 but produce effector cytokines
like IFN.gamma. and IL-4), Regulatory T cells (Tregs, suppressor T
cells, or CD4+CD25+ regulatory T cells), Natural Killer T cells
(NKT) and Gamma Delta T cells. B-cells, on the other hand, play a
principal role in humoral immunity (with antibody involvement). It
makes antibodies and antigens and performs the role of
antigen-presenting cells (APCs) and turns into memory B-cells after
activation by antigen interaction. In mammals, immature B-cells are
formed in the bone marrow, where its name is derived from.
[0074] The term "genetically engineered" or "engineered" refers to
a method of modifying the genome of a cell, including, but not
limited to, deleting a coding or non-coding region or a portion
thereof or inserting a coding region or a portion thereof. In some
embodiments, the cell that is modified is a lymphocyte, e.g., a T
cell, which may either be obtained from a patient or a donor. The
cell may be modified to express an exogenous construct, such as,
e.g., a chimeric antigen receptor (CAR) or a T cell receptor (TCR),
which is incorporated into the cell's genome.
[0075] An "immune response" refers to the action of a cell of the
immune system (for example, T lymphocytes, B lymphocytes, natural
killer (NK) cells, macrophages, eosinophils, mast cells, dendritic
cells and neutrophils) and soluble macromolecules produced by any
of these cells or the liver (including Abs, cytokines, and
complement) that results in selective targeting, binding to, damage
to, destruction of, and/or elimination from a vertebrate's body of
invading pathogens, cells or tissues infected with pathogens,
cancerous or other abnormal cells, or, in cases of autoimmunity or
pathological inflammation, normal human cells or tissues.
[0076] The term "immunotherapy" refers to the treatment of a
subject afflicted with, or at risk of contracting or suffering a
recurrence of, a disease by a method comprising inducing,
enhancing, suppressing or otherwise modifying an immune response.
Examples of immunotherapy include, but are not limited to, T cell
therapies. T cell therapy may include adoptive T cell therapy,
tumor-infiltrating lymphocyte (TIL) immunotherapy, autologous cell
therapy, engineered autologous cell therapy (eACT.TM.), and
allogeneic T cell transplantation. However, one of skill in the art
would recognize that the conditioning methods disclosed herein
would enhance the effectiveness of any transplanted T cell therapy.
Examples of T cell therapies are described in U.S. Patent
Publication Nos. 2014/0154228 and 2002/0006409, U.S. Pat. Nos.
7,741,465, 6,319,494, 5,728,388, and International Publication No.
WO 2008/081035.
[0077] The T cells of the immunotherapy may come from any source
known in the art. For example, T cells may be differentiated in
vitro from a hematopoietic stem cell population, or T cells may be
obtained from a subject. T cells may be obtained from, e.g.,
peripheral blood mononuclear cells (PBMCs), bone marrow, lymph node
tissue, cord blood, thymus tissue, tissue from a site of infection,
ascites, pleural effusion, spleen tissue, and tumors. In addition,
the T cells may be derived from one or more T cell lines available
in the art. T cells may also be obtained from a unit of blood
collected from a subject using any number of techniques known to
the skilled artisan, such as FICOLL.TM. separation and/or
apheresis. Additional methods of isolating T cells for a T cell
therapy are disclosed in U.S. Patent Publication No. 2013/0287748,
which is herein incorporated by references in its entirety.
[0078] The term "engineered Autologous Cell Therapy," which may be
abbreviated as "eACT.TM.," also known as adoptive cell transfer, is
a process by which a patient's own T cells are collected and
subsequently genetically altered to recognize and target one or
more antigens expressed on the cell surface of one or more specific
tumor cells or malignancies. T cells may be engineered to express,
for example, chimeric antigen receptors (CAR). CAR positive (+) T
cells are engineered to express an extracellular single chain
variable fragment (scFv) with specificity for a particular tumor
antigen linked to an intracellular signaling part comprising at
least one costimulatory domain and at least one activating domain.
The CAR scFv may be designed to target, for example, CD19, which is
a transmembrane protein expressed by cells in the B cell lineage,
including all normal B cells and B cell malignances, including but
not limited to diffuse large B-cell lymphoma (DLBCL) not otherwise
specified, primary mediastinal large B-cell lymphoma, high grade
B-cell lymphoma, and DLBCL arising from follicular lymphoma, NHL,
CLL, and non-T cell ALL. Example CAR T cell therapies and
constructs are described in U.S. Patent Publication Nos.
2013/0287748, 2014/0227237, 2014/0099309, and 2014/0050708, and
these references are incorporated by reference in their
entirety.
[0079] A "patient" as used herein includes any human who is
afflicted with a cancer (e.g., a lymphoma or a leukemia). The terms
"subject" and "patient" are used interchangeably herein.
[0080] As used herein, the term "in vitro cell" refers to any cell
which is cultured ex vivo. In particular, an in vitro cell may
include a T cell.
[0081] The terms "peptide," "polypeptide," and "protein" are used
interchangeably, and refer to a compound comprised of amino acid
residues covalently linked by peptide bonds. A protein or peptide
contains at least two amino acids, and no limitation is placed on
the maximum number of amino acids that may comprise a protein's or
peptide's sequence. Polypeptides include any peptide or protein
comprising two or more amino acids joined to each other by peptide
bonds. As used herein, the term refers to both short chains, which
also commonly are referred to in the art as peptides, oligopeptides
and oligomers, for example, and to longer chains, which generally
are referred to in the art as proteins, of which there are many
types. "Polypeptides" include, for example, biologically active
fragments, substantially homologous polypeptides, oligopeptides,
homodimers, heterodimers, variants of polypeptides, modified
polypeptides, derivatives, analogs, fusion proteins, among others.
The polypeptides include natural peptides, recombinant peptides,
synthetic peptides, or a combination thereof.
[0082] "Stimulation," as used herein, refers to a primary response
induced by binding of a stimulatory molecule with its cognate
ligand, wherein the binding mediates a signal transduction event. A
"stimulatory molecule" is a molecule on a T cell, e.g., the T cell
receptor (TCR)/CD3 complex, that specifically binds with a cognate
stimulatory ligand present on an antigen present cell. A
"stimulatory ligand" is a ligand that when present on an antigen
presenting cell (e.g., an APC, a dendritic cell, a B-cell, and the
like) may specifically bind with a stimulatory molecule on a T
cell, thereby mediating a primary response by the T cell,
including, but not limited to, activation, initiation of an immune
response, proliferation, and the like. Stimulatory ligands include,
but are not limited to, an anti-CD3 antibody, an MHC Class I
molecule loaded with a peptide, a superagonist anti-CD2 antibody,
and a superagonist anti-CD28 antibody.
[0083] A "costimulatory signal," as used herein, refers to a
signal, which in combination with a primary signal, such as TCR/CD3
ligation, leads to a T cell response, such as, but not limited to,
proliferation and/or upregulation or down regulation of key
molecules.
[0084] A "costimulatory ligand," as used herein, includes a
molecule on an antigen presenting cell that specifically binds a
cognate co-stimulatory molecule on a T cell. Binding of the
costimulatory ligand provides a signal that mediates a T cell
response, including, but not limited to, proliferation, activation,
differentiation, and the like. A costimulatory ligand induces a
signal that is in addition to the primary signal provided by a
stimulatory molecule, for instance, by binding of a T cell receptor
(TCR)/CD3 complex with a major histocompatibility complex (MHC)
molecule loaded with peptide. A co-stimulatory ligand may include,
but is not limited to, 3/TR6, 4-1BB ligand, agonist or antibody
that binds Toll ligand receptor, B7-1 (CD80), B7-2 (CD86), CD30
ligand, CD40, CD7, CD70, CD83, herpes virus entry mediator (HVEM),
human leukocyte antigen G (HLA-G), ILT4, immunoglobulin-like
transcript (ILT) 3, inducible costimulatory ligand (ICOS-L),
intercellular adhesion molecule (ICAM), ligand that specifically
binds with B7-H3, lymphotoxin beta receptor, MHC class I
chain-related protein A (MICA), MHC class I chain-related protein B
(MICB), OX40 ligand, PD-L2, or programmed death (PD) L1. A
co-stimulatory ligand includes, without limitation, an antibody
that specifically binds with a co-stimulatory molecule present on a
T cell, such as, but not limited to, 4-1BB, B7-H3, CD2, CD27, CD28,
CD30, CD40, CD7, ICOS, ligand that specifically binds with CD83,
lymphocyte function-associated antigen-1 (LFA-1), natural killer
cell receptor C (NKG2C), OX40, PD-1, or tumor necrosis factor
superfamily member 14 (TNFSF14 or LIGHT).
[0085] A "costimulatory molecule" is a cognate binding partner on a
T cell that specifically binds with a costimulatory ligand, thereby
mediating a costimulatory response by the T cell, such as, but not
limited to, proliferation. Costimulatory molecules include, but are
not limited to, A "costimulatory molecule" is a cognate binding
partner on a T cell that specifically binds with a costimulatory
ligand, thereby mediating a costimulatory response by the T cell,
such as, but not limited to, proliferation. Costimulatory molecules
include, but are not limited to, 4-1BB/CD137, B7-H3, BAFFR, BLAME
(SLAMF8), BTLA, CD 33, CD 45, CD100 (SEMA4D), CD103, CD134, CD137,
CD154, CD16, CD160 (BY55), CD18, CD19, CD19a, CD2, CD22, CD247,
CD27, CD276 (B7-H3), CD28, CD29, CD3 (alpha; beta; delta; epsilon;
gamma; zeta), CD30, CD37, CD4, CD4, CD40, CD49a, CD49D, CD49f, CD5,
CD64, CD69, CD7, CD80, CD83 ligand, CD84, CD86, CD8alpha, CD8beta,
CD9, CD96 (Tactile), CDl-1a, CDl-1b, CDl-1c, CDl-1d, CDS, CEACAM1,
CRT AM, DAP-10, DNAM1 (CD226), Fc gamma receptor, GADS, GITR, HVEM
(LIGHTR), IA4, ICAM-1, ICAM-1, ICOS, Ig alpha (CD79a), IL2R beta,
IL2R gamma, IL7R alpha, integrin, ITGA4, ITGA4, ITGA6, ITGAD,
ITGAE, ITGAL, ITGAM, ITGAX, ITGB2, ITGB7, ITGB1, KIRDS2, LAT,
LFA-1, LFA-1, LIGHT, LIGHT (tumor necrosis factor superfamily
member 14; TNFSF14), LTBR, Ly9 (CD229), lymphocyte
function-associated antigen-1 (LFA-1 (CD11.alpha./CD18), MHC class
I molecule, NKG2C, NKG2D, NKp30, NKp44, NKp46, NKp80 (KLRF1), OX40,
PAG/Cbp, PD-1, PSGL1, SELPLG (CD162), signaling lymphocytic
activation molecule, SLAM (SLAMF1; CD150; IPO-3), SLAMF4 (CD244;
2B4), SLAMF6 (NTB-A; Ly108), SLAMF7, SLP-76, TNF, TNFr, TNFR2, Toll
ligand receptor, TRANCE/RANKL, VLA1, or VLA-6, or fragments,
truncations, or combinations thereof.
[0086] The terms "reducing" and "decreasing" are used
interchangeably herein and indicate any change that is less than
the original. "Reducing" and "decreasing" are relative terms,
requiring a comparison between pre- and post-measurements.
"Reducing" and "decreasing" include complete depletions.
[0087] "Treatment" or "treating" of a subject refers to any type of
intervention or process performed on, or the administration of an
active agent to, the subject with the objective of reversing,
alleviating, ameliorating, inhibiting, slowing down or preventing
the onset, progression, development, severity or recurrence of a
symptom, complication or condition, or biochemical indicia
associated with a disease. In some embodiments, "treatment" or
"treating" includes a partial remission. In another embodiment,
"treatment" or "treating" includes a complete remission.
[0088] Various aspects of the disclosure are described in further
detail in the following subsections.
Chimeric Antigen Receptors
[0089] Chimeric antigen receptors (CARs or CAR-Ts) are genetically
engineered receptors. These engineered receptors may be readily
inserted into and expressed by immune cells, including T cells in
accordance with techniques known in the art. With a CAR, a single
receptor may be programmed to both recognize a specific antigen
and, when bound to that antigen, activate the immune cell to attack
and destroy the cell bearing that antigen. When these antigens
exist on tumor cells, an immune cell that expresses the CAR may
target and kill the tumor cell.
Engineered T Cells and Use
[0090] A CD19-directed genetically modified autologous T cell
immunotherapy indicated for the treatment of patients with relapsed
or refractory large B-cell lymphoma after two or more lines of
systemic therapy, including diffuse large B-cell lymphoma (DLBCL)
not otherwise specified, primary mediastinal large B-cell lymphoma,
high grade B-cell lymphoma, and DLBCL arising from follicular
lymphoma. In some embodiments, the CD19-directed genetically
modified autologous T cell immunotherapy is axicabtagene ciloleucel
(Axi-cel.TM., YESCARTA.RTM.).
[0091] The cell of the present disclosure may be obtained through T
cells obtained from a subject. T cells may be obtained from, e.g.,
peripheral blood mononuclear cells, bone marrow, lymph node tissue,
cord blood, thymus tissue, tissue from a site of infection,
ascites, pleural effusion, spleen tissue, and tumors. In addition,
the T cells may be derived from one or more T cell lines available
in the art. T cells may also be obtained from a unit of blood
collected from a subject using any number of techniques known to
the skilled artisan, such as FICOLL.TM. separation and/or
apheresis. In some embodiments, the cells collected by apheresis
are washed to remove the plasma fraction, and placed in an
appropriate buffer or media for subsequent processing. In some
embodiments, the cells are washed with PBS. As will be appreciated,
a washing step may be used, such as by using a semiautomated flow
through centrifuge, e.g., the Cobe.TM. 2991 cell processor, the
Baxter CytoMate.TM., or the like. In some embodiments, the washed
cells are resuspended in one or more biocompatible buffers, or
other saline solution with or without buffer. In some embodiments,
the undesired components of the apheresis sample are removed.
Additional methods of isolating T cells for a T cell therapy are
disclosed in U.S. Patent Pub. No. 2013/0287748, which is herein
incorporated by references in its entirety.
[0092] In some embodiments, T cells are isolated from PBMCs by
lysing the red blood cells and depleting the monocytes, e.g., by
using centrifugation through a PERCOLL.TM. gradient. In some
embodiments, a specific subpopulation of T cells, such as CD4+,
CD8+, CD28+, CD45RA+, and CD45RO+ T cells is further isolated by
positive or negative selection techniques known in the art. For
example, enrichment of a T cell population by negative selection
may be accomplished with a combination of antibodies directed to
surface markers unique to the negatively selected cells. In some
embodiments, cell sorting and/or selection via negative magnetic
immunoadherence or flow cytometry that uses a cocktail of
monoclonal antibodies directed to cell surface markers present on
the cells negatively selected may be used. For example, to enrich
for CD4+ cells by negative selection, a monoclonal antibody
cocktail typically includes antibodies to CD8, CD11b, CD14, CD16,
CD20, and HLA-DR. In some embodiments, flow cytometry and cell
sorting are used to isolate cell populations of interest for use in
the present disclosure.
[0093] In some embodiments, PBMCs are used directly for genetic
modification with the immune cells (such as CARs) using methods as
described herein. In some embodiments, after isolating the PBMCs, T
lymphocytes are further isolated, and both cytotoxic and helper T
lymphocytes are sorted into naive, memory, and effector T cell
subpopulations either before or after genetic modification and/or
expansion.
[0094] In some embodiments, CD8+ cells are further sorted into
naive, central memory, and effector cells by identifying cell
surface antigens that are associated with each of these types of
CD8+ cells. In some embodiments, the expression of phenotypic
markers of central memory T cells includes CCR7, CD3, CD28, CD45RO,
CD62L, and CD127 and are negative for granzyme B. In some
embodiments, central memory T cells are CD8+, CD45RO+, and CD62L+ T
cells. In some embodiments, effector T cells are negative for CCR7,
CD28, CD62L, and CD127 and positive for granzyme B and perforin. In
some embodiments, CD4+ T cells are further sorted into
subpopulations. For example, CD4+T helper cells may be sorted into
naive, central memory, and effector cells by identifying cell
populations that have cell surface antigens.
[0095] In some embodiments, the immune cells, e.g., T cells, are
genetically modified following isolation using known methods, or
the immune cells are activated and expanded (or differentiated in
the case of progenitors) in vitro prior to being genetically
modified. In another embodiment, the immune cells, e.g., T cells,
are genetically modified with the chimeric antigen receptors
described herein (e.g., transduced with a viral vector comprising
one or more nucleotide sequences encoding a CAR) and then are
activated and/or expanded in vitro. Methods for activating and
expanding T cells are known in the art and are described, e.g., in
U.S. Pat. Nos. 6,905,874; 6,867,041; and 6,797,514; and PCT
Publication No. WO 2012/079000, the contents of which are hereby
incorporated by reference in their entirety. Generally, such
methods include contacting PBMC or isolated T cells with a
stimulatory agent and costimulatory agent, such as anti-CD3 and
anti-CD28 antibodies, generally attached to a bead or other
surface, in a culture medium with appropriate cytokines, such as
IL-2. Anti-CD3 and anti-CD28 antibodies attached to the same bead
serve as a "surrogate" antigen presenting cell (APC). One example
is The Dynabeads.RTM. system, a CD3/CD28 activator/stimulator
system for physiological activation of human T cells. In other
embodiments, the T cells are activated and stimulated to
proliferate with feeder cells and appropriate antibodies and
cytokines using methods such as those described in U.S. Pat. Nos.
6,040,177 and 5,827,642 and PCT Publication No. WO 2012/129514, the
contents of which are hereby incorporated by reference in their
entirety.
[0096] In some embodiments, the T cells are obtained from a donor
subject. In some embodiments, the donor subject is human patient
afflicted with a cancer or a tumor. In some embodiments, the donor
subject is a human patient not afflicted with a cancer or a
tumor.
[0097] In some embodiments, the composition comprises a
pharmaceutically acceptable carrier, diluent, solubilizer,
emulsifier, preservative and/or adjuvant. In some embodiments, the
composition comprises an excipient.
[0098] In some embodiments, the composition is selected for
parenteral delivery, for inhalation, or for delivery through the
digestive tract, such as orally. The preparation of such
pharmaceutically acceptable compositions is within the ability of
one skilled in the art. In some embodiments, buffers are used to
maintain the composition at physiological pH or at a slightly lower
pH, typically within a pH range of from about 5 to about 8. In some
embodiments, when parenteral administration is contemplated, the
composition is in the form of a pyrogen-free, parenterally
acceptable aqueous solution comprising a composition described
herein, with or without additional therapeutic agents, in a
pharmaceutically acceptable vehicle. In some embodiments, the
vehicle for parenteral injection is sterile distilled water in
which composition described herein, with or without at least one
additional therapeutic agent, is formulated as a sterile, isotonic
solution, properly preserved. In some embodiments, the preparation
involves the formulation of the desired molecule with polymeric
compounds (such as polylactic acid or polyglycolic acid), beads or
liposomes, that provide for the controlled or sustained release of
the product, which are then be delivered via a depot injection. In
some embodiments, implantable drug delivery devices are used to
introduce the desired molecule.
[0099] In some embodiments, the methods of treating a cancer in a
subject in need thereof comprise a T cell therapy. In some
embodiments, the T cell therapy disclosed herein is engineered
Autologous Cell Therapy (eACT.TM.). According to this embodiment,
the method may include collecting blood cells from the patient. The
isolated blood cells (e.g., T cells) may then be engineered to
express a CAR or a TCR disclosed herein. In a particular
embodiment, the CAR T cells or the TCR T cells are administered to
the patient. In some embodiments, the CAR T cells or the TCR T
cells treat a tumor or a cancer in the patient. In some embodiments
the CAR T cells or the TCR T cells reduce the size of a tumor or a
cancer.
[0100] In some embodiments, the donor T cells for use in the T cell
therapy are obtained from the patient (e.g., for an autologous T
cell therapy). In other embodiments, the donor T cells for use in
the T cell therapy are obtained from a subject that is not the
patient. The T cells may be administered at a therapeutically
effective amount. For example, a therapeutically effective amount
of the T cells may be at least about 10.sup.4 cells, at least about
10.sup.5 cells, at least about 10.sup.6 cells, at least about
10.sup.7 cells, at least about 10.sup.8 cells, at least about
10.sup.9, or at least about 10.sup.10. In another embodiment, the
therapeutically effective amount of the T cells is about 10.sup.4
cells, about 10.sup.5 cells, about 10.sup.6 cells, about 10.sup.7
cells, or about 10.sup.8 cells. In some embodiments, the
therapeutically effective amount of the CAR T cells is about
2.times.10.sup.6 cells/kg, about 3.times.10.sup.6 cells/kg, about
4.times.10.sup.6 cells/kg, about 5.times.10.sup.6 cells/kg, about
6.times.10.sup.6 cells/kg, about 7.times.10.sup.6 cells/kg, about
8.times.10.sup.6 cells/kg, about 9.times.10.sup.6 cells/kg, about
1.times.10.sup.7 cells/kg, about 2.times.10.sup.7 cells/kg, about
3.times.10.sup.7 cells/kg, about 4.times.10.sup.7 cells/kg, about
5.times.10.sup.7 cells/kg, about 6.times.10.sup.7 cells/kg, about
7.times.10.sup.7 cells/kg, about 8.times.10.sup.7 cells/kg, or
about 9.times.10.sup.7 cells/kg. In some embodiments, the
therapeutically effective amount of the CAR-positive viable T cells
is between about 1.times.10.sup.6 and about 2.times.10.sup.6
CAR-positive viable T cells per kg body weight up to a maximum dose
of about 1.times.10.sup.8 CAR-positive viable T cells.
[0101] In some embodiments, the therapeutically effective amount of
the CAR-positive viable T cells is between about 0.4.times.10.sup.8
and about 2.times.10.sup.8 CAR-positive viable T cells. In some
embodiments, the therapeutically effective amount of the
CAR-positive viable T cells is about 0.4.times.10.sup.8, about
0.5.times.10.sup.8, about 0.6.times.10.sup.8, about
0.7.times.10.sup.8, about 0.8.times.10.sup.8, about
0.9.times.10.sup.8, about 1.0.times.10.sup.8, about
1.1.times.10.sup.8, about 1.2.times.10.sup.8, about
1.3.times.10.sup.8, about 1.4.times.10.sup.8, about
1.5.times.10.sup.8, about 1.6.times.10.sup.8, about
1.7.times.10.sup.8, about 1.8.times.10.sup.8, about
1.9.times.10.sup.8, or about 2.0.times.10.sup.8 CAR-positive viable
T cells.
Methods of Treatment
[0102] The methods disclosed herein may be used to treat a cancer
in a subject, reduce the size of a tumor, kill tumor cells, prevent
tumor cell proliferation, prevent growth of a tumor, eliminate a
tumor from a patient, prevent relapse of a tumor, prevent tumor
metastasis, induce remission in a patient, or any combination
thereof. In some embodiments, the methods induce a complete
response. In other embodiments, the methods induce a partial
response.
[0103] Cancers that may be treated include tumors that are not
vascularized, not yet substantially vascularized, or vascularized.
The cancer may also include solid or non-solid tumors. In some
embodiments, the cancer is a hematologic cancer. In some
embodiments, the cancer is of the white blood cells. In other
embodiments, the cancer is of the plasma cells. In some
embodiments, the cancer is leukemia, lymphoma, or myeloma. In some
embodiments, the cancer is acute lymphoblastic leukemia (ALL)
(including non T cell ALL), acute lymphoid leukemia (ALL), and
hemophagocytic lymphohistocytosis (HLH)), B cell prolymphocytic
leukemia, B-cell acute lymphoid leukemia ("BALL"), blastic
plasmacytoid dendritic cell neoplasm, Burkitt's lymphoma, chronic
lymphocytic leukemia (CLL), chronic myelogenous leukemia (CML),
chronic myeloid leukemia (CML), chronic or acute granulomatous
disease, chronic or acute leukemia, diffuse large B cell lymphoma,
diffuse large B cell lymphoma (DLBCL), follicular lymphoma,
follicular lymphoma (FL), hairy cell leukemia, hemophagocytic
syndrome (Macrophage Activating Syndrome (MAS), Hodgkin's Disease,
large cell granuloma, leukocyte adhesion deficiency, malignant
lymphoproliferative conditions, MALT lymphoma, mantle cell
lymphoma, Marginal zone lymphoma, monoclonal gammapathy of
undetermined significance (MGUS), multiple myeloma, myelodysplasia
and myelodysplastic syndrome (MDS), myeloid diseases including but
not limited to acute myeloid leukemia (AML), non-Hodgkin's lymphoma
(NHL), plasma cell proliferative disorders (e.g., asymptomatic
myeloma (smoldering multiple myeloma or indolent myeloma),
plasmablastic lymphoma, plasmacytoid dendritic cell neoplasm,
plasmacytomas (e.g., plasma cell dyscrasia; solitary myeloma;
solitary plasmacytoma; extramedullary plasmacytoma; and multiple
plasmacytoma), POEMS syndrome (Crow-Fukase syndrome; Takatsuki
disease; PEP syndrome), primary mediastinal large B cell lymphoma
(PMBC), small cell- or a large cell-follicular lymphoma, splenic
marginal zone lymphoma (SMZL), systemic amyloid light chain
amyloidosis, T cell acute lymphoid leukemia ("TALL"), T cell
lymphoma, transformed follicular lymphoma, Waldenstrom
macroglobulinemia, or a combination thereof.
[0104] In some embodiments, the cancer is a myeloma. In some
embodiments, the cancer is multiple myeloma. In some embodiments,
the cancer is a leukemia. In some embodiments, the cancer is acute
myeloid leukemia.
[0105] In some embodiments, the methods further comprise
administering a chemotherapeutic. In some embodiments, the
chemotherapeutic selected is a lymphodepleting (preconditioning)
chemotherapeutic. Beneficial preconditioning treatment regimens,
along with correlative beneficial biomarkers are described in U.S.
Provisional Patent Applications 62/262,143 and 62/167,750 which are
hereby incorporated by reference in their entirety herein. These
describe, e.g., methods of conditioning a patient in need of a T
cell therapy comprising administering to the patient specified
beneficial doses of cyclophosphamide (between 200 mg/m.sup.2/day
and 2000 mg/m.sup.2/day) and specified doses of fludarabine
(between 20 mg/m.sup.2/day and 900 mg/m.sup.2/day). One such dose
regimen involves treating a patient comprising administering daily
to the patient about 500 mg/m.sup.2/day of cyclophosphamide and
about 60 mg/m.sup.2/day of fludarabine for three days prior to
administration of a therapeutically effective amount of engineered
T cells to the patient.
[0106] In some embodiments, the antigen binding molecule,
transduced (or otherwise engineered) cells (such as CARs), and the
chemotherapeutic agent are administered each in an amount effective
to treat the disease or condition in the subject.
[0107] In some embodiments, compositions comprising CAR-expressing
immune effector cells disclosed herein may be administered in
conjunction with any number of chemotherapeutic agents. Examples of
chemotherapeutic agents include alkylating agents such as thiotepa
and cyclophosphamide (CYTOXAN.TM.); alkyl sulfonates such as
busulfan, improsulfan and piposulfan; aziridines such as benzodopa,
carboquone, meturedopa, and uredopa; ethylenimines and
methylamelamines including altretamine, triethylenemelamine,
trietylenephosphoramide, triethylenethiophosphaoramide and
trimethylolomelamine resume; nitrogen mustards such as
chlorambucil, chlornaphazine, cholophosphamide, estramustine,
ifosfamide, mechlorethamine, mechlorethamine oxide hydrochloride,
melphalan, novembichin, phenesterine, prednimustine, trofosfamide,
uracil mustard; nitrosureas such as carmustine, chlorozotocin,
fotemustine, lomustine, nimustine, ranimustine; antibiotics such as
aclacinomysins, actinomycin, authramycin, azaserine, bleomycins,
cactinomycin, calicheamicin, carabicin, carminomycin,
carzinophilin, chromomycins, dactinomycin, daunorubicin,
detorubicin, 6-diazo-5-oxo-L-norleucine, doxorubicin, epirubicin,
esorubicin, idarubicin, marcellomycin, mitomycins, mycophenolic
acid, nogalamycin, olivomycins, peplomycin, potfiromycin,
puromycin, quelamycin, rodorubicin, streptonigrin, streptozocin,
tubercidin, ubenimex, zinostatin, zorubicin; anti-metabolites such
as methotrexate and 5-fluorouracil (5-FU); folic acid analogues
such as denopterin, methotrexate, pteropterin, trimetrexate; purine
analogs such as fludarabine, 6-mercaptopurine, thiamiprine,
thioguanine; pyrimidine analogs such as ancitabine, azacitidine,
6-azauridine, carmofur, cytarabine, dideoxyuridine, doxifluridine,
enocitabine, floxuridine, 5-FU; androgens such as calusterone,
dromostanolone propionate, epitiostanol, mepitiostane,
testolactone; anti-adrenals such as aminoglutethimide, mitotane,
trilostane; folic acid replenisher such as frolinic acid;
aceglatone; aldophosphamide glycoside; aminolevulinic acid;
amsacrine; bestrabucil; bisantrene; edatraxate; defofamine;
demecolcine; diaziquone; elformithine; elliptinium acetate;
etoglucid; gallium nitrate; hydroxyurea; lentinan; lonidamine;
mitoguazone; mitoxantrone; mopidamol; nitracrine; pentostatin;
phenamet; pirarubicin; podophyllinic acid; 2-ethylhydrazide;
procarbazine; PSK.RTM.; razoxane; sizofiran; spirogermanium;
tenuazonic acid; triaziquone; 2, 2',2''-trichlorotriethylamine;
urethan; vindesine; dacarbazine; mannomustine; mitobronitol;
mitolactol; pipobroman; gacytosine; arabinoside ("Ara-C");
cyclophosphamide; thiotepa; taxoids, e.g. paclitaxel (TAXOL.TM.,
Bristol-Myers Squibb) and doxetaxel (TAXOTERE.RTM., Rhone-Poulenc
Rorer); chlorambucil; gemcitabine; 6-thioguanine; mercaptopurine;
methotrexate; platinum analogs such as cisplatin and carboplatin;
vinblastine; platinum; etoposide (VP-16); ifosfamide; mitomycin C;
mitoxantrone; vincristine; vinorelbine; navelbine; novantrone;
teniposide; daunomycin; aminopterin; xeloda; ibandronate; CPT-11;
topoisomerase inhibitor RFS2000; difluoromethylomithine (DMFO);
retinoic acid derivatives such as Targretin.TM. (bexarotene),
Panretin.TM., (alitretinoin); ONTAK.TM. (denileukin diftitox);
esperamicins; capecitabine; and pharmaceutically acceptable salts,
acids or derivatives of any of the above. In some embodiments,
compositions comprising CAR- and/or TCR-expressing immune effector
cells disclosed herein may be administered in conjunction with an
anti-hormonal agent that acts to regulate or inhibit hormone action
on tumors such as anti-estrogens including for example tamoxifen,
raloxifene, aromatase inhibiting 4(5)-imidazoles,
4-hydroxytamoxifen, trioxifene, keoxifene, LY117018, onapristone,
and toremifene (Fareston); and anti-androgens such as flutamide,
nilutamide, bicalutamide, leuprolide, and goserelin; and
pharmaceutically acceptable salts, acids or derivatives of any of
the above. Combinations of chemotherapeutic agents are also
administered where appropriate, including, but not limited to CHOP,
i.e., Cyclophosphamide (Cytoxan.RTM.), Doxorubicin
(hydroxydoxorubicin), Vincristine (Oncovin.RTM.), and
Prednisone.
[0108] In some embodiments, the chemotherapeutic agent is
administered at the same time or within one week after the
administration of the engineered cell or nucleic acid. In other
embodiments, the chemotherapeutic agent is administered from 1 to 4
weeks or from 1 week to 1 month, 1 week to 2 months, 1 week to 3
months, 1 week to 6 months, 1 week to 9 months, or 1 week to 12
months after the administration of the engineered cell or nucleic
acid. In some embodiments, the chemotherapeutic agent is
administered at least 1 month before administering the cell or
nucleic acid. In some embodiments, the methods further comprise
administering two or more chemotherapeutic agents.
[0109] A variety of additional therapeutic agents may be used in
conjunction with the compositions described herein. For example,
potentially useful additional therapeutic agents include PD-1
inhibitors such as nivolumab (OPDIVO.RTM.), pembrolizumab
(KEYTRUDA.RTM.), pembrolizumab, pidilizumab (CureTech), and
atezolizumab (Roche).
[0110] Additional therapeutic agents suitable for use in
combination with the compositions and methods disclosed herein
include, but are not limited to, ibrutinib (IMBRUVICA.RTM.),
ofatumumab (ARZERRA.RTM.), rituximab (RITUXAN.RTM.), bevacizumab
(AVASTIN.RTM.), trastuzumab (HERCEPTIN.RTM.), trastuzumab emtansine
(KADCYLA.RTM.), imatinib (GLEEVEC.RTM.), cetuximab (ERBITUX.RTM.),
panitumumab (VECTIBIX.RTM.), catumaxomab, ibritumomab, ofatumumab,
tositumomab, brentuximab, alemtuzumab, gemtuzumab, erlotinib,
gefitinib, vandetanib, afatinib, lapatinib, neratinib, axitinib,
masitinib, pazopanib, sunitinib, sorafenib, toceranib,
lestaurtinib, axitinib, cediranib, lenvatinib, nintedanib,
pazopanib, regorafenib, semaxanib, sorafenib, sunitinib, tivozanib,
toceranib, vandetanib, entrectinib, cabozantinib, imatinib,
dasatinib, nilotinib, ponatinib, radotinib, bosutinib,
lestaurtinib, ruxolitinib, pacritinib, cobimetinib, selumetinib,
trametinib, binimetinib, alectinib, ceritinib, crizotinib,
aflibercept, adipotide, denileukin diftitox, mTOR inhibitors such
as Everolimus and Temsirolimus, hedgehog inhibitors such as
sonidegib and vismodegib, CDK inhibitors such as CDK inhibitor
(palbociclib).
[0111] In some embodiments, the composition comprising CAR immune
cells are administered with an anti-inflammatory agent.
Anti-inflammatory agents or drugs may include, but are not limited
to, steroids and glucocorticoids (including betamethasone,
budesonide, dexamethasone, hydrocortisone acetate, hydrocortisone,
hydrocortisone, methylprednisolone, prednisolone, prednisone,
triamcinolone), nonsteroidal anti-inflammatory drugs (NSAIDS)
including aspirin, ibuprofen, naproxen, methotrexate,
sulfasalazine, leflunomide, anti-TNF medications, cyclophosphamide
and mycophenolate. Exemplary NSAIDs include ibuprofen, naproxen,
naproxen sodium, Cox-2 inhibitors, and sialylates. Exemplary
analgesics include acetaminophen, oxycodone, tramadol of
proporxyphene hydrochloride. Exemplary glucocorticoids include
cortisone, dexamethasone, hydrocortisone, methylprednisolone,
prednisolone, or prednisone. Exemplary biological response
modifiers include molecules directed against cell surface markers
(e.g., CD4, CD5, etc.), cytokine inhibitors, such as the TNF
antagonists, (e.g., etanercept (ENBREL.RTM.), adalimumab
(HUMIRA.RTM.) and infliximab (REMICADE.RTM.), chemokine inhibitors
and adhesion molecule inhibitors. The biological response modifiers
include monoclonal antibodies as well as recombinant forms of
molecules. Exemplary DMARDs include azathioprine, cyclophosphamide,
cyclosporine, methotrexate, penicillamine, leflunomide,
sulfasalazine, hydroxychloroquine, Gold (oral (auranofin) and
intramuscular), and minocycline.
[0112] In some embodiments, the compositions described herein are
administered in conjunction with a cytokine. Examples of cytokines
are lymphokines, monokines, and traditional polypeptide hormones.
Included among the cytokines are growth hormones such as human
growth hormone, N-methionyl human growth hormone, and bovine growth
hormone; parathyroid hormone; thyroxine; insulin; proinsulin;
relaxin; prorelaxin; glycoprotein hormones such as follicle
stimulating hormone (FSH), thyroid stimulating hormone (TSH), and
luteinizing hormone (LH); hepatic growth factor (HGF); fibroblast
growth factor (FGF); prolactin; placental lactogen;
mullerian-inhibiting substance; mouse gonadotropin-associated
peptide; inhibin; activin; vascular endothelial growth factor;
integrin; thrombopoietin (TPO); nerve growth factors (NGFs) such as
NGF-beta; platelet-growth factor; transforming growth factors
(TGFs) such as TGF-alpha and TGF-beta; insulin-like growth factor-I
and --II; erythropoietin (EPO, Epogen.RTM., Procne); osteoinductive
factors; interferons such as interferon-alpha, beta, and -gamma;
colony stimulating factors (CSFs) such as macrophage-CSF (M-CSF);
granulocyte-macrophage-CSF (GM-CSF); and granulocyte-CSF (G-CSF);
interleukins (ILs) such as IL-1, IL-1alpha, IL-2, IL-3, IL-4, IL-5,
IL-6, IL-7, IL-8, IL-9, IL-10, IL-11, IL-12; IL-15, a tumor
necrosis factor such as TNF-alpha or TNF-beta; and other
polypeptide factors including LIF and kit ligand (KL). As used
herein, the term cytokine includes proteins from natural sources or
from recombinant cell culture, and biologically active equivalents
of the native sequence cytokines.
Administration of CD19-Directed Genetically Modified Autologous T
Cell Immunotherapy
[0113] Indications and Usage
[0114] In some embodiments, CD19-directed genetically modified
autologous T cell immunotherapy indicated for the treatment of
adult patients with relapsed or refractory large B-cell lymphoma
after two or more lines of systemic therapy, including diffuse
large B-cell lymphoma (DLBCL) not otherwise specified, primary
mediastinal large B-cell lymphoma, high grade B-cell lymphoma, and
DLBCL arising from follicular lymphoma. In some embodiments,
CD19-directed genetically modified autologous T cell immunotherapy
is not indicated for the treatment of patients with primary central
nervous system lymphoma.
[0115] Dosage and Administration
[0116] In some embodiments, an infusion bag of CD19-directed
genetically modified autologous T cell immunotherapy comprises a
suspension of chimeric antigen receptor (CAR)-positive T cells in
approximately 68 mL. The target dose may be between about
1.times.10.sup.6 and about 2.times.10.sup.6 CAR-positive viable T
cells per kg body weight, with a maximum of 2.times.10.sup.8
CAR-positive viable T cells. In some embodiments the CD19-directed
genetically modified autologous T cell immunotherapy is Axi-cel.TM.
(YESCARTA.RTM., axicabtagene ciloleucel).
[0117] CD19-directed genetically modified autologous T cell
immunotherapy is for autologous use. The patient's identity must
match the patient identifiers on the CD19-directed genetically
modified autologous T cell immunotherapy cassette and infusion bag.
If the information on the patient-specific label does not match the
intended patient, the CD19-directed genetically modified autologous
T cell immunotherapy cannot be administered.
[0118] In some embodiments, the availability of CD19-directed
genetically modified autologous T cell immunotherapy must be
confirmed prior to starting the lymphodepleting regimen.
[0119] In some embodiments, the patient is pre-treated prior to
CD19-directed genetically modified autologous T cell immunotherapy
infusion with administration of lymphodepleting chemotherapy. In
some embodiments, a lymphodepleting chemotherapy regimen of
cyclophosphamide 500 mg/m.sup.2 IV and fludarabine 30 mg/m.sup.2 IV
on the fifth, fourth, and third day before infusion of
CD19-directed genetically modified autologous T cell immunotherapy
is administered.
[0120] In some embodiments, the patient is premedicated prior to
CD19-directed genetically modified autologous T cell immunotherapy
infusion by oral administration of acetaminophen at a dose between
about 500-1000 mg, about 600-1000 mg, about 700-1000 mg, about
800-1000 mg, about 900-1000 mg, about 500-900 mg, about 500-800 mg,
about 500-700 mg, about 500-600 mg, about 600-900 mg, about 600-800
mg, about 600-700 mg, about 700-900 mg, about 700-800 mg, or about
800-900 mg. In some embodiments, the patient is premedicated prior
to CD19-directed genetically modified autologous T cell
immunotherapy infusion by oral administration of acetaminophen at a
dose of about 500 mg, about 525 mg, about 550 mg, about 575 mg,
about 600 mg, about 625 mg, about 650 mg, about 675 mg, about 700
mg, about 725 mg, about 750 mg, about 775 mg, about 800 mg, about
825 mg, about 850 mg, about 875 mg, about 900 mg, about 925 mg,
about 950 mg, about 975 mg or about 1000 mg.
[0121] In some embodiments, the patient is premedicated prior to
CD19-directed genetically modified autologous T cell immunotherapy
infusion by administration of acetaminophen 650 mg by mouth and
diphenhydramine 12.5 mg intravenously or by mouth approximately 1
hour before CD19-directed genetically modified autologous T cell
immunotherapy infusion.
[0122] In some embodiments, the prophylactic use of systemic
steroids is avoided as it may interfere with the activity of
CD19-directed genetically modified autologous T cell
immunotherapy.
[0123] Preparation of CD19-Directed Genetically Modified Autologous
T Cell Immunotherapy for Infusion
[0124] The timing of CD19-directed genetically modified autologous
T cell immunotherapy thaw and infusion is coordinated. In some
embodiments, the infusion time is confirmed in advance, and the
start time of CD19-directed genetically modified autologous T cell
immunotherapy thaw is adjusted such that it will be available for
infusion when the patient is ready.
[0125] In some embodiments, the patient identity is confirmed prior
to CD19-directed genetically modified autologous T cell
immunotherapy thaw. Prior to CD19-directed genetically modified
autologous T cell immunotherapy preparation, patient's identity is
matched with the patient identifiers on the CD19-directed
genetically modified autologous T cell immunotherapy cassette. In
some embodiments, the CD19-directed genetically modified autologous
T cell immunotherapy product bag is not removed from the cassette
if the information on the patient-specific label does not match the
intended patient.
[0126] In some embodiments, once patient identification is
confirmed, CD19-directed genetically modified autologous T cell
immunotherapy product bag is removed from the cassette and the
patient information on the cassette label is confirmed to match the
bag label.
[0127] In some embodiments, the method comprises inspecting the
product bag for any breaches of container integrity such as breaks
or cracks before thawing. In some embodiments, the infusion bag is
placed inside a second sterile bag per local guidelines.
[0128] In some embodiments, the method comprises thawing the
CD19-directed genetically modified autologous T cell immunotherapy
at approximately 37.degree. C. using either a water bath or dry
thaw method until there is no visible ice in the infusion bag. In
some embodiments, the method comprises mixing or agitating the
contents of the bag to disperse clumps of cellular material. In
some embodiments, the contents of the bag are gently mixed or
agitated. In some embodiments, the method comprises inspecting the
bag for the presence of visible cell clumps remaining and mixing or
agitation is continued. Small clumps of cellular material should
disperse with gentle manual mixing. In some embodiments, the method
does not comprise a wash, spin down, and/or re-suspension of
CD19-directed genetically modified autologous T cell immunotherapy
in new media prior to infusion.
[0129] In some embodiments, once thawed, CD19-directed genetically
modified autologous T cell immunotherapy may be stored at room
temperature (20.degree. C. to 25.degree. C.) for up to 3 hours.
Administration
[0130] In some embodiments, the presently disclosed methods of
administration of CD19-directed genetically modified autologous T
cell immunotherapy comprise on or more of the following as steps or
as considerations: [0131] Ensure that tocilizumab and emergency
equipment are available prior to infusion and during the recovery
period. [0132] Do NOT use a leukodepleting filter. [0133] Central
venous access is recommended for the infusion of CD19-directed
genetically modified autologous T cell immunotherapy. [0134]
Confirm the patient's identity matches the patient identifiers on
the CD19-directed genetically modified autologous T cell
immunotherapy product bag. [0135] Prime the tubing with normal
saline prior to infusion. [0136] Infuse the entire contents of the
CD19-directed genetically modified autologous T cell immunotherapy
bag within 30 minutes by either gravity or a peristaltic pump.
CD19-directed genetically modified autologous T cell immunotherapy
is stable at room temperature for up to 3 hours after thaw. [0137]
Gently agitate the product bag during CD19-directed genetically
modified autologous T cell immunotherapy infusion to prevent cell
clumping. [0138] After the entire content of the product bag is
infused, rinse the tubing with normal saline at the same infusion
rate to ensure all product is delivered. [0139] CD19-directed
genetically modified autologous T cell immunotherapy contains human
blood cells that are genetically modified with replication
incompetent retroviral vector. Follow universal precautions and
local biosafety guidelines for handling and disposal to avoid
potential transmission of infectious diseases.
Monitoring
[0140] In some embodiments, administration of CD19-directed
genetically modified autologous T cell immunotherapy occurs at a
certified healthcare facility.
[0141] In some embodiments, the methods disclosed herein comprise
monitoring patients at least daily for 7 days at the certified
healthcare facility following infusion for signs and symptoms of
CRS and neurologic toxicities. In some embodiments, the methods
disclosed herein comprise monitoring patients at least daily for 10
days at the certified healthcare facility following infusion for
signs and symptoms of CRS and neurologic toxicities.
[0142] In some embodiments, patients are instructed to remain
within proximity of the certified healthcare facility for at least
4 weeks following infusion.
[0143] Management of Severe Adverse Reactions
[0144] In some embodiments, the method comprises management of
adverse reactions. In some embodiments, the adverse reaction is
selected from the group consisting of cytokine release syndrome
(CRS), a neurologic toxicity, a hypersensitivity reaction, a
serious infection, a cytopenia and hypogammaglobulinemia.
[0145] In some embodiments, the signs and symptoms of adverse
reactions are selected from the group consisting of fever,
hypotension, tachycardia, hypoxia, and chills, include cardiac
arrhythmias (including atrial fibrillation and ventricular
tachycardia), cardiac arrest, cardiac failure, renal insufficiency,
capillary leak syndrome, hypotension, hypoxia, organ toxicity,
hemophagocytic lymphohistiocytosis/macrophage activation syndrome
(HLH/MAS), seizure, encephalopathy, headache, tremor, dizziness,
aphasia, delirium, insomnia anxiety, anaphylaxis, febrile
neutropenia, thrombocytopenia, neutropenia, and anemia.
Cytokine Release Syndrome
[0146] In some embodiments, the method comprises identifying CRS
based on clinical presentation. In some embodiments, the method
comprises evaluating for and treating other causes of fever,
hypoxia, and hypotension. If CRS is observed or suspected, manage
according to the recommendations in Table 1. Patients who
experience .gtoreq.Grade 2 CRS (e.g., hypotension, not responsive
to fluids, or hypoxia requiring supplemental oxygenation) should be
monitored with continuous cardiac telemetry and pulse oximetry. In
some embodiments, for patients experiencing severe CRS, consider
performing an echocardiogram to assess cardiac function. For severe
or life-threatening CRS, intensive care supportive therapy may be
considered. In some embodiments, a biosimilar or equivalent of
tocilizumab may be used instead of tocilizumab in the methods
disclosed herein.
TABLE-US-00001 TABLE 1 CRS Grading and Management Guidance CRS
Grade (a) Tocilizumab Corticosteroids Grade 1 N/A N/A Symptoms
require symptomatic treatment only (e.g., fever, nausea, fatigue,
headache, myalgia, malaise). Grade 2 Administer tocilizumab (c) 8
Manage per Grade 3 if no Symptoms require and mg/kg IV over 1 hour
(not to improvement within 24 hours respond to moderate exceed 800
mg). after starting tocilizumab. intervention. Repeat tocilizumab
every 8 Oxygen requirement less hours as needed if not than 40%
FiO.sub.2 or responsive to IV fluids or hypotension responsive to
increasing supplemental fluids or low-dose of one oxygen.
vasopressor or Grade 2 Limit to a maximum of 3 organ toxicity (b).
doses in a 24-hour period; maximum total of 4 doses if no clinical
improvement in the signs and symptoms of CRS. Grade 3 Per Grade 2
Administer Symptoms require and methylprednisolone 1 mg/kg respond
to aggressive IV twice daily or equivalent intervention.
dexamethasone (e.g., 10 mg Oxygen requirement greater IV every 6
hours). than or equal to 40% FiO.sub.2 or Continue corticosteroids
use hypotension requiring high- until the event is Grade 1 or dose
or multiple less, then taper over 3 days. vasopressors or Grade 3
If not improving, manage as organ toxicity or Grade 4 Grade 4.
transaminitis. Grade 4 Per Grade 2 Administer Life-threatening
symptoms. methylprednisolone 1000 mg Requirements for ventilator IV
per day for 3 days; if support, continuous veno- improves, then
manage as venous hemodialysis above. (CVVHD) or Consider alternate
Grade 4 organ toxicity immunosuppressants if no (excluding
transaminitis). improvement or if condition worsens. (a) Lee D W et
al., (2014). Current concepts in the diagnosis and management of
cytokine release syndrome. Blood. 2014 Jul. 10; 124(2): 188-195.
(b) Refer to Table 2 for management of neurologic toxicity. (c)
Refer to ACEMTRA .RTM. (tocilizumab) Prescribing Information for
details, https://www.gene.com/download/pdf/actemra_prescribing.pdf
(last accessed Oct. 18, 2017). Initial U.S. approval is indicated
to be in 2010.
Neurologic Toxicity
[0147] In some embodiments, the method comprises monitoring
patients for signs and symptoms of neurologic toxicities (Table 2).
In some embodiments, the method comprises ruling out other causes
of neurologic symptoms. Patients who experience .gtoreq.Grade 2
neurologic toxicities should be monitored with continuous cardiac
telemetry and pulse oximetry. Provide intensive care supportive
therapy for severe or life threatening neurologic toxicities.
Consider non-sedating, anti-seizure medicines (e.g., levetiracetam)
for seizure prophylaxis for any .gtoreq.Grade 2 neurologic
toxicities.
TABLE-US-00002 TABLE 2 Neurologic Toxicity Grading and Management
Guidance Grading Assessment Concurrent CRS No concurrent CRS Grade
2 Administer tocilizumab per Table 1 for Administer dexamethasone
10 mg IV management of Grade 2 CRS. every 6 hours. If no
improvement within 24 hours after Continue dexamethasone use until
the starting tocilizumab, administer event is Grade 1 or less, then
taper over 3 dexamethasone 10 mg IV every 6 hours if days. not
already taking other steroids. Continue dexamethasone use until the
event is Grade 1 or less, then taper over 3 days. Consider
non-sedating, anti-seizure medicines (e.g., levetiracetam) for
seizure prophylaxis. Grade 3 Administer tocilizumab per Table 1 for
Administer dexamethasone 10 mg IV management of Grade 2 CRS. every
6 hours. In addition, administer dexamethasone 10 Continue
dexamethasone use until the mg IV with the first dose of
tocilizumab event is Grade 1 or less, then taper over 3 and repeat
dose every 6 hours. Continue days. dexamethasone use until the
event is Grade 1 or less, then taper over 3 days. Consider
non-sedating, anti-seizure medicines (e.g., levetiracetam) for
seizure prophylaxis. Grade 4 Administer tocilizumab per Table 1 for
Administer methylprednisolone 1000 mg management of Grade 2 CRS. IV
per day for 3 days; if improves, then Administer methylprednisolone
1000 mg manage as above. IV per day with first dose of tocilizumab
and continue methylprednisolone 1000 mg IV per day for 2 more days;
if improves, then manage as above. Consider non-sedating,
anti-seizure medicines (e.g., levetiracetam) for seizure
prophylaxis.
[0148] Dosage Forms And Strengths
[0149] In some embodiments, CD19-directed genetically modified
autologous T cell immunotherapy is available as a cell suspension
for infusion.
[0150] In some embodiments, a single dose of CD19-directed
genetically modified autologous T cell immunotherapy comprises a
target dose between about 1.times.10.sup.6 and about
2.times.10.sup.6 CAR-positive viable T cells per kg of body weight
(or maximum of 2.times.10.sup.8 CAR-positive viable T cells for
patients 100 kg and above) in approximately 68 mL suspension in an
infusion bag. In some embodiments, the CD19-directed genetically
modified autologous T cell immunotherapy is axicabtagene ciloleucel
(YESCARTA.RTM.).
[0151] In some embodiments, a single dose of CD19-directed
genetically modified autologous T cell immunotherapy is present in
a container. Such container may be sterile. In some embodiments,
the container is an infusion bag. In some embodiments, the infusion
bag volume is about 100 mL, 150 mL, 200 mL, 250 mL, 300 mL, 500 mL,
750 mL, 1,000 mL, 1,500 mL, 2,000 mL or 3,000 mL.
[0152] Risk Evaluation and Mitigation Strategy (REMS)
[0153] Because of the risk of CRS and neurologic toxicities, in
some embodiments, CD19-directed genetically modified autologous T
cell immunotherapy is available through a restricted program under
a Risk Evaluation and Mitigation Strategy (REMS). Typical
components of the REMS are: [0154] Healthcare facilities that
dispense and administer CD19-directed genetically modified
autologous T cell immunotherapy must be enrolled and comply with
the REMS requirements. [0155] Certified healthcare facilities must
have on-site, immediate access to tocilizumab, and ensure that a
minimum of two doses of tocilizumab are available for each patient
for infusion within 2 hours after CD19-directed genetically
modified autologous T cell immunotherapy infusion, if needed for
treatment of CRS. [0156] Certified healthcare facilities must
ensure that healthcare providers who prescribe, dispense or
administer CD19-directed genetically modified autologous T cell
immunotherapy are trained about the management of CRS and
neurologic toxicities.
Cytokine Release Syndrome (CRS)
[0157] In some embodiments, the health care facility ensures that
two doses of tocilizumab are available prior to infusion of
CD19-directed genetically modified autologous T cell immunotherapy.
In some embodiments, the health care facility ensures that four
doses of tocilizumab are available prior to infusion of
CD19-directed genetically modified autologous T cell immunotherapy.
In some embodiments, the method comprises monitoring patients at
least daily for 7 days at the certified healthcare facility
following infusion for signs and symptoms of CRS. In some
embodiments, the method comprises monitoring patients at least
daily for 7-10 days at the certified healthcare facility following
infusion for signs and symptoms of CRS. In some embodiments, the
method comprises monitoring patients at least daily for 8 days at
the certified healthcare facility following infusion for signs and
symptoms of CRS. In some embodiments, the method comprises
monitoring patients at least daily for 9 days at the certified
healthcare facility following infusion for signs and symptoms of
CRS. In some embodiments, the method comprises monitoring patients
at least daily for 10 days at the certified healthcare facility
following infusion for signs and symptoms of CRS. In some
embodiments, the method comprises monitoring patients for signs or
symptoms of CRS for 4 weeks after infusion. In some embodiments,
the method comprises counseling patients to seek immediate medical
attention should signs or symptoms of CRS occur at any time. In
some embodiments, the method comprises instituting treatment with
supportive care, tocilizumab or tocilizumab and corticosteroids as
indicated at the first sign of CRS.
Neurologic Toxicities
[0158] In some embodiments, the method comprises monitoring
patients at least daily for 7 days at the certified healthcare
facility following infusion for signs and symptoms of neurologic
toxicities. In some embodiments, the method comprises monitoring
patients at least daily for 7-10 days at the certified healthcare
facility following infusion for signs and symptoms of CRS. In some
embodiments, the method comprises monitoring patients at least
daily for 10 days at the certified healthcare facility following
infusion for signs and symptoms of CRS. In some embodiments, the
method comprises monitoring patients for signs or symptoms of
neurologic toxicities for 4 weeks after infusion and treat
promptly.
Hypersensitivity Reactions
[0159] Allergic reactions may occur with the infusion of
CD19-directed genetically modified autologous T cell immunotherapy.
In some embodiments, serious hypersensitivity reactions including
anaphylaxis, may be due to dimethyl sulfoxide (DMSO) or residual
gentamicin in CD19-directed genetically modified autologous T cell
immunotherapy.
Viral Reactivation
[0160] In some embodiments, Hepatitis B virus (HBV) reactivation,
in some cases resulting in fulminant hepatitis, hepatic failure and
death, may occur in patients treated with drugs directed against B
cells. In some embodiments, the method comprises performing
screening for HBV, HCV, and HIV in accordance with clinical
guidelines before collection of cells for manufacturing.
Prolonged Cytopenias
[0161] In some embodiments, patients may exhibit cytopenias for
several weeks following lymphodepleting chemotherapy and
CD19-directed genetically modified autologous T cell immunotherapy
infusion. In some embodiments, the method comprises monitoring
blood counts after CD19-directed genetically modified autologous T
cell immunotherapy infusion.
Hypogammaglobulinemia
[0162] In some embodiments, B-cell aplasia and
hypogammaglobulinemia may occur in patients receiving treatment
with CD19-directed genetically modified autologous T cell
immunotherapy. In some embodiments, the method comprises monitoring
immunoglobulin levels after treatment with CD19-directed
genetically modified autologous T cell immunotherapy and managing
using infection precautions, antibiotic prophylaxis and
immunoglobulin replacement.
[0163] In some embodiments, vaccination with live virus vaccines is
not recommended for at least 6 weeks prior to the start of
lymphodepleting chemotherapy, during CD19-directed genetically
modified autologous T cell immunotherapy treatment, and until
immune recovery following treatment with CD19-directed genetically
modified autologous T cell immunotherapy.
Secondary Malignancies
[0164] In some embodiments, patients treated with CD19-directed
genetically modified autologous T cell immunotherapy may develop
secondary malignancies. In some embodiments, the method comprises
monitoring life-long for secondary malignancies.
Tumour lysis syndrome (TLS)
[0165] Patients treated with CD19-directed genetically modified
autologous T cell immunotherapy may develop TLS, which may be
severe. To minimise risk of TLS, in some embodiments, the method
comprises evaluating patients for elevated uric acid or high tumour
burden and administering allopurinol, or an alternative
prophylaxis, prior to axicabtagene ciloleucel infusion. Signs and
symptoms of TLS should be monitored and events managed according to
standard guidelines.
Effects on Ability to Drive and Use Machines
[0166] Due to the potential for neurologic events, including
altered mental status or seizures, patients receiving CD19-directed
genetically modified autologous T cell immunotherapy are at risk
for altered or decreased consciousness or coordination in the 8
weeks following CD19-directed genetically modified autologous T
cell immunotherapy infusion. In some embodiments, the method
comprises advising patients to refrain from driving and engaging in
hazardous occupations or activities, such as operating heavy or
potentially dangerous machinery, during this initial period.
[0167] Storage and Handling
[0168] In some embodiments, CD19-directed genetically modified
autologous T cell immunotherapy is supplied in an infusion bag
containing approximately 68 mL of frozen suspension of genetically
modified autologous T cells in 5% DMSO and 2.5% albumin (human). In
some embodiments, CD19-directed genetically modified autologous T
cell immunotherapy is supplied in an infusion bag containing
approximately 68 mL of frozen suspension of genetically modified
autologous T cells in 5% DMSO and 2.5% albumin (human) (NDC
71287-119-01). In some embodiments, CD19-directed genetically
modified autologous T cell immunotherapy comprises Cryostor CS10.
In some embodiments, CD19-directed genetically modified autologous
T cell immunotherapy comprises 300 mg sodium per infusion. In some
embodiments, CD19-directed genetically modified autologous T cell
immunotherapy is supplied in an infusion bag containing
approximately 50-100 mL, 50-90 mL, 50-80 mL, 50-70 mL, 60-70 mL,
60-75 mL, or 65-75 mL, of suspension of genetically modified
autologous T cells in 5% DMSO and 2.5% albumin (human). In some
embodiments, CD19-directed genetically modified autologous T cell
immunotherapy is supplied in an infusion bag containing less than
100 mL, less than 90 mL, less than 80 mL, less than 70 mL, less
than 70 mL, less than 72 mL, or less than 75 mL, of suspension of
genetically modified autologous T cells in 5% DMSO and 2.5% albumin
(human). In some embodiments, CD19-directed genetically modified
autologous T cell immunotherapy is supplied in an infusion bag
containing greater than 50 mL, greater than 60 mL, greater than 65
mL, greater than 66 mL, greater than 67 mL, or greater than 68 mL,
of suspension of genetically modified autologous T cells in 5% DMSO
and 2.5% albumin (human). In some embodiments, the suspension is
frozen.
[0169] In some embodiments, the CD19-directed genetically modified
autologous T cell immunotherapy infusion bag is supplied in
ethylene-vinyl acetate cryostorage bag with sealed addition tube
and two available spike ports, containing approximately 68 mL of
cell dispersion.
[0170] In some embodiments, the CD19-directed genetically modified
autologous T cell immunotherapy infusion bag is individually packed
in a metal cassette. In some embodiments, the CD19-directed
genetically modified autologous T cell immunotherapy infusion bag
is individually packed in a metal cassette (NDC 71287-119-02). In
some embodiments, the CD19-directed genetically modified autologous
T cell immunotherapy infusion bag is stored in the vapor phase of
liquid nitrogen. In some embodiments, the CD19-directed genetically
modified autologous T cell immunotherapy infusion bag is supplied
in a liquid nitrogen dry shipper.
[0171] In some embodiments, the method comprises matching the
identity of the patient with the patient identifiers on the
cassette and infusion bag upon receipt. In some embodiments,
CD19-directed genetically modified autologous T cell immunotherapy
is stored frozen in the vapor phase of liquid nitrogen (less than
or equal to minus 150.degree. C.). In some embodiments, the
CD19-directed genetically modified autologous T cell immunotherapy
is thaw before using.
EXAMPLES
Example 1: Clinical Studies of Relapsed or Refractory Large B-Cell
Lymphoma
[0172] A single-arm, open-label, multicenter trial evaluated the
efficacy of a single infusion of Axi-cel.TM. (YESCARTA.RTM.) in
adult patients with relapsed or refractory aggressive B-cell
non-Hodgkin lymphoma. Eligible patients had refractory disease to
the most recent therapy or relapse within 1 year after autologous
hematopoietic stem cell transplantation (HSCT). The study excluded
patients with prior allogeneic HSCT, any history of central nervous
system lymphoma, ECOG performance status of 2 or greater, absolute
lymphocyte count less than 100/4, creatinine clearance less than 60
mL/min, hepatic transaminases more than 2.5 times the upper limit
of normal, cardiac ejection fraction less than 50%, or active
serious infection.
[0173] Following lymphodepleting chemotherapy, Axi-cel.TM. was
administered as a single IV infusion at a target dose of
2.times.10.sup.6 CAR-positive viable T cells/kg (maximum permitted
dose: 2.times.10.sup.8 cells). The lymphodepleting regimen
consisted of cyclophosphamide 500 mg/m.sup.2 IV and fludarabine 30
mg/m.sup.2 IV, both given on the fifth, fourth, and third day
before Axi-cel.TM.. Bridging chemotherapy between leukapheresis and
lymphodepleting chemotherapy was not permitted. All patients were
hospitalized for Axi-cel.TM. infusion and for a minimum of 7 days
afterward.
[0174] Of 111 patients who underwent leukapheresis, 101 received
Axi-cel.TM.. Of the patients treated, the median age was 58 years
(range: 23 to 76), 67% were male, and 89% were white. Most (76%)
had DLBCL, 16% had transformed follicular lymphoma, and 8% had
primary mediastinal large B-cell lymphoma. The median number of
prior therapies was 3 (range: 1 to 10), 77% of the patients had
refractory disease to a second or greater line of therapy, and 21%
had relapsed within 1 year of autologous HSCT.
[0175] One out of 111 patients did not receive the product due to
manufacturing failure. Nine other patients were not treated,
primarily due to progressive disease or serious adverse reactions
following leukapheresis. The median time from leukapheresis to
product delivery was 17 days (range: 14 to 51 days), and the median
time from leukapheresis to infusion was 24 days (range: 16 to 73
days). The median dose was 2.0.times.10.sup.6 CAR-positive viable T
cells/kg (range: 1.1 to 2.2.times.10.sup.6 cells/kg).
[0176] Efficacy was established on the basis of complete remission
(CR) rate and duration of response (DOR), as determined by an
independent review committee (Table 3 and Table 4). The median time
to response was 0.9 months (range: 0.8 to 6.2 months). Response
durations were longer in patients who achieved CR, as compared to
patients with a best response of partial remission (PR) (Table 4).
Of the 52 patients who achieved CR, 14 initially had stable disease
(7 patients) or PR (7 patients), with a median time to improvement
of 2.1 months (range: 1.6 to 5.3 months).
TABLE-US-00003 TABLE 3 Response Rate Recipients of Axi-cel .TM. (N
= 101) Objective Response Rate.sup.a 73 (72%) (95% CI) (62, 81)
Complete Remission Rate 52 (51%) (95% CI) (41, 62) Partial
Remission Rate 21 (21%) (95% CI) (13, 30) CI, confidence interval.
.sup.aPer 2007 revised International Working Group criteria, as
assessed by the independent review committee.
TABLE-US-00004 TABLE 4 Duration of Response From N of 101 Number of
Responders 73 DOR (Months).sup.a Median.sup.b 9.2 (95% CI) (5.4,
NE) Range.sup.c 0.03+, 14.4+ DOR if Best Response is CR (Months)
Median.sup.b NE (95% CI) (8.1, NE) Range 0.4, 14.4+ DOR if Best
Response is PR (Months) Median.sup.b 2.1 (95% CI) (1.3, 5.3) Range
0.03+, 8.4+ Median Follow-up for DOR (Months).sup.a,b 7.9 CR,
complete remission; DOR, duration of response; NE, not estimable;
PR, partial remission. .sup.aAmong all responders. DOR is measured
from the date of first objective response to the date of
progression or death from relapse or toxicity. .sup.bKaplan-Meier
estimate. .sup.cA + sign indicates a censored value.
Example 2: Pharmacodynamics and Pharmacokinetics after Axi-Cel.TM.
Infusion
[0177] After Axi-cel.TM. infusion, pharmacodynamic responses were
evaluated over a 4-week interval by measuring transient elevation
of cytokines, chemokines and other molecules in blood. Levels of
cytokines and chemokines such as IL-6, IL-8, IL-10, IL-15,
TNF-.alpha., IFN-.gamma., and sIL2R.alpha. were analyzed. Peak
elevation was observed within the first 14 days after infusion, and
levels generally returned to baseline within 28 days. Due to the
on-target effect of Axi-cel.TM., a period of B-cell aplasia is
expected.
[0178] Following infusion of Axi-cel.TM., anti-CD19 CART cells
exhibited an initial rapid expansion followed by a decline to near
baseline levels by 3 months. Peak levels of anti-CD19 CAR T cells
occurred within the first 7-14 days after Axi-cel.TM. infusion. Age
(range: 23-76 years) and gender had no significant impact on
AUC.sub.(0-28d) and Cmax of Axi-cel.TM..
[0179] The number of anti-CD19 CART cells in blood was positively
associated with objective response (complete remission (CR) or
partial remission (PR)). The median anti-CD19 CAR T-cell Cmax
levels in responders (n=73) were 205% higher compared to the
corresponding level in nonresponders (n=23) (43.6 cells/.mu.L vs
21.2 cells/.mu.L). Median AUC Day 0-28 in responding patients
(n=73) was 251% of the corresponding level in nonresponders (n=23)
(557.1 days*cells/.mu.L vs. 222.0 days*cells/.mu.L).
[0180] Some patients required tocilizumab and corticosteroids for
management of CRS and neurologic toxicities. Patients treated with
tocilizumab (n=44) had 262% and 232% higher anti-CD19 CART cells as
measured by AUC.sub.(0-28d) and Cmax respectively, as compared to
patients who did not receive tocilizumab (n=57). Similarly,
patients that received corticosteroids (n=26) had 217% and 155%
higher AUC.sub.(0-28d) and Cmax compared to patients who did not
receive corticosteroids (n=75).
Example 3: Management of Adverse Reactions after CD19-Directed
Genetically Modified Autologous T Cell Immunotherapy
[0181] Because clinical trials are conducted under widely varying
conditions, adverse reaction rates observed in the clinical trials
of a drug cannot be directly compared to rates in the clinical
trials of another drug and may not reflect the rates observed in
practice.
[0182] The safety data described in this section reflect exposure
to Axi-cel.TM. in the clinical trial (Study 1) in which 108
patients with relapsed/refractory B-cell NHL received CAR-positive
T cells based on a recommended dose which was weight-based.
Patients with a history of CNS disorders (such as seizures or
cerebrovascular ischemia) or autoimmune disease requiring systemic
immunosuppression were ineligible. The median duration of follow up
was 8.7 months. The median age of the study population was 58 years
(range: 23 to 76 years); 68% were men. The baseline ECOG
performance status was 43% with ECOG 0, and 57% with ECOG 1.
[0183] The most common adverse reactions (incidence .gtoreq.20%)
include CRS, fever, hypotension, encephalopathy, tachycardia,
fatigue, headache, decreased appetite, chills, diarrhea, febrile
neutropenia, infections-pathogen unspecified, nausea, hypoxia,
tremor, cough, vomiting, dizziness, constipation, and cardiac
arrhythmias. Serious adverse reactions occurred in 52% of patients.
The most common serious adverse reactions (>2%) include
encephalopathy, fever, lung infection, febrile neutropenia, cardiac
arrhythmia, cardiac failure, urinary tract infection, renal
insufficiency, aphasia, cardiac arrest, Clostridium difficile
infection, delirium, hypotension, and hypoxia.
[0184] The most common (.gtoreq.10%) Grade 3 or higher reactions
include febrile neutropenia, fever, CRS, encephalopathy,
infections-pathogen unspecified, hypotension, hypoxia and lung
infections.
[0185] Forty-five percent (49/108) of patients received tocilizumab
after infusion of Axi-cel.TM..
[0186] Table 5 summarizes the adverse reactions that occurred in at
least 10% of patients treated with Axi-cel.TM. and Table 6
describes the laboratory abnormalities of Grade 3 or 4 that
occurred in at least 10% of patients.
TABLE-US-00005 TABLE 5 Summary of Adverse Reactions Observed in at
Least 10% of the Patients Treated with Axi-cel .TM. in Study 1
Grade 3 or Adverse Reaction Any Grade (%) Higher (%) Cardiac
Disorders Tachycardia.sup.a 57 2 Arrhythmia.sup.b 23 7
Gastrointestinal Disorders Diarrhea 38 4 Nausea 34 0 Vomiting 26 1
Constipation 23 0 Abdominal pain.sup.c 14 1 Dry mouth 11 0 General
Disorders And Administration Site Conditions Fever 86 16
Fatigue.sup.d 46 3 Chills 40 0 Edema.sup.e 19 1 Immune System
Disorders Cytokine release syndrome 94 13
Hypogammaglobulinemia.sup.f 15 0 Infections And Infestations
Infections-pathogen unspecified 26 16 Viral infections 16 4
Bacterial Infections 13 9 Investigations Decreased appetite 44 2
Weight decreased 16 0 Dehydration 11 3 Musculoskelatal And
Connective Tissue Disorders Motor dysfunction.sup.g 19 1 Pain in
extremity.sup.h 17 2 Back pain 15 1 Muscle pain 14 1 Arthralgia 10
0 Nervous System Disorders Encephalopathy.sup.i 57 29
Headache.sup.j 45 1 Tremor 31 2 Dizziness.sup.k 21 1 Aphasia.sup.l
18 6 Psychiatric Disorders Delirium.sup.m 17 6 Respiratory,
Thoracic And Mediastinal Disorders Hypoxia.sup.n 32 11 Cough.sup.o
30 0 Dyspnea.sup.p 19 3 Pleural effusion 13 2 Renal and Urinary
Disorders Renal insufficiency 12 5 Vascular Disorders
Hypotension.sup.q 57 15 Hypertension 15 6 Thrombosis.sup.r 10 1 The
following events were also counted in the incidence of CRS:
tachycardia, arrhythmia, fever, chills, hypoxia, renal
insufficiency, and hypotension. .sup.aTachycardia includes
tachycardia, sinus tachycardia. .sup.bArrhythmia includes
arrhythmia, atrial fibrillation, atrial flutter, atrioventricular
block, bundle branch block right, electrocardiogram QT prolonged,
extra-systoles, heart rate irregular, supraventricular extra
systoles, supraventricular tachycardia, ventricular arrhythmia,
ventricular tachycardia. .sup.cAbdominal pain includes abdominal
pain, abdominal pain lower, abdominal pain upper. .sup.dFatigue
includes fatigue, malaise. .sup.eEdema includes face edema,
generalized edema, local swelling, localized edema, edema, edema
genital, edema peripheral, periorbital edema, peripheral swelling,
scrotal edema. .sup.fHypogammaglobulinemia includes
hypogammaglobulinemia, blood immunoglobulin D decreased, blood
immunoglobulin G decreased. .sup.gMotor dysfunction includes muscle
spasms, muscular weakness. .sup.hPain in extremity includes pain
not otherwise specified, pain in extremity. .sup.iEncephalopathy
includes cognitive disorder, confusional state, depressed level of
consciousness, disturbance in attention, encephalopathy,
hypersomnia, leukoencephalopathy, memory impairment, mental status
changes, paranoia, somnolence, stupor. .sup.jHeadache includes
headache, head discomfort, sinus headache, procedural headache.
.sup.kDizziness includes dizziness, presyncope, syncope.
.sup.lAphasia includes aphasia, dysphasia. .sup.mDelirium includes
agitation, delirium, delusion, disorientation, hallucination,
hyperactivity, irritability, restlessness. .sup.nHypoxia includes
hypoxia, oxygen saturation decreased. .sup.oCough includes cough,
productive cough, upper-airway cough syndrome. .sup.pDyspnea
includes acute respiratory failure, dyspnea, orthopnea, respiratory
distress. .sup.qHypotension includes diastolic hypotension,
hypotension, orthostatic hypotension. .sup.rThrombosis includes
deep vein thrombosis, embolism, embolism venous, pulmonary
embolism, splenic infarction, splenic vein thrombosis, subclavian
vein thrombosis, thrombosis, thrombosis in device.
[0187] Other clinically important adverse reactions that occurred
in less than 10% of patients treated with Axi-cel.TM. include the
following: [0188] Blood and lymphatic system disorders:
Coagulopathy (2%) [0189] Cardiac disorders: Cardiac failure (6%)
and cardiac arrest (4%) [0190] Immune system disorders:
Hemophagocytic lymphohistiocytosis/macrophage activation syndrome
(HLH/MAS) (1%), hypersensitivity (1%) [0191] Infections and
infestations disorders: Fungal infections (5%) [0192] Nervous
system disorders: Ataxia (6%), seizure (4%), dyscalculia (2%), and
myoclonus (2%) [0193] Respiratory, thoracic and mediastinal
disorders: Pulmonary edema (9%) [0194] Skin and subcutaneous tissue
disorders: Rash (9%) [0195] Vascular disorders: Capillary leak
syndrome (3%)
[0196] Laboratory Abnormalities:
TABLE-US-00006 TABLE 6 Grade 3 or 4 Laboratory Abnormalities
Occurring in .gtoreq.10% of Patients in Study 1 Following Treatment
with Axi-cel based on CTCAE (N = 108) Grades 3 or 4 (%) Lymphopenia
100 Leukopenia 96 Neutropenia 93 Anemia 66 Thrombocytopenia 58
Hypophosphatemia 50 Hyponatremia 19 Uric acid increased 13 Direct
Bilirubin increased 13 Hypokalemia 10 Alanine Aminotransferase
increased 10
[0197] Cytokine Release Syndrome
[0198] CRS, including fatal or life-threatening reactions, occurred
following treatment with Axi-cel.TM.. In Study 1, CRS occurred in
94% (101/108) of patients receiving Axi-cel.TM., including
.gtoreq.Grade 3 (Lee grading system.sup.1) CRS in 13% (14/108) of
patients. Among patients who died after receiving Axi-cel.TM., four
had ongoing CRS events at the time of death. The median time to
onset was 2 days (range: 1 to 12 days) and the median duration of
CRS was 7 days (range: 2 to 58 days). Key manifestations of CRS
include fever (78%), hypotension (41%), tachycardia (28%), hypoxia
(22%), and chills (20%). Serious events that may be associated with
CRS include cardiac arrhythmias (including atrial fibrillation and
ventricular tachycardia), cardiac arrest, cardiac failure, renal
insufficiency, capillary leak syndrome, hypotension, hypoxia, and
hemophagocytic lymphohistiocytosis/macrophage activation syndrome
(HLH/MAS).
Neurologic Toxicities
[0199] Neurologic toxicities, that were fatal or life-threatening,
occurred following treatment with Axi-cel.TM.. Neurologic
toxicities occurred in 87% of patients. Ninety-eight percent of all
neurologic toxicities occurred within the first 8 weeks of
Axi-cel.TM. infusion, with a median time to onset of 4 days (range:
1 to 43 days). The median duration of neurologic toxicities was 17
days. Grade 3 or higher neurologic toxicities occurred in 31% of
patients.
[0200] The most common neurologic toxicities included
encephalopathy (57%), headache (44%), tremor (31%), dizziness
(21%), aphasia (18%), delirium (17%), insomnia (9%) and anxiety
(9%). Prolonged encephalopathy lasting up to 173 days was noted.
Serious events including leukoencephalopathy and seizures occurred
with Axi-cel.TM.. Fatal and serious cases of cerebral edema have
occurred in patients treated with Axi-cel.TM..
Serious Infections
[0201] Severe or life-threatening infections occurred in patients
after Axi-cel.TM. infusion. In Study 1, infections (all grades)
occurred in 38% of patients. Grade 3 or higher infections occurred
in 23% of patients. Grade 3 or higher infections with an
unspecified pathogen occurred in 16% of patients, bacterial
infections in 9%, and viral infections in 4%. Axi-cel.TM. should
not be administered to patients with clinically significant active
systemic infections. Monitor patients for signs and symptoms of
infection before and after Axi-cel.TM. infusion and treat
appropriately. Administer prophylactic anti-microbials according to
local guidelines.
[0202] Febrile neutropenia was observed in 36% of patients after
Axi-cel.TM. infusion and may be concurrent with CRS. In the event
of febrile neutropenia, evaluate for infection and manage with
broad spectrum antibiotics, fluids and other supportive care as
medically indicated.
Immunogenicity
[0203] Axi-cel.TM. has the potential to induce anti-product
antibodies. The immunogenicity of Axi-cel.TM. has been evaluated
using an enzyme-linked immunosorbent assay (ELISA) for the
detection of binding antibodies against FMC63, the originating
antibody of the anti-CD19 CAR. Three patients tested positive for
pre-dose anti-FMC63 antibodies at baseline and months 1, 3, or 6 in
Study 1. There is no evidence that the kinetics of initial
expansion and persistence of Axi-cel.TM., or the safety or
effectiveness of Axi-cel.TM. was altered in these patients.
[0204] In Study 1, Grade 3 or higher cytopenias not resolved by Day
30 following Axi-cel.TM. infusion occurred in (28%) of patients and
included thrombocytopenia (18%), neutropenia (15%), and anemia
(3%). Monitor blood counts after Axi-cel.TM. infusion.
[0205] In Study 1, hypogammaglobulinemia occurred in 15% of
patients.
[0206] All publications, patents, patent applications, and
references, including prescribing information, that are mentioned
in this specification are herein incorporated by reference to the
same extent as if each individual publication, patent, or patent
application was specifically and individually indicated to be
incorporated by reference. However, the citation of a reference
herein should not be construed as an acknowledgement that such
reference is prior art to the present invention. To the extent that
any of the definitions or terms provided in the references
incorporated by reference differ from the terms and discussion
provided herein, the present terms and definitions control.
* * * * *
References